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Chapter 6 Somatoform and Dissociative Disorders

Chapter 6 Somatoform and Dissociative Disorders. An Overview of Somatoform Disorders. Soma = Body Preoccupation with health or appearance Physical complaints No identifiable medical condition. An Overview of Somatoform Disorders. Somatoform Disorders Hypochondriasis Somatization disorder

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Chapter 6 Somatoform and Dissociative Disorders

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  1. Chapter 6Somatoform and Dissociative Disorders

  2. An Overview of Somatoform Disorders • Soma = Body • Preoccupation with health or appearance • Physical complaints • No identifiable medical condition

  3. An Overview of Somatoform Disorders • Somatoform Disorders • Hypochondriasis • Somatization disorder • Conversion disorder • Pain disorder • Body dysmorphic disorder

  4. Hypochondriasis: An Overview • Clinical Description • Anxiety or fear of having a disease • High comorbidity with anxiety/mood disorders • Focus on bodily symptoms • Normal • Mild • Vague

  5. Hypochondriasis: An Overview • Clinical Description (cont.) • Little benefit from medical reassurance • Strong disease conviction • Misperceptions of symptoms • Checking behaviors • High trait anxiety

  6. Hypochondriasis and Panic Disorder • Similarities • Focus on bodily symptoms • Differences in hypochondriasis: • Focus on long-term process of illness • Constant concern • Constant medical treatment seeking • Wider range of symptoms

  7. Hypochondriasis: An Overview • Statistics • 1% to 14% of medical patients • 6.7% median rate • Female : Male = 1:1 • Onset at any age • Peaks: adolescence, middle age, elderly • Chronic course

  8. Hypochondriasis • Culture-Specific Syndromes • China – koro • India – dhat • Africa • Pakistan

  9. Hypochondriasis • Causes • Disorder of cognition or perception • Physical signs and sensations

  10. Hypochondriasis • Causes • Familial history of illness • Genetics • Modeling/learning • Other factors • Stressful life events • High family disease incidence • “Benefits” of illness

  11. Hypochondriasis - Treatment • Psychodynamic • Uncover unconscious conflict • Limited efficacy data • Educational & Supportive • Ongoing and sensitive • Detailed and repeated information • Beneficial for mild cases

  12. Hypochondriasis - Treatment • Cognitive-Behavioral • Identify and challenge misinterpretations • “Symptom creation” • Stress-reduction • Best efficacy data • Vs. medications (SSRI) • Immediate and 1 year follow-up

  13. Somatization Disorder • Clinical Description • Long history of physical complaints • Significant impairment • Concern about symptoms, not meaning • Symptoms = identity

  14. Somatization Disorder • Statistics • Rare • 4.4%; 16.6% in medical settings • Onset = adolescence • Female : male = ~2:1 • Unmarried, low SES • Chronic course

  15. Somatization Disorder: Causes • History of family illness or injury • Links to antisocial personality disorder • Behavioral inhibition system • Impulsivity • Novelty-seeking • Provocative sexual behavior • Socialization • Gender roles

  16. Somatization Disorder: Treatment • No “cures” • Cognitive-behavioral interventions • Initial reassurance • Stress-reduction • Reduce frequency of help-seeking behaviors

  17. Somatization Disorder: Treatment • “Gatekeeper” physician • Reduce visits to numerous specialists • Conditioning • Reward positive health behaviors • Punish problem behaviors • Remove supportive consequences

  18. Conversion Disorder • Clinical Description • Physical malfunctioning • sensory-motor areas • Lack physical or organic pathology • Lack awareness • “La belle indifference” • Possible, but not always • Intact functioning

  19. Conversion Disorder : Differential Diagnosis • Malingering • Intentionally produced symptoms • Clear benefit • No precipitating stressful event • Impaired function • Factitious Disorder/Munchausen’s • Intentionally produced symptoms • No obvious benefit • Sick role?

  20. Conversion Disorder • Statistics • Rare • Prevalence depends on setting • Female > male • Onset = adolescence • Chronic, intermittent course

  21. Conversion Disorder • Special populations • Soldiers • Children • Better prognosis? • Cultural considerations • Religious experiences • Rituals

  22. Conversion Disorder: Causes • Freudian psychodynamic view • Trauma, conflict experience • Repression • “Conversion” to physical symptoms • Primary gain • Attention and support • Secondary gain

  23. Conversion Disorder: Causes • Behavioral • Traumatic event must be escaped • Avoidance is not an option • Social acceptability of illness • Negative reinforcement

  24. Conversion Disorder: Causes • Family/Social/Cultural • Low SES • Limited disease knowledge • Family history of illness

  25. Conversion Disorder: Treatment • Similar to somatization disorder • Attending to trauma • Remove secondary gain • Reduce supportive consequences • Reward positive health behaviors

  26. Pain Disorder • Clinical Description • Pain in one or more areas • Significant impairment • Etiology may be physical • Maintained by psychological factors

  27. Pain Disorder • Statistics • Fairly common • 5% - 12% • Treatment • Combined medical and psychological

  28. Body Dysmorphic Disorder • Clinical Description • Preoccupation with imagined defect in appearance • Impaired function • Social • Occupational

  29. Body Dysmorphic Disorder • Clinical Description • Fixation or avoidance of mirrors • Suicidal ideation and behavior • Unusual behaviors • Ideas of reference • Checking/compensating rituals • Delusional disorder: somatic type?

  30. Body Dysmorphic Disorder • Statistics • 1% to 15% • Female : Male = ~1:1 • Different areas of focus • Onset = early 20s • Most remain single • Lifelong, chronic course

  31. Body Dysmorphic Disorder: Causes • Little scientific knowledge • Cultural imperatives • Body size • Skin color • Similarities with OCD • Intrusive thoughts • Rituals • Age of onset and course

  32. Body Dysmorphic Disorder: Treatment • Similar to OCD • Medications (SSRIs) • Exposure and response prevention • Plastic surgery is often unhelpful

  33. An Overview of Dissociative Disorders • Severe alterations or detachments • Normal perceptual experiences • Significant impairments • Identity • Memory • Consciousness • Depersonalization • Derealization

  34. An Overview of Dissociative Disorders • Types • Depersonalization Disorder • Dissociative Amnesia • Dissociative Fugue • Dissociative Trance Disorder • Dissociative Identity Disorder

  35. Depersonalization Disorder: An Overview • Clinical Description • Feelings of unreality and detachment • Severe/frightening • Depersonalization • Derealization • Significant impairment

  36. Depersonalization Disorder: An Overview • Statistics • 0.8% • Female : Male = ~1:1 • High comorbidities • Anxiety and mood disorders • Onset = ~ age 16 • Lifelong, chronic course

  37. Depersonalization Disorder: Causes • Cognitive deficits • Attention • Short-term memory • Spatial reasoning • Easily distracted • Decreased emotional response

  38. Depersonalization Disorder: Treatment • Psychological treatments are unstudied • Prozac appears ineffective

  39. Dissociative Amnesia • Dissociative Amnesia • Psychogenic memory loss • Generalized type • Localized or selective type

  40. Dissociative Fugue • Dissociative Fugue: • Flight or travel • Memory loss • Retrograde vs. anterograde • “How’s” or “why’s” of travel • Assumption of new identity

  41. Dissociative Amnesia and Fugue • Statistics • Tends to occur in adulthood • Rapid onset • Rapid dissipation • Females > males

  42. Dissociative Amnesia and Fugue • Causes and Treatments • Little is known • Trauma and life stress • Treatment • Resolution without treatment • Memory returns

  43. Dissociative Trance Disorder • Clinical Description • Dissociative symptoms • Sudden personality changes • State is undesirable • Cultural/religious variations

  44. Dissociative Trance Disorder: An Overview • Statistics • Female > male • Causes • Life stressor or trauma • Treatment • ?

  45. Dissociative Identity Disorder (DID) • Clinical Description • Amnesia • Dissociation of personality • Adopt several new identities or “alters” • 2 to 100 • Average = 15 • Unique characteristics • Host • Switch

  46. Can DID be Faked? • Real vs. false memories • Suggestibility • Hypnosis studies • Simulated amnesia • Demand characteristics • Physiological measures • Eye movements • GSR • EEG

  47. Dissociative Identity Disorder (DID) • Statistics • 1.5% (year) • Female : male = 9:1 • Onset = childhood • High comorbidity rates • Axis I • Axis II • Lifelong, chronic course

  48. DID: Causes • Causes • Biological vulnerability • Reactivity • Hippocampus and amygdala • Severe abuse/trauma history • Links with PTSD • Highly suggestible • Auto hypnotic model

  49. DID: Treatment • Similar to PTSD treatment • Reintegration of identities • Identify and neutralize cues/triggers • Visualization • Coping • Antidepressant medications?

  50. Future Directions • Possible changes to the DSM-V • Reorganization • Physical and psychological origins • “Health anxiety disorder” • BDD and OCD • Axis I or II classification

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