EXAM 2 - Somatic Symptom and RelatedDisorders and Dissociative Disorders

Question 1

Somatic symptom disorders

Answer 1

excessive or maladaptive response to physical symptoms or health concerns

Question 2

DSM-5 Criteria: Somatic Symptom Disorder

Answer 2

A. One or more somatic symptoms that are distressing and/or result in significant disruption of daily life.
B. Excessive thoughts, feelings, and behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. High level of health-related anxiety.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Specify if: With predominant pain (previously pain disorder): This specifier is for individuals whose somatic complaints predominantly involve pain.
Specify current severity: Mild: Only one of the symptoms in Criterion B is fulfilled.
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).
From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Question 3

Somatic Symptom Disorder - Statistics

Answer 3

Statistics
Relatively rare condition
Onset usually in adolescence
More likely to affect unmarried, low SES women
Runs a chronic course

Question 4

Ilness Anxiety Disorder very similar to DSM 4 Hypochondriasis

Answer 4

Severe anxiety about the possibility of having or acquiring a serious disease
Actual symptoms are either very mild or absent
Strong disease conviction
Medical reassurance does not seem to help

Question 5

DSM-5 Criteria: Illness Anxiety Disorder

Answer 5

A. Preoccupation with fears of having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctors’ appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, generalized anxiety disorder, or obsessive-compulsive disorder.
Specify whether: Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used. Care-avoidant type: Medical care is rarely used. From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

Question 6

Statistics on Illness Anxiety Disorder

Answer 6

Affects approximately 1-7% of the general population
Affects all ages approximately equally
Often comorbid with anxiety and mood disorders

Question 7

Causes of Somatic Symptom Disorders

Answer 7

Consistent overreaction to physical signs and sensations
Cause is unlikely to be found in isolated biological or psychological factors
Genetic component is likely present (they run in families)
May have learned from family to focus anxiety on physical sensations

Question 8

Psychological Causes for Somatic Symptoms Disorders

Answer 8

Individuals with these diagnoses amplify somatic symptoms
They have a defect in expressing emotions signaled physiologically
They engage in misattributions of normal somatic symptoms
They are reinforced for physical symptoms

Question 9

Causes of Somatic Symptom Disorders

Answer 9

Three additional factors that may contribute to etiology
Stressful life events
Illness in family during childhood
Benefits of illness (e.g., sympathy, attention)

Question 10

Somatic Symptom Disorder and Antisocial Personality Disorder

Answer 10

Findings from family and genetic studies: Link between severe forms of somatic symptom disorder and antisocial personality disorder
Shared features
Often begin early in life
Chronic and difficult to treat
More common in lower SES
Linked to substance abuse and interpersonal problems
ASPD much more common in males
SSD more common in females
Shared feature: disinhibition/impulsivity
Individuals with somatic symptom disorder impulsively seek sympathy and other benefits of illness
Different manifestations of impulsivity
Somatic symptom disorder: Dependence
Antisocial personality disorder: aggression

Question 11

Treatment for Somatic Symptom Disorders

Answer 11

Mild cases of illness anxiety disorder may benefit from detailed education and some reassurance from medical professionals
Consider the use of exposure and response prevention (reduce avoidance due to pain or other uncomfortable physical sensations)
Cognitive behavioral therapy can effectively treat illness anxiety disorder (e.g., functional pain programs)

Question 12

Conversion Disorder

Answer 12

Altered motor or sensory function that is inconsistent with neural/medical conditions and not better explained by another disorder
Often suggestive of neurological problem, but no such problem is detected
Must cause significant distress/impairment

Question 13

DSM-5 Criteria Summary: Conversion Disorder

Answer 13

A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Question 14

Conversion Disorder

Answer 14

Rare condition, with a chronic intermittent course
Often comorbid with anxiety and mood disorders
Seen primarily in females
Onset usually in adolescence
Common in some cultural and/or religious groups

Question 15

Conversion Disorder: Causes

Answer 15

Primary/secondary gains
Freud thought primary gain was the escape from dealing with a conflict
Secondary gains: Attention, sympathy, etc.
Sociocultural factors
More common in lower education, lower SES
Patients likely to adopt symptoms with which they are already familiar

Question 16

Conversion Disorder: Treatment

Answer 16

If onset after a trauma, may need to process trauma or treat posttraumatic symptoms
Remove sources of secondary gain
Reduce supportive consequences of talk about physical symptoms

Question 17

Factitious Disorders

Answer 17

Purposely faking physical symptoms
May actually induce physical symptoms or just pretend to have them
No obvious external gains
Only external gain may be benefit of “sick role” (e.g., sympathy)
Distinguished from malingering, in which physical symptoms are faked for the purpose of achieving a concrete objective (e.g., getting paid time off, avoiding military service)

Question 18

DSM-5 Criteria Summary: Factitious Disorder

Answer 18

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 disorder such as delusional belief system or acute psychosis.
Specify if: Single episode
Recurrent episodes:Two or more events of falsification of illness and/or induction of injury.

Question 19

Factitious Disorder Imposed on Another

Answer 19

More commonly known as Munchausen syndrome by proxy
Inducing symptoms in another person
Typically a caregiver induces symptoms in a dependent (e.g. child)
Purpose = receive attention or sympathy

Question 20

Depersonalization/Derealization Disorder

Answer 20

Recurrent episodes in which a person has sensations of unreality of one’s own body or surroundings
Feelings dominate and interfere with life functioning
Only diagnosed if primary problem involves depersonalization and derealization
Similar symptoms may occur in the context of other disorders, including panic disorder and PTSD

Other features
Cognitive deficits in attention, short-term memory, spatial reasoning
Easily distractible
Difficulty absorbing new information
Reduced emotional responding
May have dysregulation of the HPA axis in brain

Question 21

Diagnostic Criteria for Depersonalization- Derealization Disorder

Answer 21

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both: Depersonalization: Experiences of unreality, detach-ment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealization experience, reality testing remains intact.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medica-tion) or another medical condition (e.g., seizures).
E. The disturbance is not better explained by another mental disorder, such as schizophrenia or panic disorder.

Question 22

Dissociative Amnesia

Answer 22

Includes several forms of psychogenic memory loss
Generalized vs. localized or selective type
May involve dissociative fugue
During the amnestic episode, person travels or wanders, sometimes assuming a new identity in a different place
Unable to remember how or why one has ended up in a new place

Question 23

DSM-5 Criteria: Dissociative Amnesia

Answer 23

A. An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, or other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.
Specify if: With dissociative fugue: Apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information.

Question 24

Dissociative Amnesia and Fugue - Statistics

Answer 24

Prevalence: 2-7%
Usually begin in adulthood
Rarely appear in childhood or late adulthood
Show rapid onset and dissipation
Causes
Little is known
Trauma and stress can serve as triggers
Most recover/remember without treatment

Question 25

Dissociative Trance

Answer 25

Presentation varies across cultures
Nigeria – called vinvusa
Thailand – called phii pob
Dissociative symptoms and sudden changes in personality
Change may be attributed to possession by a spirit
Only considered a disorder if leads to distress or impairment

Question 26

Dissociative Identity Disorder (DID)

Answer 26

Clinical description
Formerly known as multiple personality disorder
Defining feature is dissociation of personality
Adoption of several new identities (as many as 100; may be just a few; average is 15)
Identities display unique behaviors, voice, and postures

Question 27

DSM-5 Criteria: Dissociative Identity Disorder

Answer 27

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption of marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not attributable to imaginary playmates
or other fantasy play.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Question 28

Dissociative Identity Disorder (DID)

Answer 28

Alters – different identities or personalities
Host – the identity that keeps other identities together
Switch – quick transition from one personality to another

Question 29

Controversy: Can DID be Faked?

Answer 29

Some patients presenting with DID symptoms are faking (possibly subconsciously)
Example: Patients more likely to “produce” a fake alter when therapist suggests this possibility
Some DID patients are not faking
Case studies reveal changes in physiological and brain function when switching between alters
Do you think this proves they are not faking?

Question 30

Causes of Dissociative Identity Disorder

Answer 30

Typically linked to a history of severe, chronic trauma, often abuse in childhood (75% of cases have this history)
Risk increases if there is no social support after the trauma
Mechanism: Dissociation offers an opportunity to escape from the impact of trauma
Closely related to PTSD, possibly an extreme subtype
Biological vulnerability possible but not well understood; almost all risk is environmental

Question 31

Treating Dissociative Identity Disorder

Answer 31

Focus is on reintegration of identities
Identify and neutralize cues/triggers that provoke memories of trauma/dissociation
Patient may have to relive and confront the early trauma

Question 32

Features of somatic symptom disorders

Answer 32

Physical concerns without a clear medical cause

well established treatments are generally lacking

Question 33

Features of dissociative disorders

Answer 33

Extreme distortions in perception and memory

well established treatments are generally lacking