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Prepared by: Ashlea R. Smith, PhD Argosy University – Phoenix Second Edition This multimedia product and its contents are protected under copyright law. The following are prohibited by law: -any public performance or display, including transmission of any image over a network; -preparation of any derivative work, including the extraction, in whole or in part, of any images; -any rental, lease, or lending of the program. Copyright © 2012 by Pearson Education, Inc. All rights reserved. Somatoform, Dissociative, and Factitious Disorders Chapter 5 Copyright © 2012 by Pearson Education, Inc. All rights reserved. Chapter Outline Somatoform Disorders Dissociative Disorders Factitious Disorders Copyright © 2012 by Pearson Education, Inc. All rights reserved. SOMATOFORM DISORDERS Copyright © 2012 by Pearson Education, Inc. All rights reserved. Somatoform Disorders Conditions in which physical symptoms or concerns about an illness cannot be explained by a medical or psychological disorder Six different disorders: somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder Copyright © 2012 by Pearson Education, Inc. All rights reserved. Somatization Disorder Pierre Briquet (1796-1881) Once called hysteria or Briquet’s syndrome The presence of many symptoms that suggest a medical condition, but without a recognized organic basis Copyright © 2012 by Pearson Education, Inc. All rights reserved. Much less common symptom is pseudoseizures, which mimic an epileptic seizure. Somatization Disorder Pain in at least four areas of the body (e.g., head, abdomen, back, joints) Gastrointestinal problems (e.g., nausea, bloating, vomiting) Sexual dysfunction and impairment (e.g., disinterest, erectile dysfunction) Pseudoneurological symptoms (e.g., paralysis, balance problems, weakness) Copyright © 2012 by Pearson Education, Inc. All rights reserved. Conversion Disorder Pseudoneurological complaints, such as motor or sensory dysfunction Paralysis or blindness 10 to 15% found to have an actual diagnosable medical condition Symptom groups: motor deficits, sensory deficits, and seizures and convulsions Copyright © 2012 by Pearson Education, Inc. All rights reserved. Treatment for phantom limb pain is the mirror box developed by Vilayanur Ramachandran Pain Disorder Persistent pain that defies medical explanation Difficult to diagnose Chronic pain vs. pain disorder Ways to be diagnosed: presence of pain (without psychological symptoms), no existing medical problems, and the pain has lasted more than six months impacting Axis IV Copyright © 2012 by Pearson Education, Inc. All rights reserved. Fact or Fiction? Body image disturbance and appearance concerns can manifest into a severe psychological disorder. Not all worries or concerns about contracting an illness equate to the diagnosis of hypochondriasis. Fact or fiction? Fact or fiction? Actually, commonly known as dysmorphophobia, body dysmorphic disorder (BDD) is an overwhelming concern that some part of the body is ugly or misshapen. Some people suffer from “transient hypochondriasis,” which results from contracting an acute illness or life-threatening illness, over even being a caretaker for someone with a medical condition. Copyright © 2012 by Pearson Education, Inc. All rights reserved. Hypochondriasis Fears or concerns about having an illness that persist despite medical reassurance Dysfunctional mind-set – leads to worry about health and illness Health anxiety disorder 78% percent experience comorbidity with anxiety disorder and major depression Copyright © 2012 by Pearson Education, Inc. All rights reserved. Body Dysmorphic Disorder (BDD) An overwhelming concern that some part of the body is ugly or misshapen Dysmorphophobia Flaw in appearance “imagined” or “very minor” Most commonly worry about skin, hair, nose, and face Women and BDD High risk for suicide Doctor shopping Cosmetic surgery and dermatologic treatments Appearance checking Grooming rituals http://www.guardian.co.uk/society/20 00/feb/01/futureofthenhs.health http://www.videojug.com/interview/understanding-bodydysmorphic-disorder-2 Copyright © 2012 by Pearson Education, Inc. All rights reserved. BDD: Michael Jackson Copyright (c) Pearson Education 2010 BDD: Jocelyn Wildenstein Copyright (c) Pearson Education 2010 I Object or Accept! What are your Can body image really thoughts? turn into a disorder? What about muscle dysmorphia and how it relates to men? 1. “Our culture has a great deal of influence on our body image. We view our bodies through a lens colored by the messages we receive from the media, the voice of the culture we live in” (Claiborn & Pedrick, 2002, p. 26). Do you agree or disagree? How does this relate to the development of the somatoform disorder: Body dysmorphic disorder? Claiborn, J., & Pedrick, C. (2002). The BDD Workbook: Overcome Body Dysmorphic Disorder and End Body Image Obsessions. Oakland, CA: New Harbinger Publications, Inc. Copyright © 2012 by Pearson Education, Inc. All rights reserved. How do somatoform disorders impact individuals? 10 to 15% of adults in U.S. report work disability as a result of chronic back pain Only 33% of patients with conversion disorder work full-time People with somatization work on average 7.8 days less than everyone else BDD and hypochondriasis is a severe and chronic condition BDD and serious social impairment Remission rates Medically unexplained physical symptoms make up 15-30% of PCP appointments Doctor-shopping Copyright © 2012 by Pearson Education, Inc. All rights reserved. Research Hot Topic: The Challenge of Chronic Fatigue Syndrome (CFS) Can occur as a result Once called a somatoform disorder of stress, challenges, or the presence of a Diagnostic criteria virus Huge economic impact CDC estimates 0.5-2% people affected in U.S. Total annual loss of $9.1 billion, $2.3 billion from lost household productivity and $6.8 billion from lost labor. Real medical condition? Some people with CFS have an extremely difficult time convincing medical professionals of their disorder. How can this be changed? Copyright © 2012 by Pearson Education, Inc. All rights reserved. Conversion disorder 0. 04% Somatization disorder to 0.4 to 0.7% Pain disorder 0.6% Hypochondriasis 4.5 to 7.7% It’s important to note that 14 to 20% of the general population report physical symptoms with no underlying medical cause. Copyright © 2012 by Pearson Education, Inc. All rights reserved. Are certain populations more at risk for somatoform disorders? Sex, race, & ethnicity -Somatization disorder is reported more frequently by women -Racial and ethnic breakdowns -The use of sociocultural explanations (e.g., family and community problems) Shenjing shuairuo – loosely translated, nerve weakness, a cultural variation of somatoform disorders found among the Chinese Copyright © 2012 by Pearson Education, Inc. All rights reserved. Developmental issues to consider… Diagnostic criteria (consistent across all age groups) Somatoform disorders (rare before adulthood) Most common symptoms in adults BDD & adolescence During adolescence, one’s appearance is believed to be a measure of self-worth. Copyright © 2012 by Pearson Education, Inc. All rights reserved. Adolescents with BDD experience suicidal ideation at 80.6%, and 44.5% actually attempt suicide. Etiology: How it all comes together… Biological (brain malfunction vs. structural abnormalities) Psychodynamic (intrapsychic conflict, personality, and defense mechanisms) Behavioral (modeling & reinforcement) Environment (stress, sexual abuse, family separation/loss, family conflict/violence, & sexual assault) Distorted cognitions (somatic amplification) Inaccurate beliefs (prevalence of illness, symptoms, & treatment) Copyright © 2012 by Pearson Education, Inc. All rights reserved. Childhood sexual abuse: An indicator for somatoform disorders? Let’s examine the evidence Fact: One study did document an association between hostility/rejection by fathers and somatoform disorders in the children (Lackner et al., 2004) 1. Is based on studies (Bowman & Markand, 1996; Brown et al., 2005) in which patients with Evidence: High conflict, somatoform disorders hostility, and rejection in the were interviewed without home can lead to a a control group dysregulation of the Meaning there was no comparison with a group of participants without a disorder. What neuroendocrine system (stress research recommendations would you responses in the body) suggest? Copyright © 2012 by Pearson Education, Inc. All rights reserved. Figure 5.3 An Integrative Model of Somatoform Disorder Not just one factor contributes to the development of these disorders. Therefore, it is best to incorporate the biological, psychological, social, and cultural factors when discussing the onset of somatoform disorders. Does the medical profession influence somatoform disorders? Why or why not? Copyright © 2012 by Pearson Education, Inc. All rights reserved. Adapted from Kirmayer, L.J., & Looper, K.J., "Somatoform disorders." In Adult Psychopathology and Diagnosis, 5th Ed., by M. Hersen, S.M. Turner, & D.C. Beidel (Eds.), pp.410-472. Copyright © 2007 John Wiley & Sons. Reproduced with permission of John Wiley & Sons, Inc. Treatment “NOT” Without: Reluctance and Resistance Challenges of getting people to reveal their symptoms to a professional (only 41% of patients with BDD reveal their Why do you think patients’ symptoms to a physician) struggle to get professional Emphasis placed on physical symptoms help? The refusal to believe one has a psychological problem in need of a psychological intervention BDD viewed as a “physical problem” (e.g., I am dissatisfied with the shape of my nose; therefore I can get a rhinoplasty), instead of a psychiatric problem The use of cosmetic surgery, dermatological treatments, etc., and BDD Copyright © 2012 by Pearson Education, Inc. All rights reserved. Biological and Psychological Treatment Options Medication -Particularly anti-depressants, selective serotonin reuptake inhibitors (SSRIs), such as Prozac with BDD Psychological -Basic education of the mind-body connection when it comes to symptoms -Cognitive behavioral therapy (CBT) Copyright © 2012 by Pearson Education, Inc. All rights reserved. Quick Recap 1. ______ is when one or more physical complaints are present for at least six months, which causes distress and functional impairment. (a) Hypochondriasis (b) Conversion disorder (c) Undifferentiated somatoform disorder (d) Pain disorder Copyright © 2012 by Pearson Education, Inc. All rights reserved. DISSOCIATIVE DISORDERS Copyright © 2012 by Pearson Education, Inc. All rights reserved. Dissociative Disorders: Real or Imagined? Long-standing controversial diagnostic group Definition -A set of disorders characterized by disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment Five types of dissociative experiences -Depersonalization, derealization, amnesia, identity confusion, & identity alteration Copyright © 2012 by Pearson Education, Inc. All rights reserved. Dissociative Amnesia Amnesia vs. Dissociative Amnesia -Both deal with the inability to recall important information; however, amnesia occurs after a medical condition or event, and dissociative amnesia follows trauma. Three types of dissociative amnesia -Localized amnesia -Generalized amnesia -Selective amnesia Copyright © 2012 by Pearson Education, Inc. All rights reserved. Dissociative Fugue Definition -A disorder involving loss of personal identity and memory, often involving a flight from a person’s usual place of residence -Fugue means “flight” -Associated with physical or mental traumas, depression, or legal problems -Most likely to seek treatment after the realization of loss of identity or memory or if approached by the police Copyright © 2012 by Pearson Education, Inc. All rights reserved. Dissociative Identity Disorder (DID) Formerly called multiple personality disorder (not to be confused with schizophrenia) Hollywood’s depiction (The Three Faces of Eve and Sybil) Definition -A presence within a person of two or more distinct personality states, each with its own pattern of perceiving, relating to, and thinking about the environment and self -Alternative personalities or “alters” Copyright © 2012 by Pearson Education, Inc. All rights reserved. Depersonalization Disorder Definition -Feelings of being detached from one’s body or mind, a state of feeling as if one is an external observer of one’s own behavior Characterized by: -Incidence of comorbidity with other medical conditions or other psychiatric disorders -Feelings of being detached from one’s body or unfamiliarity with one’s surroundings Copyright © 2012 by Pearson Education, Inc. All rights reserved. Functional Impairment and Epidemiology Lack of research Inconsistencies in research reporting Impairment result prevalence of dissociative disorder or another psychological disorder Copyright © 2012 by Pearson Education, Inc. All rights reserved. Sex, race, ethnicity, development, and the FACTS 1. Both men and women suffer from dissociative disorders 2. May represent a “culture-bound syndrome” 3. Onset ranges from adolescence to early adulthood (15.9 to 22.8 years) 4. Children and dissociative disorders Copyright © 2012 by Pearson Education, Inc. All rights reserved. Biological and Psychosocial Factors Involved in Dissociative Disorders: Biological (abnormal brain functioning, structural abnormalities, neurochemical changes, and other neurological conditions) Psychosocial (failure of normal personality integration, severely abused children, childhood sexual abuse, recovered or false memories, a method to “cope” or “block” a traumatic event, a way to “compartmentalize” trauma in the form of “alters,” and viewed as an iatrogenic disease) Copyright © 2012 by Pearson Education, Inc. All rights reserved. Ethics and Responsibility 1. Recovered/false 5. No clear link exists memories between abuse and DID 2. Controversy 6. Important things to surrounding child consider: some children abuse and DID do suffer abuse, some 3. Definition of abuse abused children develop mental disorders as 4. Post-traumatic adults Model of DID Copyright © 2012 by Pearson Education, Inc. All rights reserved. Can Therapy Cause DID? Explanation: The Let’s examine the do you believe can evidence Whatobesity really be prevented in children? 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 correlation between alters, treatment, and the therapist awareness, and appropriate cues to produce DID Conclusion: Posttraumatic model, therapist’s expectations, Iatrogenesis, and sociocultural model Copyright © 2012 by Pearson Education, Inc. All rights reserved. Treatment Factors involved in dissociative disorders: Antidepressants Cognitive-behavioral therapy -Used to work on misinterpretation of normal symptoms of fatigue, stress, or even substance abuse -Challenge misinterpretations by teaching individuals to explore alternative explanations, and “cognitive restructuring” -Exposure therapy to face fears Copyright © 2012 by Pearson Education, Inc. All rights reserved. Quick Recap 2. ______ not only results in a loss of personal memory, but also results in a loss of identity. (a) Dissociative identity disorder (b) Dissociative amnesia (c) Amnesia (d) Dissociative fugue Copyright © 2012 by Pearson Education, Inc. All rights reserved. DISSOCIATIVE DISORDERS Copyright © 2012 by Pearson Education, Inc. All rights reserved. Factitious Disorders Conditions in which physical or psychological signs or symptoms of illness are intentionally produced in what appears to be a desire to assume a sick role People may produce physical symptoms, psychological symptoms, or both Copyright © 2012 by Pearson Education, Inc. All rights reserved. Malingering…a crafty skill or a facade? A condition in which physical symptoms are produced intentionally to avoid military service, criminal prosecution, or work, or to obtain financial compensation or drugs Copyright © 2012 by Pearson Education, Inc. All rights reserved. Common practices associated with factitious disorders 1. Faking elevated body temperature 2. Putting blood in urine to stimulate infection 3. Taking blood thinners to produce hemophilia 4. Faking chest or abdominal pain 5. Often manipulate lab results 6. Engage in doctor-shopping 7. Often provide false information to medical professionals, such as their medical history or symptomology Copyright © 2012 by Pearson Education, Inc. All rights reserved. Have you ever feigned an illness to avoid something like school, work, or an event? If so what did you do? Numerous hospitalizations People with factitious disorder often visit emergency rooms on the weekend or evening shifts to be evaluated by junior clinical staff. Copyright © 2012 by Pearson Education, Inc. All rights reserved. Factitious Disorder by Proxy Also known as Munchausen by proxy A condition in which physical or psychological signs or symptoms of illness are intentionally produced in another person, most often in a child by a parent Form of child abuse and the perpetrator can be prosecuted Copyright © 2012 by Pearson Education, Inc. All rights reserved. How can trained medical professionals miss something like this? Real People, Real Disorders… The Piano Man Found on the beach in a wet suit in Kent, England No identifying information Placed in the care of psychiatrists (to discover his identity and determine his medical condition) Drew pictures of piano and later began to play the piano After five months he revealed his identity Would this be considered dissociative fugue, factitious disorder, or malingering? Have you ever wished you could start a new life with a new identity, forget your past, or even see first hand how it would be to live in a psychiatric institution? Why or why not? Copyright © 2012 by Pearson Education, Inc. All rights reserved. What other factors should be reviewed related to factitious disorders? Social and occupational functioning Outcomes for victims and perpetrators Perpetrators are predominately female at 77 to 98% (some may even have had health care training) Most common in adults Treatment issues and theories surrounding factitious disorders Copyright © 2012 by Pearson Education, Inc. All rights reserved. Reviewing Learning Objectives 1. It is extremely common for individuals to experience physical symptoms without an organic cause, which accounts for visits to the primary care physician. 2. Somatoform disorders are defined by the presence of physical symptoms or concerns about illness that cannot be explained by an established medical or psychological disorder. 3. Biological, psychological, and environmental factors should be considered when evaluating the onset of somatoform disorders. Copyright © 2012 by Pearson Education, Inc. All rights reserved. Reviewing Learning Objectives 4. Dissociative disorders, the subject of controversy and thought to represent a culture-bound syndrome, tends to involve disruption of the consciousness, memory, identity, or perception. 5. It is important to both review empirical data related to the causes of dissociative disorders and also explore iatrogenic factors to fully understand the development of these disorders. Copyright © 2012 by Pearson Education, Inc. All rights reserved. Reviewing Learning Objectives 6. The concept of repressed/recovered memories is inconsistent with current findings; however, it is possible to display amnesia and create false memories regarding events before the age of six, including those around sexual abuse. 7. Malingering involves feigning illness for a secondary gain; factitious disorders involve the deliberate creation of symptoms for no apparent reason; and people with somatoform or dissociative disorder do not deliberately produce their symptoms. Copyright © 2012 by Pearson Education, Inc. All rights reserved.