Somatic Symptom and Dissociative Disorders Chapter Six Somatic Symptom and Dissociative Disorders

Somatic Symptom Disorders Disorders that involve physical symptoms or anxiety over illness Somatic symptom disorder (SSD) Illness anxiety disorder Conversion disorder (functional neurological symptoms disorder) Factitious disorder

Somatic Symptom Disorders (cont’d.)

Somatic Symptom Disorder Pattern of reporting distressing physical symptoms combined with extreme concern about health or fears of undiagnosed medical conditions Symptoms must be present for at least six months Symptoms not under voluntary or conscious control Psychological in nature but often accompanied by medical conditions

Somatic Symptom Disorder (cont’d.) SSD with predominantly somatic complaints: Chronic complaints of specific bodily symptoms that have no physical basis SSD with pain features: Severe or lingering pain that appears to have no physical basis

Illness Anxiety Disorder Previously called hypochondriasis Persistent health anxiety and concern that one has an undetected physical illness with no or minimal somatic symptoms Symptoms must be present for at least six months

Illness Anxiety Disorder (cont’d.) Individuals with illness anxiety concerns: Catastrophize Overgeneralize Display all-or-none thinking Show selective attention Cognitively based disorder

Illness Anxiety Disorder (cont’d.)

Conversion Disorder Also known as functional neurological symptom disorder Sensory or motor impairment suggestive of a neurological disorder, but with no underlying medical cause Symptoms are not consciously being faked Individual is not malingering, but rather believes there is a genuine problem

Conversion Disorder (cont’d.) Most common symptoms: Psychogenic movement Originating from psychological cause Disturbances of stance and walking Sensory symptoms Blindness, loss of voice, motor tics, and dizziness Psychogenic seizures Some symptoms are easily diagnosed, while others require extensive neurological and physical examination

Factitious Disorders Factitious disorder: Symptoms of illness are deliberately induced, simulated, or exaggerated, with no apparent external incentive Differs from malingering: Faking a disorder to achieve some goal, such as an insurance settlement In factitious disorder, the individual is usually unaware of the motivation for the behavior

Factitious Disorders (cont’d.) Factitious disorder imposed on another: Pattern of falsification or production of physical or psychological symptoms in another individual Relatively new diagnostic category and as a result, little information is available on prevalence, age of onset, or familial pattern Diagnosis of this condition is difficult

Etiology of Somatic Symptom Disorders Figure 6-2 Multipath Model for Somatic Symptom Disorders The dimensions interact with one another and combine in different ways to result in a specific somatic symptom disorder.

Etiology of Somatic Symptom Disorders (cont’d.) Biological dimensions: Modest contribution of genetic factors Biological predisposition hardwired into central nervous system can result in: Hypervigilance or exaggerated focus on bodily sensation Increased sensitivity to mild bodily changes Tendency to react to somatic sensations with alarm Repetitive activation of nervous system can lead to increased sensitivity of pain nerves

Etiology of Somatic Symptom Disorders (cont’d.) Psychological dimension: Role of reinforcement, modeling, catastrophic cognitions, or combination of these Cognitive factors: Somatic disorders may develop in predisposed individuals Unrealistically interpret and overestimate dangerousness of bodily symptoms

Etiology of Somatic Symptom Disorders (cont’d.) Social dimension: Societal restrictions on women Rejection or abuse from family members and feeling unloved History of sexual abuse or rape Parental modeling Sociocultural dimension: Cultural factors, including lower educational levels, ethnicity, and immigrant status

Treatment of Somatic Symptom Disorders Biological: Antidepressant medications such as SSRIs are used to treat somatic symptoms disorder ad illness anxiety disorder Increased physical activity is recommended for conversion disorder

Treatment of Somatic Symptom Disorders (cont’d.) Psychological: Focus is understanding client’s view regarding problem Demonstrate empathy View disorders within social context Cognitive-behavioral approaches Correct cognitive distortions Interoceptive exposure

Dissociative Disorders Involves some sort of dissociation, or separation, of a part of a person’s consciousness, memory, or identity Dissociative amnesia Depersonalization/derealization disorder Dissociative identity disorder Relatively rare No objective assessment: Possibility of feigning

Dissociative Amnesia Sudden partial or total loss of important personal information or recall of events due to psychological factors or stressors May occur following a traumatic event or stressful circumstances May also involve a fugue state

Dissociative Amnesia (cont’d.) Localized amnesia: Lack of memory for a specific event or events Individuals may have selective amnesia or systematized amnesia May occur after a repressed memory comes to light Dissociative fugue: Episode of complete loss of memory of one’s life and identity , unexpected travel to new location, or assumption of new identity Recovery is often abrupt and complete

Depersonalization/Derealization Disorder Characterized by feelings of unreality concerning the self and the environment Depersonalization is the most common dissociative disorder Diagnosis given only when feelings of unreality and detachment cause major impairment in social or occupational functioning

Dissociative Identity Disorder (DID) Formerly called multiple personality disorder Two or more relatively independent personality states appear to exist in one person, including experiences of possession Diagnostic controversy

Etiology of Dissociative Disorders Figure 6-4 Multipath Model of Dissociative Identity Disorder The dimensions interact with one another and combine in different ways to result in dissociative identity disorder.

Etiology of Dissociative Disorders (cont’d.) Diagnosis depends on self-report, making it difficult to differentiate between genuine and faked cases Two most influential models, post-traumatic and sociocognitive, are not sufficient to explain why only some develop disorders Must look at vulnerabilities in biological, psychological, social, and sociocultural dimensions

Etiology of Dissociative Disorders (cont’d.) Biological dimension: Atypical brain functioning Inhibited activity in hippocampus and hypometabolism in area of prefrontal cortex Variations in brain activity when comparing different personalities Difficult to interpret patterns of brain activity Permanent structural changes in brain due to trauma may play a role Reduction in amygdalar and hippocampal volumes

Etiology of Dissociative Disorders (cont’d.) Psychological dimension: Psychodynamic theory Repression blocks unpleasant or traumatic events from consciousness Protects individuals from painful memories or conflicts DID results from severe childhood abuse

Etiology of Dissociative Disorders (cont’d.) Psychological dimension: (cont’d.) Four factors necessary for development of DID according to posttraumatic model (PTM) Exposure to overwhelming childhood stress Capacity to dissociate Encapsulating or walling off the experience Developing different memory systems DID results from these factors if supportive environment is unavailable or if personality is not resilient

Etiology of Dissociative Disorders (cont’d.) Figure 6-5 The Post-Traumatic Model of Dissociative Identity Disorder Note the importance of each of the factors in the development of dissociative identity disorder. Source: Adapted from Kluft (1987); Loewenstein (1994).

Etiology of Dissociative Disorders (cont’d.) Social and sociocultural dimension: Sociocognitive model (SCM): Displays of role enactments that have been created, legitimized, and maintained by social reinforcement Patients learn about phenomenon and its characteristics from mass media, cues provided by therapist, personal experiences, and observation Iatrogenic disorder: unintentionally produced by therapists actions and treatment strategies High levels of hypnotizability and suggestibility

Treatment of Dissociative Disorders Variety of treatments, including: Supportive counseling Hypnosis Personality reconstruction Currently no specific medication for dissociative disorders, but used to treat accompanying anxiety or depression

Treatment of Dissociative Disorders (cont’d.) Dissociative amnesia and fugue: Symptoms usually spontaneously end, but often associated with depression and/or stress Treating dissociative disorders indirectly by alleviating depression and stress Antidepressants or cognitive-behavioral therapy for depression Stress-management techniques for stress

Treatment of Dissociative Disorders (cont’d.) Depersonalization/derealization disorder: Also subject to spontaneous remission, but at a much slower rate Treatment focuses on alleviating feelings of depression, anxiety, or fear of going insane Antidepressants and antianxiety medications

Treatment of Dissociative Disorders (cont’d.) Dissociative identity disorder: Major goal is use of trauma-based therapy to develop healthier ways of dealing with stressors Hierarchical treatment approach involves: Working on safety issues, stabilization, and symptom reduction Reducing cognitive distortions Identifying and working through traumatic memories Stabilizing and learning to deal with stressors Developing healthy relationships and practicing self-care

Treatment of Dissociative Disorders (cont’d.) Dissociative identity disorder (cont’d.): Treatment is not always successful Greatest reduction in symptoms when individuals are able to integrate personalities

Treatment of Dissociative Disorders (cont’d.) ABC Video: Robert Oxnam (Dissociative Identity Disorder)