SOMATOFORM AND DISSOCIATIVE DISORDERS

UNDERSTANDING ABNORMAL PSYCHOLOGY
SOMATOFORM AND DISSOCIATIVE DISORDERS

SOMATOFORM DISORDER
SOMATIC SYMPTOM RELATED
DISORDER
UNIT-7
HYPOCHONDRIASIS,SOMATIZATION,PAIN,CONVERSI
ON,BODY DISMORPHIC AND FACTITIOUS DISORDER.

Somatic symptom related disorder (SSD formerly known as "somatization disorder" or
"somatoform disorder") is a form of mental illness that causes one or more bodily
symptoms, including pain. It is a group of psychiatric disorders.
The symptoms may or may not be traceable to a physical cause including general
medical conditions, other mental illnesses, or substance abuse. But regardless, they
cause excessive and disproportionate levels of distress.
The symptoms can involve one or more different organs and body systems, such as:
• Pain
• Neurologic problems
• Gastrointestinal complaints
• Sexual symptoms

People with SSD are not faking their symptoms. The distress they experience from
pain and other problems they experience are real, regardless of whether or not a
physical explanation can be found, and the distress from symptoms significantly affects
daily functioning.
Doctors need to perform many tests to rule out other possible causes before
diagnosing SSD.
• The diagnosis of SSD can create a lot of stress and frustration for patients.
• They may feel unsatisfied if there's no better physical explanation for their
symptoms or if they are told their level of distress about a physical illness is
excessive.
• Stress often leads patients to become more worried about their health, and this
creates a vicious cycle that can persist for years.

TREATMENT
 The initial steps in treating somatic symptom related disorders(somatoform disorders) are to consider
and discuss the possibility of the disorder with the patient early in the work-up and, after ruling out
organic pathology as the primary etiology for the symptoms, to confirm the psychiatric diagnosis.
 A psychiatric diagnosis should be made only when all criteria are met.
 Discussing the diagnosis requires forethought and practice. The delivery of the diagnosis may be
the most important treatment step.
 The physician must first build a therapeutic alliance with the patient
 This can be partially achieved by acknowledging the patient's discomfort with his or her
unexplained physical symptoms and maintaining a high degree of empathy toward the patient
during all encounters.

Therapy
 Once the diagnosis is made and the patient accepts the diagnosis and treatment goals, the physician
may treat any psychiatric comorbidities.
 Clinically significant depressive disorder, anxiety disorder, personality disorder, and substance abuse
disorder often coexist with somatoform disorders and should be treated concurrently
using appropriate modalities.
 Cognitive behavior therapy has been found to be an effective treatment of somatoform disorders
It focuses on cognitive distortions, unrealistic beliefs, worry, and behaviors that promulgate
health anxiety and somatic symptoms.
 Collaboration with a mental health professional can be helpful in making the initial diagnosis
of a somatoform disorder, confirming a comorbid diagnosis, and providing treatment
.
 Schedule regular, brief follow-up office visits with the patient to provide attention and reassurance.

Types in somatic symptom and related disorder are:
1. Somatic symptom disorder(somatization disorder)
2. Illness Anxiety Disorder (Hypochondriasis)
3. Pain Disorder(somatic symptom disorder)
4. Body Dysmorphic Disorder (OCD)
5. Conversion Disorder
6. Factitious disorder
7. Other Specific Somatic Symptom and Related Disorders

8. Psychological Factors affecting other medical conditions
9. Unspecified somatic symptom and related disorder

Somatic Symptom Disorder (Somatization Disorder)
Diagnostic Criteria 300.82 (F45.1)
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:
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2 Persistently high level of anxiety about health or symptoms.
3 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).

Specify if:
With predominant pain (previously pain disorder): This specified is for
individuals whose somatic symptoms predominantly involve pain.
Specify if:
Persistent: A persistent course is characterized by severe symptoms, marked
impairment, and long duration (more than 6 months).
Specify current severity:
Mild: Only one of the symptoms specified in Criterion B is fulfilled.
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
Severe: Two or more of the symptoms specified in Criterion B are fulfilled,
plus there are multiple somatic complaints (or one very severe somatic
symptom)

Causes
The exact cause of somatic symptom disorder isn't clear, but any of these factors
may play a role:
• Genetic and biological factors, such as an increased sensitivity to pain.
• Family influence, which may be genetic or environmental, or both.
• Personality trait of negativity, which can impact how you identify and perceive
illness and bodily symptoms, involves negative emotions and poor self-image
• Decreased awareness of or problems processing emotions, causing physical
symptoms to become the focus rather than the emotional issues.
• Learned behavior — for example, the attention or other benefits gained from
having an illness or increasing immobility from pain behaviors and avoidance
of activity.

Treatment of Somatic Symptom Disorders
Patients who experience SSD may cling to the belief that their symptoms have an
underlying physical cause, despite a lack of evidence for a physical explanation.
If there is a medical condition causing their symptoms, they may not recognize that
the amount of distress they are experiencing or displaying is excessive.
Patients may also dismiss any suggestion that psychiatric factors are playing a role in
their symptoms.

A strong doctor-patient relationship is key to getting help with SSD. Seeing a
single health care provider with experience managing SSD can help cut down on
unnecessary tests and treatments.
The focus of treatment is on improving daily functioning, not on managing
symptoms. Stress reduction is often an important part of getting better.
Counseling for family and friends may also be useful.
Cognitive behavioral therapy may help relieve symptoms associated with SSD. The
therapy focuses on correcting:
• Distorted thoughts
• Unrealistic beliefs

Hypochondriasis disorder
Hypochondriasis is a persistent fear of having a serious medical illness. A person with this disorder
tends to interpret normal sensations, bodily functions and mild symptoms as a sign of an illness
with a grim outcome.
For example, a person may fear that the normal sounds of digestion, sweating or a mark on the skin
may be a sign of a serious disease.
A person with hypochondriasis may be especially concerned about a particular organ system,
such as the cardiac or digestive systems.
There is a tendency to go from doctor to doctor, looking for one that will confirm the presumed illness.
The patient and the doctors may become frustrated or angry.

• Fixation on the fear of having a life-threatening medical condition.
• These patients have a non-delusional preoccupation with their
symptom or symptoms for at least six months before the
diagnosis can be made.
• Prevalence is 2 to7 percent in the primary care outpatient setting.
• There is no consistent differences with respect to age, sex, or cultural factors.
• The predominant characteristic is the fear patients exhibit when discussing their symptoms
(e.g., an exaggerated fear of having acquired human immunodeficiency virus despite
reassurance to the contrary).

ETIOLOGY
Some people with this disorder have had a serious illness in the past, commonly during childhood.
Often hypochondriasis starts in young adulthood and can last many years. But it can occur at any age
and in both men and women. Symptoms may become more intense after a stressful event, for example,
the death of a loved one.
Medical illnesses can bring benefits, such as relief from responsibilities along with the attention and
care of family members, friends and doctors. Therefore, sometimes, hypochondriasis is motivated by
these advantages, although the individual is often not aware of that motivation.
Treatment
• Pharmacotherapy
Selective serotonin reuptake inhibitors (SSRIs) are a type of medication that can help to treat
hypochondriasis.
• Psychotherapy
Research has shown that some treatments can be effective. Cognitive-behavioural therapy (CBT) has
become a popular option for treating hypochondriasis

Body Dysmorphic Disorder
Body Dysmorphic Disorder (historically known as dysmorphophobia) is a preoccupation with a
defect in appearance. The defect is either imagined, or, if a slight physical anomaly is present,
the individual's concern is markedly excessive.
For example, a woman with a small, flat mole on the shoulder may be so self-conscious of
it that she never wears clothing that would reveal it, avoids all social situations in which it
may be seen by others, and feels others are judging her because of it.
This disorder occurs equally in men and women.
Preoccupation with a real or imagined physical defect is the main
characteristic feature of this disorder.

Pain Disorder
Pain disorder is a somatoform disorder, in which a patient experiences chronic pain in
one or more areas that is thought to be caused by psychological stress.
It is characterized by acute or chronic pain with physical symptoms that have no
explained origin and are not the result of another physical illness or substance use.
Some types of mental or emotional problems can cause, increase or prolong pain.

• The pain causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
• Psychological factors are judged to have an important role in the onset, severity, or
maintenance of the pain.
The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder).

ETIOLOGY
Common sites of pain include the back (especially lower back), the head, abdomen, and chest.
Causes of pain vary depending on the site; however, in pain disorder, the severity or duration of
pain or the degree of associated disability is unexplained by observed medical or psychological
problems.
Management
Depending on whether the pain is acute or chronic, management may involve one or more of
the following:
• Pharmacological treatment (medication)- If the pain is acute, the primary goal is to
relieve the pain. Customary agents are acetaminophen or non-steroidal anti-inflammatory
drugs (NSAIDs).
• Antidepressants
Tricyclic antidepressants (TCAs) reduce pain, improve sleep, ), as well as moderate depression.

Psychotherapy (individual or group)
Family, behavioral, physical, hypnosis, and/or occupational therapy. Psychotherapy is less important
for the treatment of acute pain as compared to chronic pain disorder.
Cognitive-behavioural therapy (CBT)
Is used to restore a sense of self-efficacy by educating patients about the pain-and-tension cycle, by
teaching them how to actively manage pain and distress, and by informing them about the therapeutic
effects of their medications.
Operant conditioning
The principles of operant conditioning are taught to the patient and family members so that activity
and non-pain behaviours are reinforced or encouraged. The goal is to eliminate pain behaviours, such
as passivity, inactivity, and over-reliance on medication

Conversion Disorder
Conversion disorder is a psychological condition that causes symptoms that appear to be
neurological, such as paralysis, speech impairment, or tremors. It is a relatively rare mental
illness with fewer than 25 cases reported in a population of 100,000, according to the
National Organization for Rare Diseases
There's typically a sudden onset of symptoms that affect voluntary motor or sensory
function and these symptoms can disappear just as suddenly, without any physiological
reason.
The symptoms can be about any neurological deficit imaginable, including paralysis, loss
of voice (aphonia), disturbances in coordination, temporary blindness, loss of the sense
of smell (anosmia) or touch (anesthesia).

Eg-Imagine taking a hard fall off your bike and then not being able to move your arm –
but your arm isn’t injured. Neither is any other part of your body. Is the paralysis all in your head?
YES, it might be. It’s a neurological condition that causes physical symptoms – like a paralyzed arm –
even though doctors can’t find any injury or other physical condition to explain them.
• Single unexplained symptom involving voluntary or sensory functioning
• Patients may present in a dramatic fashion or show a lack of concern for their symptom.
• Onset rarely occurs before age 10 or after 35 years of age.
• Conversion disorder is reported to be more common in rural populations,
persons of lower socioeconomic status, and those with minimal medical or
psychological knowledge.

The onset of Conversion Disorder is generally from late childhood to early adulthood, rarely
before age 10 years or after age 35 years, but onset as late as the ninth decade of life has been
reported. Onset has been reported throughout the life course.. The symptoms can be transient
or persistent. The prognosis may be better in younger children than in adolescents and adults.
CAUSE.
• There may be a history of multiple similar somatic symptoms.
• Onset may be associated with stress or trauma, either psychological or physical in nature.
• Maladaptive personality traits are commonly associated with conversion disorder.
• Environmental-There may be a history of childhood abuse and neglect. Stressful life events
are often, but not always, present.
• Genetic and physiological. The presence of neurological disease that causes similar
symptoms is a risk factor (e.g., non-epileptic seizures are more common in patients who also
have epilepsy).

TREATMENT
The first line of treatment is to try to identify the underlying cause. Once a person
knows what the cause is, they can work on coping mechanisms and other solutions to
relieve stress and emotional trauma as much as possible. Alleviating the triggers
should, in turn, reduce the physical symptoms.
Suggested treatments for conversion disorder may include:
• Treating any underlying mental health conditions, such as depression
• Cognitive behavioral therapy (CBT)
• Psychotherapy
• Relaxation techniques, such as meditation or yoga
• Physical therapy
• Seeking additional support from friends, family, and the community

Factitious Disorder.
300.19 (F68.10)
Factitious disorder is a condition in which a person acts as if he or she has an illness
by deliberately producing, feigning , or exaggerating symptoms.
Patients with factitious disorder undertake these tribulations primarily to gain the
emotional care and attention that comes with playing the role of the patient.
In doing so, they practice artifice and art, creating hospital drama that
often causes frustration and dismay.

Diagnostic Criteria
• Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, associated with identified deception.
• The individual presents himself or herself to others as ill, impaired, or injured.
• The deceptive behavior is evident even in the absence of obvious external rewards.
• The individual presents another individual (victim) to others as ill, impaired, or
injured.
• Individuals with factitious disorder might, for example, 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 in another.

CAUSE
Researchers do not know the exact cause of factitious disorder.
They believe a variety of factors can increase the risk, including: childhood
abuse or neglect ,history of family illness, chronic illness in childhood other
trauma, family dysfunction or social isolation
TREATMENT
• Some people with factitious disorder suffer one or two brief episodes of
symptoms.
• Factitious disorder is a chronic, long term condition that can be very
difficult to treat.

Illness Anxiety Disorder ( DSM-5)
Diagnostic Criteria 300.7 (F45.21)
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.

Development and Course
The development and course of illness anxiety disorder are unclear. Illness
anxiety disorder is generally thought to be a chronic and relapsing condition
with an age at onset in early and middle adulthood.
TREATMENT
Psychotherapy
• Research has shown that some treatments can be effective. Cognitive-
behavioural therapy (CBT) has become a popular option.
• They often consult multiple physicians for the same problem and obtain
repeatedly negative diagnostic test results.
• Individuals with the disorder are generally dissatisfied with their medical
care and find it unhelpful, often feeling they are not being taken seriously
by physicians.

Psychological Factors Affecting Other Medical Conditions(DSM-5)
Diagnostic Criteria 316 (F54)
Psychological factors affecting other medical conditions is diagnosed when
psychological or behavioral factors adversely affect the course or outcome of an
existing medical condition.
Patients have one or more clinically significant psychologic or behavior factors that
adversely affect an existing medical disorder (eg, diabetes, heart disease) or symptom
(eg, pain).
These factors may increase the risk of suffering, death, or disability or aggravate an
underlying medical condition; or result in hospitalization or emergency department
visit.

DIAGNOISTIC CRITERIA
A medical symptom or condition (other than a mental disorder) is present.
B. Psychological or behavioral factors adversely affect the medical condition in
one of the following ways:
1. The factors have influenced the course of the medical condition as shown by a
close temporal association between the psychological factors and the
development or delayed recovery from, the medical condition.
2 . The factors interfere with the treatment of the medical condition (e.g., poor
adherence).
3 The factors constitute additional well-established health risks for the
individual.

4. The factors influence the underlying pathophysiology, precipitating or
exacerbating symptoms or necessitating medical attention.
C. The psychological and behavioral factors in Criterion B are not better explained
by another mental disorder (e.g., panic disorder, major depressive disorder,
posttraumatic stress disorder).
The condition can be:
Mild - increases medical risk. For example, the person doesn't regularly take a
required medication.
Moderate - affects the underlying medical condition. For example, the patient has
anxiety that makes breathing conditions worse.
Severe - requires a visit to the emergency room or causes the person to have to be
in the hospital.
Extreme - results in severe, life-threatening risk. For example, the person ignores
symptoms of a stroke.

TREATMENT
Treatment includes the person learning about the effects of their thoughts and
behaviors on their medical condition. It also includes psychotherapy to help the
person deal with their condition and to follow treatment recommendations for the
medical condition.

Other Specified Somatic Symptom and Related Disorder
300.89 (F45.8)
This category applies to presentations in which symptoms characteristic of a somatic
symptom and related disorder that cause clinically significant distress or impairment
in social, occupational, or other important areas of functioning predominate but do
not meet the full criteria for any of the disorders in the somatic symptom and related
disorders diagnostic class.

Examples of presentations that can be specified using the “other specified”
designation include the following:
1. Brief somatic symptom disorder: Duration of symptoms is less than 6 months.
2. Brief illness anxiety disorder: Duration of symptoms is less than 6 months.
3. Illness anxiety disorder without excessive health-related behavior.
4. Pseudocyesis: A false belief of being pregnant that is associated with objective
signs and reported symptoms of pregnancy

Unspecified Somatic Symptom and Related Disorder
300.82 (F45.9)
This category applies to presentations in which symptoms characteristic of a
somatic symptom and related disorder that cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning
predominate but do not meet the full criteria for any of the disorders in the somatic
symptom and related disorders diagnostic class.
The unspecified somatic symptom and related disorder category should not be used
unless there are decidedly unusual situations where there is insufficient information
to make a more specific diagnosis.

SOMATOFORM AND DISSOCIATIVE DISORDERS

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