Chapter 6 Somatoform and Dissociative Disorders

An Overview of Somatoform Disorders Soma = Body Preoccupation with health or appearance Physical complaints No identifiable medical condition Technology Tip: The following website offers several pages, informational handouts and links to resources on somatoform disorders: http://www.psychnet-uk.com/clinical_psychology/clinical_psychology_somatoform1_conversion_disorder_bodydysmorphic.htm

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

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 Contrast this with illness phobia and the fear of developing a disease. Technology Tip: The University of Maryland Medical Center website offers more information on hypochondriasis: http://www.umm.edu/altmed/articles/hypochondriasis-000089.htm Technology Tip: The Bio-Behavioral Institute website offers more information on hypochondriasis: www.bio-behavioral.com/hypochondriasis.asp

Hypochondriasis: An Overview Clinical Description (cont.) Little benefit from medical reassurance Strong disease conviction Misperceptions of symptoms Checking behaviors High trait anxiety Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Understanding Hypochondriasis.

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 Panic Disorder is marked by a focus on immediate consequences of symptoms, a decline in worry between attacks, and a decrease in treatment seeking once the individual is educated about the disorder.

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

Culture-Specific Syndromes China – koro India – dhat Africa Pakistan Hypochondriasis Culture-Specific Syndromes China – koro India – dhat Africa Pakistan Koro – genitals retracting into the abdomen, does affect some females as well Dhat- concern about losing semen, symptoms include dizziness, weakness, fatigue Africa – crawling sensation or heat in the head Pakistan – burning sensation in hands or feet

Disorder of cognition or perception Physical signs and sensations Hypochondriasis Causes Disorder of cognition or perception Physical signs and sensations Figure 6.1 Integrative model of causes in hypochondriasis (based on Warwick & Salkovskis, 1990).

Familial history of illness Genetics Modeling/learning Other factors Hypochondriasis Causes Familial history of illness Genetics Modeling/learning Other factors Stressful life events High family disease incidence “Benefits” of illness Discussion Tip: Have students discuss the current state of the art in terms of diagnosis and ability to detect medical problems. How might one’s access to medical providers shape perceptions of illness? Confidence in diagnosis?

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

Hypochondriasis - Treatment Cognitive-Behavioral Identify and challenge misinterpretations “Symptom creation” Stress-reduction Best efficacy data Vs. medications (SSRI) Immediate and 1 year follow-up “Symptom creation” refers to demonstrating how intensity of symptoms changes when they’re attended to, or produced if focused on.

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

Somatization Disorder Statistics Rare 4.4%; 16.6% in medical settings Onset = adolescence Female : male = ~2:1 Unmarried, low SES Chronic course Somatization disorder is rare, and prevalence rates range from 4.4% (in a large city) to 20% of a large sample of primary care patients.

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 Links with ASPD- neurobiology may be the same or similar, but the manifestations are different via socialization and gender roles, which result in more dependence and somatization for females. In essence, persons with these disorders may possess a weak behavioral inhibition system (BIS) that does not control the behavioral activation system (BAS). The BAS is a brain system that underlies impulsivity, thrill-seeking behavior, and excitability, whereas the BIS is involved in sensitivity to threat or danger and avoidance of situations or cues suggesting that threat or danger is imminent. Many behaviors and traits associated with somatization disorder also seem to reflect short-term gain (i.e., active BAS) and insensitivity for long-term problems (i.e., weak BIS).

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

Somatization Disorder: Treatment “Gatekeeper” physician Reduce visits to numerous specialists Conditioning Reward positive health behaviors Punish problem behaviors Remove supportive consequences Relationship with the gatekeeper physician has to be positive and supportive.

Physical malfunctioning sensory-motor areas 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 “La belle indifference” indifferent attitude that may or may not be present in people with CD. May also be present in those with actual medical disorders. Teaching Tip: The movie Talladega Nights: The Story of Ricky Bobby with Will Farrell has a scene depicting “paralysis” after a car crash.

Conversion Disorder : Differential Diagnosis Malingering Intentionally produced symptoms Clear benefit No precipitating stressful event Impaired function Factitious Disorder/Munchausen’s No obvious benefit Sick role? Technology Tip: Munchausen Syndrome and Factitious Disorders An interesting starting point for the exploration of Munchausen syndrome and factitious disorders. http://ourworld.compuserve.com/homepages/Marc_Feldman_2/ Technology Tip: Child Abuse: Statistics, Research, and Resources A good resource for current research and informational links related to child abuse. http://www.jimhopper.com/abstats/

Prevalence depends on setting Female > male Onset = adolescence Conversion Disorder Statistics Rare Prevalence depends on setting Female > male Onset = adolescence Chronic, intermittent course Conversion disorders are rare, and prevalence estimates in neurological settings range from 1 to 30%, whereas in epilepsy setting the range is between 10 and 20% of cases.

Cultural considerations Religious experiences Rituals Conversion Disorder Special populations Soldiers Children Better prognosis? Cultural considerations Religious experiences Rituals Conversion reactions are not uncommon in soldiers exposed to combat. Symptoms often disappear, but return later in the same or similar form when a new stressor occurs. Conversion symptoms are common in some cultural and rural fundamental religious groups. However, the symptoms would not meet criteria for a disorder unless they persist and interfere with life functioning.

Conversion Disorder: Causes Freudian psychodynamic view Trauma, conflict experience Repression “Conversion” to physical symptoms Primary gain Attention and support Secondary gain Primary Gain: reduction of anxiety through more acceptable means Secondary Gain: attention from others, reduction in responsibilities Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: When Have I Assumed the Sick Role?

Conversion Disorder: Causes Behavioral Traumatic event must be escaped Avoidance is not an option Social acceptability of illness Negative reinforcement Guide students through the psychodynamic and behavioral views to show the similarities between the two models.

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

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

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

Combined medical and psychological Pain Disorder Statistics Fairly common 5% - 12% Treatment Combined medical and psychological See chapter 9 for a more detailed discussion of pain disorders and health psychology

Body Dysmorphic Disorder Clinical Description Preoccupation with imagined defect in appearance Impaired function Social Occupational Technology Tip: Visit the Mayo Clinic website for more information on BDD: http://www.mayoclinic.com/health/body-dysmorphic-disorder/DS00559 Technology Tip: Visit the Los Angeles BDD Clinic website for more information on BDD: http://www.bddclinic.com/

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? Delusional disorder: somatic type will likely drop out of the DSM V, given the lack of difference between those with delusional and non-delusional BDD.

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

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

Body Dysmorphic Disorder: Treatment Similar to OCD Medications (SSRIs) Exposure and response prevention Plastic surgery is often unhelpful As many as 25% of persons requesting plastic surgery meet criteria for BDD. Those with BDD do not benefit from plastic surgery, and preoccupation with imagined ugliness may actually increase following plastic surgery.

An Overview of Dissociative Disorders Severe alterations or detachments Normal perceptual experiences Significant impairments Identity Memory Consciousness Depersonalization Derealization Depersonalization – Distortion in perception of reality Derealization – Losing a sense of the external world Technology Tip: American Society for Clinical Hypnosis A good resource for research relevant to altered states of consciousness. http://www.hypnosis-research.org/hypnosis/ Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Invited Hypnotist or Pain Specialist.

An Overview of Dissociative Disorders Types Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Trance Disorder Dissociative Identity Disorder Technology Tip: The following site offers information and connections to other web sites related to dissociative disorders. http://psyweb.com/Mdisord/jsp/dissd.jsp Technology Tip: International Society for the Study of Dissociation Offers information about diagnosis and treatment of dissociative disorders. http://www.issd.org/ Technology Tip: Also visit the Mayo Clinic site on dissociative disorders: http://www.mayoclinic.com/health/dissociative-disorders/DS00574/DSECTION=2

Depersonalization Disorder: An Overview Clinical Description Feelings of unreality and detachment Severe/frightening Depersonalization Derealization Significant impairment Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: "Normal" Dissociations

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

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

Depersonalization Disorder: Treatment Psychological treatments are unstudied Prozac appears ineffective

Psychogenic memory loss Generalized type Localized or selective type Dissociative Amnesia Dissociative Amnesia Psychogenic memory loss Generalized type Localized or selective type Generalized type – Inability to recall anything, including their identity Localized or selective type – Failure to recall specific (usually traumatic) events Teaching Tip: Have students participate in the following activity from the Instructor Resource Manual: Video Activity: Abnormal Psychology, Inside/Out, Vol. 2.

Retrograde vs. anterograde “How’s” or “why’s” of travel Dissociative Fugue Dissociative Fugue: Flight or travel Memory loss Retrograde vs. anterograde “How’s” or “why’s” of travel Assumption of new identity Generalized type – Inability to recall anything, including their identity Localized or selective type – Failure to recall specific (usually traumatic) events

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

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

Dissociative Trance Disorder Clinical Description Dissociative symptoms Sudden personality changes State is undesirable Cultural/religious variations Technology Tip: Check out the following site for a case study of DTD: http://ejm.yyu.edu.tr/old/99-2/83.pdf

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

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 Alters – The different identities Host – The identity that keeps other identities together Switch – Quick transition from one personality to another Technology Tip: Dr. Paul McHugh of Johns Hopkins discusses Multiple Personality Disorder also known as Dissociative Identity Disorder:http://www.psycom.net/mchugh.html

Demand characteristics Physiological measures Eye movements GSR EEG Can DID be Faked? Real vs. false memories Suggestibility Hypnosis studies Simulated amnesia Demand characteristics Physiological measures Eye movements GSR EEG Technology Tip: Recovered Memories of Sexual Abuse A useful scholarly source of information and links related to recovered memories of sexual abuse. http://www.jimhopper.com/memory/

Dissociative Identity Disorder (DID) Statistics 1.5% (year) Female : male = 9:1 Onset = childhood High comorbidity rates Axis I Axis II Lifelong, chronic course Axis I Anxiety, substance abuse, depression Axis II Borderline personality disorder

Biological vulnerability Reactivity Hippocampus and amygdala DID: Causes Causes Biological vulnerability Reactivity Hippocampus and amygdala Severe abuse/trauma history Links with PTSD Highly suggestible Auto hypnotic model Teaching Tip: The movies Sybil and The Three Faces of Eve provide depictions of DID.

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

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