Chapter 8: Somatoform and Dissociative Disorderss3.amazonaws.com/prealliance_oneclass_sample/8z5ZMb57q6.pdfMonday, October 29, 2012 Chapter 8: Somatoform and Dissociative Disorders

Monday, October 29, 2012

Chapter 8: Somatoform and Dissociative Disorders

- involve more complex and puzzling patterns of symptoms

Somatoform Disorders - a group of conditions that involve physical symptoms and

complaints suggesting the presence of a medical condition but without any evidence of

of physical pathology to account for them, the person is preoccupied with some aspect

of her or his health of appearance to the extent that they show significant impairments in

functioning

Dissociative Disorders - involve disruptions in a person’s normally integrated functions

of consciousness, memory, identity, or perception, included here are some of the more

dramatic phenomena in the entire domain of psychopathology: people who cannot recall

who they are or where they may have come from, and people who have 2 or more dis-

tinct identities or personality states that alternately take control of the individual’s behav-

iour

Dissociation - the human mind’s capacity to engage in complex mental activity in chan-

nels split off from or independent of conscious awareness

- somatoform and dissociative disorders were once included with anxiety disorders un-

der the general rubric neuroses, but when the focus moved to grouping disorders to-

gether on the basis of overt symptomatology, the disorders became separate

Somatoform Disorders

- soma means body, and somatoform disorders involve patterns in which individuals

complain of bodily symptoms or defects that suggest the presence of medical problems,

but for which no organic basis can be found that satisfactorily explains the symptoms

e.g. paralysis or pain

- the affected patients have no control over their symptoms and are not intentionally fak-

ing symptoms or attempting to deceive others

- they genuinely and sometimes passionately believe something is terribly wrong

- although it is thought to be characteristic of particular ethnocultural groups, re-

searchers have found that it is common in all cultural groups and societies

- differences among groups may reflect cultural styles of expressing distress, which are

influenced not only by cultural beliefs and practices but also by the nature of the culture’-

s healthcare system

Hypochondriasis


- preoccupied either with fears of contracting a serious disease or with the idea that they

actually have such a disease even though they do not

- their preoccupations are based on the misinterpretation of one or more bodily

changes, sensations or symptoms of minor ailment

- the person is not reassured by the results of a medical evaluations, the fear of having a

disease persists despite medical reassurance

- sometimes they are disappointed when no physical problem is found

- the condition must persist for at least 6 months

- usually first go to a medical doctor with their physical complaints

- they often shop for additional doctors, hoping one might discover what their problem is

- they generally resist the idea that their problem is a psychological one that might best

be treated by a psychologists or psychiatrist

- may be the most commonly seen somatoform disorder, with a prevalence in general

medical practice estimated at between 2 and 7%

- occurs equally often in men and women and can start at any age although early adult-

hood is the most common age of onset

- once it develops, it tends to be chronic if left untreated, although the severity may wax

and wane over time

- individuals with hypochondriasis often also suffer from mood disorders, panic disorder,

and/or other somatoform disorders

Major Characteristics

- often anxious and highly preoccupied with bodily functions (heart beats, bowl move-

ments, small sores or occasional coughs) or with vague and ambiguous physical sensa-

tions such as “tired heart” or “aching veins”

- they attribute these symptoms to a suspected disease and often have intrusive

thoughts about it

- the diagnoses they make for themselves range from tuberculosis to cancer, exotic in-

fections, AIDS, and numerous other diseases

- they are not malingering, which is defined as consciously faking symptoms to achieve

specific goals

- they tend to doubt the soundness of their doctor’s conclusions and recommendations,

so doctor-patient relationships are often marked by conflict and hostility

Theoretical Perspectives on Causal Factors

- cognitive-behavioural views of hypochondriasis are perhaps most widely accepts and

have as a central tenet that it is a disorder of cognition and perception


- misinterpretations of bodily sensations are currently a defining feature, but in the cog-

nitive-behavioural view, these misinterpretations also play a causal role

- it is believed that an individual’s past experiences with illnesses lead to the develop-

ment of a set of dysfunctional assumptions about symptoms and diseases

- seem to focus excessive attention on symptoms, with an attentional bias for illness-re-

lated information

- they perceive their symptoms as more dangerous than they really are and judge a par-

ticular disease to be more likely or dangerous than it really is

- once they have misinterpreted a symptom, they tend to look for confirming evidence

and to discount evidence that they are in good health

- they also perceive their probability of being able to cope with the illness as extremely

low and see themselves as weak and unable to tolerate physical effort or exercise

- this tends to create a vicious cycle in which their anxiety about illness and symptoms

results in physiological symptoms of anxiety, which provides further fuel for their convic-

tions that they are ill

- hypochondriacal patients reported much childhood sickness and missing of school,

and have an excessive amount of illness in their families while growing up, which may

lead to strong memories of being sick or in pain, and perhaps of having observed some

of the secondary benefits that sick people sometimes reap

Treatment of Hypochondriasis

- cognitive-behavioural treatment have found to be very effective

- the cognitive components focus on assessing the patient’s beliefs about illness and

modifying misinterpretations of bodily sensations

- the behavioural techniques include having patients induce innocuous symptoms by in-

tentionally focusing on parts of their body so that they can learn that selective percep-

tion of bodily sensations plays a major role in their symptoms

- summits they are also directed to engage in response prevention by not checking their

body as they usually do and by stopping their constant seeking of reassurance

- the treatment (6-16 sessions) produced large changes in the hypochondriacal symp-

toms and beliefs as well as in levels of anxiety and depression

- certain antidepressants may be effective

Somatization Disorder

- many different complaints of physical ailments, over at least several years beginning

before age 30, that are not adequately explained by independent findings of physical ill-

ness or injury and that lead to medical treatment or to significant life impairment


- there are 4 other symptom criteria that must be met at some time during the course of

the disorder before a diagnosis can be made

- the diagnostician need not be convinced that these claimed illnesses actually exist, the

mere reporting of them is sufficient

1. Four pain symptoms - must report a history of pain experienced with respect to at

least 4 different sites or functions

2. Two gastrointestinal symptoms - a history of at least 2 symptoms, other than pain,

pertaining to the gastrointestinal system, such as nausea, bloating, diarrhea, or vomiting

when not pregnant

3. One sexual symptom - at least one reproductive system symptom other than pain e.g.

sexual indifference or dysfunction, menstrual irregularity, or vomiting during pregnancy

4. One Pseudoneurological symptom - a history of at least one symptom, not limited to

pain, suggestive of a neurological condition, e.g. loss of sensation, involuntary muscle

contraction in a hand

- hypochondriacs are different because they are convinced they have an organic dis-

ease and usually only have one or a few primary symptoms

Demographics, Comorbidity, and Course of Illness

- formerly called Briquet’s syndrome, has not been extensively researched

- usually begins in adolescence and believed to be about 3-10x more common among

women than men

- tends to occur more in lower socioeconomic classes

- the lifetime prevalence estimate to be between 0.2 and 2% in women and 0.2% in men

- commonly occurs with several other disorders including major depression, panic disor-

der, phobic disorders, and generalized anxiety disorder

- generally been considered to be a relatively chronic condition with a poor prognosis,

but some recent studies have begun to challenge this view

Causal Factors in Somatization Disorder

- there is evidence that it runs in families and that there is a familial linkage between an-

tisocial personality disorder in men

- one possibility is that the 2 disorders may be linked through a common trait of impul-

sivity, but the nature of this relationship is not yet understood

- causal factors probably include an interaction of personality, cognitive, and learning

variables

- people high on neuroticism who come from certain kinds of family backgrounds may

develop a tendency to misinterpret their bodily sensations as threatening or disabling


- especially likely in families where a child is frequently exposed to models complaining

of pain and learns that complaining about symptoms can lead to sympathy and attention

(social reinforcement) and even to avoid responsibilities (a secondary gain)

- people selectively attend to bodily sensations and tend to see bodily sensations as so-

matic symptoms

- believing themselves to be weak, they may avoid activities that require much exertion

including physical activity, ironically, lowered physical activity can lead to being physical-

ly unfit, which can increase bodily sensations about which to catastrophes

- selectively attending to bodily sensations may actually increase their intensity

- patients also have elevated levels of cortisol and did not show normal habituation to

psychological stressors

Treatment of Somatization Disorder

- long been considered extremely difficult to treat

- cognitive-behavioural therapy may be quite helpful when combined with appropriate

medical management

- effective treatment involves identifying one physician who will integrate the patient’s

care by seeing the patient at regular visits and providing physical exams focused on new

complaints

- at the same time, the physician avoids unnecessary diagnostic testing and makes min-

imal use of medications or other therapies

- this combined with cognitive-behavioural therapy, which focuses on promoting appro-

priate behaviour such as better coping and personal adjustment, and discouraging inap-

propriate behaviour such as illness behaviour

- focus is on changing the way the patient thinks about bodily sensations and reducing

any secondary gain the patients may receive from physicians and family

Pain Disorder

- resemble pain symptoms seen in somatization disorder, but other kind of symptoms

are not present, it is characterized by the experience of persistent and severe pain in

one or more areas of the body

- although a medical condition may contribute to the pain, psychological factors must be

judged to play an important role

- important to remember that the pain that is experienced is very real and can hurt as

much as pain with purely medical causes

- also important that pain is always, in part, a subjective experience that is private and

cannot be objectively identified by others


- there are 2 coded subtypes: (1) pain disorder associated with psychological factors

and (2) pain disorder associated with both psychological factors and a general medical

condition

- in either case, the pain may be acute (less than 6 months) or chronic (over 6 months)

- prevalence is unknown but definitely quite common among patients at pain clinics

- diagnosed more frequently in women than in mean and is frequently comorbid with

anxiety and/or mood disorders, which may occur first or may arise later as a conse-

quence of the pain disorder

- often unable to work or to perform some other usual daily activities

- their inactivity and social isolation may lead to depression and tao loss of physical

strength and endurance, leading to a vicious cycle

- the behavioural component of pain is quite malleable in the sense that it can increase

when it is reinforced by attention, sympathy, or avoidance of unwanted activities

Treatment of Pain Disorder

- less complex and multifaceted than somatization disorder so usually easier to treat

- cognitive-behavioural techniques have been widely used in the treatment of both physi-

cal and psychogenic pain syndromes

- treatment programs generally include relaxation training, support and validation that

the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement

of “no-pain” behaviours

- patients tend to show substantial reductions in disability and distress, although

changes in the intensity of their pain tend to be smaller in magnitude

- antidepressant medications have been shown to reduce pain intensity

Conversion Disorder

- involves a pattern in which symptoms or deficits affective sensory or voluntary motor

functions lead one to think a patient has a medical or neurological condition

- upon medical examination, it becomes apparent that the pattern of symptoms or

deficits cannot be fully explained by any known medical condition

- typical examples include partial paralysis, blindness, deafness, and pseudoseizures

- psychological factors must be judged to play an important role in the symptoms or

deficits, because the symptoms usually either start or are exacerbated by preceding

emotional or interpersonal conflicts or stressors

- the person must not be intentionally producing or faking the symptoms

- show very little anxiety and fear that would be expected


- this seeming lack of concern in the way the patient describes what is wrong was

thought for a long time to be an important diagnostic criterion

- research shows that it actually occurs in only about 30-50% of patients

- it is now thought that most patients are actually quite anxious and concerned

- no more likely than people with real physical disorders to display lack of concern

- it is one of the most intriguing and baffling patterns in psychopathology

- contemporary research has been very sparse

- Freud believed that anxiety threatens to become conscious, so it is unconsciously con-

verted into a bodily disturbance, thereby allowing the person to avoid having to deal with

the conflict

Precipitating Circumstances, Escape, and Secondary Gains

- although Freud’s theory is no longer accepted outside psychodynamics circles, many

of Freud’s astute clinical observations about primary and secondary gain are still incor-

porated into physical contemporary views of conversion disorder

- the symptoms are usually seen as serving the rather obvious function of providing a

plausible excuse, enabling an individual to escape or to avoid an intolerably stressful sit-

uation without having to take responsibility for doing so

- typically, it is thought that the person first experiences a traumatic event that motivates

the desire to escape the unpleasant situation

- the primary gain for conversion symptoms is continued escape or avoidance of a

stressful situation, because that is all unconscious, the symptoms go away only if the

stressful situation has been removed or resolved

- secondary gain originally referred to advantages of the symptoms, refers to any exter-

nal circumstance, such as attention from a loved one or financial compensation

Decreasing Prevalence and Demographic Characteristics

- once relatively common in civilian and especially military life

- most frequently diagnosed psychiatric syndrome among soldiers in WWI & II

- typically occurred under highly stressful combat conditions and involved men who

would ordinarily be considered stable

- conversion symptoms enabled a soldier to avoid an anxiety-arousing combat situation

- today, conversion disorder constitute only 1-3% of all disorders referred for mental

health treatment

- the prevalence is unknown but highest estimates are around 0.005%

- decreasing prevalence seems to be closely related to our growing sophistication about

medical and psychological disorders, it apparently loses its defensive function if it can

be readily shown to lack an organic basis


- more likely to occur in rural people from lower socioeconomic circles who are medically

unsophisticated

- occurs 2-10x more often in women than in men, can develop at any age but most com-

monly occurs between early adolescence and early adulthood

- generally has a rapid onset after a significant stressor and often resolves within 2

weeks if the stressor is removed, although it commonly recurs

- like most other somatoform disorders, it frequently occurs along with other disorders,

major depression, anxiety disorders, and somatization and dissociative disorders

Range of Conversion Disorder Symptoms

- as diverse as for physically based ailments

- useful to think in terms of 4 categories of symptoms: (1) sensory, (2) motor, (3)

seizures, and (4) mixed presentation from the first 3 categories

Sensory Symptoms or Deficits

- can involve almost any sensory modality and can often be diagnosed, because symp-

toms in the affected area are inconsistent with how known anatomical sensory pathways

operate

- sensory symptoms or deficits are most often in the visual system (especially blindness

and tunnel vision), in the auditory system (especially deafness), or in the sensitivity to

feeling (especially the anesthesias - losing feeling in a part of their body)

- one of the most common is glove anesthesia, where a person cannot feel anything on

the hand in the area where gloves are worn

- with conversion blindness, the person reports that he or she cannot see and yet can

often navigate about a room without bumping into furniture

- with conversion deafness, the person reports not being able to hear yet orients appro-

priately upon “hearing” his or her own name

- can the person actually not see or hear, or is the sensory information received but

screen from consciousness

- evidence supports the idea that the sensory input is registered but that it is somehow

screened from explicit conscious recognition

Motor Symptoms or Deficits

- motor conversion reactions cover a wide range of symptoms

- e.g. conversion paralysis is usually confined to a single limb, such as an arm or a leg,

and the loss of function is usually selective for certain functions

- person may not be able to write but may be able to use the same muscles for scratch-

ing or may not be able to walk most of the time but may be able to walk in an emergen-

cy such as a fire


- the most common speech-related conversion disturbance is aphonia, in which a per-

son is able to talk only in a whisper, although he or she can usually cough in a normal

manner

Seizures

- involve pseudoseizures, which resemble epileptic seizures in some ways but can be

fairly well differentiated via modern medical technology

- they do not show any EEG abnormalities and do not show confusion and loss of mem-

ber

- often show excessive thrashing about and writhing not seen with true seizures, and

they rarely injure themselves in falls or lose control over their bowels or bladder

Important Issues in Diagnosing Conversions Disorder

- because the symptoms can stimulate a variety of medical conditions, accurate diagno-

sis can be extremely difficult

- it is crucial that a person with suspected conversion symptoms receive a thorough

medical and neurological examination

- several criteria are also commonly used for distinguishing between conversions disor-

ders and true organic disturbances:

1. The frequent failure of the dysfunction to conform clearly to the symptoms of the par-

ticular disease or disorder simulated

2. The selective nature of the dysfunction, e.g. in conversion blindness, the affected indi-

vidual does not usually bump into people

3. Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms can

usually be removed, shifted, or reinduced at the suggestion of the therapist

Distinguishing Conversion from Malingering and From Factitious Disorder

- sometimes, people do deliberately and consciously feign disability or illness

Malingering Disorder - intentionally producing or exaggerating physical symptoms and

is motivated by external incentives such as avoiding work or military service

Factitious Disorder - intentionally producing psychological or physical symptoms or

both, but there are not external incentives, instead, the person’s goal is simply to obtain

and maintain the personal benefits that playing the “sick role” provide including the at-

tention and concern of family and medical personnel

- frequently, patients alter their own physiology, by taking drugs, in order to stimulate

various real illnesses

- they may be at risk for serious injury or death and may need to be committed to an in-

stitution for their own protection


- in the past, severe and chronic forms of factitious disorder with physical symptoms

were called “Munchausen’s syndrome” where the general idea was that the person had

some kind of “hospital addiction” or a “professional patient” syndrome

Factitious Disorder By Proxy/Munchausen’s Syndrome by Proxy - the person seek-

ing medical help or consulting a mental health professional falsely reports or even in-

duces medical or psychological symptoms in another person who is under their care

- e.g. a mother presents her own child for treatment of a medical condition she has de-

liberately caused, disclaiming any knowledge of its origin, the majority of such cases in-

volve the gastrointestinal, genitourinary or central nervous system, apparently because

diseases or dysfunctions in these systems are most readily simulated by excessive ad-

ministration of widely available drugs (diuretics, laxatives)

- in 10% of cases, this form of child abuse may lead to a child’s death

Treatment of Conversion Disorder

- our knowledge of how best to treat conversion disorder is extremely limited

- some patients with motor conversion symptoms have been successfully treated with a

behavioural approach in which specific exercises are prescribed in order to increase

movement or walking and then reinforcements are provided when patients show im-

provements

- any reinforcements of abnormal motor behaviours are removed in order to eliminate

any sources of secondary gain

- some studies have used hypnosis combined with other problem-solving therapies

Body Dysmorphic Disorder (BDD)

- involves preoccupation with certain aspects of the body, people are obsessed with

some perceived or imagined flaw or flaws in their appearance

- the preoccupation is so intense that it causes clinically significant distress and/or im-

pairment in social or occupational functioning

- most people have compulsive checking behaviours (checking their appearance in the

mirror excessively)

- another common symptom is avoidance of usual activities because of fear that other

people will see the imaginary defect and be repulsed

- in severe cases, they may become so isolated that they lock themselves up in their

house and never go out even to work, with the average employment rate 50%

- may focus on almost any body part: skin has blemishes, breasts are too small, face is

too thin, visible blood vessels


- some of the more common locations are skin (73%), hair 56%, nose (37%), eyes

(20%), legs (18%), chin (11%), breasts/chest/nipples (21%)

- many sufferers have perceived defects in more than one body part

- other people do not see the defects that the person has, or if they do, they only see a

minor defect within the normal range

- a form of BDD seen mostly in males is called “muscle dysmorphia” which is manifested

in various features including a dislike of one’s current body shape and a strong desire to

change it through increases muscle mass and behaviours including excessive weight

lifting, eating large quantities of high-protein foods, use of steroids

- another common feature of BDD is that people frequently seek reassurance from

friends and family about their defects, but the reassurances almost never provide more

than very temporary relief

- they also frequently seek reassurance for themselves by checking their appearance in

the mirror countless times in a day, some avoid mirrors

- they frequently engage in excessive grooming behaviour, trying to camouflage their

perceived defect through their hairstyle, clothing or makeup

Prevalence, Gender, and Age of Onset

- no official estimates of the prevalence of BDD, and might actually be difficult to obtain

because of the great secrecy that usually surrounds this disorder

- some researchers estimate that it is not a rare disorder, affecting perhaps 1-2% of the

general population, and up to 8% of people with depression

- prevalence seems to be equal in men and women, age of onset is often adolescence

- people very commonly also have a depressive diagnosis and often leads to suicide at-

tempts or complete suicide

- sufferers commonly make their way into the office of a dermatologist or plastic sur-

geon, one estimate is that over 75% seek nonpsychiatric treatment

Relationship to OCD and Eating Disorders

- many believe that BDD is closely related to OCD and have proposed ti as one of the

OCD spectrum disorders

- similarities are prominent obsessions, engage in a variety of ritualistic behaviours

- they are even more convinced that their obsessive beliefs are accurate than people

with OCD

- the same sets of brain structures are implicated in the 2 disorders and the same kinds

of treatments work for OCD and BDD

- there is also a significant overlapping feature between BDD and eating disorders (es-

pecially anorexia nervosa) most strikingly body distortion


Why Now?

- BDD has clearly existed for centuries, but why did its examination begin only recently?

- one possible reason is that its prevalence may actually have increased in recent years

as Western culture has become increasingly focused on “looks as everything”

- another reason is that most people with the condition never seek psychological treat-

ment, they suffer silently or go to plastic surgeons or dermatologists

- also the disorder has received a good deal of media attention

A Biopsychosocial Approach to BDD

- recent research seems to suggest that a biopsychosocial approach offers some rea-

sonable hypotheses

- first, it seems likely that there is a partially genetically based personality predisposition

that people with BDD may share in common with people who have OCD

- second, BDD seems to be occurring in a sociocultural context tat places great value on

attractiveness and beauty

- perhaps as children they were reinforced more for their appearance than behaviour

- more likely to have a history of being teased about their bodily appearance

- selectively attend to positive or negative words such as ugly or beautiful more and tend

to interpret ambiguous facial expressions as contemptuous or angry

- tend to focus on details of faces rather than examining the face as a while

Treatment of Body Dysmorphic Disorder

- closely related to those used in effective treatment of OCD

- there is some evidence that antidepressant medications from selective serotonin reup-

take inhibitor category produces moderate improvement in patients with BDD

- a form of cognitive-behavioural treatment emphasizing exposure and response preven-

tion has been shown to produce marked improvement in 50-80% of patients

- these treatment approaches focus on getting the patient to identify and change distort-

ed appraisals of their body during exposure to anxiety-provoking situations

Dissociative Disorders

- dissociation refers to the human mind’s capacity to mediate complex mental activity in

channels split off form or independent of conscious awareness

- mild dissociative symptoms occur when we daydream or lose track of what is going on

around us, when we drive too far, or miss part of a conversation

- there is nothing inherently pathological about dissociation itself

- much of a normal individual’s mental life involves unconscious processes that are to a

large extent autonomous with respect to deliberate, self-aware monitoring and direction


- such unaware processing extends to the areas of memory and perception, when it can

be demonstrated that normal persons routinely show indirect evidence of remembering

things they cannot consciously recall (implicit memory) and response to sights or

sounds as if they had perceived them (as in conversion blindness), even though they

cannot report that they have seen or heard them (implicit perception)

- in dissociative disorders, this normally integrated and well-coordinated multichannel

quality of human cognition becomes much less coordinated and integrated

- the affected person may be unable to access information that is normally in the fore-

front of consciousness, such as their own personal identity

- the normally useful capacity to maintain ongoing mental activity outside of awareness

appears to be subverted, sometimes for the purpose of managing severe psychological

threat

- appear mainly to be ways of avoiding anxiety and stress and of managing life problems

that threaten to overwhelm the persons’ usual coping resources

- enables the individual to deny personal responsibility for their “unacceptable” wishes or

behaviour

Depersonalization Disorder

- 2 of the more common kinds of dissociative symptoms are derealization and deperson-

alization

Derealization - one’s sense of reality of the outside world is temporarily lost

Depersonalization - one’s sense of one’s own self and one’s own reality is temporarily

lost

- half of us have such experiences in mild form at least once in our lives, usually during

or after periods of severe distress, sleep deprivation or sensory deprivation

Depersonalization Disorder - when episodes of depersonalization and derealization be-

come persistent and recurrent and interface with normal functioning

- people have persistent or recurrent experiences of feeling detached from their own

bodies and mental processes

- they may feel they are floating about their bodies

- in derealization, the external world may be perceived as strange and new in various

ways

- in both states, the feeling puzzles the experiencers

- oneself and others are perceived as autonomous, behaving mechanically without ini-

tiative or self-control

- often report feeling as though they are living in a dream or movie


- the lifetime prevalence is unknown but occasional symptoms are common in a variety

of disorders such as schizophrenia, borderline personality disorder

- although severe depersonalization symptoms can be frightening, and may make the

victim fear imminent mental collapse, such fears are unfounded

- sometimes, feelings of depersonalization are early manifestations of impending de-

compensation and the development of psychotic states

Dissociative Amnesia and Fugue

Retrograde Amnesia - partial or total inability to recall or identify previously acquired in-

formation or past experiences

Anterograde Amnesia - the partial or total inability to retain new information

- persistent amnesia may occur in several Axis I disorders such as dissociative amnesia

and dissociative fugue, and in organic brain pathology including traumatic brain injury

and diseases of the central nervous system

- if the amnesia is caused by brain pathology, it most often involves failure to retain new

information and experiences (anterograde)

Dissociative Amnesia - usually limited to failure to recall previously stored personal in-

formation, when that failure cannot be accounted for by ordinary forgetting (retrograde)

- the gaps in memory most often occur following intolerably stressful circumstances

- forgotten personal information is still there beneath the level of consciousness and can

become apparent in interviews conducted under hypnosis or narcosis (induced by sodi-

um amytal, or so-called “truth serum”) and in cases when the amnesia spontaneously

clears up

- 4 primary types of psychogenic amnesia are recognized:

1. Localized - a person remembers nothing that happened during a specific period, most

commonly the first few hours or days following some highly traumatic event

2. Selective - a person forgets some but not all of what happened during a given period

3. Generalized - a person forgets his or her life history including their identity

4. Continuous - a person remembers nothing beyond a certain point in the past until the

present

- the 2 latter types occur rarely

- usually amnesic episodes last between a few days and a few years although some

people experience only one episode, many people have multiple episodes

- in typical dissociative amnesic reactions, individuals cannot remember certain aspects

of their personal life history or important facts about their identity, yet their basic habit

patterns such as the abilities to rad, talk and perform skills remain intact


- only a particular type of memory is affected, episodic (pertaining to events experi-

enced) or autobiographical, semantic memory (pertaining to language and concepts),

procedural (how to do things) and short-term storage

Dissociative Fugue - the person is not only amnesic for some or all aspects of his or

her past but also departs from home surroundings, this is accompanied by confusion

about personal identity or even the assumption of a new identity

- individuals are unaware of memory loss for prior stages of their life but their memory

for that happens during the fugue states itself is intact

- their behaviours during the fugue state is usually quite normal and unlikely to arouse

suspicion that something is wrong

- days, weeks, or sometimes even years later, people may suddenly emerge from the

fugue state and find themselves in a strange place working in a new occupation with no

idea how they got there

- in other cases, recovery occurs only after repeated questioning and reminders of who

they are

- in either case, the fugue state remits, their initial amnesia remits, but a new apparently

complete amnesia for their fugue period occurs

- similar to conversion symptoms except instead of avoiding an unpleasant situation but

becoming physically dysfunctional, a person unconsciously avoids thoughts about it or

in extreme cases leaves the scene

Memory and Intellectual Deficits in Dissociative Amnesia and Fugue

- very little research has been conducted

- semantic knowledge seem to be generally intact

- the primary deficit these individuals exhibit is their compromised episodic or autobio-

graphical memory

- several cases have suggested that implicit memory is intact

Dissociative Identity Disorder (DID)

- formerly called multiple personality disorder (MPD), is a dramatic dissociative disorder

in which a patient manifests 2 or more distinct identities that alternate in some way in

taking control of behaviour

- there is also an inability to recall important personal information

- each identity may appear to have a different personal history, self-image, and name

Host Identity - most frequently encountered and has the person’s real name

Alter Identities - differ in striking ways involving gender, age, handedness, handwriting,

sexual orientation, prescription for eyeglasses, foreign languages spoken


- needs and behaviours inhibited in the primary or host identity are usually liberally dis-

played by one or more alter identities

- roles such as a child and someone of the opposite sex are extremely common

- alters are not personalities but rather reflect a failure to integrate aspects of a person’s

identity, consciousness and memory

- alters take control at different points in time and the switches occur very quickly

- some identities may known more about certain alters than other identities

- other symptoms are depression, self-mutilation, frequent suicide ideation and attempts

- moodiness and erratic behaviour, headaches, hallucinations, substance abuse, post-

traumatic symptoms, and other amnesic and fugue symptoms

- usually starts in childhood although most are in their 20s or 30s when diagnosed

- 3-9x more females are diagnosed and females tend to have a higher number of alters

- some believe this is due to much greater proportion of childhood sexual abuse for girls

- 50% of people show over 10 identities,

- the historical trend of increasing multiplicity suggests the operation of social factors,

perhaps through the encouragement of therapists

- another trend is that many cases now include more unusual and even bizarre identities

(such as being an animal) and more highly implausible backgrounds (ritualized satanic

abuse in childhood)

Prevalence-Why Has DID Been Increasing?

- until recently, DID was extremely rare, prior to 1979, only 200 cases could be found but

by 1999 over 30,000 cases had been reported in North America

- factors that probably have contributed to the drastic increase in the reported preva-

lence are increased public awareness of the condition, diagnostic criteria clearly speci-

fied for DID, diagnostic criteria for schizophrenia was tightened

- also, it is almost certain that some of the increase in prevalence is artifactual, and has

occurred because some therapists looking for evidence of DID may suggest the exis-

tence of alter identities

Experimental Studies of DID

- most of what is known comes from self-reports and clinical observations

- only a small number of experimental studies have been conducted

- the primary focus has been to determine the nature of the amnesia that exists between

different identities

- one identity learns a list and then another identity may recall some of it, or will learn it

faster

- emotional reactions learned by one identity often transfer across identities


Causal Factors and Controversies About DID

- there are at least 4 serious interrelated controversies:

1. Some are concerned whether DID is a real disorder or it is faked and whether, even if

it is real, it can be fakes

2. Is DID caused by early childhood trauma, or does it involve some kind of social enact-

ment of multiple different roles

3. Are memories of early child abuse real or false

4. If abuse has occurred in most individuals with DID, did the abuse play a casual role?

General Sociocultural Causal Factors in Dissociative Disorders

- prevalence is influenced by the degree to which it is accepted or tolerated

- DID has now been identified in all racial groups, socioeconomic classes and cultures

- spirit possession and dissociative trances occur frequently in many different parts of

the world

- a trance is said to occur when someone experiences a temporary marked alteration in

state of consciousness or identity

- a possession trance is similar except the alteration of consciousness or identity is re-

placed by a new identity that is attributed to the influence of a spirit or other power

- Amok occurs when a dissociative episode leads to violent, aggressive or homicidal be-

haviour directed at other people and objects, it is found in Malaysia, Papua New Guinea,

the Philippines and Puerto Rico

Treatment and Outcomes in Dissociative Disorders

- very little is known how to treat them successfully

- depersonalization disorder is thought to be resistant to treatment although it may be

useful for associated psychopathology such as anxiety and depressive disorders

- some think that hypnosis, including training in self-hypnosis techniques, may be useful

- antidepressant medications from the serotonin reuptake inhibitory category may have

positive effects

- in dissociative amnesia and fugue, it is important for the person to be in a safe environ-

ment and simple removal from the perceived threatening situation sometimes allows for

spontaneous recovery of memory

- hypnosis as well as drugs such as benzodiazepines, barbiturates, are often used to fa-

cilitate recall of repressed and dissociated memories

- for DID patients, most current therapeutic approaches are based on the assumption of

posttraumatic theory that the disorder was caused by abuse


- most therapists set integration of the perviously separate alters, together with the col-

lective merging into the host personality as the ultimate goal

- typically, the treatment is psychodynamic and insight-oriented, focusing on uncovering

and working through trauma and other conflicts

- one of the primary techniques of DID is hypnosis

- for treatment to be successful, it must be prolonged, often lasting many years and the

more severe the case, the longer the treatment is needed

Documents

Chapter 8: Somatoform and Dissociative Disorderss3.amazonaws.com/prealliance_oneclass_sample/8z5ZMb57q6.pdfMonday, October 29, 2012 Chapter 8: Somatoform and Dissociative Disorders