Chapter 6

Question 1

Introduction

Answer 1

Illness anxiety disorder
- someone who exaggerates the slightest physical symptom
- These problems fall under the general heading of somatic symptom disorders. Soma means “body,” and the problems preoccupying these people seem, initially, to be physical disorders.
- In some cases, the medical cause of the presenting physical symptoms is known, but the emotional distress, the extreme preoccupations, or level of impairment in response to this symptom is maladaptive and may even make the condition worse.

Another new class of disorders in DSM­5 brings together several disorders that share a number of characteristics, such as driven repetitive behaviours and some other symptoms
- Previously, these disorders had been scattered in other areas of the DSM­IV.
- In addition to obsessive-compulsive disorder, which had been classified as an anxiety disorder before the DSM­5, this grouping now includes a separate diagnostic category for hoarding disorder, body dysmorphic disorder (which was previously located with the somatoform disorders), and trichotillomania (which was previously grouped with the impulse control disorders).
- Another new disorder in this group is excoriation (skin picking) disorder.

Question 2

Somatic Symptom Disorder and Related Disorders

Answer 2

The DSM­5 lists 5 basic somatic symptom and related disorders:
- somatic symptom disorder
- illness anxiety disorder
- psychological factors affecting medical condition
- conversion disorder
- factitious disorder

In each, individuals are pathologically preoccupied and concerned with the appearance or functioning of their bodies.
- The first 3 disorders — somatic symptom disorder, illness anxiety disorder, and psychological factors affecting medical condition—overlap considerably, since each focuses on a specific somatic symptom, or set of symptoms, about which the patient is so excessively anxious or distressed that it interferes with his or her functioning, or the anxiety or distress is focused on just the possibility of developing an illness as in illness anxiety disorder.

Subtopics:
1. Somatic Symptom Disorder
a. Clinical description

2. illness anxiety Disorder
   a. Clinical Description
3. Statistics for Somatic Symptom and Illness Anxiety Disorder
4. Causes of Somatic Symptom and Illness Anxiety Disorder
5. Treatment of Somatic Symptom and Illness Anxiety Disorder
6. psychological Factors affecting medical condition
7. conversion Disorder (Functional neurological Symptom Disorder)
   a. Clinical Description
   b. Closely Related Disorders
   c. Unconscious Mental Processes
   d. Statistics
   e. Causes
   f. Treatment

Question 3

Somatic Symptom Disorder - clinical description

Answer 3

Pierre Briquet described patients who came to see him with seemingly endless lists of somatic complaints for which he could find no medical basis.
- Despite his negative findings, patients returned shortly with either the same complaints or new lists containing slight variations.
- For more than a century this disorder was called Briquet’s syndrome, but now it would be known as somatic symptom disorder.

People are concerned with the symptoms themselves, not with what they might mean.
- People with somatic symptom disorder do not always feel the urgency to take action but continually feel weak and ill, and they avoid exercising, thinking it will make them worse
- Their entire life revolved around their symptoms
- they may feel that their symptoms are their identity
- they may not know how to relate to people except in the context of discussing their symptoms

Another common example of a somatic symptom disorder is the experience of severe pain in which psychological factors play a major role in maintaining or exacerbating the pain, whether or not the pain has a clear physical reason.

Psychological or behavioural factors, particularly anxiety and distress, are compounding the severity and impairment associated with the physical symptoms.
- The new emphasis in the DSM­5 on the psychological symptoms in these disorders is useful to clinicians, because it highlights the psychological experiences of anxiety and distress focused on the somatic symptoms as the most important target for treatment
- But an important feature of these physical symptoms, such as pain, is that they are real and they hurt, whether or not there are clear physical reasons for the pain

Question 4

illness anxiety Disorder

Answer 4

Illness anxiety disorder was formerly known as hypochondriasis, which is still the term widely used among the public.

In illness anxiety disorder, physical symptoms are either not experienced at the present time or are very mild, but severe anxiety is focused on the possibility of having or developing a serious disease.
- If one or more physical symptoms are relatively severe and are associated with anxiety and distress, then the diagnosis would be somatic symptom disorder.
- Using DSM­5 criteria, only about 20% of patients who used to meet the diagnostic criteria for DSM­IV hypochondriasis now meet the criteria for illness anxiety disorder, in part because they do not complain about having any somatic symptoms despite experiencing serious anxiety about contracting an illness
- This justified the creation of the illness anxiety disorder category, to cover that 20% segment who do not report symptoms.

In illness anxiety disorder, the concern is primarily with the idea of being sick instead of the physical symptom itself.
- And the threat seems so real that reassurance from physicians does not seem to help.

Question 5

illness anxiety Disorder - clinical description

Answer 5

Illness anxiety disorder and somatic symptom disorder share many features with the anxiety and mood disorders, particularly panic disorder, including similar age of onset, personality characteristics, and patterns of familial aggregation (running in families).

Indeed, anxiety and mood disorders are often comorbid with somatic symptom disorders; that is, if individuals with somatic symptom disorders have additional diagnoses, these most likely are anxiety or mood disorders

Illness anxiety disorder is characterized by anxiety or fear that one has a serious disease.
- Therefore, the essential problem is anxiety, but its expression is different from that of the other anxiety disorders.

In illness anxiety disorders, the individual is preoccupied with bodily symptoms, misinterpreting them as indicative of illness or disease.
- Almost any physical sensation may become the basis for concern.
- Some may focus on normal bodily functions, such as heart rate or perspiration, others on minor physical abnormalities, such as a cough.
- Some individuals complain of vague symptoms, such as aches or fatigue.

Because a key feature of this disorder is preoccupation with physical symptoms, individuals with these disorders almost always go initially to family physicians.
- They come to the attention of mental health professionals only after family physicians have ruled out realistic medical conditions as a cause of the patient’s symptoms.

Another important feature of this disorder is that reassurances from numerous doctors that all is well and the individual is healthy have, at best, only a short-term effect.
- It isn’t long before patients are back in the office of another doctor on the assumption that the previous doctors have missed something.
- This is because many of these individuals mistakenly believe they have a disease; this difficult-to-shake belief is sometimes referred to as “disease conviction.”
- Therefore, along with anxiety focused on the possibility of disease or illness, disease conviction is a core feature of the disorder

You may think that patients with panic disorder resemble patients with both disorders, particularly patients with illness anxiety disorder.
- Patients with panic disorder also misinterpret physical symptoms as the beginning of the next panic attack, which they believe may kill them.

Craske and Hiller, Leibbrand, Rief, and Fichter suggested several differences between panic disorder and the somatic symptom disorders.
- Although all disorders include characteristic concern with physical symptoms, patients with panic disorder typically fear immediate symptom-related catastrophes that may occur during the few minutes they are having a panic attack, and these concerns lessen between attacks.
- Individuals with somatic symptom disorders, on the other hand, focus on a long-term process of illness and disease (e.g., cancer or AIDS). Patients with these disorders also continue to seek the opinions of additional doctors in an attempt to rule out (or perhaps confirm) disease and are more likely to demand unnecessary medical treatments. Despite numerous assurances that they are healthy, they remain unconvinced and unreassured.
- In contrast, patients with panic attacks continue to believe their panic attacks might kill them, but most learn rather quickly to stop going to doctors and emergency rooms, where they are told repeatedly that nothing is physically wrong with them. Lastly, the anxieties of individuals with panic disorder tend to focus on the specific set of 10 or 15 sympathetic nervous system symptoms associated with a panic attack. Concerns range much wider in somatic symptom disorders. .

Question 6

Statistics for Somatic Symptom and Illness Anxiety Disorder

Answer 6

We can only estimate prevalence of somatic symptom disorders in the general population
- the lifetime prevalence of DSM­IV hypochondriasis, which would encompass illness anxiety disorder and part of somatic symptom disorder, is between 1% and 5%
- In primary care settings the median prevalence rate for hypochondriasis is 7%, but it is as high as 17% for distressing somatic symptoms, which should closely approximate the prevalence of somatic symptom disorder and illness anxiety disorder combined in these settings
- Severe illness anxiety has a late age of onset, possibly because more physical health problems occur with aging

Several studies have demonstrated that individuals with what would now be diagnosed as somatic symptom disorder tend to be women, unmarried, and from lower socioeconomic groups
- In addition to a variety of somatic complaints, individuals may also have psychological complaints, usually anxiety or mood disorders

A culture-specific disorder, prevalent in India, is an anxious concern about losing semen, something that obviously occurs during sexual activity.
- The disorder, called dhat, is associated with a vague mix of physical symptoms, including dizziness, weakness, and fatigue.
- These low-grade depressive or anxious symptoms are simply attributed to a physical factor: semen loss

Other specific culture-bound somatic symptoms include hot sensations in the head or a sensation of something crawling in the head, specific to African patients and a sensation of burning in the hands and feet in Pakistani or Indian patients

Question 7

Causes of Somatic Symptom and Illness Anxiety Disorder

Answer 7

Investigators agree on psychopathological processes ongoing in somatic symptom disorders.
- Faulty interpretation of physical signs and sensations as evidence of physical illness is central, so almost everyone agrees that these disorders are basically disorders of cognition or perception with strong emotional contributions

Individuals with somatic
symptom disorders experience physical sensations common to all of us, but they quickly focus their attention
on these sensations.
- the act of focusing on yourself increases arousal and makes the physical sensations seem more intense than they actually are
- If you also tend to misinterpret these as symptoms of illness, your anxiety will increase further. Increased anxiety produces additional physical symptoms, which creates a vicious cycle

Using procedures from cognitive science such as the Stroop test, a number of investigators have confirmed that participants with these disorders show enhanced perceptual sensitivity to illness cues.
- They also tend to interpret ambiguous stimuli as threatening
- Thus, they quickly become aware (and frightened) of any sign of possible illness or disease.

Smeets, deJong, and Mayer demonstrated that individuals with these disorders, compared with others, take a better-safe-than-sorry approach to dealing with even minor physical symptoms by getting them checked out as soon as possible.
- More fundamentally, they have a restrictive concept of health as being symptom-free

What causes individuals to develop this pattern of somatic sensitivity and distorted beliefs?
- Although it is not certain, the cause is unlikely to be found in isolated biological or psychological factors.
- For some patients, the fundamental causes of these disorders are similar to those implicated in the anxiety disorders
- For example, evidence shows that somatic symptom disorders run in families and that there is a modest genetic contribution. But this contribution may be nonspecific, such as a tendency to overrespond to stress, and thus may be indistinguishable from the nonspecific genetic contribution to anxiety disorders.
- Hyperresponsivity might combine with a tendency to view negative life events as unpredictable and uncontrollable and, therefore, to be guarded against at all times
- these factors would constitute biological and psychological vulnerabilities to anxiety.

Why does this anxiety focus on physical sensations and illness?
- We know that children with these concerns often report the same kinds of symptoms that other family members may have reported at one time
- It is therefore quite possible, as in panic disorder, that some individuals who develop somatic symptom disorder or illness anxiety disorder have learned from family members to focus their anxiety on specific physical conditions and illness

3 other factors may contribute to this etiological process:

1. First, these disorders seem to develop in the context of a stressful life event, as do many disorders, including anxiety disorders.
   - Such events often involve death or illness
2. Second, people who develop these disorders tend to have had a disproportionate incidence of disease in their family when they were children.
   - Thus, even if they did not develop somatic symptom disorders until adulthood, they carry strong memories of illness that could easily become the focus of anxiety.
3. Third, an important social and interpersonal influence may be involved
   - Some people who come from families where illness is a major issue seem to have learned that an ill person often gets a lot of attention.
   - The “benefits” of being sick might contribute to the development of the disorder in some people.
   - A person who receives increased attention for being ill and is able to avoid work or other responsibilities is described as adopting a “sick role.”

Question 8

Treatment of Somatic Symptom and Illness Anxiety Disorder

Answer 8

Unfortunately, relatively little is known about treating these disorders.
- It used to be common clinical practice in the past to uncover unconscious conflicts through psychodynamic psychotherapy. Results on the effectiveness of this kind of treatment have seldom been reported, however.

There is scientific support for cognitive-behavioural treatments for health anxiety and also somatic symptom disorder
- Surprisingly, clinical reports indicate that reassurance and education can be effective in some cases with health anxiety — surprisingly, because, by definition, patients with these disorders are not supposed to benefit from reassurance about their health.
- Reassurance is usually given only briefly, however, by family doctors who have little time to provide the ongoing support and reassurance that might be necessary.
- Mental health professionals may well be able to offer reassurance in a more effective and sensitive manner, devote sufficient time to all concerns the patient may have, and attend to the meaning of the symptoms (e.g., their relation to the patient’s life stress).

^^^ Fava, Grandi, Rafanelli, Fabbri, and Cazzaro tested this idea by assigning 20 patients who met diagnostic criteria for DSM­IV hypochondriasis to 2 groups.
- One received explanatory therapy in which the clinician went over the source and origins of their symptoms in some detail. These patients were assessed immediately after the therapy and again at a six-month follow-up.
- The other group was a wait-list control group that did not receive the explanatory therapy until after their six months of waiting. All patients received usual medical care from their physicians.
- In both groups, taking the time to explain in some detail the nature of the patient’s disorder in an educational framework was associated with a significant reduction in fears and beliefs about somatic symptoms and a decrease in health-care usage, and these gains were maintained at the follow-up.
- For the wait-list group, treatment gains did not occur until they received explanatory therapy, suggesting this treatment is effective.
- although explanatory therapy most likely only benefits those with more mild forms of the disorders
- Participation in support groups may also give these people the reassurance they need.

Evaluations of more robust treatments are now available:

In one study, Barsky and Ahern randomized 187 patients with DSM­IV hypochondriasis to receive either 6 sessions of cognitive-behavioural treatment (CBT) from trained therapists OR treatment as usual from primary care physicians.
- CBT focused on identifying and challenging illness-related misinterpretations of physical sensations and on showing patients how to create “symptoms” by focusing attention on certain body areas.
- Bringing on their own symptoms persuaded many patients that such events were under their control.
- Patients were also coached to seek less reassurance regarding their concerns.
- CBT was more effective after treatment and at each follow-up point for both symptoms of hypochondriasis and overall changes in functioning and quality of life.

In another study, Allen found that 40% of patients with more severe somatic symptom disorder treated with CBT (versus 7% of a group receiving standard medical care) evidenced clinical improvement, and these gains lasted at least a year.

One recent trial suggests that cognitive interventions do not seem to be necessary for treating hypochondriasis
- This study randomly assigned patients with hypochondriasis to receive cognitive therapy alone, exposure therapy without explicit cognitive interventions, or a wait-list control group.
- Compared with the control group, both treatments resulted in large-sized effects for improving symptoms of hypochondriasis.
- Although the study found a significant reduction in depressive symptoms and bodily complaints for both treatments in comparison with the waitlist, anxiety symptoms were only significantly reduced by the exposure treatment.
- The exposure procedures consisted of repeatedly confronting the patient with stimuli that are relevant for health anxieties (e.g., documentaries about diseases) without using any avoidance and safety behaviours (e.g., reassurance by doctors, checking the abdomen for cancer).

In our clinics, we concentrate on providing reassurance, reducing stress, and, in particular, reducing the frequency of help-seeking behaviours.
- One of the most common patterns is the person’s tendency to visit numerous medical specialists according to the symptom of the week.
- An extensive medical and physical workup occurs with every visit to a new physician (or to one who has not been seen for a while).
- In treatment, to limit these visits, a gate-keeper physician is assigned to each patient to screen all physical complaints. Subsequent visits to specialists must be specifically authorized by this gatekeeper. In the context of a positive therapeutic relationship, most patients are amenable to this arrangement.

Additional therapeutic attention is directed at reducing the supportive consequences of relating to significant others on the basis of physical symptoms alone.
- More appropriate methods of interacting with others are encouraged.

Question 9

psychological Factors affecting medical condition

Answer 9

A related somatic symptom disorder is called psychological factors affecting medical condition.
- The essential feature of this disorder is the presence of a diagnosed medical condition, such as asthma, diabetes, or severe pain, clearly caused by a known medical condition, such as cancer, that is adversely affected (increased in frequency or severity) by one or more psychological or behavioural factors.

These behavioural or psychological factors would have a direct influence on the course or perhaps the treatment of the medical condition.
- One example would be anxiety severe enough to clearly worsen asthma.
- Another example would be a patient with diabetes who is in denial about the need to regularly check insulin levels and intervene when necessary.

In this case, the pattern would have to be consistent in the neglect of appropriate monitoring and intervention, but the neglect is clearly a behavioural or psychological factor that is adversely affecting the medical condition.

This diagnosis would need to be distinguished from the development of stress or anxiety in response to having a severe medical condition that would more appropriately be diagnosed as an adjustment disorder

Question 10

conversion Disorder (Functional neurological Symptom Disorder)
- Clinical Description

Answer 10

The term conversion has been used off and on since the Middle Ages but was popularized by Freud, who believed the anxiety resulting from unconscious conflicts somehow was converted into physical symptoms to find expression.
- This conversion allowed the individual to discharge some anxiety without actually experiencing it.
- As in phobic disorders, the anxiety resulting from unconscious conflicts might be “displaced” onto another object.
- In the DSM­5, “functional neurological symptom disorder” is a subtitle to conversion disorder, because the term is more often used by neurologists who see the majority of patients receiving a conversion disorder diagnosis and because the term is more acceptable to patients.
- “Functional” refers to a symptom without an organic cause
- It is likely that the old term “conversion” will be dropped in future editions of the DSM

Conversion disorders generally have to do with physical malfunctioning, such as paralysis, blindness, or difficulty speaking (aphonia), without any physical or organic pathology to account for the malfunction
- Most conversion symptoms suggest that some kind of neurological disease is affecting sensory-motor systems, although conversion symptoms can mimic the full range of physical malfunctioning.
- This disorder has been associated with dissociative symptoms

Conversion disorders provide us with some of the most intriguing, sometimes astounding, examples of psychological disorders.
- What could possibly account for somebody going blind when all visual processes are perfectly normal, or experiencing paralysis of the arms or legs when there is no neurological damage?

In addition to blindness and paralysis or weakness in the limbs, conversion symptoms may include the loss of the sense of touch.
- Some people have seizures, which may be psychological in origin, because no significant EEG changes can be documented.
- These “seizures” are usually called psychogenic nonepileptic seizures.

Another relatively common symptom is globus hystericus, the sensation of a lump in the throat that makes it difficult to swallow, eat, or sometimes talk.

Conversion symptoms can also include aphonia or even total mutism

Question 11

conversion Disorder (Functional neurological Symptom Disorder)
- Closely Related Disorders

Answer 11

Distinguishing among conversion reactions, medically explained symptoms, and outright malingering (faking) is sometimes difficult.

Several factors can help:

First, conversion reactions often have the same quality of indifference to the symptoms that is present in some people with severe somatic symptom disorder.
- This attitude, called la belle indifférence, is considered a hallmark of conversion reactions but, unfortunately, it is not a foolproof sign.
- A blasé attitude toward illness is sometimes displayed by people with actual physical disorders, and some people with conversion symptoms do become quite distressed.

Second, conversion symptoms are often precipitated by marked stress.
- Often, this stress takes the form of a physical injury.
- In one large survey, 37% reported prior physical injury. But the occurrence of an identifiable stressor has not been a reliable sign of conversion disorder, since many other disorders are associated with stressful events and stressful events often occur in the lives of people without any disorders.
- For this reason, the diagnostic criterion that conversion disorder is associated with preceding stress does not appear in the DSM­5.
- Although people with conversion symptoms can usually function normally, they seem truly unaware either of this ability or of sensory input.
- For example, individuals with the conversion symptom of blindness can usually avoid objects in their visual field, but they will tell you they can’t see the objects.
- Similarly, individuals with conversion symptoms of paralysis of the legs might suddenly get up and run in an emergency and then be astounded they were able to do this.
- It is possible that at least some people who experience miraculous cures during religious ceremonies may have been dealing with conversion reactions.
- These factors may help in distinguishing between conversion and organically based physical disorders, but clinicians sometimes make mistakes, although it is not common with modern diagnostic techniques.
- For example, Moene reassessed patients diagnosed with conversion disorder and found that 11.8% had developed evidence of a neurological disorder approximately 2.5 years after the first exam.
- The rate of misdiagnosis of conversion disorders that are really physical problems is approximately 4%, having improved considerably from earlier decades.
- In any case, ruling out medical causes for the symptoms is crucial to making a diagnosis of conversion and, given advances in medical screening procedures, this is the principal diagnostic criterion in the DSM­5

It can be very difficult to distinguish between individuals who are truly experiencing conversion symptoms in a seemingly involuntary way and malingerers who are very good at faking symptoms.
- Once malingerers are exposed, their motivation is clear: They are either trying to get out of something, such as work or legal difficulties, or they are attempting to gain something, such as a financial settlement.
- Malingerers are fully aware of what they are doing and are clearly attempting to manipulate others to gain a desired end.

More puzzling is a set of conditions called factitious disorders, which fall somewhere between malingering and conversion disorders.
- The symptoms are under voluntary control, as with malingering, but the person has no obvious reason for voluntarily producing the symptoms except, possibly, to assume the sick role and receive increased attention.
- Tragically, this disorder may extend to producing symptoms in other members of the family.
- An adult, almost always a mother, may purposely make her child sick, evidently for the attention and pity then given to the mother who is causing the symptoms—a condition called factitious disorder imposed on another. It was known previously as Munchausen syndrome by proxy

Diagnostic criteria for factitious disorders:
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better accounted for by another mental dis- order, such as delusional disorder or another psychotic disorder.
Specify:
- Single episode
- Recurrent episodes (two or more events of falsification of illness and/or induction of injury)

The offending parent may resort to extreme tactics to create the appearance of illness in the child.
- Since some parents may establish a positive relationship with medical staff, the true nature of the illness is most often unsuspected and the staff perceives the parent as remarkably caring and very involved in providing for her child’s well-being. For this reason the mother is often very successful at eluding suspicion.
- Helpful procedures to assess the possibility of factitious disorder imposed on another by proxy include a trial separation of the mother and the child or video surveillance of the child while in the hospital.
- An important study has appeared validating the utility of surveillance in hospital rooms of children with suspected factitious disorder imposed on another. In this study, video surveillance was the method used to establish the diagnosis in many cases. In one case a child was suffering from recurring Escherichia coli infections, and cameras caught the mother injecting her own urine into the child’s intravenous line

Question 12

conversion Disorder (Functional neurological Symptom Disorder)
- Unconscious Mental Processes

Answer 12

Unconscious cognitive processes seem to play a role in much of psychopathology

We are capable of receiving and processing information in a number of sensory channels (like vision) without being aware of it.
- Weiskrantz discovered that people with small, localized damage to certain parts of their brains can identify objects in their field of vision, but they had no awareness whatsoever that they could see. Could this happen to people without brain damage?

Sackeim, Nordlie, and Gur evaluated the potential difference between real unconscious process and faking by hypnotizing 2 subjects and giving each a suggestion of total blindness.
- One subject was also told it was extremely important that she appears to everyone to be blind.
- The second subject was not given further instructions.
- The first subject, evidently following instructions to appear blind at all costs, performed far below chance on a visual discrimination task similar to the upright triangle task. On almost every trial she chose the wrong answer.
- The second subject, with the hypnotic suggestion of blindness but no instructions to appear blind at all costs, performed perfectly on the visual discrimination tasks—although she reported she could not see anything.

Grosz and Zimmerman evaluated a male who seemed to have conversion symptoms of blindness.
- They discovered that he performed much more poorly than chance on a visual discrimination task.
- Subsequent information from other sources confirmed that he was almost certainly malingering.

To review these distinctions, someone who is truly blind would perform at a chance level on visual discrimination tasks.
- People with conversion symptoms, conversely, can see objects in their visual field and, therefore, would perform well on these tasks, but this experience is dissociated from their awareness of sight.
- Malingerers and, perhaps, individuals with factitious disorders simply do everything possible to pretend they can’t see.

Question 13

conversion Disorder (Functional neurological Symptom Disorder)
- Statistics

Answer 13

Conversion disorder may occur in conjunction with other disorders, particularly somatic symptom disorder

Conversion disorders are relatively rare in mental health settings, but people who seek help for this condition are more likely to consult neurologists or other specialists.
- The prevalence estimate in neurological settings is high, at about 30%
- One study estimated that 30% of all patients referred to epilepsy centres have psychogenic nonepileptic seizures

Like severe somatic symptom disorder, conversion disorders are found primarily in women and typically develop during adolescence or slightly thereafter.
- Conversion reactions have also been reported in soldiers exposed to severe combat, mainly during World War I and II
- The symptoms often disappear after a time, only to return later in the same or similar form when a new stressor occurs.

A three-year longitudinal study of 88 patients by University of Toronto researchers suggests that, in the case of conversion disorders involving movement disturbances, long-term prognosis is quite poor
- The conversion disorder (i.e., the movement disturbance) had remitted or resolved in only 5% of the participants at the follow-up.

In some cultures, conversion symptoms are very common aspects of religious or healing rituals.
- Seizures, paralysis, and trances are common in some fundamentalist religious groups in North America, and they are often seen as evidence of contact with God.
- Individuals who exhibit such symptoms are thus held in high esteem by their peers.
- These symptoms do not meet the criteria for a disorder unless they persist and interfere with an individual’s functioning.

Question 14

conversion Disorder (Functional neurological Symptom Disorder)
- Causes

Answer 14

Freud described 4 basic processes in the development of conversion disorder.

First, the individual experiences a traumatic event— an unacceptable, unconscious conflict.

Second, because the conflict and the resulting anxiety are unacceptable, the person represses the conflict, making it unconscious.

Third, the anxiety continues to increase and threatens to emerge into consciousness, and the person converts it into physical symptoms, thereby relieving the pressure of having to deal directly with the conflict.
- This reduction of anxiety is considered to be the primary gain or reinforcing event that maintains the conversion symptom.

Fourth, the individual receives greatly increased attention and sympathy from loved ones and may also be allowed to avoid a difficult situation or task.
- Freud considered such attention or avoidance to be the secondary gain or the secondarily reinforcing set of events.

We believe Freud was basically correct on at least three counts and possibly a fourth, although firm evidence supporting any of these ideas is sparse and Freud’s views were far more complex than represented here.
- What seems to happen is that individuals with conversion disorder have experienced a traumatic event or events that must be escaped at all costs
- This might be combat, where death is imminent, or being exposed to an accident or a homicide.
- Because simply running away is unacceptable in most cases, the socially acceptable alternative of getting sick is substituted; but getting sick on purpose is also unacceptable, so this motivation is detached from the person’s consciousness.
- Finally, because the escape behaviour (the conversion symptoms) is successful to an extent in obliterating the traumatic situation, the behaviour continues until the underlying problem is resolved.

One study confirms these hypotheses
- In this study, 34 child and adolescent patients, 25 of them girls, were evaluated after receiving a diagnosis of psychologically based pseudoseizures (psychogenic nonepileptic seizures).
- Many of these children and adolescents presented with additional psychological disorders, including 32% with mood disorders and 24% with separation anxiety and school refusal.
- Other anxiety disorders were present in some additional patients.

When the extent of psychological stress in the lives of these children was examined, it was found that most of the patients had substantial stress, including a history of sexual abuse, recent parental divorce or death of a close family member, and physical abuse.
- The authors conclude that major mood disorders and severe traumatic stress, especially sexual abuse, are common among children and adolescents with the conversion disorder of pseudoseizures, as other studies have similarly indicated

The one step in Freud’s progression of events about which some questions remain is the issue of primary gain.
- The notion of primary gain accounts for the feature of la belle indifférence, where individuals seem not the least bit distressed about their symptoms.
- In other words, Freud thought that because symptoms reflected an unconscious attempt to resolve a conflict, the patient would not be upset by them.
- But patients with conversion disorder are in fact often quite distressed by their symptoms.
- Formal tests of this feature of indifference also provide little support for Freud’s claim.
- For example, Lader and Sartorius compared patients with conversion disorder with control groups of anxious patients without conversion symptoms. The patients with conversion disorder showed equal or greater anxiety and physiological arousal than the control group. The impression of indifference may be more in the mind of the therapist than true of the patient.

Social and cultural influences also contribute to conversion disorder, which, like somatic symptom disorder, tends to occur in less educated, lower socioeconomic groups, in which knowledge about disease and medical illness is not well developed
- For example, Binzer, Andersen, and Kullgren noted that 13% of their 30 patients with motor disabilities due to conversion disorder had attended high school, compared with 67% in a control group with motor symptoms due to a physical cause.

Prior experience with real physical problems, usually among other family members, tends to influence the later choice of specific conversion symptoms; that is, patients tend to adopt symptoms with which they are familiar
- Furthermore, the incidence of these disorders has decreased over the decades
- The most likely explanation is that increased knowledge of the real causes of physical problems by both patients and loved ones eliminates much of the possibility of secondary gain so important in these disorders.

Finally, many conversion symptoms seem to be part of a larger constellation of psychopathology.
- In some cases, individuals may have a marked biological vulnerability to develop the disorder when under stress, with biological processes like those discussed in the context of somatic symptom disorder.
- In other cases, exposure to traumatic events may play a large contributing role.
- For countless other cases, however, biological contributory factors seem to be less important than the overriding influence of interpersonal factors

Question 15

conversion Disorder (Functional neurological Symptom Disorder)
- Treatment

Answer 15

Since conversion disorder has much in common with somatic symptom disorder, many of the treatment principles are similar.

A principal strategy in treating conversion disorder is to identify and attend to the traumatic or stressful life event, if it is still present (either in real life or in memory).
- therapeutic assistance in re-experiencing or “reliving” the event (catharsis) is a reasonable first step.
- The therapist must also work very hard to reduce any reinforcing or supportive consequences of the conversion symptoms (secondary gain).

Many times, removing the secondary gain is easier said than done.

Cognitive-behavioural programs appear to hold promise in the treatment of conversion disorder.
- In one study, 65% of patients with mostly motor behaviour conversions (e.g., difficulty walking) responded well to such treatment.
- Hypnosis, which was administered to approximately half of the patients, did not confer any additional benefit to the CBT

Question 16

Obsessive-Compulsive And Related Disorders

Answer 16

Subtopics:
1. Obsessive-Compulsive disorder
a. Clinical description
b. Types of Obsessions and Compulsions
c. Tic Disorder and OCD
d. Statistics
e. Causes
f. Treatment

2. Body Dysmorphic Disorder
   a. Clinical Description
   b. Statistics
   c. Causes and Treatment
   d. Plastic Surgery and Other Medical Treatments
3. Hoarding Disorder
4. Trichotillomania and Excoriation Disorder

Question 17

Obsessive-Compulsive disorder

Answer 17

Obsessive-compulsive disorder (OCD) is the devastating culmination of the anxiety and related disorders.

It is not uncommon for someone with OCD to experience severe generalized anxiety, recurrent panic attacks, debilitating avoidance, and major depression, all occurring simultaneously in conjunction with obsessive-compulsive symptoms.

With OCD, establishing even a foothold of control and predictability over the dangerous events in life seems so utterly hopeless that victims resort to magic and rituals.

Question 18

Clinical description - Obsessive-Compulsive disorder

Answer 18

In OCD, the dangerous event is a thought, an image, or an impulse that the client attempts to avoid
- Obsessions are intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate.
- Compulsions are the thoughts or actions used to suppress the obsessions and provide relief.

Diagnostic Criteria for Obsessive-Compulsive Disorder:

A. Presence of obsessions, compulsions or both: Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2):
a. Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
b. The behaviors or mental acts are aimed at preventing or reducing distress, or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviours or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impair- ment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking disorder]; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fanta- sies, as in paraphilic disorders; impulses, as in disruptive, impulse- control and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Specify if:

With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.

With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.

Specify if:
Tic-related: The individual has a current or past history of a tic disorder.

Compulsions can be either behavioural (handwashing, checking) or mental (thinking about certain words in a specific order, counting, praying, and so on
- The important thing is that they are believed to reduce stress or prevent a dreaded event.
- Compulsions are often “magical” in that they frequently bear no logical relation to the obsession.

Question 19

Types of Obsessions and Compulsions - Obsessive-Compulsive disorder

Answer 19

Based on statistically associated groupings, there are 4 major types of obsessions and each is associated with a pattern of compulsive behaviour

Symmetry obsessions account for most obsessions (27%), followed by “forbidden thoughts or actions” (21%), cleaning and contamination (16%), and hoarding (15%)
- Symmetry refers to keeping things in perfect order or doing something in a specific way.
- People with aggressive (forbidden) obsessive impulses may feel they are about to yell out a swear word in a place of worship.

Certain kinds of obsessions are strongly associated with certain kinds of rituals
- For example, forbidden thoughts or actions seem to lead to checking rituals. Checking rituals serve to prevent an imagined disaster or catastrophe. Many are logical, such as repeatedly checking the stove to see whether you turned it off, but severe cases can be illogical.
- A mental act, such as counting, can also be a compulsion.
- Obsessions with symmetry lead to ordering and arranging or repeating rituals; obsessions with contamination lead to washing rituals that may restore a sense of safety and control

On rare occasions, patients, particularly children, will present with compulsions, but few or no identifiable obsessions.

Canadian comedian Howie Mandel has OCD.
- He is a member of the Bell Let’s Talk team and speaks very openly about it
- his obsessions centre on themes of contamination. He is concerned he will be infected by germs from other people around him.
- Thus, Mandel carefully avoids shaking hands with other people, unless he is wearing latex gloves.
- Mandel has reported that his OCD symptoms cause him disruption when he stays in hotels.
- He reportedly orders two-dozen towels when he arrives at a hotel, and makes paths with them so that he does not have to step on the hotel carpets.
- He also avoids being around people if they have any sign of illness, like a cold.
- When his OCD symptoms are at their worst, his compulsions include retreating to a second “sterile” house he had built on his property where he isolates himself from the world.
- He even retreats there to avoid family members if he suspects any of them have something contagious, like the flu
- Mandel said he was doing okay but also admitted to significant struggles: “Yeah, I don’t touch shoelaces,” he says, almost bristling with disgust. “I just won’t.” Then he brightens and says, “I’m not as bad as I was [with these things]. I have OCD, I have ADHD, I have anxiety, I have depression, I go see somebody, I’m heavily medicated, and I’m constantly in fear and constantly uncomfortable and constantly fighting. But it’s gotten to where I’m really comfortable with discomfort. I’ve learned that’s who I am, and that’s what makes me feel alive.”

Question 20

Tic Disorder and OCD - Obsessive-Compulsive disorder

Answer 20

It is common for tic disorder, characterized by involuntary movement (sudden jerking of limbs, for example), to co-occur in patients with OCD (particularly children) or in their families

More complex tics with involuntary vocalizations are referred to as Tourette’s disorder
- In some cases, these movements are not tics but may be compulsions

Approximately 10% to 40% of children and adolescents with OCD also have had tic disorder at some point
- The obsessions in tic-related OCD are almost always related to symmetry.

CBT has been found to be quite effective for treating tic disorders

Observations among one small group of children presenting with OCD and tics suggest that these problems occurred after a bout of strep throat.
- This syndrome has been referred to as pediatric autoimmune disorder associated with streptococcal infection, or “Pandas”
- Presentation of OCD in these cases differs somewhat from OCD without a history of Pandas in several ways.
- The Pandas group is more likely to be male, experience dramatic onset of symptoms, often associated with fever or sore throat, have full remissions between episodes, show remission of symptoms during antibiotic therapy, have evidence of past streptococcal infections, and present with noticeable clumsiness
- Recently, this syndrome has been revised and broadened under the umbrella term pediatric autoimmune neuropsychiatric syndrome
- The prevalence of this condition has yet to be determined.

Question 21

Statistics - Obsessive-Compulsive disorder

Answer 21

Estimates of the lifetime prevalence of OCD range from 1.6% to 2.3%
- in a given one-year period, the prevalence is about 1%

Obsessions and compulsions can be arranged along a continuum
- Intrusive and distressing thoughts are common in nonclinical (“normal”) individuals
- Spinella found that 13% of a “normal” community sample of people had moderate levels of obsessions or compulsions that were not severe enough to meet diagnostic criteria for OCD.
- Between 10% and 15% of university students engaged in checking behaviour substantial enough to score within the range of patients with OCD

It would also be unusual not to have an occasional intrusive or strange thought.
- Many people have bizarre, sexual, or aggressive thoughts, particularly if they are bored—for example

Have you had any of these thoughts? Most people do, but they let these thoughts drift into their mind and out of it again.
- Certain individuals, however, are horrified by such thoughts, considering them signs of an alien, intrusive, evil force.

OCD has a female-to- male ratio that is nearly 1:1.
- However, there is some evidence in children that there are more males than females
- This seems to be because boys tend to develop OCD earlier.

By mid-adolescence, the sex ratio is approximately equal
- The average age of onset ranges from early adolescence to the mid-20s but peaks earlier in males (at 13 to 15) than in females (at 20 to 24)
- Once OCD develops, it tends to become chronic

In Arabic countries, OCD is easily recognizable, although, as always, cultural beliefs and concerns influence the content of the obsessions and the nature of the compulsions.
- In Saudi Arabia and Egypt, obsessions are primarily related to religious practices, specifically the Muslim emphasis on cleanliness.

Contamination themes are also highly prevalent in India.

Nevertheless, OCD looks remarkably similar across cultures.
- Studies from England, Hong Kong, India, Egypt, Japan, and Norway have found essentially similar types and proportions of obsessions and compulsions, as did studies from Canada, Finland, Taiwan, Africa, Puerto Rico, Korea, and New Zealand

Question 22

Causes - Obsessive-Compulsive disorder

Answer 22

Many of us sometimes have intrusive, even horrific thoughts and occasionally engage in ritualistic behaviour, especially when we are under stress
- But very few of us develop OCD.
- as with panic disorder and post-traumatic stress disorder, one must develop anxiety focused on the possibility of having additional intrusive thoughts.

The repetitive, intrusive, unacceptable thoughts of OCD may well be regulated by the brain circuit
- However, the tendency to develop anxiety over having additional compulsive thoughts may have the same generalized biological and psychological precursors as anxiety in general

Why would people with OCD focus their anxiety on the occasional intrusive thought rather than on the possibility of a panic attack or some other external situation?
- One hypothesis is that early experiences taught them that some thoughts are dangerous and unacceptable because the terrible things they are thinking might actually happen and they would be responsible.
- The experiences would result in a specific psychological vulnerability to develop OCD. They learn this through the same process of misinformation
- Clients with OCD equate thoughts with the specific actions or activity represented by the thoughts. Rachman and his colleagues call this “thought-action fusion”
- Thought-action fusion may be caused by attitudes of excessive responsibility and resulting guilt developed during childhood where even a bad thought is associated with evil intent

Many people with OCD who believe in the tenets of fundamental religions, whether Christian, Jewish, or Islamic, present with similar attitudes of inflated responsibility and thought-action fusion.
- One study showed that the strength of religious belief, but not the type of belief, was associated with severity of OCD
- But, the vast majority of people with fundamental beliefs do not develop OCD.

But what if the most frightening thing in your life was a terrible thought that happened to pop into your head? You can’t avoid it as you would a snake, so you resist this thought by attempting to suppress it or neutralize it using mental or behavioural strategies such as distraction, praying, or checking.
- These strategies become compulsions, but they are doomed to fail in the long term because these strategies backfire and actually increase the frequency of the thought
- Christine Purdon at the University of Waterloo and David Clark at the University of New Brunswick have conducted a large body of research in this area. On the basis of their work and reviews of the literature, they conclude that there is indeed an association between attempted thought suppression and obsessional thinking
- Moreover, if someone appraises a given negative thought as unacceptable, that person will be motivated to try to suppress the thought

Generalized biological and psychological vulnerabilities must be present for OCD to develop.
- Believing some thoughts are unacceptable and therefore must be suppressed (a specific psycho- logical vulnerability) may put people at greater risk of OCD

Question 23

Treatment - Obsessive-Compulsive disorder

Answer 23

The effects of drugs on OCD have been evaluated extensively
- The most effective seem to be those that specifically inhibit the reuptake of serotonin, such as clomipramine or the SSRIs, which benefit up to 60% of patients with OCD, with no particular advantage to one drug over another.
- However, relapse frequently occurs when the drug is discontinued

Highly structured psychological treatments work somewhat better than drugs, but they are not readily available.
- The most effective approach is exposure and ritual prevention (ERP), a process whereby the rituals are actively prevented and the patient is systematically and gradually exposed to the feared thoughts or situations
- Usually, this can be done by simply working closely with patients to see that they do not wash or check.
- In severe cases, patients may be hospitalized and the faucets removed from the bathroom sink for a time to discourage repeated washing.
- No matter how the rituals are prevented, the procedures seem to facilitate “reality testing,” because the client soon learns, at an emotional level, that no harm will result whether he carries out the rituals or not.

More recent innovations to evidence-based psychological treatments for OCD have examined the efficacy of cognitive treatments with a focus on the overestimation of threat, the importance and control of intrusive thoughts, the sense of inflated responsibility present in patients with OCD who think they alone may be responsible for preventing a catastrophe, and the need for perfectionism and certainty present in these patients
- Initial results indicate that these strategies are effective, perhaps as effective as ERP.

Question 24

Body Dysmorphic Disorder

Answer 24

Some relatively normal-looking people think they are so ugly they refuse to interact with others or otherwise function normally for fear that people will laugh at their ugliness.
- This curious affliction is called body dysmorphic disorder (BDD), and at its centre is a preoccupation with some imagined defect in appearance by someone who actually looks reasonably normal
- The disorder has been referred to as “imagined ugliness”

For many years, BDD was considered a somatoform disorder because its central feature is a psychological preoccupation with somatic (physical) issues.
- But increasing evidence indicated it was more closely related to OCD, accounting for its relocation to the obsessive-compulsive and related disorders section in the DSM­5.
- For example, OCD often co-occurs with BDD and is found among family members of BDD patients
- There are other similarities. People with BDD complain of persistent, intrusive, and horrible thoughts about their appearance, and they engage in such compulsive behaviours as repeatedly looking in mirrors to check their physical features.
- BDD and OCD also have approximately the same age of onset and run the same course.
- One brain-imaging study demonstrated similar abnormal brain functioning between patients with BDD and patients with OCD

Question 25

Clinical description - Body Dysmorphic Disorder

Answer 25

The average number of body areas of concern to these individuals was 5 to 7
- In another group of adolescents with BDD, 61% focused on their skin and 55% on their hair
- A variety of checking or compensating rituals are common in people with BDD in attempts to alleviate their concerns.
- For example, excessive tanning is common, with 25% of one group of 200 patients tanning themselves in an attempt to hide skin defects
- Excessive grooming and skin picking are also common. Many people with this disorder become fixated on mirrors. They often check their presumed ugly feature to see whether any change has taken place. Others avoid mirrors to an almost phobic extent.
- Quite understandably, suicidal ideation, suicide attempts, and suicide itself are typical consequences of this disorder
- People with BDD also have “ideas of reference,” which means they think everything that goes on in their world somehow is related to them—in this case, to their imagined defect. This disorder can cause considerable disruption in the patient’s life.
- Many patients with severe cases become housebound for fear of showing themselves to other people.

For decades, this condition, previously known as dysmorphophobia (literally, fear of ugliness), was thought to represent a psychotic delusional state because the affected individuals were unable to realize, even for a fleeting moment, that their ideas were irrational.
- For example, in 200 cases examined by Phillips, Menard, Fay, and Weisberg and in 50 cases reported by Veale, Boocock, and colleagues, between 33% and 50% of participants were convinced their imagined bodily defect was real and a reasonable source of concern. Even though this lack of insight is also present in approximately 10% of patients with OCD, it is much higher in BDD based on direct comparisons of individuals with these two disorders

Phillips, Menard, Pagano, Fay, and Stout looked closely at differences that may exist between delusional and nondelusional types and found nothing significant, beyond the fact that the delusional type was more severe and found in less educated patients.
- It is also the case that these two groups both respond equally well to treatments for BDD and that the “delusional” group does not respond to drug treatments for psychotic disorders
- Thus, in the DSM­5, patients receive a BDD diagnosis whether they are “delusional” or not.

Diagnostic criteria for BDD:

A. Preoccupation with one or more defects or flaws in physical appearance that are not observable or appear slight to others.

B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.

C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Specify if:
- With muscle dysmorphia: The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.

Specify if:
Indicate degree of insight regarding body dysmorphic disorder
beliefs (e.g., “I look ugly” or “I look deformed”).
- With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.
- With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.
- With absent insight/delusional beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true.

Question 26

Statistics - Body Dysmorphic Disorder

Answer 26

The prevalence of BDD is hard to estimate because by its very nature it tends to be kept secret.
- The best estimates are that it is far more common than we had previously thought.
- Without some sort of treatment, it tends to run a lifelong course

Studies suggest that as many as 70% of college students report at least some dissatisfaction with their bodies, with 4% to 28% of these appearing to meet all the criteria for the disorder

Another study investigated the prevalence of BDD, specifically in an ethnically diverse sample of 566 adolescents between the ages of 14 and 19.
- The overall prevalence of BDD in this group was 2.2%, with adolescent girls more dissatisfied with their bodies than boys and black adolescents of both genders more satisfied with their bodies than Caucasians, Asians, and Hispanics

Overall, about 1% to 2% of individuals in community samples and from 2% to 13% of student samples meet criteria for BDD
- A somewhat higher proportion of individuals with BDD are interested in art or design compared with individuals without BDD, reflecting, perhaps, a strong interest in aesthetics or appearance

In mental health clinics, the disorder is also uncommon because most people with BDD seek other types of health professionals, such as plastic surgeons and dermatologists.
- BDD is seen equally in men and women.

In the larger series of 200 individuals reported by Phillips, Menard, Fay, and Weisberg, 68% were female, but 62% of a large number of individuals with BDD in Japan were males.
- Generally, there are more similarities than differences between men and women with BDD, but some differences have been noted
- Men tend to focus on body build, genitals, and thinning hair, and tend to have more severe BDD. A focus on muscle defects and body building is nearly unique to men with the disorder
- Women focus on more varied body areas and are more likely to also have an eating disorder.

Age of onset ranges from early adolescence through the 20s, peaking at the age of 16–17

Individuals are somewhat reluctant to seek treatment.
- In many cases, a relative will force the
issue, demanding the individual get help; this insistence may reflect the disruptiveness of the disorder for family members.
- Severity is also reflected in the high percentage (24%) of past suicide attempts among the 50 cases described by Veale, Boocock, and colleagues; 28% of the 200 cases described by Phillips, Menard, Fay, and Weisberg; and 21% of a group of 33 adolescents

One study of 62 consecutive outpatients with BDD found that the degree of psychological stress, quality of life, and impairment were generally worse than comparable indices in patients with depression, diabetes, or a recent myocardial infarction (heart attack) on several questionnaire measures
- BDD is among the more serious of psychological disorders, and depression and substance abuse are common consequences of BDD

Few people with this disorder get married.

For patients who could not afford surgery or were turned down for other reasons had attempted by their own hand to alter their appearance dramatically, often with tragic results.
- One example was a man preoccupied by his skin, who believed it was too “loose.” He used a staple gun on both sides of his face to try to keep his skin taut. The staples fell out after ten minutes and he narrowly missed damaging his facial nerve.
- In a second example, a woman was preoccupied by her skin and the shape of her face. She filed down her teeth to alter the appearance of her jawline.
- Yet another woman who was preoccupied by what she perceived as the ugliness of multiple areas of her body and desired liposuction, but could not afford it, used a knife to cut her thighs and attempted to squeeze out the fat.

BDD is also stubbornly chronic. In a prospective study of 183 patients, only 21% were somewhat improved over a year, and 15% of that group relapsed during that year

The behaviour of individuals with BDD seems remarkably strange because they go against current cultural practices that put less emphasis on altering facial features.
- In other words, people who simply conform to the expectations of their culture do not have a disorder.
- Nevertheless, aesthetic plastic surgery, particularly for the nose and lips, is still widely accepted and, because it is most often undertaken by the wealthy, carries an aura of elevated status.
- In this light, BDD may not be so strange.
- As with most psychopathology, its characteristic attitudes and behaviour may simply be an exaggeration of normal culturally sanctioned behaviour.

Question 27

Causes and treatment - Body Dysmorphic Disorder

Answer 27

We know little about the etiology of BDD specifically.
- There is almost no information on whether it runs in families, so we can’t investigate a specific genetic contribution.
- Similarly, there is no meaningful information on biological or psychological predisposing factors or vulnerabilities.
- Psychoanalytic speculations are numerous, but most centre on the defensive mechanism of displacement—that is, an underlying unconscious conflict would be too anxiety-provoking to admit into consciousness, so the person displaces it onto a body part.

What little evidence we do have on etiology comes from the pattern of comorbidity of BDD with OCD described earlier.
- The marked similarities to OCD suggest, perhaps, some-what similar patterns of etiology.
- Approximately 15% of a series of 100 patients with eating disorders suffered from comorbid BDD, with their body dysmorphic concerns
unrelated to weight and shape

Perhaps more significantly, there are 2, and only 2, treatments for BDD with any evidence of effectiveness, and these treatments are the same found effective in OCD:

First, drugs that block the reuptake of serotonin, such as clomipramine (Anafranil) and fluvoxamine (Luvox), provide relief to at least some people.
- clomipramine was significantly more effective than desipramine, a drug that does not specifically block reuptake of serotonin, for the treatment of BDD, even BDD of the delusional type
- For fluoxetine (Prozac), with 53% showing a good response compared with 18% on placebo after three months
- Intriguingly, these are the same drugs that have the strongest
effect in OCD.

Second, exposure and response prevention, the type of cognitive-behavioural therapy effective with OCD, has also been successful with BDD
- 82% of patients treated with this approach responded
- Furthermore, patients with BDD and OCD have similar rates of response to these treatments
- As with OCD, cognitive-behavioural therapy tends to produce better and longer lasting outcomes compared with medication alone. But CBT is not as readily available as drugs.

Another interesting lead on causes of BDD comes from cross-cultural explorations of similar disorders.
- You may remember the Japanese variant of social anxiety disorder, taijin kyofusho, in which individuals may believe they have horrendous bad breath or body odour and thus avoid social interaction. But people with taijin kyofusho also have all the other characteristics of social anxiety disorder. Patients who would be diagnosed with BDD in our culture might simply be considered to have severe social anxiety in Japan and Korea. Possibly, then, social anxiety is fundamentally related to BDD, a connection that would give us further hints on the nature of the disorder.
- Indeed, a recent study of BDD in Western countries indicates that concerns relating to perceived negative evaluation of their appearance by others is every bit as important as self-evaluation of the imagined defects in appearance
- Studies of comorbidity indicate that social anxiety disorder, along with OCD, is also commonly found in people with BDD

Question 28

Plastic Surgery and Other Medical Treatments - Body Dysmorphic Disorder

Answer 28

Patients with BDD believe they are physically deformed in some way and go to medical doctors to attempt to correct their deficits
- 76% had sought this type of treatment and 66% were receiving it.
- Dermatology (skin) treatment was the most often received (45%), followed by plastic surgery (23%).

In one study of 268 patients seeking care from a dermatologist, 12 percent met criteria for BDD

Because the concerns of people with BDD involve mostly the face or head, it is not surprising that the disorder is big business for the plastic surgery profession—but it is bad business.
- These patients do not benefit from surgery and may return for additional surgery or, on occasion, file malpractice lawsuits.

Investigators estimate that as many as 8% to 25% of all patients who request plastic surgery may have BDD
- The most common procedures are rhinoplasties (nose jobs), facelifts, eyebrow elevations, liposuction, breast augmentation, and surgery to alter the jawline.

Between 2000 and 2012, according to the American Society of Plastic Surgeons (2012), the total number of cosmetic procedures increased by 98%.

The problem is that surgery for individuals with BDD seldom produces the desired results.
- These individuals return for additional surgery on the same defect or concentrate on some new defect.
- Phillips, Menard, Fay, and Pagano reported that 81% of 50 individuals seeking surgery or similar medical consults were dissatisfied with the result.

In 88% of a large group of people with BDD seeking medical rather than psychological treatment, the severity of the disorder and accompanying distress either did not change or increased after surgery.

It is important that plastic surgeons screen out these patients; many do so by collaborating with medically trained psychologists

Question 29

Hoarding Disorder

Answer 29

Compulsively hoard things, fearing that if they throw something away, they then might urgently need it. Unliveable homes.
- First assumed to be a variant of OCD

Estimates of prevalence range between 2% and 5% of the population, which is twice as high as the prevalence of OCD, with nearly equal numbers of men and women, and is found worldwide

The 3 major characteristics of this problem are excessive acquisition of things, difficulty discarding anything, and living with excessive clutter under conditions best characterized as gross disorganization

It is not uncommon for some patients’ houses and yards to come to the attention of public health authorities
- Although only a tiny percentage of fires in residences occur in the homes of individuals who hoard, these fires account for 24% of all fire-related fatalities

These individuals usually begin acquiring things during their teenage years and often experience great pleasure, even euphoria, from shopping or otherwise collecting various items.
- Shopping or collecting things may be a response to feeling down or depressed and is sometimes called, facetiously, “retail therapy.”
- But unlike most people who like to shop or collect, these individuals then experience strong anxiety and distress about throwing anything away because everything has either some potential use or sentimental value in their minds, or simply becomes an extension of their own identity.
- Their homes or apartments may become almost impossible to live in.
- Most of these individuals don’t consider that they have a problem until family members or authorities insist that they seek help.

As with OCD, the extent of insight that the patients have about the problematic status of their hoarding problem is specified when making the diagnosis.
- The average age when these people come for treatment is approximately 50 years old, after many years of hoarding

Often they live alone

Careful analysis of what we know about hoarding suggests it has similarities and differences with both OCD and impulse control disorders.
- Therefore, it is best considered a separate disorder and now appears as such in the DSM­5.

OCD tends to wax and wane, whereas hoarding behaviour can begin early in life and get worse with each passing decade

Cognitive and emotional abnormalities associated with hoarding alluded include extraordinarily strong emotional attachment to possessions, an exaggerated desire for control over possessions, and marked deficits in deciding when a possession is worth keeping or not (all possessions are believed to be equally valuable).
- there are specific differences in areas of the brain related to problems identifying the emotional significance of an object and generating the appropriate emotional response

People who hoard animals compose a special group that is now being investigated more closely.
- Occasionally, articles appear in newspapers describing homes occupied by one owner, usually a middle-aged or older woman, and 30 or more animals— often cats. Sometimes, some of them will be dead, either lying on the floor out in the open or stored in the freezer.
- In addition to owning an unusually large number of animals, animal hoarders are characterized by the failure or inability to care for the animals or provide suitable living quarters, which results in threats to health and safety because of unsanitary conditions associated with accumulated animal waste
- Individuals in some studies were mostly middle-aged white women. While both studies expressed strong caretaking roles and a particularly intense love for and attachment to animals, the hoarding group was characterized by attribution of human characteristics to their animals, the presence of more dysfunctional current relationships (with other people), and significantly greater mental health concerns.
- Much like other individuals with hoarding, animal hoarders typically have little or no realization that they have a problem, despite often living in unsanitary conditions with dead and sick animals.

CBT is a promising treatment for hoarding disorder
- These treatments for hoarding teach people to assign different values to objects and to reduce anxiety about throwing away items that are somewhat less valued
- Preliminary results of CBT are promising, but results are more modest than those achieved with OCD.
- Also, more information on long-term effects of these treatments is needed.
- Little or nothing is known about effective interventions for individuals who hoard animals.

Question 30

Trichotillomania and Excoriation Disorder

Answer 30

The urge to pull out one’s own hair from anywhere on the body, including the scalp, eyebrows, and arms, is referred to as trichotillomania.
- This behaviour results in noticeable hair loss, distress, and significant social impairments.
- This disorder can often have severe social consequences, and, as a result, those affected can go to great lengths to conceal their behaviour

Compulsive hair pulling is more common than once believed and is observed in between 1% and 5% of college students, with females reporting the problem more than males

There may be some genetic influence on trichotillomania, with one study finding a unique genetic mutation in a small number of people

Excoriation (skin-picking disorder) is characterized, as the label implies, by repetitive and compulsive picking of the skin, leading to tissue damage
- Many people pick their skin on occasion without any serious damage to their skin or any distress or impairment, but for somewhere between 1% and 5% of the population, noticeable damage to skin occurs, sometimes requiring medical attention.
- There can be significant embarrassment, distress, and impairment in terms of social and work functioning.
- Excoriation is also largely a female disorder.

Before the DSM­5, both disorders were classified under impulse-control disorders, but it has been established that these disorders often co-occur with OCD and BDD, as well as with each other
- For this reason, all of these disorders, which share repetitive and compulsive behaviours, are now grouped together under obsessive- compulsive and related disorders in the DSM­5.
- Nevertheless, significant differences exist. For example, individuals with BDD may pick at their skin occasionally to improve their appearance, which is not the case for individuals with skin-picking disorder.

Until recently, it was assumed that the repetitive behaviours of hair pulling and skin picking function to relieve stress or tension.
- While this seems to be the case for many patients, a substantial number of individuals do not engage in this behaviour to relieve tension and do not show evidence of tension relief.
- For this reason, diagnostic criteria referring to tension relief, present in the DSM­IV, have been removed in the DSM­5

Psychological treatments, particularly an approach called “habit reversal training,” has the most evidence for success with these two disorders.
- In this treatment, patients are carefully taught to be more aware of their repetitive behaviour, particularly as it is just about to begin, and to then substitute a different behaviour, such as chewing gum, applying a soothing lotion to the skin, or some other reasonably pleasurable but harmless behaviour.
- Results may be evident in as little as 4 sessions, but the procedure requires teamwork between the patient and therapist and close monitoring of the behaviour throughout the day (

Drug treatments, mostly serotonin-specific reuptake inhibitors, hold some promise, particularly for trichotillomania
- but the results have been mixed with excoriation