Textbooks Barlow, D.H., & Durand, V.M. (2012). Abnormal psychology: an integrative approach, th 6 ed.

Belmont, CA: Wadsworth Cengage Learning. pp. 172-207. American Psychiatric Association (2000). Diagnostic and statistical manual of mental th disorders, 4 ed. (Text revision). Washington DC, USA: American Psychiatric Association. [including Quick Reference] Other References Bennett, P. (2011). Abnormal psychology and clinical psychology: An introductory rd textbook, 3 ed. New York, NY: Open University Press, McGraw Hill Education Butcher, J. N., Mineka, S., & Hooley, J.M. (2013). Abnormal psychology, 15 ed. Boston, MA: Pearson Education. pp. 266-298 Kearney, C.A., & Trull, T.J. (2012). Abnormal psychology & life: A dimensional approach, international edition.: Wadsworth Cengage Learning. Oltmanns, T.F., Martin, M.T., Neale, J.M. & Davison, G.C. (2007). Case studies in th abnormal psychology, 7 ed. Hoboken, NJ: John Wiley & Sons, Inc. Sadock, B.J. & Sadock V.A., (2003). Synopsis of psychiatry, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins.
th

What are Somatoform Disorders? 1. Somatoform Disorders are set of psychopathology that individuals suffering from it have the preoccupation with the functioning of their body or health, and appearance. 2. The common feature of the disorders under this section is that there is no usually identifiable medical condition, direct effects of a substance, or by another mental disorder (e.g. Panic Disorder). 3. Grouping of the disorders under this section is based on clinical utility rather than on shared etiology and mechanism. 4. There are five basic somatoform disorders mentioned in the DSM-IV-TR are hypochondriasis, Somatization Disorder, Pain Disorder, Conversion Disorder, and Body Dysmorphic Disorder. The other two are the Undifferentiated Somatoform Disorder and Somatoform Disorder Not Otherwise Specified. Only the first five disorders are included in this handout. 5. Barlow and Durand (2013) emphasized that medically unexplained physical symptoms may be among the more challenging manifestation of psychopathology. They have suggested three important pointers in dealing with this issue: a. First, a physician must rule out a physical cause for the somatic complaints before referring the patient to a mental health professional. b. Second, the mental health professional must determine the nature of the somatic complaints to know whether they are associated with a specific somatoform disorder or are part of some other psychopathological syndrome, such as panic attack. c. Third, the clinician must be acutely aware of the specific culture or sub-culture of the patient, which often requires consultation with experts in cross-cultural presentations of psychopathology.

Dimension

NORMAL

MILD

MODERATE

Somatoform Disorder LESS SEVERE

Somatoform Disorder MORE SEVERE

Source: Kearney, C.A., & Trull, T.J. (2012). Abnormal psychology & life: A dimensional approach, international edition .: Wadsworth Cengage Learning .

Case Study: An Abdominal Mass

This 38-year old physician/radiologist initiated her first psychiatric consultation after his 9-year-old son accidentally discovered his father palpating (examining by touch) his own abdomen and said, What do you think it is this time, Dad? The radiologist describes the incident and his accompanying anger and shame with tears in his eyes. He also describes his recent return from a 10-day stay at a famous out-of-state and medical diagnostic center to which he had been referred by an exasperated gastroenterologist colleague who had reportedly reached the end of the line with his radiologist patient. The extensive physical and laboratory examinations performed at the center had revealed no significant physical disease; a conclusion the patient reports with resentment and disappointment rather than relief. The patients history reveals a long-standing pattern of overconcern about personal health matters, beginning at age 13 and exacerbated by his medical school experience. Until fairly recently, however, he had maintained reasonable control over these concerns, in part because he was embarrassed to reveal them to other physicians. He is conscientious and successful in his profession and active in community life. His wife, like his son, has become increasingly impatient with his morbid preoccupation about life-threatening but undetectable diseases. In describing his current symptoms, the patient refers to his becoming increasingly aware, over the past several months, of various sounds and sensations emanating from his abdomen and of his sometimes being able to feel a firm mass in its left lower quadrant. His tentative diagnosis is carcinoma (cancer) of the colon. He tests his stool for blood weekly and palpates his abdomen for 15 to 20 minutes every 2 to 3 days. He has performed several X-ray studies of himself in secrecy after hours at his office.

1. 2.

3.

Hypochondriasis came from the old medical term hypochondrium which means below the ribs. Research indicates that hypochondriasis shares many features with the anxiety and mood disorders particularly panic disorder. More often than not, anxiety and mood disorders are usually comorbid with hypochondriasis. Individuals with a hypochondriacal disorder have additional diagnoses, these most likely are anxiety or mood disorders. Hypochondriasis is characterized by anxiety or fear that one has a serious disease. The essential problem is anxiety, but its expression is different from that of others anxiety disorders. a. In hypochondriasis 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 for individuals with hypochondriasis. Persons with this somatoform disorder almost always go initially to doctors or physicians. b. Another important feature of hypochondriasis is that reassurances from numerous doctors that all is well and the individual is healthy, have, at best, only a short term effect. This disease conviction is a core feature of hypochondriasis. i. Hypochondriasis should be distinguished from illness phobia. 1. Persons with hypochondriasis fear the possibility of already having a disease, whereas persons with illness phobia are fearful of developing some disease. 2. A further point of distinction is that those suffering from hypochondriasis are more likely to misinterpret physical symptoms, display higher rates of checking behaviors, have higher levels of trait anxiety, and have a later age of onset.

1.

It is believed that hypochondriasis is caused by distorted cognitive or perceptual and emotional factors. a. Individuals with hypochondriasis experience physical sensations common to all of us. Exacerbation of symptoms is caused by increase in anxiety through cognitive distortions and extreme self-focusing that a bodily sensation is a symptom of illness. Increased anxiety produces additional physical symptoms and becomes a vicious cycle. b. Researchers have confirmed that participants with hypochondriasis showed enhanced perceptual sensitivity to illness. They also tend to interpret ambiguous stimuli such as minor pain as threatening. c. Restrictive concept of health as being symptom free is also common among people with hypochondriasis.

Source: Barlow & Durand (2012) Abnormal Psychology: An Integrative Approach

2.

Also, there are other fundamental factors in the etiological properties of hypochondriasis. This includes genetic susceptibility, overreaction to stress, a higher predisposition to view negative life events as unpredictable and uncontrollable, and through social learning model. a. Children with hypochondriacal concerns often report the same kinds of symptoms that other family may have reported at one time. Individuals who develop hypochondriasis have learned from family members to focus their anxiety on specific physical conditions and illness. b. Hypochondriasis seems to develop in the context of a stressful life event (often involve death or illness), have experienced a disproportionate incidence of disease, and/or important social and interpersonal influence may be operating (substantial attention is given whenever someone is ill).

1. 2. 3.

The prevalence of Hypochondriasis in the general population is 1% to 5%. Among primary care outpatients, estimates of current prevalence range from 2% to 7%. Hypochondriasis may emerge at any time of life with the peak age periods found in adolescence, middle age (40s and 50s), and after age 60. Hypochondriasis has a chronic course. a. A good prognosis is associated with high socioeconomic status, treatment-responsive anxiety or depression, sudden onset of symptoms, the absence of a personality disorder, and the absence of a related nonpsychiatric medical condition.

1.

There is a limited knowledge regarding the treatment of hypochondriasis. a. Psychodynamic therapy was the common clinical treatment for hypochondriasis. It is used to reveal unconscious conflicts. As the disorder was referred as one of the hysterical psychopathology. However, its effectiveness is not yet established. b. Clinical reports indicate that reassurance and education seems to be an effective intervention in some cases. This is surprising because patients with hypochondriasis and its essential feature are not supposed to benefit from the reassurance of their health. i. Reassurance is usually given only briefly by family doctors who have little time to provide the ongoing support and reassurance that might be necessary. ii. So, it is important, particularly in the mental health profession, to offer substantial or effective and sensitive reassurance to patients. It is very essential to devote sufficient time to all concerns the patient may have, and attend to meaning of the symptoms (for example, its relation to the patients life stress). When hypochondriasis is secondary to another primary mental disorder, that disorder must be treated in its own right. When hypochondriasis is a transient situational reaction, clinician should refrain from treating equivocal or incidental physical examination findings.

c.

d. e.

Cognitive-behavioral treatment (CBT) seems to be a promising treatment to hypochondriasis as many recent research studies have suggested. i. The concentration of CBT is 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. Also, CBT focuses on helping patients to have less reliance on reassurance regarding their concerns. Group psychotherapy often benefits such patients, in part because it provides the social support and social interaction that seem to reduce their anxiety. Pharmacological interventions is also used to treat hypochondriasis especially antidepressants that are also utilize to treat depression and anxiety. An example of this drug is the selective-serotonin reuptake inhibitor (SSRI), drug paroxetine (Paxil). i. However, some studies suggest that incorporating CBT and imipramine (Paxil) is effective in treating hypochondriasis than the drug alone.

Case Study: Not-Yet-Discovered Illness

This 38-year old woman, the mother of five children, reports to a mental health clinic with the chief complaint of depression, meeting diagnostic criteria for major depressive disorder Her marriage has been a chronically unhappy one; her husband is described as an alcoholic with an unstable work history, and there have been frequent arguments revolving around finances, her sexual indifference, and her complaints of pain during intercourse. The history reveals that the patientdescribes herself as nervous since childhood and as having been continuously sickly beginning in her youth. She experiences chest pain and reportedly has been told by doctors that she has a nervous heart. She sees physicians frequently for abdominal pain, having been diagnosed on one occasion as having a spastic colon. In addition to M.D. physicians, she has consulted chiropractors and osteopaths for backaches, pains in her extremities, and a feeling of anesthesia in her fingertips. She was recently admitted to a hospital following complaints of abdominal and chest pain and of vomiting, during which admission she received a hysterectomy. Following the surgery she has been troubled by spells of anxiety, fainting, vomiting, food intolerance, and weakness and fatigue. Physical examinations reveal completely negative findings.

Case Study: Ms. D.

Ms. D. is a 52-year-old white woman who was referred to a general internist in the city for evaluation of persistent back pain and multiple other complaints. At hospitalization it was noted that the patient was disabled from her job as a machine operator at a shoe factory. Ms. D. gave a history of 10 operations: removal of a tumor from her right wrist, dilation and curettage, a hysterectomy, three abdominal gastric operations, three breast biopsies, and leg surgery. She had received care from five different hospitals and seven different hospitals and seven different physicians in the past 2 years. On physical examination, Ms. D. was an obese, chronically ill-appearing woman who came to the hospital wearing her transcutaneous electrical nerve stimulation unit. She was cooperative and showed her various scars with a certain amount of enthusiasm. The remainder of her physical examination was within normal limits except for a decreased range of motion in the area of her lumbar spine and local muscle guarding, with some tenderness. Spinal radiographs revealed some degeneration of vertebral bodies L2 to L5. On mental status examination she was cooperative and pleasant, and her behavior was somewhat seductive. There was no pressure or eccentricities in her speech. She showed little hesitation in discussing intimate details of her life. Her mood was euthymic; her affect was appropriate to mood but possibly a little shallow. The remainder of her mental examination was within normal limits. Disallowing all back-related symptoms, Ms. D. was positive for eight pain symptoms, four gastrointestinal symptoms, two sexual symptoms, and two pseudoneurological symptoms with an age of onset of 26 years. During the previous 12 months, Ms. D. reported that she had been in bed 21 days, had made seven office visits to four physicians, and had been hospitalized for a total of 52 days.

1.

2.

For many years until 1980, Somatization Disorder is commonly referred as hysteria or Briquets syndrome. It was named after Pierre Briquet, a French physician, whom encountered patients with so many somatic complaints for which he could not find any medical basis. Patients had gone back to him to report either the same complaints or new lists containing slight variations. The essential feature of Somatization Disorder is a pattern of recurring, multiple, clinically significant somatic complaints. A somatic complaint is considered to be clinically significant if it results in medical treatment (e.g. taking medication) or causes impairment in functioning. The DSM-IV requires that the onset of symptoms should be before age 30. a. People with somatization disorder are concerned with the symptoms themselves, not with what they might mean. Furthermore, these persons with this psychopathology do not feel the urgency to take action, about,

b.

c.

their symptoms, despite feeling continually weak and ill. They avoid exercising because, for them, it will make their condition worse. In somatization disorder, the symptoms become the major part of the persons identity. Their entire life is devoted in their physical complaints. Social or interpersonal aspect of the person suffering from this disorder is incapacitated by the fact that they relate with others through their symptoms. Somatization disorder had had undergone diagnostic criteria changes. i. The DSM-III-R required 13 or more symptoms from a list of 35 which is really problematic for diagnosis. The advent of the DSM-IV stipulates that there are 8 symptoms to meet the diagnostic criteria for this disorder: four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom; which are greatly simplified, validated for better usage and more accurate than the previous criteria. ii. This disorder occurs in a continuum: People with only a few medically unexplained physical symptoms may experience sufficient distress and impairment of functioning to be considered to have a disorder that is called undifferentiated somatoform disorder. Thus, this disorder has fewer than 8 symptoms.

1.

2.

Somatization disorder shares many features with hypochondriasis, including a history of family illness or injury during childhood. But this history do not significantly involve in developing somatization disorder. This is because countless families experience chronic illness or injuries without passing on severe anxiety of being ill or the sick role to children. Although there are mixed findings regarding genetic contribution to somatization disorder, family studies suggest that it runs in the families and may have heritable basis. One of the most astonishing findings is that somatization disorder is strongly associated with antisocial personality disorder (ASPD). a. ASPD occurs primarily on males while and somatization disorder occurs in women. Yet, they share the following features: both begin early in life, chronic course, predominate among lower socioeconomic status, difficult to treat, associated with marital discord, drug and alcohol abuse, and suicide attempts. b. The two differently classified disorders have different behavioral manifestations. Though some theories are speculative regarding the commonality between these two disorders, some of them encourage integrative biopsychosocial thinking in psychopathology. i. One model with some supports, indicates that the notion that ASPD and somatization disorder share a neurobiologically based disinhibition syndrome characterized by impulsive behavior. In essence, persons with these disorders may possess a weak behavioral inihibition system (BIS) that does not control the behavioral activation system (BAS). The BAS is a brain system that underlies impulsivity, thrill-seeking behavior, and excitability, whereas the BIS involved in sensitivity to threat or danger and avoidance of situations or cues suggesting that threat or danger is imminent. a. Evidence indicates that impulsiveness is common in ASPD. Many behaviors and traits associated with somatization disorder also seem to reflect short-term gain (i.e. active BAS), and insensitivity for long-term problems (i.e. weak BIS). i. The continual development of new somatic complaints gains immediate sympathy and attention (for a while) but eventually leads to social isolation. Patients with somatization disorder has been confirmed, at least in one study, that they are more impulsive and pleasure seeking than patients with other disorders such as anxiety disorders. ii. In spite of the same neurophysiological vulnerability, people with ASPD and somatization disorder behave differently. Social and cultural factors play their role in their different behavioral patterns. a. The major difference between ASPD and somatization disorder is the level of dependency. Both aggression and ASPD are strongly associated with males. Dependence and little display of aggression are usually associated with females. b. Gender socialization does its effort to make these differences among men and women through a specific biological vulnerability.

1. 2.

3. 4.

One of the disorders that are rare is somatization disorder. Prevalence rates range from 4.4% (in a large city) to 20% of a large sample in primary care patients (median prevalence is 16.6%). Psychological complaints may also be present. This includes anxiety and mood disorders, much as with hypochondriasis. Although psychotic symptoms are present, these clinical presentations are frequent to those patients who have seemingly endless psychological complaints in psychiatric clinics. There is a frequency of suicidal attempts which serve as their manipulative gestures rather than true efforts of killing themselves. Adolescence is the typical age of onset for somatization disorder. Women, particularly the unmarried and from lower socioeconomic are often the individuals with this disorder.

5.

Somatization disorder has a chronic course and often debilitating which can continue up to later years of adulthood. a. Episodes of increased symptom severity and the development of new symptoms are thought to last 6 to 9 months and may be separated by less symptomatic period lasting 9 to 12 months. Rarely, however, does a patient with somatization disorder go for more than a year without seeking medical attention. Thus, symptomatic presentation is fluctuating. b. Often, periods of increased stress are associated with the exacerbation of somatic symptoms. c. Menstrual difficulties may be one of the earliest symptoms for women. Sexual symptoms are often associated with marital discord.

1. 2.

3.

4. 5.

Treating persons with somatization disorder, as what Barlow and Durand (2012) described, is exceedingly difficult. Cognitive-behavioral treatments (CBT) are proven effective methods to manage their behaviors. It is important to provide reassurance, reduce stress, and, in particular, attenuating the frequency of help-seeking behaviors. There is a very high tendency that person with a somatization disorder to visit numerous medical specialists to address the symptom of the week. A helpful solution to this is to have a gatekeeper physician, one assigned to screen all the physical complaints and decide on whether further evaluation is warranted. Additional therapeutic attention is directed at reducing the supportive consequences of relating to significant others on the basis of physical symptoms. a. It is important to inculcate in the mind of a person with a somatization disorder that they should not rely on being sick to attain healthy, social, and personal adjustment. CBT methods are helpful in this context. Psychotherapy, both individual and group, decreases the patients personal health care expenditures by 50 percent, largely decreasing their rates of hospitalization. Although antidepressant are given by some physicians and show some effectiveness, it is not the first choice of treatment because somatic or physical side effects such as nausea, agitation, or headaches are often frightening to these patients, making drugs difficult to tolerate. a. If medications are given, it is important to closely monitor them, because persons with somatization disorder tend to use drugs erratically and unreliably.

Case Study: Mr. L

Mr. L., a 72-year-old married, Ukrainian-born, pious, wealthy retailer and father of a large family from an east coast city was admitted to the orthopedic service of a general hospital for evaluation of unbearable pain in the arches of his feet. He had fled his native country following a pogrom when he was 9. During the year of flight he had endured enormous hardships, starvation, and beatings until the surviving family members finally were able to emigrate to the United States. With incessant hard work, he had prospered economically; married a patient, supportive wife; and witnessed his six children develop promising careers. He became the major contributor to his temple and gave unstintingly to local charities for the needy and unfortunate; he had little time for personal enjoyment. Over the years each time he and his wife had time alone together and she had been affectionate with him, he would develop some excruciating bodily pain shortly thereafter: blinding headache, severe back spasm, abdominal pain, facial, or pelvic pain. These pains usually receded several days after the weekend was over or the trip was completed. Some pains occurred more frequently than others. He sought medical attention rarely except for these pains, which occurred every few months. His mood varied from glum to gloomy, but he denied that he was depressed. He often claimed to have been blessed with good fortune. He led a temperate life, drank little, and had relatively good health between the episodes of pain. Over the four decades that his physicians cared for him, they had become more frustrated with this unassuming and humble man; his ardent complaints of pain were always so nonspecific and fluctuating that they could not devise any pathophysiological mechanisms to account for his pain. Their diagnostic tests were not revealing, and Mr. L., usually refused their offers of narcotic or analgesic relief. Laboratory workup for pains in the arches was noncontributory, and he was discharged when his symptoms cleared in 3 days. Four months later he was readmitted to the surgical service of the general hospital with severe, unrelenting, left-side upper abdominal pain. This time Mr. L. described his new pain in meticulous detail. A brief workup revealed very advanced carcinoma of the tail of the pancreas. He took the news from his physician stoically and asked to be discharged home that day.

1. 2.

3.

Pain Disorder refers to pain in one or more sites in the body that is associated with significant distress or impairment. There may have been clear reasons for pain, at least initially, but psychological factors play a major role in the persistence of the pain. An essential feature of pain disorder is that the pain is real and it hurts, regardless of the causes. The disorder has been called somatoform pain disorder, psychogenic pain disorder, idiopathic pain disorder, and atypical pain disorder. The DSM-IV-TR lists three subtypes for this somatoform disorder. These are Pain Disorder Associated With Psychological Factors, Pain Disorder Associated With Both Psychological Factors and a General Medical Condition , and Pain Disorder Associated With a General Medical Condition. The last one is not a codable disorder for Axis I since it is not considered as a mental disorder. These three subtypes run the gamut (range) from pain judged to be due primarily to psychological factors to pain judged to be due primarily to a general medical condition.

1.

Although there is no established integrative model to explain causal pattern of pain disorder there are different perspectives why there are people who suffer from pain disorder. a. Psychodynamic Factors. Patients who experience bodily aches and pains without identifiable and adequate physical causes may be symbolically expressing an intrapsychic conflict through the body. By displacing the problem to the body, they may feel that they have a legitimate claim to the fulfillment of their dependency needs. The symbolic meaning of body disturbances may also relate to atonement for perceived sin, to expiation of guilt, or to suppressed aggression. Many patients have intractable and unresponsive pain because they are convinced that they deserve to suffer. Pain can function as a method as a method of obtaining love, a punishment for wrongdoing, and a way of expiating guilt an atoning for an innate sense of badness. Among the defense mechanisms used by patients with pain disorder are displacement, substitution, and repression.

b.

c.

d.

Identification plays part when a patient takes on the role of an ambivalent love object who also has pain, such as a parent. Behavioral Factors. Pain behaviors are reinforced when rewarded and are inhibited when ignored or punished. For example, moderate pain symptoms may become intense when followed by solicitous and attentive behavior of others, by monetary gain, or by successful avoidance of distasteful activities. Interpersonal Factors. Intractable pain has been conceptualized as a means of manipulation and gaining advantage in interpersonal relationships, for example, to ensure the devotion of a family member or to stabilize a fragile marriage. Such secondary gain is most important to patients with pain disorder. Biological Factors. The cerebral cortex can inhibit the firing of afferent pain fibers. Serotonin is probably the main neurotransmitter in the descending inhibitory pathways, and endorphins also play a role in the central nervous system modulation of pain. Endorphin deficiency seems to correlate with augmentation of incoming sensory stimuli. Some patients may have pain disorder, rather than another mental disorder, because of sensory and limbic structural or chemical abnormalities that predispose them to experience pain.

1. 2. 3. 4.

Pain is perhaps the most frequent complaint in medical practice, and intractable pain syndromes are common. Pain disorder is diagnosed twice as frequently as in men. Several studies suggest that this is a fairly common condition, with 5% to 12% of the population meeting criteria for pain disorder. The pain in pain disorder generally begins abruptly and increases in severity for a few weeks or months. The prognosis varies, although pain disorder can often be chronic, distressful, and completely disabling. When psychological factors predominate in pain disorder, the pain may subside with treatment or after the elimination of external reinforcement. The patients with the poorest prognoses, with or without treatment, have preexisting characterological problems, especially pronounced passivity; are involved in litigation or receive financial compensation; use addictive substances; and have long histories of pain.

1.

2.

The treatment approach for persons with pain disorder must address rehabilitation. Clinicians should discuss the issue of psychological factors early in treatment and should frankly tell patients that such factors are important in the cause and consequences of both physical and psychogenic pain. Therapists should also explain how various brain circuits that are involved with emotions (e.g. the limbic system) may influence the sensory pain pathways. For example, persons who hit their head while happy at a party can seem to experience less pain than when they hit their head while angry and at work. Nevertheless, therapists must fully understand that the patients experiences of pain are real. There are different treatment methods for persons with pain disorder. a. Pharmacotherapy. Antidepressants, such as tricyclics and selective serotonin reuptake inhibitors (SSRIs), are the most effective pharmacological agents. Amphetamine and other drugs which are serve as adjunct medications to SSRIs should be monitored carefully. b. Psychotherapy. Some outcome data indicate that psychodynamic therapy benefits patients with pain disorder. The first step in psychotherapy is to develop a solid therapeutic alliance by empathizing with the patients suffering. Clinicians should not confront somatizing patients with comments such as This is all in your head. For the patient, the pain is real, and clinicians must acknowledge the reality of pain, even as they understand that it is largely intrapsychic in origin. A useful entry point into the emotional aspects of the pain is to examine its interpersonal ramifications in the patients life. In marital therapy, for example, the psychotherapist may soon get to the source of the patients psychological pain and the function of the physical complaints in significant relationships. Cognitive therapy has been used to alter negative thoughts to foster a positive attitude. c. Biofeedback can be helpful in the treatment of pain disorder, particularly with migraine pain, myofacial pain and muscle tension states, such as tension headaches. d. Pain Control Programs. Pain control programs use multimodal approach which includes cognitive, behavior and group therapies. They provide extensive physical conditioning through physical conditioning through physical therapy and exercise and offer vocational evaluation and rehabilitation. Patients who have been dependent to drugs to alleviate pain such as analgesics and hypnotics are detoxified.

Case Study: A Wife with Fits

Mrs. Chatterjee, a 26-year-old patient, attends a clinic in New Delhi, India, with complaints of fits for the last 4 years. The fits are always sudden in onset and usually last 30 to 60 minutes. A few minutes before a fit begins, she knows that it is imminent, and she usually goes to bed. During the fits she becomes unresponsive and rigid throughout her body, with bizarre and thrashing movements of the extremities. Her eyes close and her jaw is clenched, and she froths at the mouth. She frequently cries and sometimes shouts abuses. She is never incontinent of urine or feces, nor does she bite her tongue. After a fit she claims to have no memory of it. These episodes recur about once or twice a month. She functions well between the episodes. Both the patient and her family believe that her fits are evidence of a physical illness and are not under her control. However, they recognize that the fits often occur following some stressor such as arguments with family members or friends She is described by her famil y as being somewhat immature but quite social and good company. She is self -centered, she craves attention from others, and she often reacts with irritability and anger if her wishes are not immediately fulfilled. On physical examination, Mrs. Chatterjee was found to have mild anemia but was otherwise healthy. A mental status examination did not reveal any abnormalityand her memory was normal. An electroencephalogram showed no seizure activity.

1.

2.

3.

4.

The word conversion has been used off and on since the Middle Ages but was popularized by Freud, who believed the anxiety resulting from unconscious conflict somehow was converted into physical symptoms to find expression. a. This allowed the individual to discharge some anxiety without actually experiencing it. b. The anxiety resulting from unconscious conflicts might be displaced onto another object. Conversion disorders refer to physical malfunctioning without any physical or organic pathology to account for the malfunction, especially in sensory-motor areas. a. Examples of these physical malfunctioning is paralysis, blindness, or difficulty speaking (aphonia). b. It may also include total mutism and the loss of sense of touch, astasia-abasia (weakness in legs and loss of balance), globus hystericus (sensation of lump in throat). c. Most conversion symptoms suggest some kind of neurological disease, but can mimic the full range of physical functioning. d. Some people have seizures, which may be psychological in origin because no significant electroencephalogram (EEG) changes can be documented. The DSM-IV-TR tells that if a person diagnosed of conversion disorder, it should be classified further based on the nature of the presenting symptom or deficit. a. With Motor Symptom or Deficit. Includes impaired coordination or balance, paralysis or localized weakness, aphonia, globus hystericus. Aphonia, as mentioned in earlier part, is difficulty in speaking; the person suffering from this condition is able to talk only in whisper although he or she can usually cough in a normal manner. (in true, organic laryngeal paralysis, both the cough and the voice are affected) b. With Sensory Symptom or Deficit. Conversion disorder can involve almost any sensory modality, and it can often be diagnosed as a conversion disorder because symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate. This includes symptoms or deficits in visual system (e.g. blindness, double vision), auditory system (deafness), and loss of touch or pain sensation (anaesthesias). Example of anaesthesia is glove anaesthesia in which the person cannot feel anything on the hand in the area where gloves are worn, although the loss of sensation usually makes no anatomical sense. c. With Seizures or Convulsions. Includes seizures or convulsions with voluntary motor or sensory components. Patients with conversion seizures often show excessive thrashing about and writhing not seen with true seizures, and they rarely injure themselves in falls or lose control over their bowels or bladder, as patients with true seizures frequently do. d. With Mixed Presentation. This is used if the manifestations of conversion symptoms types are more than one. Conversion Disorders differs from actual or real physical disorders, malingering (i.e. deliberately faking symptoms), and factitious disorder (i.e. symptoms are feigned and under voluntary control, but without any obvious reason for doing so aside from assuming the sick role and to gain attention) factitious disorder by proxy (i.e. caregiver making others sick; sometimes referred to as Munchausen syndrome by proxy)

a.

b. c.

d.

First, as with somatization disorder, conversion disorder is often (but not always) marked by la belle indifference, or general apathy toward ones symptoms. However, latest research says that blas attitude toward illness is sometimes displayed by people with actual physical disorders, and some people with conversion symptoms do become quite distressed. So, this finding suggests that la belle indifference is not useful diagnostic tool for diagnosing conversion disorder. Conversion symptoms are often precipitated by some stressful event. Persons with conversion disorder often function normally but display little insight to this ability. Still, an awareness of sensory and motor information is disturbed. For example, individuals with the conversion symptom of blindness can usually avoid objects in their visual field, but they will tell you they cannot see the objects. Another example is those people with conversion symptoms of paralysis of the leg. If an emergency event is taking place, they might suddenly get up and run but were astounded they were able to do this. People who are attending religious ceremonies and experience miraculous heals have the possibility from suffering from conversion reactions. People with conversion disorder, generally, are dissociated from sensory-motor awareness, whereas those who malinger or have a factitious disorder attempt to fake this effect and often look worse than blind persons who perform at chance levels. Someone who is truly blind would perform at a chance level on a visual discrimination tasks. People with conversion symptoms, on the other hand, can see objects in their visual field and therefore would perform well on these tasks, but this experience are dissociated from their awareness of sight. Malingerers and, perhaps, individuals with factitious disorders simply do everything possible to pretend they cannot see.

1.

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According to Sigmund Freud, the founder of psychoanalysis, there are four basic processes in the development of conversion disorder: a. First: The individual experiences a traumatic event, or unacceptable, unconscious conflict. b. Second: The conflict and resulting anxiety are unacceptable; the person represses the conflict, making it unconscious. c. Third: Anxiety continues to fester and threatens to arise into the consciousness. The person converts the conflicts into physical symptoms, and thereby relieves 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 conversion symptom. d. 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, the secondarily reinforcing set of events. In spite of Freuds famous postulations about conversion disorder, little evidence supports his notions. Though the role of trauma does have support. A modification of his approach stipulates that, following a traumatic event, patients develop symptoms purposefully but detach this motivation from consciousness. The behaviors are subsequently maintained by negative reinforcement. The following is a detailed explanation of modified concept of Freud about conversion symptoms: a. Most often, individuals with conversion disorder have experienced a traumatic event that must be escaped at all costs. Examples are combat, where death is imminent, or an impossible interpersonal situation. b. 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 persons consciousness. c. Finally, the escape behavior (the conversion symptom) is successful to an extent in obliterating the traumatic situation, the behavior continues until the underlying problem is resolved. Other contributory factors to conversion disorder are social and cultural influences. a. Like somatization disorder, conversion disorder tends to occur to people with low socioeconomic status, less educated, where knowledge about disease and medical illness is not well developed. b. Prior experience with real physical problems, usually among other family members, tends to influence later choice of specific conversion symptoms; that is patients with which they are familiar. c. A marked biological vulnerability to develop conversion disorder when under stress, with biological processes like those discussed in the context of somatization disorder. Through the use of highly sophisticated brainimaging procedures, neuroscientists have a strong presumption that there is a connection between conversion symptom and structures of the brain, such as amygdala, related to emotion regulation. Although there is no a concrete answer whether brain function is the cause or effect of conversion symptoms, brain imaging technologies brings us closer to the inexplicable nature of conversion disorder. d. But interpersonal factors seem to be more powerful than biological contributory factors. Too much concern and attention from significant individuals or guardians can heavily reinforced conversion symptoms.

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Conversion disorders are relatively rare in mental health settings, but remember that people who seek help for this condition are more likely to consult neurologists or other specialists. a. The prevalence estimate in neurological setting is high, averaging about 30%. b. A study conducted in 2000, estimated that 10% to 20% of all patients referred to epilepsy centers have psychogenic, nonepileptic seizures. c. There is a decreasing prevalence in people suffering from conversion disorder. The highest estimate of APA in 2000, as mentioned in DSM-IV-TR, is 500/100,000 or 0.005%. This could be attributed to sophistication of medical and psychological disorders. People, especially nowadays, have increased knowledge of the real causes of physical problems. It also eliminates much of the possibility of secondary gain which so important in these disorder Conversion disorder, like somatization disorder, is primarily found in women and typically develop during adolescence or slightly thereafter. However, they occur relatively often in males at times of extreme stress. Conversion symptoms are usually found among soldiers exposed to combat. The conversion symptoms often disappear after a time, only to return later in the same or similar form when a new stressor occurs. Good prognosis of conversion disorder are associated with: a. An easily identifiable stressor. b. No comorbid disorders. c. Symptoms of paralysis, aphonia, and blindness are associated with good prognosis, whereas tremors and seizures are not. d. Sudden onset. Children and adolescents seem to have a better long-term outlook than adults. Meaning, they have the best chance of recovery especially with those who are diagnosed early. e. The longer the conversion symptoms are present, the worse the prognosis. Patients with conversion disorder must have complete medical and neurological evaluations at the time of diagnosis. Conversion disorder and dissociative disorders share common features. Feelings of unreality were significantly more common in persons diagnosed of conversion disorder than those who are not. Some cultural and religious groups treat conversion symptoms as part of their healing rituals. In United States, for example, seizures, paralysis, and trances are common among rural fundamentalist religious groups. These behaviors are often seen as evidence of contact with God. a. However, the symptoms would not meet the criteria for a disorder unless they serve as hindrances to individuals functioning.

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Treatment approaches to persons with conversion disorder has similarities of treating individuals with somatization disorder. Identifying and attending the traumatic or stressful events, if it still present (either in real or in memory) is the fundamental strategy in treating conversion disorder. Catharsis, re-experiencing or reliving the event, is a reasonable first step. The therapist must also work 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. So, it is very essential to make necessary steps in monitoring the progress of the person in alleviating the symptoms such as making follow-ups. The therapist and the persons living with the individual with conversion disorder should work hand in hand earnestly. With patients who are resistant to the idea of psychotherapy, physicians can suggest that the psychotherapy will focus on issues of stress and coping. Psychotherapy for conversion disorders ranges from psychodynamic, brief and short-term psychotherapy, and cognitive-behavioral therapy. a. Psychodynamic approaches include psychoanalysis and insight-oriented psychotherapy, in which explore intrapsychic conflicts and the symbolism of the conversion disorder symptoms. b. Brief and direct forms short-term term psychotherapy have also been used to treat conversion disorder. c. Cognitive-behavioral interventions is also a promising treatment to persons with conversion disorder particularly those with motor symptom behavior conversions. The longer the duration of patients sick role and the more they have regressed, the more difficult the treatment.

Case Study: The Elephant Man

Chris is a shy, anxious looking, 31-year-old carpenter who has been hospitalized after making a suicide attemptHe asks to meet with the psychiatrist in a darkened room . He is wearing a baseball cap pulled down over his forehead. Looking down at the floor, Chris says he has no friends, has just been fired from his job, and was recently rejected by his girlfriend. Its my nosethese huge pockmarks on my nose. Theyre grotesque! I look like a monster. Im as ugly as the Elephant Man! These marks on my nose are all that I can think about. Ive thought about them every day for the past 15 years, and I think that everyone can see them and that they laugh at me because of them. Thats why I wear this hat all the time. And thats why I couldnt talk to you in a bright roomyoud see how ugly I am. The psychiatrist couldnt see the huge pockmarks that Chris was referring to, even in a brightly lit room. Chris is, in fact, a handsome man with normal-appearing facial pores. [Later Chris says,] Ive pretty much kept this preoccupation a secret because its so embarrassing. Im afraid people will think of Im vain. But Ive told a few people about it, and theyve tried to convince that the pores real ly arent visible This problem has ruined my life. All I can think about is my face. I spend hours a day looking at the marks in the mirror I started missing more and more work, and I stopped going out with my friends and my girlfriendstaying in the house most of the time. .. Chrishad seen a dermatologist to request dermabrasion, but was refused the procedure because there was nothing there. He finally convinced another dermatologist to do the procedure but thought it did not help. Eventually he felt so desperate that he looked in the mirror and was horrified by what he sawI saw how awful I looked, and I thought, Im not sure its worth it to go on living if I have to look this and think about this all the time.

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Body Dysmorphic Disorder (BDD; formerly known as dysmormophobia which means fear of ugliness). Its essential feature is a preoccupation with an imagined defect in physical appearance despite reasonably normal appearance. This somatoform disorder has been referred as imagined ugliness. a. The name dysmomorphobia was given more than 100 years ago by Emil Kraeplin who considered it a compulsive neurosis; Pierre Janet called it obsession de la honte du corps (obsession with the shame of the body). Although dysmomorphobia was widely recognized and studied in Europe, it was not until the publication of DSM-III in 1980 that dysmomorphobia, as an example of a typical somatoform disorder, was specifically mentioned in the U.S. diagnostic criteria. In DSM-IV-TR, the condition is known as body dysmorphic disorder, because the DSM editors believed that the term inaccurately implied the presence of a behavioral pattern of phobic avoidance. b. People with BDD have behavioral manifestations that are signs of impairment in functioning. i. A variety of checking or compensating rituals are common in attempts to alleviate their concerns. Examples are excessive usage of cosmetic products to cover skin defects, excessive grooming or skin picking. ii. Among adolescents, their predominant focus of attention is skin and hair which means that the disorder is largely influence by cultural standards of beauty. Examples are including skin condition, facial width, slope of nose, and lip, neck, and foot size. iii. Many of them are also fixated on mirrors and frequently check their appearance. However, some of them might avoid mirrors to an almost phobic avoidance such covering them or removing them from their environment. iv. To some extreme cases, it is quite understandable that one of the consequences of BDD is suicide-related behaviors (i.e., ideations, attempts, completion). v. Ideas of reference is also common among persons with BDD which means they think everything that goes in their world somehow is related to themparticularly to their imagined defect. vi. The disorder incapacitates the patients life such as avoidance of usual activities may lead to extreme social isolation. Many patients with severe cases become housebound for fear of showing themselves to other people.

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There is little knowledge regarding the etiology of BDD. It is still unknown whether it runs in families and there are no established biological or psychological factors to say that an individual is predisposed to have this disorder. Proponents of psychoanalysis suggest many speculations which are further centralized to the defense mechanism, displacement. The person experiences too much anxiety because of an underlying unconscious conflict that urges to admit into the consciousness. But he or she displaces it onto a body part. Other defense mechanisms involved are repression, dissociation, distortion, symbolization, and projection BDD is a somatoform disorder in a sense that its core feature is a psychological preoccupation with somatic (physical) issues specifically physical appearance. Nevertheless, BDD does not tend to be a comorbid or co-occur with the other somatoform disorders, nor does it occur in family members of patients with other somatoform disorders. Considerable evidence shows that BDD tend to co-occur with an anxiety disorder, Obsessive-Compulsive Disorder. The two disorders have similarities in: a. Overt symptomatology. People with BDD complain of persistent, intrusive, and horrible thoughts about their appearance, and they engage to compulsive behaviors as repeatedly looking in mirrors to check their physical features. b. Course. BDD and OCD approximately the same age of onset and run the same course. c. Brain abnormalities. A research using brain-imaging techniques have a finding which suggests that BDD and OCD have the same abnormal brain functioning.

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The onset of body dysmorphic disorder is usually gradual. An affected person may become increasingly concerned about a particular body part until he or she notices that functioning is being affected. Then the person may seek medical or surgical help to address the presumed problem. The prevalence of BDD is hard to estimate because its very nature tends to be kept secret. However, the best estimates are that it is far more common than previously thought. The level of concern about the problem may wax and wane over time, although the disorder tends to run a lifelong, chronic course if left untreated. A somewhat higher proportion of individuals with BDD are interested in art or design compared to individuals without BDD, reflecting, perhaps, a strong interest in aesthetics or appearance. BDD is equally seen in males and females; few marry, and age of onset ranges from early adolescence through the 20s, peaking age at age 18 or 19. Individuals with BDD are uncommon in mental health settings by the fact that they frequently go to cosmetic surgeons and dermatologists. However, some of them who did not qualified to undergo plastic surgeries had attempted by their own hand to alter their appearance dramatically, often with tragic results.

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It was found that psychopharmacological interventions and cognitive-behavior therapy has been found to be effective with OCD and BDD as well. a. SSRIs. Although tricyclic drugs, monoamine oxidase inhibitors, and primozide (Orap) have reportedly been useful in individual cases, SSRIs such as clomipramine (Anafranil) and fluvoxamine (Luvox) provide relief and reduce symptoms to at least 50% of patients. Cognitive-behavior therapy, specifically exposure and response prevention, is a very effective treatment approach to BDD compared to medication alone. The field of cosmetic surgery, or plastic surgery, has increasing amounts of income because BDD is a big business for them. An estimate of 8% to 25% of all patients who request plastic surgery may have BDD. Although plastic surgeries have made beautiful changes in physical appearances, they are not beneficial to persons with BDD. a. The problem is that surgery on the proportion of these people with BDD seldom produces the desired results. b. Preoccupation with imagined ugliness may actually increase following plastic surgery. Individuals with BDD return for some additional surgery or concentrate on some new defect.