Download Figure 5.3 An Integrative Model of Somatoform Disorder

Prepared by:
Ashlea R. Smith, PhD
Argosy University – Phoenix
Second Edition
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Somatoform, Dissociative, and
Factitious Disorders
Chapter 5
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Chapter Outline
Somatoform Disorders
Dissociative Disorders
Factitious Disorders
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SOMATOFORM DISORDERS
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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
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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
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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)
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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
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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
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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.
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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
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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
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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.
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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
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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?
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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.
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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
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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.
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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)
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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?
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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?
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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
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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)
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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
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DISSOCIATIVE DISORDERS
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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
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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
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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
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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”
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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
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Functional Impairment and
Epidemiology
Lack of research
Inconsistencies in
research reporting
Impairment result
prevalence
of dissociative
disorder or another
psychological
disorder
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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
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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)
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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
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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
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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
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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
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DISSOCIATIVE DISORDERS
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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
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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
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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
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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.
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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
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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?
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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
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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.
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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.
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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.
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