Week 6 Somatic Symptom and Related Disorders & Dissociative Disorders

Question 1

Essential somatic symptoms & related disorders

Answer 1

• The prominence of somatic symptoms associated with significant,
  excessive distress and impairment. - Medical explanation of symptoms may be present (i.e., somatic symptom
  disorder) or absent (i.e., conversion)

Question 2

Somatic symptom & related disorders facts

Answer 2

 Among the most prevalent mental health problems in primary care and other
medical settings
 Present in 10 – 15% of primary care patients
 Functional impairment comparable with that seen in depressive and anxiety
disorders
 Excessive health care use

Question 3

What are the five major disorders of Somatic symptom & related disorders

Answer 3

Five major disorders (DSM-5-TR):
1. Somatic symptom disorder
2. Illness anxiety disorder
3. Functional Neurological Symptom Disorder (Conversion disorder)
4. Factitious disorder
5. Psychological factors affecting other medical conditions

Question 4

DSM-5 Somatic symptom disorder:

Answer 4

A) One or more somatic symptoms that are distressing or result in
significant disruption to 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:
* Disproportionate and persistent thoughts about seriousness of symptoms
* Persistently high level of anxiety about health or symptoms
* Excessive time and energy devoted to these symptoms
C) Symptomatic state persists > 6 months
Specify if with predominant pain
 5-7% prevalence; more common in females
 Pain and gastrointestinal complaints most common
 Suicidal thoughts and attempts are frequent  Extensive medical history  “Doctor-shopping”

Question 5

DSM-5-TR Illness Anxiety Disorder

Answer 5

A) Preoccupation with having or acquiring a serious illness
B) Somatic symptoms are not present or if present are only mild in
intensity
C) High level of anxiety about health & the individual is easily alarmed
about personal health status
D) Performs excessive health-related behaviours or exhibits maladaptive
avoidance
E) Illness preoccupation present for at least six months (specific feared
illness might change over that time)
F) Preoccupation not better explained by another mental disorder

Previously known as hypochondriasis  Prevalence rates 1-10%
 Similar rates in males and females
 Belief that one has an illness is sustained despite evidence to the
contrary
 Somatosensory amplification

Question 6

DSM-5-TR Conversion Disorder

Answer 6

A) One or more symptoms of altered motor or sensory function
B) Clinical findings provide evidence of incompatibility between symptoms &
recognised neurological/medical condition
C) Symptom or deficit not better explained by another medical or mental
disorder
D) Symptom or deficit causes clinically significant distress or impairment
(various specifiers e.g., with seizures, with paralysis etc.)
 Symptoms not intentionally produced
 Symptoms mimic neurological disorder or other
medical condition
 May make no anatomical sense
 Implies psychological conflicts are being converted
into physical symptoms
 ≠ Malingering
 Rare/prevalence unknown – 50 cases per 100,000
 10-15% originally diagnosed later found to have a
physical disorder

Diagnosis by Exclusion
Known physical causes must be ruled out Possibility that a physical cause has been overlooked

Question 7

What do Lupus, AIDS, Multiple Sclerosis and Lyme disease have in common?

Answer 7

All were previously thought to be “psychological” prior to advancement in
diagnostic capabilities
Absence of evidence ≠ evidence of absence
Possibly insufficient research or technology, poor methods, closed minds, lack
of clinical experience…
Conversion disorder exists, but can be misdiagnosed – we need to be very
careful.

Question 8

Distinguishing Conversion Disorders from “True” Medical Problems

Answer 8

Neurological anatomical inconsistencies
 E.g., marked weakness of ankle plantar-flexion when tested on the bed in an individual who is
able to walk on tiptoes
Unexpected course of development  e.g., muscle tone in paraplegia
Selective symptomatology
 e.g., conversion blindness

Question 9

DSM-5-TR Factitious disorder

Answer 9

A) Falsification of physical or psychological symptoms associated with identified
deception
 i.e., deliberately creating symptoms
B) Presents to others as ill, impaired or injured
C) The deceptive behaviour is evident even in the absence of obvious external
rewards
D) Not better explained by another mental disorder Can be imposed on self or on another (i.e., “Factitious Disorder Imposed on
Another” diagnosis)

Question 10

Differentials

Answer 10

 In Somatic Symptom Disorder, patients may present with what symptom(s)?  any
 In Conversion Disorder, patients typically present with what symptom(s)? 
neurological  In which of the following disorders, does the individual deliberately falsify
symptoms?  Factitious Disorder  In which of the following disorders might the physical symptoms be medically
explained or unexplained?  Somatic Symptom Disorder  Trauma is theorised to underlie the presentation of symptoms in which
disorder?  Conversion Disorder

Question 11

Somatic Symptom
Disorders
Aetiology Genetics

Answer 11

Twin studies: lack of support for genetics
 Family studies – evidence that somatisation disorder runs
in families

Question 12

Somatic Symptom
Disorders
Aetiology Biological vulnerabilities

Answer 12

Neurological abnormalities
Abnormalities in the right hemisphere
Somatosensory amplification
Greater physiological sensitivity
Tendency to concentrate on internal sensations
Subjects with hypochondriasis show enhanced perceptual sensitivity to illness cues

Question 13

Somatic Symptom
Disorders
Aetiology
Psychological vulnerabilities

Answer 13

Cognitive Somatic symptoms are a form of communication
Misinterpretation of body sensations
Misinterpretation of body sensations and/or signs as indicating severe illness
View negative life events as unpredictable, threatening and uncontrollable
 Tendency to interpret ambiguous stimuli as threatening
Negative Affectivity (NA) NA linked to worry, pessimism, fear of uncertainty, guilt, fatigue, poor self
esteem, shyness & depression
Greater NA - particularly worry and pessimism - predicts increased severity of
somatization
History of personal or family illness

Question 14

Somatic Symptom
Disorders
Aetiology Stressors

Answer 14

Stress, trauma and/or emotional conflict  Freud – one of the first to link physical symptoms with a history of
trauma/conflict  He described four basic processes in the development of conversion disorder: 1. Traumatic event is experienced (i.e., an unacceptable, unconscious
conflict) 2. The conflict is repressed and made unconscious 3. Anxiety increases and threatens to push the conflict into consciousness,
and is “converted” into physical symptoms, thereby relieving the pressure
of having to deal directly with the conflict (primary gain) 4. Increased attention and sympathy is received (secondary gain)
Supporting evidence?
Association between somatization and childhood abuse?
Somatoform disorders more prevalent in cultures that discourage open
discussion of psychological problems and that stigmatize mental disorders

Supporting evidence?
Association between somatization and childhood abuse?
Somatoform disorders more prevalent in cultures that discourage open
discussion of psychological problems and that stigmatize mental disorders

Question 15

Somatic Symptom
Disorders
Treatment

Answer 15

Few systematic studies
Challenges of getting people to reveal their symptoms to a professional  Emphasis placed on physical symptoms
 Refusal to believe one has a psychological problem
 Psychological treatment often sought as last resort Less common than other problems

Review of RCTs Kroenke (2007) 34 RCTs involving 3922 patients
Potentially effective treatments established for most somatic symptom
disorders CBT best established treatment Preliminary positive evidence for antidepressants

CBT
Exposure and response prevention
Exposed to physical sensations
Reinforcement strategies
Becoming more functional in everyday life
Relaxation training
Cognitive restructuring

Question 16

Dissociative Disorders Description

Answer 16

 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

Question 17

What are the Three major disorders of dissociative disorders?

Answer 17

Three major disorders (DSM-5-TR): 1. Dissociative Identity Disorder
2. Dissociative Amnesia
3. Depersonalisation/Derealisation Disorder

Question 18

1. Dissociative identity disorder:
   DSM-5-TR Criteria

Answer 18

A) Two or more distinct personality states or experiences of possession. Marked
discontinuity in sense of self Alterations in affect, behaviour, consciousness, memory, perception, cognition,
and/or sensory-motor function
B) Recurrent gaps in recall of everyday events, personal info., and/or traumatic
events inconsistent with ordinary forgetting
C) Symptoms cause clinically significant distress or impairment
D) Disturbance is not a normal part of a broadly accepted cultural or religious
practice
E) Symptoms are not attributable to a substance or other medical condition

 Transition from one personality to another is usually sudden
 Transition often triggered by overwhelming stress  Often first diagnosed in late adolescence or young adulthood  Symptoms usually develop in early childhood after abuse and/or
maltreatment  Relatively rare disorder  70%+ have attempted suicide  Alternate personalities vary from 2 to 60; average ~ 13

Question 19

Differences between Sub-Personalities (Dissociative identity disorder)

Answer 19

1. Personality characteristics
2. Demographics
3. Abilities and preferences
4. Physiological responses

Question 20

1. Dissociative identity disorder present time

Answer 20

Growing belief in authenticity of D.I.D. and hence willingness to
diagnose amongst professionals
 Increasing rates of diagnosis:  Number of cases of D.I.D. rose from 79 in 1970 to tens of thousands in 2000
 80% to 100% have no knowledge of alters before therapy
 Seek treatment due to emotional distress or discomfort and then
alters discovered in therapy

Question 21

Dissociative Disorders - Biological factors

Answer 21

Fragmented sleep-wake cycle might help explain dissociative symptoms (van
der Kloet et al., 2012)  Sleep disturbance associated with dissociation
 Improved sleep  decreased dissociation in experimental studies
Ae

Question 22

Dissociative Disorders - Social Factors

Answer 22

Iatrogenesis
The manufacture of a disorder by its treatment Mersky (1992) – Some “cases” created by the expectations of therapists?
But: DID diagnosed in countries where there is no public awareness of the disorder Suggestibility alone does not explain dissociation

Question 23

Psychological views of Dissociative Disorders

Answer 23

D.I.D. is a failure of the normal developmental process of personality
integration
 Hypothesised to result from traumatic experiences during critical
developmental periods
Psychodynamic View
 Key element - dissociation - a defence against painful events
 DDs represent extreme use of repression
 Roots in childhood trauma
 Empirical confirmation of assumptions lacking

Question 24

The Behavioural View of Dissociative Disorders

Answer 24

Patients play social role learned via: Modelling Exposure to information about the disorder Operant conditioning
Selective reinforcement of personalities
Limited by: Dependence on case studies Can’t explain how dissociation occurs

Question 25

Dissociative Disorders Similarities

Answer 25

Both Psychodynamic and Behavioural theories agree that- DDs precipitated by traumatic experiences DDs represent ways of avoiding extreme anxiety The patients are unaware that their disorder is protecting them from facing a
painful reality

Question 26

Dissociative Disorders Differences

Answer 26

Psychodynamic Theory
 DDs represent attempts at
forgetting that although
unconscious are purposeful from
the start  Hardworking unconscious keeps
patients unaware that dissociation
is used as means of escape

Behavioural Theory
 The initial development of
dissociative reactions is more
accidental  Subtle reinforcement process keeps
patients unaware that dissociation
is used as means of escape

Question 27

Principles of Treatment for D.I.D. 49

Answer 27

1. Integrate sub-personalities into one
2. Each sub-personality is helped to understand that he/she is part of one
   person
3. All sub-personalities should be treated with fairness and empathy
4. Therapist should encourage empathy and co-operation among
   personalities
5. Help patient to recognise breadth of their disorder