Somatic Symptom and Somatic Symptom and Related Dissociative Disorders Disorders Tiffany Daniels, M.S. Somatic Symptom and Related Somatic Symptom and Related Disorders Disorders • All of the disorders in this category (DSM-5 • Somatic Symptom Disorders can also Chapter) share a common feature: the accompany diagnosed medical disorders. prominence of somatic symptoms associated with significant distress and impairment. • When genuine medical conditions are present, the person’s reaction is in excess of what would • Individuals with these disorders are commonly typically be expected. encountered in primary care and other medical settings but are less commonly encountered in mental health settings. Distinguishing Somatic Symptom Distinguishing Somatic Symptom from Other Stuff from Other Stuff • Do you recall from PSY2012 the other name • In contrast, Psychosomatic-Actual physical for the cell body of a neuron? illness in which psychological factors • Soma = Body contribute (e.g., hypertension where anxiety • So to help you remember….somatic and stress eating make the symptoms symptom disorders are those involving the worse). body 1 Somatic Symptom Disorder Somatic Symptom Disorder 1. Disproportionate and persistent thoughts about • A person with Somatic Symptom Disorder the seriousness of one’s symptoms. has one or more somatic complaints that are distressing and result in significant disruption of 2. Persistently high level of anxiety about health daily life. or symptoms. 3. Excessive time and energy devoted to these symptoms or health concerns. • Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by AT LEAST • Although any one somatic symptom may not one of the following: be continuously present, the state of being symptomatic is persistent (typically more than 6 months). Somatic Symptom Disorder • There is often a high level of medical care utilization, which rarely alleviates the individual’s concerns. • Consequently, the patient may seek care from multiple doctors for the same symptoms. • These individuals often seem unresponsive to • People who complain primarily of pain are medical interventions, and frequently feel as given a diagnosis of Somatic Symptom though their medical assessment and treatment Disorder With Predominant Pain. have been inadequate. Somatic Symptom Disorder Causes of Somatic Symptom • Prevalence may be around 5-7%, females Disorder >males. • More frequent in individuals with few years of • A cognitive theory of Somatic Symptom education and low SES and in those who Disorder suggests that persons with these have recently experienced stressful life disorders tend to experience bodily events. sensations more intensely than other people, pay more attention than others to their • Presentation varies by culture. physical symptoms, and catastrophize their • Associated with high rates of comorbidity symptoms. with medical disorders as well as anxiety and depressive disorders. 2 Treatments for Somatic Symptom Illness Anxiety Disorder Disorder • The primary distinction between Illness Anxiety Disorder (formerly known as • Explaining to people that they have a Somatic Hypochondriasis) and Somatic Symptom Symptom Disorder is not easy. Disorder is that people with Illness Anxiety Disorder WORRY excessively that they have a • SSRI’s have some benefit. serious illness, but actual somatic symptoms are not present or, if present, are only mild in intensity. • Chronic Pain Rehabilitation Programs • Not easily treatable, and hard to convince people with this disorder that their problems are caused by psychological factors. Illness Anxiety Disorder Illness Anxiety Disorder • Has a Care-Seeking Type and Care-Avoidant Type • Prevalence rate not completely clear since diagnosis has changed since DSM-IV-TR, with a lot of people (75%) previously diagnosed with Hypochondriasis now not better fitting Somatic Symptom Disorder rather than Illness Anxiety Disorder. Could be between 1.3% and 10%. • Woody Allen’s characters in almost every • Significant cultural variance. movie (though Hannah and Her Sisters would probably be the best example) often appear to have Illness Anxiety Disorder. Causes of Illness Anxiety Disorder Treatment of Illness Anxiety Disorder • Faulty interpretation of physical signs & sensations • Reassurance and education regarding the • Heightened arousal & attention to every little true meaning of bodily sensations is effective sensation in the body can create anxiety, • CBT that focuses on challenging illness- which can create more bodily sensations… related misinterpretations and showing it’s a vicious cycle patients how they are creating symptoms by • Runs in families, can be a learned response, focusing attention on specific body areas can develop in response to stressful life • Antidepressants such as Paxil (an SSRI) events, can develop as a need for increased shown to be effective attention in one’s life 3 Treatment of Illness Anxiety Conversion Disorder Disorder • In a study conducted by Greeven and • People with conversion disorder (also known colleagues (2007), 45% of patients as Functional Neurological Symptom Disorder) responded to CBT, 30% to Paxil, and have one or more symptoms of altered 14% to Placebo. voluntary motor or sensory functioning • Thoughts on prescribing meds to those with Illness Anxiety Disorder?? • Clinical findings provide evidence of • Do you think IAD patients respond to incompatibility between the symptom and placebo at a greater rate than the general recognized neurological or medical conditions. population? Conversion Disorder Conversion Disorder • Glove anesthesia- Unique example of a • Prevalence unknown, though approximately 5% Conversion Disorder in which people lose all of referrals to neurology clinics qualify for this sensory feeling in only one hand. diagnosis. • Psychogenic Non-Epileptic Seizures • 2-3 times more common in females. • Other examples can include weakness • Changes resembling Conversion Disorder are (paresis), paralysis, abnormal movements (e.g., common in certain culturally sanctioned rituals. tremor, dystonia, myoclonus, gait disturbance), swallowing symptoms (dysphagia), speech • Anxiety Disorders, ESPECIALLY Panic symptoms (e.g, dysphonia, slurring), other Disorder, and depressive disorders commonly forms of anasthesia or sensory loss. co-occur with Conversion Disorder. Diagnosis Example: Andria • For a Conversion Disorder to be diagnosed, it must be demonstrated definitively that the From left to • A good friend of mine was involved right: Patrick, symptoms of such disorders are not Andria, and Me consistent with medical pathophysiology. in an accident where, during surgery, an inadequately • A difficult, often overdiagnosed disorder. anesthetized horse she was • Many doctors falsely presume that because operating on bucked and kicked her, they (or current science) can’t figure out knocking her backwards, where she what’s wrong with you, it must be slammed her head into a set of psychological. double doors. Shortly after the event, she began having seizures. 4 Example: Andria Example: Andria • Doctors could initially find no evidence (such • Another (presumably more qualified) as brain damage) that would be causing her neurologist performed a full workup on her, seizures, and one doctor suggested that she including 24 hour epilepsy monitoring, and had conversion disorder. He also told her did in fact find her seizures to be epileptic in that she was latently homosexual and would nature, of a generalized, and consistent with need years of therapy to cope with these the damage caused by her accident. facts (sounds pretty psychoanalytic, huh?) • Moral of the story: Tread lightly before diagnosing conversion disorder! Causes of Conversion Disorder Causes of Conversion Disorder, according to our dear friend, Freud Freud cont. • 3) The anxiety continues to increases, • According to Freud, 4 Basic threatening to emerge into consciousness, Processes lead to the development thus the person “converts” it into physical of conversion disorder: symptoms, reducing the anxiety & pressure of • 1) Individual experiences traumatic having to deal with the conflict (primary gain) event • 4) The individual receives greatly increased • 2) Because the conflict and attention and sympathy from loved ones and resulting anxiety are unacceptable, may also be allowed to avoid a difficult the person represses the conflict, situation or task (secondary gain) making it unconscious Other Potential Causes of Other Potential Causes of Conversion Disorder Conversion Disorder • Social & cultural influences also contribute • For example, CD tends to occur among • Behaviorists would say that prior experience individuals who are less educated, and come with real physical problems can lead to CD from lower socioeconomic status groups where knowledge about disease & medical • Biological vulnerability; there is a connection illness not well developed between the amygdala & conversion disorder, more research needed 5 Treatment of Conversion Disorder Distinguishing Somatoform from Other Stuff • Behavioral treatments focus on relieving the person’s anxiety around the initial trauma • Malingering- Deliberate faking of physical that caused the conversion symptoms and symptoms for SECONDARY GAIN, such as on reducing any benefits the person is avoidance of military service, criminal receiving from the conversion symptoms. prosecution, or trying to get money from an insurance company. • Factitious Disorders- Deliberate faking