6 - Somatic and Dissociative Disorders

Question 1

What are the essential features of somatic symptoms and related disorders?

Answer 1

Physical symptoms suggest a physical disorder but there are no demonstrable organic findings or known physiological mechanisms; the symptoms are presumed to be linked to psychological factors or conflicts (e.g. hypochondriac)

Question 2

How prevalent are somatic disorders?

Answer 2

Among the most prevalent in primary and other medical settings; (10-15% of primary care patients); functional impairment is comparable with that seen in depressive and anxiety disorders; associated with excessive health care use

Question 3

List the 5 major categories of somatic related disorders according to DSM-5

Answer 3

Somatic symptom disorder; illness anxiety disorder; conversion disorder; factitious disorder; psychological factors affecting other medical conditions

Question 4

How is somatic symptom disorder diagnosed, and how can this be problematic?

Answer 4

By exclusion; known physical causes must be ruled out; But there’s a possibility a physical cause has been overlooked (absence of evidence not the same as evidence of absence)

Question 5

What is somatic symptom disorder?

Answer 5

Multiple, current somatic symptoms that are distressing or result in significant disruption to daily life

Question 6

Somatic symptom disorder refers to excessive thoughts, feelings or behaviours related to associated health concerns as manifested by at least one of which three symptoms?

Answer 6

Disproportionate and persistent thoughts; persistently high level of anxiety about health or symptoms; excessive time and energy devoted to these symptoms (symptomatic state persists > 6 months)

Question 7

What are the most typical somatic symptoms that people report?

Answer 7

Pain and gastrointestinal complaints

Question 8

What are some of the most distressing issues in regards to somatic symptom disorder?

Answer 8

Suicidal thoughts and attempts are frequent; chronic/fluctuating course; extensive medical history (doctor-shopping); anxiety and depression common; somatisation and antisocial personality disorder run in families

Question 9

What can somatic symptom disorder be specified with?

Answer 9

Predominant pain (similar to DSM-IV pain disorder)

Question 10

Describe the prevalence rates of somatic symptom disorder

Answer 10

More frequently diagnosed in females; onset age often between 30s-40s; invalid role often assumed; co-existing psychiatric disorders

Question 11

Describe the features of illness anxiety disorder (previously known as hypochondriasis)

Answer 11

Preoccupation with having or acquiring a serious illness; somatic symptoms not present (or only mild); high level of anxiety about health and easily alarmed about health status; perform excessive health-related behaviours or exhibit maladaptive avoidance; illness preoccupation for at least 6 months; belief they have an illness despite evidence to the contrary; somatosensory amplification

Question 12

Describe the prevalence rates of illness anxiety disorder

Answer 12

Similar in males and females; 78% experience comorbidity with anxiety disorder or major depression

Question 13

Describe Conversion Disorder

Answer 13

Symptoms mimic a neurological disorder or other medical condition; may make no anatomical sense; implies psychological conflicts are being converted into physical symptoms; not the same as malingering; rare (prevalence unknown); 10-15% originally diagnosed later found to have a diagnosable condition

Question 14

What are 4 ways of distinguishing conversion disorder from “true” medical problems?

Answer 14

Those with conversion disorder show unusual emotional reactions (la belle indifference – emotions don’t equate with what they’re saying); neurological anatomical inconsistencies; unexpected course of development (e.g. muscle tone in paraplegia); selective symptomology (e.g. conversion blindness – don’t show the same mishaps as a blind person)

Question 15

Describe Factitious Disorder

Answer 15

They deliberately create the symptoms, which can be imposed on the self or another; munchausen syndrome is a rare, repetitive pattern of factitious disorder

Question 16

Describe Malingering

Answer 16

Symptoms created for the purpose of compensation or to avoid a negative event (not apparent in factitious disorder)

Question 17

Describe how somatic symptom disorders (SSD) are frequently linked to antisocial personality disorder (APD)

Answer 17

APD is characterised by habitual violations of social rules; male relatives of people with SSD have higher rates of APD than do males in control families; APD occurs primarily in males and SSD in females (may be different expressions of high negative affectivity and disinhibition)

Question 18

What are some similarities between SSD and APD?

Answer 18

They begin early in life; chronic; predominate among low SES groups; difficult to treat; related to marital discord, substance abuse and suicide attempts

Question 19

Describe the neurobiologically based disinhibition syndrome theory about people with SSD and APD?

Answer 19

They have a weak behavioural inhibition system that’s incapable of exerting sufficient control over the behavioural activation system

Question 20

What does the psychodynamic perspective suggest about psychological vulnerabilities in people with SSD?

Answer 20

Negative feelings repressed and converted into physical symptoms; poor self-awareness and ability to self regulate; less psychologically minded

Question 21

The cognitive view suggests that somatoform symptoms are a form of communication, and have shown a strong correlation between psychosomatic symptoms and Alexithymia. What is it?

Answer 21

A poor capacity to identify or describe emotions (so more likely to report as a physical symptom; e.g. children expressing anxiety as a tummy ache)

Question 22

The cognitive view also suggests SSD to reflect a misinterpretation of body sensations. How so?

Answer 22

They misinterpret bodily sensations as signs of a severe illness; view negative life events as unpredictable, threatening and uncontrollable; interpret ambiguous stimuli as threatening

Question 23

What features are negative affectivity (NA) linked to?

Answer 23

Worry; pessimism; fear of uncertainty; guilt; fatigue; poor self-esteem; shyness; depression; greater NA predicts increased severity of somatization (history of personal/family illness may also be a predictor, as they learn that they can gain attention)

Question 24

Describe the 4 basic processes in the development of conversion disorder, according to Freud

Answer 24

Traumatic event is experienced (e.g. conflict); the conflict is repressed and made unconscious; anxiety increases, threatening to push the conflict into consciousness, and is converted into physical symptoms relieving the pressure of having to deal directly with the conflict (primary gain); increased attention and sympathy is received (secondary gain)

Question 25

In which cultures is somatoform more prevalent?

Answer 25

Those that discourage open discussion of psychological problems and that stigmatise mental disorders

Question 26

In a review of RCTs by Kroenke involving 3922 patients, effective treatments were established for all somatic symptom disorders except for which 2? Which was the best established treatment?

Answer 26

Conversion disorder and Pain disorder; CBT most effective; (preliminary positive evidence for antidepressants)

Question 27

What kinds of strategies are typically used in CBT for treating SSDs?

Answer 27

Exposure and response prevention (exposing them to physical sensations); reinforcement strategies (becoming functional in everyday life); relaxation training; cognitive restructuring (changing maladaptive beliefs about the symptoms)

Question 28

In a controlled treatment study by Warwick et al., patients were asked to identify and challenge illness related misinterpretations of physical sensations. What approach did they take, and how effective was it?

Answer 28

They showed patients how to create symptoms by focusing attention on certain body areas, and coached them to seek less reassurance; 76% of treatment patients improved

Question 29

Although there’s been long-standing controversy in terms of diagnosis, how are dissociative disorders defined?

Answer 29

As a set of disorders characterised by disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment

Question 30

Define Depersonalisation

Answer 30

Feeling detached from one’s body (e.g. out of body experience)

Question 31

Define Derealisation

Answer 31

Feeling of unfamiliarity or unreality about one’s physical or interpersonal environment

Question 32

Dissociative amnesia can be defined as an inability to recall important personal information (not due to an organic mental disorder). What are some typical types of disturbances in recall?

Answer 32

Localised amnesia (an event/period of time); selective (specific aspect of an event); generalised (identity/life history); retrograde (before an event); anterograde (transferring new info from STM to LTM); post-traumatic amnesia

Question 33

Describe the onset of dissociative amnesia

Answer 33

Begins suddenly (following stress); ends abruptly (recovery complete; recurrences rare)

Question 34

In dissociative amnesia, there’s a loss of past both recent and remote; personal identity is lost but general knowledge intact; events after amnesia starts are remembered well; and amnesia often reverses abruptly. How can organic amnesia be distinguished from this?

Answer 34

Distant past remembered well, but recent past remembered poorly; both personal and general knowledge is lost; this aspect of memory is lost and is the primary symptom; memory gradually returns for retrograde memories, seldom returns for memories since brain damage, and memory of trauma never revived

Question 35

Dissociative amnesia can be specified with dissociative fugue. What is it?

Answer 35

Sudden, unexpected travel away from home/work locale with assumption of a new identity and inability to recall one’s previous identity; following recovery, no recollection of events that took place during the fugue; is usually brief and ends suddenly; may be extensive (they establish a well integrated new identity)

Question 36

What’s the essential feature of Dissociative identity Disorder (formerly known as multiple personality disorder)

Answer 36

A presence within a person of 2 or more distinct personality states, each within it’s own pattern of perceiving, relating to, and thinking about the environment and self

Question 37

As well as having 2 or more personality states or experiences of possession, describe the other symptoms of dissociative identity disorder (DID)

Answer 37

Recurrent episodes of amnesia; very sudden transitions between personalities; transitions often triggered by overwhelming stress; often first diagnosed in late adolescence or early adulthood; usually develops in early childhood after abuse and/or maltreatment; relatively rare; 70%+ attempted suicide; personalities range from 2-60 (average 13)

Question 38

What are some of the differences found between sub-personalities in DID

Answer 38

Personality characteristics; demographic characteristics; abilities and preferences; physiological responses (heart rate, etc)

Question 39

There’s a growing belief in the authenticity of DID and changes in diagnostic biases and criteria. What do most clients (80-100%) have no knowledge of before therapy?

Answer 39

Of the existence of their alters

Question 40

What are the essential features of Depersonalisation/Derealisation Disorder?

Answer 40

Feelings of being detached from one’s body or mind, as if they’re an external observer of their own behaviour; usually sudden onset, precipitated by extreme stressor (extreme fatigue, pain or trauma); occurs mostly in adolescents; transient depersonalisation is common

Question 41

DID is a failure of the normal developmental process of personality integration, hypothesised to result from traumatic experiences during critical developmental periods. What’s the psychodynamic view on the aetiology?

Answer 41

Dissociation is a defence against painful events; represent extreme use of repression; roots in childhood; but empirical confirmation of these assumptions is lacking

Question 42

What’s the behavioural view on the aetiology of DID, and what are the limitations?

Answer 42

Patients play a social role learned via: modelling; exposure to information about the disorder; operant conditioning; selective reinforcement of personalities (non-clinical Ps can adopt the role of a person with DID); Limitations: dependence on case studies; can’t explain how dissociation occurs

Question 43

What do both psychodynamic and behavioural theories agree on?

Answer 43

DDs are precipitated by traumatic experiences; they represent ways of avoiding extreme anxiety; the patients are unaware that their disorder is protecting them from facing a painful reality

Question 44

The psychodynamic theory proposes that DDs represent attempts at forgetting and are purposeful from the start (although unconscious), and the hardworking unconscious keeps patients unaware that dissociation is used as means of escape. How does the behavioural view differ?

Answer 44

The initial development of dissociative reactions is more accidental; subtle reinforcement process keeps patients unaware that dissociation is used as means of escape (different mechanisms give rise to the same things)

Question 45

Describe some parallels between hypnotic amnesia and DDs

Answer 45

Material is forgotten for the period of time yet later realised; forgetting without insight; events more readily forgotten than basic knowledge

Question 46

What has increased sleep been shown to decrease in experimental situations?

Answer 46

Dissociation (a fragmented sleep-wake cycle helps explain dissociative symptoms)

Question 47

What is Iatrogenesis, in terms of social factors leading to DDs, and what’s a problem with this view?

Answer 47

The manufacture of a disorder by its treatment (cases created/implanted by therapists); But DID is diagnosed in countries where there’s no awareness of the disorder (suggestibility alone doesn’t explain dissociation)

Question 48

How does the dissociation-trauma model explain the aetioogy of DID?

Answer 48

Severe early childhood trauma > child attempts psychological escape (through imagining a new identity/self-hypnosis) > dissociated experiences leading to distinct memories/unique feelings/new identity > these identities reappear as alter personalities; or stressors occurring in adulthood > alter personalities

Question 49

What’s the diathesis-stress perspective on DDs?

Answer 49

Diathesis (high levels of imaginary involvement and fantasy proneness; highly hypnotisable; history of childhood trauma) + stressors (sudden, unexpected trauma; strong emotional conflict; sleep disturbance) = DDs

Question 50

What does the psychodynamic perspective focus on in treatment?

Answer 50

Recovering lost memories

Question 51

Hypnosis facilitates the recall of painful experiences, but can lead to Abreaction. What is this?

Answer 51

The emotional reliving of a past traumatic experience (can be dangerous/misleading memories implanted)

Question 52

What kind of medications may be prescribed to DD patients?

Answer 52

Medications that reduce stress; sodium amobarbital (Amytal) or sodium pentobarbital (Pentothal) - “truth serum”

Question 53

Describe the principles for treatment of DID

Answer 53

Integrate sub-personalities into one; each sub-personality helped to understand they’re part of the same person; all should be treated with fairness and empathy; therapist should encourage empathy and cooperation among personalities; recover gaps in their memory; help the patient recognise the breadth of their disorder