somatoform and dissociative disorders. somatoform disorders concerns with appearance or functioning...
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Somatoform and Dissociative Disorders
Somatoform Disorders
Concerns with appearance or functioning of body Absence of medical condition
1. Hypochondriasis
2. Somatization Disorder
3. Conversion Disorder
4. Pain Disorder
5. Body Dysmorphic Disorder
Hypochondriasis
Anxiety over belief one has a disease, without evident cause
Reassurance from doctors no help, in the long-term
Misinterpretation of bodily signals as disease Disorder realized after physician visits
Hypochondriasis - Statistics
Little information Prevalence estimate 3%
Equal in men and women, age groups
Causes of Hypochondriasis
Faulty thoughts/interpretation of physical signs (cognition)
Enhanced sensitivity to illness cues Increased awareness and fright
Family/genetic influences Might be unspecific anxiety Children report symptoms of parents
Causes of Hypochrondriasis
Context of stressful life events - often involving death or illness
Disproportionate incidence of disease in family
Social influence Attention paid to sick relatives
Treatment of Hypochrondriasis
Little information regarding treatment
Cognitive therapy Exposure to symptoms Decreased reassurance
seeking re: symptoms
Stress management program
Somatization Disorder
History of physical complaints, occurring over years
Result in treatment being sought or impairment
4 pain symptoms 2 GI symptoms
1 sexual symptom 1 pseudo-neurologic
symptom Not explained by
medical condition Complaints not
intentionally produced or feigned
Somatization Disorder - Statistics
Rare Continuum 20% estimated
prevalence in primary care settings
Adolescent age of onset
Causes and Treatment
History of family illness Few research studies Genetic link with Antisocial PD Difficult to treat
Conversion Disorder
Physical malfunctioning, suggesting neurological impairment, with no medical cause
E.g., blindness, paralysis Rare Causes - trauma Insight focused treatment, identifying trauma
Pain Disorder
True pain Psychological factors play role May have been original physical cause
Body Dysmorphic Disorder
Preoccupation with imagined defect in appearance
Suicidality common Focused on self and defect (similar to social
anxiety) Can significantly disrupt life
Body Dysmorphic Disorder - Statistics
Difficult to estimate prevalence Chronic course Often seek plastic surgery or other medical
attention 2% of plastic surgery patients?
Little information on cause Link with OCD
Conversion Disorder vs. Malingering
Conversion patients are indifferent to symptoms
Precipitated by stress - 52-93% cases Can function normally, but often unaware of
this ability or sensory input E.g., avoiding objects in visual field
Dissociative Disorders
What is Dissociation?
Derealization: Losing sense of reality of the external world
Common to some degree for everyone (a great example of dimensionality)
Dissociative Disorders
Incredibly puzzling category of mental disorder
Disruption of normal integration of: Consciousness Memory Perception
Separating from identity
Types of Dissociative Disorders
1. Depersonalization Disorder
2. Dissociative Amnesia
3. Dissociative Fugue
4. Dissociative Trance Disorder**
5. Dissociative Identity Disorder
1. Depersonalization Disorder
Feelings of detachment from self “living in a dream” or “going through the motions” Feeling of watching self Can include disconnection from body
Knows this is a feeling, does not believe Common with other disorders (up to 40%) Prevalence unknown Common reaction to stress/burnout
Treating Depersonalization Disorder
No controlled studies; lots of books Supportive + insight-oriented therapy
1. Recognize source2. Reconnect with others & life3. Discuss abuse (if present)
– Medication for certain symptoms (depression)
– Progressive relaxation - increase anxiety?
2. Dissociative Amnesia
Loss of autobiographical memory E.g. the loss of one event memory
Not due to brain damage Usually in response to trauma (which is
forgotten) Spontaneous recovery Prevalence unknown Controversy over existence
3. Dissociative Fugue
Amnesia for past + sudden moving Most are not very long-term
Confusion re: identity Assumption of a new identity May last: hours to months Prevalence estimated: 1 in 500 Usually in response to stressor
Treating Dissociative Amnesia and Fugue
Supportive therapy Usually recover on own Fugue often needs couples/family therapy
Feelings of abandonment At risk of relapse when stressed
Preventive approaches helpful Stress management skills
5. Dissociative Identity Disorder
*Formerly Multiple Personality Disorder Presence of 2+ distinct identities Recurrently control an individual “Alters” & “Host Personality” Alters & Host Personality may/may not be
aware of what is going on
Dissociative Identity Disorder
Alters who are unaware have lapses in memory unaccounted for
Own constellation of behavior, voice tone, gestures
Different reactions to medications, eyeglass prescriptions
May claim to be different in age, gender, race, family history
Alters’ Awareness of Each Other
Mutually amnesic
Mutually cognizant
One-way amnesic
Dissociative Identity Disorder
Preceded by headaches Rare: 1% of general population Few believe prevalence is that high Higher rates of diagnosis?
Better identification? Overused? Iatrogenic?
Dissociative Identity Disorder
Course is unpredictable and varies May be long time b/w treatment & diagnosis
(e.g. 6-7 years) Little insight Chronic or episodic
What Causes Dissociative Disorders?
Trauma (child abuse, etc) Derealization Child abuse as first onset -> coping in
children Common in reporters of child abuse
90% of patients report child abuse
Psychodynamic Perspective
DID results from defense mechanisms Massive repression
Recent work suggests adult stress may also be a risk factor, not just childhood experiences
Trauma & Dissociation
Problem: reports are1. Self-report2. Retrospective
– 1/3 report abuse prior to age 3– Autobiographical memory rarely accurate
before 5– Why no evidence of alters during
childhood?
Causes of Dissociative Disorders
Suggestibility How are people who develop dissociative
disorders different from those who develop PTSD?
Those who develop are better @ dissociating
Suggestibility = personality trait re: ease of accepting ideas proposed by others
Suggestibility
Highly suggestible people: Have more detailed fantasy lives Respond more dramatically to hypnosis
The Autohypnotic Model of DID Select people use self-hypnosis as defense
against emotional trauma Retreat into a trance during trauma that is
protective and provides amnesia
Autohypnotic Model of DID
Trauma(Repeated)
SuggestiblePersonality
Self-hypnosis AltersForm
Flaws in the Autohypnotic Model
Why develop only with abuse? Not war related. Not in bullying Involves a betrayal of trust?
How exactly do alters develop from hypnotic state?
May be little/no evidence of alters until adulthood
Treating DID
No controlled treatment studies Agree: People cannot function well with alters Disagree: How to integrate alters Identify & map alters, then integrate Mapping alters may create more? Others argue - ignore, and will go away
Treating DID
Important to establish trust Usually unsuccessful treatment history Secretive about symptoms Skepticism from other providers
Culture and DID
Rare until late 1980s 1st case 1817, by 1960s lit review = 77
cases 1970s = 300 cases, doubled in 1980s Why the rapid increase? Is it real?
Increase is largely North American Rare in France, where theorists played a
big role
Controversies Surrounding DID
Could Therapists Shape DID? Sociocognitive model of DID (Spanos, 1994)
Symptoms shaped by available info & therapist responses To avoid responsibility? Interest due to rarity Normal social reinforcement Ignore to treat
Controversies Surrounding DID
Recovered Memories Use recovered memory
techniques to assess People repress painful
memories of abuse Therapists encourage
recovery of memory
Evidence Against Recovered Memories
1. Little scientific evidence for repressed memories
2. Can implant false memories in children/adults
3. Techniques used to implant same as therapists use to “recover”
Recovered Memories in Court
Some therapists held liable for harmful techniques
Courts increasingly rejecting recovered memories
Continues to be an intense controversy