somatoform

SOMATOFORM DISORDERS

Body Dysmorphic Disorder

preoccupation with an imagined or grossly exaggerated defect in appearance
(Mr. Carlson’s toupee; Elaine’s “big head”)
not delusional
if confronted, will usually admit that they are exaggerating
no reliable figures on its prevalence
most are unmarried, average age of onset is 15

Related to Obsessive-Compulsive Disorder:
1) obsessional thinking and compulsive behavior (e.g., mirror checking)
2) appear in adolescence; chronic
3) may respond to same drugs, such as Prozac
4) occur in families
5) may coexist in same patient

Hypochondriasis

fear of disease, with misinterpretation of physical signs and sensations as abnormal
don’t “fake” symptoms
tend to confine anxieties to more ordinary syndromes
find fears quite reasonable, don’t see why others question them

Developmental factors predisposing to hypochondriasis:
1) more likely than others to have suffered, or to have had a family member who suffered, a true organic disease
2) if sick person in past were a parent, current symptoms likely to be similar
3) some evidence of overprotective mothers

Somatization Disorder

numerous and recurrent physical complaints, beginning by age 30
less educated
in cultures which frown upon expression of emotional distress
like hypochondriasis, often accompanied by depression and anxiety
highly hypnotizable

Somatization Disorder vs. Hypochondriasis:
1) focus of distress (disease vs. symptoms)
2) approach to the symptoms (scientific vs. vague, dramatic, exaggerated)
3) number of complaints (one particular disease vs. multitude of symptoms)
4) both doctor shop
5) gender prevalence (equal in hypochondriasis, more women somatization)

Conversion Disorder

there is an actual disability
no organic pathology to explain it
“hysteria,” wandering uterus per Hippocrates (twice as common in women)
Freud, cure thru hypnosis - etiology=“sexual conflict”
1/3 seem completely unperturbed by their symptoms - la belle indifference
symptoms often are selective (epileptics without incontinence or injury; blind who don’t bump into things, or catch balls)

Conflict Resolution Hypothesis:
1) primary gain - blocks the person’s awareness of internal conflict
2) secondary gain - excusing person from responsibilities and attracting sympathy and attention

Somatization Disorder vs. Malingering:
1) malingerers usually cautious and defensive when questioned about symptoms
2) malingerers would not claim blindness and then catch a ball

Somatization Disorder vs. True Organicity:
1) “neurological nonsense” - glove anesthesia
2) rapid appearance of symptoms, especially after psychological trauma
3) indifference
4) selective symptoms (“paralyzed” leg moves during sleep)

caution that some cases dxed as Conversion later developed neurological disease
estimated that 5-14% of all consultations in a general medical setting are for conversion symptoms
the poorer, less educated, more rural, less psychological sophisticated a community, the greater the prevalence of conversion disorder

ETIOLOGY OF SOMATOFORM DISORDERS
Psychoanalytic
sexual conflict?

Behavioral Ullmann and Krasner (1975)
Two conditions increase chances that a healthy person will adopt the sick role:
1) person must have had some experience with the role, either directly or indirectly
2) adoption of the sick role must be reinforced

Treatment

Behavioral
Same as for dissociative:
1) withdraw reinforcement (non-reinforcement)
2) coping skills training (social skills, assertiveness)

try to provide some face-saving means of giving up the symptoms

Sociocultural

culture’s attitude toward emotional expression
more prevalent in non-Western/less industrialized cultures, such as China, Nigeria, Libya, Mexico

Cognitive

“cognitive style” predisposing them to exaggerate normal bodily sensations and catastrophize over minor symptoms
when under stress, they say, “I am having a heart attack” rather than “I am nervous”
somatizers have high rate of pessimism, self-blame, general unhappiness
DSM should change description of hypochondriasis as a fear of disease “despite medical reassurance” to “because of repeated reassurance”

Biological

among 1st degree relatives of patients with somatization disorder:
women show an increased frequency of somatization disorder
men show an increased frequency of antisocial personality disorder
women with somatization disorder tend to marry antisocial personality disorders
coexist in same person more than by chance
twin study, some suggestion for higher concordance rate in MZ vs. DZ, but small sample
tests of brain waves show cortex is accurately receiving info
electrical stimulation of brain produces movement
problem must be in processing of sensory signals
high levels of inhibitory activity in brain
some evidence that hypoxia and hypoglycemia can bring on conversion symptoms
in study of 430 patients with conversion disorder, 70% had symptoms on left side of body