Chapter 5 - Dissociative Disorder and Somatic Symptom and Related Disorders

Question 1

What are Dissociative Disorders?

Answer 1

• normally speaking there is a unity to consciousness that gives rise to a sense of self
• we perceive ourselves as progressing though space and time
  
  • a sense on continuity
• In the dissociative disorders, one or more of these aspects of daily living is disturbed, there is shift in identity, something intrinsic to them has changed, here arises the disorder

Question 2

What are Somatoform Disorders?

Answer 2

• somatoform disorders involved physical complaints that reflect underlying psychological conflicts or issues
• important to do a full medical evaluation to determine whether or not it is psychological and not physical

Question 3

-Dissociative Identity Disorder (DID)

Answer 3

• a condition in which a person has two or more distinct or alternative personalities
  
  • previously called multiple personality disorder

Question 4

DSM-5 Criteria: DID

Answer 4

• A.Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behaviour, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
• B.Recurrent gaps in the recall of every day events, important personal information, and/ or traumatic events that are inconsistent with ordinary forgetting
• C.The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• D.The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

• E.The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behaviour during alcohol intoxication) or another medical condition (e.g., complex partial seizures)

Question 5

DID vs Schizophrenia

Answer 5

• these two are sometimes confused by lay persons
• Schizophrenia (GR. Split mind) refers to loosening of connections between various psychic functions (e.g., ideas, perceptions, emotions, behaviors
• DID involves the formation of separate, but (at least partly) integrated personality structures

Question 6

• A lot of clinicians and researchers are highly skeptical about DID

Answer 6

• about 21 % of Board certified psychiatrists felt there was strong evidence for the condition
• 58% voiced skepticism and/or thought it should removed from DSM
• Piper and Merskey (2004)
• No proof that it results from childhood trauma as broadly believed
• Very low base rate
• Number of alters appears to be increasing with time

Question 7

• Spanos (2001) research

Answer 7

reflects inadvertent role-play, a person’s suggestibility plays a major role and end up not being to distinguish between
• Almost unheard of outside North America
• Appearance is highly influenced by cultural factors
• A form of role-playing inadvertently cued by interviewers?
• Eventually becomes habitual
• Emphasizes the importance of careful interviewing

Question 8

What is a dissociative disorder (text)

Answer 8

A change disturbance in functions of self identity, memory or consciousness, that make the personality whole

Question 9

What are the dissociative disorders?

Answer 9

• dissociative identity disorder
• dissociative amnesia disorder
• depersonalization/Derealization disorder

-in each case there is a dissociation (splitting off) of the functions of identity, memory, consciousness - functions that normally combine to make us whole

Question 10

DID (text)

Answer 10

-dissociative disorder in which a person has two or more distinct or alternate personalities

They may or may not be aware of one another

-the dominant personality is often unaware of the existence of alternates (alters) but may sense that something is amiss

Question 11

Want do some psychologists like Spanos believe DID to be ?

Answer 11

That it is not a distinct disorder but a form of role playing in which individuals first come to construe themselves as having multiple selves and then begin to act in ways that are consistent with their conception of the disorder. Eventually their role playing becomes so ingrained that it becomes reality to them
-thought that their therapist may play into it as well, reinforcing

Question 12

What reinforcers may become contingent on enacting the role of a multiple personality type

Answer 12

• Attention
• evading accountability
• attention from the therapist

Question 13

Social reinforcement with DID may cause

Answer 13

Some therapists to “discover” many more cases of DID than others
-certain cues and prompts may cause the client to adopt the role of a multiple personality to please their clinicians

Question 14

Some more facts on DID

Answer 14

• Alters may or may not be aware of each other

• “Co-conscious” or may communicate indirectly through other people
or leaving notes.
– At other times may be in apparent conflict
• People Dx’d with DID were often highly imaginative children and suggestible adults.
• Therapeutic goal has traditionally been “reintegration” (discussed further below)

Question 15

Dissociative Amnesia

Answer 15

• type of dissociative disorder in which a person experiences memory losses in the absence of any identifiable organic cause
  
  • would be retrograde except general knowledge, habits, personal tastes, and skills are usually retained
  • forgotten material is usually related to trauma
  • may be localized, selective or generalized
  • Specifier: With fugue (to take off)

Question 16

Dissociative amnesia (text)

Answer 16

Dissociative disorder in which a persons experiences memory losses in the absence of any identifiable organic cause. General knowledge and skills are usually retained

• usually involves material relating to traumatic or stressful experiences that cannot be accounted for simple forgetfulness
• unlike Alzheimer’s, the loss is reversible (controversial). May happen gradually but usually spontaneously
• involves localized amnesia, which means that events occurring during specific time periods are lost to memory
• selective amnesia - only forget the disturbing particulars in an event
• generalized amnesia - people forget their entire lives, who they are, where they live, and whom they live. Tend to retain baits, tastes, and skills

Question 17

-selective amnesia -

Answer 17

only forget the disturbing particulars in an event

Question 18

localized amnesia,

Answer 18

which means that events occurring during specific time periods are lost to memory

Question 19

-generalized amnesia -

Answer 19

people forget their entire lives, who they are, where they live, and whom they live. Tend to retain traits, tastes, and skills

Question 20

DSM-5 – Dissociative Amnesia

Answer 20

A.An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder, post-traumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder

-Specifier: 300.13 with dissociative fugue: apparently purposeful travel or bewildered wandering that is associated with amnesia for identity or for other important autobiographical information
• Type of dissociative disorder in which one suddenly flies from one’s life situation, travels to a new location, assumes a new identity, and has amnesia for past personal material.
• The person usually retains skills and other abilities and may appear to others in the new environment to be leading a normal life

Always consider malingering… (pretending not creation, always motivated by consequences)

• faking illness so as to avoid or escape work or other duties, or to obtain benefits. Not a dissociative disorder
• faking amnesia is quite common. Usually an attempt to escape criminal or other responsibility

Question 21

Malingering

Answer 21

Faking illness to avoid or escape work or other duties, or to obtain benefits

Question 22

Depersonalization (text)

Answer 22

Feelings of unreality or detachment from ones self or ones body, as if owner were a robot or functioning on auto pilot or observing oneself from outside

Question 23

Depersonalization/ Derealization Disorder

Answer 23

• disorder characterized by persistent or recurrent episodes of depersonalization
• feelings of unreality or detachment from ones self or ones body, as if one were a robot, or functioning on automatic pilot or observing oneself form outside
• Patients may interpret as an “out-of-body” or transcendental experience

Question 24

-Depersonalization:

Answer 24

temporary alteration form usual sense of reality. E.g., like watching oneself on TV, feeling detached from body or thought processes, some perceptual interferences

Question 25

-Derealization:

Answer 25

episodes of Derealization are characterized by the sense that one’s surroundings have become strange or unreal-for example, colours may seems washed out or very bright-and time may seem to be oddly slowed down or sped up

Question 26

Depersonalization and Derealization both

Answer 26

• neither is a psychosis because contact with reality is maintained
• both can be triggered by anxiety/trauma

Question 27

Derealization (text)

Answer 27

Loss of sense of reality of ones surroundings, experienced in terms of strange changes in ones environment (people or objects changing shape or size) or in the sense of the passage of time

Question 28

depersonalization / derealization disorder

Answer 28

characterized be persistent episodes of depersonalization

Question 29

theoretical perspectives - Psychodynamic

Answer 29

• believe in the massive use of repression which leads to “splitting off” from consciousness or acceptable impulses and painful memories, especially sexual abuse
• may retreat into themselves as a defense to the terrible things happening to them, distance from suffering creating another personality to help cope
• in dissociate amnesia the ego protects itself from becoming flooded with anxiety by blotting out disturbing memories or dissociating threatening impulses of a sexual or aggressive nature

Question 30

Learning and cognitive therories

Answer 30

• view dissociation as a learned response that involves not thinking about disturbing acts or thoughts to avoid feelings of guilt and shame evoked by those experiences
• negatively reinforced by escape

Question 31

the vast majority of people with DID

Answer 31

were sexually abused as children

Question 32

Controversies

-Recovered memory

Answer 32

• an ancillary issue: claim is that some traumatic memories may be repressed but lead to depression, anxiety, and other psychological symptoms
  
  • thought the use of hypnosis psychotherapy these can supposedly be recovered
  • there is much controversy about this
• Repressed memories may or may not be a real phenomenon, but false memories are a reality and may be “induced” in most people

Question 33

Suggestibility and probing

Answer 33

• false memories can be produced in experiments
  
  • 26% Porter et al (1999)
• True vs False memories
  
  • constructivist nature of normal memory

Question 34

Treatment - psychoanalysis

Answer 34

in DID uncover and deal with childhood trauma

-the self will work through the trauma with the personalities

Question 35

Somatic symptom and related disorders

Answer 35

disorders in which people complain of physical problems although no physical problems can be found

Question 36

Somatic Symptom Disorders

Answer 36

-disorder in which people complain of physical (somatic) problems although no physical abnormality can be found

Question 37

SOMATIC SYMPTOM DISORDER: DSM-5 Criteria

Answer 37

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Specifiers: With predominant pain; Persistent (>6 months); Mild/Moderate/Severe

Question 38

Illness Anxiety Disorder

Answer 38

-the preoccupation with the idea that one is sick is accompanied by substantial anxiety about health and disease. Individuals with illness anxiety disorder are easily alarmed about illness, such as hearing about someone else falling ill or reading a health-related news story. Their concerns about undiagnosed disease do not respond to appropriate medical reassurance, negative diagnostic tests, or benign course

Question 39

ILLNESS ANXIETY DISORDER – DSM-5 Criteria

Answer 39

A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
D. The individual performs excessive health-related behaviours (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
(E & F Omitted)
• Specifiers: Care-seekingType; Avoidant Type

Question 40

Conversion Disorder (Functional Neurological Symptom Disorder)

Answer 40

A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
• Symptom Specifiers: With weakness or paralysis; With abnormal movement; With swallowing symptoms; With speech symptom (e.g., dysphonia, slurred speech); With attacks or seizures; With anesthesia or sensory loss; With special sensory symptom (e.g., visual, olfactory, or hearing disturbance); With mixed symptoms
• With/Without Psychological Stress
• Acute/Persistent

Question 41

Factitious Disorder (Munchausen’s Syndrome)

Answer 41

-the essential feature of factitious disorder is the falsification of medical of psychological sings and symptoms in oneself or others that are associated with the identified deception. Individuals with factitious disorder can also seek treatment for themselves of another (by proxy) following induction of injustice or disease

Question 42

FACTITIOUS DISORDER: DSM-5 Criteria

Answer 42

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired, or injured.
C. The deceptive behaviour is evident even in the absence of obvious external rewards.
D. The behaviour is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.
– Note: The perpetrator, not the victim, receives this diagnosis

Question 43

la belle indifference

Answer 43

French term describing the lack of concern over ones symptoms displayed by some people with conversion disorder but also by people with real physical disorder

Question 44

Illness Anxiety Disorder

Answer 44

a disorder characterized by a preoccupation with the fear of having or the belief that one has a serious medical illness, but no medical basis for the complaints can be found

Question 45

care-avoidant subtype

Answer 45

who postpone or avoid medical visits of lab tests because of high levels of anxiety about what may be discovered

Question 46

care-seeking subtype

Answer 46

people who go doctor shopping, in the hopes of finding one medical pro who might confirm their worst fears

Question 47

somatic symptom disorder (text)

Answer 47

a disorder involving one or more somatic symptoms which cause excessive concern to the extent that it affects the individuals thoughts, feelings, and behaviours in daily life

Question 48

Factitious Disorder (text)

Answer 48

type of psychological disorder characterized by the intentional fabrication of physiological or psychological symptoms for no apparent gain

Question 49

Theoretical Perspectives -

Answer 49

• Primary gains: in psychodynamic theory, the relief from anxiety obtained though the development of neurotic symptoms
• Secondary Gains: side benefits associated with neurosis or other disorders, such as expressions of sympathy and increased attention form others and release from ordinary responsibilities

-psychodynamic theory - hysteria symptoms are functional, allow the person to achieve primary and secondary gains

Question 50

Learning theories

Answer 50

• conversion disorders relieve anxiety, negative reinforcement
• focus more on the the direct reinforcing properties of the symptoms and its secondary role in helping the individual avoid or escape uncomfortable or anxiety-invoking situations