SOMATOFORM DISORDERS
The preoccupation causes clinically
These are closely related to anxiety
disorders and person tends to suffer
from poor insight - does not recognize
that concerns are excessive or
unreasonable and reassurance from
others, including Drs. is not helpful.
HYPOCHONDRIASIS
A disorder of cognition or perception with
strong emotional contributions.
SOMATIZATION DISORDER
Linked to antisocial, or psychopathic,
personality disorder and might have a
heritable component.
PAIN DISORDER
Could be psychologically or medically
related.
BODY DYSMORPHIC DISORDER
"Imagined Ugliness"
DIAGNOSTIC CRITERIA FOR
HYPOCHONDRIASIS
l. Preoccupation with fears of having, or
ideas that one has, a serious
disease based on the person's
misinterpretations of bodily symptoms.
2. The preoccupation persists despite
appropriate medical evaluation and
reassurance.
3. The belief (Criterion 1) is not of
delusional intensity and is not
restricted to a circumscribed concern
about body appearance.
1
4.
significant distress or impairment in
social, occupational, or other important
areas of functioning.
5. The duration of the disturbance is at
least 6 months.
6. The preoccupation is not better
accounted for by Generalised Anxiety
Disorder, Obsessive-Compulsive Disorder,
Panic Disorder, a Major Depressive
Episode, Separation Anxiety, or another
Somatoform Disorder
HYPOCHONDRIASIS
CLINICAL DESCRIPTION:
l. ANXIETY DISORDER - Person
develops severe anxiety focused on
possibility of having a serious disease.
2. Possibility is so real that even medical
reassurance will not help.
3. Key feature: concern or preoccupation
with physical symptoms.
4. Core feature: disease conviction.
5. Prevalence in Population: 4% to 9%
higher in elderly. Ration men to
women 50/50.
6. Reinforcers/Contributors:
a. Society - is socially approved
and at times even rewarded.
b. Fear of having illness increases
anxiety, which increases symptom
perception, etc. - vicious cycle.
c. Enhanced perceptual sensitivity
to illness cues, causing them to
interpret as dangerous and threatening
any stimuli, no matter how minor or
ambiguous.
 d. Past background of trauma or
disproportionate incidences of
illness when a child.
7. Symptom variety dependent on cultural
believes.
8. Assessment must look at:
a. Rule out physical cause for
complaint.
b. Its association with a specific
somatoform disorder or part of
some other psychopathological disorder
or syndrome.
c. Cultural and subcultural
awareness.
HYPOCHONDRASIS
TREATMENT
l. Focus on illness preoccupaiton.
2. Focus directly on the anxiety.
3. Cognitive Behavioural approaches.
4. Psychopharmacological treatments.
5. Direct reassurance.
5. REM
6. Relaxation and guided imagery
techniques.
7. Hypnosis/self hypnosis.
8. Group therapy.
9. Support Groups.
SOMATIZATION DISORDER
CRITERIA FOR SOMATIZATION
DISORDER
2
l. History of many physical complaints
beginning before age 30 that occur
over a period of several years and result
in treatment being sought or
significant impairment in social,
occupational, or other important areas of
functioning.
2. Each of the following criteria must
have been met, with individual
symptoms occurring at any time during
the course of the disturbance:
a. Four pain symptoms: A history
of pair related to at least four
different sites or functions (such as
head, abdomen, back, joints,
extremities, chest, rectum, during sexual
intercourse, during menstruation,
or during urination.
b. Two gastrointestinal symptoms:
A history of at least two
gastrointestinal symptoms other than pain
(such as nausea, diarrhoea,
bloating, vomiting other than during
pregnancy, or intolerance of several
different foods).
c. One sexual symptom: A history
of at least one sexual or
reproductive symptom other than pain
(such as sexual indifference, erectile
or ejaculatory dysfunction, irregular
menses, excessive menstrual bleeding,
vomiting throughout pregnancy.
d. One pseudoneurologic symptom:
A history of at least one symptom or
deficit suggesting a neurological disorder
not limited to pain (conversion
symptoms such as blindness, double vision,
deafness, loss of touch or pain
sensation, hallucinations, aphonia,
impaired coordination or balance,
paralysis or localised weakness, difficulty
swallowing, difficulty breathing,
urinary retention, seizures; dissociative
symptoms such as amnesia; or loss
of consciousness other than fainting)
SOMATIZATION DISORDER
CLINICAL DESCRIPTION
1. Long list of somatic complaints with no
medical basis.
2. Preoccupation persists despite
appropriate medical evaluation and
reassurance. Clients return with some
variations to initial complaint.
3. Focus on symptom itself and not what
the symptom means. Life itself may
revolve around the symptom, as well as
relationships.
4. Prevalence in Population: 0 to 0.7% - on
a continuum of impairment
because of disorder. Tendency for
somewhat higher incidence in females.
6. Reinforcers/Contributors:
a. society - is socially approved
and at times even rewarded.
b. past background of
disproportionate incidence of illness or
injury
while growing up.
c. linked to heredity and to
antisocial behaviour characteristics;
including vandalism, persistent lying,
theft, irresponsibility with finances
and at work, and outright physical
aggression. Insensitivity to punishment or
negative consequences of behaviour is also
a characteristic, as is little
3
anxiety or guilt over their aggression or
criminal behaviour.
d. Neurobiologically based
disinhibition syndrome, as found in
antisocial personality disorders that is
incapable of exerting sufficient
control over the behavioural activation
system.
SOMATIZATION DISORDER
TREATMENT
l. Provide reassurance
2. Focus on the stress associated with
the disorder.
3. Focus on reducing the help-seeking
behaviour
4. Reducing any reinforcing or supporting
consequences of relating to
significant others on the basis of physical
symptoms alone.
5. Group Therapy
6. Cognitive Behavioural approaches
7. REM
8. Hypnosis/self hypnosis
CONVERSION DISORDER
CRITERIA FOR CONVERSION
DISORDER
l. One or more symptoms or deficits
affecting voluntary motor or sensory
function that suggest a neurological or
general medical condition.
2. Psychological factors are judged to be
associated with the symptom or
deficit because the initiation or
exacerbation of the symptom or deficit is
preceded by conflicts or other stressors.
3. The symptom or deficit is not
intentionally produced or feigned (as in
factitious disorder or malingering).
4. The symptom or deficit cannot, after
appropriate investigation, be fully
explained by a general medical condition,
or by the direct effects of a
substance, or as a culturally sanctioned
behaviour or experience.
5. The symptom or deficit causes
clinically significant distress or
impairment in social, occupational, or
other important areas of functioning
or warrants medical evaluation.
6. The symptom or deficit is not limited
to pain or sexual dysfunction, does
not occur exclusively during the course of
somatization disorder, and is not
better accounted for by another mental
disorder.
CONVERSION DISORDER
CLINICAL DESCRIPTION
1. Generally refers to physical
malfunctioning, such as a paralysis,
blindness, or difficulty speaking (aphonia),
without any physical or organic
pathology what would account for the
malfunction.
2. Anxiety resulting from an unconscious
conflict and needing to express
itself "convert" itself into physical
symptoms.
4
3. Key features :
a. at times perceived to be
indifferent to the symptom.
b. precipitated by some marked
stress.
c. people usually function
normally, but are unaware of this ability
or of the sensory input.
d. usually not trying "to get out of
something" like malingerers.
e. not like "factitious disorder"
(e.g. Munchausen or Munchausen by
roxy), who feign illness but who have no
obvious good reason to be sick.
4. Prevalence in Population : 1% to 30%;
primarily found in women, in
adolescence and thereafter, tough
frequently seen in men enduring great
stress and trauma, such as combat
soldiers. Tends to occur in less educated,
lower socioeconomic groups where
knowledge about disease and medical
illness
is not as well developed. Other member's
experience with illness may
influence disorder chose (patients tend to
"pick-up" symptoms).
5. Reinforcers/Contributors:
a. First, The experience of a
traumatic event (Freud believed it to
be some unacceptable, unconscious
conflict)that must be avoided at all cost.
Second, conflict repressed or
made unconscious because conflict
is unacceptable and creates anxiety
Third, as anxiety increases,
threatening to emerge into
consciousness, person "converts" it into
physical symptoms, thus relieving
pressure to deal with it directly (the
primary gain or primary reinforcers
maintaining disorder).
Fourth, individual receives
increased attention and sympathy
from loved ones and may even avoid or
escape dealing with some difficult
situations (the secondary gain or
secondary reinforcer of disorder).
b. is a substitute for "running
away" which is not acceptable
socially and illness is
detached/dissociated because getting
sick on purpose
is also unacceptable.
c. success of "conversion"
maintains condition until the underlying
problem or set of maintaining factors is
resolved.
d. Seem to be part of a larger
constellation of psychopathology and
vulnerability under stress.
CONVERSION DISORDER
TREATMENT
l. Attention to traumatic or stressful life
event, if present, by "reliving"
the event first, (catharsis) and removing
source of secondary gains.
2. Reduction of any reinforcing or
supportive consequences of the symptom
(the primary gains). This needs strong
collaboration for family and
social structure of the client.
3. REM
4. Hypnosis/self-hypnosis
5. Cognitive Behaviour therapies
5
PAIN DISORDER
DIAGNOSTIC CRITERIA
1. Pain in one or more anatomical sites is
the predominant focus of the
clinical presentation and is of sufficient
severity to warrant clinical
attention.
2. The pain causes clinically significant
distress or impairment i social,
occupational, or other important areas of
functioning.
3. Psychological factors are judged to
have an important role in the onset,
severity, exacerbation, or maintenance of
the pain.
4. The symptom or deficit is not
intentionally produced or feigned (as in
factitious disorder or malingering).
5. The pain is not better accounted for
by a mood, anxiety, or psychotic
disorder and does not meet criteria for
dyspareunia.
ACUTE: less 6 mo. CHRONIC: 6 mo. or
more
PAIN DISORDER
CLINICAL DESCRIPTIONS
l. Very difficult to assess if pain is
primarily psychological or if causes
are primarily physical.
2. Important feature: pain is real
whether psychological or physical.
TREATMENT
l. Better treated in a multidisciplinary
clinic.
2. Cognitive Behaviour therapies.
3. Pharmacology
4. Biofeedback
5. Group and Individual therapy
BODY DYSMORPHIC DISORDER
CRITERIA FOR BODY DYSMORPHIC
l. Preoccupation with an imagined defect
in appearance. If a slight
physical anomaly is present, the person's
concern is markedly excessive.
2. The preoccupation causes significant
distress or impairment in social,
occupational, or other important areas of
functioning.
3. The preoccupation is not better
accounted for by another mental disorder
(e.g. dissatisfaction with body shape and
size in anorexia nervosa).
BODY DYSMORPHIC DISORDER
CLINICAL DESCRIPTION
1. "Imagined ugliness" and "mirror
fixation" either phobic avoidance or
frequent checks to see if changes have
occurred.
2. Usually accompanied by suicidal
ideation, and suicide attempts.
3. Possible association to defensive
mechanism of displacement - underlying
unconscious conflict is too anxiety
provoking - "displaced" to a body part.
6
4. Association to somatoform disorder.
5. Related to anxiety.
6. Frequently co-occurs obsessive-
compulsive disorders. This is also found
in family members of BDD sufferers.
7. "Ideas of Reference" - everything that
goes on in the world related to
their imagined defect.
8. Prevalence in population: Greater than
thought . Up to 70% of college
students had some degree of
dissatisfaction with their bodies. About
equal
male to female ration, with slightly more
females in Western World (62% males
noted in Japan). Starts around
adolescence, peaking at l9 y.o. Very few
sufferers get married.
9. Reinforcers/Contributors:
a. societal beauty values
b. cultural standards/desirability
factor
c. family/partners values
DYSMORPHIC DISORDER
TREATMENT
l. Only one treatment so far found
successful: drugs that block the reuptake
of serotonin, such as clomipramine and
fluoxide. This same drug has effect
on obsessive-compulsive disorders.
Plastic Surgery usually used by these
sufferers, but they are never satisfied
and keep returning for more surgery or
file malpractice law suits. Studies
have also shown preoccupation with
imagined ugliness increases in many cases.

DISSOCIATIVE DISORDER
Description: Individual feels detached of
surrounding and/or themselves - as
if in a dream or living life in slow motion.
Any body can feel this at times
of great stress/trauma/accident or when
very tired or extremely stressed
mentally or physically.
CLINICAL PRESENTATIONS
Feelings created by experience of
unreality:
- depersonalisation - temporary loss of
sense of owns reality due to
alteration in perception.
- derealization - loss of sense of
"realness" of external world.
Symptoms of unreality are prevalent:
dissociation from reality. It can be part
of a more serious set of
conditions where reality, experience, and
even one's identity disintegrate.
-DEPERSONALISATION DISORDER
CRITERIA FOR DEPERSONALISATION
l. Persistent or recurrent experiences of
feeling detached from, and as if
one is an outside observer of, one's
mental processes or body (e.g., feeling
like one is in a dream).
2. During the depersonalisation
experience, reality testing remains intact.
3. The depersonalisation causes clinically
significant distress or
7
impairment in social, occupational, or
other important areas of functioning.
4. The depersonalisation experience does
not occur exclusively during the
course of another mental disorder, such
as schizophrenia, panic disorder,
acute stress disorder, or another
dissociative disorder, and is not due to
the direct physiological effects of a
substance (e.g., a drug abuse, a
medication) or a general medical condition
(e.g. temporal lobe epilepsy).
DEPERSONALISATION DISORDER
CLINICAL DESCRIPTION
l. Feelings of being unreal or detached are
so severe and frightening that
they dominate the individual's life and
prevents normal functioning.
2. Is not associated, or is not, the major
problem of another disorder.
-DISSOCIATIVE AMNESIA
CLINICAL DESCRIPTION
l. Generalised amnesia : unable to
remember anything, including who they
are
(from l y. prior to onset to forever).
2. Localised amnesia (more common) :
failure to recall specific events that
occur during a specific period of time.
DISSOCIATIVE AMNESIA
DIAGNOSTIC CRITERIA
l. The predominant disturbance is one or
more episodes of inability to
recall important personal information,
usually of a traumatic or stressful
nature, that is too extensive to be
explained by ordinary forgetfulness.
2. The disturbance does not occur
exclusively during the course of
dissociative identity disorder, dissociative
fugue, posttraumatic stress
disorder, acute stress disorder, or
somatization disorder and is not due to
the direct physiological effects of a
substance (e.g. , a drug abuse, a
medication) or a neurological or other
general medical condition (e.g.,
amnestic disorder due to head trauma).
3. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning.
-DISSOCIATIVE FUGUE
Description: "Flight" - not only is there
memory loss but it revolves around
a very specific incident, where the
individual "takes off" and later finds
her/himself in some new place, usually
leaving behind some very difficult
situation they find intolerable. During
these "flights" the individual
sometimes takes on a new identity or
becomes confused about the old one.
CLINICAL PRESENTATIONS
l. Usually do not appear until adolescence;
more commonly in adults. Rare
after age 50.
2. Usually end rather abruptly and the
individual returns home recalling
most of what happened.
8
3. Disorder goes beyond memory loss. It
involves some disintegration of
identity to the adoption of a completely
new one.
DISSOCIATIVE FUGUE
CRITERIA FOR DISSOCIATIVE FUGUE
l. The predominant disturbance is sudden,
unexpected travel away from home
or one's customary place of work, with
inability to recall one's past.
2. Confusion about personal identity or
assumption of new identity (partial
or complete).
3. The disturbance does not occur
exclusively during the course of
dissociative identity disorder and is not
due to the direct physiological
effects of a substance (e.g., drug abuse,
a medication) or a general medical
condition (e.g., temporal lobe epilepsy).
4. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning.
-DISSOCIATIVE TRANCE DISORDER
Characteristics: culturally determined
trance
possession
Symptoms: dissociative symptoms such as
sudden changes in personality.
Changes attributed to possession by a
spirit, which is culturally defined.
Prevalence in Population: More common in
women, except for "amok".
Contributor: Associated with some life
stress or trauma.
Stress or trauma is
current.
Cultural or traditional
practice (then, not considered an
abnormality, unless seen as undesirable or
pathological by
culture/tradition).
DISSOCIATIVE TRANCE DISORDER
CRITERIA FOR TRANCE AND
POSSESSION
A. Either (1) or (2):
l. Trance, i.e., temporary marked
alteration in the state of
consciousness or loss of customary sense
of personal identity without
replacement by an alternate identity,
associated with at least one of
the following:
a. narrowing of awareness of
immediate surroundings, or
unusually narrow and selective focusing on
environmental stimuli.
b. stereotyped behaviours or
movements that are experienced as
being beyond one's control.
2. Possession trance, a single or
episodic alteration in the state
of consciousness characterised by the
replacement of customary sense of
personal identity by a new identity. This
is attributed to the influence of
a spirit, power, deity, or other person, as
evidenced by one (or more) of
the following:
a. stereotyped and culturally
determined behaviours or movements
that are experienced as being controlled
by the possessing agent.
9
b. full or partial amnesia of the
event.
B. The trance or possession state is not
accepted as a normal part of a
collective cultural or religious practice.
C. The trance or possession state causes
clinically significant distress or
impairment in social, occupational, or
other important areas of functioning.
D. The trance or possession trance state
does not occur exclusively during
the course of a Psychotic Disorder
(including Mood Disorder With Psychotic
Features and Brief Reactive Psychosis) or
Dissociative Identity Disorder and
is not due to the direct physiological
effects of a substance or a general
medical condition.
DISSOCIATIVE TRANCE DISORDER
CLINICAL DESCRIPTION
1. Differ greatly across cultures (trance
or possession).
2. Symptoms: dissociative symptoms
such as sudden changes in personality
but attributed to possession by a spirit
known by the culture of the person.
if part of some traditional religious or
cultural practice it is then
considered normal. If undesirable and
considered pathological by culture,
then it is considered a disorder.
3. Prevalence in population: more common
in women.
4. Reinforces/Contributors: associated to
a present stress or trauma.

-DISSOCIATIVE IDENTITY
DISORDER
MULTIPLE PERSONALITY DISORDER
CRITERIA FOR DISSOCIATIVE
IDENTITY DISORDER
1. The presence of two or more distinct
identities or personality stated
(each with its own relatively enduring
pattern of perceiving, relating to,
and thinking about the environment and
self).
2. At least two of the above recurrently
take control of the person's
behaviour.
3. Inability to recall important personal
information that is too extensive
to be explained by ordinary forgetfulness.
4. The disturbance is not due to the
direct physiological effects of a
substance (e.g., blackouts on chaotic
behaviour during alcohol intoxication)
or a general medical condition (e.g.,
complex partial seizures).
Note: In children, the symptoms are not
attributable to imaginary playmates
or other fantasy play.
DISSOCIATIVE IDENTITY DISORDER
CLINICAL DESCRIPTION
1. Characteristics:
a. Person may adopt from one to
l00 or more identities (alters) that
coexist within mind and body.
b. Each personality may be
completely different to the other in
10
voice, gestures, behaviours, believes,
postures, physical disabilities, even
pattern of facial, number of changes in
optical functioning wrinkles and
handedness, or be partially dependent of
each other and to be cross
gendered.
c. Personalities score different in
personality and other tests.
d. There is usually a "host"
identity (the client, which is seldom
the first one to seek treatment), which
tends to develop later.
e. Each personality has a
different role. One is usually impulsive
and another one has knowledge of all
others.
f. Switch - transition from one
personality to another, can be
instantaneous and physical
transformations can take place during
these
switches.
g. Number of personalities in an
individual is l5 on the average.
h. Onset: around 7 yo, but as
young as 4 yo.
i. Duration - usually a lifetime if
not treated. Form of disorder
remains the same throughout life but
switching decreases with age.
Different personalities appear over years
in reaction to new life situations.
j. Additional accompanying
disorders: substance abuse,
depression,
somatization disorder, borderline
personality disorder, panic attacks and
eating disorders.

2. Symptoms: fragmented identity (parts
of person's identity become
detached or dissociated), dissociative
amnesia and dissociative fugue.
3. Symptoms shared with other
disorders, such as with borderline,:
self-destructive, sometimes suicidal
behaviours and emotional instability,
are due to severity of reaction to usually
horrible childhood abuse. DID
also has much similarity with PTSD -
severe and strong emotional reactions to
experiencing severe trauma, to point that
there is a believe DID is an
extreme case of PTSD, with emphasis on
process of dissociation rather than
symptoms of anxiety.
4. Prevalence in Population: Not known in
population at large, but more
common than thought previously. There
are about 9 females to 1 male.
5. Suggestibility is great in these
individuals. Because of this, at times
it is difficult to assess if DID is real,
fake, or suggested by therapist's
leading questions.
6. Veracity Tests can include:
a. optical changes such as in
measures of visual acuity, manifest
refraction, and eye muscle balance, which
are difficult to fake.
b. different physiological
responses to emotionally laden words
(GRS
and EEG)).
c. developmental history that
suggests early onset.
11
d. failure to attain substantive
information from relatives and
friends.
e. failure to create more
personalities under suggestion (escalation
when under investigation).
f. lack of test response
differentiation amongst personalities.
g. assessment indicates no gains
received from having disorder.
h. "faking tests" with symptoms
shown by some of the personalities.
7. Reinforcers/ Contributors:
a. horrible child abuse, bizarre
and sadistic.
b. satanic or ritual abuse.
c. witnessing a traumatic event,
such as the murder of loved ones.
d. being forced to commit a crime
or sacrifice loved one,(eg satanic
sacrifice).
e. DID is rooted in a natural,
normal tendency to escape or
"dissociated" from the unremitting
negative affect associated with severe
abuse.
f. lack of social support during or
after abuse.
g. suggestibility and
hypnotisability traits which makes them
able to
use dissociation as a defence against
extreme trauma.
SEIZURES AND DISSOCIATIVE
SYMPTOMS
Description: A biological vulnerability to
reacting with a seizure to
trauma.
A Possible Explanation for this disorder
could be based on an abnormal
electrical activity of the brain.
Neurological seizure sufferers experience
a lot of dissociative symptoms (6% of
temporal lobe report "out of body
experiences"; 50% of temporal lobe
display some kind of dissociative
symptoms, such as alternate identities or
identity fragments. Yet, there are
differences between dissociative disorder
patients who have seizures and
those who do not. Also, in seizure
patients. Dissociative symptoms develop
in adulthood and are not associated with
trauma.
TREATMENT FOR DISSOCIATIVE
DISORDERS
Episodes of dissociative amnesia or fugue
state:
Individual usually gets better on
their own and go back to their
homes or "remember".
If memories do not return,
therapy focus on uncovering forgotten
information and to confront it, integrating
it into their experience.
Therapeutic resolution of
stressful situation.
Increasing strength of coping
mechanisms.
REM
12
Dissociative Identity Disorder:
Treatment for Dissociative Disorders
Long-term psychotherapy to
reintegrate identities (successful only in
5 of 20).
Goal is to confront and relive early
trauma in a way that the
individual gains control over the horrible
events, as they continue to occur
in patient's mind in the present and to
make the trauma simply a
terrible memory of a particular past
period.
Hypnosis, particularly for
"unconscious" memories and to bring forth
"alters"
Same treatment procedures as
used in PTSD.
pharmacology
strategies to gradually
confront feared situations and do
reality testing
gradual exposures paired
with relaxation exercises
panic control treatment
techniques - the recreation of
feelings felt during past, traumatic and
feared experiences, during treatment
paired with CBT techniques
relaxation and breathing exercises to help
cope with stress of
memories
REM
Note:
l. reemerging memories of the trauma
may trigger further dissociation.
Therapist must be vigilant
2. very important in therapy are
therapeutic relationship and sense of
trust
3. Medication, not yet proven to be
helpful there are indications that
antidepressant drugs help.
4. VERY IMPORTANT IN TREATMENT:
a. Setting treatment plan that will
define:
safety area
which personality would like to
meet
therapist first
assessment of past treatment(s)
and what
helped/did not help
assessment of developmental/past
history:
- when aware of dissociations
- memories held
- gaps in memories
- affects in daily life and job
getting names of each personality
or
identity and their roles
genesis of each personality state
and
duration of time it has executive
control of the body
why did each personality state
appear,
in terms of precipitatives and
perpetuating events associated
with its development and why it
is present at this time in life
where was client at time of each
13
personality state's creation,
where
each personality state fits in the
power structure, and where each
personality state fits into the
system
of the client's personality
the function of each personality
state
and how he or she aids the system
as a whole
b. Making a Contract (or
hospitalise):
- Type and regularity of
treatment
- No set time for duration of
sessions
or of treatment
- Use of specific procedures (e.g.,
hypnosis)
No self hurt, suicide or homicide
(e.g.:
" I will not hurt myself or kill
myself, nor anyone else external
or
internal, either accidentally or on
purpose at any time."
c. taping sessions and taking good
notes -
clients tend to not remember
great parts
of the session because of shifts
and
defence mechanisms.
d. giving client copy of notes to
remember
session and when ready, with
therapist
 present, go over tapes (helpful to
get to
know other personalities).
e. therapist must have great
sensitivity to
client's reactions during therapy
and
must ensure client leaves in a well
state.
f. therapist must be very aware of
him/herself and reactions to
horrific
revelations and be able to deal
with
these, without showing
disturbance or
fear as personalities will realise
therapist's inability to deal with
issues
and stop making themselves
available to
therapy and stop memory
recovery
process.
g. therapist must be available 24
hrs. a day
for emergencies as clients, once
memory
starts to reemerge, will have
flashbacks
during sleep and waking - at any
time
and will not be able to deal with
these
without help.
Factitious disorders:
Jenny (a pseudonym) was one of those
"invisible" people we all know and overlook
each day. A secretary for a
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manufacturing company, Jenny was as a
diligent employee, but one who hadn't
developed many friends at work.
Nevertheless, she seemed to find all the
companionship she needed in her
relationship with her live-in boyfriend.
Week in and week out, her world seemed
never to change, and yet she seemed
satisfied. Then one day everything,
suddenly and quietly, fell apart.
Jenny's boyfriend announced he was
leaving her: he had fallen in love with
another woman and was moving out.
Horrified and adrift, with no one to call
on for comfort, Jenny chose a remarkable
way out of her loneliness. She mobilized
an instant support network by showing up
at work one day and announcing, "I've just
been diagnosed with breast cancer. And
it's too late. It's terminal."
It was also a lie. Jenny had found a
remarkable and desperate way to mobilize
an instant support network of
sympathetic co-workers. Eventually she
enrolled in a breast cancer support group,
shaved her head to mimic the effects of
chemotherapy, and dieted to lose 50
pounds all to keep the illusion alive.
Jenny was suffering not only from a
broken heart, but from an emotional
ailment called "factitious disorder."
People with factitious disorder feign or
actually induce illness in themselves,
typically to garner the nurturance of
others. In bizarre cases called
"Munchausen syndrome by proxy," they
even falsify illness in another person
(such as their own children) in order to
garner attention and sympathy for
themselves as the heroic caregiver.
Desperate? Of course. Yet more common
than you might think. Experts estimate
that one percent of hospitalized patients
are faking their ailments. The medical
bills in one case alone amounted to $6
million. Clearly factitious disorders are
sapping an already-burdened health care
system.
They also defy the imagination. Patients
have bled themselves into anemia and
then showed up at a doctor's office
stating they haven't a clue about how
they became so ill. Others have secretly
taken laxatives to induce diarrhea, or
mimicked seizures so convincingly that
neurologists hospitalized them on the
spot.
The good news: this phenomenon is
finally coming out of the closet. In
recent months, newspapers, magazines,
and TV news programs have all
described cases of factitious disorder,
helping both health professionals and
the general public to become aware. At
the same time, factitious disorder
patients are recognizing that, twisted
as their behavior may seem even to
themselves, help is available.
In Jenny's case, the ruse of cancer
came crashing down when the leaders
of the breast cancer support group
discovered that she had lied about her
medical care. Referred for psychiatric
care, Jenny revealed feelings of
overwhelming depression, and this deep
depression had fueled her factitious
behavior. Treated with antidepressant
medication and psychotherapy, Jenny
ended her illness portrayals and moved
on--decisively--with her life. She has
never resorted to factitious illness
again.
The first step for factitious disorder
patients is to realize they cannot go it
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alone. Though this is a hurdle they
inevitably find intimidating, they simply
must reach out to a therapist. The
therapist can help them realize why the
feigned illnesses began in the first
place: why had the need for sympathy
become so intense? The therapist can
also discover underlying emotional
problems--as in Jenny's case--that
must be treated at once, and also
provide the very caring these patients
had previously had to go to extremes to
elicit. Finally, the therapist can help
teach the patient ways to get needs
met without resorting to self-
defeating, and even literally self-
destructive, actions.
Families who suspect that a loved one
has factitious disorder are invariably
hungry for education about it.
Consulting with a knowledgeable
professional or reading about the
disorder are important steps to take
before they actually confront the
patient. Heavy-handed, punitive
confrontation doesn't work. Instead,
we now know that factitious disorder is
among the trickiest of psychological
ailments to address, and intervention
must be informed, carefully planned,
and, above all, humane.
Notes:
"Factitious" literally means,
"contrived," and the meaning could
hardly be more apt. People with
factitious disorder are great con men
or con women, although what they
obtain through their conning most
people would far rather not have. They
fake either mental disorders or
physical disorders - two specific types
of factitious disorder - or a mixture of
the two, which qualifies them for the
third classification, Facititious
Disorder With Combined Psychological
and Physical Signs and Symptoms.
Finally, there is the usual "Not
Otherwise Specified" category, which
includes people who concoct symptoms
in others, typically children, so that the
concocter can assume the sick role by
proxy.
People with Factitious Disorder (FD)
are not pretending to be sick in order
to gain benefits external to the
disorder, for example, to get insurance
money. Thus they differ from
malingerers, who are dishonest but do
not have a mental disorder. People with
FD are such expert liars that the
syndrome has been called "Munchausen
syndrome" in honor of a German baron
who was a famous liar. In this respect
FD patients share characteristics with
people who have Antisocial Personality
Disorder.
People with FD are willing and eager to
pay for their symptoms by having
unnecessary tests, treatments, and
operations. They may become expert in
producing the symptoms of disorders,
expert enough in many cases to con
physicians and surgeons into treating
them or operating on them for
nonexistent maladies, or mental health
professionals into treating them for
imaginary disorders. The person with
FD thus appears to the outsider to
share characteristics with masochists,
in that they arrange to cause pain to
themselves. Maxmen and Ward1 report
that one person with FD had over 420
documented hospitalizations. Further,
they note that the state of Washington
saved $100,000 per patient per year by
installing a tracking system that
identified patients with FD and
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prevented them from being repeatedly
admitted to hospitals for treatment.
Patients with FD vehemently deny that
they are faking symptoms, and they do
not seek, or willingly accept, treatment
from mental health professionals.
Nevertheless, Maxmen and Ward1 warn
examiners not to assume that there are
no physical problems co-occurring with
the FD. Also, they suggest that the
patients be kept in the hospital and
placed in long-term treatment with a
mental health professional, despite the
small likelihood that the FD will be
cured. If a child is being victimized by
a parent who concocts symptoms for
the child, the child should be protected
through admission to the hospital. In
these cases, the diagnosis given to the
parent is Munchausen Syndrome by
Proxy, a type of child abuse.
MUNCHAUSEN BY PROXY (MBP):
(Also called Munchausen Syndrome by
Proxy, Munchausen by Proxy Syndrome,
and Factitious Disorder by Proxy) is a
label for a pattern of behavior in which
caretakers deliberately exaggerate
and/or fabricate and/or induce physical
and/or psychological-behavioral-mental
health problems in others.
This pattern of behavior constitutes a
separate kind of maltreatment
(abuse/neglect) that manifests as
physical abuse, sexual abuse, emotional
abuse, neglect, or a combination. The
primary purpose of this behavior is to gain
some form of internal gratification, such
as attention, for the perpetrator.