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Chapter Overview/Summary
The DSM-5 now includes somatic symptom disorder (formerly known as somatoform disorders), which is
comprised of disorders previously known as hypochondriasis, somatization disorder, and pain disorder. Related
disorders now include illness anxiety disorder, conversion disorder, and factitious disorder. In somatic symptom
and related disorders, psychological problems are manifested in physical disorders (or complaints of physical
disorders) that often mimic medical physical conditions, but for which there can be found no evidence of
corresponding organic pathology. In hypochondriasis, one of the former somatoform disorders most commonly
seen, there is an anxious preoccupation with having a disease based on a misinterpretation of bodily signs or
symptoms. Medical reassurance does not help. The former somatization disorder was characterized by many
different complaints of physical ailments in four symptom categories spreading over several years. The symptoms
did not need to have actually existed as long as they were complained about. The former pain disorder was
characterized by pain severe enough to cause life disruption. Although a medical condition could contribute to the
pain, psychological factors were judged to play an important role in the onset, severity, exacerbation, or
maintenance of the pain. Illness anxiety disorder is new to the DSM-5 and involves high anxiety about having or
developing a serious illness. Conversion disorder involves patterns of symptoms or deficits affecting sensory or
voluntary motor functions, leading one to think there is a medical or neurological condition, even though a medical
examination reveals no physical basis for the symptoms. Body dysmorphic disorder involves obsessive
preoccupation with some perceived flaw or flaws in ones appearance. Compulsive checking behaviors (such as
mirror checking) and avoidance of social activities, because of fear of being rejected, are also common.
Dissociative disorders occur when the normal processes regulating awareness and the multichannel
capacities of the mind apparently become disorganized, leading to various anomalies of consciousness and personal
identity. Depersonalization/derealization disorder occurs in people who experience persistent and recurrent
episodes of derealization (losing ones sense of reality) and depersonalization (losing ones own sense of self and
ones own reality). Dissociative amnesia involves an inability to recall previously stored information that cannot be
accounted for by ordinary forgetting and seems to be a common initial reaction to stressful circumstances. The
memory loss is primarily for episodic or autobiographical memory. In dissociative fugue, a person not only goes
into an amnesiac state but also leaves his or her home surroundings and becomes confused about his or her identity,
sometimes assuming a new one. In dissociative identity disorder (DID), the person manifests at least two or more
distinct identities or personality states that alternate in some way in taking control of behavior. Alter identities may
differ in many ways from the host identity. There are many controversies about DID, including whether it is real or
faked, how it develops, whether memories of childhood abuse are real, and, if the memories are real, whether the
abuse played a causal role.
Detailed Outline
thepersonsgoalistoobtainandmaintainthebenefitsthatplayingthesickrole(eventotheextentofundergoingrepeatedhospitalizations)
mayprovide,includingtheattentionandconcernoffamilyandmedicalpersonnel)
However,therearenotangibleexternalrewards.
4. Somatic symptom disorder. Changes in the DSM-5 include dropping the old disorders
of (1) hypochondriasis, (2) somatization disorder, and (3) pain disorder. Most people who
would have previously been diagnosed with one of these disorders will now be diagnosed
with somatic symptom disorder. The history and research are based on the old disorders
and are important to discuss.
somaticsymptomdisordersinvolvepatternsinwhichindividualscomplainofbodilysymptomsthatsuggestthepresenceofmedicalproblems
butwherethereisnoobviousmedicalexplanationthatcansatisfactorilyexplainthesymptomssuchasparalysisorpain.
althoughthepatientscomplaintssuggestedthepresenceofa,medicalconditionnophysicalpathologycouldbefoundto
accountforthem
theaffectedpatientshavenocontrolovertheirsymptoms
theyarenotintentionallyfakingsymptomsorattemptingtodeceiveothers.
theygenuinelybelievesomethingisterriblywrongwiththem
FOUR DISORDERS
(1)somaticsymptomdisorder;hypochondriasis,somatizationdisorder,and,paindisorder,whichhaveallnowdisappearedfromDSM5
(1)disproportionateandpersistentthoughtsabouttheseriousnessofonessymptoms;
(2)persistentlyhighlevelofanxietyabouthealthorsymptoms;and/or
(3)excessivetimeandenergydevotedtothesesymptomsorhealthconcerns
peoplewithsomaticsymptomdisorderstendtohaveacognitivestylethatleadsthemtobehypersensitivetotheirbodilysensations,tendtothink
catastrophicallyabouttheirsymptomsandthusoftenoverestimatingthemedicalseverityoftheircondition
(2)illnessanxietydisorder;
(3)conversiondisorder;
(4)factitiousdisorder.
B. Hypochondriasis
1. Major characteristics
a. Estimated that 75 percent of the people previously diagnosed with
hypochondriasis will be diagnosed with somatic symptom disorder in
the DSM-5.
b. Vague and ambiguous physical symptoms are common.
c. Sincere in their conviction that the symptoms represent illness.
d. Around 2 percent to 7 percent of general medical practice patients
are hypochondriacs.
e. Case study: An abdominal mass.
2. Major characteristics
a. Highly preoccupied with bodily functions, minor physical abnormalities,
and ambiguous physical sensations.
highlypreoccupiedwithbodilyfunctions(e.g.,heartbeatsorbowelmovements),orwithminorphysicalabnormalities(e.g.,asmallsoreoran
occasionalcough),orwithvagueandambiguousphysicalsensations(suchasatiredheartorachingveins).
thepersonispreoccupiedeitherwithfearsofcontractingaseriousdiseaseorwiththeideathatofhavingthatdiseaseeventhoughtheydonot.
verydistressingpreoccupationsarethoughttoallbebasedonamisinterpretationofoneormorebodilysignsorsymptoms(e.g.,beingconvinced
thataslightcoughisasignoflungcancer).
thepersoncannotbereassuredbytheresultsofamedicalevaluation
thefearorideaofhavingadiseasepersistsdespitelackofmedicalevidence
Indeed,theseindividualsaresometimesdisappointedwhennophysicalproblemisfound.
theyareneverreassuredforlongandareinclinedtosuspectthattheirdoctorhasmissedsomething,theysometimesshopforadditionaldoctors,
hopingonemightdiscoverwhattheirproblemreallyis
cognitivebehavioralviewsofhypochondriasisareperhapsmostwidelyaccepted
theyperceivetheirsymptomsasmoredangerousthantheyreallyareandjudgeaparticulardiseasetobemorelikelyordangerousthanitreallyis
saidtobeadisorderofcognitionandperception
perceivetheirprobabilityofbeingabletocopewiththeillnessasextremelylowandseethemselvesasweakandunabletotoleratephysicaleffort
orexercise
4. Treatment of hypochondriasis
a. Cognitive-behavioral treatments have been found to be quite effective.
focusonassessingthepatientsbeliefsaboutillnessandmodifyingmisinterpretationsofbodilysensations
Sometimestheyarealsodirectedtoengageinresponsepreventionbynotcheckingtheirbodiesastheyusuallydoandbystoppingtheirconstant
seekingofreassurance.
thesehadtobeginbeforeage30,lastforseveralyears,andnotbeadequatelyexplainedbyindependentfindingsofphysicalillnessorinjury.
thesepeopleareenormouslycostlytohealthcaresystemsbecausetheyoftenhavemultipleunnecessaryhospitalizationsandsurgeries
beginsinadolescenceandisbelievedbymanytobeaboutthreetotentimesmorecommonamongwomenthanamongmen
occurmoreamonglesseducatedindividualsandinlowersocioeconomicclasses
involvesapatterninwhichsymptomsor
deficitsaffectingthesensesormotorbehaviorstronglysuggest
thatthepatienthasamedicalorneurologicalcondition.
Thepersonisnotintentionallyproducingor
fakingthesymptoms,
conversionofunconsciousandunacceptablefeelingsintoacceptablesymtoms
I.Dissociative Disorders
II. Dissociation Refers to the Human Minds Capacity To Engage in Complex Mental Activity
agroupofconditionsinvolvingdisruptionsinapersonsnormallyintegratedfunctionsofconsciousness,memory,identity,orperception
e.g. peoplewhocannotrecallwhotheyareorwheretheymayhavecomefrom,andpeoplewhohavetwoormoredistinctidentitiesor
personalitystatesthatalternatelytakecontroloftheindividualsbehavior
A. Depersonalization/Derealization Disorder
1. Depersonalization/Derealization Disorder
a. Depersonalization (loss of self or ones own reality) and derealization
(ones sense of the reality of the outside world).
b. Reality testing remains intact.
c. Implicit memory.
d. Implicit perception.
e. Out-of-body experiences can occur.
f. Acute stress triggers the reactions.
g. Personal reactions to the symptoms.
h. The experience is usually frightening.
i. Comorbid anxiety and mood disorders.
j. Average age of onset is 23.
k. Chronic course in 80 percent of cases.
l. Differential diagnosis is important.
m. Depersonalization symptoms can signal decompensation.
n. Psychotic states often show early depersonalization symptoms.
o. Case Study: A Foggy Student.
Key Terms
alter identities conversion disorder
depersonalization
depersonalization/derealization disorder
derealization
dissociation
dissociative amnesia
dissociative disorders
dissociative fugue
dissociative identity disorder (DID)
factitious disorder
factitious disorder imposed on another host identity
hypochondriasis
hysteria
implicit memory
implicit perception
malingering
pain disorder
posttraumatic theory (of DID)
primary gain
secondary gain
sociocognitive theory (of DID)
soma
somatic symptom disorders
somatization disorder
somatoform disorders