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Somatoform disorder
From Wikipedia, the free encyclopedia Somatoform disorder | Classification and external resources | ICD-10 | F45 | ICD-9 | 300.8 | DiseasesDB | 1645 | eMedicine | med/3527 | MeSH | D013001 |
In psychology, a somatoform disorder is a mental disorder characterized by physical symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition, direct effect of a substance, or attributable to another mental disorder (e.g. panic disorder).[1] The symptoms that result from a somatoform disorder are due to mental factors. In people who have a somatoform disorder, medical test results are either normal or do not explain the person's symptoms. Patients with this disorder often become worried about their health because the doctors are unable to find a cause for their health problems. This causes severe stress, due to preoccupations with the disorder that portrays an exaggerated belief about the severity of the disorder. [2]Symptoms are sometimes similar to those of other illnesses and may last for several years. Usually, the symptoms begin appearing during adolescence, and patients are diagnosed before the age of 25 years. [3]
Somatoform disorders are not the result of conscious malingering (fabricating or exaggerating symptoms for secondary motives) or factitious disorders (deliberately producing, feigning, or exaggerating symptoms) – sufferers perceive their plight as real. Additionally, a somatoform disorder should not be confused with the more specific diagnosis of a somatization disorder. Mental disorders are treated separately from physiological or neurological disorders. Somatoform disorder is difficult to diagnose and treat since doing so requires psychiatrists to work with neurologists on patients with this disorder. [4] Contents [hide] * 1 Recognized somatoform disorders * 2 Proposed somatoform disorders * 3 See also * 4 References * 5 External links |
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[edit]Recognized somatoform disorders
The somatoform disorders are actually a group of disorders, all of which fit the definition of physical symptoms that mimic physical disease or injury for which there is no identifiable physical cause. They are recognized by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association as the following:[1] * Conversion disorder * Somatization disorder * Hypochondriasis * Body dysmorphic disorder * Pain disorder * Undifferentiated somatoform disorder – only one unexplained symptom is required for at least 6 months.
Included among these disorders are false pregnancy, psychogenic urinary retention, and mass psychogenic illness (so-called mass hysteria). * Somatoform disorder Not Otherwise Specified (NOS)[5]
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[edit]Proposed somatoform disorders
Additional proposed somatoform disorders are: * Abridged somatization disorder[6] – at least 4 unexplained somatic complaints in men and 6 in women * Multisomatoform disorder[3] – at least 3 unexplained somatic complaints from the PRIME-MD scale for at least 2 years of active symptoms
These disorders have been proposed because the recognized somatoform disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:[7] * Somatization disorder – 1% * Abridged somatization disorder – 6% * Multisomatoform disorder – 24% * Undifferentiated somatoform disorder – 69%

Conversion disorder is a neurosis marked by the appearance of physical symptoms such as partial loss of muscle function without physical cause but in the presence of psychological conflict. Symptoms include numbness, blindness, paralysis, or fits without a neurological cause. It is thought that these problems arise in response to difficulties in the patient's life, and conversion is considered apsychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV).[1]
Formerly known as "hysteria", the disorder has arguably been known for millennia, though it came to greatest prominence at the end of the 19th century, when the neurologists Jean-Martin Charcot and Sigmund Freud and psychiatrist Pierre Janet focused their studies on the subject. The term "conversion" has its origins in Freud's doctrine that anxiety is "converted" into physical symptoms.[2] Though previously thought to have vanished from the west in the 20th century, some research has suggested it is as common as ever.[3]
The DSM-IV classifies conversion disorder as a somatoform disorder while the ICD-10 classifies it as a dissociative disorder. Contents [hide] * 1 Definition * 2 History * 3 Presentation * 4 Mass Psychogenic Illness * 5 Diagnosis * 5.1 Exclusion of neurological disease * 5.2 Exclusion of feigning * 5.3 Establishing a psychological mechanism * 6 Causes * 7 Epidemiology * 7.1 Prevalence * 7.2 Culture * 7.3 Gender * 7.4 Age * 8 Treatment * 9 Prognosis * 10 See also * 11 References |
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[edit]Definition
DSM-IV defines conversion disorder as follows: * One or more symptoms or deficits are present that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition. * Psychological factors are judged, in the clinician's belief, to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit. A diagnosis where the stressor precedes the onset of symptoms by up to 15 years is not unusual. * The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). * The symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally sanctioned behavior or experience. * The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. * The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by anothermental disorder.
The nature of the association between the psychological factors and the neurological symptoms remains unclear. Earlier versions of the DSM-IV employed psychodynamic concepts, but these have been incrementally removed from successive versions.
The tenth revision of the World Health Organization's International Classification of Diseases uses the term "conversion" as an alternative descriptor for the dissociative disorders class of mental and behavioural disorders (i.e. the F44 class), with the explicit suggestion that dissociative and conversion symptoms probably share common psychological mechanisms.[4] In ICD-10, the dissociative [conversion] disorders class includes 10 disorders that, in addition to specific criteria for each individual disorder, must each meet the following general criteria: * No evidence of a physical disorder that can explain the symptoms that characterize the disorder (but physical disorders may be present that give rise to other symptoms); * Convincing associations in time between the symptoms of the disorder and stressful events, problems or needs.[4]
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[edit]History
In the 19th century, physicians such as Silas Weir Mitchell in the US and Paul Briquet and Jean-Martin Charcot in France developed ideas about patients sharing unexplained neurological symptoms. Charcot specialised in treating patients who were suffering from a variety of unexplained physical symptoms including paralysis, contractures (muscles which contract and cannot be relaxed) and seizures. Some of these patients sporadically and compulsively adopted a bizarre posture (christened arc-de-cercle) in which they arched their body backwards until they were supported only by their head and their heels.
The term "Conversion disorder" originated with Freud. He viewed these apparently neurological symptoms as a result of the conversion of intrapsychic distress into physical symptoms. This distress was thought to cause the brain to unconsciously disable or impair a bodily function as a side effect of the original repression, which served to relieve the patient's anxiety.[5]However, recent evidence suggests that patients do remain distressed by their symptoms in the long term[6]
It has also been suggested that at least some of the classic psychoanalytic cases of hysteria, such as "Anna O.",[7] may actually have suffered from organic illness. In fact, in Studies On Hysteria in which Breuer's Anna O. case was first presented, Freud wrote this: "Others of the patient's symptoms were not of a hysterical nature at all. This is true, for example, of the neck cramps, which I consider a modified version of migraine and which as such are not to be classified as a neurosis but as an organic disorder. Hysterical symptoms, however, regularly become attached to these." Freud believed that all hysterical symptoms ultimately have some organic components.[8]
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[edit]Presentation
Conversion disorder can present with any motor or sensory symptom including any of the following: * Weakness/paralysis of a limb or the entire body (hysterical paralysis or motor conversion disorders) * Impaired vision (hysterical blindness) or impaired hearing * Loss/disturbance of sensation * Impairment or loss of speech (hysterical aphonia) * Psychogenic non-epileptic seizures * Fixed dystonia unlike normal dystonia[clarification needed] * Tremor, myoclonus or other movement disorders * Gait problems (Astasia-abasia) * Syncope (fainting) * Hallucinations of a childish or fantastical nature * Tourette-like symptoms
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[edit]Mass Psychogenic Illness
Main article: Mass Psychogenic Illness
The DSM-IV-TR does not have specific diagnosis for Mass Psychogenic Illness but the text describing conversion disorder states that "In 'epidemic hysteria,' shared symptoms develop in a circumscribed group of people following 'exposure' to a common precipitant."
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[edit]Diagnosis
The diagnosis of conversion disorder involves three elements: the exclusion of neurological disease, the exclusion of feigning, and the determination of a psychological mechanism. Each of these has difficulties.
[edit]Exclusion of neurological disease
Conversion disorder presents with symptoms that typically resemble a neurological disorder such as stroke, multiple sclerosis, epilepsy or hypokalemic periodic paralysis. The neurologist must carefully exclude neurological disease, through examination and appropriate investigations.[9] However, it is not uncommon for patients with neurological disease to also have conversion disorder[10].
In excluding neurological disease, the neurologist has traditionally relied partly on the presence of positive signs of conversion disorder — certain aspects of the presentation that were thought to be rare in neurological disease, but common in conversion. The validity of many of these signs has been questioned, however, by a study showing that they also occurred in neurological disease.[11] One such symptom, for example, is La belle indifférence, described in DSM-IV as "a relative lack of concern about the nature or implications of the symptoms". In a later study no evidence was found that patients with "functional" symptoms are any more likely to exhibit this than patients with a confirmed organic disease.[12]
Another feature thought to be important was that symptoms would tend to be more severe on the non-dominant (usually left) side; there were a variety of theories such as the relative involvement of cerebral hemispheres in emotional processing, or more simply just that it was "easier" to live with a functional deficit on the non-dominant side. However, a literature review of 121 studies established that this was not true, with publication bias the most likely explanation for this commonly held view.[13] Although agitation is often assumed to be a positive sign of conversion disorder, release of epinephrine is a well-demonstrated cause of paralysis from hypokalemic periodic paralysis[14].
The process of exclusion is not perfect, so misdiagnoses will occur. However, in a highly influential[15] study from the 1960s, Eliot Slater demonstrated that misdiagnoses had occurred in one third of his 112 patients with conversion disorder.[16] Later authors have argued that the paper was flawed, however,[6][17] and a meta-analysis has shown that misdiagnosis rates since that paper are around 4%, the same as for other neurological diseases.[18]
[edit]Exclusion of feigning
Conversion disorder is unique in DSM-IV in explicitly requiring the exclusion of deliberate feigning. Unfortunately, this is only likely to be demonstrable where the patient confesses, or is "caught out" in a broader deception, such as a false identity.[19] One neuroimaging study suggested that feigning may be distinguished from conversion by the pattern of frontal lobe activation;[20] however this is a research, rather than a clinical technique. True rates of feigning in medicine remain unknown, though neurological presentations of feigning may be among the more common.[21]
[edit]Establishing a psychological mechanism
The psychological mechanism can be the most difficult aspect of the conversion diagnosis. DSM-IV requires that the clinician believe preceding stressors or conflicts to be associated with the development of the disorder, though how this might come about is still the subject of debate.
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[edit]Causes
The original Freudian model[2] suggested that the emotional charge of painful experiences would be consciously repressed as a way of managing the pain, but this emotional charge would be somehow "converted" into the neurological symptoms. Freud later argued that the repressed experiences were of a sexual nature.[22] As Peter Halligan comments, conversion has 'the doubtful distinction among psychiatric diagnoses of still invoking Freudian mechanisms'[23]
Janet, the other great theoretician of hysteria, argued that symptoms arose through the power of suggestion, acting on a personality vulnerable to dissociation.[24] In this hypothetical process, the subject's experience of their leg, for example, is split-off from the rest of their consciousness, resulting in paralysis or numbness in that leg. Later authors have attempted to combine elements of these models, but none of them has a firm empirical basis.[25]
Some support for the Freudian model comes from findings of high rates of childhood sexual abuse in conversion patients[26] and from a recent neuroimaging study showing abnormal emotion processing of a traumatic event linked to motor processing of the affected limb, in a patient with conversion.[27] Support for the dissociation model comes from studies showing heightened suggestibility in conversion patients,[28] and in abnormalities in motor imagery.[29]
There has been much recent interest in functional neuroimaging in conversion. As researchers identify the mechanisms which underlie conversion symptoms it is hoped these will allow the development of a neuropsychological model. A number of such studies have been performed, including some which suggest that blood flow in patients brains may be abnormal while they are unwell. These have all been too small to be confident of the generalisability of their findings, however, so no neuropsychological model has been clearly established.
A 2007 review stated that conversion disorder and dissociative disorders are statically associated, share features such as a history of abuse and high suggestability, and likely have common underlying causes. It recommended that DSM should follow ICD-10 and reclassify conversion disorder from a somatoform disorder to a dissociative disorder.[30]
An evolutionary psychology explanation for conversion disorder is that the symptom may have been evolutionarily advantageous during warfare. A non-combatant with these symptoms signals non-verbally, possibly to someone speaking a different language, that she or he is not dangerous as a combatant and also may be carrying some form of dangerous infectious disease. This can explain that conversion disorder may develop following a threatening situation, that there may be a group effect with many people simultaneously developing similar symptoms (as in Mass Psychogenic Illness), and the gender difference in prevalence.[31]
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[edit]Epidemiology
[edit]Prevalence
Information on the prevalence of conversion disorder in the West is limited, in part due to the complexities of the diagnostic process. In neurological settings, rates of unexplained symptoms are very high, at between 30 and 60%,[32][33][34] which suggests conversion to be more common than most neurological diseases. However, the diagnosis of conversion typically requires an additional psychiatric evaluation, yet few patients will see a psychiatrist[35] so an unknown fraction of those unexplained symptoms will be due to conversion. Large scale psychiatric registers in the US and Iceland found rates of 22 and 11 per 100,000 per year, respectively,[36] but it is unclear what proportion of unexplained symptoms these represent.
[edit]Culture
It is often thought that rates are higher outside of the West, perhaps related to cultural and medical attitudes, though evidence for this is again limited.[3] A community survey of urban Turkey found a rate of 5.6%.[37] Many authors have found rates to be higher in rural and lower socio-economic groups where technological investigation of patients is limited.[38][39][40]
[edit]Gender
'Hysteria' was originally understood to be a condition exclusively affecting women, though it has increasingly been recognised in men. In recent, larger studies,[32][41] women continue to predominate, with between 2 and 6 female patients for every male.
[edit]Age
Conversion disorder may present at any age but is rare in children younger than 10 years or in the elderly. Studies suggest a peak onset in the mid-to-late 30s.[32][42][43]
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[edit]Treatment
Treatment may include the following:[44] 1. Explanation. This must be clear and coherent as attributing physical symptoms to a psychological cause is not accepted by many educated people in western cultures. It must emphasise the genuineness of the condition, that it is common, potentially reversible and does not mean that the sufferer is a "psycho". Taking an aetiologically neutral stance by describing the symptoms as functional may be helpful but further studies are required. Ideally, the patient should be followed up neurologically for a while to ensure that the diagnosis has been understood. 2. Physiotherapy where appropriate; 3. Occupational Therapy to maintain autonomy in activities of daily living;[45] 4. Treatment of comorbid depression or anxiety if present.
There is little evidence-based treatment of conversion disorder.[46][Full citation needed] Other treatments such as cognitive behavioral therapy, hypnosis, EMDR, and psychodynamic psychotherapy need further trials.
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[edit]Prognosis
The DSM-IV-TR states that conversion symptoms will in most cases disappear within 2 weeks in those hospitalized. One-fifth to one-quarter will have a recurrence within a year with this also predicting future recurrences. Acute onset, clearly identifiable stress at this time, and short time between onset and treatment are associated with a favorable prognosis.

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Somatization disorder
From Wikipedia, the free encyclopedia Somatization disorder, Psycosomatic Symptoms | Classification and external resources | ICD-10 | F45.0 | ICD-9 | 300.81 | DiseasesDB | 1645 | MedlinePlus | 000955 | eMedicine | ped/3015 | MeSH | D013001 |
Somatization disorder (also Briquet's syndrome or hysteria) is a somatoform disorder characterized by recurring, multiple, clinically significant complaints about pain, gastrointestinal, sexual and pseudoneurological symptoms. Those complaints must begin before the individual turns 30 years of age,[1] and could last for several years, resulting in either treatment seeking behavior or significant treatment.[2]Individuals with somatization disorder typically visit many doctors in pursuit of effective treatment. Somatization disorder also causes challenge and burden on the life of the caregivers or significant others of the patient. Contents [hide] * 1 Diagnosis * 2 Prevalence and Comorbidity * 3 Explanations * 3.1 Neuroimaging Evidence * 4 Treatments * 5 References * 6 See also |
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[edit]Diagnosis
The DSM-IV-TR diagnostic criteria are:[1] * A history of somatic complaints over several years, starting prior to the age of 30. * At least four different sites of pain on the body, AND at least two gastrointestinal problems, AND one sexual dysfunction, AND one pseudoneurological symptom. * Such symptoms cannot be fully explained by a general medical condition or substance use OR, when there is an associated medical condition, the impairments due to the somatic symptoms are more severe than generally expected. * Complaints are not feigned as in malingering or factitious disorder.
The symptoms do not all have to occur at the same time, but may occur over the course of the disorder. A somatization disorder itself is chronic but fluctuating that rarely remits completely. A thorough physical examination of the specified areas of complaint is critical for Somatization disorder diagnosis. Medical examination would provide object evidence of subjective complaints of the individual.[1]
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[edit]Prevalence and Comorbidity
Somatization disorder is uncommon in the general population. It is thought to occur in 0.2% to 2% of females,[3][4][5][6] and 0.2% of males. Research showed cultural differences in prevalence of somatization disorder. For example, somatization disorder and symptoms were found to be significantly more common in Puerto Rico.[7]
There is usually co-morbidity with other psychological disorders, particularly mood disorders or anxiety disorders.[1][8] Research also showed comorbidity between somatization disorder and personality disorder, especially antisocial, borderline, narcissistic, histrionic, avoidant, and dependent personality disorder.[9]
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[edit]Explanations
Although somatization disorder has been studied and diagnosed for more than a century, there is debate and uncertainty regarding its pathophysiology. Most current explanations focus on the concept of a misconnection between the mind and the body. Widely held theories on this troublesome, often familial disorder fit into three general categories.
The first and one of the oldest theories is that the symptoms of somatization disorder represent the body’s own defense against psychological stress. This theory states that the mind has a finite capacity to cope with stress and strain. Therefore, increasing social or emotional stresses beyond a certain point are experienced as physical symptoms, principally affecting the digestive, nervous, and reproductive systems. In recent years, researchers have found connections between the brain, immune system, and digestive system which may be the reason why somatization affects those systems and that people with Irritable bowel syndrome are more likely to get somatization disorder.[1] This theory also helps explain why depression is related to somatization. It is also experienced in very high levels in women with a history of physical, emotional or sexual abuse[10]
The second theory for the cause of somatization disorder is that the disorder occurs due to heightened sensitivity to internal physical sensations. Some people have the ability to feel even the slightest amount of discomfort or pain within their body. With this hypersensitivity, the patient would sense pain that the brain normally would not register in the average person such as minor changes in one's heartbeat. Somatization disorder would then be very closely related to panic disorder under this theory. However, not much is known about hypersensitivity and its relevance to somatization disorder. The psychological or physiological origins of hypersensitivity are still not well understood by experts.
The third theory is that somatization disorder is caused by one’s own negative thoughts and overemphasized fears. Their catastrophic thinking about even the slightest ailments such as thinking a cramp in their shoulder is a tumor, or shortness of breath is due to asthma, could lead those who have somatization disorder to actually worsen their symptoms. This then causes them to feel more pain for just a simple thing like a headache. Often the patients feel like they have a rare disease. This is because their doctors would not be able to have a medical explanation for their unconsciously exaggerated pain that the patient actually thinks is there. This thinking that the symptom is catastrophic also often reduces the activities they normally do. They fear that doing activities that they would normally do on a regular basis would make the symptoms worse. The patient slowly stops doing activities one by one until they practically shut themselves from a normal life. With nothing else to do it leaves more time to think about the “rare disease” they have and consequently ending in greater stress and disability.[11]
[edit]Neuroimaging Evidence
A recent review of the cognitive–affective neuroscience of somatization disorder suggested that catastrophization in patients with somatization disorders tend to present a greater vulnerability to pain. The relevant brain reigns include the dorsolateral prefrontal, insular, rostral anterior cingulate, premotor, and parietal cortices.[12][13]
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[edit]Treatments
To date, cognitive behavioral therapy (CBT) is the best established treatment for a variety of somatoform disorders including somatization disorder.[14][15][16] CBT helps with the patient realizing that the ailments are not as catastrophic and enabling them to slowly get back to doing activities that they once were able to do without fear of “worsening their symptoms.” Consultation and collaboration with the primary care physician also demonstrated some effectiveness.[16][17] The use of antidepressants is preliminary but not yet show conclusive evidence.[16][18] Electroconvulsive shock therapy (ECT) has been used in treating somatization disorder among the elderly; however, the results were still debatable with some concerns around the side effects of using ECT.[19] Overall, Psychologists recommend addressing a common difficulty in patients with somatization disorder in the reading of their own emotions. This may be a central feature of treatment; as well as developing a close collaboration between the GP, the patient and the mental health practitioner[20]
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Hypochondriasis
From Wikipedia, the free encyclopedia
For the anatomical term, see Hypochondrium. | This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Seetalk page for details. Unsourced material may be challenged and removed. (June 2009) |

Hypochondriasis | Classification and external resources | ICD-10 | F45.2 | ICD-9 | 300.7 | MeSH | D006998 |
Hypochondriasis or hypochondria (sometimes referred to as health phobia or health anxiety) refers to excessive preoccupation or worry about having a serious illness.[1] This debilitating condition is the result of an inaccurate perception of the body’s condition despite the absence of an actual medical condition.[2] An individual suffering from hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical symptoms they detect, no matter how minor the symptom may be. They are convinced that they have or are about to have a serious illness.[3] Often, hypochondria persists even after a physician has evaluated a person and reassured them that their concerns about symptoms do not have an underlying medical basis or, if there is a medical illness, their concerns are far in excess of what is appropriate for the level of disease. Many hypochondriacs focus on a particular symptom as the catalyst of their worrying, such as gastro-intestinal problems, palpitations, or muscle fatigue. The duration of these symptoms and preoccupation is 6 months or longer.[4]
The DSM-IV-TR defines this disorder, "Hypochondriasis," as a somatoform disorder[5] and one study has shown it to affect about 3% of the visitors to primary care settings.[6]
Hypochondria is often characterized by fears that minor bodily symptoms may indicate a serious illness, constant self-examination and self-diagnosis, and a preoccupation with one's body. Many individuals with hypochondriasis express doubt and disbelief in the doctors' diagnosis, and report that doctors’ reassurance about an absence of a serious medical condition is unconvincing, or un-lasting. Additionally, many hypochondriacs experience elevated blood pressure, stress, and anxiety in the presence of doctors or while occupying a medical facility, a condition known as "white coat syndrome." Many hypochondriacs require constant reassurance, either from doctors, family, or friends, and the disorder can become a disabling torment for the individual with hypochondriasis, as well as his or her family and friends. Some hypochondriacal individuals completely avoid any reminder of illness, whereas others frequently visit doctors’ surgeries. Other hypochondriacs will never speak about their terror, convinced that their fear of having a serious illness will not be taken seriously by those in whom they confide. Contents [hide] * 1 Characteristics * 2 Diagnosis * 3 Cause * 4 Treatment * 5 See also * 6 References * 7 External links |
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[edit]Characteristics
Hypochondriac Syndrome is categorized as a somatic amplification disorder— a disorder of "perception and cognition" [2] that involves a hyper-vigilance of the bodys situation and a tendency to react to the initial perceptions in a negative manner that is further debilitating. Hypochondriasis manifests in many ways. Puri B. K, Laking P.J, Treasaden I.H, (2000) states that hypochondriasis can manifest at any age, but usually between the ages of 20 and 30 years.[dubious – discuss] Some people have numerous intrusive thoughts and physical sensations that push them to check with family, friends and physicians. Other people are so afraid of any reminder of illness that they will avoid medical professionals for a seemingly minor problem, sometimes to the point of becoming neglectful of their health when a serious condition may exist and go undiagnosed. Again, some people are afraid of getting a disease because they have a disease. Yet, some others live in despair and depression, certain that they have a life-threatening disease and no physician can help them. Some consider the disease as a punishment for past misdeeds.[7]
Hypochondriasis is often accompanied by other psychological disorders. Clinical depression, obsessive-compulsive disorder (also known as OCD), phobias and somatization disorder are the most common accompanying conditions in people with hypochondriasis, as well as a generalized anxiety disorder diagnosis at some point in their life.[8] Autism/Aspergers can be another sign of this.[clarification needed]
Many people with hypochondriasis experience a cycle of intrusive thoughts followed by compulsive checking, which is very similar to the symptoms of obsessive-compulsive disorder. However, while people with hypochondriasis are afraid of having an illness, patients with OCD worry about getting an illness or of transmitting an illness to others.[7] Although some people might have both, these are distinct conditions.
Patients with hypochondriasis often are not aware that depression and anxiety produce their own physical symptoms that might be mistaken for signs of a serious medical disease. For example, people with depression often experience changes in appetite and weight fluctuation, fatigue, decreased interest in sex and motivation in life overall. Intense anxiety is associated with rapid heart beat, palpitations, sweating, muscle tension, stomach discomfort, and numbness or tingling in certain parts of the body (hands, forehead, etc.).[citation needed]
Some people suggest that hypochondriasis is a "mild form" of paranoid schizophrenia, as patients tend to show a paranoid framework in which the target is their body]]. Also, the persistent paranoid feeling about illness can be regarded as delusion from reality. Patients with hypochondriasis have shown a remarkable response to atypical antipsychoticsmedication, but much research needs to be done in this field.
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[edit]Diagnosis
The ICD-10 defines hypochondriasis as follows:
A. Either one of the following: * A persistent belief, of at least six months duration, of the presence of a maximum of two serious physical diseases (of which at least one must be specifically named by the patient). * A persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder).
B. Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living, and leads the patient to seek medical treatment or investigations (or equivalent help from local healers).
C. Persistent refusal to accept medical advice that there is no adequate physical cause for the symptoms or physical abnormality, except for short periods of up to a few weeks at a time immediately after or during medical investigations.
D. Most commonly used exclusion criteria: not occurring only during any of the schizophrenia and related disorders (F20-F29, particularly F22) or any of the mood disorders (F30-F39).
The DSM-IV defines hypochondriasis according to the following criteria:[5]
A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as inBody Dysmorphic Disorder).
D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.
F. The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.
It may be further specified as "with poor insight if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable."[5]
A proposed change in the next revision of the DSM (DSM-5), scheduled for publication in May 2013, would combine hypochondriasis with somatization disorder, pain disorder, and undifferentiated somatoform disorder under a single classification known as complex somatic symptom disorder.[9]
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[edit]Cause
Cyberchondria is a colloquial term for hypochondria in individuals who have researched medical conditions on the Internet. The media and the Internet often contribute to hypochondria, as articles, TV shows and advertisements regarding serious illnesses such as cancer and multiple sclerosis (some of the diseases hypochondriacs commonly think they have)[citation needed]often portray these diseases as being random, obscure and somewhat inevitable. Inaccurate portrayal of risk and the identification of non-specific symptoms as signs of serious illness contribute to exacerbating the hypochondriac’s fear that they actually have that illness.
Major disease outbreaks or predicted pandemics can also contribute to hypochondria. Statistics regarding certain illnesses, such as cancer, will give hypochondriacs the illusion that they are more likely to develop the disease. A simple suggestion of mental illness can often trigger one with hypochondria to obsess over the possibility[citation needed].
It is common for serious illnesses or deaths of family members or friends to trigger hypochondria in certain individuals. Similarly, when approaching the age of a parent's premature death from disease, many otherwise healthy, happy individuals fall prey to hypochondria. These individuals believe they are suffering from the same disease that caused their parent's death, sometimes causing panic attacks with corresponding symptoms.
A majority of people who experience physical pains or anxieties over non-existent ailments are not actually "faking it", but rather, experience the natural results of other emotional issues, such as very high amounts of stress. “ | Grief that finds no vent in tears makes other organs weep. | ” | —Dr. Henry Maudsley, British psychiatrist |
Family studies of hypochondriasis do not show a genetic transmission of the disorder. Among relatives of people suffering from hypochondriasis only somatization disorder and generalized anxiety disorder were more common than in average families.[7] Other studies have shown that the first degree relatives of patients with OCD have a higher than expected frequency of a somatoform disorder (either hypochondriasis or body dysmorphic disorder).[10]
Some anxieties and depressions are believed to be mediated by problems with brain chemicals such as serotonin and norepinephrine. The physical symptoms that people with anxiety or depression feel are indeed real bodily symptoms, and are believed to be triggered by neurochemical changes. For example, too much norepinephrine will result in severe panic attacks with symptoms of increased heart rate and sweating, shortness of breath, and fear. Too little serotonin can result in severe depression, accompanied by a sleep disturbance, severe fatigue, and typically is treatable with medical intervention.[citation needed]
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[edit]Treatment
If a person is ill with a medical disease such as diabetes or arthritis, there will often be psychological consequences, such as depression. Some even report being suicidal. In the same way, someone with psychological issues such as depression or anxiety will sometimes experience physical manifestations of these affective fluctuations, often in the form of medically unexplained symptoms. Common symptoms include headaches; abdominal, back, joint, rectal, or urinary pain; nausea; fever and/or night sweats; itching; diarrhea; dizziness; or balance problems. Many people with hypochondriasis accompanied by medically unexplained symptoms feel they are not understood by their physicians, and are frustrated by their doctors’ repeated failure to provide symptom relief. Common to the different approaches to the treatment of hypochondriasis is the effort to help each patient find a better way to overcome the way his/her medically unexplained symptoms and illness concerns rule her/his life. Current research makes clear that this excessive worry can be helped by either appropriate medicine or targeted psychotherapy.
Recent scientific studies have shown that cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs; e.g., fluoxetine and paroxetine) are effective treatment options for hypochondriasis as demonstrated in clinical trials.[11][12][13][14][15] CBT, a psycho-educational “talk” therapy, helps the worrier to address and cope with bothersome physical symptoms and illness worries and is found helpful in reducing the intensity and frequency of troubling bodily symptoms. SSRIs can reduce obsessive worry through adjusting neurotransmitter levels and have been shown to be effective as treatments for anxiety and depression as well as for hypochondriasis.
Another treatment that has proved effective in the treatment of hypochondriasis is exposure therapy. In one study, this was shown to be equally as effective as cognitive therapy and the improvements in condition were maintained after the study.[16]

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Body dysmorphic disorder
From Wikipedia, the free encyclopedia Body Dysmorphic Disorder | Classification and external resources | ICD-10 | F45.2 | ICD-9 | 300.7 | DiseasesDB | 33723 | eMedicine | med/3124 |
Body Dysmorphic Disorder (BDD, also body dysmorphia, dysmorphic syndrome; originally dysmorphophobia) is a type of mental illness, a somatoform disorder, wherein the affected person is exclusively concerned with body image, manifested as excessive concern about and preoccupation with a perceived defect of their physical features.[1] [2] The person complains of a defect in either one feature or several features of their body; or vaguely complains about their general appearance, which causes psychological distress that impairs either occupational or social functioning, or both. Occasionally, BDD occurs to the degree of causing severe emotional depression and anxiety, and the possible development of other anxiety disorders, social withdrawal, or social isolation.[3]
The causes of Body Dysmorphic Disorder are different for each person, usually a combination of biological, psychological, and environmental factors from either the person's past or present life. Furthermore, mental and physical abuse, and emotional neglect, are life-experiences that can contribute to a person developing BDD.[4][5] The onset of the symptoms of a mentally unhealthy preoccupation with body image occurs either in adolescence or in early adulthood, whence begins self-criticism of the personal appearance, from which develop atypical aesthetic-standards derived from the internal perceptualdiscrepancy between the person's ‘actual self’ and the ‘ideal self’.[6] The symptoms of body dysmorphia include psychological depression, social phobia, and obsessive compulsive disorder. Even causing the effected to become hostile towards family members for no reason is accepted as a symptom.[7]
As a form of mental illness, BDD is linked to a diminished quality of life, can be co-morbid with major depressive disorder and social phobia (chronic social anxiety); features a suicidal ideation rate of 80 percent, in extreme cases linked with dissociation, and thus can be considered a factor in the person's attempting suicide.[8] BDD can be treated with eitherpsychotherapy or psychotropic medication, or both; moreover, cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are effective treatments.[9][10]Although originally a mental-illness diagnosis usually applied to women, Body Dysmorphic Disorder occurs equally among men and women, and occasionally in children and older adults. About 76% of parents think their child is either over conceited or simply lying about their condition. [11] Approximately one-to-two percent (1–2%) of the world's population might meet the diagnostic criteria for a diagnosis of Body Dysmorphic Disorder. [12] Contents [hide] * 1 Overview * 2 Symptoms * 2.1 Symptoms * 2.2 Compulsive behaviors * 2.3 Common locations of perceived defects * 2.4 Comorbidity * 3 Causes * 3.1 Psychological * 3.2 Environmental * 3.3 Personality * 4 Diagnoses * 5 Treatment * 6 Prognosis * 7 Epidemiology * 8 History * 9 See also * 10 References * 10.1 Footnotes * 10.2 Notations * 11 Further reading * 12 External links |
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[edit]Overview
The Diagnostic and Statistical Manual of Mental Disorders defines body dysmorphic disorder as a somatoform disorder marked by a preoccupation with an imagined or trivial defect in appearance that causes clinically significant distress or impairment in social, occupational or other important areas of functioning. The individual's symptoms must not be better accounted for by another disorder; for example, weight concern is usually more accurately attributed to an eating disorder.
The disorder generally is diagnosed in those who are extremely critical of their mirror image, physique or self-image, even though there may be no noticeable disfigurement or defect. The three most common areas of which those suffering from BDD will feel critical have to do with the face: the hair, the skin, and the nose. Outside opinion will typically disagree and may protest that there even is a defect. The defect exists in the eyes of the beholder, and one with BDD really does feel as if they see something there that is defective.
People with BDD say that they wish that they could change or improve some aspect of their physical appearance even though they may generally be of normal or even highly attractive appearance. Body dysmorphic disorder causes sufferers to believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation about their appearance. This can cause those with this disorder to begin to seclude themselves or have trouble in social situations. More extreme cases may cause a person to develop love-shyness, a chronic avoidance of all intimate relationships. They can become secretive and reluctant to seek help because they fear that seeking help will force them to confront their insecurity. They feel too embarrassed and unwilling to accept that others will tell the sufferer that they are suffering from a disorder. The sufferer believes that fixing the "deformity" is the only goal, and that if there is a disorder, it was caused by the deformity. In extreme cases, patients report that they would rather suffer from their symptoms than be 'convinced' into believing that they have no deformity. It has been suggested that fewer men seek help for the disorder than women.[13]
BDD is often misunderstood as a vanity-driven obsession, whereas it is quite the opposite; people with BDD do not believe themselves to be better looking than others, but instead feel that their perceived "defect" is irrevocably ugly or not good enough. People with BDD may compulsively look at themselves in the mirror or, conversely, cover up and avoid mirrors. They typically think about their appearance for at least one hour a day (and usually more) and, in severe cases, may drop all social contact and responsibilities as they become a recluse.
A German study has shown that 1–2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (Psychological Medicine, vol. 36, p. 877). Chronic low self-esteem is characteristic of those with BDD, because the assessment of self-value is so closely linked with the perception of one's appearance.
BDD is diagnosed equally in men and women and causes chronic social anxiety for its sufferers.[14]
Phillips & Menard (2006) found the completed-suicide rate in patients with BDD to be 45 times higher than that of the general United States population. This rate is more than double that of those with clinical depression and three times as high as that of those with bipolar disorder.[15] Suicidal ideation is also found in around 80% of people with BDD.[16] There has also been a suggested link between undiagnosed BDD and a higher-than-average suicide rate among people who have undergone cosmetic surgery.[17]
It may be difficult to distinguish BDD from accurate (and justifiably emotionally fraught) self-perception by a perceptive individual who is actually physically disfigured in some way that would be acknowledged by others. This is a societally awkward topic, as we have a tendency today to use inclusive and supportive language in discussing body form. However, it must be acknowledged that humans do judge others' faces and bodies according to standards or spectra of physical attractiveness; that these judgements are not arbitrary but when studied tend to indicate general preference for such properties as symmetry and proportions close to the population average. There may be a tendency to over-diagnose BDD rather than to acknowledge this "unjust" or unfair aspect of human existence and human relations. It should be pointed out in this regard that the descriptions of the disorder hedge on the question of whether there is possibly actual disfigurement. "may be no noticeable disfigurement" "though they may generally be of normal or even highly attractive appearance". The use of the term "perceived defect" in the diagnostic definition does not distinguish between an accurately or inaccurately perceived defect, and this may lead to over-diagnosis, because BDD can only be a psychiatric disorder if in essence it is based on a misperception. In short, "emotional distress caused by rationally perceived body dysmorphia" should be categorized and treated differently than "misperceived or self-exaggerated body dysmorphia".
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[edit]Symptoms
There are many common symptoms and behaviors associated with BDD. Often these symptoms and behaviors are determined by the nature of the BDD sufferer's perceived defect; for example, use of cosmetics is most common in those with a perceived skin defect. Due to this perception dependency many BDD sufferers will only display a few common symptoms and behaviors.
[edit]Symptoms
Common symptoms of BDD include: * Obsessive thoughts about (a) perceived appearance defect(s). * Obsessive and compulsive behaviors related to (a) perceived appearance defect(s) (see section below). * Major depressive disorder symptoms. * Delusional thoughts and beliefs related to (a) perceived appearance defect(s). * Social and family withdrawal, social phobia, loneliness and self-imposed social isolation. * Suicidal ideation. * Anxiety; possible panic attacks. * Chronic low self-esteem. * Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect(s). * Strong feelings of shame. * Avoidant personality: avoiding leaving the home, or only leaving the home at certain times, for example, at night. * Dependent personality: dependence on others, such as a partner, friend or family. * Inability to work or an inability to focus at work due to preoccupation with appearance. * Problems initiating and maintaining relationships (both intimate relationships and friendships). * Alcohol and/or drug abuse (often an attempt to self-medicate). * Repetitive behavior (such as constantly (and heavily) applying make-up; regularly checking appearance in mirrors; see section below for more associated behavior). * Seeing slightly varying image of self upon each instance of observing a mirror or reflective surface. * Perfectionism (undergoing cosmetic surgery and behaviors such as excessive moisturizing and exercising with the aim to achieve an ideal body type and reduce anxiety). * Note: any kind of body modification may change one's appearance. There are many types of body modification that do not include surgery/cosmetic surgery. Body modification (or related behavior) may seem compulsive, repetitive, or focused on one or more areas or features that the individual perceives to be defective.
[edit]Compulsive behaviors
Common compulsive behaviors associated with BDD include: * Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces. * Alternatively, an inability to look at one's own reflection or photographs of oneself; also, the removal of mirrors from the home. * Attempting to camouflage the imagined defect: for example, using cosmetic camouflage, wearing baggy clothing, maintaining specific body posture or wearing hats. * Use of distraction techniques: an attempt to divert attention away from the person's perceived defect, e.g. wearing extravagant clothing or excessive jewelry. * Excessive grooming behaviors: skin-picking, combing hair, plucking eyebrows, shaving, etc. * Compulsive skin-touching, especially to measure or feel the perceived defect. * Becoming hostile toward people for no known reason, especially those of the opposite sex, or same sex if homosexual. * Seeking reassurance from loved ones. * Excessive dieting or exercising, working on outside appearance. * Self-harm * Comparing appearance/body parts with that/those of others, or obsessive viewing of favorite celebrities or models whom the person suffering from BDD wishes to resemble. * Compulsive information-seeking: reading books, newspaper articles and websites that relate to the person's perceived defect, e.g. hair loss or being overweight. * Obsession with plastic surgery or dermatological procedures, often with little satisfactory results (in the perception of the patient). * In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results. * Excessive enema use (if obesity is the concern).
[18]
[edit]Common locations of perceived defects
In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows; * Skin (73%) * Hair (56%) * Weight (55%) * Nose (37%) * Toes (36%) * Abdomen (22%) * Breasts/chest/nipples (21%) * Eyes (20%) * Thighs (20%) * Teeth (20%) * Legs (overall) (18%) | * Body build/bone structure (1.5%) * Facial features (general) (1.4%) * Face size/shape (20%) * Lips (12%) * Buttocks (12%) * Chin (11%) * Eyebrows (11%) * Hips (11%) * Ears (9%) * Arms/wrists (9%) | * Waist (9%) * Genitals (8%) * Cheeks/cheekbones (8%) * Calves (8%) * Height (7%) * Head size/shape (6%) * Forehead (6%) * Feet (6%) * Hands (6%) * Jaw (6%) | * Mouth (6%) * Back (6%) * Fingers (5%) * Neck (5%) * Shoulders (3%) * Knees (3%) * Ankles (2%) * Facial muscles (1%) |
[19]
People with BDD often have more than one area of concern. Please, pay attention to anyone who has BDD. It may even eventually become suicidal.
[edit]Comorbidity
There is comorbidity with other psychological disorders, which often results in misdiagnoses by medical individuals. New research indicates that around 76% of people with BDD will experience major depressive disorder at some point in their lives,[20][citation needed] significantly higher than the 10–20% expected in the general population. Nearly 36% of people with BDD will also produce agoraphobia[20] and around 32% are also affected by obsessive–compulsive disorder.[20]
The most common disorders found in individuals with BDD are avoidant personality disorder, social phobia, social anxiety disorder, borderline personality disorder and dependent personality disorder, which conforms to the introverted, shy and neurotic traits usually found in BDD sufferers. Eating disorders are also sometimes found in people with BDD, as aretrichotillomania, dermatillomania, and sub-type disorders Olfactory Reference Syndrome and muscle dysmorphia.[20]
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[edit]Causes
BDD usually develops in teenagers, a time when individuals are most concerned about the way they look to others. However, many patients suffer for years before seeking help. There is no single cause of body dysmorphic disorder; research shows that a number of factors may be involved and that they can occur in combination. BDD can be associated with eating disorders, such as compulsive overeating, anorexia nervosa or bulimia, or it can be more of a phobia, associated instead with social phobia or social anxiety disorder. * Obsessive–compulsive disorder.
BDD can often occur with OCD, where the patient practices unmanageable habitual behaviors that may literally take over their life. A history of, or genetic predisposition to obsessive–compulsive disorder may make people more susceptible to BDD. Other phobias like social phobia or social anxiety disorder may also be co-occurring.
[edit]Psychological
* Teasing or criticism:
It has been suggested that teasing or criticism regarding appearance could play a contributory role in the onset of BDD. While it is unlikely that teasing causes BDD, likewise, extreme levels of childhood abuse, bullying and psychological torture are often rationalized and dismissed as "teasing," sometimes leading to traumatic stress in vulnerable persons.[21] Around 60% of people with BDD report frequent or chronic childhood teasing.[21] * Parenting style:
Similarly to teasing, parenting style may contribute to BDD onset; for example, parents who either place excessive emphasis on aesthetic appearance, or disregard it altogether, may act as a trigger in the genetically-predisposed.[21] * Other life experiences:
Many other life experiences may also act as triggers to BDD onset; for example, neglect, physical and/or sexual trauma, insecurity and rejection.[21]
[edit]Environmental
* Media:
It has been theorized that media pressure may contribute to BDD onset; for example, glamour models and the implied necessity of aesthetic beauty. However, BDD occurs in all parts of the world, including isolated areas where access to media is limited or (practically) non-existent. Media pressure is therefore an unlikely cause of BDD, although it may act as a trigger in those already genetically predisposed or could worsen existing BDD symptoms.[22]
[edit]Personality
Certain personality traits may make someone more susceptible to developing BDD. Personality traits which have been proposed as contributing factors include: [23] * Perfectionism * Introversion / shyness * Neuroticism * Sensitivity to rejection or criticism * Unassertiveness * Avoidant personality * Schizoid personality * Shyness * Social phobia * Social anxiety disorder
Since personality traits among people with BDD vary greatly, it is unlikely that these are the direct cause of BDD. However, like the aforementioned psychological and environmental factors, they may act as triggers in individuals.[23]
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[edit]Diagnoses
According to the DSM IV to be diagnosed with BDD a person must fulfill the following criteria: * "Preoccupation with an imagined or slight defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive." * "The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." * "The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)."[24]
In most cases, BDD is under-diagnosed. In a study of 17 patients with BDD, BDD was noted in only five patient charts, and none of the patients received an official diagnosis of BDD.[25]This under-diagnosis is due to the disorder only recently being included in DSM IV; therefore, clinician knowledge of the disorder, particularly among general practitioners, is not widespread.[26]
Also, BDD is often associated with shame and secrecy; therefore, patients often fail to reveal their appearance concerns for fear of appearing vain or superficial.[26]
BDD is also often misdiagnosed because its symptoms can mimic that of major depressive disorder or social phobia.[27] and so the cause of the individual's problems remain unresolved.
Many individuals with BDD also do not possess knowledge or insight into the disorder and so regard their problem as one of a physical rather than psychological nature; therefore, individuals suffering from BDD may seek cosmetic treatment rather than mental health treatment.
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[edit]Treatment
Studies have found that cognitive behavior therapy (CBT) has proven effective. In a study of 54 BDD patients who were randomly assigned to cognitive behavior therapy or no treatment, BDD symptoms decreased significantly in those patients undergoing CBT. BDD was eliminated in 82% of cases at post treatment and 77% at follow-up.[28]
Due to believed low levels of serotonin in the brain, another commonly used treatment is SSRI drugs (selective serotonin reuptake inhibitors). 74 subjects were enrolled in a placebo-controlled study group to evaluate the efficiency of fluoxetine (Prozac); patients were enrolled in a 12-weeks, double-blind, randomized study. At the end of treatment, 53% of patients responded to the fluoxetine.[29]
A combined approach of cognitive behavior therapy (CBT) and anti-depressants is more effective than either alone. The dose of a given anti-depressant is usually more effective when it exceeds the maximum recommended doses that are given for obsessive compulsive disorder (OCD) or a major depressive episode.
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[edit]Prognosis
Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Plastic surgery on these patients can lead to manifest psychosis, suicidal tendencies or never-ending requests for more surgery. [30][31] Treatment can improve the outcome of the illness for most people. However, some may function reasonably well for a time and then relapse, while others may remain chronically ill. Outcome without therapy has not been researched but it is thought the symptoms persist unless treated.[citation needed]
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[edit]Epidemiology
Studies show that BDD is common in not only non-clinical settings but clinical settings as well. A study was performed on 200 people with DSM-IV Body Dysmorphic Disorder, being of age 12 or older and being available to be interviewed in person. They were referred by mental health professionals, friends and relatives, non-psychiatric physicians or responded to advertisements. Out of the subjects, 53 were receiving medication, 33 were receiving psychotherapy, and 48 were receiving both medication and psychotherapy.
The severity of BDD was assessed using the Yale–Brown Obsessive Compulsive Scale modified for BDD, and symptoms were assessed using a Body Dysmorphic Disorder Examination Sheet. Both tests were designed specifically to assess BDD. The results showed that BDD occurs in 0.7–1.1% of community samples and 2–13% of non-clinical samples. 13% of psychiatric inpatients were diagnosed with BDD.[32] Some of the patients initially diagnosed with obsessive-compulsive disorder (OCD) had BDD, as well.
53 patients with OCD and 53 patients with BDD were compared on clinical features, comorbidity, family history, and demographic features. Nine of the 62 subjects (14.5%) of those with OCD also had BDD.[33]
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[edit]History
The disorder was first documented in 1886 by the researcher Morselli, who dubbed the condition "dysmorphophobia". BDD was recognized by the American Psychiatric Association in 1987 and was recorded and formally recognized as a disorder in 1987 in the DSM-III-R. It has since been changed from "dysmorphophobia" to "body dysmorphic disorder" because the original implies a phobia of people, not a reluctance to interact socially because of poor body image.
In his practice, Freud had a patient who would today be diagnosed with the disorder: Russian aristocrat Sergei Pankejeff (nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity), had a preoccupation with his nose to such an extent it greatly limited his functioning. It even came to the point where "The Wolf Man" wouldn't go out in public for fear of being scrutinized by others around him.

Pain disorder is when a patient experiences chronic pain in one or more areas, and is thought to be caused by psychological stress. The pain is often so severe that it disables the patient from proper functioning. Duration may be as short as a few days or as long as many years. The disorder may begin at any age, and more women than men seem to experience it.[citation needed] This disorder often occurs after an accident or during an illness that has caused pain, which then takes on a 'life' of its own.[1] Contents [hide] * 1 Sub-diagnoses * 2 Causes * 3 Symptoms * 4 Treatment * 5 Prevention * 6 References * 7 See also |
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[edit]Sub-diagnoses
The DSM-4 specifies two coded subdiagnoses: pain disorder associated with psychological factors and pain disorder associated with both physiological factors and general medical condition.
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[edit]Causes
The causes of pain disorder appear to be complex, including organic or medical etiologies such as injury, peptic ulcer and fibromyalgia; stress caused by continuing, severe or badly managed pain; impairment, loss and emotional distress, all of which may be caused by and in turn increase pain; and related depression and anxiety.[2]
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[edit]Symptoms
Common symptoms of pain disorder are: negative or distorted cognition, such as feelings of despair or hopelessness; inactivity and passivity, in some cases disability; increased pain, sometimes requiring clinical treatment; sleep disturbance and fatigue; disruption of social relationships; depression and/or anxiety.[2]
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[edit]Treatment
Treatment may include psychotherapy (with cognitive-behavioral therapy or operant conditioning), medication (often with antidepressants but also with pain medications[3]), and sleep therapy. According to a study preformed at the University of Miami School of Medicine, antidepressants have an analgesic effect on patients suffering from pain disorder. In a randomized, placebo-controlled antidepressant treatment study, researchers found that "antidepressants decreased pain intensity in patients with psychogenic pain or somatoform pain disorder significantly more than placebo"[4] .Other techniques used in the management of chronic pain may also be of use; these include massage, transcutaneous electrical nerve stimulation, trigger point injections, surgical ablation, and non-interventional therapies such as meditation, yoga, and music and art therapy.[2]
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[edit]Prevention
Early intervention when pain first occurs or begins to become chronic offers the best opportunity for prevention of pain disorder.[2]

Factitious disorders are conditions in which a person acts as if he or she has an illness by deliberately producing, feigning, or exaggeratingsymptoms. Factitious disorder by proxy is a condition in which a person deliberately produces, feigns, or exaggerates symptoms in a person who is in their care. Münchausen syndrome is an older term for Factitious disorder. People with this condition may produce symptoms by contaminating urine samples, taking hallucinogens, injecting themselves with bacteria to produce infections, and other such similar behaviour. They might be motivated to perpetrate factitious disorders either as a patient or by proxy as a caregiver to gain any variety of benefits including attention, nurturance, sympathy, and leniency that are unobtainable any other way. Somatoform disorders are characterised by multiple somatic complaints.[1] Contents [hide] * 1 Motives * 2 Differential diagnosis * 3 Criteria * 3.1 Münchausen syndrome * 3.2 Münchausen by proxy * 3.3 Ganser syndrome * 4 Causes of factitious disorder * 5 Treatment * 6 Treatment of Münchausen by proxy * 7 Prognosis * 8 See also * 9 References * 9.1 Notes * 9.2 Bibliography * 10 External links |
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[edit]Motives
The motives of the patient can vary: for a patient with factitious disorder, the primary aim is to obtain sympathy, nurturance, and attention accompanying the sick role.[2] This is in contrast to malingering, in which the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty. Factitious disorder and malingering cannot be diagnosed in the same patient, and the diagnosis of factitious disorder depends on the absence of any other psychiatric disorder.[2] While they are both listed in the DSM-IV-TR, factitious disorder is considered a mental disorder, while malingering is not.[3]
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[edit]Differential diagnosis
Factitious disorders should be distinguished from somatoform disorders, in which the patient is truly experiencing the symptoms and has no intention to deceive. These disorders include body dysmorphic disorder, conversion disorder, somatization disorder, and pain disorder. In these conditions the patient believes he or she has a particular medical disorder and, like the Factitious disorder patient, may seek contact from multiple physicians, emergency departments, and hospitals. A person with factitious disorder often works in a medical environment.
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[edit]Criteria
Criteria for diagnosis includes intentionally fabricating (or faking) to produce physical or psychological signs or symptoms and the absence of any other mental disorder. Motivation for their behaviour must be to assume the 'sick role', and they do not act sick for personal gain as in the case of malingering sentiments. When the individual applies this pretended sickness to a dependent, for example a child, it is often referred to as 'factitious disorder by proxy.'
[edit]Münchausen syndrome
Münchausen syndrome, or Factitious disorder, has specified symptoms. Factitious disorder symptoms may seem exaggerated; individuals undergo major surgery repeatedly, and they 'hospital jump' or migrate in order to avoid detection.
[edit]Münchausen by proxy
Main article: Münchausen syndrome by proxy
The word 'proxy' means 'substitute'. It is coded in the DSM-IV under Factitious Disorder NOS (not otherwise specified). Münchausen by proxy is the involuntary use of another individual to play the patient role. For example, false symptoms are produced in children by the caregivers or parents (almost always mothers), to produce the appearance of illness, or they may give misleading medical histories about their children. The parent may falsify the child's medical history or tamper with laboratory tests in order to make the child appear sick. Occasionally, in Münchausen by proxy, the caregiver will actually injure the child to ensure that the child will be treated. Such parents enjoy the attention that they receive from having a sick child.
[edit]Ganser syndrome
Ganser syndrome was in the past regarded to be a separate factitious disorder. It is a reaction to extreme stress[citation needed] or an organic condition; the patient suffers from approximation or giving absurd answers to simple questions. The syndrome is sometimes diagnosed as merely malingering; however, it is more often defined as a Factitious disorder. This has been seen in prisoners following solitary confinement, and the symptoms are consistent in different prisons, though the patients do not know one another.
Symptoms include a clouding of consciousness, somatic conversion symptoms, confusion, stress, loss of personal identity, echolalia, and echopraxia. Individuals also give approximate answers to simple questions such as, "How many legs on a cat?" "Three"; "What's the day after Wednesday?" "Friday"; and so on. The disorder is extraordinarily rare with fewer than 100 recorded cases. While individuals of all backgrounds have been reported with the disorder, there is a higher inclination towards males (75% or more). The average age of those with Ganser syndrome is 32 and it stretches from ages 15–62 years old.
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[edit]Causes of factitious disorder
There are many possible causes for this disorder. One such possibility is an underlying personality disorder. Individuals with FD may be trying to repeat a satisfying childhood relationship with a doctor. Perhaps also an individual has a desire to deceive or test authority figures. The underlying desire to resume the role of a patient and to be cared for can also be considered an underlying personality disorder. Abuse in childhood is also another probable cause for the disorder. A background of neglect and abandonment may contribute to the development of FD.
These individuals may be trying to reenact unresolved issues with their parents. A history of frequent illnesses may also contribute to the development of this disorder. Perhaps individuals afflicted with FD are accustomed to actually being sick, and thus return to their previous state in order to recapture what was once considered to be the 'norm.' Another cause is a history of close contact with someone (a friend or family member) who had a severe or chronic condition. The patients found themselves subconsciously envious of the attention said relation received, and felt that they themselves faded into the background. Thus medical attention makes them feel glamorous and special.
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[edit]Treatment
No true psychiatric medications are prescribed for factitious disorder. However, selective serotonin reuptake inhibitors (SSRIs) can help manage underlying problems. Medicines such as SSRIs which are used to treat mood disorders can be used to treat FD, as a mood disorder may be the underlying cause of FD. Some authors (such as Prior and Gordon 1997) also report good responses to antipsychotic drugs such as Pimozide. Family therapy can also prove to be of assistance. In such therapy, families are helped to better understand patients (the individual in his or her family with FD) and his or her need for attention. In this therapeutic setting, the family is urged not to condone or reward the FD individual's behavior. This form of treatment can be unsuccessful if the family is uncooperative or displays signs of denial and/or antisocial disorder. Psychotherapy is another method used to treat the disorder. These sessions should focus on the psychiatrist's establishing and maintaining a relationship with the patient. Such a relationship may help to contain symptoms of FD. Monitoring is also a form that may be indicated for the FD patient's own good; FD (especially proxy) can prove to be very detrimental to an individual's health—if they are, in fact, causing true physiological illnesses. Even faked illnesses/injuries can be dangerous and might be monitored for fear that unnecessary surgery may subsequently be performed.
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[edit]Treatment of Münchausen by proxy
Treatment for FD proxy is not so subtle. Physicians who suspect the disorder should notify authorities immediately. Authorities will then initiate steps for immediate protection of the proxy (i.e. victim). Criminal charges may be deemed necessary. Many times, help may be sought for the caregiver with Münchausen by proxy as well as for the affected target. Careful monitoring of the family for an extended period of time is often a necessary precaution – with a goal of preventing either translocation or the insinuation of a possible upheaval of the detrimental disorder.
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[edit]Prognosis
Some individuals experience only a few outbreaks of the disorder. However, in most cases, factitious disorder is a chronic and long-term condition that is difficult to treat. There are relatively few positive outcomes for this disorder; in fact, treatment provided a lower percentage of positive outcomes than did treatment of individuals with obvious psychotic symptoms such as schizophrenics. In addition, many individuals with factitious disorder do not present for treatment, often insisting their symptoms are genuine. Some degree of recovery, however, is possible. The passage of time seems to help the disorder greatly. There are many possible explanations for this occurrence, although none are currently considered definitive. It may be that an FD individual has mastered the art of feigning sickness over so many years of practice that the disorder can no longer be discerned. Another hypothesis is that many times an FD individual will be placed in a home or experience health issues that are not self-induced or feigned. In this way, the problem with obtaining the 'patient' status is resolved because symptoms arise without any effort on the part of the individual.
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Attention seeking
From Wikipedia, the free encyclopedia
Enjoying the attention of others is quite socially acceptable. In some instances, however, the need for attention can lead to difficulties. The term attention seeking (or attention-seeking) is generally reserved for such situations where excessive and "inappropriate attention seeking" is seen.[1] Contents [hide] * 1 Styles * 2 In different pathologies or contexts * 3 Tactical ignoring * 4 See also * 5 References * 6 Further reading * 7 External links |
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[edit]Styles
The following styles of attention seeking have been identified:[2] * Extroverted positive overt style – associated with narcissism, bragging and boasting. May also include shocking exhibitionist behavior such as streaking. * Extroverted positive subdued style – similar but more subtle such as wearing designer clothes, wearing sexy clothes or dominating the conversation. * Extroverted negative overt style – to gain pity and reassurance. * Extroverted negative subdued style – making a negative statement to the world by, for example, dressing in an unusual style.

Victim playing (also known as playing the victim or self-victimization) is the fabrication of victim-hood for a variety of reasons such as to justify abuse of others, to manipulate others, a coping strategy or attention seeking. Contents [hide] * 1 By abusers * 2 By manipulators * 3 Other types * 4 In corporate life * 5 Transactional analysis * 6 Object relations * 7 See also * 8 References * 9 External links |
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[edit]By abusers
Victim playing by abusers is either: * diverting attention away from acts of abuse by claiming that the abuse was justified based on another person's bad behavior (typically the victim) * soliciting sympathy from others in order to gain their assistance in supporting or enabling the abuse of a victim (known as proxy abuse).
It is common for abusers to engage in victim playing. This serves two purposes: * justification to themselves – as a way of dealing with the cognitive dissonance that results from inconsistencies between the way they treat others and what they believe about themselves. * justification to others – as a way of escaping harsh judgment or condemnation they may fear from others.
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[edit]By manipulators
Manipulators often play the victim role ("poor me") by portraying themselves as victims of circumstances or someone else's behavior in order to gain pity or sympathy or to evokecompassion and thereby get something from another. Caring and conscientious people cannot stand to see anyone suffering, and the manipulator often finds it easy and rewarding to play on sympathy to get cooperation.[1]
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[edit]Other types
Victim playing is also: * an attention seeking technique (see for example Münchausen syndrome, Münchausen syndrome by proxy and Münchausen by Internet). * a strategy used by alcoholics to elicit constructive criticism, rescue, or enabling behavior from others[2]
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[edit]In corporate life
The language of "victim playing" has entered modern corporate life, with pundits expressing 'frustration around highly competent professionals who constantly played the victim in virtually every aspect of their careers...always someone else's fault'.[3] Taking the position that 'when someone plays the victim, they act as if they are powerless and not responsible for their actions...irresponsible and dishonest',[4] may be empowering; as may be the knowledge that 'individuals with boundary issues will play the victim, expect you to act in certain unstated ways based on how a parent or sibling treated them'.[5]
The danger is perhaps that, in the hustle of office politics, the term may be abused to penalize or victimize those to whom it is applied, on the principle of 'Dostoevsky's famous "knife that cuts both ways"': as Freud long since warned regarding the politicization of therapeutic language, 'the use of analysis as a weapon of controversy can clearly lead to no decision'.[6]
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[edit]Transactional analysis
Main article: Transactional analysis
Transactional analysis has devoted much attention to the idea of adopting the role of "Victim", as 'distinguished from the real victim. The Victim is someone who inauthentically behaves as if they are being victimised in situations where they actually have reasonable opportunities to alter the situation'.[7] Eric Berne had early explored the game of "Look How Hard I've Tried" - 'played from either of two positions: "I am helpless" or "I am blameless"' - as well as that of "Wooden Leg", characterised by 'such pleas as: what do you expect of a man who (a) comes from a broken home; (b) is neurotic; (c) is in analysis or (d) is suffering from a disease called alcoholism?'[8]
Subsequently TA developed the idea of the Karpman drama triangle, with role switches between Victim, Persecutor, and Rescuer. 'Judith (speaking as the victim of emotional troubles): Rescue me. Dr Q (speaking as a rescuer): I'll rescue you. Judith (switching into the role of a persecutor): Wise guy!'[9]
R. D. Laing considered that 'it will be difficult in practice to determine whether or to what extent a relationship is collusive' - when 'the one person is predominantly the passive "victim"',[10]and when they are merely playing the victim. The problem is intensified once a pattern of victimization has been internalised - for example, 'when the victim has learnt to perceive his universe in double bind terms'.[11]
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[edit]Object relations
Main article: Object relations theory
Object relations theory has explored the impact of the false self on neurotic personalities, in terms of 'the effects of the discordant source. The processes of their mind are always being interfered with and being cut off from the source of action, and so they are always victim'.[12] Such theorists emphasise that 'if one is preoocupied...[with] the false self, the sense is less of living one's life than of being at the mercy of fate'.[13] In addition, 'when the personality is victim to the discordant source, the subject feels victim to outside pressures...It is a false perception of my inner relation to the other object. I have no responder within'.[14]
To break out of 'the spell cast by the negative complex', and to escape the passivity of victimhood, requires you to 'develop a great deal of patience and tolerance in order to take responsibility for your desire and not blame another for failing you before you have fully tried'.[15]