Chapter 8 Flashcards
How many people say they have had somatic symptoms in the past week?
80% of people in the general population
Somatic symptom disorder (general definition)
When concern about physical somatic symptoms is severe and leads to significant distress or impairment. formally known as somatoform disorders
Dissociative disorder (general definition)
One feelings of being out of it becomes so persistent and recurrent that the person has profound and unusual memory deficits, such as not knowing who they are
Neurosis
Somatic symptom disorders and dissociative disorders were considered to be forms of neurosis, and were included with the various anxiety disorders in the past. This was because anxiety was thought to be the underlying cause of all neuroses whether or not the anxiety was experienced overly. In the DSM three the anxiety, mood, somatic symptoms, and dissociative disorders each became separate categories, as attempts to link the disorders together on the basis of hypothesized underlying causes were abandoned and instead the focus was on grouping disorders together on the basis of overt symptomatology
Somatic symptom disorder and dissociative disorders in the DSM-V
In the DSM five, somatic symptom disorders and dissociative disorders are regarded as distinct diagnostic entities
“Soma”
“Body”
Somatic symptom and related disorders
A new category in the DSM five. The disorders in it lie at the interface between abnormal psychology and medicine. Included in this category are conditions that involve physical symptoms combined with abnormal thoughts, feelings, and behaviours in response to those symptoms. People with somatic symptom disorder‘s experienced bodily symptoms that caused them significant psychological distress and impairment. The affected patients have no control over their symptoms. They are also not intentionally faking symptoms or attempting to deceive others.
Somatic symptom disorder’s versus normal bodily sensations and symptoms
Experiencing bodily sensations or symptoms is very common. In most cases these symptoms go away spontaneously. but in about 25% of cases, if symptoms persist for a longer period, prompting people to visit their doctors. Somewhere between 20 and 50% of the physical symptoms that caused people to seek medical care or medically unexplained. A subset of patients will continue to be very worried that something is seriously wrong. These people tend to continue to seek help for their physical problems, asking for and undergoing more and more tests. They become preoccupied with some aspect of their health to the extent that they show significant impairments in functioning. Such patients are more commonly found in medical settings than mental health clinics. 20% of doctor visits are caused by complaints of this sort
Somatic symptom disorder in the DSM four versus the DSM five
In the DSM for a great deal of emphasis was placed on the idea that the symptoms were medically unexplained. The patient’s complaints suggested the presence of a medical condition but no physical pathology could be found to account for them. An important change in the DSM five is that no distinction is now made between medically explained and medically unexplained symptoms. The idea 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 their predominant cultural beliefs. Nonetheless medically unexplained symptoms are still a key part of some disorders such as conversion disorder
The four most important disorders in a somatic symptom and related disorders category of the DSM five
There are four important disorders in this category: somatic symptom disorder; illness anxiety disorder; conversion disorder; factitious disorder.
Old disorders that her now included within somatic symptom disorder
Hypochondriasis; somatization disorder; pain disorder. These disorders have now disappeared but previously had a separate diagnosis in the DSM four. Most of the people who would in the past have been diagnosed with one of these disorders will now be diagnosed with somatic symptom disorder.
Hypochondriasis
Where individuals are preoccupied either with fears of contracting a serious disease or with the idea that they have a disease even though they do not. This was a diagnosis in the DSM four, but is now included within somatic symptom disorder in the DSM five. It is estimated that around 25% of people who would have been diagnosed with hypochondriasis in DSM four will be diagnosed with illness anxiety disorder in DSM five. The remaining 75% will be diagnosed with somatic symptom disorder. When hypochondriasis is accompanied by significant physical symptoms, the diagnosis will be somatic symptom disorder. When there is hypochondriasis without any physical symptoms or with very mild ones, the diagnosis will be illness anxiety disorder
Diagnosis of somatic symptom disorder
Diagnosis is a descriptive one. It contains no assumptions about cause. The name of the diagnosis is chosen to reduce some of the negative connotations associated with older diagnostic terms such as hypochondriasis, as well as ideas that disorders such as these were all in the mind. For the diagnosis to be made, individuals must be experiencing chronic somatic symptoms that are distressing to them. They must also be experiencing dysfunctional thoughts, feelings and behaviors. The physical symptoms no longer need to be medically unexplained
The addition of the psychological component to somatic symptom disorder in the DSM five
For a diagnosis of somatic symptom disorder, the person must be experiencing dysfunctional thoughts, feelings and or behaviors. The addition of this psychological component is new. In the DSM for all that was required was that people be experiencing somatic symptoms that were medically unexplained. No psychological features were required
DSM-V criteria for somatic symptom disorder
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life
B. Excessive thoughts, feelings or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1. Disproportionate or persistent thoughts about the seriousness of one’s symptoms
2. Persistently high level of anxiety about health or symptoms
3. Excessive time and energy devoted to these symptoms or health concerns
C. Although anyone somatic symptom may not be continuously present, the state of being symptomatic is persistent, typically more than six months
How many somatic symptoms are required for a diagnosis in the DSM-V of somatic symptom disorder?
Only one somatic symptom is required. This is a diagnostic change that has occurred in the DSM five. If a person has any physical problem that they find distressing, even if it only involves a single symptom and is medically explained, the diagnosis of somatic symptom disorder is possible. Many patients have many physical complaints. The new DSM five criteria will likely lead to an increase in the diagnosis of somatic symptom disorder for this reason. It has been suggested that women will be disproportionately affected because they’re more frequent users of medical services and they’re most at risk of being dismissed by their doctors as catastrophizers
Suggested revised diagnostic criteria for somatic symptom disorder
There has been criticism about the DSM five somatic symptom disorder criteria, considering it loosely defined and Fadily flood. This is one professionals revised diagnostic criteria offering for this disorder:
A. One or more prominent physical symptoms
B. Excessive and maladaptive thoughts, feelings and behaviours related to the physical symptoms. All three of the following must be present: clearly disproportionate and intrusive worries about the seriousness of the symptoms; extreme anxiety about the symptoms; excessive time and energy devoted to the symptoms or health concerns
C. Excessive concerns have persisted at a clearly problematic level for at least six months
D. The excessive concerns about physical symptoms are pervasive and cause significant disruption and impairment in daily life
E. If a diagnosed medical condition is present, thoughts, feelings and behaviours are grossly an excess of what would be expected given the nature of the medical condition
F. If no medical diagnosis has been made, I throw medical work up has been performed to rule out possible causes and is repeated at suitable intervals to uncover medical conditions that may declare themselves with the passage of time
G. The physical symptom or concern is not better accounted for by another mental disorder
Criticism of the current DSM-V criteria for somatic symptom disorder
The current DSM5 criteria may result in a wide range of patients being assigned to the same diagnosis. Some will have any symptoms and some will have very few. Someone will have symptoms that have a medical cause and others will not.
It’s estimated that the prevalence of somatic symptom disorder will increase, and in the general population it will be around 5 to 7%.
Historical reasons for why it was thought people develop somatoform disorders
This thinking date‘s back to the psychoanalytic concept of hysteria and the work of Freud, Brewer and to Janet. It was a long thought that symptoms developed as a defence mechanism against unresolved or unacceptable unconscious conflicts. Rather than being expressed directly, psychic energy was instead of channelled into more acceptable physical problems
Current views on why people develop somatic symptom disorder
Several different models exist but their core features tend to be similar. First there is a focus of attention on the body. The person is hyper vigilant and has 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 catastrophize Ing cognition. Fourth because of this worry the person is very distressed and seek medical attention for their perceived physical problems
Somatic symptom disorder can be viewed as a disorder of both ________ and _________.
Perception and cognition. Individuals who are especially anxious about their health and tend to believe that they are very aware of and sensitive to what is happening in their bodies. But experimental studies show that these individuals have unintentional bias for illness related information. Top down processes rather than bottom-up processes seem to account for the problems that they have. People with somatic symptom disorder‘s seems to focus excessive attention on their physical experiences, labelling physical sensations as symptoms. They perceive their symptoms as more dangerous than they are and judge a disease is more likely than it really is. Once a symptom has been misinterpreted, they look for confirming evidence and discount evidence that they’re in good health. They also perceive their probability of being able to cope with the illness is extremely low and see themselves as weak and unable to tolerate physical effort or exercise. This creates a vicious cycle where anxiety about illness results in physiological symptoms of anxiety
Past experiences with illness and somatic symptom disorder
It’s believed that an individuals past experiences with illness 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. These dysfunctional assumptions might include: if you don’t go to the doctor as soon as you notice anything unusual, then it will be too late. This is another example of top down cognitive processes at work
Negative effect and somatic symptom disorder
Negative effect is regarded as a risk factor for developing somatic symptom disorder. But it is not sufficient. Only a subset of people who are gloomy when their personalities will also be habitual reporters of physical symptoms. Other characteristics that may be important are absorption and alexithymia. People who report many symptoms but who do not have any medical conditions tend to score high on all of these three traits
Absorption
The tendency to become absorbed in one’s experiences and is often associated with being highly hypnotizable
Alexithymia
Refers to having difficulties identifying one’s feelings.
When people who report a lot of physical problems are put into a negative mood, they’re reporting a physical symptoms increases. Why?
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. These alterations in the attentional system may  triggered memories or past representations of symptoms that were formed as a result of prior experiences with illness. Once these schemas become active, they may cause the person to become aware of minor physical sensations or even trigger experiences of symptoms that are as real as they would be if they resulted from a known medical cause. Because all of this happens automatically, the person has no insight into or control over the process
Patients with somatic symptom disorder are more likely to be…
Female and have high levels of comorbid depression and anxiety
Impairment with somatic symptom disorder
Patients with somatic symptom disorder often have high levels of functional impairment, and many patients are severely disabled by their physical symptoms
Somatic symptom disorder’s and financials
Because these patients repeatedly seek medical advice, their annual medical costs are much higher than average
Somatic symptom disorders and secondary reinforcements
An example of the disorder of hypochondriacus, it was found that patients reported much childhood sickness and missed a lot of school. People with hypochondriacis also tend to have an excessive amount of illness in their families will growing up, which may lead to strong memories of being sick or in pain and perhaps of having observed some of the secondary benefits that sick people sometimes get
Malingering
Consciously faking symptoms to achieve a specific goal such as winning a personal injury lawsuit.
Treatment of somatic symptom disorder
Cognitive behavioural 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 a reassurance. In addition to CBT, a certain type of medical management may provide some further benefits. Doctors can be educated in how to better manage and treat patients with these disorders so that they are less frustrated by them.
CBT for somatic symptom disorder
Generally the duration of CBT is relatively brief, 6 to 16 sessions. Sessions can also be delivered in a group format. CBT approaches can also reduce levels of anxiety and depression more generally. Patients do better if they receive more sessions of treatment. Patient reported that considering alternative reasons for the presence of their bodily symptoms was the most valuable aspect of CBT
Medical management for somatic symptom disorder‘s
medical management may provide some further benefits. Doctors 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 to the patients care by seeing the patient at regular visits and by providing physical exams focussed on new complaints. The physician avoids a necessary diagnostic testing and makes minimal use of medication‘s or other therapies. Studies have found that patients show substantial decreases in healthcare expenditures over subsequent months and sometimes an improvement in physical functioning. Approach should be combined with CBT as it does not necessarily result in lowered psychological distress
Cognitive behavioural techniques in the treatment of somatic symptom disorder that involves pain
Treatment programs generally include relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of no pain behaviors. patients receiving such treatments tend to show substantial reductions in disability and distress, although changes in the intensity of their pain tend to be smaller in magnitude. Antidepressant medication‘s and certain selective serotonin reuptake inhibitors have been shown to reduce pain intensity in a manner independent of the effects the medication‘s may have on mood
Illness anxiety disorder
This disorder is new to the DSM five. People 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.
DSM five criteria for illness anxiety disorder
A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are not present or, if present, I only mild and intensity. If another medical condition is present or there is high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate
C. There is a high level of anxiety about health and the individual is easily alarmed about personal health status
D. The individual performs excessive health related behaviours or exhibit maladaptive avoidance
E. Illness preoccupation has been present for at least six months but the specific illness that is feared me change over that period of time
F. Illness related preoccupation is not better explained by another mental disorder
Conversion disorder [functional neurological symptom disorder]
Within the diagnostic category of somatic symptom and related disorders. This is a recent term. Historically this disorder was one of several disorders that were grouped together under the term hysteria. Characterized by the presence of neurological symptoms in the absence of a neurological diagnosis. The patient has symptoms or deficits affecting the senses or motor behaviour that strongly suggest a medical or neurological condition. But the pattern of symptoms or deficits is not consistent with any neurological disease or medical problem. Example: partial paralysis, blindness, deafness. The diagnosis can only be made after a full medical and neurological work up has been conducted. The person is not intentionally producing or faking the symptoms but psychological factors are often judged to play an important role because symptoms usually either start or are exacerbated by preceding emotional or interpersonal conflicts or stressors
Early observations of people with conversion disorder: “la belle indifference”
These early observations suggest the 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. This seeming lack of concern was known as “la belle indifference”. It was thought to be an important diagnostic criterion for conversion disorder. But it occurs only in about 20% of patients. Lack of concern about symptoms or other implications is also not specific to conversion disorder so this phenomenon has become de emphasized in more recent additions of the DSM
Changing the term used to describe conversion disorder
Authors of the DSM-V wanted to change the term used to describe the disorder but in the end, the term conversion disorder was retained, although this is now followed in parentheses by “functional neurological symptom disorder”.
DSM five criteria for a conversion disorder
A. One or more symptoms of altered voluntary motor or sensory function
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions
C. The symptom or deficit is not better explained by another medical or mental disorder
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational or other important areas a functioning or warrants medical evaluation
Symptoms of conversion disorder
There are four categories of symptoms:
Sensory
Motor
Seizures
Mixed presentation of the first three categories 
Sensory symptoms or deficits of conversion disorder
Involve almost any sensory modality, symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate. Most often in the visual system, the auditory system, or in the sensitivity to feeling. 
Sensory symptoms of conversion disorder: sensitivity to feeling
Especially the anesthesia’s. In the anesthesia’s, the person loses their sense of feeling in a part of the body. One of the most common is glove anesthesia, in which the person cannot feel anything on the hand in the area where gloves are worn, but loss of sensation usually makes no anatomical sense.
Sensory symptoms of conversion disorder: visual system and auditory system
With conversion blindness, the person reports that they can’t see, and yet can often navigate about a room without bumping into furniture or other objects. With conversion deafness, the person reports not being able to hear, and yet orients appropriately upon hearing their name. The evidence supports the idea that the sensory input is registered, but is somehow screened from explicit, conscious recognition: explicit perception. 
Motor symptoms or deficits of conversion disorder
 covers a wide range of symptoms. For example, conversion paralysis is usually confined to a single limb, such as an arm or leg, and the loss of function is usually selective for certain functions. For example, a person may not be able to write, but may be able to use the same muscles for scratching. the most common speech related conversion disturbance is aphonia, where a person is able to talk only in a whisper, so they can usually cough in a normal manner. Another common motor symptom is called Globus, involving a sensation of a lump in the throat. 
Seizures in conversion disorder
A relatively common form of conversion symptoms. These resemble epileptic seizures, but they are not true seizures. Patients do not show any EEG abnormalities and do not show confusion and loss of memory afterwards as patients with true epileptic seizures do. Also patients with conversion seizures, often show excessive thrashing about, and rising not seem with true seizures, and they rarely injure themselves in falls, or lose bowel or bladder control as patients with true seizures frequently do.
Misdiagnosis of conversion disorder
Because the symptoms can simulate a variety of medical conditions, accurate diagnosis is difficult. Misdiagnoses can still occur. As medical tests have become increasingly sophisticated, the rate of misdiagnoses has declined, with estimates of misdiagnoses in the 1990s, only 4%, down from nearly 30% in the 1950s.
Criteria for Distinguishing between conversion disorders, and true neurological disturbances
-frequent failure of the disfunction to conform clearly to the symptoms of a particular disease or disorder simulated.
-The nature of the disfunction is highly selective.
-Under hypnosis or narcosis, asleep, like state induced by drugs, the symptoms can usually be removed, shifted, or reintroduced at the suggestion of the therapist. For example, A person abruptly awakened from a sound asleep, made suddenly be able to use a paralyzed limb.
Prevalence of conversion disorders
They were once a relatively common in civilian and military life.
Conversion disorders are found in approximately 5% of people referred for treatment at neurology clinics. The prevalence in the general population is unknown, but the highest estimates of being around only 0.005%. 
Conversion disorders and war 
In World War I conversion disorder was the most frequently diagnosed psychiatric syndrome among soldiers, and was relatively common during World War II. They typically occurred under highly stressful combat conditions, and involved men who would ordinarily be considered stable.
Why do conversion disorders have decreased prevalence?
The decreased prevalence seems to be closely related to growing sophistication about medical and psychological disorders: a conversion disorder apparently loses its defensive function if it can be readily known to lack a medical basis. When it does occur today, it is most likely to occur in people who are medically unsophisticated. 
Demographic characteristics of conversion disorders
Conversion disorder occurs 2 to 3 times more often in women and men. It most commonly occurs between early adolescence and early adulthood, but can develop at any age. It has a rapid onset after a significant stressor and often resolves within two weeks if the stressor is removed, although a commonly Rickers. It frequently occurs along with other disorders, especially major depression, anxiety disorders, and other forms of somatic symptom or dissociative conditions 
Conversion hysteria
Freud‘s term for conversion disorders, which were fairly common in his practice, because he believed that the symptoms were an expression of repressed sexual energy; that is the unconscious conflict that a person felt about their repressed sexual desires. In Freud‘s view, the repressed anxiety threatens to become conscious so it is unconsciously converted into a bodily disturbance there by allowing the person to avoid having to deal with the conflict. This is not done consciously, 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. Freud‘s theory is no longer excepted outside psychodynamic circles, but many of his observations about primary and secondary gain are still incorporated into contemporary views of conversion disorder. 
Freud’s theories on conversion disorder when cast in terms of learning theory 
When cast in terms of learning theory, the physical symptoms can be seen as providing negative reinforcement, relief, or removal of an aversive stimulus, because being incapacitated in someway, make an able to individual to escape or avoid an intolerably stressful situation, without having to take responsibility for doing so. Also, they may provide positive reinforcement in the form of care, concern and attention from others. 
Conversion disorder when viewed through a sociocultural lens
In some cultures, expressing intense emotions is not socially acceptable. When viewed through a sociocultural lens, a diagnosis of conversion disorder can therefore be seen as a more socially, sanctioned way of expressing distress and escaping an unpleasant situation. However, although becoming sick, or disabled is more socially acceptable, it is important to keep in mind that the person is not deliberately choosing to lose their site or become unable to walk. Instead, unconscious processes are thought to be at work. 
Studies attempting to show the causes of conversion disorders
One study compared 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. But the greater than negative impact of the preceding life events, the greater the severity of the conversion disorder symptoms.
Another study compared levels of the neurobiological marker of stress in individuals with conversion disorder versus major depression versus no disorder. Both those with depression, and those with conversion disorder showed reduced levels of this market relative to the non-disordered controls. This also provides support for the link between stress and the onset of conversion disorder.
Neural imaging studies of conversion disorder are relatively rare, but provocative findings our emerging 
What can neural imaging tell us about conversion disorder
In one study, three patients with sensory loss received brain scans while they vibrating stimulus. It was applied to the right and left hands or feet. When the stimulus was applied to the side that had sensation and was unaffected, the brain scans revealed the expected findings. But when tactile stimulation was applied to the affected, numb body part, there was no activation in the contralateral area of the sensory cortex. Instead of the tactile stimulus activated regions in the orbitofrontal cortex and the anterior cingulate cortex. Both of these brain regions are involved in neural networks that I thought to regulate emotion and the expression of emotion.
Similar results were found in another study, but the activation was found in the insula cortex, a part of the limbic system that is thought to mediate emotional responses. When patients were asked to imagine, mentally rotating a paralyzed limb, there was activation in the anterior cingulate cortex .
Another study found that when the numb 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. This is consistent with the idea that sensory areas may be inhibited by overactive emotion-based processing. Abnormal activation in limbic areas might be overriding activation in motor or sensory areas, shutting off the persons, ability to detect, stimuli or move 
Treatment of conversion disorder
Knowledge and how to treat conversion disorder is limited. Some hospitalized patients with motor conversion symptoms have been successfully treated with a behavioural approach in which specific exercises are prescribed in order to increase movement or walking, and then reinforcements are provided when patients show improvement. Any reinforcement of abnormal motor behaviours are removed. Studies have shown success in this treatment, and the improvements were maintained over a two-year follow up. Another study used CBT to successfully treat conversion seizures. Some studies have used Hipnosis combined with other problem-solving therapies, and there are suggestions that Hipnosis, or adding Hipnosis, to other therapeutic techniques, can be useful 
Factitious disorder
A person intentionally produces, psychological, or physical symptoms, or both. The persons 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.
Factitious disorder in the DSM
In the DSM four, factitious disorder it was in a category of its own. In DSM five, it has been moved into the category of somatic symptoms and related disorders. The reason is because in most cases of factitious disorder, the person presents with somatic symptoms, and with expressed belief that they are ill. But many regard to the inclusion of this disorder in this category has unfortunate. This is because it runs the risk of further perpetuating negative stereotypes of the other disorders in this category.
