Chapter 8
Chapter 7
Somatoform and Dissociative Disorders
Alice Cheng, Ph.D.
University of Hartford
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Somatoform Disorders
The somatoform disorders are a group of conditions
that involve physical symptoms and complaints suggesting the presence of a medical condition
without any evidence of physical pathology to account for them
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Somatoform Disorders
The word somatoform derives from the Greek soma, meaning “body.”
Somatoform disorders - A disorder characterized by complaints of physical problems or symptoms that cannot be explained by physical causes.
The concept of somatoform disorder presumes that the physical symptoms reflect psychological factors or conflicts.
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Somatoform Disorders
Somatoform disorders follow one of five more or less distinct patterns
Conversion disorde
Hypochondriasis
Body dysmorphic disorde
Somatization disorde
Pain disorde
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Overview of Somatoform Disorders
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Somatoform Disorders
Malingering - Faking illness in order to avoid work or duty.
Factitious disorder - A disorder characterized by intentional fa
ication of psychological or physical symptoms for no apparent gain.
Münchausen syndrome - A type of factitious disorder characterized by the fa
ication of medical symptoms.
Münchausen syndrome by proxy
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Hypochondriasis
Hypochondriasis - A somatoform disorder characterized by misinterpretation of physical symptoms as signs of underlying serious disease.
The fear persists despite medical reassurances that it is groundless.
Hypochondriasis is believed to affect about 1% to 5% of the general population and about 5% of patients seeking medical care (APA, 2000; Barksy & Ahern, 2004).
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Somatoform Disorders
People with hypochondriasis are preoccupied with fears of getting a serious disease or the idea that they already have one
Cognitive-behavioral views of hypochondriasis are most widely accepted
Cognitive-behavioral therapy can be a very effective treatment
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Somatization Disorde
Somatization disorder - A somatoform disorder characterized by repeated multiple complaints that cannot be explained by physical causes.
These complaints persist for at least several years, and result either in the seeking of medical attention or in significant impairment in fulfilling social or occupational roles.
Reported rates of somatization disorder vary from 0.2% to 2% in women to less than 0.2% in men (APA, 2000).
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Somatoform Disorders
Somatization disorder is characterized by many different complaints of physical ailments
over several years beginning before age thirty
that are not adequately explained by independent findings of physical illness or injury
that lead to medical treatment or to significant life impairment
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Somatoform Disorders
In addition to the requirement of multiple physical complaints, DSM-IV-TR lists four other symptom criteria needed for a diagnosis of somatization disorder can be made:
Four pain symptoms
Two gastrointestinal symptoms
One sexual symptom
One pseudoneurological symptom
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Somatoform Disorders
Somatization disorde
usually starts in adolescence
is about ten times more common in women
often occurs with other disorders such as major depression or panic disorde
There may be a genetic predisposition to the disorde
Other contributory causal factors may include personality, cognitive, and learning variables
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Somatoform Disorders
Somatization disorder is extremely difficult to treat
A combination of medical management and cognitive-behavioral therapy may be helpful
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Somatoform Disorders
Pain disorder is characterized by the experience of persistent and severe in one or more areas of the body
The symptoms of pain disorder resemble the pain symptoms of somatization disorder, but with pain disorder, the other symptoms are not present
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Pain Disorde
Pain disorder - A somatoform disorder in which psychological factors are presumed to play a significant role in the development, severity, or course of chronic pain.
The psychological factors may contribute to the development, severity, or maintenance of the pain.
The pain is severe enough and persistent enough to interfere with the person’s daily functioning.
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Somatoform Disorders
DSM-IV-TR specifies two coded subtypes of pain disorder:
Pain disorder associated with psychological factors
Pain disorder associated with both psychological factors and a general medical condition
Cognitive-behavioral techniques are widely used in the treatment of both subtypes of pain disorde
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Somatoform Disorders
Conversion disorder involves a pattern in which symptoms or deficits affecting sensory or voluntary motor functions lead one to think a patient has a medical condition
Freud believed that the symptoms were an expression of repressed sexual energy
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Somatoform Disorders
In contemporary terms, the primary gain for conversion symptoms is continued escape or avoidance of a stressful situation
Secondary gains include attention and financial compensation
Conversion disorders are no longer as prevalent as they once were
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Somatoform Disorders
The symptoms of conversion disorder fall under one of the following four categories:
sensory symptoms or deficits
motor symptoms or deficits
seizures
mixed presentation from the first three categories
It is important that patients receive a thorough medical and neurological examination to rule out organic illness
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Somatoform Disorders
Conversion disorders are considered distinct from malingering disorder or factitious disorder in which a person intentionally produces or grossly exaggerates physical symptoms
Knowledge of how best to treat conversion disorder is extremely limited
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Conversion Disorde
Conversion disorder - A somatoform disorder characterized by loss or impairment of physical function in the absence of any apparent organic cause.
The person is not malingering. The physical symptoms usually come on suddenly in stressful situations.
A soldier’s hand may become “paralyzed” during intense combat, for example.
The fact that conversion symptoms first appear in the context of, or are aggravated by, conflicts or stressors suggest a psychological connection (APA, 2000).
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Body Dysmorphic Disorde
Body dysmorphic disorder (BDD) - A somatoform disorder characterized by preoccupation with an imagined or exaggerated physical defect of appearance.
They may spend hours examining themselves in the mi
or and go to extreme measures to co
ect the perceived defect, even undergoing invasive or unpleasant medical procedures, including unnecessary plastic surgery (Crerand et al., 2005).
Others remove all mi
ors from their homes so as not to be eminded of the glaring flaw in their appearance.
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Somatoform Disorders
People with body dysmorphic disorder are obsessed with some perceived or imagined flaws in their appearance
Perhaps 1 to 2 percent of the general population suffers from the disorde
People with the disorder commonly have a depressive diagnosis
Many researchers believe BDD is closely related to OCD and eating disorders
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Percentage of People with BDD Who Experienced a Problem due to BDD
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20
40
60
80
100
99
Interference with social functioning
95
Periods of avoidance of nearly all social interactions
90
Interference with work or academic functioning
80
Periods of complete avoidance of work, school, etc.
29
Housebound for at least one week
94
Felt depressed
26
Psychiatrically hospitalized at least once
63
Thought about suicide
14
Attempted suicide
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Psychodynamic Theory
According to psychodynamic theory, hysterical symptoms are functional:
They allow the person to achieve primary gains and secondary gains.
The primary gain of the symptoms is to allow the individual to keep internal conflicts repressed.
Secondary gains from the symptoms are those that allow the individual to avoid burdensome responsibilities and to gain the support—rather than condemnation—of those around them.
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Treatment of Somatoform Disorders
The treatment approach that Freud pioneered, psychoanalysis, began with the treatment of hysteria, which is now termed conversion disorder.
Psychoanalysis seeks to uncover and
ing unconscious conflicts that originated in childhood into conscious awareness.
Once the conflict is aired and worked through, the symptom is no longer needed and should disappear.
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Learning Theory
Learning theorists focus on the more direct reinforcing properties of the symptom and its secondary role in helping the individual avoid or escape anxiety-evoking situations.
From the learning perspective, the symptoms in conversion and other somatoform disorders may also ca
y the benefits, or reinforcing properties, of the “sick role.”
Some learning theorists link hypochondriasis and body dysmorphic disorder to obsessive–compulsive disorder.
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Conceptual models of conversion disorder.
Psychodynamic and learning theory offer conceptual models of conversion disorder that emphasize the role of conversion symptoms leading to escape or relief from anxiety.
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Cognitive Theory
Cognitive theorists have speculated that some cases of hypochondriasis may represent a type of self-handicapping strategy, a way of blaming poor performance on failing health (Smith, Snyder, & Perkins, 1983).
Cognitive theorists speculate that hypochondriasis and panic disorder, which often occur together, may share a common cause: a distorted way of thinking that leads the person to misinterpret minor changes in bodily sensations as signs of pending catastrophe (Salkovskis & Clark, 1993)
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Somatoform Disorders
Treatments include
Antidepressant medications
Cognitive-behavioral treatment focused on exposure and response prevention
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Dissociative Disorders
Dissociative disorder - A disorder characterized by disruption, or dissociation, of identity, memory, or consciousness.
The major dissociative disorders include dissociative identity disorder, dissociative amnesia, dissociative fugue, and depersonalization disorder.
In each case, there is a disruption or dissociation (“splitting off ”) of the functions of identity, memory, or consciousness that normally make us whole.
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Dissociative Disorders
The dissociative disorders are a group of conditions involving disruptions in a person’s normally integrated functions of
consciousness
memory
identity
perception
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Overview of Dissociative Disorders
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Dissociative Disorders
In derealization one’s sense of the reality of the outside world is temporarily lost
In depersonalization one’s sense of one’s self and one’s reality is temporarily lost
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Depersonalization Disorde
Depersonalization - Feelings of unreality or detachment from one’s self or one’s body.
Derealization - A sense of unreality about the outside world.
Depersonalization disorder - A disorder characterized by persistent or recu
ent episodes of depersonalization.
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Dissociative Disorders
Dissociative amnesia involves a failure to recall previously stored personal information when that failure cannot be accounted for by ordinary forgetting
In a dissociative fugue the person also departs from home su
oundings
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Dissociative Amnesia
Amnesia derives from the Greek roots a-, meaning “not,” and mnasthai, meaning “to remember.”
Dissociative amnesia - A dissociative disorder in which a person experiences memory loss without any identifiable organic cause.
Unlike some progressive forms of memory impairment, the memory loss in dissociative amnesia is reversible, although it may last for days, weeks, or even years.
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“Jane Doe.”
This woman, called “Jane Doe” by rescue workers, was found wandering in a Florida park in a dazed state. She reported she had no memory of her background or even who she was. Her parents recognized her after she appeared on a national TV program. She reportedly never regained her memory.
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Dissociative Amnesia
Dissociative amnesia is divided into five distinct types of memory problems:
Localized amnesia.
Selective amnesia.
Generalized amnesia.
Continuous amnesia.
Systematized amnesia.
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Dissociative Fugue
Fugue derives from the Latin fugere, meaning “flight.” The word fugitive has the same origin.
Fugue is like amnesia “on the run.”
Dissociative fugue - A dissociative disorder in which one suddenly flees from one’s life situation, travels to a new location, assumes a new identity, and has amnesia for personal material.
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Dissociative Disorders
Dissociative identity disorder is a dramatic dissociative disorder in which a patient manifests two or more distinct identities or personality states that alternate in some way in taking control of behavio
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Dissociative Disorders
Dissociative identity disorder - A dissociative disorder in which a person has two or more distinct, or alter