1
Q
% of physical symptoms that cause people to seek medical care that are medically unexplained
A
20-50%
2
Q
4 most important disorders in somatic symptom category (need to be able to differentiate for exam)
A
new category in DSM5!
- somatic symptom disorder
- illness anxiety disorder
- conversion disorder
- factitious disorder
3
Q
Somatic symptom disorder
A
- has been called hypochondriasis, somatization disorder, and pain disorder
- for diagnosis, need to be experiencing chronic somatic symptoms that are distressing to them AND dysfunctional thoughts/feelings/behaviors
- prevalence: 5-7%
4
Q
Controversy around Somatic symptom disorder
A
- Freud: defense against repressed ideas
- recent focus on cognitive factors (increased awareness of body, see sensations as somatic symptoms+attribute them to illness, catastrophizing cognitions, seek help bc very distressed)
- criteria probably too broad bc physical symptoms do not need to be medically unexplained
5
Q
Causes and Risk Factors of Somatic Symptom Disorder
A
- disorder of both perception and cognition
- attentional bias for illness-related information
- can be predisposed by past experiences w illness and dysfunctional assumptions ab symptoms/diseases
- risk factors: negative affect, absorption (degree to which you can absorb ideas – makes you hypnotizable), alexithymia (don’t have language for internal experiences)
6
Q
Characteristics of Somatic Symptom Disorder
A
- more likely to inflict women
- high comorbid levels w depression and anxiety
- symptoms may be maintained to some degree by secondary reinforcements (ie negative reinforcement by getting out of hard stuff)
- not malingering (consciously faking symptoms)
7
Q
Treatment of Somatic Symptom Disorder
A
- CBT widely used for treatment (but clients are often resistant to psychological intervention bc they believe problem is only physical pain)
- focus on assessing beliefs ab illness and modifying misinterpretations of bodily sensations
- might include having patient induce innocuous symptoms by focusing on parts of body to learn that selective perception of bodily sensations could play major role in symptoms
8
Q
Treatment of Somatic Symptom Disorder involving chronic pain
A
- relaxation training
- support and validation that pain is real (have to act like you believe patient)
- scheduling of daily activities (ppl with pain have overly sedentary lifestyle, getting them moving helps)
- cognitive restructuring
- reinforcement of ‘no pain’ behaviors
- tricyclic antidepressants and SSRIs shown to reduce pain intensity (independent of effects on mood)
9
Q
Illness Anxiety Disorder
A
- new to DSM5
- have high anxiety about having or developing a serious illness
- anxiety is distressing/disruptive, but few (or very mild) somatic symptoms
- less severe than Somatic Symptom Disorder where ppl have more comorbid conditions and visit doctor more
- avg onset at 20yrs (same as somatic symptom disorder)
10
Q
Conversion Disorder
A
- characterized by presence of neurological symptoms in absence of a neurological diagnosis
- symptoms or deficits affecting either senses or motor behavior
- ex: partial paralysis, blindness, deafness, episodes of limb shaking w impairment or loss of consciousness resembling seizures
- 4 categories of symptoms: sensory, motor, seizures, and mixed presentation
11
Q
Conversion Disorder - Sensory Symptoms
A
- visual system deficits, auditory system deficits, deficits in sensitivity to feeling (esp in anesthesias)
- anesthesias: person loses feeling in part of body
- conversion blindness: person reports being unable to see but navigates spaces without problems
- conversion deafness: report not being able to hear but orient appropriately upon ‘hearing’ own name
12
Q
Conversion Disorder - Motor Symptoms or Deficits
A
- wide range, including
- conversion paralysis, usually single limb
- aphonia (speech-related disturbance)
- globus (sensation of lump in throat)
13
Q
Conversion Disorder - Seizures
A
- resemble epileptic seizures, but are not true seizures
- no EEG abnormalities and no confusion or memory loss afterwards
14
Q
Diagnosis of Conversion Disorder
A
- need to distinguish between disorder and true neurological disturbances
- look for frequent failure to conform clearly to symptoms of particular disease/disorder
- see if during hypnosis or narcosis symptoms can be removed, shifted, or reinduced at suggestion of therapist
15
Q
Prevalence and Demographic Characteristics of Conversion Disorder
A
- most frequently diagnosed psychiatric symptom among soldiers in WWI, common in WWII
- found in approx 5% of ppl referred for treatment at neurology clinics
- gen. pop. prevalence unknown
- occurs more in rural populations from lower SES
- 2-3x more often in women vs men
- rapid onset after significant stressor; often resolves within 2 weeks if stressor is removed
16
Q
Causes of Conversion Disorder
A
- thought to develop as result of stress/internal conflicts
- Freud used term conversion hysteria; believed symptoms were expression of repressed sexual energy
- repressed anxiety threatens to become conscious so is unconsciously converted into bodily disturbance
- primary gain: reduction in anxiety and intrapsychic conflict
- secondary gain: receiving sympathy/attention
- theory no longer accepted! (but clinical observations of primary/secondary gain reflected in current views)
- likely linked to stress; genetic marker linked to depression also linked to conversion disorder
17
Q
Treatment of Conversion Disorder
A
- knowledge is very limited bc few studies (and pretty low prevalence plus quick recovery)
- behavioral approach: specific exercises prescribed to increase movement or walking, reinforcement provided when patient shows improvement
18
Q
Factitious Disorder
A
- intentionally producing psychological or physical symptoms (or both)
- used to be called munchausen’s
- goal to obtain and maintain benefits of ‘sick role’
- factitious disorder imposed on another (Munchausen’s by proxy); diagnosis is for the person making the other sick/appear sick
19
Q
Identifying factitious disorder
A
- no tangible external rewards
- being the focus of medical attention is what is rewarding
- different from malingering bc no tangible external rewards
20
Q
Malingering
A
- intentionally producing or grossly exaggerating physical symptoms
- motivated by external incentives (avoiding work, evading prosecution, etc.)
- prevalence not well established
21
Q
Dissociative Disorders
A
- group of conditions involving disruptions in normally integrated functions of consciousness, memory, identity, or perception
- only pathological when symptoms perceived as disruptive/recurrent/intrusive
- we don’t know much about why/how they develop or how to treat them
- dissociation itself is naturally occurring and happens to a lot of people (ie arriving at destination and not remembering drive)
22
Q
Key Dissociative Disorders for the course
A
- Depersonalization/derealization disorder (lose sense of self/place)
- Dissociative amnesia (forget major parts of life)
- Dissociative identity disorder (multiple personalities)
23
Q
Derealization/depersonalization disorder (+ age of onset and comorbid disorders)
A
- derealization: temporary loss of sense of reality of outside world
- depersonalization: temporary loss of sense of self, memory distortion, time distortion
- may be diagnosed when episodes become consistent or recurrent and interfere with normal functioning (can involve feeling detached, attenuated emotional experiences, higher levels of memory fragmentation)
- in DSM4 were two diff. disorders, combined in DSM5
- no exact prevalence data, no clearly effective treatment yet
- mean age of onset is 16
- 80% of cases are chronic
- comorbid disorders: esp. mood/anxiety, avoidant/borderline/o-c PDs
24
Q
Retrograde/Anterograde Amnesia and Dissociative Amnesia
A
- Retrograde amnesia: partial or total inability to recall or identify previously acquired info or experiences
- Anterograde amnesia: partial or total inability to retain new info
- dissociative amnesia characterized primarily by retrograde amnesia
- following head injury, problems are primarily characterized by anterograde amnesia
25
Dissociative Amnesia
- failure to recall previously stored personal info
- gaps in memory most often occur after intolerably stressful experiences
- typically cannot remember certain aspects of personal life history/important facts ab identity
- only affects episodic/autobiographical memory (not semantic and procedural memory), implicit memory remains intact
- symptoms cause distress/impairment
- amnesic episodes last days-years
26
Dissociative Fugue
- subtype of dissociative amnesia where person also flees home surroundings
- accompanied by confusion ab personal identity or even assumption of new identity
- unaware of memory loss for prior stages of life
- memory of what happens during fugue intact
- behavior usually quite normal/unlikely to arouse suspicion but is different from old lifestyle
27
Dissociative Identity Disorder
- formerly known as multiple personality disorder
- disruption of identity characterized by two or more distinct personality states as well as recurrent episodes of amnesia
- DSM5 includes pathological possession in diagnostic criteria (common form of DID); here alters are external and not 'part of you'
28
Spiegel argued that the problem with DID is not having more than one personality, it is _______
having less than one
29
Symptoms of Dissociative Identity Disorder
- host identity: most frequently encountered and carries person's real name (usually not original identity)
- alter identity: fragments of a single person; take control at different times; can switch very quickly
- depression, self-injurious behavior, frequent suicidal ideation/attempts, erratic behavior, headaches, hallucinations, posttraumatic symptoms, other amnesic and fugue symptoms
- one study found avg 5 comorbid diagnoses
30
Onset and Prevalence of DID
- usually starts in childhood; most patients in teens-20s-30s at time of diagnosis
- 3-9x more females vs males (women also have more alters)
- number of alters varies a lot, has increased over time
- recent trend of bizarre and unusual identities
- childhood abuse reported in significant number of patients (not specific risk factor for DID); might be more likely to seek treatment
31
Controversies About DID
- controversial diagnostic issue, can be used strategically to avoid conviction
- according to trauma theory, DID starts in early childhood to protect individual from overwhelming sense of hopelessness/powerlessness
32
Sociocognitive Theory and DID
- DID develops when highly suggestible person learns to adopt and enact roles of multiple identities
- mostly bc clinicians inadvertently reinforce/legitimize/suggest them
- consistent with evidence of no clear DID symptoms prior to therapy and increase in # of alters throughout therapy
- also consistent with increased DID, as more therapists become aware of condition
33
Repressed memories in DID
- repressed memories may be false (product of leading questions/suggestion techniques)
- not sure if memories are repressed or even exist
34
Prevalence of DID
- 1-1.5% prevalence
- more evidence supports sociocognitive model
- multiple causal pathways likely to be involved
35
Cultural factors in DID
- no diagnosis if spirit possession is sanctioned in culture
- prevalence influenced by degree to which they are accepted as normal or as legitimate mental disorders
36
Treatment and Outcomes in DID
- little known ab effective treatment (absence of randomized controlled trials)
- hypnosis may be useful; modest effect of some meds
- treatment typically psychodynamic/insight oriented (based on trauma model and not sociocognitive model)
- goal to integrate personalities
- need long treatment to be successful (often years)
37
Trance and Possession
Trance
- temporary marked alteration in state of consciousness or identity
- narrowing of awareness of immediate surroundings, stereotypes behaviors/movements beyond person's control
Possession
- similar except alteration in consciousness//identity is replaced by new identity attributed to influence of deity/spirit
- amnesia for trance state present for both
- pathological when occur involuntarily, outside accepted cultural contexts, and cause distress
- common form of DID in non-western countries
PSYC 337
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