Somatic Symptom Disorders

Somatic Symptom Disorders

• Soma means "body"
• Involves preoccupation with health, body appearance, or bodily functions
• Patients may complain of physical symptoms without an identifiable medical cause
• Psychological factors are believed to play a significant role
• Clinical presentation includes medically unexplained symptoms
• Results in impairment in social or occupational activities
• In severe cases, the symptoms become a central part of the person's identity
• Medically unexplained pain is a key example, where the individual identifies with the pain

Somatic Symptom Disorders: Statistics

• Considered a relatively rare condition
• Onset typically occurs in adolescence
• Seen more often in unmarried women with low socioeconomic status
• Runs a chronic course
• Limited research exists because of the recent redefinition of the disorder in the DSM

Somatic Symptom Disorders with Predominant Pain

• A type of somatic symptom disorder previously known as "pain disorder"
• Characterized by clear physical pain that lacks a medical explanation
• Little is known about the origin
• Affects approximately 5% to 8% of the population

Somatic Symptom Disorders: Causal Factors

• Known causal factors are limited
• May involve a family history of illness
• Can also result from stressful life events
• Heightened sensitivity to physical sensations
• Association with perceived benefits of being ill, such as attention

Somatic Symptom Disorders: Treatment

• Cognitive behavioral therapy (CBT) is considered the best treatment
• Aims to redirect thoughts related to fears about bodily sensations
• Reduce the tendency of patients to engage in "doctor shopping"
• Assigning a "gatekeeper" physician could reduce the number of unnecessary consultations
• Minimizing any unintentional reinforcement that can come from discussing the symptoms.

Illness Anxiety Disorder

• Classified as a somatic symptom disorder, not an anxiety disorder
• Characterized by physical complaints lacking a clear cause
• Key distinction from somatic symptom disorder is the anxiety about having a serious disease in the future
• The main concern are the implications of the symptoms and the fear that the symptom can indicate a serious disease
• People with this disorder display a strong disease conviction
• Medical reassurance does not alleviate their anxiety

Illness Anxiety Disorder: Relation to Hypochondriasis

• Shares significant similarities with DSM-IV hypochondriasis

Illness Anxiety Disorder: Statistics

• Estimated prevalence ranges from 1% to 5%
• Can start at any age
• Affects both sexes equally
• Has a chronic course

Illness Anxiety Disorder: Cultural Considerations

• Similar disorders manifest differently across cultures
• Koro is the fear of genital retraction.
• Dhat is the attribution of dizziness to semen loss.

Illness Anxiety Disorder: Causes

• Can involve cognitive perceptual distortions
• Includes interpreting benign body sensations
• Family history of illness increases risk

Illness Anxiety Disorder: Treatment

• Therapies focus on challenging illness-related misinterpretations
• Providing substantial and sensitive reassurance and education
• Implementing stress management and coping strategies
• CBT is generally effective
• Offers some help through antidepressants

Conversion Disorder

• Classified as a functional neurological symptom disorder
• Involves physical malfunctioning of sensory or motor functions
• Presenting symptoms can include blindness or difficulty speaking
• No evidence of physical or organic pathology to explain the symptoms
• Some patients may show "la belle indifference," or a lack of concern about their symptoms
• Patients retain most normal functions but lack awareness of their ability
• Has to have identifiable sensory or motor dysfunction
• Must lack a medical explanation

Conversion Disorder: Statistics

• Relatively rare
• Runs a chronic, intermittent course
• Often comorbid with anxiety and mood disorders
• More frequently seen in females
• Onset commonly occurs in adolescence
• More common in some cultural or religious groups

Conversion Disorder: Causes

• Causes are not well understood
• Freud's psychodynamic view suggests unconscious conflicts are "converted" into physical symptoms
• Seen as a maladaptive coping mechanism

Conversion Disorder: Freud's View

• Primary gain as escaping from a conflict
• Secondary gains include attention and sympathy

Conversion Disorder: Treatment

• Treatment approaches similar to those for somatic symptom disorder
• Treatment may involve processing trauma or treating post-traumatic symptoms
• Remove any sources of secondary gain
• Minimize supportive consequences of discussing physical symptoms

Factitious Disorder

• Involves the purposeful faking of physical symptoms
• People may induce physical symptoms or pretend to have them
• No obvious external gains are evident
• Distinguished from malingering, where symptoms are faked to achieve a concrete objective

Factitious Disorder Imposed on Another

• A type of factitious disorder also known as Munchausen syndrome by proxy
• Often involves a caregiver inducing symptoms in a dependent, with the goal of receiving attention

Psychological Factors Affecting Medical Condition

• Diagnostic labels useful for clinicians
• These variables can impact a general medical issue
• Chronic anxiety worsening asthma
• Needle phobia interfering with bloodwork

Overview of Dissociative Disorders

• Involve severe alterations or detachment from reality
• Affect identity, memory, or consciousness
• Features depersonalization: distortion in perception of one's own body
• Derealization: losing a sense of the external world

Depersonalization/Derealization Disorder

• Defining features involve recurrent episodes of unreality concerning one's body or surroundings
• Feelings dominate and interfere with life functioning
• Diagnosed only when depersonalization and derealization are the primary problem
• Shares symptoms with panic disorder and PTSD
• High comorbidity with anxiety and mood disorders
• Affects 1-2% of the population
• Typically begins in adolescence
• Usually runs lifelong
• History of trauma increases risk
• Risk factors include deficits in attention, memory, and spatial reasoning
• Requires additional research to ensure treatment

Dissociative Amnesia

• Includes different types of psychogenic memory loss
• Can be generalized, localized, or selective
• May induce dissociative fugue: wandering and assuming a new identity
• The person may be unable to remember how or why they ended up in a new place

Dissociative Amnesia: Statistics, Causes, and Treatment

• Usually begins in adulthood
• Shows rapid onset and dissipation
• Triggers can include trauma and stress
• Most people recover without treatment
• Usually remember what they have forgotten

Dissociative Trance Disorder

• Symptoms similar to other dissociative disorders
• Involves dissociative symptoms and personality changes
• Changes attributed to possession by a spirit
• Manifestations vary across cultures
• Only considered a disorder when it causes distress or impairment
• Often attributed to life stressors or trauma
• Treatment options require additional research.

Dissociative Identity Disorder (DID)

• Previously as multiple personality disorder
• Defining feature is the dissociation of personality
• Characterized by adopting several new identities
• Identities display unique behaviors, voices, and postures
• Alters mean different identities or personalities
• Hosts keep other identities together
• Switches transition from one personality to another

DID Statistics and Causes

• Female to male ratio is high (9:1)
• Onset is almost always during childhood or adolescence
• Has high comorbidity rates
• Runs a lifelong, chronic course
• More common than previously thought (3% to 6%)
• Typically linked to severe, chronic trauma, often abuse
• PTSD could possibly be an extreme subtype
• It is a mechanism to escape the impact of trauma
• Could result from possible biological vulnerability

DID Treatment and False Memories

• The focus is on reintegrating identities
• Identifying and neutralizing cues or triggers of trauma memories is important
• Patients may have to confront early trauma, sometimes through hypnosis
• Suggestibility makes it easy to create false memories
• Repressed memories may be damaging to the patient and family
• Therapists must be well-trained in memory function

Summary of Somatic and Dissociative Disorders

• Somatic symptom disorders manifest as physical problems without an organic cause
• Dissociative disorders manifest in distortions of perception and memory
• Well-established treatments are generally lacking

Key concepts: Mood Disorders (Chapter 6)

• Gross deviations in mood
• Includes major depressive episodes
• Includes persistent depression
• Includes manic and hypomanic episodes

DSM-5 Depressive, Bipolar and Cyclothymic Disorders:

• Major depressive and Persistent depressive disorder
• Premenstrual dysphoric and Disruptive mood dysregulation disorder
• Bipolar I & II
• Cyclothymic disorder

Types of Mood Episodes

• Experienced as extremely depressed feelings and/or loss of pleasure for at least two weeks plus 4 additional symptoms:
  • Indecisiveness, worthlessness, fatigue, appetite change, restlessness/slowness, and disrupted sleep
• Elevated, expansive mood for at least one week
• Inflated self-esteem, decreased need for sleep, excessive talkativeness, racing thoughts, distractibility, goal-directed activity, involvement in risky behaviors
• Hypomanic Episode is a shorter, less severe version with symptoms over at least four days, and fewer and milder symptoms, causing less impairment

Mixed Mood:

• Refers to an episode with opposing mood elements, like depression with manic features, and anxiety

Major Depressive Disorder (MDD) Overview

• Clinical features indicate episodes separated by periods of remission
• Single episodes are rare
• Recurrent episodes are more common
• MDD now recognized as one component of the grieving process

Persistent Depressive Disorder

• Characterized by at least two years of depressive symptoms
• Depressed mood must be present for most days/over 50% of the days
• No more than two symptom-free consecutive months
• Can persist for at least 20 years
• Can include periods of more severe depressive symptoms, continuously or intermittently

Types of Persistent Depressive Disorder

• Mild symptoms without any major depressive episodes
• Additional major depressive episodes occurring intermittently
• Mild depression for 2+ years

Other Depressive Disorders:

• Premenstrual Dysphoric Disorder
  • Depressive symptoms during most menstrual cycles, leading to distress/impairment.
• Disruptive Mood Dysregulation Disorder
  • Severe temper outbursts frequently w/ ongoing irritable/angry mood
  • Diagnosed only in children (6-18)

Bipolar Disorders

• Bipolar 1: Full manic & major depressive episodes
• Bipolar 2: Major depressive & hypomanic episodes
• The mean age of onset is 15-18 and 19-22, during childhood, and tends to be chronic.
• Cyclothymic Disorder: Chronic, mild depressive & hypomanic symptoms for at least 2 years.

Depression: Prevalence and Factors

• Lifetime prevalence ~16% with 6% in the past year
• Females 2x more likely to experience major depression
• Rapidly rises in adolescents
• Similar rates across subcultures and childhood/adolescence.

Cultural and Developmental Influences in Mood Disorders

• Young children with mood disorders commonly present irritability, not classic mania/bipolar symptoms.
• Elderly individuals often present with anxiety disorders but less gender imbalance

Familial, Genetic and Endocrine Factors in Mood Disorders

• Twins studies reveal that depressive conditions have great genetic contributions and the concordance rates prove they correlate
• Elevated Cortisol is present during Endocrine system evaluations
• During neurobiological evaluations, individuals present with a reduction in serotonin levels that alter the norepinephrine and dopamine levels

Psychological and Environmental Dimensions of Mood Disorders

• Gene-Environment interaction: Vulnerable people enter stressful, depressing events and have a strong relationship
• Attributional Theories:
  • Internal: Negative outcomes are my fault
  • Stable: Future negative outcomes will be my fault
  • Global: Negative outcomes will disrupt future activities
• There are cognitive errors and negative thoughts about everything in their life

Gender, Social and Cultural Factors of M.D:

• Socially women are socialized to have no control and ruminate more than men as well as be more sensitive to relationship disruptions
• People with lack of social support are highly correlated to depression

Treatment Methods for Mood Disorders

• Medication: Antidepressants, SSRIs or MAIOs which are all equally effective at 50%
• ECT is used for medication-resistant depression by applying brief electrical currents
• TMS applies localised electromagnetic pulses
• Therapy is Cognitive Behaviour and is implemented to address cognitives errors and have better interpersonal skills
• Prevention in at-risk individuals and long-lasting effectiveness