Session-12 Somatoform Disorders

Question 1

What is Somatization?

Answer 1

Refers to psychological stress that manifests in the form of physical symptoms; a person’s physical symptoms are traceable to a mental or emotional cause rather than to a physical one.

Question 2

(Somatization) What are the prominent somatic (bodily) symptoms, directly related to?

Answer 2

directly related to anxiety (deep-seeded, anxiety-producing cognitive schemas)

Question 3

What is the most common clinical manifestation of anxiety disorders worldwide?

Answer 3

Somatization (somatoform disorders)- no basis really for distinguishing from anxiety disorders.

Question 4

What was Freud’s original conceptualization of hysteria?

Answer 4

Somatization

note:

Freud’s original work is how the field got started, around 1890 or so, he began talking to people, he was an MD, a neurologist, but he started to get referrals in Vienna where he was living, a majority of the people coming to talk to him had somatoform presentations, basically at that time there were, many of the patients had paralysis, they could not move or feel parts of their body. And he started to notice a theme, he was seeing a theme in some of the young woman patients, many of the young woman patients had symptoms of paralysis below their, in the lower portions of their body. Now what you learn through the case of Anna O and others, he originally theorized that the reason why there was paralysis was not due to a medical issue, he thought the theme seemed to be that these woman had been traumatized, he thought they had been raped and that the paralysis was secondary to trauma. And that is called the seduction hypothesis; he thought these young woman had been the victims of incest in their families, they were abused and the paralysis was second to this abuse. How the field got started, our belief in trauma, and the bodily response to trauma. He hypothesized that these woman were seduced and violated incecuassly. As he began to talk about this, he had a bunch of followers and they started to talk about mental health issues, as they talk to him in this group, they tell him you cant just make this public because it will ruin the reputation of all these woman fathers and stuff. He was in higher power so his followers told him that he could not just state that all these woman are having these symptoms because they had been violated by their family. So he abandoned this hypothesis, he gave up that view and his revised view was this; that it was not the paralysis in these woman, in their lower portion was not a response to sexual abuse, it was due to a mental conflict, and the mental conflict is this; these young woman had a wish and wish for him meant the ID, the wish of these woman were to have sex, they had sexual desire as they were becoming woman (12/13/14), they had the wish for sexuality, and the fear connected to that was that this made them dirty. This made them bad, that made them hoars, so there is a triangle; the wish (sexualisty), fear (bad to have sexual desire), defense (somatization, paralyzing the vagina and often the legs). His original view of this was that if they cant feel stimulation they wont want it and if they want it they wont be able to walk to it.
Abandonement of seduction was replaced by the theory of conflit; this was sort of the first model of psychopathology. The wish of course was the ID, the fear is the Super Ego (values, religion, family), for Freud in the 1890s, woman should not be sexual at all, the Super Ego was making woman believe that if they had these wishes it made them naughty.
Theory of hysteria, hysterical; the first medical disease, the hysteria was the somatization symptoms due to sexual conflict about sexuality.
The reason why anxiety is a part of this, when there is a Wish and the Fear, this wish fear thing creates anxiety, that’s the anxiety that Freud thought about. Once there is anxiety it has to be defended against. We can say that somatoform disorders is the first set of disorders in the fear; the anxiety must be relieved some how, the way it is relieved is with a fear; wish, fear, release
Many feminist; one of the reasons why he was so criticized, they said it wasn’t really that they were having mental conflicts it was that they were sexually violated.

Question 5

What point does Castillo make over and over again?

Answer 5

That there is significant (arbitrary) overlap between anxiety, somatoform, and mood disorders.

Question 6

DSM-IV-TR: What are the “Somatoform Disorders”?

Answer 6

somatization disorder

undifferentiated somatoform disorder

conversion disorder

pain disorder

hypochondriasis

body dysmorphic disorder

somatoform disorder NOS

Question 7

DSM-IV-TR: Somatization Disorder requires a history of ____ and have a duration of___?

Answer 7

history of recurrent multiple somatic complaints that begin before age 30 and have a duration of at least several years and are characterized by a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms

Question 8

DSM-IV-TR: What is the highly specific criteria for Somatization Disorder?

Answer 8

Pain symptoms in 4 areas of the body

2 gastrointestinal disturbances other than pain: example, nausea, bloating, vomiting

1 sexual symptom other than pain: example, irregular menses, excessive menstrual bleeding, sexual indifference, erectile or ejaculatory dysfunction

1 pseudoneurological (dissociative) symptom (conversion symptoms) such as paralysis or seizure, impaired coordination or balance, difficulty swallowing, blindness.

Question 9

DSM-IV-TR: What is Somatization Disorder often comorbid with?

Answer 9

With mood and anxiety disorders; for example, panic disorder, generalized anxiety disorder, and major depressive disorder

note: there is no known medical cause or symptoms and complaints are in excess of what is normally expected based on the medical condition and rarely occurs in men.

Question 10

DSM-IV-TR: Somatization Disorder

What are Pseudo-neurological conditions?

Answer 10

They are illnesses that mimic a wide range of diseases of the nervous system, but are not caused by any organic disorder.

Question 11

What are pseudo-neurological conditions in the classical form?

Answer 11

They are truly psychosomatic (caused or aggravated by mental conflict) and reflect the close links between the brain and the peripheral nervous system, and the interplay between mind and body.

Question 12

Are pseudo-neurological symptoms fake?

Answer 12

They are not “put on” and affected individuals should not feel they are being branded as frauds.

Although difficult to distinguish from feigned (pretend) illness, in genuine cases, the symptoms are as real and disabling as those caused by organic disease.

Question 13

What is the second group of pseudo-neurological conditions?

Answer 13

They are pseudo-syndromes; this is when the symptoms of one disorder produce effects which mimic those of another unrelated disease.

Question 14

What are the symptoms and signs of pseudo-neurological conditions?

Answer 14

seizures

pain, especially headaches

weakness or paralysis

numbness or tingling

spasms, tics or tremors

abnormal posture

gait abnormalities

disturbances of vision

loss of taste and smell

loss of voice, stuttering is often, not always, a conversion problem

delirium

loss of memory

dizziness or vertigo

Question 15

What are pseudo-neurological conditions though to arise from?

Answer 15

by a psychological mechanism called Conversion (previously known as hysteria)

note: When there is a wish for sex and the fear, the anxiety that erupts from that conflict gets converted, this is conversion. It gets converted from mind, meaning anxiety to body, the paralysis and you can say this conversion is the defense. When you convert mental conflict to bodily experience, this is conversion.

Question 16

Somatization Disorder was historically known as?

Answer 16

Hysteria/ Briquet’s Syndrome

Poor, inconsistent historians: they cannot historically describe when things emerged for them, everything is vague and unclear and sometimes the information contradicts.

Question 17

DSM-IV-TR: What is “undifferentiated somatoform disorder”?

Answer 17

Residual category for persistent somatoform-type illnesses that do not meet criteria for somatization disorder. One or more physical complaints that cannot be explained medically and the duration of the disturbance is at least 6 months.

Question 18

DSM-IV-TR: Why is “undifferentiated somatoform disorder” important for cross-cultural assessment?

Answer 18

Important for cross-cultural assessment (culture-bound syndromes). For example, “neurasthenia” in China (depression rare, but emotional distress demonstrated in culturally-bound physical symptoms as an idiom of expression).

Cultural schemas differ re: pattern recognition of symptoms, meaning, and acceptance of particular constructs.

note: Cross culturally there are some people in areas that somatization is standard, it is an idiom of expression, idiom a way to express cultural anguish. A way of expressing mental constructs is through the body; meaning if it is culturally bound, an idiom of distress, the way of expressing mental distress is through the body, you would not assign this disorder to them; you would not be attending to their cultural context

Back of DSM-IV, idioms of distress

Question 19

DSM-IV-TR criteria for “undifferentiated somatoform disorder”?

Answer 19

Residual category for persistent somatoform-type illnesses that do not meet criteria for Somatization disorder.

One or more physical complaints that cannot be explained medically and the duration of the disturbance is at least 6 months

Important for cross-cultural assessment (culture-bound syndromes)
For example, “neurasthenia” in China: depression is rare, but emotional distress demonstrated in culturally-bound physical symptoms as an idiom of expression

Cultural schemas differ with regard to recognition of symptoms, meaning assigned to symptoms, and acceptance of particular constructs to explain illness

Question 20

DSM-IV-TR: What is “conversion disorder”?

Answer 20

One or more symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition;

Psuedoneurological (dissociative) symptoms such as amnesia, paralysis, impaired coordination or balanced, blindness, deafness, seizures without medical explanation, etc.

Symptoms are not intentionally produced and cannot be explained by a physical etiology.

Question 21

DSM-IV-TR: What is criteria for “Conversion Disorder”?

Answer 21

Pseudoneurological dissociative symptoms that affect sensory or motor function and suggest a neurological or general medical condition, but are without medical basis

Symptoms defined as dissociative because the sensory or motor experience is considered to be split from awareness; also, individuals may be amnestic for episodes of more severe symptoms, such as seizures

Symptoms are considered to be the result of psychological problems and are often preceded by an identifiable stressor or trauma – symptoms become the focus of attention and allow the person to escape the stressful or traumatic experience

Symptoms include: impaired coordination or balance, paralysis or localized weakness, difficulty swallowing, urinary retention, blindness, deafness, double vision or seizures (not neurologically based)

note: Not neurologically based, a pseudo seizure, shows symptoms but not enough abnormality to be neurological.
Patient presents with symptoms consistent with seizure but etiology is unknown.
Some people think possession is really conversion; a defense against the anxiety; generally would be good and evil, wish is to be good and the fear is evil. Freud at some point, refined the theory of mental conflict, he argued that a lot of fears are actually wishes; a battle ground for the wish to be good and evil,
*esoteric conversion; like the old biblical of speaking in tongues, this is this but your able to voice different languages, so consciously you don’t posses knowledge of these languages,

Many people have conflicts with things outside of them and others have conflicts with things within them.

Question 22

Prior to the diagnosis of “Conversion Disorder” what is necessary?

Answer 22

A full medical workup is essential to rule out medical explanations prior to the diagnosis of conversion disorder

People with conversion symptoms may also have coexisting bona fide medical or neurological conditions

Primary gain

Conversion symptoms function to keep some psychological conflict out of consciousness, thereby reducing anxiety

Secondary gain

Benefits (e.g., attention) are obtained and responsibilities (e.g., work, housekeeping) are evaded

However, in contrast to Factitious Disorder (sick role) or Malingering (secondary gain), in Conversion disorder, although there may be primary or secondary gain, symptoms are not deliberately produced to obtain those benefits

note: a typical conversion presentation; they go to multiple doctor visits, for scans, xrays and all these things and find nothing, now what its doing is primary gain; they are basically moving the highlight on their mental conflict to their bodily issue.

Question 23

What are other features of a Conversion Disorder?

Answer 23

Other features

La belle indifference:
Apparent lack of concern about the symptoms or the implications of the symptoms
Present in some cases, although people may also be more overtly dramatic in their presentation

Possible reinforcement of the sick role over time

Associated disorders: dissociative disorders, major depressive disorder, histrionic PD, antisocial PD, borderline PD, dependent PD

Not diagnosed if conversion symptoms are part of Somatization disorder

Question 24

DSM-IV-TR:

What is “Pain Disorder”?

Answer 24

Subjective experience of pain with no sufficient medical justification; psychological factors judged to play a role in the onset, severity exacerbation, or maintenance of the pain, and symptoms are not intentionally produced or feigned.

Subtypes: (1) with psychological factors, (2) with a general medical condition – code on Axis III, and (3) with both psychological factors and a general medical condition

Condition can be chronic, leading to a downward spiral of problems and psychological issues.

Question 25

What is DSM-IV-TR criteria for “Pain Disorder”?

Answer 25

Subjective experience of pain

Psychological factors are judged to play a role in the onset, severity exacerbation, or maintenance of the pain – in some cases, there is a general medical condition present as well, but it DOES NOT have a major role in the onset, severity, exacerbation or maintenance of the pain

Symptoms are not intentionally produced or feigned

Subtypes: Pain Disorder associated with (1) psychological factors, (3) both psychological factors and a general medical condition

Condition can be chronic, leading to severe impairment in functioning and ongoing psychological issues

Question 26

DSM-IV-TR: What is “hypochondriasis”?

Answer 26

Persistent and unfounded fears of having or belief that one has a serious disease based on misinterpretation of normal bodily functioning or minor symptoms. Belief is unsupported by medical evaluation, and the preoccupation lasts at least 6 months.

Fear that something is wrong; will see many doctors for a diagnosis.

False cognition that there is a serious medical condition causes severe anxiety.

Clinicians need to implement symbolic interventions to appease the patient’s mental construction of the problem.

Question 27

What is DSM-IV-TR Criteria for “Hypochondriasis”?

Answer 27

Persistent and unfounded fears of having or belief that one has a serious disease based on misinterpretation of normal bodily functioning or minor symptoms

Belief is unsupported by medical evaluation, and the preoccupation lasts at least 6 months

Belief persists despite medical evaluations and reassurances to the contrary

Patients will often see several different doctors in their attempts to obtain a medical diagnosis

Specifier: With Poor Insight – if the person does not recognize that their concern is excessive or unreasonable

Question 28

DSM-IV-TR: What is “body dysmorphic disorder”?

Answer 28

Discrimination and humiliation concerning some part of one’s appearance; preoccupation with an imagined defect in appearance, i.e., aspect of the body is seriously defective.

Preoccupation must be associated with significant emotional distress and social or occupational impairment.

Concerns may be based on real prevailing cultural schemas (the “Jewish nose”).

Obsessive concern about body shape and size; compulsive checking of the body in the mirror. May correspond to low self-esteem, social isolation, etc.

Question 29

What is DSM-IV-TR Criteria for Body Dysmorphic Disorder?

Answer 29

Preoccupation with an imagined defect in appearance or excessive preoccupation with a slight anomaly in appearance

Preoccupation is not better accounted for by another disorder; e.g., dissatisfaction with body shape and size as seen in anorexia nervosa

Compulsive checking and excessive scrutiny of defective body part; efforts to conceal or camouflage the imagined defect; or efforts to change the imagined defect via surgery or other procedures

Question 30

What is “Somatoform Disorder NOS”?

Answer 30

Somatoform symptoms that do not meet the criteria (or duration criteria) for any specific Somatoform disorder

E.g., Pseudocyesis/pseudopregnancy: a physical condition caused by emotional factors or by a tumor, etc., in which a female’s body manifests signs of pregnancy, including amenorrhea and enlargement of the abdomen; false pregnancy.

Question 31

DSM-5 General Issue regarding “somatoform disorders”?

Answer 31

DSM-5 argued that the DSM-IV criteria over-emphasized the importance of an absence of a medical condition (medically unexplained symptoms used to be the main emphasis)

note: DSM-5 classification defines disorders on the basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms).
Medically unexplained symptoms do remain a key feature in Conversion Disorder and Pseudocyesis because it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical psychophysiology.

They are emphasizing politically that they are there rather than they are unfounded; a politcal refinement.

Question 32

What are DSM-5: “Somatic Symptom and Related Disorders”?

Answer 32

Somatic Symptom Disorder (SSD)

Illness Anxiety Disorder

Conversion Disorder (Functional Neurological Symptom Disorder)

Psychological Factors Affecting Other Medical Conditions (PFAMC)

Factitious Disorder

Other Specified Somatic Symptom and Related Disorder

Unspecified Somatic Symptom and Related Disorder

Question 33

DSM-5: What is “Somatic Symptom Disorder (SSD)”?

Answer 33

Added to the DSM-5 to better recognize the complexity of the interface between psychiatry and medicine.

Psychiatric symptoms and general medical symptoms can and do co-exist.

DSM-5 does not question the reality of patient’s suffering and emphasizes instead that psychiatric disorders are more properly diagnosed on the basis of features such as disproportionate and excessive thoughts, feelings, and behaviors, rather than by negative features like “medically unexplained symptoms.”

DSM-5: a patient’s suffering is now considered to be authentic, whether or not it is medically explained.

Diagnosis of SSD subsumes (takes over) the former diagnoses of Somatization Disorder, Hypochondriasis, Undifferentiated Somatoform Disorder, and Pain Disorder.

There was significant problematic overlap across the somatoform disorders and a lack of clarity about their boundaries.

Question 34

What is DSM-5 Criteria: Somatic Symptom Disorder (SSD)?

Answer 34

A. one or more somatic symptoms that are distressing or result in disruption of daily life.

B. excessive thoughts, feelings or behaviors related to the somatic symptoms with at least one of the following:

1. pervasiveness about seriousness of symptoms
2. high level of anxiety persists about health
3. excessive time and energy devoted to health concerns

C. Although any one somatic symptoms may not be continuously present, the state of being symptomatic must be for at least 6 months.

Specify if: with predominant pain
Specify if: Persistent
Specify current severity: mild, moderate, severe.
Note: for specifiers see pp. 311, DSM 5

Question 35

DSM-5: Is Somatic Symptom Disorder (SSD) a medical condition?

Answer 35

Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition.

note: We assume that they may or may not have a diagnosed medical condition, they are trying to downplay this for a political purpose
Example. Fainting spells, there is a patient that is fainting all the time, they get negative blood test back, the person keeps fainting and they think there is a parasite in them, so they go to an infectious disease specialist and nothing, they get worried and worried, they are upset, they have somatic symptoms, they cant do stuff, they don’t go to work, the assumption is that they may or may not have something. They took out, that there is no medical cause because they thought it was a little inhumane, so they opened this up to therapy, so that way they are not running around trying to get answers but we can try and figure it out.

Question 36

What disorder do those diagnosed with DSM-IV-TR “somatization disorder” generally meet criteria for in DSM-5?

Answer 36

(SSD) Somatic Symptom Disorder:

Individuals previously diagnosed with Somatization Disorder usually meet the DSM-5 criteria for SSD if they have the above-mentioned criteria that define the disorder, in addition to their somatic symptoms.

Question 37

DSM-5: What is “Illness Anxiety Disorders”?

Answer 37

Hypochondriasis has been eliminated as a disorder, in part because the name was perceived as pejorative and not conducive to an effective therapeutic alliance.
Most individuals who would previously have been diagnosed with hypochondriasis have significant somatic symptoms in addition to their high health anxiety, and therefore now have a DSM-5 diagnosis of SSD.
In DSM-5, individuals with high health anxiety without somatic symptoms receive a diagnosis of Illness Anxiety Disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as GAD)

note: hypochondriasis has been nooked/fucked (DSM-IV-TR)

Question 38

What is DSM-5 Criteria for Illness Anxiety Disorder?

Answer 38

A. preoccupation with having or acquiring a serious illness

B. Somatic symptoms are not present, or, if present, are only mild in intensity. If another medical condition is present, or there is a high risk of developing a medical condition, preoocupation is disproportionate or excessive.

C. high level of anxiety about health and easily alarmed about health condition

D. excessive health related exercises (e.g. checking) and also maladaptive behaviors.

E. illness preoccupation for at least 6 months, but, specific illness that is feared may change over time.

F. Illness related preoccupation is not explained by another mental disorder.

Specify if:
Care seeking type
Care avoidant type

Question 39

DSM-5: What is “conversion disorder”?

Answer 39

DSM-5 criteria have been modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis

Question 40

What is DSM-5 Criteria for Conversion Disorder (Functional Neurological Symptom Disorder)?

Answer 40

A. one or more symptoms of altered voluntary motor or sensory function.

B. no clinical evidence for neurological or medical condition.

C. not explained by another medical condition.

D. cause sig. distress, disability or warrants medical evaluation.
For specifiers, see page 318-319

note: They are almost making it sound like a ligitimate neurological problem; this is a political maneuvor, this is basically the pseudo neurologic features, but they are calling it functional neurological symptom, can you imagine your patient—the client might think, wow I am really sick. Reinforcing their disallusion.

Question 41

What are “psychological factors affecting other medical conditions (PFAMC)”?

Answer 41

In DSM-IV-TR, pain disorder diagnoses assumed that some pains are associated solely with psychological factors, some with medical disease or injuries, and some with both.

There was the belief that a lack of evidence existed re: being able to make such distinctions reliably and validly, because much research indicates that psychological factors influence all forms of pains

Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences.

In the DSM-5, some individuals with chronic pain should therefore be diagnosed as having SSD, With Predominant Pain. For others, Psychological Factors Affecting Other Conditions or an Adjustment Disorder are more appropriate.

Psychological Factors Affecting Other Medical Conditions was added to DSM-IV in the part of the manual reserved for conditions that may be of interest to clinicians, even though they are explicitly not to be considered mental disorders.

In DSM-5, PFAMC and Factitious Disorder are placed among the Somatic Symptom and Related Disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings.

PFAMC might describe someone’s stress precipitating a stroke, a patient’s noncompliance with treatment, Type A personality traits that are a risk factor heart attack, a sedentary lifestyle predisposing to obesity, or unsafe sexual practices.

Question 42

What is DSM-5 Criteria for PFAMC?

Answer 42

A. A medical condition (other than mental disorder) is present.

B. Psych. Factors adversely impact medical condition in one of the following ways:

1. close temporal link between psych. Factors and development of medical condition
2. psych. Factors interfere with txt of med. Condition
3. factors contribute to high health risks of the individual
4. factors affect underlying psychopathology

C. Psychological or behavioral factors in Criterion B are not better explained by another mental disorder
Specify current severity: mild, moderate, severe, extreme
See page 322, DSM 5.

Question 43

What is DSM-5 Criteria for Factitious Disorder?

Answer 43

Factitious Disorder Imposed on another (previously factitious disorder by proxy)

A. falsification of physical or psych. Signs or induce injury or disease, intended for deception.

B. presents self to others as ill, impaired etc.

C. deceptive behaviors even in the absence of external rewards.

D. behav. Not explained by another mental disorder.

Specify: Single episode, recurrent episodes (pp.324)

Question 44

DSM-5: What are the “other” and “unspecified” disorders in Somatoform Disorders?

Answer 44

Other Specified Somatic Symptom and Related Disorder

Unspecified Somatic Symptoms and Related disorder