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A Brief Lecture on Somatic and Dissociative Disorders by DSM-5, NIMH, NIH and SAMHSA

 

Introduction to Abnormal Psychology and Life

Perspectives on Abnormal Psycholog

Risk and Prevention of Psychological Disorders

Diagnosis and Assessment of Psychological Disorders

Anxiety, Obsessive-Compulsive, and Trauma-Related Disorders

Somatic Symptom and Dissociative Disorders

Depressive and Bipolar Disorders

Eating Disorders

Substance-Related Disorders

Personality Disorders

Sexual Dysfunctions

Schizophrenia and Other Psychotic Disorders

Developmental and Disruptive Behavior Disorders

 
 
 

Description of Somatic and Related Disorders

Causes of Somatic and Related Disorders

Treatments for Somatic and Related Disorders

 

Description of Dissociative Disorders

Types of Dissociative Disorders

Causes of Dissociative Disorders

Treatment for Dissociative Disorders

 
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Somatic Disorders

Some of the somatic and related disorders listed in the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5, 2013) include the somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder. Significant impairment and distress in relation to prominent somatic symptoms are the common features of these disorders.

 
 
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Somatic Symptom Disorder

Individuals diagnosed with somatic symptom disorder complain of one or more physical symptoms that may or may not be explained through medical examinations. In response to the physical symptoms, the individual experiences high levels of anxiety, ruminates about their seriousness, and wastes significant time and energy. These symptoms are authentic and not intentionally produced (DSM-5, 2013). According to DSM-5 (2013), diagnostic criteria for somatic symptom disorder are:

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.

B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

  • Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
  • Persistently high level of anxiety about health or symptoms.
  • Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

 
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Illness Anxiety Disorder

Individuals diagnosed with illness anxiety disorder experience excessive worry about having or acquiring a serious illness. Characteristics associated with illness anxiety disorder last for at least six months and may include: bodily symptoms that are either absent or present in mild form, preoccupation with health and health related behaviors (such as checking one's body for lumps and tumors), and easily alarmed (DSM-5, 2013).  The individual’s anxiety about a suspected diagnosis is more troublesome than the actual physical symptoms of illness. If a medical diagnosis is present, the individual’s anxiety is disproportionate and excessive, in comparison to the severity of medical diagnosis. According to DSM-5 (2013), diagnostic criteria for illness anxiety disorder are:

A. Preoccupation with 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 doctor 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, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

 
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Factitious Disorders

Factitious disorder features the falsification of psychological or medical signs and symptoms in relation to the identified deception. These deceptions can be imposed on oneself or others. Fabrication, exaggeration, induction, and simulation can be included in the falsification, and there are no obvious external rewards present in misrepresentation of illness. “Individuals with factitious disorder might, for example, report feelings of depression and suicidality following the death of a spouse despite the death not being true or the individual's not having a spouse; deceptively report episodes of neurological symptoms (e.g., seizures, dizziness, or blacking out); manipulate a laboratory test (e.g., by adding blood to urine) to falsely indicate an abnormality; falsify medical records to indicate an illness; ingest a substance (e.g., insulin or warfarin) to induce an abnormal laboratory result or illness; or physically injure themselves or induce illness in themselves or another (e.g., by injecting fecal material to produce an abscess or to induce sepsis).”(DSM-5, 2013).

Factitious Disorder Imposed on Self

Individuals diagnosed with factitious disorder imposed on self intentionally produce and complain of physical and psychological symptoms to present themselves as ill, impaired, or injured (even without any rewards) (DSM-5, 2013). According to DSM-5 (2013), diagnostic criteria for factitious disorder imposed on self are:

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 explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Factitious Disorder Imposed on Another

Individuals diagnosed with factitious disorder on another deceivingly falsify physical and psychological symptoms, or produce injury and illness in another person to present them as ill, impaired, or injured (even without any rewards) (DSM-5, 2013). According to DSM-5 (2013), diagnostic criteria for factitious disorder imposed on another are:

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.

B. The individual presents another individual (victim) 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 explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Note: The perpetrator, not the victim, receives this diagnosis.

 
 
 
 
 
 
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Conversion Disorder

Individuals diagnosed with conversion disorder experience symptoms and deficits that affect voluntary and sensory functions. The symptoms are inconsistent with neurological and physical symptoms. “In conversion disorder, there may be one or more symptoms of various types. Motor symptoms include weakness or paralysis; abnormal movements, such as tremor or dystonic movements; gait abnormalities; and abnormal limb posturing. Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing. Episodes of abnormal generalized limb shaking with apparent impaired or loss of consciousness may resemble epileptic seizures (also called psychogenic or non-epileptic seizures).” (DSM-5, 2013) According to DSM-5 (2013), diagnostic criteria for conversion disorder are:

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.

F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

 
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Explanations for the Causes of Somatoform Disorders

 

Biological Explanation

According to the biological perspective, people are much more susceptible to somatic symptom disorder when they show increased sensitivity to bodily sensations, have a lower pain threshold, and have had an illness or an injury (Sue, et. al., 2013).

Psychological Explanations

Psychodynamic/Psychoanalytic Explanation

Psychodynamic theorists view somatic symptom and related disorders as, the result of an internal conflict (such as unpleasant or traumatic memories), which originated during childhood. This conflict is anxiety provoking, and thus, remains unconscious (Comer, 2014).

Cognitive Explanation

According to the cognitive theory, people diagnosed with these disorders have a distorted perception of their bodily sensations. That is, they interpret every sensation as being catastrophic, alarming, and life threatening. For example, a minor headache may be misinterpreted as having a malignant brain tumor.

Behavioral Explanation

According to the behavioral view, somatic symptom and related disorders develop from operant and/or observational learning (modeling). That is, the attention gained from the symptoms and the avoidance of responsibility can reward (reinforce) and maintain these disorders.

Lack of Coping Skills as a Contributing Factor

According to this idea, the emotional pain (discomfort) of individuals who do not have the necessary skills to cope with life's challenges may become internalized and expressed via bodily (somatic) symptoms.

 

Treatment for Somatoform Disorders

 
 
 

Biologically-Based Treatment

Biological treatment utilizes medications that increase serotonin level. Therapists often encourage exercise and increased physical activity.

Cognitive-Behaviorally-Based Treatments

Successful cognitive-behavioral therapy assists the client’s ability to identify and deal with the source of his/her emotional stress through education, cognitive modification, and teaching healthy behavior and coping skills. Specifically, the client learns to:

  • Identify and modify distorted thoughts into adaptive and realistic ones.
  • Differentiate between bodily sensations, pain, anxiety and stress.
  • Manage stress through relaxation techniques. Thus, he/she can reduce autonomic arousal in response to life's stressors.
  • Increase enjoyable activities and meaningful relationships.
  • Gain assertiveness.
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Dissociative Disorders

 
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Dissociative Amnesia

In dissociative amnesia, the individual is unable to remember autobiographical information associated with a stressful or traumatic event, and it may or not involve travel away from home. This inability to recall information goes beyond normal forgetting. Memory may come back abruptly or gradually. According to DSM-5 (2013), the diagnostic criteria for dissociative amnesia are:

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, 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.

 
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Dissociative Identity Disorder
(Multiple Personality Disorder)

In dissociative identity disorder (DID), the individual experiences two or more relatively independent personality states, which can significantly disrupt the person’s sense of self (who she/he is), mood, thoughts, behavior, consciousness, memory, emotion, sensation, perception, and motor control functioning. This inability to recall information is not normal forgetting.

According to DSM-5 (2013), the diagnostic criteria for dissociative identity disorder are:

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 in identity involves 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 better explained by 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).

 
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Depersonalization/Derealization Disorder

Depersonalization/derealization disorder is characterized by persistent or repeated experience of feelings of depersonalization, derealization, or both. Feeling detached from reality, or unfamiliar with the world, people, things, or all surroundings, are characterized in derealization experiences. According to DSM-5 (2013), the diagnostic criteria for depersonalization/derealization disorder are:

A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:

  • Depersonalization: Experiences of unreality, detachment, 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 experiences, 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, medication) or another medical condition (e.g., seizures).

E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

 
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Explanations for the Causes and Treatment of Dissociative Disorders

Biological Explanations

A number of studies have demonstrated that childhood trauma and repeated stress can cause permanent modifications in certain areas of the brain associated with memory and emotional responses (Sue, et. al., 2013; Janjua, Rapport, & Ferrera, 2010).

Psychological Explanations

Psychodynamic/Psychoanalytic Explanation

The psychodynamic perspective views dissociative disorders as the individual's excessive use of repression—this is the ego's defense against anxiety by blocking unpleasant or traumatic memories from awareness/consciousness (Comer, 2014)

Behavioral Explanation

The behavioral perspective assumes that patients, through operant conditioning, learn dissociative behaviors.

Treatment for Dissociative Disorders

According to Sue, et al. (2013), therapists use cognitive-behavioral therapy, supportive counseling, hypnosis and personality reconstructing to treat dissociative disorders. In addition, medication is often prescribed to treat the accompanied symptoms of depression and anxiety.

 
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Behavioral Health Treatment Services Locator

Behavioral Health Treatment Services Locator By entering your zip code at findtreatment.samhsa.gov, you can quickly find alcohol and drug abuse treatment or mental health treatment facilities in your area. This service is courtesy of the Substance Abuse and Mental Health Services Administration (SAMHSA) which works to "to improve the quality and availability of substance abuse prevention, alcohol and drug addiction treatment, and mental health services." (SAMHSA)

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