chapter 6 preoccupation and obsession

illness anxiety disorder

severe anxiety over belief in having a disease without any evident physical cause
- formally knows as "hypochondriasis"
- concern is "idea" of being sick

somatic symptom disorder

disorders involving extreme and long-lasting focus on multiple physical symptoms for which no medical cause is evident
- Pierre Briquet - Briquet's syndrome

DSM-IV-TR definitions

overemphasized that bodily symptoms are medically unexplained

DSM-5 definitions

emphasize distress that accompanies or is in response to the bodily concerns

clinical description of somatic symptom disorder

continuously feeling weak and ill
- avoid exercising
- life revolves around symptoms

clinical description of illness anxiety disorder

- anxiety focused on the possibility of disease; preoccupied with bodily symptoms
- disease conviction
- remain unconvinced and unsure of absence of disease; go from doctor to doctor
- focus on long term process of illness and disease (e.g., cancer)

disease conviction

a belief that a person has a disease

causes of somatic symptom and illness anxiety disorder

cognitive factors are considered central in illness anxiety disorder (disorders of cognition)
- "catastrophic" misinterpretation of bodily sensations
- distorted beliefs: strong beliefs that unexplained bodily changes are always a sign of serious illness
- dysfunctional mindset: leads to worry about health and illness

four contributing factors of causes of somatic symptom and illness anxiety disorder

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 (a function of the two factors that will increase anxiety and two factors that will reduce anxiety)
- perceived likelihood of illness and perceived costs and burden of illness
- perceived ability to cope and the perceived presence of rescue factors (availability of medical help)

treatment of somatic symptom and illness anxiety disorder

- explanatory therapy (education and reassurance)
- CBT (reduces stress, minimize help-seeking behaviour)
- exposure based therapies

psychological factors affecting medical condition

somatic condition in which a psychological characteristic affects a diagnosed medical condition, such as asthma being exacerbated by anxiety
- diagnosed medical condition (e.g., asthma, diabetes, severe pain)
- adversely affected by psychological or behavioural factors (e.g., anxiety, denial)

conversion disorder (functional neurological symptom disorder)

physical malfunctions suggesting neurological impairment, with no organic pathology to account for it
- hysteria
- conversion
- functional

hysteria

term originally used to describe what are now known as conversion disorders
- was specific to women due to the wandering of the uterus through the body
- presumed to symbolize the longing to produce a child

"conversion"

derived originally from Freud-the energy of repressed instinct was derived into sensory-motor channels and blocked functioning
- unconscious conflicts expressed through (converted to) physical symptoms

"functional"

severe physical dysfunction without an organic cause

clinical description of conversion disorder

physically healthy people experience sensory or motor symptoms suggesting or neurological illness (although the body organs and NS are found to be fine)
- globus hystericus
- astasia-abasia
- psychogenic non-epileptic seizures)

globus hystericus

the sensation of a lump in the throat that makes swallowing, eating difficult

astasia-abasia

the inability to stand and to walk, despite sparing of motor function underlying the required balance and gestures

symptoms of conversion disorder

- motor symptoms or deficits (the most common group of symptoms): impaired coordination or balance, paralysis, muscle weakness (most frequent symptom in this group), abnormal limb posturing
- sensory abnormalities (a less common symptom group): double vision or blindness, deafness, hallucinations, psychogenic seizures
- anaesthesias (loss or impairment of sensations): blindness or tunnel vision
- aphonia: loss of the voice and all but whispered speech
- anosmia: loss if impairment of the sense of smell

malingering

deliberate faking of a physical or psychological disorder motivated by gain
- the classic description of conversion disorder includes a symptom: la belle indifférence (beautiful indifference): substantial emotional indifference to the presence of the dramatic physical symptoms (e.g., inability to walk-some people appear undisturbed by their paralysis; can help differentiate conversion disorder from malingering

factitious disorders

nonexistent physical or psychological disorders deliberately faked or no apparent gain except possibly sympathy and attention
- the symptoms are under voluntary control; "sick role"; attention
- factitious disorder imposed self
- factitious disorder imposed on another (previously called Munchausen syndrome by Proxy)

causes of conversion disorder: biological factors

- evidence is weak
- may be some relationship between brain structure/function and conversion disorder
- conversion symptoms are more likely to occur on the left side than on the right side of the body
- recent FMRI: when processing stressful events, people with conversion disorder have a failure to activate the right inferior frontal cortex and the connectivity between the amygdala and motor areas of the brain are enhanced in these people

causes of conversion disorder: behavioural view

the maladaptive pattern may strengthen because of attention it received or the excuses it provides
- strategy to explain poor performance in evaluative situations
- illness behaviours-learned behaviours acquired via exposure to parental illness and health anxiety in childhood

Freud proposed 4 basic processes:

1. traumatic events lead to a conflict = anxiety
2. repression of conflict (unconscious)
3. when anxiety becomes conscious person converts it to physical symptoms (reduction of anxiety-primary gain)
4. person gets attention (secondary gain)

interpersonal factors (conversion disorder)

substantial stress: abuse, parental divorce

social and cultural factors (conversion disorder)

less educate, lower socioeconomic groups
- knowledge about disease and medical illness is not well developed

treatment for conversion disorder

- identify source of stress; reduce stress
- reduce any supportive consequences of the conversion symptoms-minimize help-seeking behaviours
- cognitive-behavioural programs

obsessive compulsive disorder (OCD)

disorder involving unwanted, persistent, intrusive thoughts and impulses as well as repetitive actions intended to suppress them
- chronic disorder
- other symptoms may include: severe GAD, recurrent panic attacks, debilitating avoidance, major depression, suicidal ideation and suicide attempts, severe obsessions

clinical description of OCD

- fear of unwanted and intrusive thoughts (obsessions)
- repeated ritualistic actions or mental acts (compulsions) designed to neutralize the unwanted thoughts (both behavioural and mental; the activity is not always realistically connected with its apparent purpose and is clearly excessive
- significant distress and interference with everyday functioning

tic disorder and OCD

- involuntary movements
- tourettes syndrome
- co-occurs with OCD
- movements may not be tics but compulsions
- obsessions in OCD tic-related OCD-symmetry

causes of OCD: biological factors

- genetic evidence
- high rates of anxiety disorders occur among the first-degree relatives (10.3%) than control (1.9%)
- two brain areas: the frontal lobes-PET scan (increased activation in frontal lobes)
- basal ganglia: control of motor behaviour (a set of subcortical structures the caudate putamen, globus pallidus, and amygdala)

Rachman and Shafran's theory of obsessions

- catastrophic misinterpretation of negative intrusive thoughts
- an inflated sense of personal responsibility for outcomes
- a cognitive bias involving thought-action fusion

thought-action fusion involves 2 beliefs:

1. the mere act of thinking about unpleasant events increases the perceived likelihood that they will actually happen
2. at a moral level, thinking something unpleasant is the same as actually having carried it out

treatment for OCD

- SSRIs
- exposure and ritual prevention (ERP)
- CBT and internet-based CBT
- physical exercise
- psychosurgery-cingulate-surgical lesions to the cingulate bundle (an area near the corpus callosum)
- deep brain stimulation

body dysmorphic disorder (BDD)

- featuring a disruptive preoccupation with some imagined deficit in appearance ("imagined ugliness")
- previously known as dysmorophobia
- repeated looking in mirrors
- co-occurs with OCD

clinical description of BDD

- checking and compensating rituals
- excessive grooming, skin picking, mirror checking
- suicidal: attempt and ideation

muscle dysmorphia

the idea that his/her body is too small or insufficiently muscular

good/fair insight (BDD)

individual recognizes that the body dysmorphic beliefs are definitely or probably not true

poor insight (BDD)

individual thinks that the beliefs are probably true

absent insight/delusional beliefs

individual is completely connected that their beliefs are true

causes of BDD: biological factors

brain volume research found individuals with BDD: decrease volumes right orbitofrontal cortex and left anterior cingulate cortex

causes of BDD: cognitive factors

- catastrophic interpretations of appearance-related thoughts, focus on unwanted thoughts
- efforts to regulate the resulting emotions are not adaptive: (avoidance of social situations, engaging in mirror checking, and applying makeup to hide imperfections)

causes of BDD: psychoanalytic explanation

displacement

treatments of BDD

two treatments with some evidence of effectiveness:
- drugs that block reuptake of serotonin
1. SSRIs, clomipramine and fluvoxamine
2. CBT: exposure and response prevention

plastic surgery and other medical treatments: BDD

- skin treatments most sought after
- many patients of plastic surgeons return for additional surgery
- 8-25% who request plastic surgery have BDD; should be screened by plastic surgeons

hoarding disorder

appears as a separate disorder in DSM-5
- hoarding starts early in life; gets worse
- can be hazardous
- patients come for treatment after age 50

3 major characteristics of hoarding:

1. excessive acquisition of things
2. difficulty discarding anything
3. living with excessive clutter under conditions best characterized as gross disorganization

causes of hoarding disorder

- evidence for genetic contribution
- cognitive factors: errogenous cognitions about the importance and meaning of possessions; misguided attachments with objects to seemingly compensate for emotional deficits in attachment to people

treatment for hoarding disorder

- SSNRIs (venlafaxine)
- Cognitive behavioural therapy given

trichotillomania

(hair pulling disorder)
people's urge to pull out their own hair from anywhere on the body, including scalp, eyebrows, arms
- has severe social consequences
- intense shame following a hair pulling episode, try to hide it by wearing hats, wigs, etc

excoriation

(skin picking disorder)
recurrent, difficult-to-control picking of one's skin leading to significant impairment or distress
- scabs, scars, open wounds common
- any part of body, mostly face, hands, arms
- fingernails used or tweezers, needles, etc

trichotillomania and excoriation causes

- emotion regulation model: trigger- negative emotions; serve to decrease the negative emotions (is negatively reinforcing)
- frustrated action model: trigger-boredom, frustration; engaging alleviates frustration and boredom

treatment for trichotillomania and excoriation

habit reversal training
- self monitoring
- awareness training (identification of trigger)
- competing response