This is the 2007 version. Click here for the 2017 chapter 12 table of contents.

Somatoform, Dissociative, and Factitious Disorders

Axis 1 of DSM-IV includes a category called somatoform disorder s. A somatoform disorder is a psychological problem that takes on a physical form. We will consider five types of somatoform disorder: (1) somatization disorder, (2) conversion disorder, (3) pain disorder, (4) hypochondriasis, and (5) body dysmorphic disorder.

What are somatoform disorders?

The most general type of somatoform disorder is the somatization disorder. A person with a somatization disorder will have many vague medical complaints, but repeated medical investigations reveal no known physical cause. Often somatization disorder begins in early childhood or adolescence. A child or teenager may develop stomach aches, headaches, or other bodily complaints that seem to reflect a stressful situation at home or school rather than a medical problem. Notice the difference between somatoform disorders (a general category) and somatization disorder, a specific type of somatoform disorder. For obvious reasons, students often confuse the two.

What is distinctive about conversion disorder?

The conversion disorder, another type of somatoform disorder, occurs when physical symptoms bear an obvious symbolic relationship to some traumatic event. Typically the physical symptoms involve a loss of functioning, for example, a paralyzed limb, inability to smell, or blindness. The problem is precipitated by stress and seems to be an attempt to escape some trouble or problem.

One student had an uncle who "made himself deaf" to avoid war sounds.

My uncle was one of the men who went to the Vietnam War and was fortunate enough to come home alive. He was not quite the same person that he was when he left, though. You see, there were times when he would have flashbacks of what I guess were bad experiences. These, at first, were very mild. Even though they were being treated, as time went by they got worse (or so it seemed to all of us). I never heard him say so myself, but my other uncles said that he claimed to hear people screaming over and over and loud war-like sounds. When this happened he would go into a mental hospital in Missouri. We were later informed that he was losing his sense of hearing without a reason. That didn't mean much to me before but after reading this chapter, I realized that maybe he made himself go deaf in order not to hear these sounds he heard. Unfortunately his deafness did not prevent what he was hearing, which was all in his mind. His sight was also being affected but he never really went blind. About six months later my uncle committed suicide. [Author's files]

What treatments often work with conversion disorder?

Conversion Disorder often responds well to treatments that emphasize belief or involvement of imagination, such as hypnosis and placebo treatments. An example is the case of "Anna O." described in Chapter 13. She suffered a variety of ailments related symbolically to traumatic events. In 1860 this was called hysteria. Her symptoms were eliminated one by one, under hypnosis, by leading her to remember the psychologically painful events that caused them.

How is pain disorder often treated, using behavior therapy?

Pain disorder is chronic (long-term) pain without biological cause. The disorder often starts with a genuine injury. After the biological wound is healed, the pain continues. Some psychologists see this as a learning process. The patient learns to feel pain. Behavior therapies based on this assumption have been very successful. The pain is accepted as real, not imaginary, but the patient is taught to ignore it, stop complaining, and resume activity, while phasing out pain medication. This therapy usually works well, if a patient is brave enough to see it through to the end. Many patients resist the idea that they can get along without pain medication and unlearn their pain, however. Dropouts from such programs are common. Patients who do not like the behavioral approach can usually find a different type of clinic or a doctor who will supply them with powerful pain-killing medications. The behavioral treatment of pain is described in more detail in Chapter 14 as an example of behavioral medicine.

What is hypochondriasis?

Hypochondriasis is an obsession with imagined illnesses. It is characterized not by a fear of sickness but a certainty one is sick. Whereas a person with somatization disorder will have numerous physical complaints, a hypochondriac is likely to be obsessed with a specific illness. Hypochondriacs often become "doctor shoppers" as they look for a physician willing to confirm their suspicions.

What sorts of things do "closet hypochondriacs" do?

In recent years psychologists have come to recognize that mild versions of hypochondria are widespread in the normal, non-clinical population. So-called closet hypochondriacs are extremely health-conscious individuals who may perform daily rituals that consume hours. They examine their bodies in detail, looking for lumps or other signs of disease, monitoring the frequency and quality of their bowel movements, and otherwise administering to themselves. They tend to become involved in health fads. Meister (1980) reports another characteristic trait:

...One common denominator of the hypochondriac personality has been noted by observers almost without exception: hypochondriacs are highly unsure of themselves, and they live in a striking dependency relationship to a parent or parent substitute.

What is body dysmorphic disorder?

Body dysmorphic disorder, historically known as "dysmorphobia," is a somatoform disorder in which a person is preoccupied with a defect in appearance which may be entirely imaginary or based on some minor problem that other people hardly notice.

Schrof (1991) describes one case:

Every day is a nightmare for David X. Rather than going to work or to school, the 30-year-old gets only as far as his bedroom mirror, where he finds a hideously distorted face-a crooked, swollen nose covered with scars, a bulging eye. After four cosmetic surgeries, the defects remain. David quit college and moved home to his parents 10 years ago when he first began to see a repulsive image in the mirror. Since then, he has rarely left his room, afraid to let anyone catch sight of him.

How can a BDD sufferer get a plastic surgeon to operate on imaginary defects? Does surgery relieve the problem?

Schrof adds, "David's story is doubly tragic because the flaws he sees exist not on his face, but in his mind." Remarkably, he was able to convince plastic surgeons to operate on his defects, even though they were only imaginary; probably because they thought he was exaggerating his problems and only wanted minor improvements in an otherwise normal face. To David, however, the "hideous, distorted face" was real and did not change after the surgeries. Body dysmorphic disorder (BDD) often responds to anti-depressive drugs that encourage synthesis of the neurotransmitter serotonin.

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