Week Nine - Somatic Symptoms & Dissociative Disorders

Question 1

Somatic symptom disorders are characterised by

Answer 1

The prominence of somatic symptoms (bodily sensation) that are associated with distress and impairment.

Question 2

Somatic Symptom Disorder DSM-5 Criteria?

Answer 2

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 and 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 any one somatic symptom may not be
continuously present, the state of being symptomatic
is persistent (typically more than 6 months)

Question 3

SSD has high rates of comorbidity with

Answer 3

– Medical disorders
– Anxiety disorders
– Depressive disorders

Question 4

Illness Anxiety Disorder

Answer 4

Preoccupation with having a medical illness (despite no
medical symptoms), accompanied by behavioural change.

• Previously hypochondriasis in and referred to as ‘health
anxiety’ in the literature.

• Similar presentation to other obsessive compulsive and
related disorders (obsessive compulsive disorder and body
dysmorphic disorder)…
- Preoccupations cause anxiety to increase
- Checking behaviours cause anxiety to decrease

Question 5

Illness Anxiety Disorder DSM-5 criteria

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. If another medical condition is present or
there is a 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 (e.g., repeatedly checks body for signs of
illness) or exhibits maladaptive avoidance (e.g., avoids
doctor appointments and hospitals).

E. Illness preoccupation has been present for at least 6
months, but the specific illness that is feared may change
over that period of time.

F. The illness-related preoccupation is not better explained
by another mental disorder.

Question 6

Illness Anxiety Disorder Specifiers

Answer 6

Care-seeking type: Medical care, including physician
visits or undergoing tests and procedures, is frequently
used.

Care-avoidant type: Medical care is rarely used.

Question 7

Conversion Disorder DSM-5 Criteria

Answer 7

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

B. Clinical findings provide evidence of incompatibility
between the symptom and recognised 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 or warrants medical evaluation.

Question 8

Conversion Disorder Onset, Prev and Co-Morbid

Answer 8

Typically adolescence or early adulthood
– Often follows life stress

Prevalence <1%
– More common in women than men

Often co-morbid with:
– Other somatic symptom disorders
– Major depressive disorder
– Substance use disorder

Question 9

Conversion Disorder more prevalent in?

Answer 9

– Rural areas
– Low SES communities
– Non western cultures.

Question 10

Conversion Disorder symptom type specifiers

Answer 10

– With weakness or paralysis
– With abnormal movement
– With swallowing symptoms
– With speech symptoms
– With attacks or seizures
– With anesthesia or sensory loss
– With special sensory symptom (e.g., visual, olfactory, or hearing disturbance).
– With mixed symptoms.

Question 11

Factitious Disorder

Answer 11

Falsification of medical and/or psychological symptoms.

- Exact prevalence is unknown but thought to be around ~1%

Question 12

Factitious Disorder can be diagnosed as

Answer 12

– Factitious disorder imposed on self

– Factitious disorder imposed on another

Question 13

Factitious disorder imposed on self DSM-5?

Answer 13

A. Falsification of physical and psychological signs and
symptoms, or induction of injury or disease, associated
with identified deception.
B. The individual presents himself or herself as ill, impaired or
injured.
C. The deceptive behaviour is evident even in the absence of
obvious external rewards.
D. The behaviour is not better explained by another mental
disorder, such as delusional disorder or another psychotic
disorder.

Question 14

Factitious disorder imposed on another DSM-5?

Answer 14

A. Falsification of physical and psychological signs and
symptoms, or induction of injury or disease in another,
associated with identified deception.
B. The individual presents another individual (victim) to
others as ill, impaired or injured.
C. The deceptive behaviour is evident even in the absence of
obvious external rewards.
D. The behaviour is not better explained by another mental
disorder, such as delusional disorder or another psychotic
disorder.
Note: The perpetrator, not the victim, receives the diagnosis.

Question 15

Genetics and Neurology for somatic disorders?

Answer 15

No support for genetic influence
- Concordance rates between MZ and DZ twins do not
differ.

Attempt to understand why some people are more aware
and distressed by bodily sensations than others.
Hyperactivity:
• Anterior insula
• Anterior cingulate

Question 16

Cognitive-behavioural theories for somatic disorders (COGNITIVE PROCESSES) 4

Answer 16

– Hypervigilance to somatic symptoms: Tend to notice
changes in body that other people don’t notice.

– Overestimation of dangerousness of symptoms: Think
that harmless somatic symptoms mean something awful
is going to happen

– Confirmatory bias: Clients attend to and encode
information that is consistent with their beliefs and
dismiss information that is inconsistent

– Intolerance of uncertainty: Unable to cope with
elements of uncertainty

Question 17

Cognitive-behavioural theories for somatic disorders (BEHAVIOURAL PROCESSES) 3

Answer 17

– Avoidance and escape behaviours: Avoid doctors or
regular medical visits because of fears that something
‘awful’ will be found.

– Checking behaviour: Pulse, urine, body for signs of
change etc.

– Reassurance seeking: Asking others in their life and
medical professionals for reassurance (often go to
multiple doctors).

Question 18

Treatment for Somatic Disorders?

Answer 18

Few controlled treatment studies (most relate to illness
anxiety disorder)

CBT is effective and involves:
- Changing maladaptive cognitive and behavioural
processes

Question 19

Dissociation

Answer 19

Some aspect of cognition or experience becomes inaccessible to consciousness.

Sudden disruption in the continuity of:
– Consciousness
– Emotions
– Motivation
– Memory
– Identity

Question 20

Dissociative Identity Disorder (DID)

Answer 20

Experiencing two or more identity/personality states, which alternate in control of behaviour.

Typically there is a primary ‘host’ personality and one or more ‘alters’ that are often extremely different to the ‘host’ in traits and behaviours.

Question 21

DID DSM-5 Criteria?

Answer 21

A. Disruption of identity characterised by two or more
distinct personality states, which may be described in
some cultures as an experience of possession.
- The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory motor functioning.
- These signs and symptoms may be observed by others or
reported by the individual

B. Recurrent gaps in the recall of everyday events, important
personal information, and/or traumatic events that are
inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or
impairment in social, occupational or other important area of functioning.

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.

E. The symptoms are not attributable to the physiological
effects of a substance or another medical condition.

Question 22

DID clinical features

Answer 22

Prevalence ~ 1.5%

More common in women than men.

About 70% of outpatients with DID have attempted suicide

Often portrayed as having no shared memory or awareness, however this has been questioned.

Evidence of physiological changes (EEG variation, voice
patterns, handedness)

Question 23

DID - Etiology

Answer 23

There are two explanations for DID:

1. Post-traumatic Model
2. Socio-cognitive Model

Question 24

DID Post-traumatic Model

Answer 24

An early trauma such as abuse has led the person to develop
multiple personalities to cope with stress (eg mistreatment
happened to ‘someone else’)
• Some evidence that severe abuse occurred in up to 90% of
individuals with DID

Question 25

DID Socio-cognitive Model

Answer 25

Questions the validity of having numerous personalities,
suggests DID develops as a result of psychotherapeutic
techniques. This is evidenced by the findings that:
– Most DID cases show few, if any, signs prior to therapy,
with number of identities increasing with length of time in
therapy
– Therapy often reinforces the idea that there are multiple
personalities
– A small number of therapists are responsible for the
majority of diagnoses

Question 26

DID Treatment?

Answer 26

No clear consensus for treatment (no controlled studies)
BUT
psychotherapy should take a phase-oriented approach.
1. Establishing safety, stabilization, and symptom reduction
2. Confronting, working through, and integrating traumatic memories
3. Identity integration and rehabilitation

Question 27

Dissociative Amnesia DSM-5 Criteria?

Answer 27

A. An ability to recall important autobiographical information. Usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
B. The symptoms cause clinically significant distress or impairment
C. The disturbance is not attributable to the physiological effects of a substance or a neurological or other medical condition.

Question 28

Dissociative Amnesia?

Answer 28

The forgetting of personal information,

particularly surrounding a stressful event

Question 29

Criticisms of Dissociative Amnesia diagnosis?

Answer 29

• Intentional forgetting vs amnesia
• We have gaps in memory normally
• Little empirical support – many cases better attributed to
organic brain damage, suppression of thoughts etc.
• The disorder usually spontaneously remits.

Question 30

Depersonalisation Disorder

Answer 30

Recurrent experience of derealisation and/or depersonalisation

Question 31

Derealisation?

Answer 31

The feeling your surroundings are not real, or that familiar places are new/unknown

Question 32

Depersonalisation?

Answer 32

The feeling you are not real, living in a dream or movie, or are watching yourself from the outside

Question 33

Depersonalisation/Derealisation Disorder DSM-5 Criteria?

Answer 33

A. The presence of persistent or recurrent experiences of
depersonalisation, derealisation, or both:
B. During the depersonalisation or derealisation experiences,
reality testing remains intact.
C. The symptoms cause clinically significant distress or impairment in functioning
D. The disturbance is not attributable to the physiological effects of a substance or other medical condition.
E. The disturbance is not better explained by another mental disorder.

Question 34

Derealisation/depersonalization in real life? Clinical features

Answer 34

Relatively common experiences (more that 50% of general population – more in adolescent populations), but disorder itself not common

• 2%
• No gender differences
• Onset is generally in adolescence.

Question 35

Memory in dissociative disorders

Answer 35

There appears to be deficits in explicit but not implicit memory
– Explicit memory
• Involves conscious recall of experiences (important birthday party, birth of child)
– Implicit memory
• Underlies behaviours based on experiences that cannot
be consciously recalled (riding a bike or driving a car)