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Block 2 Unit 4 Somatoform Disorder and Dissociative Disorder

1) What is the main difference between Somatisation disorder and Pain disorder?

The main difference is that Somatisation disorder involves multiple physical symptoms at different locations of the body (at least 4 pain symptoms, 2 gastrointestinal symptoms, 1 sexual symptom and 1 pseudoneurological symptom), whereas Pain disorder primarily involves pain in one or more sites of the body.

2) What is la belle indifference?

La belle indifference is a peculiar lack of concern and anxiety that a person with Conversion disorder might display about their loss of function. For example, a person might be unconcerned about a sudden loss of vision.

3) What is Body Dysmorphic disorder?

Body Dysmorphic Disorder is a somatoform disorder in which a person is preoccupied with a perceived defect or flaw in their physical appearance that appears minor or is not observable to others.

4) Define dissociation.

Dissociation refers to the separation of a person’s activities from their conscious awareness.

5) How prevalent are Dissociative disorders?

The prevalence of Dissociative disorders in population is not well researched. Amnesia probably occurs in about 5% to 7% of the population. Fugue is much less common, about 0.2%. Depersonalisation disorder occurs in about 2% to 3%. Dissociative Identity disorder was once considered to be very rare. Later on its diagnosis has been influenced by the scientific culture of the time. Some doctors diagnose it more, some merge it with schizophrenia. It may be prevalent in 1% to 2 % of the population.

6) Discuss the symptoms and clinical features of different types of somatoform disorders with case examples.

• Somatisation Disorder: Characterised by multiple physical symptoms in different body locations. It must begin before age 30 and include at least 4 pain symptoms, 2 gastrointestinal symptoms, 1 sexual symptom, and 1 pseudoneurological symptom.
• Pain Disorder: Predominant symptom is pain in one or more sites of the body.
• Hypochondriasis: Characterised by a preoccupation with the idea of having a serious illness, despite medical evaluations not finding any evidence of physical illness.
• The source material does not provide any case examples of this disorder.
• Conversion Disorder: Symptoms involve a loss of function that is not explained by a neurological condition. Symptoms may include 'glove anesthesia', lack of concern for the symptoms, and paralysis that may be selective in time and space.
• Body Dysmorphic Disorder: Involves a preoccupation with a perceived physical defect or flaw, that appears minor or unobservable to others.

7) Discuss the prevalence of different somatoform Disorders.

• Prevalence of the different types of Somatoform disorders is not the same. 
• Somatisation Disorder usually begins in adolescence. It is more common in lower socio-economic class and among women. Lifetime prevalence is 0.2% to 2% in women and 0.2% in men. The prevalence of
• Pain Disorder in general population is not known. It is seen more often in women.
• Hypochondriasis is the most commonly seen Somatoform disorder, being present in 2% to 7% of the general population. It often starts in early adulthood and is equal in both sexes. 
• Conversion Disorder was quite common at one time, but with knowledge of the dynamics of this disorder and with psychological sophistication of the general population, it has come down to less than .005% of the population. 
• The exact prevalence of the Body Dysmorphic Disorder is not known as many of us may have slight preoccupation with body parts. An estimated 2% to 5% of general population may have crossed the limit of normal preoccupation and may be said to be suffering from the disorder. It is equal across both sexes.

8) Discuss the aetiological factors of somatoform Disorders.

• Biological factors are considered less significant than psychological factors. A vulnerable personality might be inherited.
• Psychological factors include psychoanalytical, learning, and cognitive approaches:
  • Psychoanalytical approach: Suggests that physical symptoms may be an unconscious expression of repressed emotions or conflicts.
  • Learning approach: Proposes that symptoms may be a way of escaping a stressful situation, which is reinforced by the relief it provides.
  • Cognitive approach: Focuses on the individual’s maladaptive thought patterns or misinterpretations of bodily sensations.
• Stressors and vulnerable personality are also cited as potential factors.

9) Discuss the treatment options of somatoform Disorders.

Psychoanalytically oriented treatment and insight therapies are more applicable for some of these disorders, while medicine has relatively little impact. Cognitive-behavioral approach seems to be another option.

10) Discuss the symptoms and clinical features of different types of dissociative disorders with case examples.

• Dissociative Amnesia and Fugue:
  • Dissociative amnesia is an inability to remember important personal information, usually of a traumatic or stressful nature. The amnesia can be selective about certain events.
  • Dissociative fugue involves sudden, unexpected travel away from home or work, coupled with amnesia about the past and confusion about one’s identity.
• Depersonalisation Disorder: Characterised by a sense of detachment from one's own self or body, as though one is an outside observer.
• Dissociative Identity Disorder: Involves the existence of two or more distinct personalities or identities that take control of the person’s behaviour.

11) Discuss the aetiological factors of dissociative disorders.

• Biological factors: The source material doesn't provide any details about biological factors other than to say that twin studies have not been able to provide strong biological evidence so far.
• Psychological factors:
• Psychoanalytic Approach: Views dissociation as a defence mechanism to wipe away difficulties in handling emotionally difficult situations.
• Behavioural approach: Suggests that dissociation is an attempt to avoid extreme stress that is then reinforced by the relief it brings.
• Cognitive approach: Suggests that selective memory deficits take place, usually affecting episodic or autobiographical memory, with semantic memory being relatively intact.
• Cultural and Social Factors: The source material does not provide any specific examples, however, it mentions that those with vulnerable personalities and stressful life events are more prone to these disorders.

12) What is the cultural explanation of decrease in prevalence of Conversion disorder in recent years?

Cultural Explanation for Decrease in Conversion Disorder Prevalence

• Conversion disorder was once quite common, but its prevalence has decreased with increased knowledge about it.
• The decline is likely because conversion is seen as a defence mechanism, so in cultures where this knowledge is not available, the disorder is more prevalent.
• This implies that as understanding of psychological defence mechanisms becomes more widespread, individuals may be less likely to express psychological distress through physical symptoms.

13) What is the nature of cognitive bias in Somatoform disorders?

Nature of Cognitive Bias in Somatoform Disorders

• The cognitive approach to somatoform disorders emphasises that individuals have problems in information processing and display cognitive bias.
• People with somatoform disorders tend to:
  • Pay greater attention to bodily symptoms.
  • Have more accurate memory of bodily symptoms.
  • Consider mild symptoms as catastrophic.
• In Conversion disorder and Hypochondriasis, individuals tend to reflect what they know and expect through their disorders.

14) State the difference between depersonalisation and derealisation.

Difference Between Depersonalisation and Derealisation

• Depersonalisation: feeling detached from one's own body and mind, as if one is not oneself.
• Derealisation: a dissociated state of mind where one feels that what is happening around them is not real.
• So, depersonalisation is detachment from oneself, while derealisation is detachment from one's surroundings.

15) What is dissociative fugue?

Dissociative Fugue

• Dissociative fugue involves sudden, unexpected travel away from home or work, combined with amnesia about the past and confusion about one’s identity.
• This is understood as a psychological escape from stress.

16) Discuss the treatment options of dissociative disorders

Treatment Options for Dissociative Disorders

• The primary focus of treatment is to create a safe environment for the individual.
• If a precipitating stressful event is identified, reassuring the person that they are safe from that danger may be beneficial.
• Treatment approaches include:
  • Psychoanalytically oriented therapies and hypnotherapy may help to recover lost memories.
  • Anxiolytic medicines can be used as an adjunct to psychotherapy.
  • For Dissociative Identity Disorder, hypnotherapy and insight therapy can be used, with the goal of integrating the personalities and helping the person learn coping mechanisms without splitting.
  • Therapists should be empathic toward each of the identities in DID.

Important Points

• For Conversion disorder, insight therapy is best.
• Persons with Body Dysmorphic disorder often have first degree relatives with OCD implying possible common genetic disposition.
• Dissociative amnesia can be selective about certain events, with the person being unable to remember certain events or periods of time.
• In Dissociative Identity Disorder, the purpose of therapy is to integrate the personalities and convince each of them that there is no need to stay separate.
• During depersonalisation the reality testing is usually intact.