Somatoform Disorders, Psychological Factors Affecting

Medical Conditions & Dissociative Disorders

Somatoform Disorders

 These are conditions in which psychological conflicts become translated into physical problems or
complaints that cause distress or impairment in a person’s life.

 They are considered psychological rather than physical disorders, because there is no physical abnormality
that can explain the bodily complaints.

 Somatoform disorders include Conversion disorder, Somatization disorder and related conditions, Body
Dysmorphic disorder, Hypochondriasis and conditions related to somatoform disorders.

Conversion disorder

 Conversion disorder involves the translation of unacceptable drives or troubling conflicts into bodily
motor or sensory symptoms that suggest a neurological or other kind of medical condition.

 Conversion symptoms fall into four categories:

1) motor symptoms or deficits

2) sensory symptoms or deficits
3) seizures or convulsions, and
4) mixed presentation

 The person is not intentionally producing the symptoms; however clinicians cannot establish a medical
basis for the symptoms, and it appear that the person is converting the psychological conflict or need into a
physical problem.

 In mid-1800s, Paul Briquet systematically described and categorized the symptoms of hysteria based on his
review of more than 400 patients.

 Later, Jean Charcot used hypnosis to show that psychological factors played a role in physical symptoms
of hysteria.

 Pierre Janet theorized that this was due to the dissociated contents of the mind.

 Freud eventually developed a radically different theory of hysteria in his work with Breuer, calling it
hysterical neurosis, implying that it was a physical reaction to neurosis (anxiety).

 Psychological factors are judged to be associated with the condition, which began or was aggravated
following a conflict or stressor.
 Some patients of conversion disorder show la belle indifference (beautiful lack of concern) - where the
individual is not distressed by what might otherwise be perceived as very inconveniencing physical
problem.

 Conversion disorder is rare affecting 1 to 3% of those referred for mental health care.

 It runs in the family, generally appears between ages 10 and 35 and found more commonly in women and
those with less education.

 Conditions that might be diagnosed as Chronic fatigue syndrome or fibromyalgia may represent forms of
conversion disorders.

 Course: the condition usually appears suddenly and dissipates in less than 2 weeks but may be recur
within a year.

Symptoms involving paralysis, speaking problems and blindness have a better prognosis.

 As many as half of those with conversion disorder also suffer from a dissociative disorder, making it more
chronic and severe.

Somatization Disorder and Related Conditions

 Somatization disorder is a somatoform disorder characterized by recurring, multiple, clinically significant

complaints that begin before the individual turns 30 years of age resulting in serious social,
occupational and interpersonal functioning problems.

 The individual experiences symptoms in each of the four categories: pain, gastrointestinal, sexual and
pseudo-neurological symptoms.

 In many cases, Somatization disorder first appears during adolescence and progresses to a fluctuating
lifelong course.

 It is relatively rare with the prevalence in the general U.S. population being 0.23 % in women and .02 % in
men from lower socioeconomic classes with less education.

 They may also come from cultures which emphasize less on expression of emotions, from disturbed homes
where they witnessed frequent sickness.

 Often the patients may have a history of substance abuse and some may be at risk for suicide.

 While they do not voluntarily seek psychotherapy, treatment involves helping the client draw the
connections between physical problems and psychological deficits.

 In pain disorder, a related condition, a form of pain is the predominant focus of the client’s medical
complaint.

 Researchers have suggested that chronic pain disorder may be on a spectrum of what are called internalizing
disorders.
 The diagnosis of pain disorders is difficult in cases in which a medical condition is evident.

Body Dysmorphic Disorder

 Body Dysmorphic Disorder (BDD), is a type of a somatoform disorder, wherein the affected person is
exclusively concerned with body image, manifested as excessive concern about and preoccupation with a
perceived defect of their physical features.

 They may believe that there is something wrong with the texture of their skin, that they have too much or
too little facial hair or there is a deformity in the shape of their nose, mouth, jaw or eyebrows.

 Women are most preoccupied with breasts and abdomens and men with premature balding. The most recent
addition to the DSM is muscularity and body build.

 In a study on Germans, the prevalence of BDD was estimated to be 1.7%.

 Individuals with BDD tend to have lower income, lower rates of having a partner and higher unemployment
rates.

 The rates of suicidal ideation and suicidal attempts also tend to be high.

 Some patients consider cosmetic or reconstructive surgery to deal with their concerns.

 Researchers view BDD as a part of a spectrum disorder including OCD and eating disorders. Those with
BDD may also have a personality disorder.

 CBT and in certain cases medications provide symptom relief.

Hypochondriasis

 Hypochondriasis refers to excessive preoccupation or worry about having, or the idea that they have a
serious illness.

 This debilitating condition is the result of an inaccurate perception, exaggeration of the body’s condition
despite the absence of an actual medical condition.

 No amount of reassurance from the medical authorities can relieve their fears, yet they are not delusional.

 Its prevalence is about 1 to 5 % in the general population.

 Explanations:

1.) These individuals are more sensitive than most other people to what is happening inside their bodies.

2.) They selectively focus on information that confirms their worries.

3.) Hypochondriasis may also represent the expression of high levels of the personality trait neuroticism.

 The course tends to be stable over time, especially in those who also suffer from anxiety and depressive
disorders.

 Intervention in these cases is thought as care rather than cure.

 Conditions Related to Somatoform Disorders

1.) Malingering, involves deliberately feigning the symptoms of physical illness or psychological
disorder for an ulterior motive.

 Psychologists use the MMPI to help determine whether clients are faking bad.

 Another instrument is the Validity Indicator Profile, which consists of verbal and nonverbal tasks to
determine whether the subject is responding legitimately or is trying to look impaired.

 Study by Baker et al., on people presenting symptoms of amnesia-pg. 220

2.) Factitious disorder, involves people faking symptoms or disorders, not for the purpose of any
particular gain (ulterior motive) but because of an inner need to maintain a sick role.

 The symptoms may be either physical or psychological or both.

 The person may fabricate symptoms like excruciating headaches or inflict physical harm or make a
medical condition worse.

 They relish the idea of being ill while for some the thought of undergoing surgery is appealing.

 Many develop extensive medical knowledge to ensure that their stories correspond to the technical
aspects of the disorder about which they are complaining.

 Munchausen’s syndrome is a type of factitious disorder that involves chronic cases, in which the
individual’s whole life becomes consumed with the pursuit of medical care.

 The individuals spend time inflicting injury on themselves in order to look so sick that
hospitalization is necessary.

 Although factitious disorder is more common in females, the most chronic and severe cases of
Munchausen’s syndrome tend to appear in men.

 In factitious disorder with psychological symptoms, the individual feigns psychological problems, such
as psychosis or depression - the symptoms tend to be vague and fail to correspond to any particular
psychological disorder.

 In factitious disorder by proxy or Munchausen’s syndrome by proxy, a person induces physical

symptoms in another person who is under that individual’s care. (Case on page 221)

 Many of these individuals tend to have an impaired sense of reality and a poorly consolidated sense of
self.

 In treatment, a nonconfrontational approach is preferred in which the clinician attempts to help the
client integrate reality and fantasy, while supporting the client’s strengths and avoiding rewards for
acting-out behaviours.
 Theories and Treatment of Somatoform Disorders

 Primary and secondary gain (However there are several potential costs of adopting the sick role.)

 Society makes it more acceptable for people to receive care for a physical illness than for stress-related
problems that seem more under voluntary control.

 Somatoform disorders can be best explained as interplay of biological factors, learning experiences,
emotional factors and faulty cognitions.

 Treatment of somatoform disorders involve exploring a person’s need to play the sick role, evaluating
the contribution of stress in the person’s life and using CBT to control their symptoms.

 Medication may be added to the treatment plan.

Dissociative Disorders

A dissociative disorder is defined as a state of disrupted “consciousness, memory, identity or

perception of the environment.”

 Formerly known as Multiple Personality Disorder, DID involves the presence of more than one
distinct self/identity/personality.

 These personalities are referred to as “alters”, in contrast to the core personality, the host.

 In DID each alter has a consistent and enduring pattern of perceiving, relating to and thinking about the
environment and the self.

Characteristics of DID

 The individual with DID has at least two distinct identities or personality states, one of which takes
charge of the person’s behaviour at different times.

 The primary identity (host) associated with their given name, is usually passive and dependent.

 The alters can be extremely different from one another in age, gender, intelligence, affective styles,
etc and tend to act in ways that are hostile, demanding or self-destructive.

 The transition from one alter to another is usually sudden, triggered by psychosocial stress or a
personality salient stimulus.

 Only one alter interacts with the environment at a time although others may actively perceive or
influence what’s happening.

 People with DID claim to have significant periods of blank spells or one-way amnesia.

 The alters can take many forms and perform many functions - common are child, persecutor, and
protector alters.

 Self-destructive behaviour is very common among people with DID and is of the reason for seeking
treatment.
  DID was included in the DSM in 1980 and there was a sudden increase in the number of cases of DID
being reported.

 There is considerable skepticism about the diagnostic criteria of DID, suggesting that they are too vague
and that the condition cannot be reliably diagnosed.

 Nicholas Spanos believed that the display of DID may be shaped by: social factors, therapist’s
suggestions (hypnotic interviews), fabricating the diagnosis for external gains.

 The SCID-D-R has been developed to improve diagnostic standardization (Tb 6.4, page 235).

Theories and Treatment of DID

1. Traumatic childhood experiences of abuse may result in a failure to develop an integrated and
continuous sense of self.

 Therapy involves helping clients to integrate the alters into a unified whole (using hypnotherapy) and
develop adequate coping strategies.

 However the use of hypnosis in the treatment has been controversial.

2. Spanos proposed a sociocognitive model of DID, which suggests that clients enact roles that they feel
are demanded by the situation.

 The critics argue that there is no compelling evidence that childhood abuse is related to development
of amnesia/ dissociation, so it’s pointless to focus therapy on recovering and working through the
traumatic experiences.

3. Another issue is the concept of repressed memories - some professionals believe that they are common
and can be recovered in a therapeutic way while others insist that their recovery may involve ethical
violations if clients are led to believe that events occurred that cannot be substantiated.

4. Some believe in the use of CBT to deal the dysfunctional core beliefs of DID patients.

Improving the individual’s sense of self-efficacy through the process of temporizing, in which the
client controls the way that the alters make their appearance.

 Several factors contribute to difficulties in treating DID:

 Controversies about the validity of the diagnosis.

 Comorbidity with mood or personality disorders.

 Repairing the damage done by abuse and trauma decades ago may be difficult.

 Clinicians may find it difficult to deal with clients whose problems and styles of presentations are so
diverse and contradictory.

 In spite of these difficulties, studies have shown that treatment with DID clients has been quite
successful.
 DID and the Legal System

 Forensic psychologists and other members of the judicial system face difficulties in differentiating
between a true dissociative disorder from instances of malingering.

 Those who seek to explain their crimes through DID, often claim an insanity defense suggesting that
impaired judgement led to the criminal actions and that their symptoms would interfere with their
participation in court proceedings.

 In certain cases they may admit to having committed the crime but under the influence of an alter.

 Although DID is easy to fake, malingerers find it difficult to maintain consistency in the dissociated
feelings, thoughts and memories associated with the different personality states.

 Unlike DID clients, malingerers rarely have histories marked by confused and fragmented experiences and
failed treatment attempts.

 Malingerers may describe stereotypical personalities that carry out criminal actions, but their alters and
host personalities are less likely to be explainable in terms of their traumatic experiences.

 DID clients may feel ashamed of their disorder while malingerers play up their symptoms for greater
attention.