Somatic Symptom And Related Disorders And Dissociative Disorders

Somatic Symptom and Related Disorders

  • Somatic symptom disorders involve an excessive or maladaptive response to physical symptoms or health concerns

  • Types of disorders

    • Somatic Symptom Disorder

    • Illness Anxiety Disorder

    • Psychological factors affecting medical condition

    • Conversion Disorder

Somatic Symptom Disorder

  • Presence of one or more somatic symptoms

    • Symptoms may or may not have known medical causes

    • Excessive thoughts, feelings, and behaviors related to the symptoms

    • Substantial impairment in social or occupational functioning

      • Specify the predominant pain

  • Relatively rare condition

    • Onset usually in adolescence

    • More likely to affect unmarried, low-SES women

  • Runs a chronic course

Illness Anxiety Disorder

  • Very similar to DSM-IV hypochondriasis

  • Clinical description: Severe anxiety about the possibility of having or acquiring a serious disease

  • Actual symptoms are either very mild or absent

  • Medical reassurance does not seem to help

  • Severe illness anxiety has a late age of onset, possibly because more physical health problems occur with aging

  • Often comorbid with anxiety and mood disorders

Treatment for Somatic Symptom Disorders

  • Limited research on treatment effectiveness to date

  • Mild cases of illness anxiety disorder may benefit from cognitive behavioral treatments, detailed education, and some reassurance from medical professionals

  • Exposure treatment can effectively treat illness anxiety disorder

  • Antidepressants may be helpful

  • “Gatekeeper” physician assigned to limit excessive use of medical services

  • Reduce the supportive consequences of illness

Psychological Factors Affecting Medical Condition

  • Diagnostic label useful for clinicians

  • Indicates that psychological variables may be impacting a general medical issue

  • Examples:

    • Concentration difficulties make it hard to take medication on time

    • Failure to follow medical advice due to being in denial about the diagnosis or due to impulsivity associated with certain disorders

Conversion Disorder

  • Also called functional neurological symptom disorder

  • Key feature: Altered motor or sensory function that is inconsistent with neurological or other medical conditions

    • Often suggestive of a neurological problem, but no such problem is detected

    • Must cause significant distress/impairment

    • May display an indifferent attitude toward symptoms (“La Belle Indifference”)

    • Functioning may be mostly normal

    • Not deliberately faking symptoms for the purpose of concrete gains (Malingering)

  • Seen primarily in females

  • Onset usually in adolescence

  • Rare condition, with a chronic, intermittent course

  • Often comorbid with anxiety and mood disorders

  • Common in some cultural and/or religious groups

Conversion Disorder: Etiology and Treatment

  • Causes not well understood

    • Freudian psychodynamic view is still common, but not all pieces are supported by research

    • Past trauma or unconscious conflict is “converted” to a more acceptable manifestation, LE, physical symptoms

      • Primary/secondary gains

  • Sociocultural factors

    • More common in those with less knowledge about the disease

  • Treatment

    • If the onset is after a trauma, one may need to process the trauma or treat posttraumatic symptoms

    • Remove sources of secondary gain

Culture-Specific Disorders

  • Koro: Fear in some asian cultures of genitals retracting into the abdomen

  • Dhat: Symptoms such as dizziness and fatigue are believed to be related to semen loss in some indian cultures

  • Other culture-bound somatic symptoms include:

    • Hot sensations in the head or a sensation of something crawling in the head, specific to African patients

    • Sensation of burning in the hands and feet in Pakistani or indian patients

Factitious Disorders

  • Formerly called Munchausen Syndrome

  • Purposely including physical symptoms

    • No obvious external gains

    • Distinguished from malingering, in which physical symptoms are faked for the purpose of achieving a concrete objective

  • Factitious disorder imposed on another involves including symptoms in another person

    • Typically, a caregiver induces symptoms in a dependent

    • The purpose is to receive attention or sympathy

An Overview of Dissociative Disorders

  • Severe alterations or detachments from reality

    • Affect identity, memory, or consciousness

      • Depersonalization

      • Derealization

  • Types of DSM-5 dissociative disorders

    • Depersonalization/derealization disorder

    • Dissociative amnesia

    • Dissociative trance

    • Dissociative identity disorder

Depersonalization/Derealization Disorder

  • Recurrent episodes in which a person has sensations of unreality of one’s own body or surroundings

  • Feelings dominate and interfere with life functioning

  • Only diagnosed if the primary problem involves depersonalization and derealization

  • Occurs in 1 to 3% of the population

  • Comorbid with anxiety and depression

  • Treatment

    • Research is very scarce

Dissociative Amnesia

  • Includes several forms of psychogenic memory loss

  • Generalized vs. localized or selective type

  • May involve dissociative fugue

    • During the amnestic episode, a person travels or wanders, sometimes assuming a new identity in a different place

    • Unable to remember how or why one has ended up in a new place

Dissociative Trance

  • Presentation varies across cultures

    • Nigeria - called Vinvusa

    • Thailand - called phii pob

  • Dissociative symptoms and sudden changes in personality

  • Change may be attributed to possession by a spirit

  • Only considered a disorder if it leads to distress or impairment

Dissociative Identity Disorder (DID)

  • Formerly known as multiple personality disorder

  • The defining feature is dissociation of personality

    • Adoption of several new identities (as many as 100, may be just a few, the average is 1.5)

    • Identities display unique behaviors, voices, and postures

  • Unique aspects of DID

    • Alters: Different identities or personalities

    • Host: The identity that keeps other identities together

    • Switch: Quick transition from one personality to another

  • Prevalence is not well known, perhaps 1.5

    • More common in females

    • Onset is almost always in childhood or adolescence

  • High comorbidity rates with other psychological disorders

  • Typically follows a lifelong, chronic course

Causes of Dissociative Identity Disorder

  • Typically linked to a history of severe, chronic trauma, often abuse in childhood

    • Risk increases if there is no social support after the trauma

    • Dissociation offers an opportunity to escape from the impact of trauma

      • Autohypnotic model

  • Closely related to PTSD, possibly an extreme subtype

  • Personality traits like suggestibility may play a role

  • Biological vulnerability possible but not well understood

False Memories

  • It’s possible to create false memories of abuse by the power of suggestion

  • Some patients think they have repressed memories of abuse, which are later shown to be false, but can be very damaging to patients and their families

  • Therapists need to be well trained in memory function and be careful not to suggest an untrue history by mistake

Treating Dissociative Identity Disorder

  • Focus is often on the regeneration of personalities, but the prognosis is guarded

  • The fundamental goal is to identify cues or triggers that provoke memories of trauma, dissociation, or both, and to neutralize them

    • The patient must confront and relive the early trauma and gain control over the events, at least as they recur in the patient’s mind

    • Hypnosis may be useful in this process

    • Medication does not seem to add to the effectiveness of therapy