5 Somatoform Disorders:

  Somatization Disorder

·      Conversion Disorder

·      Pain Disorder

·      Hypochondriasis

·      Body Dysmorphic Disorder

Major Characteristics of the Somatoform Disorders  (282)

·      Physical pain is relative to psychological factors

·      Person has numerous medical tests/evaluations

·      Results do not explain physical symptoms

·      Some medical procedures may be dangerous

Personality Disorders:  The Clinical Picture

Must have at least 4 pain sites:  different areas

·      Gastrointestinal – symptoms must be in addition to the pain,

Sexual or reproductive

   (Pseudo) Neurological condition 

    Tests/evaluations that report no other medical conditions

·      Complaints exceed & usually occur over a period of years

·      If person has medical condition, the symptoms warrant a separation diagnosis

·      Symptoms are not intentionally produced or feigned as in a factitious disorder or malingering

Usually co-occurs with other psychological disorders, such as mood or anxiety disorders

·      Substance-related disorders may be present

·      Conversion disorder may partially explain symptoms

·      Hypochondriasis can have multiple physical symptoms

Conversion Disorder (formerly known as “Hysteria”)

   Loss or change in physical functioning

·      Freud contribution – unconscious complex – individual had to express feelings, converted in the mind into physical symptoms to get rid of the anxiety without having to “talk” about it.  Freud was credited with “Conversion Disorder” in the case of Anna O (woman in mental institute who spoke of sexual abuse as a child, Freud had to change what was heard & believed “convert” beliefs into acceptable terms).

·      Physical problem without underlying physical pathology, psychopathology dynamic

·      Resembles neurological conditions

·      Ensure appropriate Rule Outs – to include medical

·      Weakness or paralysis of a limb or the entire body

·      Impaired vision or hearing

·      Loss or disturbance of sensation

·      Impairment or loss of speech

·      Pseudoseizure

·      Fixed dystonia (ability to control the motion & function of the muscles in the body)

·      Tremor, myoclonus (sudden, involuntary jerking of a muscle or a group of muscles) or other movement disorders

·      Gait problems (or the inability to stand or walk in a normal manner also called astasia-abasia)

·      Fainting (or syncope)

·      Subjective experience

·      Difficult to measure

·      Pain is usually severe and often chronic

·      Frequently occurs after accident or during illness

·      Last a few days to as long as several years

·      When pain in 1 or more areas, it is thought to be psychological stress

·      Pain disorder associated with psychological factors

·      Pain disorder associated with both psychological factors and a general medical condition

·      Specifiers:  Acute – less than 6 months / Chronic – 6+ months

·      Diagnosis of pain disorder associated with a medical condition OR pain with psychological factors

·      Somatoform disorder if distribution, timing, or description of pain is atypical of general medical condition

·      Malingering if compensation for pain

·      NOT:  conversion or hypochonriasis

Hypochondriasis

 Excessive preoccupation with or worry about having a serious illness

·      Fears of illness

·      Preoccupation

·      Cannot be reassured

·      Ideas are not delusional

·      Cause stress

·      Problems must have existed for 6+ months

·      Not better explained by another diagnosis

·      Fears that minor bodily symptom may indicate a serious illness

·      Doctor shopping

·      Because of bodily symptoms are misinterpreted, the person becomes preoccupied with thoughts of having a serious illness

·      Appropriate medical tests or examinations and reassurance does not relieve these ideas

·      Person’s ideas are not delusional and are not restricted to concerns about appearance

·      Distress is found in important social, work, or personal areas of functioning

Variations of Hypochondriasis

Cyberchondria – if person believes they have a condition, search internet to find info that can be used in self-diagnosis

·      Medical Student Syndrome – studying medical issues & begin seeing the symptoms in themselves

Body Dysmorphic Disorder (BDD)

      Excessive concern @ & preoccupied with perceived deficits of physical features

·      Preoccupied with imaginary defect of appearance or is excessively concerned about a very slight physical anomaly

·      Preoccupation causes significant distress in social life, occupation, or other important areas of one’s life

·      High risk for suicide due to depression / anxiety about appearance

·      Beginning may be abrupt or gradual and has a fairly continuous course with few symptom-free intervals (intensity may wax/wane over time)

·      Person’s preoccupation is not better explained by another mental disorder, anorexia nervosa for example

Differential Assessment for Body Dysphormic Disorder

(BDD)

  Co-occurs – major depression, generalized anxiety

·      Avoidant personality disorder & dependent personality disorder traits of being introverted & shy

·      Social phobia or OCD

·      NOT:  hypochondriasis, anorexia, schizophrenia, delusional disorder, somatic type

Somatoform Disorder 

Residual

o   Pseudocyesis – false belief that one is pregnant, can have endocrine and/or hormone changes

o   Transient Hypochondriac State – unexplained physical symptoms that meet criteria for hypochondriasis except has not lasted 6 months

o   Environmental illness and total environmental allergy syndrome – people claim to be allergic to most foods, clothing, perfumes, gasses, or many compounds found in chemicals – for less than 6 months

·      Client fabricates symptoms

·      More common in males

·      Slow recovery to continue to receive benefits

·      Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives

·      Difficult to detect

·      Consider:  medical & legal context to referral, discrepancy b/t person’s subjective complaints & objective findings, extent of cooperation during the interview, and/or presence of a prior diagnosis of antisocial personality disorder

·      Pure – false production of nonexistent symptoms

·      Partial – person exaggerates preexisting symptoms

·      Positive – involves feigning symptoms of an illness

·      Negative – hiding or misreporting symptoms

·      Distinguished from somatoform disorders – person is truly experiencing symptoms

o   Person intentionally feigns physical or psychiatric symptoms

o   Apparent motive for this behavior is to assume the role of a sick person

No other motives such as those found in malingering

·      Memory and awareness – keep stress at arms length

·      Lack of connection b/t things usually associated with each other

·      Experiences not integrated into the usual sense of self, resulting in discontinuities of conscious awareness

·      Onset – each specific disorder typically begins & ends suddenly

·      Memory – most of the dissociative disorders show a profound disturbance of memory (w/exception of depersonalization disorder)

·      Precipitants – episodes tend to be precipitated by psychological conflicts (such as an overwhelming stress generated by traumatic events or by intolerable inner conflict)

·      Prevalence – dissociative disorders are considered rare and not often seen in practice

·      Functioning – impaired functioning or a subjective feeling of distress is shown (with the exception of dissociative identity disorder)

3 Common Themes of DID

 Childhood home trauma

·      Suggestibility – personality trait

·      Biological Factors

·      Amnesia – * most common - loss of one’s identity or periods of time in one’s past

·      Depersonalization – * most common - feeling of being detached from oneself, seeing the person go through things

·      Derealization – objects in a person’s world are strange, or unreal – can happen in own home, feels unreal

·      Identify Confusion – being unsure of one’s identity or of who one really is

·      Identity Alteration – behaving in a way that suggests the individual has assumed a new identity

Dissociative Amnesia             formerly psychogenetic amnesia

o   Localized – person has recall for none of the events during a particular time, such as a natural disaster

o   Selective – type of forgetting is less common and is where certain portions of a time have been forgotten by the individual, such as the birth of a child

o   Generalized – person forgets all of the experiences during lifetime

o   Continuous – considered extremely real, when person forgets events from a given time forward to the present

o   Systematized – pattern of forgetting is when the person has forgotten certain class of information, for example, relating to work or to family

Dissociative Amnesia subtypes

o   Those who are unable to remember anything, including who they are, struggle with generalized amnesia – 6 months to a year

o   Localized or selective amnesia – failure to recall specific events, usually of a traumatic nature, that occur during a specific period of time

Prevailing Pattern for Dissociative Amnesia

·      At least 1 episode of inability to recall info; forgotten info usually concerns trauma or stress & is more extensive than what could be explained by common forgetfulness

·      Significant distress experienced

·      Work, social, or personal functioning is impaired

·      Most often happens during extreme stress such as after a natural disaster or war

·      Involves abrupt travel away from home

·      Person is unable to remember important aspects of his/her life

·      Adopts new identity or partially new identity

·      Rarely lasts longer than a month

Depersonalization Disorder 

·      Estranged or unreal

·      Detached

·      Acute stressor is often precursor to onset

·      Person has feelings of unreality & that his/her body does not belong to them

·      Episodes begin & end suddenly, typically ending on their own after a period of time