[ABPSY] Disorders of Physical Body and Behavior

somatoform/somatic symptom and related disorders

• Malinger: pretend when they’re sick 

• Psychological problems take a physical form

• Broad group of illnesses with bodily signs and symptoms, not under voluntary control or intentionally produced

types of somatoform disorders

1. somatic symptom disorder

2. illness anxiety disorder

3. functional neurological symptom disorder (conversion disorder)

4. factitious disorder

somatic symptom disorder

• Experience of physical symptoms suggesting the presence of a medical condition for which there is no apparent physical cause 

  • E.g. undergo MRI 

  • Psychological problem 

• duration: 6 months

characterized by at least one:

1. Excessive time and energy deviated

2. health-related anxiety

3. disproportionate concerns regarding gravity of symptoms 

• Specify: predominant somatic complaints, predominant health anxiety, predominant pain 

• DSM-IV:  Clustered under one big disorder: pain order + somatization disorder
  

[SSD] specifiers and severity

• Formerly Somatization Disorder

• Persistent severe symptoms > 6 months

• Specificers: predominant pain 

• Severity: mild, moderate, severe

• Ex. would go to hospital and ask for a doctor to explain -> gone thru lab tests

• Emphasis on symptomatic 

illness anxiety disorder

• Severe anxiety about relatively mild symptoms taken as signs of a serious undiagnosed illness 

  • Care-avoidant subtype 

  • Care-seeking subtype 

• Formerly Hypochondriasis 

• Filipinos are hospital aversive

• Liver enzymes, kidney enzymes, creatine levels

• Lab test results: can’t stop worrying despite providing evidence 

• Preoccupation for more than 6 months to be considered as a diagnosis 

functional neurological symptom disorder

• Neurologic symptoms affecting voluntary motor function, sensory function, cognition, or seizure-like episodes 

  • Common: paralysis, blindness, mutism

  • Inconsistent or incongruent with a recognized neurological disorder and cannot be explained by a medical condition 

• DSM-IV criteria: symptoms are related to conflict or stress and not intentionally produced

• Doesn’t show up in the tests

• Specifiers

  • With weaknesses, paralysis

  • Abnormal movement 

  • Speech symptoms 

  • Attacks or seizures

• Physical health can affect mental health 

factitious disorder

• Munchausen syndrome 

• Intentional fabrication of psychological or physical symptom for no apparent gain 

• Intent to deceive others that one is ill, impaired or injured without apparent external rewards

• Factitious disorder imposed on another = munchausen syndrome by proxy 

• For no apparent reason; no external rewards, money, attention, etc.

• E.g. gypsy rose; malingering by proxy

malingering

• Vs. malingering: faking of illness clearly motivated by external rewards or incentives 

etiology of SSD and IAD

1. hypochondriasis

2. psychosocial

3. psychodynamic

4. biological factors

5. neurological factors

[SSD & IAD] hypochondriasis

• Prevalence: 4-6%, as high as 15%

• Men and women equally

• Typically begins in early adulthood, tends to be chronic

• Transient hypochondrial complaints common in early medical students

[SSD & IAD] psychosocial

• Parental teaching, examples and ethnic moves may teach some children to somatize

• Symptoms as social communication whose result is to avoid obligations, express emotions, or symbolize a feeling 

• E..g. more accommodating to people who are sick = unconscious motivation to appear sick = understand them more

[SSD & IAD] psychodynamic

• May be symbolically expressing an intrapsychic conflict through the body 

  • Unconscious regard of emotional pain as weak and lacking legitimacy 

• Displaces problem to the body, enabling legitimate claim to the fulfillment of dependency needs

[SSD & IAD] biological factors

• Anterior cingulate cortex: attributed to complex cognitive functions like empathy, impulse control emotion, and decision making 

• Anterior insula: involved in emotional experience and subjective feelings

• They don’t just make it up -> Real for them = subjective

[SSD & IAD] neurological factors

• Hyperactive anterior insula and anterior cingulate

• Somatic symptoms are influenced by emotions and stress

on somatic symptom disorders only

1. cognitive behavioral factors (dissociative disorders)

2. functional neurological disorder

3. environmental and stress trauma

[SSD] cognitive behavioral factors (dissociative disorders)

• Distorted cognitions lead to somatic amplification 

• Attention to bodily sensations + attributions of those sensations -> tend to focus on physical health cues and overreact with overly negative interpretations 

• Sick role limits healthy life alternatives

• Affect the way they present themselves unconsciously

• help-seekin g behaviors are reinforced by attention or sympathy

• Easily getting dismissed

• E.g. AI consult

[SSD] functional neurological disorder

• Prevalence: <1%, women > men 

• Onset from late childhood to early adulthood, after a major life stressor 

• 95% remit spontaneously within 2 weeks 

• Prognosis dimmer, the longer, the conversion is present 

• comorbid : MDD, anxiety, substance use, schizophrenia, personality disorder

• Freud: conversion, Joseph Brewer (Anna O)

  • Mental health concern

  • She experienced blindness, etc. 

  • Conversion disorder

• Symptoms allowed for the partial expression of unacceptable impulses

• sackheim’s 2 stage model

[FND] hysteria

• Hippocrates: hysteria (wandering uterus)

  • Used to believe that people would have seamen in their body, including women 

  • Lead to problems in that specific body part

  • Headaches start to occur -> physiological manifestations

• Longer it stays, lead to more permanent

[FND] Sackheim’s 2 Stage Model

• Blindsight: people have unconscious perceptual abilities in visual cortex

• Some people may be more motivated to appear disabled

• Can process visual information outside of their consciousness through the vision system, consisting of modules within the brain

• It is possible for some people to truthfully claim that they cannot see even if tests confirm otherwise

[SSD] environmental stress and trauma

• Stress 

• Sexual abuse 

• Family separation/loss 

• Family conflict/violence 

• Sexual assault

difference between disorders

Differences

	Voluntary Control	Clear Motive
Somatic	No	No
Factitious	Yes	No
Malingering	Yes	Yes

treatment and interventions of SSD

1. cognitive behavioral factors

2. pharmacotherapy

[treatment] cognitive behavioral factors

• Identify and change triggering emotions 

• Change cognitions about symptoms 

  • Nothing wrong with body but feel symptoms-> integrate in session 

• Replace sick role behaviors with more appropriate social interactions 

  • Empowering clients that they benefit from being not sick

[treatment] pharmacotherapy

• Few controlled treatment outcome studies

• Analgesics don’t generally benefit patients 

• Antidepressants - imipramine (Tofranil)

  • In low doses, to reduce chronic pain and distress

dissociative disorders

• Disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment 

• May be sudden, gradual, transient or chronic

types of dissociative disorders

1. dissociative amnesia

   1. dissociative fugue

2. dissociative identity disorder

3. depersonalization/derealization disorder

[DD] dissociative amnesia

• Extensive memory loss

• No identifiable organic cause

• Frequently in those who experienced acute trauma 

• May be reversible 

  • Amnesic episode may last several hours or years

• More rarely, patient retains implicit memory but loses explicit memory 

• Can be transient 

• Can be localized or generalized 

  • Generalized; individuals that may not be related to traumatic experience 

• Affect implicit or explicit memory 

• Specify if with dissociative fatigue

[DA] implicit memory

• Unconscious retrieval 

• Non-verbal

[DA] explicit memory

• conscious retrieval 

• Verbal

• declarative

course and prognosis on dissociative amnesia

• Acute dissociative amnesia frequently spontaneously resolves once the person is removed to safety from traumatic or overwhelming circumstances

• Some patients do develop chronic forms of generalized, continuous or severe localized amnesia and are profoundly disabled and require high levels of support 

• Individuals who would have anterograde amnesia: don’t take in new experiences 

• Rare cases: require hospitalization, neurologist

[DD] dissociative fugue

• Losing autobiographical information even identity

• Subtype of dissociative amnesia 

• Sudden, unprecedented away from home or place of origin with inability to recall some or all of one’s past

• May also be confusing about personal identity or assumption of a new identity 

• Disappearing from one’s community

• recovery often complete 

• E.g.  shutter island

[DD] dissociative identity disorder

• Changed to MDD to DID Starting DSM 5 until current version

  • Wanted to focus less on persona 

• Was Multiple Personality Disorder 

• Involves the adoption of several new identities or alters 

• Defining feature: dissociation of certain aspects of the personality

• Forming of a new identity

• Evident in memory gaps or loss for days or weeks

• Doesn’t know that there are alters 

[DID] alters

• Doesn’t know that there are alters 

  • But alters are aware that they exist

  • There can be less dominant ones 

  • Main persona is unaware

  • Form a system

  • Each alter plays a role -> change in the tone of voice/language that they use

    • Centered on trying to protect the main persona

  • There’s forming a new identity from a consciousness of another person 

  • Manifests in the change of biological features 

  • E.g. Main person; woman -> alter; men

  • Main persona is not gaining the memory -> wake up in someone else’s house 

  • TAKES TIME 

  • 2-3 alters 

    • Guardian 

    • Protector

    • mothers/parents

    • 2500 alters = Rare case than l

• Can stem from traumatic event / extreme sexual physical violence from family members during childhood to early teenage years

• Alters can reach out to the main persona = knows about it 

[DID] example: Sybil

• The story of a woman believed to have 16 distinct personalities 

• Based on Shirley Mason’s life 

• Suffered from physical and sexual abuse by her mother 

• Sybil Exposed in 2011

• Because of her consults with her psychiatrist, she was aware -> check how suggestible they are

• Didn’t know what the other alters were doing if it was out of their consciousness 

• E.g. SPLIT

• Psychodynamic perspective: regressing the memories, stored in the unconscious 

• Make sure that you earn their trust of alters for main persona

more about dissociative identity disorder

• Usually begins in childhood but rarely diagnosed until adulthood 

• Prevalence rates: 0.4 to 1.3% 

  • VERY RARE

  • More people share on stories

• Male to female ratio: 9:1

• High comorbidity with a chronic course - usually accompanied by headaches, substance abuse, phobias, hallucinations, suicide attempts, sexual dysfunction and self-abusive behavior

• E.g. kids in war -> have adults as alters 

• Man up

• Repress 

[DD] depersonalization/derealization disorder

• Persistent or recurrent feeling of detachment or estrangement from oneself 

• Reality testing remains intact during the experience 

• Feel disconnected from body -? Form of hallucination

• Usually as a specifier for PTSD, panic disorder and other mental disorders

• Depersonalization:

• Derealization:

[DDD] depersonalization

• detachment from the self, sense of self and reality is temporarily lost 

experience of depersonalized

• The sense of bodily changes 

• Duality of self as observer and actor (outside their body)

• Being cut off from others/their own emotions

• Dissociation depends on nature of triggering event

• Some body parts are disconnected/limbs

[DDD] derealization

• sense of reality of the outside world is lost; detached from reality

more about depersonalization/derealization disorder

• Transient experiences of depersonalization and derealization extremely common in normal & clinical; populations

• Similar episodes may occur in: schizophrenia, panic attacks, PTSD, and borderline personality disorder 

• Usually begins in adolescence, persists until adulthood 

• Comorbid ODs are frequent 

on dissociative disorders

1. course and prognosis (dissociative amnesia)

2. the experience of depersonalized

3. depersonalization/derealization disorder

4. dissociative identity disorder

etiology of dissociative disorders

1. social cognitive

2. psychodynamic

3. biological

4. models for DID

[etio] social cognitive

• Learned response (Psychologically distancing) 

• Form of role playing acquired through observational learning and reinforcement

[etio] psychodynamic

• Massive use of repression 

  • Splitting off from consciousness unacceptable impulses & painful memories 

• Adaptive function of blotting out or disconnecting one’s conscious self from awareness or traumatic experiences or other sources of psychological pain or conflict

[etio] biological

• Abnormal brain functioning, structural abnormalities, neurochemical changes, and other neurological conditions

[etio] models for DID

• Unconsciously; start to dissociate from consciousness -> alters were formed 

1. post-traumatic : dissociation begins in childhood from severe abuse, as a way of escaping the trauma 

2. Socio-cognitive; appears in adulthood due to learned social role enactment, typically manifest from a therapist's suggestion

treatment of dissociative amnesia

1. Cognitive therapy

2. Hypnosis, self-hypnosis

3. Somatic therapies

4. Group psychotherapy

5. Through the sense 

6. Mindfulness exercises

treatment of dissociative identity disorder

• From traumatic events that are blocked from consciousness 

• May be treated as a complex, chronic, trauma-based disorder 

  • PTSD as a most commonly diagnosed comorbid disorder with DID 

• Psychoanalysis

  • To address repression 

  • Hypnosis may help retrieve lost memories (risky) 

• It can be a process: TRAUMA INFORMED CARE (recalling) -> psychodynamic 

• TIC -> willing to remember thru hypnosis -> psychoanalytic -> once they remember, address that 

• PTSD therapy

• Can apply CBT: when stable already

• Ex. trauma informed care -> most common treatment for PTSD to avoid retraumatization 

general treatment of DD

• Anti-depressants 

• Long-term therapy

• CBT 

  • Work on misinterpretations of normal symptoms such as fatigue, stress, or substance abuse 

  • Cognitive restructuring: challenging misinterpretations and exploring alternative explanations 

• Psychoanalysis 

  • To help process childhood experiences of trauma 

  • Exposure therapy

treatment of depersonalization disorder

• SSRIs: fluoxetine (prozac), sertraline (zoloft)

• Adjunct psychotherapy

goal

• Integration of the different aspects of the self 

• For DID, reintegration of alters

• More than 10: harder and longer to integrate to main persona 

• Lose the alters - not meant to exist in the first place 

• Limited capacity of memory during integration 

• Depends on how many alters -> need to understand/gals they’re serving

• Need to encourage them that they have to be reintegrated back into the main persona 

• Assess in every session

• Make them feel capable and empowered in  ma

• Do hypnosis for others to come out