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Somatoform and Dissociative Disorders

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Whitney Landon

on 28 March 2013

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Transcript of Somatoform and Dissociative Disorders

Whitney Landon
Brooke Eichelberger Somatoform and Dissociative Disorders Hypochondriasis Somatoform Disorders Current Research and Treatment psychodynamic psychotherapy: uncover unconscious conflicts

reassurance and education - by a mental health professional: explaining each symptom and why they are not sick

cognitive-behavioral treatment: identifying and challenging illness-related symptoms while demonstrating how to "create" symptoms.

Antidepressants (paroxetine and SSRI)- also helpful in treating anxiety

*many refuse to enter treatment Course and Etiology can appear at any age though peak periods include adolescence, 40-50s, and after 60


1. trigger 2. apprehension 3. increased preoccupation with perceived alterations of body state 4. more misinterpretation of body sensation 5. more apprehension

genetic contribution (runs in families) - more responsive to stress, tendency to view life as unpredictable

environment - may have learned to focus anxiety on illness, seems to develop in the context of a stressful event, disproportionate amount of disease in the family, attention seeking behavior

often comorbid with anxiety or mood disorders

under the DSM V, hypochondriasis might be better classified as an anxiety disorder Conversion Disorder Prevalence and
Cultural Issues "medically unexplained physical symptoms" Dissociative Disorders Sources pathologically concerned about the appearance or function of their body

five somatoform disorders

DSM V proposes hypochondriasis, somatization
disorder, and pain disorder be combined under
complex somatic symptom disorder Prevalence and Cultural Issues 1-5% of the general population

1:1 sex ratio

fairly spread across age range

Koro in China and dhat in India A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.

B. The preoccupation persists despite appropriate medical evaluation and reassurance. ('disease conviction')

C. The belief in criterion A is not of delusional intensity and is not restricted to a circumscribed concern about appearance.

D. The preoccupation causes clinically significant distress of impairment in social, occupational, or other important areas of functioning.

E. The duration of the disturbance is 6 months.

F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-complusive disorder, panic disorder, a major depressive disorder, separation anxiety, or another somatoform disorder.

Specify if 'With poor insight" Somatization Disorder Etiology and Course Prevalence and Cultural Issues Treatment and Current Research Pain Disorder Etiology and Course Prevalence and Cultural Issues Treatment and Current Research Body Dysmorphic Disorder Depersonalization Disorder Dissociative Fugue Dissociative Trance Disorder Dissociative Identity Disorder Thank you for watching our presentation! A. Pain in one or more anatomical sites of sufficient severity

B. Pain causes clinically significant distress or impairment in social, occupational, or other important areas of function

C. Psychological factors are judged to have an important role in onset, severity, exacerbation, or maintenance of the pain.

D. The symptom is not intentionally produced or feigned.

E. Pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia

Acute or Chronic often related to a medically relevant condition

ranges from primarily psychological to primarily physiological

abuse is often implicated

pain is real and it hurts 5% - 12% of the population pain clinics


cognitive-behavioral therapy individuals feel detached from their surrounding or themselves; dissociates from reality

often a result of a tramatic event - postramatic model

sociocognitive model dissociative experiences are common depersonalization and derealization Prevalence and Cultural Issues .8% of population

1:1 ratio between men and women Etiology and Course mean onset 16 yrs


anxiety, mood, and personality disorders also common

dysregulation in the hypothalamic-pituitary-adrenocortical axis - deficits in emotional responding

cognitive deficits: attention, processing, ST memory, and spatial reasoning Treatment and Recent Research psychological treatments not systematically studied

psychological therapy
behavioral-cognitive therapy

sleep hygiene therapy

drug therapies
selective serotonin reuptake inhibitor
anticonvulsant lamotrigine A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body.

B. During depersonalization experience, reality testing remains intact.

C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The depersonalization experience does not occur exclusively during the course of another mental disorder and is not due to the direct physiological effects of a substance or a general medical condition. A. Predominant disturbance is sudden, unexpected travel away from home or one's customary place of work

B. Confusion about personal identity or assumptions of new identity (partial or complete)

C. The disturbance does not occur exclusively in the course of dissociative identity disorder and if not

D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of function A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

(1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)

(2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)

(3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)

(4) one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

C. Either (1) or (2):

(1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)

(2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings

D. The symptoms are not intentionally feigned or produced (as in Factitious Disorder or Malingering). Onset often in adolescence


Possible hereditary component:

Strongly linked to Antisocial Personality Disorder in family and genetic studies

Cyclical Causes:
*Immediate sympathy and attention
*Continual development of new symptoms
* Eventual social isolation more prevalent in low SES groups

2:1 female to male ratio

wide age range due to chronic nature

overuse and misuse of health-care systems

*19% of people with somatization on disability
*medical bills as much as 9 times more than average Extremely difficult to treat

Antidepressants are an option

Cognitive-behavioral therapy works best

Provide reassurance, reduce stress, and minimize help-seeking behaviors, encourage employment

Therapy to broaden basis for relating to others A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of asubstance, or as a culturally sanctioned behavior or experience.

E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

Specify type of symptom or deficit:
Mixed presentation "dissociates from reality" Etiology and Course Etiology and Course Etiology and Course Etiology and Course Prevalence and
Cultural Issues Prevalence and
Cultural Issues Prevalence and
Cultural Issues Treatment and
Recent Research Treatment
Recent Research Treatment
Recent Research Treatment
Recent Research onset usually in adolescence or just after

patients learn symptoms from observing real illness and injury

experience incapacitating symptoms (blindness, paralysis, or aphonia)

often triggered by life stresses or psychological conflict

continues unless treated/ stress subsides relatively rare in mental health setting

found primarily in women/ in men under extreme stress (soldiers)

high comorbidity with somatization disorder, anxiety, and other mood disorders

contextually based (fundamentalist religions) treatment is very similar to somatization treatments

cognitive-behavioral therapy

*specifically attending to the trauma or stressful life event

*eliminating reinforcements for symptoms "Imagined Ugliness"

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder(e.g., dissatisfaction with body shape and size in Anorexia Nervosa). prevalence difficult to estimate (often kept secret)

1-2% community / 2-13% student samples

equally observed in (but manifests differently for) men and women

high comorbidity with obsessive-compulsive disorder and social phobia many seek cosmetic or plastic surgery as treatment

cognitive-behavioral therapy treatments seem most effective
exposure and response prevention therapy

prescription drugs can provide relief for some suffers
block reuptake of serotonin (same drugs used to treat OCD)

without treatment, the disorder will last throughout the lifetime

proposed DSM V changes include BDD with anxiety disorders due to recent research Case Study J.T. -23 yrs old Sister: “J.T. was 6’2” and would go to the doctor and have them measure him. He would look at the measurement, look the doctor in the eye and tell him he was wrong. He would break the soles out of his shoes to make himself look shorter. He would stomp around the block for an hour every day without shoes to try to smash his legs shorter. He wouldn’t take medication to make him better because, in his mind, surgery was the only option. He would measure himself 5-10 times a day and was convinced that the only thing that could help was to surgically shorten his legs. The surgery would have cost $70,000 and wouldn’t have helped at all. He still would have thought he towered over everyone.” Dissociative Amnesia A. The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.

B. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative Fugue, Posttraumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma).

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. memory loss is caused by stressful or traumatic events

episodic and sometimes recurring

generalized amnesia: lifelong- or extended period of time- patient unable to remember anything

localized amnesia: failure to recall specific events (usually traumatic) during a period of time rare among general population

cases are more prevalent after war
or natural disaster Barlow, D. H., & Durand, V. M. (2011). Abnormal psychology: An integrative approach. (6th
ed.). Belmont, CA: Wadsworth, Cengage Learning.

During, E. H., Elahi, F. M., Taieb, O., Moro, M., & Baubet, T. (2011). A
critical review of dissociative trance and possession disorders: Etiological, diagnostic, therapeutic, and nosological issues. The Canadian Journal Of Psychiatry / La Revue Canadienne De Psychiatrie, 56(4), 235-242.

Kikuchi, H., Fujii, T., Abe, N., Suzuki, M., Takagi, M.,
Mugikura, S., & ... Mori, E. (2010). Memory repression: Brain mechanisms underlying dissociative amnesia. Journal Of Cognitive Neuroscience, 22(3), 602-613. doi:10.1162/jocn.2009.21212

Ross, C. A. (2009). Dissociative amnesia and
dissociative fugue. In P. F. Dell, J. A. O'Neil (Eds.) , Dissociation and the dissociative disorders: DSM-V
and beyond (pp. 429-434). New York, NY US: Routledge/Taylor & Francis Group.

The Cleveland Clinic Staff. (2005, 05 11). Cleveland
clinic. Retrieved from Http://my.clevelandclinic.org/disorders/dissociative_disorders/hic_dissociative_amnesia.aspx psychotherapy and clinical hypnosis: try to sort out the stressful event being blocked from memory

cognitive therapy: attempts to change dysfunctional thinking patterns that repress memories

study by Kikuchi found that memory repression in dissociative amnesia is related to an altered pattern of neural activity
-possible neurobiological treatments? proposal for DSM V is to diagnose dissociative trance as a subtype of dissociative identity disorder Characteristics:

•Sudden changes in personality accompany a trance or “possession”
•Causes significant distress and/or impairment in functioning
•Often associated with stress or trauma episodic


often associated with stress or trauma Etiology and Course triggered by current stress or trama

amnesia revolves around flight and usually includes identity confusion

brief episodes that end abruptly

rare to develop before adolescence or after 50

will likely become a subtype of dissociative amnesia more common in women than men

prevalent worldwide, usually in a religious context

rare in Western culture

vinvusa- India, Nigeria

phii pob- Thailand Prevalence and Cutural Issues During's assessment of world-wide articles on dissociative trance found:

equal prevalence between males/females

possession is the most common form of trance

a cross-cultural approach seems necessary for understanding and managing the disorder Little is known about the successful treatment of dissociative trance disorder 0.2% of the population

amok: a running syndrome
Native Artic people: pivloktoq
Navajo: frenzy witchcraft Treatment and Current Research cognitive-behavioral therapy


psycodynamic therapy

usually recover from fugue states on their own Case Study onset ranges from adolescence through the 20s, peaking at ages 16-17

"stubbornly" lifelong

Cycle of Causes:

•Intensified focus on imagined defects accompanied by extreme self-consciousness

•Intrusive, anxiety-provoking idea that individual has a physical defect apparent to everyone

•Pathological attempts to “fix” the problem that prevents a more reality-based appraisal of the “defect”

•Increased anxiety A. The presence of two or more distinct identities or personality states.

B. At least two of these identities or personality states recurrently take control of the person's behavior.

C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.

D. the disturbance is not due to the direct physiological effects of a substance or general medical condition. Course onset in childhood, as young as four though diagnosis is usually later

lasts a lifetime

comorbid with anxiety, substance abuse, depression, or personality disorders

auditory hallucinations are common

average number of 15 personalities, as many as 100
identities may be completely independent but are usually partially independent
host identity seeks help, alters can be aware of one another
often an impulsive alter, can have cross gender alters
additional personalities can emerge throughout life Prevalence and Cultural Issues 1.5% in a community and 3-6% in an inpatient population

female to male ratio is 9:1

Can it be faked?
therapist induced
susceptible personalities
differences in microstrabismus
differing physiologic responses

Memory formation
35 three-year-olds receive a genital exam
Repressed and forgotten memories Etiology post tramatic model
horrible child abuse, war
unable to escape physically, they escape mentally
subtype of PTSD - emphasis on dissociation rather than anxiety

sociocognitive model

biological contributions
heritable traits: tension and responsiveness to stress
smaller hippocampus and amygdala Treatment and Current Research psychotherapy - long term

identify cues or triggers that provoke tramatic memories

confront and relive tramatic events


~20% achieve full integration Sybil or Shirley A. Manson severe child abuse

Dr. Cornelia Wilbur
sodium pentothal
lack of boundaries

16 personalities
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