Somatoform
and
Dissociative Disorders
Dr.Saman Anwar Faraj
psychiatrist
M.B.Ch.B, F.I.B.M.S (psych)
I. Somatoform Disorders
• Somatoform disorders describe a group of
disorders that share in common the presence of
physical symptoms that suggest a general
medical condition but are not fully explained by a
general medical condition or the effects of a
substance or another mental disorder. Some
somatoform disorders are better understood than
others, although most have not received the
research attention that other Axis I disorders
(e.g., depression) have received. Thus, these are
among the most poorly understood of the mental
disorders.
Somatoform disorders
Soma = Body
Form = Like
Somatoform = Body like
Are group of Mental disorders characterized by
physical symptoms that are not explained by
organic factors.
Somatoform disorders are differentiated from malingering and
factitious disorder because symptoms in somatoform
disorders are not seen as intentional, voluntary, and
consciously produced. However, elaboration of symptoms in
patients with somatoform disorders may sometimes have a
component of volition.
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Somatoform disorders
Body dysmorphic
disorder
Somatization
disorder
Hypochondriasis
Conversional
disorder
Pain disorder
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Sick Role
• Have you ever “played sick” in order to get
out of something? How did that work out
(did you get what you wanted)?
• Sick  attention (friends, family, medical) =
secondary gains
• Likely link between secondary gains and
somatoform disorders
• Some medical condition may actually exist
• People who are sick get lots of attention from
medical personnel, families, friends, etc. and this
attention can be very psychologically rewarding.
Although somatoform disorders are more complex
than simply an elaborate scheme to achieve
secondary gains from the sick role, there is likely a
link between these gains (which are reinforcing)
and the continuation of the presentation of the
disorder. It is also important to note that the
person suffering from a somatoform disorder may
in fact have a medical condition of some sort, but
that medical condition does not account for the
entirety of the physical symptom complaints put
forth by the patient.
Somatization Disorder
1. Historical perspective
•
•
•
•
In the medical/clinical nomenclature since the
mid-1600’s
Known as “Hysteria,” “hypochondriasis,” and
“melancholia” until 1800’s when mental
disorders were differentiated
Briquet’s syndrome, named for the French
physician who initially defined it in 1859
Term “somatization disorder” was first used in
DSM-III (1980)
Somatization (cont.)
DSM-IV criteria
A. History of many physical complaints
beginning before age 30 occurring over
several years resulting in treatment being
sought or significant impairment in
functioning
DSM-IV criteria (cont.)
B. Each of the following met at some point
during disorder:
1) 4 pain symptoms
2) 2 gastrointestinal symptoms
3) 1 sexual symptom
4) 1 pseudoneurological symptom
DSM-IV criteria (cont.)
C. Either:
1) symptoms in Criterion B cannot be fully
explained by a known GMC
or 2) when a GMC does exist, the
symptoms in Criterion B are in excess of
what would be expected based on medical
facts
D. Symptoms not intentionally feigned or
produced
Somatization (cont.)
***Additional descriptive information
•
•
•
•
Report of symptoms usually colorful or
exaggerated; factual info usually lacking
Lab findings do not support somatic complaints
Treatment sought from several doctors at once
 hazardous mix of treatments
Other disorders, such as anxiety disorders, mood
disorders, and personality disorders, often coexist
Additional info (cont.)
• Primary relationships are with doctors; personal
relationships usually have problems
• Often seem indifferent about what symptoms
represent
– Concerned with individual symptoms, not what symptoms
might indicate in terms of a disease
• Physical symptoms become part of their identity (ego
syntonic)
Somatization (cont.)
4. Statistics and course
– Lifetime prevalence:
•
•
•
0.2 – 2% in women
less than 0.2% in men
Rates affected by rater, method of assessment, and
demographic variables:
– Non-physicians diagnose it less frequently
– In primary medical care settings, rate is 4.4 – 20%
– Typical demographic is lower SES unmarried woman
Somatization (cont.)
5. Causes
a) familial/genetic
•
Genetic influence (30-50%) on somatization symptoms
b) Social learning
•
•
Parents may reinforce somatic complaints in children  gain
attention (sick role)
Research shows somatization features and help seeking for
illness in parents of somatizing children
Causes (cont.)
c) Cultural
– Cultural differences in type of symptoms
– Different rates across cultures
– Possible differences in the use of somatic
references in communication (not a disorder, just
differences in communication?)
d) Societal
– More acceptance of medical vs. psychological
problems
Somatization (cont.)
6. Treatment
– No treatment shown to be effective
– Behavioral approach  limit doctor visits
•
Use a gatekeeper physician
– Train patient to relate to others without using
physical complaints
Conversional disorder
Hysteria=(Hystero) (Uterus-Greek)
Conversion=a process where by psychological distress was
converted into physical symptoms.
• Descriptions of conversion disorders appeared as far back as
1900 BC when multiple symptoms were attributed by
Egyptian physicians to a wandering of the uterus within the
body.
• The term conversion was first used by Sigmund Freud and his
associate Josef Breuer.
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Sudden onset, sudden termination, sudden reappearance
Mostly women; men in combat
Often misdiagnosed: Overpathologized
• Conversion disorder is an illness of symptoms or deficits that
affect voluntary motor or sensory functions, which suggest
another medical condition, but that is judged to be caused by
psychological factors because the illness is preceded by conflicts
or other stressors.
• The symptoms or deficits of conversion disorder are not
intentionally produced, are not caused by substance use, are not
limited to pain or sexual symptoms, and the gain is primarily
psychological and not social, monetary, or legal.
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Clinical features
A. The patient complain of symptoms or deficits.
 Motor symptoms (weakness, difficulty in
swallowing, aphonia, impaired coordination)
 Sensory symptoms (blindness, deafness, loss of
touch or pain sensation).
 Seizure or convulsions
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B. The temporal relation of symptoms to a stressful event
suggest association of psychological factors.
C. Symptoms are not explained by an organic etiology or
another mental illness.
D. Symptoms result in significant functional impairment.
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• The onset of conversion disorder is generally
from late childhood to early adulthood and is
rare before 10 years of age or after 35 years of
age, but onset as late as the ninth decade of
life has been reported.
• When symptoms suggest a conversion
disorder onset in middle or old age, the
probability of an occult neurological or other
medical condition is high.
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Management:
 Medical and psychiatric hx. From patient and relatives.
 Full examination and investigation to exclude physical causes.
 Sympathetic but positive reassurance that the patient is suffering
from an acute temporary condition and doesn't have disabling
medical disorder.
 Discussion of the expected rapid recovery.
 Avoidance of reinforcement of disability or symptoms.
 Offering continuing assessment and treatment of related psychiatric
or social problems.
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• Resolution of the conversion disorder symptom is usually
spontaneous, although it is probably facilitated by insight-oriented
supportive or behavior therapy. The most important feature of the
therapy is a relationship with a caring and confident therapist. With
patients who are resistant to the idea of psychotherapy, physicians
can suggest that the psychotherapy will focus on issues of stress and
coping.
• Telling such patients that their symptoms are imaginary often makes
them worse.
• Hypnosis, Anxiolytic, and behavioral relaxation exercises are
effective in some cases.
• Parenteral amobarbital or lorazepam may be helpful in obtaining
additional historic information, especially when a patient has
recently experienced a traumatic event.
• The longer the duration of these patients' sick role and the more
they have regressed, the more difficult the treatment.
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Course and Prognosis
• The onset of conversion disorder is usually acute. Symptoms or
deficits are usually of short duration, and approximately 95 percent
of acute cases remit spontaneously, usually within 2 weeks in
hospitalized patients.
• Recurrence occurs in one fifth to one fourth of people within 1 year
of the first episode. Thus, one episode is a predictor for future
episodes.
• A good prognosis is heralded by acute onset, presence of clearly
identifiable stressors at the time of onset, a short interval between
onset and the institution of treatment, and above average
intelligence.
• Paralysis, aphonia, and blindness are associated with a good
prognosis, whereas tremor and seizures are poor prognostic factors.
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Pain Disorder
• Main symptom is pain
• May be exacerbated by psychosocial factors
• May be maintained by gain: Eugene
– Primary gain
– Secondary gain
Hypochondriasis
• No physical symptoms are necessary
• Preoccupied with the possibility that normal
sensations are symptoms of serious disease
• Frequent visits to physicians
• Persists despite medical reassurance
• Over-report bodily sensations
Prevalence is 6-15% in general medical clinic.
Men and women equally affected.
Clinical features
A. Preoccupation with fear of having a serious disease, based on
misinterpretation of symptoms.
B. The patient is not assured by a negative medical evaluation.
C. The disorder result in significant functional impairment.
D. Duration is greater than 6 months.
F. Symptoms are not accounted for by another mental disorder
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Treatment
• Measures to control investigation, correct
misattributions.
• Cognitive behavioral treatment.
• Medication (fluoxetin) may beneficial.
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Body Dysmorphic Disorder
• Excessive concern with real or imagined
defects in appearance, especially facial marks
or features.
• Frequent visits to plastic surgeons
• Culturally-influenced, but not culture-bound
• May be a symptom of more pervasive
disorders: Obsessive-compulsive or delusional
disorder, for example.
Do advertisements
affect BDD?
“Your nose is central to the
way you feel about your
appearance and the way
other people first perceive
you.
“If you are in the slightest way
unhappy about it, and feel it
detracts from your looks, you
will probably always be
unhappy about it.”
Can you see the difference?
Treatment
• Surgical, dermatological, medical treatment
are unsuccessful.
• Psychotherapy
• Medication( SSRI, Clomipramine)
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More somatoform-like disorders
• Malingering
• Factitious disorder
– Personal: Symptoms only when observed
– By proxy (NOS)
• Undifferentiated Somatoform Disorder
• Somatoform Disorder NOS
– Pseudocyesis (no everted umbilicus)
– Hypochondriacal symptoms < 6 months
Somatoform and Dissociative
Disorders
II. Dissociative Disorders
Overview
• Disorders are marked by disruption in the
usually integrated functions of consciousness,
memory, identity, or perception of the
environment
• What are some “normal” dissociative
experiences that people have sometimes?
• arriving home but not remembering the
drive; intending to go to your friend’s
house but end up heading to work/school
out of habit; calling a friend and being
surprised when your mom answers
because you misdialed
Some General Considerations
• The four diagnoses are hierarchical and only
one can be used at any given time
– Dissociative Identity Disorder
– Dissociative Fugue
– Dissociative Amnesia
– Depersonalization Disorder
A. Common Features of Dissociative
Disorders
1. Depersonalization = distortion in perception
such that a sense of reality is lost
2. Derealization = losing a sense of the external
world
•
e.g., things change size or shape
B. Dissociative Identity Disorder (DID)
•
Formerly known as multiple personality
disorder
1. DSM-IV criteria
A. presence of 2 or more distinct identities
or personality states
B. At least 2 identities/personalities
recurrently take control of the person’s
behavior
1. DSM-IV criteria (cont.)
C. Inability to recall important personal
information (goes beyond ordinary
forgetfulness)
D. Not due to effects of a substance or GMC;
in children, symptoms not attributable to
imaginary playmates or fantasy play
Dissociative Fugue
• The predominant disturbance is sudden, unexpected travel
away from home or once customary place of work, with
inability to recall one's past.
• Confusion about personal identity or assumption of a new
identity.
• The disturbance does not occur exclusively during the course
of Dissociative Identity Disorder and is not due to direct
physiologic effects of a substance or a general medical
condition.
• The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas
of functioning
Depersonalization Disorder
• 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).
• During the depersonalization experience, reality testing
remains intact.
• The depersonalization causes clinically significant distress
or impairment in social, occupational, or other important
areas of functioning.
• The depersonalization experience does not occur
exclusively during the course of another mental disorder,
such as Schizophrenia, Panic Disorder, Acute Stress
Disorder, or other Dissociative Disorder, and is not due to
the direct physiologic effects of a substance or a general
medical condition.
Summary
• Somatoform disorders involve a focus on
physical symptoms that are either not real or
are exaggerated
• Dissociative disorders involve a disturbance in
normally integrated functions (memory,
identity, etc.)
• Course is usually chronic
• Causes for most are unknown
Thank you