Transcript abnormal PSYCHOLOGY Third Canadian Edition

abnormal
PSYCHOLOGY
Fourth Canadian Edition
Chapter 7
Somatoform and
Dissociative Disorders
Prepared by:
Tracy Vaillancourt, Ph.D.
Modified by: Réjeanne Dupuis, M.A.
Definitions
• Somatoform disorders— individual complains of
bodily symptoms that suggest a physical defect
or dysfunction but for which no physiological
basis can be found; Psychological problems take
a physical form
• Dissociative disorders— individual experiences
disruptions of consciousness, memory, and
identity
– Onset of both classes of disorders assumed to be
related to stressful experience
– Two classes sometimes co-occur
Summary: Table 7.1
Disorder
Description
Pain disorder
Psychological factors play a significant role in the onset
and maintenance of pain.
Body dysmorphic disorder
Preoccupation with imagined or exaggerated defects in
physical appearance.
Hypochondriasis
Preoccupation with fears of having a
serious illness.
Conversion Disorder
Sensory or motor symptoms without any physiological
cause.
Somatization
Recurrent, multiple physical complaints that have no
biological basis.
Pain Disorder
• Person experiences pain that causes significant
distress and impairment
• Psychological factors are viewed as playing an
important role in the onset, maintenance, and
severity of the pain
• In women diagnosed with pain disorder
(compared to healthy women), fMRI showed
significant grey-matter decreases in prefrontal,
cingulated, and insular cortex, regions of the
brain, which are critically involved in the
modulation of subjective pain
Body Dysmorphic Disorder
• Person is preoccupied with an imagined or
exaggerated defect in appearance, frequently in
the face
– Examples: facial wrinkles, excess facial hair, or the
shape or size of the nose.
• Women tend to focus on the skin, hips, breasts, and legs
• Men tend to focus on height, penis size, and body hair
– Occurs mostly among women
– Typically begins in late adolescence
– Comorbid with depression, social phobia, eating
disorders, thoughts of suicide, substance use, and
personality disorders
Hypochondriasis
• Individuals are preoccupied with persistent fears
of having a serious disease, despite medical
reassurance to the contrary
– Typically begins in early adulthood and has a chronic
course.
– Comorbid with mood or anxiety disorders
– Prevalence rate is 5% of the general population
– The term ‘hypochondriasis’ has become pejorative
and tends to be called ‘health anxiety disorder’
Hypochondriasis (cont.)
• Theory
– Hypochondriacs overreact to and misinterpret
ordinary physical sensations and minor
abnormalities and see these as evidence for
their beliefs
– Contemporary researchers focus on ‘health
anxiety’ and not hypochondriasis
Health Anxiety
• Health anxiety has been defined as “health-related fears
and beliefs, based on interpretations, or perhaps more
often, misinterpretations, of bodily signs and symptoms
as being indicative of serious illness” (Asmundson,
Taylor, Sevgur, & Cox, 2001, p. 4)
• Often measured with the Illness Anxiety Scale (IAS),
which contains 4 factors
• Health Anxiety could be present in both hypochondriasis
and an illness phobia
– Hypochondriasis = fear of having an illness
– Illness phobia = fear of contracting an illness
Salkovskis and Warwick (2001)
Health Anxiety Model
1. A critical precipitating
incident
2. A previous experience
of illness and related
medical factors
3. The presence of
inflexible or negative
cognitive assumptions
4. The severity of anxiety
Conversion Disorder
• Physically healthy people experience sensory or motor
symptoms suggesting an illness related to neurological
damage of some sort, although the body organs and nervous
system are found to be fine.
• Examples:
–
–
–
–
–
–
–
–
Sudden loss of vision
Paralysis of arms or legs
Seizures and coordination disturbances
Sensation of prickling, tingling, or creeping on the skin
Insensitivity to pain
Anesthesias (loss or impairment of sensations)
Aphonia (loss of the voice and all but whispered speech)
Anosmia (loss or impairment of the sense of smell)
• Tends to appear suddenly in stressful situations
Hysteria
• Term originally used to describe what are now
known as conversion disorders
Malingering and Factitious
Disorder
• Conversion disorder is difficult to distinguish
from malingering
– Faking an incapacity in order to avoid a responsibility
• Conversion reactions or malingering?
– La belle indifférence can help differentiate the two
– Characterized by a relative lack of concern or a blasé
attitude toward the symptoms
– Found with conversion disorder
Somatization Disorder
• Recurrent, multiple somatic complaints, with no
apparent physical cause, for which medical
attention is sought
• Prevalence is less than 1%
• Symptoms are more pervasive than in
hypochondriasis and usually cause impairment
• Considerable overlap with conversion disorder
• Comorbid with anxiety and mood disorders,
substance abuse, & several personality disorders
• Specific symptoms may vary across cultures
Etiology of
Somatoform Disorders
Somatization Disorder
– More sensitive to physical sensations, over-attend to
them, or interpret them catastrophically
– May have a memory bias for information that
connotes physical threat
– Unrealistic anxiety about bodily systems
– Patients with somatization disorder have high levels
of cortisol
Theories of Conversion Disorders
• Psychoanalytic Theory
– Freud: Unresolved Electra Complex
– Psychodynamic: 2-stage defensive reaction
• Behavioural Theory and Cognitive Factors
– Similar to malingering in that the person adopts the
symptom to secure some end
• Social and Cultural Factors
–  in the incidence of conversion disorder over the
last century
– Conversion disorder is  among people with lower
socio-economic status and from rural areas
Theories (cont.)
• Biological Factors in Conversion Disorder
– Evidence is weak
– May be some relationship between brain
structure and conversion disorder
• Conversion symptoms are more likely to occur on
the left side than on the right side of the body
• Biopsychosocial Model
– Takes into account triggering, perpetuating,
and risk factors
Therapies for
Somatoform Disorders
• Little controlled research on treatment
because somatoform disorders are rarer
than other disorders
– Although they so tend to seek more medical
treatment than people with other disorders
• Comorbid with anxiety and depression
– See treatment sections for these disorders
• Cognitive-behavioural approaches
Dissociative Disorders
Dissociative Amnesia
• Person unable to recall important personal information,
usually after some stressful episode.
– Information not permanently lost, but cannot be retrieved
during the episode of amnesia
– Most often memory loss involves all events during a limited
period of time
• Total amnesia
– Patient does not recognize relatives and friends, but retains
the ability to talk, read, and reason
– Retains talents and previously acquired knowledge
• Amnesic episode may last several hours or as long as
several years.
– Usually disappears as suddenly as onset
Dissociative Fugue
• Memory loss more extensive in dissociative
fugue than in dissociative amnesia.
– Person becomes totally amnesic and
suddenly leaves home and work and
assumes a new identity.
• Fugues typically occur after a person has
experienced some severe stress
Depersonalization Disorder
• Person’s perception or experience of the self is
disconcertingly and disruptively altered
– Unusual sensory experiences
– Impression that they are outside their bodies
– May feel mechanical
• Typically triggered by stress
• Usually begins in adolescence and has a chronic course
• Comorbid with personality disorders, anxiety disorders,
and depression
• Note. Inclusion in DSM-IV-TR is controversial because
unlike other dissociative disorders it does not involves
disturbance of memory
Dissociative Identity Disorder
(DID)
• Diagnosis requires that a person have at least two
separate ego states (called alters) that exist
independently of each other and that come forth and
are in control at different times
– Usually one primary personality and two to four alters at
time of diagnosis
– Treatment sought by the primary alter
– Gaps in memory occur in all cases
– Existence of alters must be long-lasting and cause
considerable disruption in one’s life
– Often accompanied by headaches, substance abuse,
phobias, hallucinations, suicide attempts, sexual
dysfunction, and self-abusive behaviour and other
dissociative symptoms such as amnesia and
depersonalization
DID (cont.)
• Presumably begins in childhood, but rarely
diagnosed until adulthood
• More common in women than in men
• Comorbid with depression, borderline
personality disorder, and somatization disorder
– In one study 90% had a history of suicidal tendencies,
depression, recurring headaches, and sexual abuse
– Another study is suspecting poor attachment due to
exposure of frightening or chaotic behaviour from
caregiver
• Diagnosis of DID is a very controversial
Etiology of DID
Etiology of DID
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Psychoanalytic & behavioural perspectives:
Dissociation as an avoidance response that protects
the person from stressful events and memories of
these events
2 major theories
1. Result of severe physical or sexual abuse
2. Enactment of learned social roles
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Therapies
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Psychoanalytic treatment
See treatment for PTSD
Treatments of
Dissociative Disorders
• Psychoanalytic Treatment
– Goal: to lift repression of traumatic events
• Treatments for PTSD applied to
dissociative disorders
• Treatment of DID
– Hypnosis used for ‘age regression’
– Goal: integration of the several personalities
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