Disorders Focusing on Somatic and Dissociative Symptoms

1. Disorders Focusing on Somatic and Dissociative Symptoms Chapter 7 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

2. Disorders Focusing on Somatic and Dissociative Symptoms • In addition to disorders covered earlier, stress and anxiety also contribute to several other kinds of disorder, particularly disorders that focus on somatic and dissociative symptoms Comer, Abnormal Psychology,8e DSM-5 Update

3. Disorders Focusing on Somatic Symptoms • In these disorders, the somatic symptoms are primarily caused by psychosocial factors or the symptoms trigger excessive anxiety and concern • These disorders are different than psychophysiological disorders, in which psychosocial factors interact with genuine physical ailments Comer, Abnormal Psychology,8e DSM-5 Update

4. Disorders Focusing on Dissociative Symptoms • Dissociative disorders are each characterized by significant memory loss or identity disruption Comer, Abnormal Psychology,8e DSM-5 Update

5. Disorders Focusing on Somatic and Dissociative Symptoms • Disorders that focus on somatic symptoms and those that focus on dissociative symptoms have much in common: • Both may occur in response to severe stress • Both have traditionally been viewed as forms of escape from stress • A number of individuals suffer from both a somatic-related and a dissociative disorder • Theorists and clinicians often explain and treat the two groups of disorders in similar ways Comer, Abnormal Psychology,8e DSM-5 Update

6. Disorders Focusing on Somatic Symptoms • DSM-5 lists a number of disorders in which bodily symptoms or concerns are the primary features Comer, Abnormal Psychology,8e DSM-5 Update

7. Factitious Disorder • Sometimes when physicians cannot find a medical cause for a patient’s symptoms, he or she may suspect other factors are involved. • Patients may malinger, intentionally fake illness to achieve external gain (e.g., financial compensation, military deferment) • Patients may be manifesting a factitious disorder - intentionally producing or faking symptoms simply out of a wish to be a patient Comer, Abnormal Psychology,8e DSM-5 Update

8. Factitious Disorder • Known popularly as Munchausen syndrome, people with a factitious disorder often go to extremes to create the appearance of illness • Many secretly give themselves medications to produce symptoms • Patients often research their supposed ailments and are impressively knowledgeable about medicine Comer, Abnormal Psychology,8e DSM-5 Update

9. Factitious Disorder • Clinical researchers have a hard time determining the prevalence of this disorder as patients hide the true nature of their problem • Overall, the pattern appears to be more common in women than men and the disorder usually begins during early adulthood Comer, Abnormal Psychology,8e DSM-5 Update

10. Factitious Disorder • Factitious disorder seems to be particularly common among people who (a) received extensive medical treatment as children, (2) carry a grudge against the medical profession, or (3) have worked as a nurse, lab technician, or medical aide Comer, Abnormal Psychology,8e DSM-5 Update

11. Factitious Disorder • The precise causes of factitious disorder are not understood, although clinical reports have pointed to factors such as depression unsupportive parental relationships, and an extreme need for social support Comer, Abnormal Psychology,8e DSM-5 Update

12. Factitious Disorder • Psychotherapists and medical practitioners often become angry at people with a factitious disorder, feeling that they are wasting their time • People with the disorder, however, feel they have no control over their problems and often experience great distress Comer, Abnormal Psychology,8e DSM-5 Update

13. Factitious Disorder • In a related pattern, factitious disorder imposed on another, known popularly as Munchausen syndrome by proxy, parents make up or produce physical illnesses in their children Comer, Abnormal Psychology,8e DSM-5 Update

14. Conversion Disorder • Conversion disorder • People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases • In short, the individuals experience neurological-like symptoms – blindness, paralysis, or loss of feeling – that have no neurological basis Comer, Abnormal Psychology,8e DSM-5 Update

15. Conversion Disorder • Conversion disorder often is hard to distinguish from genuine medical problems • It is always possible that a diagnosis of conversion disorder is a mistake and the patient’s problem has an undetected medical cause • Physicians sometimes rely on oddities in the patient’s medical picture to help distinguish the two • For example, conversion symptoms may be at odds with the known functioning of the nervous system, as in cases of glove anesthesia Comer, Abnormal Psychology,8e DSM-5 Update

16. Conversion Disorder • Unlike people with factitious disorder, those with conversion disorder don’t consciously want or produce their symptoms • This pattern is called “conversion” disorder because clinical theorists used to believe that individuals with the disorders are converting psychological needs into neurological symptoms Comer, Abnormal Psychology,8e DSM-5 Update

17. Conversion Disorder • Conversion disorder usually begins between late childhood and young adulthood • It is diagnosed in women twice as often as in men • It typically appears suddenly, at times of stress • It is thought to be rare, occurring in at most 5 of every 1,000 persons Comer, Abnormal Psychology,8e DSM-5 Update

18. Somatic Symptom Disorder • People with somatic symptom disorder become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing • Two patterns of somatic symptom disorder have received particular attention: • Somatization pattern • Predominant pain pattern Comer, Abnormal Psychology,8e DSM-5 Update

19. Somatic Symptom Disorder • People with a somatization pattern experience many long-lasting physical ailments that have little or no organic basis • Also known as Briquet’s syndrome • A sufferer’s ailments often include pain symptoms, gastrointestinal symptoms, sexual symptoms, and neurological symptoms • Patients usually go from doctor to doctor in search of relief Comer, Abnormal Psychology,8e DSM-5 Update

20. Somatic Symptom Disorder • Somatization pattern • Patients with this pattern often describe their symptoms in dramatic and exaggerated terms • Most also feel anxious and depressed • The pattern typically lasts for many years • Symptoms may fluctuate over time but rarely disappear completely without therapy Comer, Abnormal Psychology,8e DSM-5 Update

21. Somatic Symptom Disorder • Somatization pattern • Between 0.2% and 2% of all women in the U.S. experience a somatization pattern in any given year (compared with less than 0.2% of men) • The pattern often runs in families and begins between adolescence and young adulthood Comer, Abnormal Psychology,8e DSM-5 Update

22. Somatic Symptom Disorder • Predominant pain pattern • If the primary feature of somatic symptom disorder is pain, the individual is said to have a predominant pain pattern • Although the precise prevalence has not been determined, this pattern appears to be fairly common • The pattern often develops after an accident or illness that has caused genuine pain • The pattern may begin at any age, and more women than men seem to experience it Comer, Abnormal Psychology,8e DSM-5 Update

23. What Causes Conversion and Somatic Symptom Disorders? • For many years, conversion and somatic symptom disorders were referred to as hysterical disorders • This label was to convey the prevailing belief that excessive and uncontrolled emotions underlie the bodily symptoms • Today’s leading explanations come from the psychodynamic, behavioral, cognitive, and multicultural models • None has received much research support, and the disorders are still poorly understood Comer, Abnormal Psychology,8e DSM-5 Update

24. What Causes Conversion and Somatic Symptom Disorders? • The psychodynamic view • Freud believed that hysterical disorders represented a conversion of underlying emotional conflicts into physical symptoms • Because most of his patients were women, Freud centered his explanation on the psychosexual development of girls and focused on the phallic stage (ages 3 to 5)… Comer, Abnormal Psychology,8e DSM-5 Update

25. What Causes Conversion and Somatic Symptom Disorders? • The psychodynamic view • During this stage, girls develop a pattern of sexual desires for their fathers (the Electra complex) and recognize that they must compete with their mothers for his attention • Because of the mother’s more powerful position, however, girls repress these sexual feelings • Freud believed that if parents overreact to such feelings, the Electra complex would remain unresolved and the child might re-experience sexual anxiety throughout her life • Freud concluded that some women unconciously hide their sexual feelings in adulthood by converting them into physical symptoms Comer, Abnormal Psychology,8e DSM-5 Update

26. What Causes Conversion and Somatic Symptom Disorders? • The psychodynamic view • Today’s psychodynamic theorists take issues with parts of Freud’s explanation • They continue to believe that sufferers of these disorders have unconscious conflicts carried from childhood Comer, Abnormal Psychology,8e DSM-5 Update

27. What Causes Conversion and Somatic Symptom Disorders? • The psychodynamic view • Psychodynamic theorists propose that two mechanisms are at work in hysterical disorders: • Primary gain: bodily symptoms keep internal conflicts out of conscious awareness • Secondary gain: bodily symptoms further enable people to avoid unpleasant activities or receive sympathy from others Comer, Abnormal Psychology,8e DSM-5 Update

28. What Causes Conversion and Somatic Symptom Disorders? • The behavioral view • Behavioral theorists propose that the physical symptoms of hysterical disorders bring rewards to sufferers • May remove individual from an unpleasant situation • May bring attention from other people Comer, Abnormal Psychology,8e DSM-5 Update

29. What Causes Conversion and Somatic Symptom Disorders? • In response to such rewards, people learn to display symptoms more and more • This focus on rewards is similar to the psychodynamic idea of secondary gain, but behaviorists view the gains as the primary cause of the development of the disorder • Like the psychodynamic explanation, the behavioral view of these disorders has received little research support Comer, Abnormal Psychology,8e DSM-5 Update

30. What Causes Conversion and Somatic Symptom Disorders? • The cognitive view • Some cognitive theorists propose that hysterical disorders are a form of conversion and somatic symptom disorder, providing a means for people to express difficult emotions Comer, Abnormal Psychology,8e DSM-5 Update

31. What Causes Conversion and Somatic Symptom Disorders? • Like psychodynamic theorists, cognitive theorists hold that emotions are being converted into physical symptoms • This conversion is not to defend against anxiety but to communicate extreme feelings • Like the other explanations, this cognitive view has not been widely tested or supported by research Comer, Abnormal Psychology,8e DSM-5 Update

32. What Causes Conversion and Somatic Symptom Disorders? • The multicultural view • Some theorists believe that Western clinicians hold a bias that sees somatic symptoms as an inferior way of dealing with emotions • The transformation of personal distress into somatic complaints is the norm is many non-Western cultures • The lesson to be learned from multicultural findings is that both bodily and psychological reactions to life events are often influenced by one's culture Comer, Abnormal Psychology,8e DSM-5 Update

33. What Causes Conversion and Somatic Symptom Disorders? • A possible role for biology • The impact of biological processes on somatoform disorders can be understood through research on placebos and the placebo effect • Placebos: substances with no known medicinal value • Treatment with placebos has been shown to bring improvement to many – possibly through the power of suggestion but likely because expectation triggers the release of endogenous chemicals • Perhaps traumatic events and related concerns or needs can also trigger our “inner pharmacies” and set in motion the bodily symptoms of hysterical somatoform disorders Comer, Abnormal Psychology,8e DSM-5 Update

34. How Are Conversion and Somatic Symptom Disorders Treated? • People with these disorders usually seek psychotherapy only as a last resort Comer, Abnormal Psychology,8e DSM-5 Update

35. How Are Conversion and Somatic Symptom Disorders Treated? • Many therapists focus on the causes of the disorders and apply techniques including: • Insight – often psychodynamically oriented • Exposure – client thinks about traumatic event(s) that triggered the physical symptoms • Drug therapy – especially antidepressant medication Comer, Abnormal Psychology,8e DSM-5 Update

36. How Are Conversion and Somatic Symptom Disorders Treated? • Other therapists try to address the physical symptoms of these disorders, applying techniques such as: • Suggestion – usually an offering of emotional support that may include hypnosis • Reinforcement – a behavioral attempt to change reward structures • Confrontation – an overt attempt to force patients out of the sick role • Researchers have not fully evaluated the effects of these particular approaches on these disorders Comer, Abnormal Psychology,8e DSM-5 Update

37. Illness Anxiety Disorder • People with illness anxiety disorder, previously known as hypochondriasis, experience chronic anxiety about their health and are concerned that they are developing a serious medical illness, despite the absence of somatic symptoms Comer, Abnormal Psychology,8e DSM-5 Update

38. Illness Anxiety Disorder • They repeatedly check their bodies for signs of illness and misinterpret bodily symptoms as signs of a serious illness • Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or sweating • Although some patients recognize that their concerns are excessive, many do not Comer, Abnormal Psychology,8e DSM-5 Update

39. Illness Anxiety Disorder • Although this disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers • Between 1% and 5% of all people experience the disorder • For most patients, symptoms rise and fall over the years Comer, Abnormal Psychology,8e DSM-5 Update

40. Illness Anxiety Disorder • Theorists explain this disorder much as they explain various anxiety disorders: • Behaviorists: classical conditioning or modeling • Cognitive theorists: oversensitivity to bodily cues Comer, Abnormal Psychology,8e DSM-5 Update

41. Illness Anxiety Disorder Comer, Abnormal Psychology,8e DSM-5 Update • Individuals with illness anxiety disorder typically receive the kinds of treatments applied to OCD: • Antidepressant medication • Exposure and response prevention (ERP) • Cognitive-behavioral therapies

42. Body Dysmorphic Disorder Comer, Abnormal Psychology,8e DSM-5 Update • People with this disorder, also known as dysmorphobia, become deeply concerned about some imagined or minor defect in their appearance • Most often they focus on wrinkles, spots, facial hair, swelling, or misshapen facial features (nose, jaw, or eyebrows)

43. Body Dysmorphic Disorder Comer, Abnormal Psychology,8e DSM-5 Update • As many as half of people with this disorder seek plastic surgery or dermatology treatment, and often they feel worse rather than better afterward • Most cases of the disorder begin in adolescence but are often not revealed until adulthood • Up to 5 percent of people in the United States experience BDD, and it appears to be equally common among women and men

44. Body Dysmorphic Disorder Comer, Abnormal Psychology,8e DSM-5 Update Theorists typically account for BDD by using the same kinds of explanations – both physical and psychological – that have been applied to anxiety disorders and OCD Similarly, clinicians typically treat clients with this disorder by applying the kinds of treatment used with OCD, particularly anti-depressant drugs, exposure and response prevention, and cognitive therapy

45. Dissociative Disorders • The key to our identity – the sense of who we are and where we fit in our environment – is memory • Our recall of past experiences helps us to react to present events and guides us in making decisions about the future • People sometimes experience a major disruption of their memory Comer, Abnormal Psychology,8e DSM-5 Update

46. Dissociative Disorders • When such changes in memory lack a clear physical cause, they are called “dissociative” disorders • In such disorders, one part of the person’s memory typically seems to be dissociated, or separated, from the rest Comer, Abnormal Psychology,8e DSM-5 Update

47. Dissociative Disorders • There are several kinds of dissociative disorders, including: • Dissociative amnesia • Dissociative identity disorder (multiple personality disorder) • Depersonalization-derealization disorder • These disorders are often memorably portrayed in books, movies, and television programs Comer, Abnormal Psychology,8e DSM-5 Update

48. Dissociative Amnesia • People with dissociative amnesia are unable to recall important information, usually of an upsetting nature, about their lives • The loss of memory is much more extensive than normal forgetting and is not caused by physical factors • Often an episode of amnesia is directly triggered by a specific upsetting event Comer, Abnormal Psychology,8e DSM-5 Update

49. Dissociative Amnesia • Dissociative amnesia may be: • Localized – most common type; loss of all memory of events occurring within a limited period • Selective – loss of memory for some, but not all, events occurring within a period • Generalized – loss of memory beginning with an event, but extending back in time; may lose sense of identity; may fail to recognize family and friends • Continuous – forgetting continues into the future; quite rare in cases of dissociative amnesia Comer, Abnormal Psychology,8e DSM-5 Update

50. Dissociative Amnesia • All forms of the disorder are similar in that the amnesia interferes mostly with a person’ • Memory for abstract or encyclopedic information – usually remains intact • Clinicians do not known how common dissociative amnesia is, but many cases seem to begin serious threats to health and safety Comer, Abnormal Psychology,8e DSM-5 Update