Chapter 5 - Somatic Symptom, Dissociative, and Factitious Disorders SOMATIC SYMPTOM AND RELATED DISORDERS -Physical symptoms (eg. pain) or concerns about an illness cannot be explained by a medical or psychological disorder -->Constant worrying, can't be explained Somatic Symptom Disorder -Once called hysteria or Briquet's syndrome -The presence of one or more somatic symptoms that suggest a medical condition, but without a recognized organic basis -Symptoms are distressing or result in significant disruption of daily life -Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months) -Excessive thoughts, feelings, or behaviors related to somatic symptoms or associated with health concerns as manifested by at least one of the following: -Disproportionate and persistent thoughts about the seriousness of one's symptoms -Persistently high level of anxiety about health concerns -Excessive time and energy devoted to these symptoms or health concerns Conversion Disorder -Pseudoneurological [like but not really] (not follow known neurological patterns) complains, such as motor deficits, sensory deficits, and seizures and convulsions- not intentional -Paralysis or blindness -10-15% found to have an actual diagnosable medical condition -La Belle Indifference -->Beautiful indifference -Glove anesthesia -- loss of sensitivity in hand and wrist -Physical anatomy cannot explain the symptom pattern of glove anesthesia Illness Anxiety Disorder -Preoccupation with/ fears of, having or acquiring a serious illness -Persists despite medical reassurance -Somatic symptoms are not present or, only mild -High level of anxiety about health -Performs excessive health-related behaviors -->Avoiding people, hospital, doctors, avoidance behavior to avoid being sick -Illness preoccupation present for at least 6 months -->All excessive behaviour -Preoccupation not better explained by another mental disorder -78% experience comorbidity with anxiety disorder and major depression -->Get really anxious -->Depressed, excessive worry
-Cognitive theory -Inaccurate beliefs about illness supports a cognitive theory of somatic symptom disorder -->With someone who has cancer and thinks that you'll get it too because you were near this person -->Misrepresentation Factitious Disorder -Physical or psychological signs/symptoms of illness are intentionally produced to assume a sick role -Malingering - intentionally produces physical symptoms to avoid work, or to obtain financial compensation or drugs -Factitious disorder - imposes deceptive practices designed to produce signs of illness on self -Factitious disorder imposed on another occurs as an individual produces physical symptoms on another- normally mother imposing on a child -Giving the child Gravol making the child sick and bringing the child to emerge because of the benefits that the parents may receive (babysit?) Impact of somatic symptom disorders -10-15% of adults report work disability due to chronic back pain -Only 33% with conversion disorder work full-time -People with somatoform disorders work on average 7.8 days per month less than everyone else -Medically unexplained physical symptoms make up 15-30% of PCP (primary common practitioner) appointments -Doctor-shopping -->Maybe for more medications -->Not satisfied with doctor A so go and find doctor B Risk for somatic symptom disorder -Gender, race, and ethnicity -Factitious disorder (imposed on self and others) is reported more by women -These disorders occur equally across racial and ethnic groups -Etiology poorly understood Developmental issues -Diagnostic criteria (consistent across all age groups) -Somatoform disorders (rare before adulthood) -Most common symptoms in adults -Pain, headaches Etiology -Biological (brain malfunction vs. structural abnormalities) -Psychodynamic (intrapsychic conflicts into physical symptoms, via defense mechanisms) -Behavioral (modeling & reinforcement)
-Environment (stress) -Distorted cognitions (somatic amplification) -Inaccurate beliefs Treatment: Reluctance and Resistance -Challenges of getting people to reveal their symptoms to a professional -Emphasis placed on physical symptoms due to the refusal to believe one has a psychological problem in need of a psychological intervention Psychological Treatments -Psychological -Basic education of the physical & emotional connection re: symptoms -Cognitive behavioural therapy (CBT) relaxation, correct automatic thoughts, symptom disengagement -no controlled studies for conversion disorder DISSOCIATIVE DISORDERS Dissociative Disorders: -Long-standing controversial diagnostic group -Definition: -A set of disorders- disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment -Depersonalization- detached from one's body -->acute or chronic (then worry) -Derealization - feeling of unfamiliarity or unreality about one's environment -Identity confusion- who am I? -Identity alteration- assume alternative identity Dissociative Amnesia -Dissociative Amnesia -Inability to recall important information; however, amnesia occurs after a personal trauma -Three types of dissociative amnesia -Localized amnesia -->forget a specific time period -Generalized amnesia -->can't remember anything about your life -->don't know who I was, what I do as a living, what my name was -->wiped out -Selective amnesia -->traumatic event Dissociative Fugue
-Loss of personal identity and memory, often involving a confused flight from a person's usual place of residence -Fugue means "flight" -->memory loss and ending up somewhere else (another state, province, etc) -Associated with physical or mental traumas, depression, or legal problems -Seek treatment after the realization of loss of identity or memory or if approached by the police Dissociative Identity Disorder (DID) -Formerly multiple personality disorder (not schizophrenia) -A presence within a person of two or more distinct alternative personalities (alters), each with its own pattern of perceiving, relating to, and thinking about the environment and self Depersonalization/Derealization Disorder -Feelings of being detached from one's body or unfamiliarity with one's surroundings feeling as it one is an external observer of one's own behaviour -->Self dead and sees self on the surgical table -->Near death experience -Incidence of comorbidity with other medical conditions or other psychiatric disorders Sex, race, ethnicity, development -1. Both men and women -2. May represent a "culture-bound syndrome" -3. Onset- from adolescence to early adulthood (15.9 to 22.8 years) -->if child is diagnosed usually associated with other disorders or problems -4. Children -->have unusual beliefs Biological and Psychosocial Factors -Biological (abnormal brain functioning due to structural abnormalities & neurochemical changes) -Psychosocial- failure of normal personality integration (due to being severely abused as a child?), a method to "cope" or "block" a traumatic event, to "compartmentalize" trauma in the form of "alters," and viewed as an iatrogenic disease Recovered/false memories -Even if someone can provide a detailed memory of an event and is confident that it is accurate, the remembered event may not actually have happened Ethics and Responsibility -1. Recovered/ false memories -2. Post-traumatic Model of DID -post traumatic stress -3. No clear link exists between abuse and DID = controversy (correlational)
Can Therapy Causes DID? -1. Number of cases of DID rose from 79 in 1970 to tens of thousands in 2000 (after movie Sybil) -2. 80% to 100% have no knowledge of alters before therapy -The correlation between alters, treatment, and the therapist awareness, and appropriate cues to produce DID -Post-traumatic model, therapist's expectations, iatrogenesis, and sociocultural model Treatments for dissociative disorders: -Antidepressants -Cognitive-behavioural therapy -Focuses on misinterpretation of normal symptoms of fatigue, stress, or even substance abuse -Challenge physiological misinterpretations by teaching individuals to explore alternative explanations, and "cognitive restructuring" Malingering -Malingering- feigning illness for a secondary gain -Factitious disorders - the deliberate creation of symptoms for no apparent reason -Somatoform or dissociative disorder do not deliberately produce their symptoms -Figure 5.3 An Integrative Model of Somatoform Disorder