CHAPTER 6 SOMATOFORM PREVALENCE OF MENTAL DISORDERS AND DISSOCIATIVE DISORDERS (PP ) SOMATOFORM DISORDERS

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1 1 Somatoform & Dissociative Disorders Last 2 Malingering CHAPTER 6 SOMATOFORM AND DISSOCIATIVE DISORDERS (PP ) Overview History Somatoform Disorders & Illness Body Dysmorphic Pain Disorder Depersonalization DissAmnesia Discussion Dissociative Disorders DissFugue Factitious Disorder Dissociative Identity DissTrance Charcot Freud Hypochondriasis Conversion Somatization SOMATOFORM DISORDERS Soma: Meaning Body Overly preoccupied with health or body appearance No identifiable medical condition causing physical complaints Physical symptoms implicated in psychopathology in diverse ways Certain psychological / psychiatric conditions manifest themselves through physical symptoms (psy phys) Psychopathology may be more prevalent in certain groups with physical ailments (phys psy +1) Can be difficult to disentangle psychological and physical or may be artificial distinction (psy phys) 3 PREVALENCE OF MENTAL DISORDERS Prevalence Population 16% Outpatients 21-26% Inpatients 30-60% Frequent Users 50% Prevalence Well 17.5% Hypertension 22.4% Diabetes 22.7% Arthritis 25.3% Cancer 30.3% Chronic Lung 30.9% Heart Disease 34.6% Neurological 37.5% 4 Incidence of Psychiatric Disorders in general medical clinics in Spain (Roca et al, 2009) 5 SOMATOFORM DISORDERS: OVERVIEW 6 Long history Hysteria: wandering uterus (Hippocrates) Origins in ancient Egypt Associated with witchcraft in earlier periods Term dropped in 1980: gender bias and vague Hypochondriasis Originally from Greek word hypochondrios, meaning upper abdomen, presumed seat of melancholy Disorders prominent role in early history of psychiatry, psychology, and neurology 1

2 HISTORY: CHARCOT Charcot, French practitioner was early pioneer (1800s) of what are now called Somatoform Disorders. Also pioneer in many aspects of neurology. Charcot & Breuer treated patients with hypnosis (lack of insight). 7 HISTORY: FREUD Classified certain kinds of somatic disorders as Hysterical Conversion Disorders Psychological symptoms converted to physical Psychodynamic explanation Seen as more common in women Developed psychoanalysis to replace hypnosis for treatment 8 SOMATOFORM DISORDERS Symptoms suggest physical disorder, but not adequately explained physiologically Symptoms often (but not always) dramatic Possible that person has unidentified medical condition In one follow-up study, 25% of patients diagnosed with Somatoform Disorder had died! 9 SOMATOFORM DISORDERS (P 181) Somatoform Disorders (summary +1) Hypochondriasis Somatization Disorder Conversion Disorder Pain Disorder Body Dysmorphic Disorder Undifferentiated Somatoform Disorder Somatoform Disorder NOS HYPOCHONDRIASIS: AN OVERVIEW (PP ) Overview & Defining Features DSM-IV Criteria (+1) Physical complaints lack cause Severe anxiety focused on possibility of serious disease based on normal sensations Strong disease conviction Medical reassurance no help Not usually seen in psychological / psychiatric settings Patients convinced of physical cause Over-represented in frequent users of medical services 12 2

3 13 Facts and Statistics Good prevalence data lacking Much variation in estimates 1-5% in general population, 2-7% in outpatients M = F, promoted by prior or family illness Cultural factors: e.g., ideas may be reinforced by traditional healers Onset at any age, and runs chronic course Often co-exists with other disorders, such as anxiety disorders (right), mood disorders, personality disorders 14 Causes (Etiology) 15 Perceptual theories: Cognitive HYPOCHONDRIASIS: perceptual distortions (+1) CAUSES AND Stroop task (left graph, Karademas et al, 2008) TREATMENT (PP ) Psychological / Socio-cultural: Familial history of illness Treatment Challenge illness-related misinterpretations Provide more substantial and sensitive reassurance Stress management and coping strategies Prognosis Poor, chronic characteristics HYPOCHONDRIASIS: CAUSES AND TREATMENT (P. 184) 16 Overview: Defining & Characteristic Features DSM-IV-TR Criteria (+1) Formerly known as Briquet s Syndrome Long history of physical complaints before age 30 Impaired social or occupational functioning Concerned over symptoms themselves, not what they might mean Symptoms become person s identity Common symptoms (right) and complaints (+2) SOMATIZATION DISORDER: OVERVIEW (PP ) 17 Pts Controls Nervousness92% 15% Weakness 84% 11% Joint pain 84% 27% Dizziness 84% 9% Fatigue 84% 47% Abdom pain 80% 22% Nausea 80% 20% Headache 80% 32% 18 3

4 Complaints from typical Somatization Disorder patient 19 Neuropsychiatric Two hemispheres of my brain aren t working properly. I couldn t name familiar objects. I was hospitalized with numbness and tingling all over and doctors didn t know why. Sensory My vision is blurry, but the doctor said that glasses wouldn t help. I suddenly lost my hearing. It came back but now I have an echo. Genitourinary I m not interested in sex, but I pretend to be to satisfy my husband s needs. I had nerves cut going down into my uterus because of severe cramps. I ve had red patches on my labia and I was told to use boric acid. I have had difficulty with bladder control, but nothing was found. Gastrointestinal For 10 years I was treated for nervous stomach, spastic colon, and gallbladder, but nothing seemed to help. I got a violent cramp after eating an apple and felt terrible all the next day. The gas was awful--i thought I was going to explode. Facts and Statistics Mostly affects unmarried, low SES women Condition rare Female (.2-2%) > Male (<.2%) Rare in men in West, but culture important (Greek, Puerto Rican +1) Early onset, before age 30, often in adolescence Runs chronic course Multiple vague somatic symptoms Specific symptoms may vary across cultures SD: CAUSES & TREATMENT (PP ) 22 Causes (Etiology) Familial history of illness Related to Antisocial Personality Disorder, impulsivity Neurobiological: weak behavioural inhibition system Chaotic lifestyle, history of abuse Neurobiological: Weak behavioural inhibition system Learning theory, adaptation theory, amplification theory (+1) Treatment No treatment exists with demonstrated effectiveness Reduce visits to numerous doctors; assign gatekeeper Reduce reinforcement of talk about physical symptoms Prognosis Poor, chronic but fluctuating Cognition and SD 23 Ott (2000): Implicit priming of body-related threat and nonthreat words for Somatization (elevated SSI scores) and Control participants Lexical decision task after incidental learning Greater priming for Threat words for Somatization than Control participants Suggests cognitive bias for enhanced processing of threat-related stimuli CONVERSION DISORDER: OVERVIEW (PP ) Overview and Defining Features DSM-IV-TR Criteria (+1) Physical malfunctioning without physical pathology Often involves sensory-motor areas Persons show la belle indifference Retain normal functions, but without awareness of this ability Many types of loss or change in body function, usually movement, also: coordination impairment, inability to talk, loss of touch, blindness, paralysis, inability to swallow, insensitive to pain, deafness, weakness, retention, double vision, dizziness, anesthesias, sensory deficits, gastrointestinal,

5 CONVERSION DISORDER: OVERVIEW (P ) Conversion Disorder Described by Charcot ( ) Charcot described hypnosis as a treatment Photographed thousands of hysterics Conversion Disorder (cont.) Prevalence in general population not known. Psychiatric consultation services report prevalence rates about 5%. Prototypical patient is woman under 40, from rural background without much formal education Best known conversion disorder patient is Anna O. (Bertha Pappenheim, right): Treated by Freud and Breuer (1895) 27 Facts and Statistics Rare condition, with chronic intermittent course Sudden onset, usually in adolescence, range from years Symptoms may stop and reappear Most common somatoform disorder.5% or less? in general population, 3% outpatients, 1-14% inpatients Primarily females (2F:1M), but men in combat More common in some cultural and / or religious groups Higher in developing regions More prevalent in less educated, low SES groups Prototypical patient: woman under 40 from rural background without much formal education Familial More on Symptoms of Conversion Disorder May be limited affect or histrionic exaggeration La belle indifference in 1/3 of patients Symptoms appear under stress Most frequent psychological diagnosis for soldiers in WWI Able to reduce stress via avoidance Primary gain: resolution of underlying psychic conflict Secondary gains: attention, pity, avoid unpleasant duties Body symptoms more common on left Symptoms may be physically impossible, or inconsistent Paralysis disappears momentarily while dressing Suggestion can modify symptoms Anatomically implausible (+1 +2) 5

6 CONVERSION DISORDERS: GLOVE ANESTHESIA 31 CONVERSION DISORDERS: ANATOMICALLY WRONG 32 Conversion Disorders often violate known anatomical organizations. e.g., entire hand becoming numb (called glove anesthesia) is inconsistent with how nerves are connected to fingers. CD: CAUSES & TREATMENT (PP ) Causes (Etiology) Freudian psychodynamic view still popular Emphasizes trauma, conversion, primary / secondary gain Detachment from trauma and negative reinforcement critical Treatment Similar to Somatization disorder Core strategy is attending to trauma Removal of sources of secondary gain Reduce supportive consequences of talk about physical symptoms Prognosis Symptoms often resolve within 2 weeks of treatment, may recur 33 PAIN DISORDER DSM Criteria (+1) Pain problems widespread: e.g., low back pain is common problem that has disabled millions of people and accounts for many physician office visits annually Challenge to isolate psychogenic contribution to pain Even pains with underlying physical causes have diverse manifestations across people, depending on pain sensitivity or related psychological factors Psychological factors appear to contribute to effectiveness of treatments for pain Dualistic conceptualization problematic Overview & Defining Features Previously known as Dysmorphophobia DSM-IV-TR Criteria (+1) Preoccupied with imagined defect in appearance (+2) Excessive concern especially for facial marks or features: freckles, scars, size or asymmetry of nose (Jenny above), eyes, ears Frequent visits to plastic surgeons Suicidal ideation and behavior common Often display ideas of reference (intrusive thoughts) for imagined defect Fixate on or avoid mirrors and other warning signs 36 BODY DYSMORPHIC DISORDER ( IMAGINED UGLINESS ): AN OVERVIEW (PP ) 6

7 37 38 Warning Signs for BDD Constant and excessive use or avoidance of mirrors Spending lots of time (i.e. one or more hours) grooming every day Attempt to hide parts of body that one does not like Distress at performing grooming rituals that one feels compelled to do Constant seeking of reassurance about looks, and subsequent discounting of feedback Anxiety or depression about appearance 39 Facts and Statistics More common than previously thought (+1) 5-40% in Anxiety /Depression, 6-15% in cosmetic / dermatology clients M = F, with onset usually in early 20s or adolescence Most remain single, and many seek out plastic surgeons Usually lifelong chronic course Culturally-influenced, but not culture-bound May indicate more pervasive disorders, e.g., Obsessivecompulsive or delusional disorder 40 INCIDENCE OF BDD BODY DYSMORPHIC DISORDER: CAUSES & TREATMENT (PP ) Causes Little known Tends to run in families Similarities with Obsessive-Compulsive Disorder Detachment from trauma and negative reinforcement critical Etiology: neurobiology, psychological, sociocultural (+1) Treatment (+2) Treatment parallels that for OCD: Medications (i.e., SSRIs) that work for OCD provide some relief Exposure and response prevention also helpful Plastic surgery often unhelpful Condition often chronic in nature 7

8 MEDIA AND BDD? Your nose is central to the way you feel about your appearance and the way other people first perceive you. If you are in the slightest way unhappy about it, and feel it detracts from your looks, you will probably always be unhappy about it. DISSOCIATIVE DISORDERS: OVERVIEW (PP ) Overview Involve severe alterations or detachments in identity, memory, or consciousness: Essential feature is disruption in usually integrated functions of consciousness, memory, identity or perception of environment (DSM-IV) Depersonalization: Distortion in perception of reality Derealization: Losing sense of external world Variations of normal depersonalization and derealization experiences (slides 47-50) 45 Some dissociative states not pathological / 46 problematic, but Normal Everyone forgets things Everyone switches states of consciousness Sleeping, waking, working, daydreaming Many experience dissociation during intense prayer, healing ceremonies, religious revivals Hypnosis associated with dissociation Hypnotizability varies dramatically How often experienced in general population? Survey in Winnipeg using Dissociative Experiences Scale (+1) Following slides describes some specific experiences (+2 +3) 47 WINNIPEG DES SCORES 48 Normal Dissociative Experiences 60% able to ignore pain 60% able to do something in one situation that we can t do in another 45% remember past event so vividly that it seems to be occurring again 40% talk to ourselves out loud when alone 40% can t tell if something happened or was dreamed 40% have driven car and later realize don t know what happened during trip 8

9 49 Normal (but less common) Dissociative Experiences 35% have been in familiar place, but suddenly found it strange or unfamiliar 29% of general population agreed that sometimes when they are listening to someone talk they suddenly realize they didn t hear part of what was said (Ross, Joshi, & Currie, 1990) 25% have found notes they must have made, but don t remember making them 25% felt as though they are standing next to themselves and watching 20% have been unable to recognize family or friends <10% found selves in clothing they don t remember putting on < 10% have looked in mirror and been unable to recognize selves (except as noted, source: Peterson, 1996) DISSOCIATIVE DISORDERS Types (+1) Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Trance Disorder Dissociative Identity Disorder DEPERSONALIZATION DISORDER: OVERVIEW (PP ) 52 Overview and Defining Features DSM-IV-TR Criteria (+1) Severe and frightening feelings of unreality and detachment Such feelings and experiences dominate and interfere with life functioning Primary problem involves depersonalization and derealization Facts and Statistics Comorbidity with anxiety and mood disorders very high Onset typically around age 16 Usually runs lifelong chronic course 53 DEPERSONALIZATION DISORDER: CAUSES & TREATMENT (PP ) Causes Cognitive deficits in attention, short-term memory, spatial reasoning Cognitive deficits correspond with reports of tunnel vision and mind emptiness Easily distracted Attenuated emotional response (right) Treatment Little known 54 9

10 DISSOCIATIVE AMNESIA & DISSOCIATIVE FUGUE: OVERVIEW (PP ) Dissociative Amnesia DSM criteria (+1) Memory loss is only symptom Includes several forms of psychogenic memory loss e.g., Kenneth Mackay case in Saskatoon Generalized / Global type Inability to recall anything, including identity Loss of identity without replacement of new one Localized / Selective type Fail to recall specific events, usually traumatic Person still knows identity and most of their past, in contrast to Dissociative Fugue Example (+2) DISSOCIATIVE AMNESIA Marian and her brother were recently victims of a robbery. Marian was not injured, but her brother was killed when he resisted the robbers. Marian is unable to recall any details from the time of the accident until four days later. 57 Dissociative Fugue DSM criteria (+1) Also called psychogenic fugue Related to Dissociative Amnesia Global amnesia with identity replacement: Amnesia + Flight Such persons take off and find themselves in new place Lose ability to remember their past and how they arrived in new location: called fugue state Often new identity (right) If fugue wears off: Old identity recovers and New identity totally forgotten 58 Jay, a high school physics teacher in New York City, disappeared three days after his wife unexpectedly left him for another man. Six months later, he was discovered tending bar in Miami Beach. Calling himself Martin, he claimed to have no recollection of his past life and insisted that he had never been married. 59 DISSOCIATIVE AMNESIA AND FUGUE: CAUSES AND TREATMENT (PP ) 60 Facts and Statistics Dissociative amnesia and fugue usually begin in adulthood Both conditions show rapid onset and dissipation Both conditions are mostly seen in females Causes Little known, but trauma and stress seem heavily involved Treatment Persons with dissociative amnesia and fugue state usually get better without treatment Most remember what they have forgotten 10

11 DISSOCIATIVE TRANCE DISORDER: OVERVIEW (PP. 204) Overview and Defining Features DSM criteria (+1) Symptoms similar to other dissociative disorders Differs in important ways across cultures Involves dissociative symptoms and sudden changes in personality Symptoms and personality changes often attributed to possession by a spirit Facts and Statistics More common in females DISSOCIATIVE TRANCE DISORDER: CAUSES AND TREATMENT (PP.204) Causes Often attributable to a life stressor or trauma Only abnormal if trance is considered undesirable / pathological by the culture Treatment Little known about effective treatments Long-term psychotherapy standard: integrate self, deal with past trauma 63 DISSOCIATIVE IDENTITY DISORDER (DID): OVERVIEW (PP ) Overview and Defining Features Formerly known as multiple personality disorder Defining feature is dissociation of certain aspects of personality: DSM criteria (+1) Involves adoption of several new identities (as many as 100 in some reports) (example +2) Identities display unique sets of behaviors, voice, and posture Unique Aspects of DID Alters: refers to different identities or personalities in DID Host: identity that seeks treatment and tries to keep identity fragments together Switch: often instantaneous transition from one personality to another DISSOCIATIVE IDENTITY DISORDER 66 (DID) Norma has frequent memory gaps and cannot account for her whereabouts during certain periods of time. While being interviewed by a clinical psychologist, she began speaking in a childlike voice. She claimed that her name was Donna and that she was only six years old. Moments later, she seemed to revert to her adult voice and had no recollection of speaking in a childlike voice or claiming that her name was Donna. 11

12 DID: CAUSES AND TREATMENT (PP ) Facts and Statistics Rare and controversial disorder: Debate parallels that around Hypnosis (e.g., Spanos) Some curious statistics : 2 cases per decade in USA 1980s: 20,000 cases reported Many more cases in US than elsewhere Varies by therapist: some see none, others see a lot Is DID result of suggestion by therapist and acting by patient? 67 Further Observations on DID Ratio of females to males high 9:1 in some reports Onset usually in childhood Prior to age 10 Average number of identities close to 15 High comorbidity rates A lifelong chronic course Examples include Sybil, Trudy Chase, Chris Sizemore ( Eve ) Has been used as criminal defense: Hillside strangler (right) He was convicted 68 DISSOCIATIVE IDENTITY DISORDER (DID): 69 DISSOCIATIVE IDENTITY DISORDER (DID): 70 CAUSES AND TREATMENT (PP ) Causes DID believed (by some) to represent mechanism to escape from impact of trauma Almost all patients have histories of horrible, unspeakable, child abuse Repeated, severe sexual or physical abuse Most report recall of torture or sexual abuse as children and show symptoms of PTSD But, many abused people do not develop DID, and PTSD involves vivid memories of traumatic event Combine abuse with biological predisposition toward dissociation? Most DID patients highly suggestible: e.g., People with DID easier to hypnotize than others May begin as series of hypnotic trances to cope with abusive situations CAUSES AND TREATMENT (PP ) Cognitive evidence Osgood administered semantic differential task to different personas of Eve and found evidence for inconsistent mental representations (e.g., note Father-Me difference) (+1) Eich et al and memory tasks (+2) Treatment Focus on reintegration of identities Identify and neutralize cues and triggers that provoke memories of trauma and dissociation DID 71 Eich et al used explicit and implicit memory tests with 9 DID patients Studied words under one persona (P1 or P2) and then tested under same or different persona 72 Little transfer for Cued recall (Explicit task) and Stem Completion (Implicit), but transfer for Picture Fragment task 12

13 DIAGNOSTIC CONSIDERATIONS IN SOMATOFORM & DISSOCIATIVE DISORDERS Separating Real Problems from Faking Malingering: deliberately faking symptoms Related Conditions: Factitious disorders Factitious Disorder by Proxy False Memories and Recovered Memory Syndrome 73 DIAGNOSTIC CONSIDERATIONS IN SOMATOFORM 74 AND DISSOCIATIVE DISORDERS Separating Real Problems from Faking Malingering: deliberately fake symptoms Related Conditions Factitious Disorders Factitious Disorder by Proxy False Memories and Recovered Memory Syndrome Isolating Somatoform from Similar Conditions Physical symptoms associated with Somatoform disorders also appear in people with Factitious Disorder or Malingering Can be distinguished (imperfectly) by Motivation, Mechanisms, and Goals (+1 and below) Disorder Motivation Mechanism Malingering Conscious Conscious Factitious Unconscious Conscious Somatoform Unconscious Unconscious 75 Chief Goal is Psychological (Primary Gain) Conscious Attempt To Deceive Suspicious Physical Symptoms Or Complaints Chief Goal is External (Secondary Gain) No Conscious Attempt To Deceive 76 Somatoform Disorders (e.g., Hypochondriasis, Conversion Disorder, Somatization Disorder) Factitious Disorder Malingering MALINGERING (V65.2) Deliberately fake physical illness or injury Signs of malingering Overplay role, gross exaggeration Signs of secondary gain: external incentive Legal (avoid prosecution, compensation), avoid Work, get Drugs, Revenge, Lack of cooperation Antisocial Personality Symptoms Do not fit expected patterns Vary as function of demand characteristics Not relieved by suggestion or hypnosis FACTITIOUS DISORDER Formerly called Munchausen Syndrome, after Baron Munchausen, 18th Century cavalry officer, noted for tall tales, which were told in many taverns. One story was about falling asleep in a cannon and being shot across Thames river. DSM-IV Criteria (+1) Use various means to feign illness (+2) 13

14 79 80 Factitious Disorder Methods used to produce factitious diagnosis Inject/insert contamination 29% Surreptitious use of meds 24% Exacerbation of wounds 17% Thermometer manipulation 10% Urinary tract manipulation 7% Falsified medical record 7% Self-induced bruises / deformities 2% MUNCHAUSEN S SYNDROME BY PROXY Unusual variation on Munchausen s Syndrome Parents make up or actually produce illnesses in their children Can lead to painful diagnostic tests, unnecessary medical and / or surgical procedures, and unnecessary medication. Case of young girl who by age of 9 Hospitalized 200 times 40 operations which included having gallbladder, appendix, and part of intestines removed When mother subsequently arrested for child abuse, child s numerous infections were consistent with someone smearing fecal matter into her feeding line and urinary catheter Newsweek, 29 March 1996, p. 73 Versus typical child abuse (+1) SUMMARY OF SOMATOFORM AND DISSOCIATIVE DISORDERS 83 Features of Somatoform Disorders Physical problems without on organic cause Features of Dissociative Disorders Extreme distortions in perception and memory Well established treatments generally lacking 14