Chap 8- Somatic Symptoms

March 18, 2024

Disorders featuring somatic symptoms

●
○

  • ●  Symptoms trigger excessive anxiety or concern

  • ●  They have a bad rep and are sometimes not considered "real disorders"

    even though they are:

    • ○  Factitious disorder

    • ○  Conversion disorder

    • ○  Somatic symptom disorder

    • ○  Illness anxiety disorder

    • ○  Psychological factors affecting other medical conditions

    • ○  E.g. Having a that you watched get worse, caused by stress

      • Random pain that gets worse when you notice it

      • Nausea (very distressed)

  • ●  Primary symptoms = affect

  • ●  Secondary symptoms are the sympathy and attention you receive from others

    The concept of "gain"

  • ●  Gain is an important factor

  • ●  Think about gain from a non-judgmental lens

  • ●  It may take the form of sympathy, love, financial reward

  • ●  E.g. You have lower back pain, take time off work, or your co-worker takes on a

    presentation you didn't want to do.

  • ●  Primary gain produces positive internal motivations.

○ For example, a patient might feel guilty about being unable to perform some task. If a medical condition justifying an inability is present, it may lead to decreased psychological stress.

● Secondary gain Secondary gain refers to the external benefits that may be derived as a result of having symptoms.

Factitious disorder (previously called Munchausen's)

● Imposed on self

  • ○  False creation of physical or psychological symptoms, or deceptive

    production of injury or disease, even without external rewards

  • ○  Presentation of oneself as ill, damaged, or hurt

  • ○  Munchausen syndrome

Primarily caused by psychological factors

It comes out as physical symptoms that can't be scientifically explained

○ People with these disorders sometimes feel like they have little to no control over situations/ life

Factitious disorder

● Imposed on another ○

False creation of physical or psychological symptoms, or deceptive

production of injury or disease, in another person

rewards

  • ○  Presentation of another person (victim) as ill, damaged, or hurt

  • ○  Munchausen syndrome by proxy

  • ●  Common with people who are familiar with the medical system, and who have had access to such information at a young age

  • ●  More common in women than men

  • ●  Begins in early adulthood

    Factitious disorder

    ● Links

    • ○  Poor social support or relationships and little family life

    • ○  Extensive medical treatment in childhood

    • ○  Grudge against the medical profession

    • ○  Employment as a nurse, lab technician, or aide, even without external

Factitious disorder: causes and treatment

●
● Clinicians have been

disorder

Conversion disorder: functional neurological symptom disorder

●

  • ●  Usually beginning in late childhood and young adulthood; it often appears suddenly during extreme stress

  • ●  Not consciously wanted or purposely produced

  • ●  Affects voluntary movement or sensory systems (e.g. Blindness, glove

    anesthesia)

    Conversion disorder

    ●

    • ○  In this (see below figure) the entire hand, extending

      from the fingertips to the wrist, becomes numb

    • ○  The entire hand is numb. The whole "glove" of not having feeling

■ REMINDER: THEY DON'T WANT IT

The precise causes of factitious disorder are not understood

disease

unable to develop dependably effective treatments for this

Neurological-like symptoms inconsistent with known neurological or medical

Glove anesthesia

conversion symptom

Somatic symptom disorder

  • ●  At least one upsetting or repeatedly disruptive physical (somatic) symptom

  • ●  An unreasonable number of thoughts, feelings, and behaviours

  • ●  Physical symptoms usually continue to some degree for more than 6 months

    Somatic symptom disorder

    ●

  • ●  A person experiences an unreasonable number of thoughts, feelings, and behaviors about physical symptoms, including one of the following:

  • ●  Repeated,

  • ●  Continual about their nature or health implications.

  • ●  Disproportionate amounts of time and energy spent on the symptoms or their

    health implications.

  • ●  Physical symptoms usually continue to some degree for more than 6 months.

  • ●  Somatization pattern

    ○

    • ○  Treatment sought from doctor to doctor (doctor shopping)

    • ○  Prevalence: 4 percent

    • ○  Abuse and genetic links

    • ○  Presenting setting?

  • ●  Predominant pain pattern

○ Pain source known or unknown

A person experiences at least one upsetting or repeatedly disruptive physical

symptom.

excessive thoughts about their seriousness.

high anxiety

Long-lasting physical ailment with no physical basis; dramatic and

exaggerated

○ May develop after an accident or illness that initially caused genuine pain

ME TED TALK:

  • ●  Is a somatic disorder

  • ●  Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a serious,

    long-term illness that affects many body systems.

  • ●  People with ME/CFS are often not able to do their usual activities.

  • ●  At times, ME/CFS may confine them to bed.

  • ●  People with ME/CFS have severe fatigue and sleep problems.

    Conversion Disorder

  • ●  Conversion disorder, also known as functional neurological symptom disorder (FND), is a psychiatric disorder characterized by symptoms affecting sensory or motor function.

  • ●  These signs and symptoms are inconsistent with patterns of known neurologic diseases or other medical conditions.

    Conversion disorder and somatic symptom disorder

● These groups of disorders have much in common

  • ○  Both may occur in response to severe stress

  • ○  Both have traditionally been viewed as forms of escape from stress

  • ○  Individuals often suffer from both types of disorders

  • ○  Theorists and clinicians often explain and treat the two groups of disorders

    in similar ways

    Mass hysteria

● Can social media spread “mass hysteria”? ○ Bartholemew

  • Argues that

  • Suggests future outbreaks may be more numerous, wide-ranging, and sever

    Causes: Mass Hysteria

  • ●  Previously called hysterical disorders

  • ●  Widely considered unique and in need of special explanation ●

in mass hysteria

social media are a major factor in the current increase

No explanation has received much research support, and the disorders are still

poorly understood

Psychodynamic view (Freud)

  • ●  Argued that a hysterical disorder first happened when a daughter showed first sexual desire, mainly towards her father (during the phallic stage)

  • ●  The first psychodynamic theory of these two disorders

  • ●  Underlying emotional conflicts converted into physical symptoms and concerns

  • ●  Two defence mechanisms

    ○ ○

    ●

  • ●  Agree that patients carry unconscious conflicts from childhood, causing anxiety

  • ●  Anxiety turns into physical pain

    Cognitive-behavioural view

● Point to ○

■ Hyper attentiveness ○ Rewards

■ Brings rewards to the person
■ In a way brings attention from others or relief (in a way

secondary gain) ○ Communication skills

■ These symptoms are a mode of communication for extreme feelings, so it's coming out as visible symptoms

Primary gain - bodily systems kept these internal conflicts out of

awareness

Secondary gain - bodily symptoms enable people to avoid unpleasant

activities OR receive sympathy from others

Contemporary

psychodynamic theories

Disagree with Freud on many points

three realms to help explain conversion and somatic symptom disorders

Somatic vigilance

Multicultural view

  • ●  Some Western clinicians

  • ●  Formation of somatic complaints is the norm in many non-Western cultures

    Treatments for conversion and somatic disorders

  • ●  Don't want to be told it is psychological as many people believe it is a physical medical problem

  • ●  Focus on the cause of the disorder

    • ○  Insight

    • ○  Exposure

    • ○  Drug therapies - can be really helpful in reducing anxiety related

  • ●  Focus on the symptoms

    • ○  Education- explaining the disorder with emotional support

    • ○  Reinforcement - think about other ways of reinforcement, removing the

      rewards, and increasing for positive wins and healthy behaviours

    • ○  Cognitive restructuring - focusing on changing thinking of causes of

      symptoms

      Illness anxiety disorder (hypochondriasis)

do not advocate excessive focus on somatic

symptom disorders included in DSM-5; others see this as bias

Preoccupation with thoughts or high anxiety about having or getting a significant

●

  • ●  Absence of substantial somatic symptoms ●

  • ●  Concerns continue to some degree for at least 6 months

  • ●  The disorder can begin at any age but starts most often in early adulthood

  • ●  Affects men and women in equal numbers

  • ●  Theoretical explanation and treatment are similar to those for anxiety disorders

    (OCD)

○ Drug and cognitive-behavioural approaches

Chronic fatigue syndrome

  • ●  Myalgic encephalomyelitis (ME/CFS)

  • ●  Extreme fatigue for at least 6 months

  • ●  Not otherwise medically explained

  • ●  Difficulties with cognition, memory, focus, sensory changes

  • ●  Extreme exhaustion the following output

  • ●  Headaches

    Psychological factors affecting other medical conditions

● Early DSM labels
○ Included psychophysiological (psychosomatic) disorders

● DSM-5 label
○ Includes psychological factors affecting other medical conditions

● Characteristics of these disorders

  • ○  Are different from factitious, conversion, and illness anxiety disorders

  • ○  Involve significant medical symptoms and conditions

  • ○  Often result in serious physical damage

  • ○  E.g. Illness that can impact previous medical illnesses

    • Ulcers

    • Asthma

    • Insomnia

    • Headaches

    • Etc. ■
      ■

(in reality when the person has almost no, or very mild somatic symptoms)

○ Searching for symptoms out of fear of what the symptom might mean

illness

Unduly high number of health-related behaviours or dysfunctional

health-avoidance behaviours

All can trigger or worsen medical conditions

And can make the treatment of other conditions worse

Psychophysiological disorders

  • ●  Affected persons have a medical condition

  • ●  Psychological factors negatively affect the medical condition

    • ○  Affect the course of the medical condition

    • ○  Provide obstacles to the treatment of medical condition

    • ○  Pose new health risks

    • ○  Trigger or worsen the medical condition

      Traditional psychophysiological disorders

  • ●  Ulcers

  • ●  Asthma

  • ●  Insomnia

  • ●  Chronic headaches

  • ●  Migraine headaches

  • ●  Hypertension

    Contributions to psychophysiological disorders

● Biological factors
○ Defects in the autonomic nervous system (ANS) may contribute to the

development of psychophysiological disorders Other more specific

biological problems ● Psychological factors

○ Needs, attitudes, emotions, personality, or coping styles may cause people to overreact repeatedly to stressors Increasing their chances of developing psychophysiological disorders

Sociocultural factors

● Adverse social conditions that produce stress trigger and interact with biological and psychological factors

  • ○  Poverty and dangerous environments

  • ○  Discrimination

  • ○  Health problems

  • ○  Genetic predispositions

    New psychophysiological disorders

    ● Psychoneuroimmunology

○ Examines how stressful events result in viral or bacterial infection

and the connection between psychosocial stress, immune system, and health.

● Many physical illnesses are linked to psychosocial stress.
○ Stress can slow lymphocyte activity and interfere with the immune

system’s ability to protect against viral and bacterial infection during times

of stress. ○

Are physical illnesses related to stress?

●

  • ○  Examined the

  • ○  Linked stressors of various kinds to a wide range of physical conditions

  • ○  Does not consider particular stress reactions within specific populations

■ The greater the amount of stress, the greater the likelihood of illness

Most stressful life events

The immune system

  • ●  How these stressors are very real and the body's immune system has ley relationship with navigating stress and the immune system

  • ●  Stress can slow down the activity of the immune system

    Psychoneuroimmunology and stress influence on immune system

● Biochemical activity
○ Stress pathways (sympathetic nervous system and

hypothalamic-pituitary-adrenal pathway); cytokines, norepinephrine, chronic inflammation

Norepinephrine and cortisol activity, behavioural changes, personality

style, and social support affect immune functioning.

Social Adjustment Rating Scale (1967)

relationship between life stress and the onset of illness

● Behavioural changes
○ Anxiety or depressive disorder; unhealthy behaviours that impact the

immune system ● Personality style

○ Hardy or resilient personality style; hopelessness; spirituality ● Social support

○ Loneliness group; affiliation; supportive therapy

Psychological treatments for physical disorders

●

Behavioural medicine combines psychological and physical interventions to treat

or prevent medical problems

  • ○  Relaxation training

  • ○  Biofeedback (EMG)

  • ○  Meditation

  • ○  Hypnosis

  • ○  Cognitive-behavioural intervention

  • ○  Support groups and emotional expression

  • ○  Combination approaches