Chapter 8 (Dissociative Disorders and Somatic-Symptom Related Disorders)

Page 1

Chapter 8 (Dissociative Disorders and Somatic-Symptom Related Disorders)

Both types of disorders tend to be associated with stressful experiences, not direct expressions of anxiety

Dissociative Disorders vs. Somatic-Symptom Related Disorders:

1) Dissociative: Disruptions of consciousness; loses self-awareness, memory, and identity

2) Somatic-Symptom Related: Bodily symptoms that suggest a physical defect or dysfunction (sometimes dramatic)

Sometimes has no physiological basis or the psychological reaction to the symptoms appears excessive

Both disorders tend to be comorbid

Dissociative Disorders

Three major dissociative disorders:

Depersonalization/derealization disorder

Dissociative amnesia

Dissociative identity disorder (DID) aka Multiple personality disorder

Core feature of all disorders: dissociation (involves some aspect of emotion, memory, or experience being inaccessible consciously)

Depersonalization/derealization:

Involves form of dissociation involving detachment (person feels removed from the sense of self and surroundings)

"Spaced out" or numb, similar to being in a dream state

Disconcerting and disruptive sense of detachment from one's self or surroundings

Depersonalization = being an observer outside one's body

Also common during panic attacks and marijuana intoxication

Derealization = detachment from one's surroundings, surroundings seem unreal

DSM-5 Symptoms:

Symptoms must be persistent or recurrent

Unlike the other dissociative disorders, this disorder involves no disturbance of memory

Symptoms cannot be explained by substances, another dissociative disorder, another psychological disorder, or by a medical condition

Often times linked to childhood trauma

Dissociative amnesia and DID:

More dramatic form of dissociation, person cannot access important aspects of memory

With DID, the gaps in memory are so extensive that the person loses all sense of having a unified identity

Dissociative amnesia typically triggered by a stressful event

Page 2

Somatic Symptom and Related Disorders:

Defined by excessive concerns about physical symptoms or health

Seek frequent medical treatment, sometimes at great expense

Often see several different physicians for a given health concern, and they may try many different medications

Hospitalization and surgery are common

They are dissatisfied when no medical explanation or cure can be identified

Diagnostic criteria has been criticized because...

These conditions are remarkably varied. Some people develop somatic symptoms in the context of anxiety and depressive disorders, whereas others do not. Some may have medical conditions that provoke the symptoms while others do not.

Somatic symptom disorder and illness anxiety disorder are defined by health concerns that are a cause of excessive anxiety or involve too much expenditure of time and energy. These are very subjective criteria. What is the threshold for too much concern or too much energy expenditure? Subjective nature may lead to overdiagnosis.

Patients often find the diagnosis of somatic symptom and related disorders to be stigmatizing. In hopes of reducing the stigma associated with diagnosis, the DSM-5 committee removed the criterion that symptoms be medically unexplained from somatic symptom disorder.

Concerns about somatic symptoms and illness anxiety tend to develop early in adulthood

The symptoms may wax and wane, and for some, recovery occurs naturally

Somatic symptom-related disorders tend to co-occur with anxiety disorders, mood disorders, substance use disorders, and personality disorders

More common in women than men

Somatic symptom disorder

Clinical description of somatic symptom disorder:

Excessive thought, distress, and behavior related to somatic symptoms

Even small physical concerns can be taken as a sign of looming disease

Others experience pain as the major concern

Can be diagnosed regardless of whether symptoms can be explained medically

Somatic symptoms may begin or intensify after some conflict or stress

May seem like person using somatic symptoms is trying to avoid some unpleasant activity or to get attention and sympathy

They experience their symptoms as completely physical; distress over symptoms is authentic

For patients for whom pain is the central concern, dependency on painkillers is a risk

Illness anxiety disorder

Clinical description of illness anxiety disorder:

Unwarranted fears about a serious illness in the absence of any significant somatic symptoms

Fears must lead to excessive care seeking or maladaptive avoidance behaviors hat persist for at least 6 months

Tend to worry about the possibility of cancer, heart attacks, AIDS, and strokes

Fears are not easily calmed and others may become frustrated when attempts to soothe worries fail

Often co-occurs with anxiety and mood disorders

Somatic symptom disorder and illness anxiety disorder both involve health anxiety

Somatic symptom disorder is 3 times as common as illness anxiety disorder

Conversion disorder

Clinical description of conversion disorder:

Neurological symptom(s) (i.e. blindness, seizures, paralysis) that cannot be explained by medical disease or culturally sanctioned behavior

Suggest an illness related to neurological damage, but medical tests indicate that the bodily organs and nervous system are fine

May experience anesthesia (loss of sensation)

May experience tunnel vision (visual field is constricted as it would be if the person were peering through a tube)

May experience aphonia (loss of the voice other than whispered speech)

Many people with conversion disorder do not connect their symptoms with their stressful situations

Originally referred to as hysteria (limited to women with the wandering of the uterus through the body), "hystera" = womb

Freud coined the term "conversion" = anxiety and psychological conflict were converted into physical symptoms

Genuinely phsyical problems are misdiagnosed as conversion disorder about 4% of the time

Some symptoms that seem medically implausible have been shown to have a biological basis

To enhance the reliability of conversion disorder, the DSM-5 provides guidelines to clinicians about how to assess whether symptoms might be medically unexplained

Symptoms of conversion disorder usually develop in adolescence or early adulthood, typically after a major life stressor

Prevalence = <1%, more women than men

Highly likely to meet criteria for another somatic symptom disorder

Factitious disorder

Falsification of psychological or physical symptoms, without evidence of gains from those symptoms

Sole goal often seems to be to adopt the patient role

People intentionally produce physical symptoms (or sometimes psychological ones) to assume the role of a patient

May be diagnosed in a parent who creates physical illness in a child (Facticious disorder imposed on another or Munchausen syndrome by proxy)

Motivation: need to be regarded as an excellent parent who is tireless in seeing to the child's needs

DSM-5 Symptoms:

Deceptive behavior is present in the absence of obvious external rewards

Malingering

Intentionally faking psychological or somatic symptoms to gain from those symptoms

Symptoms under voluntary control (insurance companies investigate this)

Etiology of Somatic Symptom-Related Disorders

Little concordance among twins for somatic symptom disorder or conversion disorder

These disorders do not appear to be heritable

Somatic symptom disorder and illness anxiety disorder include excessive attention to somatic symptoms and disproportionate anxiety about one's health

Neurobiological factors that increase awareness of and distress over somatic symptoms

Key issue: Not whether people have some bodily sensation, but rather why some people are more keenly aware of and distressed by these sensations

Brain regions activated by unpleasant body sensations

Pain and uncomfortable physical sensations (i.e. heat) increase activity in regions of the brain called the anterior insula and the anterior cingulate cortex (ACC)

Regions have strong connections with the somatosensory cortex (processing bodily sensations)

Heightened activity in these regions is related to greater propensity for somatic symptoms and more intense pain ratings in response to a standardized stimulus

Hyperactive brain regions involved in evaluating the unpleasantness of body sensations --> more vulnerable to experiencing and noticing somatic symptoms and pain

Pain and somatic symptoms can be increased by anxiety, depression, and stress hormones

The involvement of these same regions in experiences of physical and emotional pain may help explain why emotions and depression can intensify experiences of pain

The more that people learned to control their ACC, the more they were able to reduce their experiences of pain

Cognitive behavioral factors that increase awareness of and distress over somatic symptoms

The mechanisms that could contribute to the excessive focus on and anxiety over health concerns

Two important cognitive variables:

Attention to body sensation

Interpretation of those sensations

Patients with somatic symptom-related disorders had more difficulty ignoring words that were related to physical health than other words

Focusing attention on the body may also increase awareness of unusual physical sensations that would otherwise have gone unnoticed

Panic disorder vs. somatic symptom disorder:

Panic disorder: person often believes that the symptoms are a sign of an immediate threat (i.e. heart attack)

Somatic symptom disorder: believes that symptoms are a sign of an underlying LT disease (e.g. cancer or AIDS)

Tendency to be overly concerned with one's health may have evolved from early experiences of medical symptoms or from family attitudes to physical illness

Children missed school because of illness --> somatic symptom-related disorders

Two behavioral consequences:

Person may assume the role of being sick and avoid work, exercise, and social tasks; these avoidant behaviors in turn can intensify symptoms by limiting other healthy behaviors (disengagement and isolation)

Person may seek reassurance from doctors and family members, and this help-seeking behavior may be reinforced if it results in the person getting attention or sympathy (excessive help-seeking behavior)

People often times experience depression and interpersonal insecurity (attention for health concerns may be particularly reinforcing)

Disability payments

Many different behavioral factors can maintain and intensify anxiety

Etiology of Conversion Disorder

Psychodynamic perspectives

Symptoms provide a clear example of the role of the unconscious

On a conscious level, they are telling the truth; they believe that their arm is paralyzed. On an unconscious level, some psychological factor is at work, making them unable to move their arm despite the absence of any physical cause. The physical symptom is therefore a response to an unconscious psychological conflict.

Unexplained blindness:

(1) Unconscious processing of perceptual stimuli and (2) motivation to be symptomatic

Because people may not be processing visual inputs at a higher level, they can truthfully claim that they cannot see, even when tests suggest they can

Motivation:

Some people are motivated to appear blind

People could be unconscious of certain perceptions and could be motivated to have certain symptoms

Social and cultural factors in conversion disorder

Symptoms of conversion disorder are more common among people from rural areas and people of lower SES

"Mass hysteria" = group of people with closer contact develop inexplicable medical symptoms that would likely warrant a diagnosis of conversion disorder

Modeling and social factors

Treatment-seeking and diagnostic practices may be the factors that have changed overtime. The level of interest in conversion disorder within psychiatry has waxed and waned.

Prevalence has been stable over time

Treatment

Major obstacle: Most people with somatic symptom-related disorders usually want medical care, not mental health care

Resent mental health referrals because they assume the doctor thinks their illness is "all in their head"

Gentle reminder of the mind-body connection can enhance willingness to consider psychological treatment approaches

Interventions in primary care

Because most people with somatic symptom-related disorders will seek treatment through general practitioners, one important approach has been to teach primary care teams to tailor care for people with somatic symptom-related disorders

Establish a strong doctor-patient relationship

Inform physicians when a patient appears to be an intensive user of health care services so they can minimize the use of diagnostic tests and medications

Cognitive behavioral treatment

Identify and change the emotions that trigger their somatic concerns

Change their cognitions regarding their somatic symptoms

Change their behaviors to stop playing the role of a sick person and to gain more reinforcement for engaging in other types of social interactions

The negative emotions that accompany anxiety and depressive disorders often trigger physiological symptoms and intensify the distress about those somatic symptoms

Treating anxiety and depression often reduces somatic symptoms

Some strategies involve training people to pay less attention to their body

Cognitive strategies might help people identify and challenge negative thoughts about their bodies

Focus less on what patients cannot do due to their pain and symptoms and more on encouraging them to reengage in satisfying activities and to gain a greater sense of control

Therapist might teach family members about operant conditioning to reduce the amount of attention they give the person's somatic symptoms

CBT as effective as an antidepressant in reducing illness anxiety symptoms

After CBT, people with healthy anxiety symptoms attend less to negative stimuli, help reduce activity in the regions of the brain that are involved in responding to pain stimuli

Treatment for somatic symptom disorder with pain

Hypnosis helps reduce pain levels and has been shown to influence brain regions involved in experiencing and interpreting pain

Antidepressants can also be helpful when pain is a dominant symptom of somatic symptom disorder

Antidepressants are preferred over opioid medications which are highly addictive

Meditation may also help patients reduce their health focus and anxiety.

CBT, hypnosis, ACT, and low doses of antidepressant medication

Page 3

What causes dissociation?

Sleep deprivation

Avoidance response that protects the person from consciously experiencing stressful events

Prevalence of these disorders:

2.5% of people endorsed the lifetime diagnostic criteria for depersonalization/derealization

7.5% for dissociative amnesia

1-3% for DID

Dissociative amnesia:

Unable to recall important personal information, usually information about some traumatic experience

Beyond ordinary forgetfulness

Information not permanently lost, cannot be retrieved during an amnesia episode (several hours-several years)

Usually involves information about some part of a traumatic experience (i.e. witnessing sudden death of loved one)

Procedural memory remains intact even though they cannot remember specific events

Severe subtype = fugue

"To flee," the memory loss is more extensive

Person disappears from home and work

New name, new job, new home, new set of personality characteristics

Recovery is usually complete but takes varying amounts of time; after recovery, people are fully able to remember the details of their life and experiences, except for those events that took place during the fugue

DSM-5 Symptoms:

Amnesia is not explained by substances, or by other medical or psychological conditions

Assure that there were no prior head injuries, medication use, or substance use

Specify dissociative fugue subtype if the amnesia is associated with bewildered or apparently purposeful wandering

Dementia vs. Dissociative amnesia:

Dementia: Memory fails slowly over time, is not linked to stress, and is accompanied by other cognitive deficits (i.e. inability to learn new information)

Amnesia can occur after severe stress (i.e. marital discord, personal rejection, financial or occupational difficulties, war service, or a natural disaster); not all amnesias immediately follow trauma

Psychodynamic theory: Traumatic memories are repressed...

Memories are forgotten (i.e. dissociated) because they are so aversive

Does repression actually occur? Questionable because research shows that extreme stress usually enhances rather than impairs memory

People under stress tend to focus on the central features of the threatening situation and to stop paying attention to peripheral features

Since these findings contradict the memory loss in dissociative amnesia, one answer may be that dissociative amnesia involves unusual ways of responding to stress

Extremely high levels of stress hormones could interfere with memory formation

Chronic stress (i.e. repeated abuse) might have more detrimental effects on memory than acute stress

Debates About Repression: Recovered Memories of Abuse in Childhood

People can deliberately forget material, but are people with recovered memories better at forgetting than are others?

People with recovered memories of CSA do not show any superior ability to forget words related to their trauma

The word lists used in the study may not be painful enough to inspire repression

Those with more severe abuse memories were more likely to remember and disclose their abuse

Lack of reported recall might reflect other processes rather than repression:

People may not want to disclose distressing events to a researcher

Too young at the time of abuse to remember the event

Some of the traumas may have caused brain injury that could explain the gaps in memory

Where could recovered memories come from, if not from actual experiences?

Popular writings

Therapists' suggestions

Hypnotic age regression and guided imagery

Guided imagery: Person closes their eyes and tries to imagine an event occurring, tends to increase confidence that a false memory actually occurred

Once memory distortions occur, they hold emotional power; even false memories can be associated with a lot of pain

Using recovered memories in court cases could result in an injustice to either the accused or the accuser

Dissociative identity disorder:

Clinical descriptions of DID:

At least two separate personalities/alters (different modes of being, thinking, feeling, and acting that exist independently of one another and that emerge at different times

Typically one primary personality, usually the alter that seeks treatment

Usually 2-4 alters identified when diagnosis is made, but over the course of treatment others may emerge

Each alter may be quite complex with its own behavior patterns, memories, and relationships

Usually the different alters are very different from each other, usually polar opposites

Different handedness, wear glasses with different prescriptions, like different foods, have different food allergies

In some cultures, alters may be understood as spirits that take control of the person's body

More common in women rather than men

DSM-5 Symptoms:

Symptoms are not part of a broadly accepted cultural or religious practice

Symptoms are not due to drugs or a medical condition

DID is commonly accompanied by:

Headaches, hallucinations, suicide attempts, self-injurious behavior; dissociative symptoms such as amnesia and depersonalization

The epidemiology of DID: increases over time...

There were almost no identified reports of DID or dissociative amnesia before 1800

The Three Faces of Eve and Sybil

Etiology of DID:

Both theories suggest severe physical or sexual abuse during childhood

Posttraumatic model: Some people are particularly likely to use dissociation to cope with trauma, how people develop alters after trauma

There is evidence that children who are abused are at risk for developing dissociative symptoms

There is evidence that children who dissociate are more likely to develop psychological symptoms after trauma

Sociocognitive model: People who have been abused seek explanations for their symptoms and distress, and alters appear in response to suggestions by therapists, exposure to media reports of DID, or other cultural influences

Implies that DID could be iatrogenic (created within treatment) in that the person often learns to role-play these symptoms within treatment

Issue not whether DID is real or not but rather how it develops

Sometimes created by therapeutic techniques that reinforce clients' identification of different alters (i.e. interviewing clients about their identities after administering hypnosis or sodium pentothal - drug linked to false memories)

A small number of clinicians contribute most of the diagnoses of DID

Therapists who diagnoses more people with DID tend to use hypnosis, to urge clients to try to unbury unremembered abuse experiences, or to name different alters

Most patients are unaware of having alters until after they begin treatment, and as treatment progresses, they report a rapid increase in the number of alters they can identify

DID symptoms can be role-played

Alters share memories, even when they report amnesia...

In explicit memory tests, researchers might ask a person to remember words. In implicit memory tests, experimenters determine if the word list have subtler effects on performance.

On tests of implicit memory, people performed comparably to people without DID. People with DID seem to demonstrate more accurate memory than they tend to acknowledge.

Treatment of DID:

Importance of an empathic and gentle stance, with the goal of helping the client function as one wholly integrated person

Goal of treatment should be to convince the person that splitting into different personalities is no longer necessary to deal with traumas

Teach them more effective ways to cope with stress

People with DID are hospitalized to help them avoid self-harm and to offer more intensive treatment

Psychodynamic treatment:

Overcome repressions

Use hypnosis as a means of helping patients diagnosed with dissociative disorders to gain access to repressed material

Age regression: Person is hypnotized and encouraged to go back in his/her mind to traumatic events in childhood

Hope is that by accessing these traumatic memories, the person will realize that childhood threats are no longer present and that adult life need not be governed by these ghosts from the past

DID is often comorbid with anxiety and depression, which can sometimes be lessened with antidepressant medications. However, these medications have no effect on the DID itself.

Page 4

Page 5

Page 6