- Mental disorders characterized by physical symptoms for which no physical basis can be found.

- Several distinct types exist according to the DSM IV:

Hypochondriasis:  Severe anxiety (fear of illness) is focused on the possibility of having a serious disease.  The threat seems so real that no amount of medical reassurance seems to help.

- Not surprisingly, hypochondriasis shares many features with anxiety disorders, particularly panic disorder.

- I.e., hypochondriasis and panic disorder have: a similar age of onset; a strong familial component; and similar personality characteristics.

- Thus, both disorders often occur in the same individual (comorbidity).

- Hypochondriasis is characterized by anxiety or fear that one has a serious disease.   Therefore the core problem is anxiety, but the expression is different from that of OCD or other anxiety disorders.

- Expression concerns bodily functions.  Almost any physical sensation is a concern.  Some individuals focus on normal bodily functions (i.e., heart rate, or perspiration), others on minor abnormalities (i.e., cough, dry skin), while other complain of vague symptoms (aches or fatigue).

- Another important feature of the disorder is medical reassurance that one is well and for the most part healthy.  And, at most, their problem is only a short-term effect.

- Despite these medical reassurances persons with hypochondriasis often find themselves in another doctor's office.  They assume that the first doctor may have missed something.

- Hypochondriasis is different from an 'illness phobia' in this respect.  Persons with an illness phobia will avoid places of contamination (i.e., a doctor's office) and do not think that they have a specific disorder.  Hypochondriacs often seek medical attention and mistakenly believe that they have a current disorder.  Thus, hypochondriacs display higher rates of checking physical symptoms and feel good when a symptom matches the disorder they believe they have.  Often (60%) person's with illness phobia will go on to develop hypochondriasis or panic disorder.

- You may be thinking that hypochondriasis and panic disorder are the same thing, since persons with panic disorder often misinterpret physical symptoms as the beginning of a panic attack.

- While they are similar, persons with hypochondriasis seem to focus on the long-term process of illness and fatigue, while individuals with panic typically fear immediate symptoms.

- Also persons with panic disorder often stop going to doctors and emergency rooms.

- The symptomology of panic usually focuses on 10-15 symptoms associated with the sympathetic nervous system; hypochondrial symptoms and fears are much broader.

- Minor physical complaints that seemingly do not have a physical basis often occur in kids.  The majority of these complaints are usually passing responses to stress and do not develop into full-blown chronic hypochondriasis.

- It is estimated that between 4-9 % of medical patients have the disorder (major strain on health care system)

- It is equally common in males and females.

- Does not seem to be overly represented in any demographic (i.e., it is not more common in the elderly).

- Hypochondriasis can occur at any point in life, but seems to have peak periods (adolescence, middle-age (40-50), and after 60).

- In China, a disorder similar to hypochondriasis is Koro.  A belief that ones genitals are retracting into the abdomen.  Why, does this occur in China more than other cultures?

- Importance of sexual functioning in Chinese males. 

Causes: 

- Most experts point to a disorder of cognition or perception with strong emotional contributions as  a likely basis for hypochondriasis.  Thus, the person's faulty interpretation of physical signs and sensations as evidence of physical is at the heart of the illness.

- Like all of us, persons with hypochondriasis experience physical sensations, but they quickly focus their attention on these sensations.  Focusing causes arousal to increase and the sensations become even more intense.  Combine this with a tendency to misinterpret these symptoms as signs of illness, and your state of anxiety will increase even further.  This, in turn, will lead to additional symptoms.  A vicious circle. 

- Stroop tests show that persons with hypochondriasis have enhanced perceptual sensitivity to illness cues.

- What causes this pattern of distorted beliefs and somatic sensitivity?

-  We don't know for sure, but the fundamental causes are likely similar to those in anxiety disorders:

- Genetic predisposition for an enhanced response to stress;

- Tendency to view negative life events as unpredictable and uncontrollable and thus be guarded against at all times.

- In childhood, kids may learn from family members to focus their anxiety on specific physical conditions and illnesses.

- In most cases the following are present:

- Seems to develop in context of a stressful life event;

- Persons tend to have a disproptionate incidence of illness in their family;

- Social and interpersonal influence is common (i.e., increased attention).

Treatment:

- Not a lot of scientific research.

- In a study by Warwick et al. (1996), 76% of persons in CBT treatment improved.   Only 5% of the control group improved.

- What would CBT involve?

- Indentifying and challenging illness-related misinterpretation of physical sensations and on showing patients how they can create symptoms by focusing attention on certain body areas.

- The process of bringing on their own symptoms gives patients a sense of control over their symptoms. 

-  Also want to coach patients to seek less reassurance regarding their concerns.

- Why?

-  Drugs like prozac do seem to help.  However, there are few controlled studies.

Somatization Disorder (Briquet's syndrome):

- Typically the patient presents with a history of diverse physical complaints usually before 30 years that appear to be psychological in origin.  Thus, somatization is very similar to hypochondriasis.

-  The main difference between somatization and hypochondriasis is fear.   Persons with somatization disorder tend to be less afraid.  Patients tend to be more concerned with the symptoms they have, and not with what they mean.

- Thus, the person's life and identity is often their symptoms.  Patients often report that without their symptoms they would not know who they were!

-  Persons with somatization disorder often have few friends since they find it difficult to to relate to people except in terms of their symptoms.  Most of their friends are health care providers.

- Onset of the disorder is usually in adolescence.

- Occurs more often in women (2:1), who are unmarried and from a lower socioeconomic group.

- Individuals with somatization disorder also have psychological complaints, i.e., mood or anxiety disorders.

- Suicide attempts that appear to be manipulative gestures rather than true attempts are common.

Causes:

- Tends to be more common in women whose fathers were steady drinkers; the sons of steady drinkers tend to drink steadily.

- Thus, the genes that predispose a man to become a steady-drinking alcoholic (antisocial type), seem to predispose a woman to develop somatization disorder.

- Can you think of how the social/family environments may lead females to somatization and males to drinking?

- A family illness or injury during childhood seems to be a predisposing factor.   However, this probably plays a minor role, since many families experience these events without passing on the sick role.

Treatment:

- Somatization is very difficult to treat and no treatments seem to 'cure' the disorder.

- Treatments are aimed at: a) providing reassurance; b) reducing stress; c) reducing the frequency of help-seeking behaviour; d) interacting more effectively with other people.

-  These types of treatment do not seem to improve the patient's mental or physical health, but did help to reduce the frequency of help-seeking.  This is important since it reduces the tremendous cost to health care systems.

Conversion Disorder:

- Type of somatoform disorder in which the healthy body organs are perceived as defective.  Appears as though some neurological disease is affecting the sensory-motor systems.

- e.g., Tommy (Pin-Ball Wizard): goes deaf, blind and mute after seeing his mother’s lover kill his father.

- Patients can display seizures which may be psychological since no abnormal EEG patterns can be found.

- It is often difficult to distinguish between conversion reactions and malingering (faking).  However, the following may help;

1) La belle indifference (beautiful indifference).  Persons with conversion disorder often don't seem to care that they have lost their vision or hearing.  This is often not the case in malingering.  (Be very careful when using this approach, why?)

2) Conversion disorders are often precipitated by stress.

3) Persons with conversion disorder can usually function normally.  For example, persons with conversion blindness can often avoid things in their path (or play pin-ball) but they say they can't see the objects.  May this (conversion disorder) be the basis for miraculous cures at religious ceremonies?  Persons who are faking usually function abnormally.

-  It is estimated that at least 30% of persons diagnosed with conversion disorder do have a physical disorder. 

Munchausen's Syndrome or Factitious Disorders:

- The deliberate fabrication of physical or psychological complaints.  Thus, this is different from a somatoform disorder where individuals do not voluntarily create their symptoms.

- Often the complaints are plausible.  Thus, not surprisingly, many of the individuals who display this type of disorder are medical practitioners.

- These types of disorders seem to fall between conversion disorder and malingering.   They are feigned (pretend) and under voluntary control, but there seems to be no good reason why, except maybe to assume the sick role and receive increased attention.   With malingering the motivation is often financial (compensation) and with conversion disorder there seems to be an unconscious and involuntary cause.

- In some cases, adults with factitious disorders may purposely make their children sick to gain attention and pity.  This is termed factitious disorder by proxy, or Munchausen's syndrome by proxy.

Causes of Conversion Disorders:

- Unconscious Mental Processes:

- An underlying feature of conversion disorder is escape from a traumatic event (war, impossible personal situation).  And since escape behaviour is usually socially unacceptable, the alternative of getting sick is unconsciously substituted.  This unconscious substitution is then maintained by reinforcement (see below). 

- Conversion disorders may be maintained by both positive and negative reinforcement:

a) positive reinforcement: sympathy and attention from loved ones or authority figures;

b) negative reinforcement: removed from perceived threatening situations.

- We now know that we are capable of processing information in all sensory systems without being aware of it.  How do we know this? Cortical lesioning experiments.   Thus, perhaps many persons with conversion have actual physical problems that lead to their impairments.

- Social and cultural influences also appear to contribute to conversion disorder.   Conversion disorder occurs more in less educated groups, and in groups with lower socioeconomic status.  The knowledge about disease is less well developed in these groups.  Interestingly, the incidence of conversion disorder and somatization disorder has declined over the last 20 years.  Any theories?

Treatment:

- Very few studies have systematically looked at different treatments.

- Most treatments typically follow the thinking on etiology.  That is:

- Identify and attend to the stressful life event, even if not present (i.e., memory).

- Remove the positive reinforcement: Attention and sympathy from loved ones; do not allow the client to avoid a difficult task or situation.

-  These types of treatments tends to help in the short-term (3-months), but relapse is very common after a year.

- Do you wish you could change part of your appearance?  Most people fantasize about improving something, but some relatively normal-looking people imagine they are so ugly that they cannot interact with others and thus cannot function normally.  They may have body dysmorphic disorder (BDD), or 'imagined ugliness'.

- Many people with this disorder have either a fixation or phobia with mirrors.

- Suicidal thinking is a frequent consequence of this disorder.  This leads to inreased suicide attempts and to successful suicide in many cases.  Thus, it is not to be taken lightly.

- Often these individuals have "ideas of reference".  They think that everything that goes on in the world is related to them and their imagined defect.   Thus, many are given a second diagnosis of delusional disorder.

- Often persons with BDD become housebound, and few get married.

- Tends to develop during between 13 and 25, with the peak around 18 or 19.

- Generally seems to occur more in females in North America (about 60%); but in Japan it appears to be more common in males (about 60%). 

- Culture determines what is beautiful and what is deformed.  Thus, culture is thought to play a large role in the development of BDD.  Can you think of any examples?

- Some New Guinea tribes: the front teeth are knocked out, or filed to sharp points.

- Burma: women wear brass neck rings to stretch their neck.

- China: Old practice of bindings girls' feet, since small feet was associated with beauty and grace.  Any parallels to Cinderella?

Causes and Treatment:

- We know very little about the causes and treatement of BDD.

- We don't know if it runs in families, thus it is hard to investigate a genetic contribution.

- We do not yet have enough meaningful information of psychological predisposing factors or vulnerabilities.

- We do know that it frequently occurs with OCD.

- We also know that drugs that block the reuptake of serotonin (prozac) and CBT helps both people with OCD and BDD. 

- Thus, BDD may eventually be defined as a variant of OCD.

- Dose surgery cure BDD? 

- Answer is probably no!  Persons with BDD are often unsatisfied with their surgery and return for additional surgery, or they have some other perceived 'defect' altered.

- These types of disorders are characterized by sudden alterations in consciousness, identity, or motor behaviour.

- Persons feel detached from themselves or their surroundings.  It may appear as though they are living in slow motion or are dreamimg.

- Theses types of experiences may happen occasionally to many of us.  Can you think of examples?

- Often these types of experiences happen after an extremely stressful event, i.e., accidence, marital breakup or fight.

- However, these events can also happen when you're very tried or under physical or mental stress (i.e., long-distance running, cramming all night).  For most, these types of dissociations are ususally not to bothersome because you know the cause.   For some, however, these events can be very frightening.

- Dissociative symptoms can include:

1) disturbed sense of time (time seems to stand still or move very quickly);

2) perception of reality is altered (things around you seem unreal or feel like you're in a dream);

3) altered emotions (can feel estranged or distanced from others or even your own emotions).

- Often dissociative experiences can be divided into 2 types:

1) depersonalization: where you temporarily lose sense of your own reality (reality, experience, and one's identity may seem to disintegrate).

2) derealization: where you temporarily lose the sense of reality for the external world (things to seem change shape or size, people may appear dead or mechanical).

- Dissociation in influenced by social and cultural factors:

- In some cultures the ability to dissociate is praised or considered to be a basic emotional pattern.  Can you think of examples?

- Amok and dissociative trance disorder.

- However, when dissociation begins to result in distress and impairment it becomes pathological.  Interestingly, the expression of pathology with dissociation does not vary too much from the norms established and sanctioned by society.

- Amnesia for a certain period of time;

- Appears to be an active motivation to forget;

- Usually occurs after experiencing severe stress, trauma, or incidences when an individual had to violate their own standards.

- Can occur in two forms: Generalized Amnesia- where individuals cannot remember anything including who they are.  In some cases this can be life-long!  Localized or Specific Amnesia - where individuals fail to recall certain events, usually during a traumatic event.  This type is common during war.

- Usually occurs in adulthood, but typically before age 50.

- Females are more likely than males to experience dissociative amnesia.

- Fugue literally means 'flight'.  Thus, this type of memory loss involves an unexpected trip.  Persons just take-off and find themselves in a new place.  It is usually precipitated by an intolerable situation in their lives.  Wouldn't you just like to do this sometimes?

- Often these individuals take on new identities and new lives;

- Like dissociative amnesia, fugue states usually begin in adulthood and are more common in females.

- These states tend to end rather abruptly, and the person remembers most of what happened.

- Characterized by an individual possessing two or more distinct personalities;

- Pesons can adopt as many as 100 different identities, called alters, all coexisting!   The average number appears to be about 15.

- In terms of the DSM IV, the number of personalities is relatively unimportant, the defining feature of the disorder is the dissociation of certain aspects of the person's personality.

- This is the reason the term multiple personality was changed to dissociative identity disorder (DID) in the DSM IV.

- In some cases each personality comes to prominence at different times and for different lengths of time;

- Often each personality has its own set of behaviours, tone of voice, facial expressions and gestures.

- In other cases, only a few characteristics are distinct because the identities are only partially independent.

- It is more common, than not, for the host (the identity who asks for treatment--this is usually not the individual's original personality), not to be aware of the alters.   Thus, there is not much sharing of information.

- Generally people seek help because they begin to forget or lose part of their day (black-out);

- Often the personalities are very different:

- Many patients have at least one impulsive alter that handles sexuality and generates income (often by acting as a prostitute).  At the other extreme, some patients and all their alters may abstain from sex.

- Cross-gender alters are common, i.e., a small fragile woman may have a large male alter, who protects her.

- A gatekeeper is also common.

- For example, Nancy shared her body with 13 others, some include: the actress, the flirt, the nun, the moralist, the kid, a mischievous 5-year-old, Marsha who faints (stress), Richard (the gatekeeper), Alice who is suicidal;

- Moving between alters, called a switch, is usually seemless and instantaneous, but some physical transformations may occur during switches (i.e., posture, facial features, disabilities, even handedness)

- Much more common in females than males (9:1), but this is based on clinical cases.   Some researchers contend that many males with DID may be institutionalized (i.e., prison populations).

- Onset is almost always in childhood, usually betweem 4-7 years of age.  The window of development for DID  however, seems to close at about 9.  That is, DID is unlikely to develop after 9 years of age.  Do you remember any of your developmental personality theory?  Does this make sense?  Is the child's ability to distinguish between reality and fantasy now complete?

- The disorder tends to last a lifetime, unless untreated.

- The frequency of switching tends to decrease over time.  Does this make sense? Why?

- Until not long ago the disorder was thought to be rare 1 in 10000 people.  More recent estimates suggest that the disorder may occur in 0.5 - 1 % of the general population; and as high as 5% in severly disturbed patients.

- Not surprisingly, a very large percentage of DID patients also suffer from other psychological disorders; the most common include: substance abuse; depression; somatization; borderline personality; panic attacks, and eating disorders.

- Since auditory hallucinations are common in DID (you hear other voices in your head), it is often misdiagnosed as a psychotic disorder.  There is one main difference in the voices however: in DID the voices appear to come from inside the head; whereas psychotic patients often report the voices are coming from outside or in the environment.   Also DID patients often know they are hallucinating and as a result do not report their hallucinations and try to suppress them.

- These individuals usually have very high IQS and score high on tests of creativity.

- Interestingly, each personality presents with a unique EEG (brain-wave) pattern, and score very differently on standardized test of personality.

- This is not the case in very good actors playing a role.

Causes

- In almost every case (about 97%) the person experienced physical and/or sexual abuse during early childhood;

- Apparently the other personalities arose as a defence against the abuse, or a way to cope with this trauma.

- What else could a child do?  They cannot run away or fight back.  They have no way of knowing that this terrible pain is abnormal or wrong.  But they can escape into a fantasy world.  If escape reduces the trauma, it is rewarding, and is likely to occur again.  You do whatever it takes to get through life.

- DID and PTSD seem to have a lot in common.  Both feature a strong emotive reaction to trauma.  However, only those with a psychological vulnerability to anxiety (exaggerated stress response) appear to develop PTSD.