Ch.8, Somatic Disorders Flashcards
SOMA
means body
DSM 4 VS DSM 5 MEDICALLY EXPLAINED VS MEDICALLY UNEXPLAINED SYMPTOMS
-In DSM-IV a great deal of emphasis was placed on the idea that the symptoms were medically unexplained. In other words, although the patient’s complaints suggested the presence of a medical condition, no physical pathology could be found to account for them
-DSM-5, an important change was introduced. No distinction is now made between medically explained and medically unexplained symptoms. The idea of medically unexplained symptoms is less prominent because it is recognized that medicine is fallible and that a medical explanation for symptoms cannot always be provided. Whether symptoms are deemed to have a medical cause or not could also depend on the personality of the doctor or on his or her predominant cultural beliefs
Somatic symptom disorder
-most major diagnosis in its category-The diagnosis of somatic symptom disorder is a descriptive one
-individuals must be experiencing chronic somatic symptoms that are distressing to them. They must also be experiencing dysfunctional thoughts, feelings, and/or behaviors.
3 disorders present in DSM-IV that became somatic symptom disorder in the DSM 5
hypochondriasis, (2) somatization disorder, and (3) pain disorder are gone
DSM 4 vs DSM 5 somatic symptom disorder criteria
DSM-IV all that was required was that people experience somatic symptoms that were medically unexplained. In other words, no psychological features were required. This was a rather strange omission because a common characteristic of DSM mental disorders is that there are psychological features in addition to other signs and symptoms
-DSM-5 only one somatic symptom is required. In other words, if a person has any physical problem that they find distressing (even if it involves only a single symptom and is medically explained), the diagnosis of somatic symptom disorder is possible = new DSM-5 criteria will likely lead to an increase in the diagnosis of somatic symptom disorder for this reason.
DSM 5 new diagnostic criteria of somatic symptom disorder and women
It has also been suggested that women will be disproportionately affected because they are more frequent users of medical services and because they are most at risk of being dismissed by their doctors as “catastrophizers”
CAUSES Why do people develop somatic symptom disorders? psychodynamic vs current views
. It was long thought that symptoms developed as a defense mechanism against unresolved or unacceptable unconscious conflicts. Rather than being expressed directly, psychic energy was instead channeled into more acceptable physical problems.
cognitive approach explains it: person is hypervigilant and has an increased awareness of bodily changes. Second, the person tends to see bodily sensations as somatic symptoms, meaning that physical sensations are attributed to illness. Third, the person tends to worry excessively about what the symptoms mean and has catastrophizing cognitions. Fourth, because of this worry, the person is very distressed and seeks medical attention for his or her perceived physical problem
CAUSES Sensitive to body sensations vs illness info biases
- Individuals who are especially anxious about their health tend to believe that they are very aware of and sensitive to what is happening in their bodies. But this does not seem to be the case. Rather, experimental studies show that these individuals have an attentional bias for illness-related information
In other words, top-down (cognitive) processes, rather than bottom-up processes (such as differences in bodily sensations), seem to account for the problems that they have. - individual’s past experiences with illnesses (in both him- or herself and others, and also as observed in the media) contribute to the development of a set of dysfunctional assumptions about symptoms and diseases that may predispose a person to developing a somatic symptom disorder
CAUSES Absorption and alexithymia in somatic symptom disorder
Absorption is a tendency to become absorbed in one’s experiences and is often associated with being highly hypnotizable. Alexithymia, on the other hand, refers to having difficulties identifying one’s feelings. People who report many symptoms but who do not have any medical conditions tend to score high on all of these three traits
CAUSES Negative mood and increase in somatic symptom disorder symptoms
? People who have difficulty identifying their feelings and who are also highly susceptible to being absorbed in their own experiences may be especially sensitive to having certain attentional (top-down) processes activated when they experience negative events.
malingering—
consciously faking symptoms to achieve a specific goal such as winning a personal injury lawsuit. They experience physical problems that cause them great concern.
TREATMENT,
- cognitive-behavioral treatments are widely used to treat these disorders
-Sometimes patients treated with CBT are also directed to engage in response prevention by not checking their bodies as they usually do and by stopping their constant seeking of reassurance.
-General practitioners can be educated in how to better manage and treat patients with these disorders so that they are less frustrated by them: One moderately effective treatment involves identifying one physician who will integrate the patient’s care by seeing the patient at regular visits (thereby trying to anticipate the appearance of new problems) and by providing physical exams focused on new complaints (thereby accepting all symptoms as valid; At the same time, however, the physician avoids unnecessary diagnostic testing and makes minimal use of medications or other therapies: improvement in physical functioning (although not necessarily in psychological distress; e.g., Rost et al., 1994). That is why this approach is best combined with CBT
antidepressants and somatic symptoms
antidepressant medications (especially the tricyclic antidepressants) and certain selective serotonin reuptake inhibitors have been shown to reduce pain intensity in a manner independent of the effects the medications may have on mood
Illness anxiety disorder
-People with this disorder have high anxiety about having or developing a serious illness. This anxiety is distressing and/or disruptive, but there are very few (or very mild) somatic symptoms
conversion disorder (function neurological symptom disorder)
-Historically this disorder was one of several disorders that were grouped together under the term hysteria.
- presence of neurological symptoms in the absence of a neurological diagnosis: patient has symptoms or deficits affecting either the senses or motor behavior. These would ordinarily strongly suggest a medical or neurological condition. However, the pattern of symptoms or deficits is not consistent with any neurological disease or medical problem.
la belle indifférence conversion disorder
-Freud suggested that most people with conversion disorder showed very little of the anxiety and fear that would be expected in a person with a paralyzed arm or loss of sight
-Lack of concern about symptoms or their implications is also not specific to conversion disorder. For these reasons, this phenomenon has become de-emphasized in more recent editions of the DSM
4 categories of conversion disorder symptoms
four categories of symptoms: (1) sensory: can involve almost any sensory modality. The diagnosis is often made when symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate. Sensory symptoms or deficits are most common in the visual system (especially blindness and tunnel vision), in the auditory system (especially deafness), or in the sensitivity to feeling (especially the anesthesias)= ***sensory input is registered but is somehow screened from explicit conscious recognition (explicit perception)
(2) motor: . The most common speech-related conversion disturbance is aphonia. Here, the person is able to talk only in a whisper although he or she can usually cough in a normal manner= In true, organic laryngeal paralysis, both the cough and the voice are affected.)
(3) seizures = These resemble epileptic seizures, although they are not true seizures
and , patients do not show any EEG abnormalities and do not show confusion and loss of memory afterward, as patients with true epileptic seizures do.
(4) a mixed presentation of the first three categories
anesthesias conversion disorder/ glove anasthesia
In the anesthesias, the person loses feeling in a part of the body. One of the most common is glove anesthesia, where the person cannot feel anything on the hand in the area where gloves are worn, although the loss of sensation usually makes no anatomical sense (nerves do not stop at the wrist).
How to differentiate between an actual neurological diagnosis and conversion disorder
The frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease or disorder simulated. For example, little or no wasting away or atrophy of a “paralyzed” limb occurs in conversion paralyses, except in rare and long-standing cases.
The nature of the dysfunction is highly selective. As already noted, in conversion blindness the affected individual does not usually bump into people or objects, and “paralyzed” muscles can be used for some activities but not others.
Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms can usually be removed, shifted, or reinduced at the suggestion of the therapist. Similarly, a person abruptly awakened from a sound sleep may suddenly be able to use a “paralyzed” limb.
Most common psychiatric syndrome in WWI soldiers
Conversion disorder typically occurred under highly stressful combat conditions and involved men who would ordinarily be considered stable. Here, conversion symptoms—such as paralysis of the legs—enabled a soldier to avoid an anxiety-arousing combat situation without being labeled a coward or being subject to court-martial.
Medical basis and conversion disorder symptoms
conversion disorder apparently loses its defensive function if it can be readily shown to lack a medical basis. When it does occur today, it is most likely to occur in people who are medically unsophisticated.
MORE OFTEN IN WOMEN BY TWO TO THREE TIMES
conversion hysteria FREUD/ primary and secondary gain
he believed that the symptoms were an expression of repressed sexual energy—that is, the unconscious conflict that a person felt about his or her repressed sexual desires. However, in Freud’s view, the repressed anxiety threatens to become conscious, so it is unconsciously converted into a bodily disturbance, thereby allowing the person to avoid having to deal with the conflict. This is not done consciously, of course, and the person is not aware of the origin or meaning of the physical symptom. Freud also thought that the reduction in anxiety and intrapsychic conflict was the primary gain that maintained the condition, but he noted that patients often had many sources of secondary gain as well, such as receiving sympathy and attention from loved ones.
Primary and secondary gain modern science
many of Freud’s clinical observations about primary and secondary gain are still incorporated into contemporary views of conversion disorder. For example, viewed through the lens of learning theory, the physical symptoms can be seen as providing negative reinforcement (relief or removal of an aversive stimulus) because being incapacitated in some way may enable the individual to escape or avoid an intolerably stressful situation without having to take responsibility for doing so. In addition, they may provide positive reinforcement in the form of care, concern, and attention from others. = person is not deliberately choosing to lose his or her sight or become unable to walk. Instead, unconscious processes are thought to be at work.
stressful life events and conversion disorder vs depression
the frequency of stressful life events in the recent past in patients with conversion disorder and depressed controls and did not find a difference in frequency between them. However, the greater the negative impact of the preceding life events, the greater the severity of the conversion disorder symptoms
fmri data and conversion disorder
This functional magnetic resonance image shows somatosensory activity evoked by stimulation in a patient with sensory conversion disorder affecting the left hand. When the patient’s left hand was stimulated, no activity was seen in the primary somatosensory cortex (arrow). However, increased activity was seen in this area of the brain when the patient’s right hand was stimulated (circle) = there was activation in somatosensory areas of the brain on the opposite side to the side being stimulated. (This is because most human motor and sensory fibers cross the midline and so stimulation of the right side of the body affects the left side of the brain.) However, when tactile stimulation was applied to the affected (numb) body part, there was no activation in the contralateral area of the sensory cortex. Figure 8.2 provides an illustration of this. Instead, the tactile stimulus activated regions in the orbitofrontal cortex and the anterior cingulate cortex (Ghaffar et al., 2006). This is interesting because both of these brain regions are involved in neural networks that are thought to regulate emotion and the expression of emotion.
=anesthetic body part is stimulated, there is decreased activation in the somatosensory cortex but increased activation in areas such as the anterior cingulate cortex, insula, and other brain areas implicated in emotion processing
Treatment for conversion disorder
Some hospitalized patients with motor conversion symptoms have been successfully treated with a behavioral approach in which specific exercises are prescribed in order to increase movement or walking, and then reinforcements (e.g., praise and gaining privileges) are provided when patients show improvements.
-At least one study has also used cognitive-behavior therapy to successfully treat conversion seizures
Facticious disorder
people do deliberately and consciously feign disability or illness. person intentionally produces psychological or physical symptoms (or both). Although this may strike you as strange, the person’s goal is to obtain and maintain the benefits that playing the “sick role” (even to the extent of undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel.
DSM IV VS DSM 5 categorization of facticious disorder
In DSM-IV, factitious disorder was in a category of its own. In DSM-5 it has been moved into the category of somatic symptom and related disorders. in most cases of factitious disorder, the person presents with somatic symptoms and with the expressed belief that he or she is ill.
Why is it a problem that facticious disorder is in the somatic disorder section of the DSM 5?
These disorders have a history of being stigmatized and many doctors do not take them very seriously. To group them now with a disorder that is characterized by deliberately feigning illness runs the risk of further perpetuating these negative stereotypes.
What is the difference between factitious disorder and malingering?
The key difference is that, in factitious disorder, the person receives no tangible external rewards. In contrast, the person who is malingering is intentionally producing or grossly exaggerating his or her physical symptoms and is motivated by external incentives such as avoiding work or military service or evading criminal prosecution
risks with fictious disorder
In factitious disorder, patients may surreptitiously alter their own physiology—for example, by taking drugs—in order to simulate various real illnesses. Indeed, they may be at risk for serious injury or death and may even need to be committed to an institution for their own protection.
MORE COMMEN IN WOMEN
factitious disorder imposed on another (sometimes referred to as Munchausen’s syndrome by proxy).
the person seeking medical help has intentionally produced a medical or psychiatric illness (or the appearance of an illness) in another person. This person is usually someone (such as a child) who is under his or her care =a mother presents her own child for treatment of a medical condition she has deliberately caused. = the health of the victims is often seriously endangered by this form of child abuse and the intervention of social service agencies or law enforcement is sometimes necessary. In as many as 10 percent of cases, the actions of the mother may lead to a child’s death
When is facticious disorder imposed by another suspected?
this disorder may be suspected when the victim’s clinical presentation is atypical, when lab results are inconsistent with each other or with recognized diseases, or when there are many frequent returns or increasingly urgent visits to the same hospital or clinic. The perpetrators (who often have extensive medical knowledge) tend to be highly resistant to admitting the truth about what they are doing = average length of time to confirm the diagnosis is 14 months
