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Chapter 6
Somatoform and Dissociative Disorders
An Overview of Somatoform Disorders
 Soma = Body
 Preoccupation with health or appearance
 Physical complaints
 No identifiable medical condition
An Overview of Somatoform Disorders
 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
Hypochondriasis: An Overview
 Clinical Description (cont.)
 Little benefit from medical reassurance
 Strong disease conviction
 Misperceptions of symptoms
 Checking behaviors
 High trait anxiety
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
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
Hypochondriasis
 Culture-Specific Syndromes
 China – koro
 India – dhat
 Africa
 Pakistan
Hypochondriasis
 Causes
 Disorder of cognition or perception
 Physical signs and sensations
Hypochondriasis
 Causes
 Familial history of illness
 Genetics
 Modeling/learning
 Other factors
 Stressful life events
 High family disease incidence
 “Benefits” of illness
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
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: Causes
 History of family illness or injury
 Links to antisocial personality disorder
 Behavioral inhibition system
 Impulsivity
 Novelty-seeking
 Provocative sexual behavior
 Socialization
 Gender roles
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
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
Conversion Disorder : Differential Diagnosis
 Malingering
 Intentionally produced symptoms
 Clear benefit
 No precipitating stressful event
 Impaired function
 Factitious Disorder/Munchausen’s
 Intentionally produced symptoms
 No obvious benefit
 Sick role?
Conversion Disorder
 Statistics
 Rare
 Prevalence depends on setting
 Female > male
 Onset = adolescence
 Chronic, intermittent course
Conversion Disorder
 Special populations
 Soldiers
 Children
 Better prognosis?
 Cultural considerations
 Religious experiences
 Rituals
Conversion Disorder: Causes
 Freudian psychodynamic view
 Trauma, conflict experience
 Repression
 “Conversion” to physical symptoms
 Primary gain
 Attention and support
 Secondary gain
Conversion Disorder: Causes
 Behavioral
 Traumatic event must be escaped
 Avoidance is not an option
 Social acceptability of illness
 Negative reinforcement
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
Pain Disorder
 Statistics
 Fairly common
 5% - 12%
 Treatment
 Combined medical and psychological
Body Dysmorphic Disorder
 Clinical Description
 Preoccupation with imagined defect in
appearance
 Impaired function
 Social
 Occupational
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?
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
An Overview of Dissociative Disorders
 Severe alterations or detachments
 Normal perceptual experiences
 Significant impairments
 Identity
 Memory
 Consciousness
 Depersonalization
 Derealization
An Overview of Dissociative Disorders
 Types
 Depersonalization Disorder
 Dissociative Amnesia
 Dissociative Fugue
 Dissociative Trance Disorder
 Dissociative Identity Disorder
Depersonalization Disorder: An Overview
 Clinical Description
 Feelings of unreality and detachment
 Severe/frightening
 Depersonalization
 Derealization
 Significant impairment
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
Dissociative Amnesia
 Dissociative Amnesia
 Psychogenic memory loss
 Generalized type
 Localized or selective type
Dissociative Fugue
 Dissociative Fugue:
 Flight or travel
 Memory loss
 Retrograde vs. anterograde
 “How’s” or “why’s” of travel
 Assumption of new identity
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
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
Can DID be Faked?
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Real vs. false memories
Suggestibility
Hypnosis studies
Simulated amnesia
Demand characteristics
Physiological measures
 Eye movements
 GSR
 EEG
Dissociative Identity Disorder (DID)
 Statistics
 1.5% (year)
 Female : male = 9:1
 Onset = childhood
 High comorbidity rates
 Axis I
 Axis II
 Lifelong, chronic course
DID: Causes
 Causes
 Biological vulnerability
 Reactivity
 Hippocampus and amygdala
 Severe abuse/trauma history
 Links with PTSD
 Highly suggestible
 Auto hypnotic model
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