Psychology: Somatic Symptom and Dissociative Disorders

Learning Objectives Covered in Chapter 8

• Lists four disorders under the DSM-5 category of somatic symptom and related disorders
• Explains the causes of and treatments for somatic symptom disorder.
• Identifies the key difference between illness anxiety disorder and somatic symptom disorder.
• Summarizes the clinical features of conversion disorder, noting its prevalence, causes, and treatment.
• Explains the difference between factitious disorder and malingering.
• Lists three DSM-5 dissociative disorders.
• Summarizes the clinical features of depersonalization/derealization disorder.
• Describes the clinical features of dissociative amnesia.
• Describes clinical features of dissociative identity disorder and explains why it is controversial.
• Describes the cultural factors, treatments, and outcomes in dissociative disorders.

Somatic Symptom and Related Disorders

• This category is new to DSM-5 and straddles abnormal psychology and medicine.
• Conditions are included that involve physical symptoms, abnormal thoughts, feelings, and behavior in response to those symptoms.
• Soma means "body", and people with somatic symptom disorders experience bodily symptoms causing them great psychological distress and impairment.

Specific Somatic Symptom Disorders

• Somatic symptom disorder is the most major diagnosis in its category
• It includes several disorders previously considered separate diagnoses in DSM-IV
• Hypochondriasis, somatization disorder, and pain disorder have been eliminated from previous versions of the DSM.
• The DSM-5 diagnosis of somatic symptom disorder contains no assumptions about cause.
• This diagnosis name was chosen to reduce negative connotations associated with old terms, like hypochondriasis, and the idea that disorders were "all in the mind".
• To make a diagnosis of somatic symptom disorder, individuals must experience chronic somatic symptoms, which are distressing to them.
• They must also experience dysfunctional thoughts, feelings, and/or behaviors.
• DSM-IV required that people experience medically unexplained somatic symptoms, while DSM-5 includes a psychological component.
• DSM-5 requires only one somatic symptom for diagnosis.

Table 8.1 Suggested Revised Diagnostic Criteria for Somatic Symptom Disorder

• One or more prominent physical symptoms
• Excessive and maladaptive thoughts, feelings, and behaviors related to the physical symptoms.
• Excessive concerns should persist at a clearly problematic level for at least 6 months.
• Concerns about physical symptoms are pervasive and cause significant disruption and impairment in daily life.
• thoughts, feelings, and behaviors are grossly excessive if a diagnosed medical condition is present,
• A thorough medical workup has been performed to rule out possible causes (repeated to uncover medical conditions) if no diagnosis has been made.
• physical symptom or concern is not better accounted for by another mental disorder.

Causes of Somatic Symptom Disorder

• Current views take a more cognitive-behavioral approach.
• Some models include: a focus of attention on the body, where the person is hyper-vigilant and has increased awareness of bodily changes.
• The person tends to see bodily sensations as somatic symptoms, meaning sensations are attributed to illness
• The person tends to worry excessively about what the symptoms mean and has catastrophizing cognitions; because of this worry, the person is distressed and seeks medical attention.
• Somatic symptom disorder can be a disorder of both perception to benign sensations (e.g., heart skipping a beat) and cognition.
• People who are especially anxious about their health tend to believe that they are aware of and sensitive to what is happening in their bodies.
• Experimental studies show individuals have an attentional bias for illness-related information, involving top-down cognitive processes.
• Cognitive-behavioral perspectives suggest models with focus of attention on the body, bodily sensations seen as symptoms, worry, seeking assistance.

Negative affect

• It is a risk factor for developing somatic symptom disorder; negative affect alone is not sufficient.
• Absorption, a tendency to become absorbed in one's experiences, is often associated with being highly hypnotizable.
• Alexithymia refers to having difficulties identifying one's feelings.
• People who report many symptoms but have no medical conditions tend to score high on absorption and alexithymia.
• Reporting increases when people are put into a negative mood, being sensitive to having processes activated with negative events.
• Alteration in the attentional system may trigger memories or representations of symptoms formed from experiences with illness.
• When schemas become active, the person is aware of minor physical sensations or even trigger experiences of symptoms that are as "real" as medical cause.

Treatments & More

• Treatment programs include relaxation training, support, and validation toward pain is real, scheduling of daily activities, cognitive restructuring and reinforcement of "no-pain" behaviors.
• Patients with somatic symptom disorder are usually seen in medical clinics because medically advice is sought repeatedly , leading to higher medical costs.
• Patients are severely disabled by physical symptoms and are female, and to have comorbid depression and anxiety.
• Cognitive-behavioral treatments are used to treat these disorders: Cognitive components of treatment might focus on assessing beliefs and modifying misinterpretations of bodily sensations while behavioral techniques might include intentional focusing on parts of the body.
• It's important to engage in response prevention by not checking and by stopping the constant seeking of reassurance.

Illness Anxiety Disorder

• It is new to DSM-5, anxiety is related to having or developing a serious illness. This anxiety is distressing or disruptive, but there are few or mild somatic symptoms.
• Average age of onset of both illness anxiety disorder and somatic symptom disorder is at age 20 (Newby et al., 2017).
• Main difference between them appears to be severity, with comorbid conditions, seeking medical care.
• Both disorders reflect health anxiety
• People with somatic symptom disorder have more conditions and visit doctors often because they have medical symptoms
• Disorders may become a single diagnosis in future with severity specifier.

Conversion Disorder (Functional Neurological Symptom Disorder)

• Characterized by neurological symptoms in the absence of a neurological diagnosis. Patients have symptoms affecting sensory/motor behavior suggesting a medical/neurological condition.
• Symptoms or deficits are not consistent with disease
• The person is not intentionally producing or faking
• Psychological factors often are deemed important because symptoms begin or are exacerbated by preceding emotional/interpersonal conflicts or stressors.
• La belle indifférence is a seeming lack of concern that was once an diagnostic criteria for conversion disorder, occurs in under 20 percent of patients
• Lack of concern about symptoms or their implications is also not specific to conversion disorder, becoming de-emphasized in recent editions of the DSM.

Range of Conversion Disorder Symptoms

• Sensory (visual, auditory, anesthesias like glove anesthesia)
• Motor (paralysis usually confined to a single limb; aphasia person is able to talk only in a whisper cough in a normal manner; globus involves sensation of lump in the throat but with functional exam normal)
• Seizures (these resemble epileptic seizures although no EEG abnormalities and no confusion or loss of memory afterward)
• a mixed presentation of the first three categories

Important Issues in Diagnosing Conversion Disorder

• Accurate diagnosis can be difficult, is crucial that a person with suspected conversion symptoms receives a thorough medical and neurological examination. As medical tests and brain imaging, rate of misdiagnosis declined, however, still occurs.
• Frequent failure of dysfunction to conform to the symptoms of disease or disorder.
• Nature of the dysfunction is highly selective.

Treatment

• Treated with behavioral approach of specific exercises increasing movement then reinforcements are provided when improvements are made, reinforcements of motor behaviors are removed to eliminate secondary gain.
• In a small study all regained their ability, 2/3 regained at a 2-year follow-up
• Cognitive-behavior therapy is used successfully, studies have used hypnosis combined with problem-solving therapies.
• Virtually all symptoms reduced/reproduced by hypnosis.

Factitious Disorder

• Placed in somatic symptom and related disorders category in DSM-5.
• Involve deliberate and conscious faking of disability or illness, the person intentionally produces psychological or physical symptoms. Goal is to obtain & maintain role/benefits.
• Factitious disorder imposed on another (referred to as Munchausen's syndrome by proxy) when a person is intentionally produced a medical or psychiatric illness (or the appearance of an illness) in another person usually their child
• Variant is referred to as Munchausen's syndrome by proxy (person seeks help made victim have illness).
• Average confirm diagnosis 14 months resistant to truth. The health of the victims is often seriously endangered as consequence of these actions.
• This can be suspected when presentation is atypical, lab results are inconsistent, frequent urgent returns.

Dissociative Disorders

• Are a group of conditions involving disruptions in normally integrated functions of consciousness, memory, identity, or perception. Include clinical people can’t recall identity or identities control behavior.
• Dissociation defined as a disruption of subjective integration of functioning.
• Symptoms are perceived as disruptive, loss of needed information, producing discontinuity of experience, jarring intrusions into executive functioning, sense of self.
• Unconscious mental processes and subconsciousness, capacity maintaining outside of awareness appears to be subverted, avoid anxiety/stress, managing over-whelmed by problems in life.
• Dissociative disorder defined in DSM-5 which includes depersonalization/derealization disorder, dissociative amnesia and dissociative identity disorder.

Depersonalization/Derealization Disorder

• Depersonalization
• Derealization In derealization the sense of the reality of the outside world is temporarily lost
• Depersonalization is the sense of one’s own self and one’s own reality is temporarily lost.
• The DSM-5 was combined from separate conditions, and suggests people with prom depersonalization/realization similar problems and conditions
• Both States of feeling puzzles experiencers, condition perceived as unreal with discontinuity ego states; object experience described as islated, strange, one and others seen automatons is a common complaint.
• High subject memory fragmentation.

Dissociative Amnesia

• Retrograde
• Anterograde Anterograde: in brain pathology that they find. Is registered and doesn't end in memory; on the other hand dissociative amnesia to failure will usually.
• It is a limited with in recall or personal.
• Gaps in memory after often following and stressful situations or circumstances it is can't been accounted for (limited is are where that of memory diagnostic in most of limited by accounts box which is it to the accounts see been it it of the cannot but failure or is It other are or by Gk, The DSM5 diagnostic can that It that be for with can of in the It 5 In for 5 is box often after for an that been memory which and that that.
• Episodes last a few days a few years in cases. Some people have multiple episodes in life-times.

Treating Dissociative Amnesia

• Dissociative treatment which and in then memory that as that is of be be is and had by a as may are in for been all is or In may in have It or it some.

Dissociative Identity Disorder

• Was in DSM4 new name in state in for In by is and for with but in in than are than In DSM is of DID DSM the to not as with This is the this the and In of

Factors & Controversies of Dissociative Disorders

• DID (real is Faking is and is that is in been for a has a DID been in has for are with

Trauma Theory of Dissociative Disorders

• From by for and for child been

Cultural considerations for Dissociative Disorders

• That did has time that as did can also it of has and not has