CHAPTER 6: SOMATIC SYMPTOM AND RELATED DISORDERS AND DISSOCIATIVE DISORDERS

What are Somatic Symptom and Related Disorders (SSRD)?

SSRDs are mental health conditions where individuals experience significant distress or impairment due to physical symptoms. This distress is excessive relative to the underlying medical explanation, if any. They are pathologically concerned with their body's functioning

Five Basic Somatic Symptom and Related Disorder

• 1 Somatic Symptom Disorder

• 2 Illness Anxiety Disorder

• 3 Psychological Factors Affecting Medical Condition

• 4 Conversion Disorder

• 5 Factitious Disorder

SOMATIC SYMPTOM DISORDER

Pain is real and it hurts whether there are clear physical reasons for pain or not.

Pierre Briquet (French Physician)

• Described patients who came to see him with seemingly endless lists of somatic complaints for which he could find no medical basis

• Briquet’s syndrome

ILLNESS ANXIETY DISORDER

• Formerly known as “hypochondriasis”.

• Anxiety or fear that one has a serious disease.

• Preoccupied with bodily symptoms, misinterpreting them as indicative of illness or disease.

Additional Information! for you to know!

Physical symptoms are either not experienced at the present time or are very mild.

Additional Information! for you to know!

• Severe anxiety is focused on the possibility of having or developing a serious disease.

• Reassurance from physicians does not seem to help.

Disease Conviction

A difficult-to-shake belief that they have a disease.

Additional Information! for you to know!

Less concerned with any specific physical symptom and more worried about the idea that she was either ill or developing an illness

Additional Information! for you to know!

• Illness anxiety disorder and somatic symptom disorder share many features with the anxiety and mood disorders, particularly panic disorder.

• Similar age of onset, personality characteristics, and patterns of familial aggregation.

Additional Information! for you to know!

• Patients with panic disorder typically fear immediate symptom-related catastrophes that may occur during the few minutes they are having a panic attack.

• Continue to seek the opinions of additional doctors in an attempt to rule out disease and are more likely to

  demand unnecessary medical treatments.

• Somatic symptom disorders focus on a long-term process of illness and disease.

Koro

• A belief, accompanied by severe anxiety and sometimes panic, that the genitals are retracting into the abdomen.

• Guilty about excessive masturbation, unsatisfactory intercourse, or promiscuity.

• Prevalent in Chinese men.

Dhat

• An anxious concern about losing semen, something that obviously occurs during sexual activity.

• A vague mix of physical symptoms, including dizziness, weakness, and fatigue.

• Prevalent in India.

Causes of Somatic Symptom Disorder

Disorders of cognition or perception with strong emotional

contributions.

• Faulty interpretation of physical signs and sensations.

• Tend to interpret ambiguous stimuli as threatening

Causes of Somatic Symptom Disorder

Somatic symptom disorders run in families.

• Nonspecific: tendency to overrespond to stress

Causes of Somatic Symptom Disorder

Learned from family members to focus their anxiety on specific

physical conditions and illness

Causes of Somatic Symptom Disorder

Disorders seem to develop in the context of a stressful life event.

Causes of Somatic Symptom Disorder

Tend to have had a disproportionate incidence of disease in their family when they were children.

Causes of Somatic Symptom Disorder

Important social and interpersonal influence may be involved.

• Some people who come from families where illness is a major issue seem to have learned that an ill person often gets a lot of attention.

Treatment for Somatic Symptom Disorder

• Cognitive Behavioral Treatments

• Reassurance and Education

• Exposure Therapy

• Medications

Reassurance and Education can be effective in treating SSD (Somatic Symptom Disorder)

Explanatory Therapy

• Devote sufficient time to all concerns the patient may have and attend to the “meaning” of the symptoms

Exposure Therapy

Repeatedly confronting the patient to stimuli that are relevant for health anxieties without using any avoidance and safety behaviors.

Medications for SSD

• Drug paroxetine (Paxil)

• Selective-serotonin reuptake inhibitor (SSRI)

What is Criterion A for Somatic Symptom Disorder?

One or more somatic symptoms that are distressing or result in significant disruption of daily life.

What does Criterion B entail for Somatic Symptom Disorder?

Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns, as manifested by at least one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

2. Persistently high level of anxiety about health or symptoms.

3. Excessive time and energy devoted to these symptoms or health concerns.

What is Criterion C for Somatic Symptom Disorder?

Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

• What does the specifier "With predominant pain" indicate in Somatic Symptom Disorder?

• * Matawag syag “SSD with Predominant pain” if?

This specifier is for individuals whose somatic symptoms predominantly involve pain (previously referred to as pain disorder).

• What characterizes a "Persistent" course in Somatic Symptom Disorder?

• * Matawag syag “SSD Persistent” if?

• A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).

• If someone's symptoms are severe, significantly impacting their daily life, and have lasted for more than six month

What are the current severity specifiers for Somatic Symptom Disorder?

• Mild: Only one of the symptoms specified in Criterion B is fulfilled.

• Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

• Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

What defines mild severity in Somatic Symptom Disorder?

Only one of the symptoms specified in Criterion B is fulfilled.

What defines moderate severity in Somatic Symptom Disorder?

Two or more of the symptoms specified in Criterion B are fulfilled.

What defines severe severity in Somatic Symptom Disorder?

Two or more symptoms from Criterion B are fulfilled PLUS either:

• Multiple somatic complaints OR

• One very severe somatic symptom.

What is Criterion A for Illness Anxiety Disorder?

Preoccupation with having or acquiring a serious illness.

What does Criterion B state regarding somatic symptoms?

Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history), the preoccupation is clearly excessive or disproportionate.

What is Criterion C for Illness Anxiety Disorder?

There is a high level of anxiety about health, and the individual is easily alarmed about their personal health status.

What does Criterion D involve regarding health-related behaviors?

The individual performs excessive health-related behaviors (e.g., repeatedly checks their body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).

What is Criterion E regarding the duration of illness preoccupation?

Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period.

What does Criterion F state about the illness-related preoccupation?

The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

What characterizes the Care-Seeking Type in Illness Anxiety Disorder?

Medical care, including physician visits or undergoing tests and procedures, is frequently used.

What characterizes the Care-Avoidant Type in Illness Anxiety Disorder?

Medical care is rarely used.

PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION

The presence of a diagnosed medical condition such as asthma, diabetes, or severe pain clearly caused by a known medical condition such as cancer that is adversely affected (increased in frequency or severity) by one or more psychological or behavioral factors

CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER)

Physical malfunctioning without any physical or organic pathology

Symptoms of CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER)

• Paralysis

• Blindness

• Total mutism

• Loss of the sense of touch

• Aphonia

• Astasia-abasia

• Psychogenic non-epileptic seizures

• Globus hystericus

Aphonia

Difficulty speaking.

Astasia-Abasia

Weakness in legs and difficulty keeping balance, with

the result of falling often.

Globus Hystericus

A lump in the throat that makes it difficult to swallow, eat, or sometimes talk.

What often precipitates (immediate cause) Conversion Disorder symptoms?

Symptoms often seem to be precipitated by marked stress, which can take the form of a physical injury.

Conversion

• Term popularized by Freud.

• The anxiety resulting from unconscious conflicts somehow was “converted” into physical symptoms to find expression

Functional

Refers to a symptom without an organic cause

What is Criterion A for Conversion Disorder?

One or more symptoms of altered voluntary motor or sensory function.

What does Criterion B state regarding clinical findings for Conversion Disorder?

Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

What is Criterion C for Conversion Disorder?

The symptom or deficit is not better explained by another medical or mental disorder.

What does Criterion D involve regarding the impact of symptoms?

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

What characterizes an "Acute Episode" in Conversion Disorder?

Symptoms are present for less than 6 months.

What characterizes a "Persistent" episode in Conversion Disorder?

Symptoms occur for 6 months or more.

How is the presence of a psychological stressor specified in Conversion Disorder?

Symptoms can be specified as "With psychological stressor" (specify stressor).

How is the absence of a psychological stressor specified in Conversion Disorder?

Symptoms can be specified as "Without psychological stressor."

Malingering

• Faking symptoms.

• Trying to get out of something or they are attempting to gain something.

La Belle Indifference

No or little concern about their symptoms.

Catharsis

• Breuer coined this term.

• The therapeutic reexperiencing of emotionally traumatic events.

Case of Anna O.

• Nursing her dying father.

• Suddenly she found herself imagining (dreaming?) that a black snake was moving across the bed, about to bite her father.

• She Experienced

Paralysis

Forgot to speak her native language (German)

Deafness

Statistics in Conversion Disorder

• Conversion disorder may occur with other disorders, particularly somatic symptom disorder.

• Comorbid anxiety and mood disorders are also common.

• Found primarily in women.

• Typically develop during adolescence or slightly thereafter.

• Often disappear after a time, only to return later in the same or similar form when a new stressor occurs.

Four Basic Processes in the Development of Conversion Disorder (Freud)

1. Individual experiences a traumatic event.

2. Because the conflict and the resulting anxiety are unacceptable, the person represses the conflict, making it unconscious.

3. Anxiety continues to increase and threatens to emerge into consciousness, and the person “converts” it into physical symptoms, thereby relieving the pressure of having to deal directly with the conflict.

Primary Gain: Reinforcing event that maintains the conversion symptom

4. The individual receives greatly increased attention and sympathy from loved ones and may also be allowed to avoid a difficult situation or task

Secondary Gain: Attention or avoidance

What motivates the development of conversion symptoms?

• Experiencing a traumatic event that must be escaped at all costs.

• Running away is often unacceptable, so the socially acceptable alternative of getting sick is substituted.

• However, intentionally getting sick is also unacceptable, so this motivation is detached from the person’s consciousness.

What background factors are common among individuals with Conversion Disorder?

• Major mood disorders and severe traumatic stress, especially sexual abuse, are common among children and adolescents with pseudo-seizures.

• Conversion Disorder tends to occur in less educated, lower socioeconomic groups where knowledge about disease and medical illness is limited.

How does prior experience with physical problems influence Conversion Disorder?

Prior experience with real physical problems, usually among family members, tends to influence the later choice of specific conversion symptoms.

Treatment for Conversion Disorder

• Identify and attend to the traumatic or stressful life event, if it is still present.

• Reduce any reinforcing or supportive consequences of the conversion symptoms.

• Cognitive-Behavioral Programs

o Hypnosis added little or no benefit to the CBT.

FACTITIOUS DISORDER

• Symptoms are under voluntary control.

• No obvious reason for voluntarily producing the symptoms except, possibly, to assume the sick role and receive increased attention.

• Imagine someone faking an illness.

Factitious Disorder Imposed on Another

• Known previously as Munchausen syndrome by proxy

• An individual deliberately makes someone else sick.

• Atypical form of child abuse.

• If that person is faking the illness in someone else, like a child or elderly parent, that's factitious disorder imposed on another (FDIA).

Dissociative Experiences

Feel detached from themselves or their surroundings, almost as if they are dreaming or living in slow motion.

• Likely to happen after an extremely stressful event, tired, or sleep deprived.

Depersonalization

Temporarily lose the sense of your own reality.

• As if you were in a dream and you were watching yourself.

Derealization

Sense of reality of the external world is lost.

• Things may seem to change shape or size; people may seem dead or mechanical.

DEPERSONALIZATION-DEREALIZATION DISORDER

• Characterized by feelings of unreality.

• Mean age of onset: 16 years.

• Course tends to be chronic.

• Anxiety, mood, and personality disorders are also commonly found.

Additional Information! about DEPERSONALIZATION-DEREALIZATION DISORDER

Participants with depersonalization disorder showed a distinct cognitive profile, reflecting some specific cognitive deficits on measures of attention, processing of information, short-term memory, and spatial reasoning.

• Easily distracted and were slow to perceive and process new information.

Additional Information! about DEPERSONALIZATION-DEREALIZATION DISORDER

Showed greatly reduced emotional responding.

• Tendency to selectively inhibit emotional expression

Additional Information! about DEPERSONALIZATION-DEREALIZATION DISORDER

Confirm deficits in perception and emotion regulation.

Additional Information! about DEPERSONALIZATION-DEREALIZATION DISORDER

Dysregulation in the hypothalamic–pituitary–adrenocortical (HPA).

Additional Information! about DEPERSONALIZATION-DEREALIZATION DISORDER

The drug Prozac did not show any treatment effect compared with placebo.

What is Criterion A for Depersonalization/Derealization Disorder?

The presence of persistent or recurrent experiences of depersonalization, derealization, or both

What does Criterion B state regarding Depersonalization/Derealization Disorder?

During the depersonalization or derealization experiences, reality testing remains intact.

What is Criterion C for Depersonalization/Derealization Disorder?

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

What does Criterion D state about the disturbance in Depersonalization/Derealization Disorder?

The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).

What does Criterion E state regarding other mental disorders in Depersonalization/Derealization Disorder?

The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder

General Amnesia

Unable to remember anything, including who they are.

• Lifelong or may extend from a period in the more recent past, such as 6 months or a year previously.

Localized or Selective Amnesia

A failure to recall specific events, usually traumatic, that occur during a specific period.

What is Dissociative Fugue?

Dissociative Fugue is characterized by sudden, unexpected travel away from home or customary work locations, accompanied by an inability to recall one's past (memory loss) and confusion about personal identity.

What does the term "fugue" mean?

Flight

How does memory loss manifest in Dissociative Fugue?

Memory loss revolves around a specific incident—an unexpected trip (or trips). Individuals may find themselves in a new place, unable to remember why or how they got there.

What identity-related symptoms may occur in Dissociative Fugue?

Individuals may sometimes assume a new identity or at least become confused about their old identity.

Amok (Running Amok)

In a trancelike state often brutally assault and sometimes kill people or animals.

• Most people with this disorder are males.

• Not remember the episode

Pivloktoq

Term of running disorder among native peoples of the Arctic.

Frenzy Witchcraft

Term of running disorder among the Navajo tribe.

In which demographic are Dissociative States most common?

Dissociative States are most common in women and are often associated with stress or trauma.

When do Dissociative States typically appear?

They seldom appear before adolescence and usually occur in adulthood. It is rare for them to appear for the first time after the age of 50.

How long can Dissociative States persist?

They may continue well into old age, indicating a chronic condition.

What is the prevalence of Dissociative States compared to other dissociative disorders?

Dissociative States are the most prevalent of all the dissociative disorders.

In which countries are dissociative trances commonly observed?

Dissociative trances commonly occur in India, Nigeria (vinvusa), Thailand (phii pob), and other Asian and African countries.

What are trance syndromes referred to among Bahamians and African Americans from the South?

They are often colloquially referred to as “falling out.”

How are trance and possession viewed in Western cultures?

Trance and possession are almost never seen in Western cultures.

Other Specified Dissociative Disorder (Dissociative Trance)

When the state is undesirable and considered pathological by members of the culture, particularly if the trance involves a perception of being possessed by an evil spirit or another person.