Chapter 5: Somatoform and Dissociative Disorders (focus on somatoform disorders)

Somatoform Disorders (soma means body) refer to pathological concerns of individuals with the appearance of functioning of their bodies, usually in the absence of any identifiable medical condition.

Types and Characteristics of Somatoform Disorders.

1) Hypochondriasis

Definition: Somatoform disorder involving severe anxiety over the belief that one has a disease process without any evident physical cause.

Clinical Descripion:
- Usually comorbid with anxiety and mood disorders, panic disorder in particular.
- Preoccupation with bodily symptoms, misinterpreting them as indicative of illness or disease (eg. Increase in heart rate and perspiration indicates heart attack and headache indicates brain tumour).
- Preoccupation persists despite appropriate medical evaluation and reassurance.
- Distinction from illness phobia: individuals have marked fear of developing a disease. Hypochondriacs have high disease conviction. Illness phobic individuals have lower rates of checking behaviours and trait anxiety and earlier age of onset.
- Illness phobics can later on develop hypochondriasis and panic disorder.

Statistics:
- Prevalence is unclear: 1%-14%. Recent studies show 3%.
- Sex ratio is 50-50.
- Onset is possible at any time of life, with peak periods in adolescence, 40s and 50s and after 60s.
- Culture-specific syndromes such as koro (belief, accompanied by severe anxiety and panic that genitals are retracting into abdomen, common in Chinese cultures) and dhat (anxious concern about losing semen, common in India).

Etiology:
- Cognitive and perception distortion.
- Vicious cycle: increase focus on self increases arousal and makes physical sensations more intense than they are. With further misinterpretation as illness, anxiety is increased with additional physical symptoms.
- Better safe than sorry: restrictive concept of heath as being totally symptom free.
- Tendency to overrespond to stress, view life negatively and hence, importance of being guarded.
- Learned from family members.
- Stressful life event and memories of illness by family members.
- Secondary gain of increased attention.

Treatment:
- Cognitive-behavioral therapy (CBT)
- General stress management
- Effective and sensitive reassurance form mental health professionals (as opposed to family doctors).
- Antidepressants (for anxiety and depression).

2) Somatization Disorder (Briquet’s Symdrome)

Definition: Somatoform disorder involving extreme and long lasting focus on multiple physical symptoms for which no medical cause is evident.

Clinical Description:
- History of many physical complaints beginning before 30 that occur over the years, resulting in treatment being sought or significant impairment in important areas of functioning.
- Physical complaints cannot be fully explained by a known medical condition or effects of substance (medication or drug abuse).
- Complaints and impairment are not malingered.

Statistics:
- 8 symptoms required for DSM-IV diagnosis (but usually fewer than eight, ie. 4-6).
- Onset begins early in life.
- Chronic course.
- Greater tendency for single women from lower socioeconomic groups.
- Sex ratio for somatic complaints are uniform but that of somatic disorder is approximately 2:1 female.

Etiology:
- Strongly linked to antisocial personality disorder (from family and genetic studies).
- Associated with marital discord, drug and alcohol abuse, suicide attempts etc.
- Learned in a maladaptive family setting.
- Impulsive behaviour with aims at secondary gains of attention, but usually ignored eventually.
- Pleasure seeking and desire short term gratification (eg. provocative sexual behaviour).
- Sociocultural factors: strong degree of dependence in women as opposed to men (possibly as a result of socialization of gender roles).

Treatment:
- No treatment with proven effectiveness as of now.
- Possible to concentrate on providing reassurance, reducing stress and frequency of help-seeking behaviours.
- CBT and antidepressants.

3) Conversion Disorder

Definition: Physical malfunctioning, such as blindness or paralysis, suggesting neurological impairment but with no organic pathology to account for it.

It was backed by strong Freudian beliefs that anxiety resulting from unconscious conflicts somehow was “converted” into physical symptoms to find expression (displacement defense mechanism).

Clinical description:
- Physical malfunctioning such as blindness, paralysis and aponia (difficulty in speaking), total mutism (refusal/inability to speak), loss of sense of touch, seizures, globus hystericus (sensation of lump in throat which inhibits swallowing, eating and speech) etc.
- La belle indifference (to distinguish from malingering).
- Precipitated by marked stress.
- Can usually function normally but unaware of the ability or sensory input.
- Misdiagnosis of physical problems for conversion disorder (5-10%).
- Factitious disorder: non existent physical or psychological disorder deliberately faked for no apparent gain except possibly sympathy and attention.
- Factitious disorder or Munchausen syndrome by proxy: when an individual deliberately makes someone sick.

*To distinguish between real unconscious process and malingering, people with conversion disorders are usually able to perform well on tasks requiring the use of their supposedly impaired body functions under, perhaps, hypnosis where they are dissociated from their awareness. Malingerers usually perform poorly, especially those with factitious disorders who would probably do everything at all costs to prove their impairment.

Statistics:
- Commonly comorbid with anxiety and mood disorders.
- Prevalence vary from 1%-30%.
- Found primarily in women.
- Onset typically during adolescence and slightly after.
- Frequent in males under extreme stress (eg. soldiers exposed to combat).
- Occur in less educated, lower socioeconomic groups.
- In some cultures, such symptoms are common aspects of religious or healing rituals and even seen as contact with God. In these cases, they would not meet the criteria as a disorder since it is culturally accepted and seemingly does not interfere with the individual’s functioning.

Etiology:
- Psychanalytic view: individual experiences a traumatic event which represents an unccepted and unconscious conflict, hence repressed. As anxiety increases and threatens to emerge into consciousness, the person converts it into physical symptoms, so direct dealing with the conflict can be avoided. Such reduction of anxiety is considered the primary gain or reinforcing even that maintains the conversion symptom.
- Major mood disorders and environmental stress, especially sexual abuse.
- Learned from family members with such disorder (secondary gain).

Treatment:
- Carthasis: to recall and relive emotional trauma that has been made unconscious and to release the accompanying tension (chapter 1).
- Treatments as used in somatization disorder.
- Reduce reinforcing or supportive consequences of conversion symtoms, especially the secondary gains.

4) Pain disorder

Definition: Somatoform disorder featuring true pain but for which psychological factors play an important role in onset, severity or maintenance.

Clinical description:
- Pain is real and hurts, regardless of causes.
- Presence of pain in one or more anatomical sites.
- Causes significant distress or impairment in functioning.
- Psychological factors judged to play primary role in onset, severity, exacerbation (worsening of symptoms) or maintenance of the pain.
- Pain is not malingered.

More on causes and treatment in chapter 7.

5) Body Dysmorphic Disorder (BDD)

Definition: Somatoform disorder featuring a disruptive preoccupation with some imagined defect in appearance.

Clinical description:
- Preoccupation with imagined defect in appearance.
- Eg. fixation on mirrors or phobia of mirrors.
- Suicide attempts as common consequences of disorder.
- Ideas of reference: perception that everything that goes on in their world is somehow related to them, ie. their imagined defect.
- Similar to OCD (obsessive-compulsive disorder), individuals with BDD believe that their imagined bodily defect is a real and reasonable source of concern (delusional? Remains controversial till now).

Statistics:
- Prevalence is hard to estimate because BDD patients usually attempt to keep it secret.
- Life-long course without treatment.
- Onset ranges from early adolescence through the 20s, peaking at 18 or 19.
- Most people with BDD seek help from plastic surgeons and dermatologists.
- High percentage of suicide attempts.

Etiology:
- Little is known, but it tends to run in families.
- Comorbid with OCD (similar age of onset and course).

Treatment:
- Drugs that block the reuptake of serotonin.
- CBT: exposure and response prevention.
- Generally similar to treatments of OCD.
- Plastic surgery, but severity of disorder and distress is usually increased after which.