Transcript abnormal PSYCHOLOGY Third Canadian Edition

Chapter 7
Somatic Symptoms Disorders
And Dissociative Disorders
Somatic Symptom and Related
Disorders
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Previously called Somatoform Disorders
(DSM-IV-TR)
DSM-IV-TR definitions:
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overemphasized that bodily symptoms are medically
unexplained
reinforced mind-body dualism
DSM-5 definitions:
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emphasize distress that accompanies or is in
response to the bodily concerns
Overview: DSM-IV-TR Somatoform
Disorders
DSM-IV-TR Disorder
Description
Pain disorder*
*term no longer in DSM-5
Psychological factors play a significant role in the onset
and maintenance of pain.
Body dysmorphic disorder*
*DSM-5 OCD condition
Preoccupation with imagined or exaggerated defects in
physical appearance.
Hypochondriasis*
*term no longer in DSM-5
Preoccupation with fears of having a
serious illness
Conversion Disorder*
*now also called Functional
Neurological Symptom
Disorder (DSM-5)
Sensory or motor symptoms without any physiological
cause.
Somatization*
*term no longer in DSM-5
Recurrent, multiple physical complaints that have no
biological basis.
Pain Disorder (DSM-IV-TR)
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No longer diagnosed in DSM-5
Psychological factors are viewed as playing an
important role in the onset, maintenance, and severity
of the pain
Most likely now diagnosed with somatic symptom
disorder with predominant pain
Body Dysmorphic Disorder (BDD)
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DSM-5 includes BDD as an OCD condition
preoccupation with an imagined or exaggerated defect
in appearance, frequently in the face
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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
Hypochondriasis (DSM-IV-TR)
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begins in early adulthood and has a chronic
course
when bodily concerns are present, diagnosed in
DSM-5 as: somatic symptom disorder
When bodily symptoms are not present but
person is preoccupied with persistent fears of
having a serious medical disease, then
diagnosed as: illness anxiety disorder
the term “hypochondriac” is pejorative, no
longer used
Illness (Health) Anxiety
• Cognitive factors are considered central
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“catastrophic” misinterpretations of bodily sensations
strong beliefs that unexplained bodily changes are always a sign
of serious illness
Cognitive Model of Health Anxiety
Four contributing factors:
1. Critical precipitating
incident
2. Previous experience of
illness and related
medical factors
3. Presence of inflexible
or negative cognitive
assumptions
4. Severity of anxiety
Conversion Disorder
• Also termed Functional Neurological Symptom Disorder
(DSM-5)
• Physically healthy people experience sensory or motor
symptoms suggesting a neurological illness (although the
body organs and nervous system are found to be fine).
• Examples:
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Paralysis of arms or legs
Seizures and coordination disturbances
Sensation of prickling, tingling, or creeping on the skin
Insensitivity to pain
• Anaesthesias (loss or impairment of sensations)
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Sudden loss or partial loss of vision (blindness or tunnel vision)
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
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Term originally used to describe what are now
known as conversion disorders
Conversion Disorder or Malingering?
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Difficult to distinguish
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Faking an incapacity in order to avoid a
responsibility is termed malingering
La belle indifférence
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Can help differentiate conversion disorder from
malingering
Characterized by a relative lack of concern or a
blasé attitude toward the symptoms
Diagnostic of conversion disorder not malingering
Factitious Disorder
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Intentionally produce symptoms (usually physical
such as pain) or cause self-injury
In contrast to malingering, the symptoms are less
obviously linked to some benefit or secondary gain
Somatization Disorder (DSM-IV-TR)
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Dropped from DSM-5
Mainly diagnosed now as somatic symptom disorder
Recurrent, multiple somatic complaints, with no apparent
physical cause, for which medical attention is sought
Prevalence is low in primary care - less than 1% (which
is one reason why DSM-5 changes were made)
Somatization Disorder (DSM-IV-TR)
(cont’d)
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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
Theories of Conversion Disorders
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Psychoanalytic Theory
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Specific symptoms related to traumatic events
Freud: Unresolved Electra Complex
Behavioural Theory and Cognitive Factors
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Similar to malingering in that the person adopts the
symptom for some additional benefit (secondary gain)
Social and Cultural Factors
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 incidence of conversion disorder in the last century
 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
• triggering events (ie abuse), perpetuating factors (ie life
stress), and risk factors (social class)
Therapies for Somatoform Disorders
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Little controlled research on psychological
treatments because somatoform disorders are
less commonly seen in psychological practices
than other conditions
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tend to undergo costly medical investigations and
medical treatments than other disorders
• Comorbid with anxiety and depression
• See treatment sections for these disorders
• Cognitive-behavioural approaches
Dissociative Disorders – DSM-5
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Characterized by disruptions of consciousness,
memory, and identity
Dissociative Amnesia – memory loss following a
stressful experience
Depersonalization/derealization disorder – altered
experience of the self
Dissociative Identity Disorder – at least two different
(alternative) ego states (alters)
Other Specified Dissociative Disorder
Dissociative Amnesia
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Person unable to recall important personal information,
usually after some stressful episode.
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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
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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.
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Usually disappears as suddenly as onset
Dissociative Fugue
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Previously (DSM-IV-TR) was considered a
category, now it is specific form of dissociative
amnesia.
Memory loss more extensive in dissociative fugue
than in dissociative amnesia.
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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
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Depersonalization/Derealization
Disorder
Person’s perception or experience of the self is
disconcertingly and disruptively altered
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Unusual sensory experiences
May have ‘out of body’
May feel mechanical (as if they or others are
‘robots’)
Typically triggered by stress
Usually begins in adolescence and has a chronic
course
Comorbid with personality disorders, anxiety
disorders, and depression
DSM-5 changed Depersonalization criteria to
include Derealization, which is a sense of
detachment from situational context
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Dissociative Identity Disorder (DID)
Diagnosis requires that a person have at least two
separate ego states (called ‘alters’) that exist
independently of each other
Alters emerge and are in control at different times
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Usually one primary ego state 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.)
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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
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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
DID Case example
Herschel Walker – Football star
Etiology of Dissociative Disorders
• Etiology of DID
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Psychoanalytic & behavioural perspectives:
Dissociation as an avoidance response that protects
the person from memories of traumatic experiences
2 major theories
• Result of severe physical or sexual abuse
• Enactment of learned social roles
Treatments of
Dissociative Disorders
• Psychoanalytic Treatment
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Goal: to lift repression of traumatic events
• Treatments for PTSD trauma applied to
dissociative disorders
• Treatment of DID
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Hypnosis used for ‘age regression’
Goal: integration of the several personalities
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