Disorders Focusing on Somatic and Dissociative Symptoms

Disorders Focusing on Somatic and Dissociative Symptoms
Chapter 7 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

In addition to disorders covered earlier, stress and anxiety also contribute to several other kinds of disorder, particularly disorders that focus on somatic and dissociative symptoms Comer, Abnormal Psychology,8e DSM-5 Update

Disorders Focusing on Somatic Symptoms
In these disorders, the somatic symptoms are primarily caused by psychosocial factors or the symptoms trigger excessive anxiety and concern These disorders are different than psychophysiological disorders, in which psychosocial factors interact with genuine physical ailments Comer, Abnormal Psychology,8e DSM-5 Update

Disorders Focusing on Dissociative Symptoms
Dissociative disorders are each characterized by significant memory loss or identity disruption Comer, Abnormal Psychology,8e DSM-5 Update

Disorders that focus on somatic symptoms and those that focus on dissociative symptoms have much in common: Both may occur in response to severe stress Both have traditionally been viewed as forms of escape from stress A number of individuals suffer from both a somatic-related and a dissociative disorder Theorists and clinicians often explain and treat the two groups of disorders in similar ways Comer, Abnormal Psychology,8e DSM-5 Update

Disorders Focusing on Somatic Symptoms
DSM-5 lists a number of disorders in which bodily symptoms or concerns are the primary features Comer, Abnormal Psychology,8e DSM-5 Update

Comer, Abnormal Psychology,8e DSM-5 Update
Factitious Disorder Sometimes when physicians cannot find a medical cause for a patient’s symptoms, he or she may suspect other factors are involved. Patients may malinger, intentionally fake illness to achieve external gain (e.g., financial compensation, military deferment) Patients may be manifesting a factitious disorder - intentionally producing or faking symptoms simply out of a wish to be a patient Comer, Abnormal Psychology,8e DSM-5 Update

Factitious Disorder Known popularly as Munchausen syndrome, people with a factitious disorder often go to extremes to create the appearance of illness Many secretly give themselves medications to produce symptoms Patients often research their supposed ailments and are impressively knowledgeable about medicine Comer, Abnormal Psychology,8e DSM-5 Update

Factitious Disorder Clinical researchers have a hard time determining the prevalence of this disorder as patients hide the true nature of their problem Overall, the pattern appears to be more common in women than men and the disorder usually begins during early adulthood Comer, Abnormal Psychology,8e DSM-5 Update

Factitious Disorder Factitious disorder seems to be particularly common among people who (a) received extensive medical treatment as children, (2) carry a grudge against the medical profession, or (3) have worked as a nurse, lab technician, or medical aide Comer, Abnormal Psychology,8e DSM-5 Update

Factitious Disorder The precise causes of factitious disorder are not understood, although clinical reports have pointed to factors such as depression unsupportive parental relationships, and an extreme need for social support Comer, Abnormal Psychology,8e DSM-5 Update

Factitious Disorder Psychotherapists and medical practitioners often become angry at people with a factitious disorder, feeling that they are wasting their time People with the disorder, however, feel they have no control over their problems and often experience great distress Comer, Abnormal Psychology,8e DSM-5 Update

Factitious Disorder In a related pattern, factitious disorder imposed on another, known popularly as Munchausen syndrome by proxy, parents make up or produce physical illnesses in their children Comer, Abnormal Psychology,8e DSM-5 Update

Conversion Disorder Conversion disorder People with this disorder display physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases In short, the individuals experience neurological-like symptoms – blindness, paralysis, or loss of feeling – that have no neurological basis Comer, Abnormal Psychology,8e DSM-5 Update

Conversion Disorder Conversion disorder often is hard to distinguish from genuine medical problems It is always possible that a diagnosis of conversion disorder is a mistake and the patient’s problem has an undetected medical cause Physicians sometimes rely on oddities in the patient’s medical picture to help distinguish the two For example, conversion symptoms may be at odds with the known functioning of the nervous system, as in cases of glove anesthesia Comer, Abnormal Psychology,8e DSM-5 Update

Conversion Disorder Unlike people with factitious disorder, those with conversion disorder don’t consciously want or produce their symptoms This pattern is called “conversion” disorder because clinical theorists used to believe that individuals with the disorders are converting psychological needs into neurological symptoms Comer, Abnormal Psychology,8e DSM-5 Update

Conversion Disorder Conversion disorder usually begins between late childhood and young adulthood It is diagnosed in women twice as often as in men It typically appears suddenly, at times of stress It is thought to be rare, occurring in at most 5 of every 1,000 persons Comer, Abnormal Psychology,8e DSM-5 Update

Somatic Symptom Disorder
People with somatic symptom disorder become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing Two patterns of somatic symptom disorder have received particular attention: Somatization pattern Predominant pain pattern Comer, Abnormal Psychology,8e DSM-5 Update

People with a somatization pattern experience many long-lasting physical ailments that have little or no organic basis Also known as Briquet’s syndrome A sufferer’s ailments often include pain symptoms, gastrointestinal symptoms, sexual symptoms, and neurological symptoms Patients usually go from doctor to doctor in search of relief Comer, Abnormal Psychology,8e DSM-5 Update

Somatization pattern Patients with this pattern often describe their symptoms in dramatic and exaggerated terms Most also feel anxious and depressed The pattern typically lasts for many years Symptoms may fluctuate over time but rarely disappear completely without therapy Comer, Abnormal Psychology,8e DSM-5 Update

Somatization pattern Between 0.2% and 2% of all women in the U.S. experience a somatization pattern in any given year (compared with less than 0.2% of men) The pattern often runs in families and begins between adolescence and young adulthood Comer, Abnormal Psychology,8e DSM-5 Update

Predominant pain pattern If the primary feature of somatic symptom disorder is pain, the individual is said to have a predominant pain pattern Although the precise prevalence has not been determined, this pattern appears to be fairly common The pattern often develops after an accident or illness that has caused genuine pain The pattern may begin at any age, and more women than men seem to experience it Comer, Abnormal Psychology,8e DSM-5 Update

What Causes Conversion and Somatic Symptom Disorders?
For many years, conversion and somatic symptom disorders were referred to as hysterical disorders This label was to convey the prevailing belief that excessive and uncontrolled emotions underlie the bodily symptoms Today’s leading explanations come from the psychodynamic, behavioral, cognitive, and multicultural models None has received much research support, and the disorders are still poorly understood Comer, Abnormal Psychology,8e DSM-5 Update

The psychodynamic view Freud believed that hysterical disorders represented a conversion of underlying emotional conflicts into physical symptoms Because most of his patients were women, Freud centered his explanation on the psychosexual development of girls and focused on the phallic stage (ages 3 to 5)… Comer, Abnormal Psychology,8e DSM-5 Update

The psychodynamic view During this stage, girls develop a pattern of sexual desires for their fathers (the Electra complex) and recognize that they must compete with their mothers for his attention Because of the mother’s more powerful position, however, girls repress these sexual feelings Freud believed that if parents overreact to such feelings, the Electra complex would remain unresolved and the child might re-experience sexual anxiety throughout her life Freud concluded that some women unconciously hide their sexual feelings in adulthood by converting them into physical symptoms Comer, Abnormal Psychology,8e DSM-5 Update

The psychodynamic view Today’s psychodynamic theorists take issues with parts of Freud’s explanation They continue to believe that sufferers of these disorders have unconscious conflicts carried from childhood Comer, Abnormal Psychology,8e DSM-5 Update

The psychodynamic view Psychodynamic theorists propose that two mechanisms are at work in hysterical disorders: Primary gain: bodily symptoms keep internal conflicts out of conscious awareness Secondary gain: bodily symptoms further enable people to avoid unpleasant activities or receive sympathy from others Comer, Abnormal Psychology,8e DSM-5 Update

The behavioral view Behavioral theorists propose that the physical symptoms of hysterical disorders bring rewards to sufferers May remove individual from an unpleasant situation May bring attention from other people Comer, Abnormal Psychology,8e DSM-5 Update

In response to such rewards, people learn to display symptoms more and more This focus on rewards is similar to the psychodynamic idea of secondary gain, but behaviorists view the gains as the primary cause of the development of the disorder Like the psychodynamic explanation, the behavioral view of these disorders has received little research support Comer, Abnormal Psychology,8e DSM-5 Update

The cognitive view Some cognitive theorists propose that hysterical disorders are a form of conversion and somatic symptom disorder, providing a means for people to express difficult emotions Comer, Abnormal Psychology,8e DSM-5 Update

Like psychodynamic theorists, cognitive theorists hold that emotions are being converted into physical symptoms This conversion is not to defend against anxiety but to communicate extreme feelings Like the other explanations, this cognitive view has not been widely tested or supported by research Comer, Abnormal Psychology,8e DSM-5 Update

The multicultural view Some theorists believe that Western clinicians hold a bias that sees somatic symptoms as an inferior way of dealing with emotions The transformation of personal distress into somatic complaints is the norm is many non-Western cultures The lesson to be learned from multicultural findings is that both bodily and psychological reactions to life events are often influenced by one's culture Comer, Abnormal Psychology,8e DSM-5 Update

A possible role for biology The impact of biological processes on somatoform disorders can be understood through research on placebos and the placebo effect Placebos: substances with no known medicinal value Treatment with placebos has been shown to bring improvement to many – possibly through the power of suggestion but likely because expectation triggers the release of endogenous chemicals Perhaps traumatic events and related concerns or needs can also trigger our “inner pharmacies” and set in motion the bodily symptoms of hysterical somatoform disorders Comer, Abnormal Psychology,8e DSM-5 Update

How Are Conversion and Somatic Symptom Disorders Treated?
People with these disorders usually seek psychotherapy only as a last resort Comer, Abnormal Psychology,8e DSM-5 Update

Many therapists focus on the causes of the disorders and apply techniques including: Insight – often psychodynamically oriented Exposure – client thinks about traumatic event(s) that triggered the physical symptoms Drug therapy – especially antidepressant medication Comer, Abnormal Psychology,8e DSM-5 Update

Other therapists try to address the physical symptoms of these disorders, applying techniques such as: Suggestion – usually an offering of emotional support that may include hypnosis Reinforcement – a behavioral attempt to change reward structures Confrontation – an overt attempt to force patients out of the sick role Researchers have not fully evaluated the effects of these particular approaches on these disorders Comer, Abnormal Psychology,8e DSM-5 Update

Illness Anxiety Disorder
People with illness anxiety disorder, previously known as hypochondriasis, experience chronic anxiety about their health and are concerned that they are developing a serious medical illness, despite the absence of somatic symptoms Comer, Abnormal Psychology,8e DSM-5 Update

They repeatedly check their bodies for signs of illness and misinterpret bodily symptoms as signs of a serious illness Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or sweating Although some patients recognize that their concerns are excessive, many do not Comer, Abnormal Psychology,8e DSM-5 Update

Although this disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers Between 1% and 5% of all people experience the disorder For most patients, symptoms rise and fall over the years Comer, Abnormal Psychology,8e DSM-5 Update

Theorists explain this disorder much as they explain various anxiety disorders: Behaviorists: classical conditioning or modeling Cognitive theorists: oversensitivity to bodily cues Comer, Abnormal Psychology,8e DSM-5 Update

Individuals with illness anxiety disorder typically receive the kinds of treatments applied to OCD: Antidepressant medication Exposure and response prevention (ERP) Cognitive-behavioral therapies Comer, Abnormal Psychology,8e DSM-5 Update

Body Dysmorphic Disorder
People with this disorder, also known as dysmorphobia, become deeply concerned about some imagined or minor defect in their appearance Most often they focus on wrinkles, spots, facial hair, swelling, or misshapen facial features (nose, jaw, or eyebrows) Comer, Abnormal Psychology,8e DSM-5 Update

As many as half of people with this disorder seek plastic surgery or dermatology treatment, and often they feel worse rather than better afterward Most cases of the disorder begin in adolescence but are often not revealed until adulthood Up to 5 percent of people in the United States experience BDD, and it appears to be equally common among women and men Comer, Abnormal Psychology,8e DSM-5 Update

Theorists typically account for BDD by using the same kinds of explanations – both physical and psychological – that have been applied to anxiety disorders and OCD Similarly, clinicians typically treat clients with this disorder by applying the kinds of treatment used with OCD, particularly anti-depressant drugs, exposure and response prevention, and cognitive therapy Comer, Abnormal Psychology,8e DSM-5 Update

Dissociative Disorders
The key to our identity – the sense of who we are and where we fit in our environment – is memory Our recall of past experiences helps us to react to present events and guides us in making decisions about the future People sometimes experience a major disruption of their memory Comer, Abnormal Psychology,8e DSM-5 Update

When such changes in memory lack a clear physical cause, they are called “dissociative” disorders In such disorders, one part of the person’s memory typically seems to be dissociated, or separated, from the rest Comer, Abnormal Psychology,8e DSM-5 Update

There are several kinds of dissociative disorders, including: Dissociative amnesia Dissociative identity disorder (multiple personality disorder) Depersonalization-derealization disorder These disorders are often memorably portrayed in books, movies, and television programs Comer, Abnormal Psychology,8e DSM-5 Update

Dissociative Amnesia People with dissociative amnesia are unable to recall important information, usually of an upsetting nature, about their lives The loss of memory is much more extensive than normal forgetting and is not caused by physical factors Often an episode of amnesia is directly triggered by a specific upsetting event Comer, Abnormal Psychology,8e DSM-5 Update

Dissociative Amnesia Dissociative amnesia may be: Localized – most common type; loss of all memory of events occurring within a limited period Selective – loss of memory for some, but not all, events occurring within a period Generalized – loss of memory beginning with an event, but extending back in time; may lose sense of identity; may fail to recognize family and friends Continuous – forgetting continues into the future; quite rare in cases of dissociative amnesia Comer, Abnormal Psychology,8e DSM-5 Update

Dissociative Amnesia All forms of the disorder are similar in that the amnesia interferes mostly with a person’ Memory for abstract or encyclopedic information – usually remains intact Clinicians do not known how common dissociative amnesia is, but many cases seem to begin serious threats to health and safety Comer, Abnormal Psychology,8e DSM-5 Update

Dissociative Fugue An extreme version of dissociative amnesia is dissociative fugue People with dissociative fugue not only forget their personal identities and details of their past, but also flee to an entirely different location For some, the fugue is brief – a matter of hours or days – and ends suddenly For others, the fugue is more severe: people may travel far from home, take a new name and establish new relationships, and even a new line of work; some display new personality characteristics Comer, Abnormal Psychology,8e DSM-5 Update

Dissociative Fugue ~0.2% of the population experience dissociative fugue It usually follows a severely stressful event Fugues tend to end abruptly When people are found before their fugue has ended, therapists may find it necessary to continually remind them of their own identity The majority of people regain most or all of their memories and never have a recurrence Comer, Abnormal Psychology,8e DSM-5 Update

Dissociative Identity Disorder (Multiple Personality Disorder)
A person with dissociative identity disorder (DID; formerly multiple personality disorder) develops two or more distinct personalities (subpersonalities) each with a unique set of memories, behaviors, thoughts, and emotions Comer, Abnormal Psychology,8e DSM-5 Update

At any given time, one of the subpersonalities dominates the person’s functioning Usually one of these subpersonalities – called the primary, or host, personality – appears more often than the others The transition from one subpersonality to the next (“switching”) is usually sudden and may be dramatic Comer, Abnormal Psychology,8e DSM-5 Update

Cases of this disorder were first reported almost three centuries ago Many clinicians consider the disorder to be rare, but some reports suggest that it may be more common than once thought Comer, Abnormal Psychology,8e DSM-5 Update

Most cases are first diagnosed in late adolescence or early adulthood Symptoms generally begin in childhood after episodes of abuse Typical onset is before age 5 Women receive the diagnosis three times as often as men Comer, Abnormal Psychology,8e DSM-5 Update

How do subpersonalities interact? The relationship between or among subpersonalities varies from case to case Generally there are three kinds of relationships: Mutually amnesic relationships – subpersonalities have no awareness of one another Mutually cognizant patterns – each subpersonality is well aware of the rest One-way amnesic relationships – most common pattern; some personalities are aware of others, but the awareness is not mutual Those who are aware (“co-conscious subpersonalities”) are “quiet observers” Comer, Abnormal Psychology,8e DSM-5 Update

How do subpersonalities interact? Investigators used to believe that most cases of the disorder involved two or three subpersonalities Studies now suggest that the average number is much higher – 15 for women, 8 for men There have been cases of more than 100! Comer, Abnormal Psychology,8e DSM-5 Update

How do subpersonalities differ? Subpersonalities often display dramatically different characteristics, including: Identifying features Subpersonalities may differ in features as basic as age, sex, race, and family history Abilities and preferences Although encyclopedic information is not usually affected by dissociative amnesia or fugue, in DID it is often disturbed It is not uncommon for different subpersonalities to have different abilities, including being able to drive, speak a foreign language, or play an instrument Comer, Abnormal Psychology,8e DSM-5 Update

How do subpersonalities differ? Subpersonalities often display dramatically different characteristics, including: Physiological responses Researchers have discovered that subpersonalities may have physiological differences, such as differences in autonomic nervous system activity, blood pressure levels, and allergies Comer, Abnormal Psychology,8e DSM-5 Update

How common is DID? Traditionally, DID was believed to be rare Some researchers even argue that many or all cases are iatrogenic; that is, unintentionally produced by practitioners These arguments are supported by the fact that many cases of DID first come to attention only after a person is already in treatment Not true of all cases Comer, Abnormal Psychology,8e DSM-5 Update

How common is DID? The number of people diagnosed with the disorder has been increasing Although the disorder is still uncommon, thousands of cases have been documented in the U.S. and Canada alone Two factors may account for this increase: A growing number of clinicians believe that the disorder does exist and are willing to diagnose it Diagnostic procedures have become more accurate Despite changes, many clinicians continue to question the legitimacy of this category Comer, Abnormal Psychology,8e DSM-5 Update

How Do Theorists Explain Dissociative Disorders?
A variety of theories have been proposed to explain dissociative disorders Older explanations have not received much investigation Newer viewpoints, which combine cognitive, behavioral, and biological principles, have captured the interest of clinical scientists Comer, Abnormal Psychology,8e DSM-5 Update

The psychodynamic view Psychodynamic theorists believe that dissociative disorders are caused by repression, the most basic ego defense mechanism People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness Comer, Abnormal Psychology,8e DSM-5 Update

The psychodynamic view In this view, dissociative amnesia and fugue are single episodes of massive repression DID is thought to result from a lifetime of excessive repression, motivated by very traumatic childhood events Comer, Abnormal Psychology,8e DSM-5 Update

The psychodynamic view Most of the support for this model is drawn from case histories, which report brutal childhood experiences, yet: Some individuals with DID do not seem to have these experiences of abuse Further, why might only a small fraction of abused children develop this disorder? Comer, Abnormal Psychology,8e DSM-5 Update

The behavioral view Behaviorists believe that dissociation grows from normal memory processes and is a response learned through operant conditioning: Momentary forgetting of trauma leads to a drop in anxiety, which increases the likelihood of future forgetting Like psychodynamic theorists, behaviorists see dissociation as escape behavior Also like psychodynamic theorists, behaviorists rely largely on case histories to support their view of dissociative disorders Moreover, these explanations fail to explain all aspects of these disorders Comer, Abnormal Psychology,8e DSM-5 Update

State-dependent learning If people learn something when they are in a particular state of mind, they are likely to remember it best when they are in the same condition This link between state and recall is called state-dependent learning This model has been demonstrated with substances and mood and may be linked to arousal levels Comer, Abnormal Psychology,8e DSM-5 Update

State-dependent learning People who are prone to develop dissociative disorders may have state-to-memory links that are unusually rigid and narrow; each thought, memory, and skill is tied exclusively to a particular state of arousal, so that they recall a given event only when they experience an arousal state almost identical to the state in which the memory was first acquired Comer, Abnormal Psychology,8e DSM-5 Update

Self-hypnosis Although hypnosis can help people remember events that occurred and were forgotten years ago, it can also help people forget facts, events, and their personal identity Called “hypnotic amnesia,” this phenomenon has been demonstrated in research studies with word lists The parallels between hypnotic amnesia and dissociative disorders are striking and have led researchers to conclude that dissociative disorders may be a form of self-hypnosis Comer, Abnormal Psychology,8e DSM-5 Update

How Are Dissociative Disorders Treated?
People with dissociative amnesia often recover on their own Only sometimes do their memory problems linger and require treatment In contrast, people with DID usually require treatment to regain their lost memories and develop an integrated personality Treatment for dissociative amnesia tends to be more successful than treatment for DID Comer, Abnormal Psychology,8e DSM-5 Update

How do therapists help people with dissociative amnesia? The leading treatments for these disorders are psychodynamic therapy, hypnotic therapy, and drug therapy Psychodynamic therapists guide patients to search their unconscious and bring forgotten experiences into consciousness In hypnotic therapy, patients are hypnotized and guided to recall forgotten events Sometimes intravenous injections of barbiturates are used to help patients regain lost memories Often called “truth serums,” the key to the drugs’ success is their ability to calm people and free their inhibitions Comer, Abnormal Psychology,8e DSM-5 Update

How do therapists help individuals with DID? Unlike victims of dissociative amnesia, people with DID do not typically recover without treatment Treatment for this pattern, like the disorder itself, is complex and difficult Comer, Abnormal Psychology,8e DSM-5 Update

How do therapists help individuals with DID? Therapists usually try to help the client by: Recognizing the disorder Once a diagnosis of DID has been made, therapists try to bond with the primary personality and with each of the subpersonalities As bonds are forged, therapists try to educate the patients and help them recognize the nature of the disorder Some use hypnosis or video as a means of presenting other subpersonalities Many therapists recommend group or family therapy Comer, Abnormal Psychology,8e DSM-5 Update

How do therapists help individuals with DID? Therapists usually try to help the client by: Recovering memories To help patients recover missing memories, therapists use many of the approaches applied in other dissociative disorders, including psychodynamic therapy, hypnotherapy, and drug treatment These techniques tend to work slowly in cases of DID Comer, Abnormal Psychology,8e DSM-5 Update

How do therapists help individuals with DID? Therapists usually try to help the client by: Integrating the subpersonalities The final goal of therapy is to merge the different subpersonalities into a single, integrated identity Integration is a continuous process; fusion is the final merging Many patients distrust this final treatment goal and their subpersonalities see integration as a form of death Once the subpersonalities are integrated, further therapy is typically needed to maintain the complete personality and to teach social and coping skills to prevent later dissociations Comer, Abnormal Psychology,8e DSM-5 Update

Depersonalization-Derealization Disorder
DSM-5 categorizes depersonalization-derealization disorder as a dissociative disorder, even though it is not characterized by memory difficulties Comer, Abnormal Psychology,8e DSM-5 Update

The central symptom is persistent and recurrent episodes of depersonalization (a change in one’s experience of the self in which one’s mental functioning or body feels unreal or detached) and/or derealization (the sense that one’s surroundings are unreal or detached) Comer, Abnormal Psychology,8e DSM-5 Update

People with this disorder feel as though they have become separated from their body and are observing themselves from outside This sense of unreality can extend to other sensory experiences and behavior Comer, Abnormal Psychology,8e DSM-5 Update

In contrast to depersonalization, derealization is characterized by the feeling that the external world is unreal and strange Comer, Abnormal Psychology,8e DSM-5 Update

Depersonalization and derealization experiences by themselves do not indicate a disorder Transient depersonalization or derealization reactions are fairly common The symptoms of a depersonalization-derealization disorder are persistent or recurrent, cause considerable distress, and interfere with social relationships and job performance Comer, Abnormal Psychology,8e DSM-5 Update

The disorder occurs most frequently in adolescents and young adults, hardly ever in people older than 40 The disorder comes on suddenly and tends to be long-lasting Few theories have been offered to explain this disorder Comer, Abnormal Psychology,8e DSM-5 Update

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