CHAPTER 5 SOMATOFORM AND DISSOCIATIVE DISORDERS

1. CHAPTER 5SOMATOFORM AND DISSOCIATIVE DISORDERS

2. AIMS AND OBJECTIVES Define somatoform and dissociative disorders Describe historical approaches Review information regarding prevalence, age of onset, and course Discuss current aetiological findings Outline treatment approaches

3. SOMATOFORM AND DISSOCIATIVE DISORDERS Somatoform disorders involve the presentation of medically unexplained symptoms Dissociative disorders involve the loss of normal integration of identity, memory, perception, or consciousness Dissociation is the mechanism whereby one part of mental functioning (e.g., memory, consciousness, perception, or identity) is split off from the rest Factitious disorders involve the deliberate feigning of illness, usually to gain the security or care of medical attention (e.g., Munchausen’s syndrome)

4. SOMATOFORM AND DISSOCIATIVE DISORDERS Historical approaches The ancient term “hysteria,” referred to nonfatal malady of women that included different types of bodily symptoms The most classic case of hysteria is Anna O, written by Joseph Breurer and Sigmund Freud Anna O was a young Viennese woman who reported multiple somatoform symptoms, which were suggested to be associated with the psychological trauma of her father’s illness and death

5. SOMATOFORM AND DISSOCIATIVE DISORDERS Historical approaches The term conversion signifies the transformation of psychological material into somatic symptoms The treatment of Anna O was the first described case of the psychoanalysis, the “talking cure” Freud theorised that hysteria was the result of consciously unacceptable sexual fantasies from childhood

6. Somatoform disorders To be assigned a somatoform disorder diagnosis, the symptoms must be understood to derive from psychological factors, rather than having a medical basis DSM-IV-TR somatoform diagnoses include: Conversion disorder - a motor or sensory neurological disturbance (e.g., paralysis) that onsets after a psychological stress, with no physical disorder to explain the impairment Pain disorder -severe pain in one or more anatomical sites, not fully explainable by physical pathology Somatoform and dissociative disorders

7. Somatoform disorders DSM-IV-TR somatoform diagnoses (cont.) Somatisation disorder - a history of multiple physical complaints in several different body sites, beginning before age 30 and occurring over several years Hypochondriasis – Preoccupation with fears of having or belief that one has a serious disease despite appropriate medical reassurance Body dysmorphic disorder – preoccupation with an imagined defect in appearance, with markedly excessive concern Somatoform and dissociative disorders

8. Somatoform disorders Epidemiology Medically unexplained physical symptoms are common, not just in those with somatoform disorders Formal clinical somatoform disorders are rare in the general community; much more prevalent among high utilisers of health services Anxiety and depression are common in people with unexplained physical symptoms and those with somatoform disorder Somatoform disorders are more common among women SOMATOFORM AND DISSOCIATIVE DISORDERS

9. Aetiology Biological factors Research has found underactivity of hypothalamic-pituitary-adrenal (HPA) axis in patients with unexplained symptoms, such as fatigue Neurobiological models focus on how sensory/motor info is processed Gate Control Theory (Melzak & Wall, 1965)of pain: Neural “gates” in the spinal cord can be opened or closed, determining the amount of pain the individual experiences More activity in the pain fibers  more gates are opened More activity in the peripheral fibers regarding stimuli around the body  more gates are closed Messages from the brain can open or close the gates SOMATOFORM AND DISSOCIATIVE DISORDERS

10. Aetiology Trauma and personality factors Patients with somatoform disorders more likely to have experienced adverse events in childhood One theory proposes that memory of early trauma is contained in emotions, reflex actions, or bodily sensations (van der Kolk, 1994) Negative events in childhood may also give rise to personality characteristics that predispose the person to a somatoform disorder People with somatoform disorders have higher rates of alexithymia, difficulty experiencing or expressing emotions Failing to identify and express emotional distress may lead to increased physiological arousal SOMATOFORM AND DISSOCIATIVE DISORDERS

11. Aetiology Cognitive and behavioural factors Cycle of somatosensory amplification – tendency to experience somatic sensations as intense and distressing SOMATOFORM AND DISSOCIATIVE DISORDERS

12. Treatment Acute somatoform disorders When patient presents to GP with pain and tests are normal, GP may undertake reattribution, which consists of 3 steps: Thorough history and physical examination “Broadening the agenda” – explaining that pain may be caused by psychosocial factors Making the link between psychological factors and physical symptoms SOMATOFORM AND DISSOCIATIVE DISORDERS

13. Treatment Chronic somatoform disorders Conduct thorough physical and psychiatric assessment Identify single case manager to ensure coordinated approach Employ specific psychological interventions, such as: challenging illness attributions, self-monitoring, and coping strategies, such as progressive muscle relaxation Specific somatoform disorders Hypochondriasis Specific CBT interventions, including education, reattribution, attention exercises Body dysmorphic disorder Graduated exposure, cognitive restructuring, attention training SOMATOFORM AND DISSOCIATIVE DISORDERS

14. Dissociative disorders Description of dissociative experiences and disorders Amnesia – absence of memory for a period of time Depersonalisation – change in individual’s sense of physical self Derealisation – change in individual’s sense of the world Identity confusion – feelings of uncertainty regarding one’s identity Identity alteration – objective behaviours indicating that an individual has assumed alternative identities at different times DSM-IV-TR diagnoses of dissociative disorders Depersonalisation disorder Dissociative amnesia Dissociative fugue – sudden unexpected travel away from home with inability to recall one’s past and identity confusion Dissociative identity disorder – 2 or more distinct identities SOMATOFORM AND DISSOCIATIVE DISORDERS

15. Dissociative disorders Epidemiology Prevalence data for dissociative disorders not well established Depersonalisationis a common experience (26 - 74%), but depersonalisation disorder is not (.8 - 2.4%) Prevalence of dissociative amnesia is controversial, but recent estimate of 1.8% in a community sample Dissociative identity disorder – 1% in the community, but much higher in clinical samples Why increased prevalence of this disorder in the past 50 years? Increased recognition? Culture-bound syndrome? More prevalence studies needed SOMATOFORM AND DISSOCIATIVE DISORDERS

16. Dissociative disorders Aetiology Most dissociative disorders believed to be stress-related Depersonalisation disorder – most common immediate precipitants are extreme stress, depression, anxiety, and substance use Dissociative amnesia - biological explanations focus on the effects of stress on different brain symptoms, e.g., hippocampus and amygdala, while psychological explanations focus motivations for not remembering Dissociative identity disorder – dominant theory is that it is related to severe childhood trauma SOMATOFORM AND DISSOCIATIVE DISORDERS

17. Dissociative disorders Treatment Depersonalisation disorder – no evidence for efficacy of pharmacotherapy yet, some preliminary support for CBT Dissociative fugue and amnesia – most cases resolve spontaneously, some clinical case reports of use of imaginal exposure or hypnosis Dissociative identity disorder – treatment guidelines suggest a 3 phase approach: Develop trusting relationship Exposure-based techniques for traumatic memories Bringing together separate identities Much more empirical support is needed, particularly controlled trials SOMATOFORM AND DISSOCIATIVE DISORDERS

18. Dissociative disorders Current challenges and controversies Recovered memory/false memory debate Dissociative amnesia position: severe traumatic experiences are often repressed False memory position: trauma is always remembered, so-called recovered memories are actually false memories Evidence that participants report having had amnesia for traumas Some participants later retract allegations of abuse and claim the therapist implanted the memory Other experimental evidence that false memories can be created for non-traumatic events SOMATOFORM AND DISSOCIATIVE DISORDERS

19. SUMMARY Historical Approaches to Somatoform and Dissociative Disorders Somatoform Disorders DSM-IV-TR Diagnosis Epidemiology Aetiology Treatment Dissociative Disorders DSM-IV-TR Diagnosis Epidemiology Aetiology Treatment Current Controversies and Challenges