Case Studies - Somatoform and Dissociative Disorders

Question 1

body dismorphic disorder

case study who and overview

Answer 1

tina
skin picking
each episode = 30 mins
7-10 times a day
3-5 hours a day
extended periods unable to leave the house, work. this is often triggered by a stressor such as having to present at work
self -concious actions (makeup, looking in the mirror etc)
checks though she would see imperfections = skin picking outbreak
after outbreak = brief relief in her distress quickly followed by embarrasement, guilt and heightened anxiety

Question 2

tina clinical history

Answer 2

oldest sister - bulimia
father - OCD and major depression, also worried about his weight and so yo-yo dieted
chubby as a child
age 15 exercise and calorie counting - received praise for weight loss
then concern for weight diminshed and instead concern = face, no reassurance would help
skin picking before school, missed classes, socially withdrawn
did not like leabing home, if out in social situations so busy comparing her skin to others could not engage in conversation
2 previous relationships, last one resistance to enter social situations/ leave home = reason it ended
realised herself was getting in the way of work etc
also described herself as a worrier

Question 3

DSM-IV-TR

BDD key features

Answer 3

preocupatoin with imagined defect in appearance
preoccupation causes clinically sig distress and impairment in social, occupational or other importatn area of functioning
preoccupation is no better accounted for by some other meidcal disorder

Question 4

what other mental disorders muct BDD be distinguished from

Answer 4

OCD type symptoms - this only applies when the obsesses behaviour is not restricted to concerns with appearance
social phobia
impulse control
eating disorders
delusional disorder comorbidity can be appropriate
BDD is special because is entirely to fix a perceived physical defect

Question 5

what is trichotillomania

Answer 5

recurrent hair pulling that results in noticeable hair loss

to relieve tensions

Question 6

what scale can be used to measure BDD behaviour

Answer 6

BDD-YBOCS measures the severity of appearance-related thoughts and behaviours
also assesses insight and degree of avoidance behaviour

Question 7

BDD may be a variation on…

Answer 7

OCD
behaviour similarities
age of onset
run similar course
similar treatment
shared genetic risk factor
brain imaging = brain functioning abnormalities

Question 8

brain differences in processing in those with BDD

Answer 8

focused in excruciating detail on specific facial features and disregarded the overall context of the face
diifer on both verbal and nonverbal learning and memory - thye use a strategy of focusing on isolated detials rather than recalling the global properties of verbal infor and visual stimuli
frontal striaral and prefrontal regions
also been found in OCD and anorexia
misinterpretation of ambiguous social situations as threatening
mistenterprate facial expressions as contempt and anger

Question 9

environmental risk factros of BDD

Answer 9

childhood neglect
low parental warmth
child abuse
teasing
neuroticism, perfection and aesthetic sensitivity (heightened emotional response to more attractive persons and inclination to place more imporatnce on physical appearance in forming ones self identitiy

Question 10

behaviours of BDD are…

Answer 10

reinforcing
eg tina
short term relief of skin picking, avoiding social situations, covering blemishes with makeup etc

Question 11

treatment goals and planning for BDD tina

Answer 11

reduce rituals and avoidance realted to appearance concerns
reduce distress associated with appearance concerns
increase value driven hobbies and social activities
increase overall functioning and quality of life
CBT protocol
exposure with response prevention
habit reversal training

Question 12

how tina’s treatment went

Answer 12

22 sessions
at first pscyhoeducation
cognitive restructuring - identification and modification of maladaptive appearance related thoughts
asked to monitor and her self-defeating thoughts (at first she thought this would be bad and make her think about skin picking more)
restructured own core beliefs
self-esteem pie on card in purse
exposure and response prevention
taught to focus on other sensations
habit reversal = make it harder to skin pick or do something else like squeeze a stress ball
mirror training
relapse prevention strategies
encouraged to continue self-sessions after formal therapy had ended

Question 13

BDD prevalence

Answer 13

only slightly more common in females than males
1-2% of population
in mental health settings = high
cosmetic surgery patients = 5-15%, dematology = 12%
BDD not usually diagnosed will 10 to 15 years after onset de to belief there is an actual physical defect so patient will take a long time to visit a health professional
adolescent onset
chronic without treatment
lower financial income, lower rates of living with a partner, higher rates of unemployment

Question 14

comorbidities in BDD

Answer 14

depression
social phobia
OCD
substance ise
suicidal ideation and attempts
aggression or violence towards property or people in response to their symptoms
tend to seek surgery (doesn’t help) and occasionally self -surgery can occur

Question 15

what treatments do we think work for BDD

Answer 15

CBT
SSRIs
but often relapse after SSRIs are discontinued

Question 16

patient Wendy very brief background

Answer 16

horrific sexual abuse led by mum inc various boyfriends, grandfather, prostitution, forced enemas and insurtion into anus and vagina
had been molested by a doctor
rape at 15 = baby son
somehow had held togther in a fragile state = dropped out of school, got a state diploma and had been working 5 years as a telephone operator
used enemas to go to the bathroom so couldnt go out in public / out for long as bathroom so feared

Question 17

what triggered Wendy’s downward spiral

Answer 17

no longer able to contiue job. poor equipment meant she needed some corrective surgery (carpal tunnel) but she refused as fear of being molested by doctor
also son in alcohol treatment and thoughts he could be bipolar - to obtain the family history had to visit his father in prison (her rapist)
= total overwhelm

Question 18

Wendys symptoms

Answer 18

severe PTSD
flashbacks (would physcially feel the abuse during these flashbacks)
drawer and painter
exaggerated startle reflex
couldn’t then calm down again (eg after even hearing a baloon popping)
significant problems with memory and concentration
couldn’t sleep in a bed or if other people were nearby
suicide attempt
self-harm to distract from intrusive thoughts - 15 year old foot wound, vaginally cutting = anemia
self taght dissociation = 20 diff personalities, was amnesic of what had happened during these dissociation periods = forgetting hours of her day

Question 19

Wendy’s distinct personalities

Answer 19

totally different
age, sex, appearance
different responses to medications, allergies, eyesight tests
different personalities used for different aspects of her life / traumaso could fucntion at one level
eg one personalitu used when orally raped by her grandfather had no taste sensation and a minimal gag reflex
another personality that coped with her mother burning her had an extremely high pain threshold
personalities were children of the age the particular abuse occured at (so vocab, penmanship, voice, posture all totally age appropriate for their age)
had a purpose eg on that handled torture was anesthetic so tended to undertake self harming behaviours
personalities that were left with the pain of the torture appeared autistic whereas school and work personalities were charming and relateable
so wendy was very functional in highly structured consistent environments were switching of personalities was less likely
some personalities didnt know of the abuse
“susan” - loved sex as was way to make the prostitution easier if she found gratification from it
boy personality as boys were safe from the abuse = totally untouchable

Question 20

how Wendy felt

Answer 20

thought dissociation was normal
didnt want to confront it and change it
did not like being challenged by others about it
self-hatred and blame for engaging in these protective manners
no connection between the protcetive behaviours and her traumatic experiences thought she was crazy
would self harm to stop memories but then be angry at herself for being so perverse that she did that to herself

Question 21

why did Wendy have a provisional diagnosis

Answer 21

features of the disorder are present but there is uncertainty about whether the formal criteria for the disorder are met

Question 22

why does everyone who is abused not develop DID

Answer 22

people who are more hypnosible (suggestible) are able to dissociate as a survival skill against extreme trauma
self-hypnosis = self suggest dissociation
wendy = extremely hypnotizanle and relied on this to distance herself from the distress

Question 23

How we treat DID

Answer 23

recognize the existence and get to know the alters
understanding purpose each alter serves
learning new coping strategies + increased support so more awareness of traumatic memories is tolerable
confronting and reliving the early traumas to understand the original need for walls and to process intense negative feelings and thoughts
coming to understand the ways in which the traumas affected many ways of coping and learning how the present differs from the past

Question 24

how treatment of DID and PTSD differ

Answer 24

goal of DID = to uncover each of patients personalities formed and work out their purpose

Question 25

Wendy’s treatment

Answer 25

therpist lent $500 for rent
so blown away = trust
normally bad as confuses relationship but in this case first time no strings were attached and the therapist clearly trusted her
therpist relationship was unbelieveably important here
high self harm started to decrease especially as cause of self harm began to be explained and understood by her
better coping strategies taught
eg one personality used to remove stitches so mum wouldnt do it painfully. once wendy understood his role could now get stitches in her foot and realise it would be ok (but obviously alot of painful recall had to occur to reacht his place)
self harm was also used as a gateway into hypnosis, instead taught how to properly self hypnose without harm
slowly realisation she wasn’t crazy but a normal person who a horrific trauma had occured to

Question 26

wendy now better

Answer 26

4 years and 400 sessions of treatment
personalities all still exist
however dissociation not used regularly now
treatment just twice a month
relationships strating to form
appropriate reltions with child forming
sexual problems still remain but yet to be adressed
but enjoying flirtation for the first time
self harm stopped
now commerical artist and bought housing

Question 27

dissociative symptoms may result from

Answer 27

abnormal brain electricity

as found in those with temporal lobe epilepsy,

Question 28

prevalence of DID

Answer 28

more common than previously thought
9:1 female: male
childhood onset
not cure but switch frequencies tend to decrease with age and treatment
prognosis poor: 5 out of 20 sucessful in treatment
medications = little cure