1. Chapter 6 Somatoform and Dissociative Disorders

2. 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:

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

4. 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:
Technology Tip: The Bio-Behavioral Institute website offers more information on hypochondriasis:

5. 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.

6. 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.

7. 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

8. 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

9. 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).

10. 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?

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

12. 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.

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

14. 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.

15. 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).

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

17. 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.

18. 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.

19. 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.
Technology Tip: Child Abuse: Statistics, Research, and Resources A good resource for current research and informational links related to child abuse.

20. 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.

21. 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.

22. 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?

23. 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.

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

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

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

27. 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

28. 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:
Technology Tip: Visit the Los Angeles BDD Clinic website for more information on BDD:

29. 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.

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

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

32. 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.

33. 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.
Teaching Tip: Have students participate in the following Instructor Resource Manual Activity: Invited Hypnotist or Pain Specialist.

34. 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.
Technology Tip: International Society for the Study of Dissociation Offers information about diagnosis and treatment of dissociative disorders.
Technology Tip: Also visit the Mayo Clinic site on dissociative disorders:

35. 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

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

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

38. Depersonalization Disorder: Treatment
Psychological treatments are unstudied
Prozac appears ineffective

39. 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.

40. 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

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

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

43. 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:

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

45. 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:

46. 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.

47. 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

48. 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.

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

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