Chapter 6 Flashcards
Supernatural explanations
Dissociation and related complaints were now seen as the result of demonic possession, and exorcism was the favoured treatment
History: Dissociative disorders and Somatic symptom disorders viewed as Hysteria
An outdated psychiatric term once used to describe a symptom pattern characterized by emotional excitability and physical symptoms (e.g., convulsions, paralyses, numbness, loss of vision) without any organic cause.
-Caused in women by a wandering womb (hysteros)
Freud and Beuer hysteria
posited that trauma, often of a sexual nature, was a predisposing factor for hysteria and established a relationship between dissociation and hypnotic-like states
Freud Conversion symptoms as expressions of unconscious psychological conflicts
He suggested that “conversion” of anxiety to more acceptable physical symptoms relieved the pressure of having to deal directly with the conflict. This avoidance of conflict was termed primary gain and was viewed as the main reinforcement maintaining the somatic symptoms. Freud also recognized that hysterical symptoms could help a patient avoid responsibility and gain attention and sympathy, referring to these reinforcements as secondary gains of the symptoms. The term secondary gain is still commonly used today to refer to the benefits a patient may either unknowingly or knowingly seek by adopting the sick role.
Dissociative disorders
are characterized by severe maladaptive disruptions or alterations of identity, memory, and consciousness that are experienced as being beyond one’s control
Main symptom of dissociative disorders
Dissociation- the lack of normal integration of one or more aspects of psychological functioning, such as identity, memory, consciousness, emotion, sensorimotor functioning, or behaviour
Dissociative tendency fall into two main groups
1) involves mild, non-pathological forms of dissociation, such as absorption and imaginative involvement, that are normally distributed on a continuum across the general population
2) involves more severe, pathological types of experiences, such as amnesia, derealization, depersonalization, and identity alteration, that do not normally occur in the general population and that form a discrete category or taxon
Memories repressed
Referring to memories that a person cannot call into awareness, but that remain in the person’s subconscious and can be retrieved under certain conditions or with the help of a psychotherapist.
Three Major Dissociative Disorders
dissociative amnesia (which includes dissociative fugue as a subtype), depersonalization/derealization disorder, and dissociative identity disorder (formerly known as multiple personality disorder)
Dissociative amnesia
Inability to recall important personal information
-Includes dissociative fugue, a rare condition in which individuals unexpectedly leave home and may turn up in a distant city with no memory of their past
Dissociative identity disorder
-Presence of two or more personality states
-Formerly known as multiple personality disorder; the classic case is The Three Faces of Eve
Depersonalization/derealizatin disorder
Feeling of being detached from oneself and one’s physical and social environment
-Depersonalization experienced for a short period of time is very common and not pathological
Dissociative amnesia occurence
following a traumatic event, such as an automobile accident, or exposure to war trauma or torture that many people have confronted before claiming refugee status in Canada. Afflicted individuals usually have no memory of the precipitating traumatic event, and may be unable to recall their own name, occupation, and other autobiographical information, even though they may still retain general knowledge of world events, such as the name of the current prime minister of Canada
Four patterns of Dissociative Amnesia
(1) localized amnesia, wherein the person fails to recall information from a very specific time period (e.g., the events immediately surrounding a trauma); (2) selective amnesia, wherein only parts of the trauma are forgotten while other parts are remembered; (3) generalized amnesia, wherein the person forgets all personal information from their past; and (4) systematized amnesia, wherein the individual only forgets certain categories of information, such as certain people or places.
Subtype of Dissociative Amnesia: Dissociative Fugue
A type of dissociative amnesia in which an individual suddenly and unexpectedly travels away from home and may take up a new identity, accompanied by a loss of memory for their own identity or other important biographical information.
-The fugue is usually brief in duration, lasting from a few days to a few weeks, but there are rare cases where the individual disappears for a prolonged period of time. The behaviour of individuals presenting with dissociative fugue is not all that unusual; they are able to function reasonably well and may even successfully adopt a new identity and occupation if the disorder is prolonged. Dissociative fugue may end either abruptly or gradually with persistent confusion or amnesia about identity. Often, those who have recovered from the disorder report no memory of what occurred during the fugue state.
Depersonalization/derealization disorder
is a dissociative disorder in which the individual has persistent or recurrent experiences of depersonalization and/or derealization
Depersonalization
is a condition in which individuals have a distinct sense of unreality and detachment from their own thoughts, feelings, sensations, actions, or body. Fleeting experiences of depersonalization are relatively common, with approximately half of the general population reporting such symptoms, often during times of stress
Depersonalization/derealization disorder diagnosed
only when severe depersonalization is the primary problem, and when the symptoms are persistent and cause clinically significant impairment or distress. Individuals with this disorder experience recurrent episodes of depersonalization, in which they feel as though they are living in a dream, observing their own mental processes or body from the outside, or as if time is moving slowly. They commonly describe feeling like a robot that is able to respond to their environment, but without feeling connected to their actions
Derealization
A dissociative symptom in which one has a sense of unreality or detachment with respect to objects or other people in the environment, experiencing them as unreal, dreamlike, foggy, or distorted.
Disorder is present
-High rates of comorbidity with anxiety, depression, personality disorders, and other dissociative disorders have been found
-reduced emotional reactivity to stressful or emotionally arousing stimuli
-Cognitive disruptions in perceptual and attentional processes
Brain regions and the disorder
reduced activity in brain regions responsible for processing emotional information (e.g., the insula and limbic regions including hypothalamus and amygdala) is associated with depersonalization/derealization
Dissociative Identity Disorder (DID)
The most severe and chronic of the dissociative disorders, characterized by the existence of two or more unique personalities in a single individual. Each personality may have its own constellation of behaviour, tone of voice, and physical gestures, and so on.
DID: Alternative personality states
resemble different identities or personalities that periodically intrude into the consciousness and assume control of a person’s behaviour.
Alters: DID
Refers to each of the unique personalities in an individual who has dissociative identity disorder (DID). Alters may be very different from each other, with opposite personality traits (e.g., one very extraverted and another very introverted) and differences in the age, sex, race, and family history they claim to have.
Switching: DID
The transition from one alter to another in an individual with dissociative identity disorder. Occurs suddenly and is often precipitated by stress or some other identifiable cue in the surrounding environment.
Diagnosis of DID
no longer required to display distinct “identities” that appear to “take control” of behaviour in order to receive a diagnosis of this disorder. Instead, it is recognized that alternative personality states may vary according to their level of overtness, and signs of identity disturbance may be quite subtle. For example, the emergence of an alternative personality state could correspond with the sudden occurrence of emotions or behaviours that individuals find perplexing and not within their control.
Self destructive behaviour in DID
elf-inflicted burns, wrist slashing, and overdosing
-Suicide attempts
Two competiting theories of the etiology of dissociative identity disorder
1) Trauma Model
2)Socio-cognitive model
The trauma model
The theory that dissociative identity disorder is caused by severe childhood trauma, including sexual, physical, and emotional abuse, accompanied by personality traits that predispose the individual to employ dissociation as a defence mechanism or coping strategy.
For children, dissociation can imply
means of escape when no other means is possible. If the child can escape into a fantasy world and become somebody else and if this escape blunts the physical and emotional pain temporarily, they will likely do it again
Brain areas affected due to DID
smaller cortical and subcortical volumes in areas of the brain that involve perception and personal awareness (hippocampus, amygdala, parietal structures) and in brain regions that pertain to movement and fear learning (frontal cortical structures). They also exhibit larger white matter tracts, responsible for communication between somatosensory association areas
Attachment theory and DID
The lack of such sensitive responding by the caregiver results in insecure attachment, wherein children lack confidence in relations with others
Disorganized pattern: Insecure Attachment style
Can be seen to be connected
Social Cognitive Model
The theory that dissociative identity disorder is a form of role-playing in which individuals come to construe themselves as possessing multiple selves and then begin to act in ways consistent with their or their therapist’s conception of the disorder.
-Diagnosed in adults and almost never during childhood
-represents a very different etiological position that is taken by many mental health professionals who do not accept DID as a legitimate disorder
DID is an iatrogenic
iterally meaning “caused by treatment”) condition, which means that it is largely caused by therapists themselves during the course of therapy
treatment of DID- prolonged and arduous process
going through a series of stages leading to the eventual integration of the various personalities
-The first stage of therapy involves the establishment of a trusting, safe environment for stabilization, safety, and symptom reduction. During this stage, the patient has the opportunity to discuss emotionally charged memories of past trauma. The next stage begins by helping patients develop new coping skills that will be required when discussions of past history of abuse take place. Agreements for open communication between alters may be necessary to establish these new patterns of responding to stress. Therapy can then focus on remembering and grieving the abuse that the patients experienced at the hands of those who should have protected them.
-final stage: integration of the personalities. Here the goal is for the alters to merge into a single personality or at least a group of alters that are working together and are aware of each other.
Hyponosis for DID
Hypnosis has been a popular treatment method for many clinicians working with patients with DID to confirm the diagnosis, to contact alters, and to uncover memories of traumatic childhood abuse
Hypnosis flaws
others have criticized the use of hypnosis in this patient population because of the potential of retrieving confabulated memories and personalities
Medication
“Truth serum” or sodium amytal, a barbiturate causing drowsiness, has sometimes been used to help the individual recall previously forgotten memories or identify additional alters. However, other psychotherapies are typically used at the same time because the chemical does not always work, or the individual does not remember what was reported while under the influence of this drug.- evidence is limited
Neurosurgical Treatments
Repetitive transcranial magnetic stimulation (rTMS)
noninvasive procedure involves the generation of a magnetic field at the level of the scalp using a metal coil, which in turn influences the electrical activity in nearby regions of the brain. A study of patients with depersonalization/derealization disorder reported that 20 sessions of rTMS to the right ventrolateral prefrontal cortex significantly improved symptoms of depersonalization in six out of seven cases
Somatic symptom and related Disorders
re a group of disorders in which individuals present with physical symptoms suggestive of medical illnesses, along with significant psychological distress and functional impairment.
Physical symptoms
In dramatic cases, they involve substantial impairment of a sensory or muscular system, such as a loss of vision or paralysis in one arm. In other disorders, individuals become unduly preoccupied with the belief that they may have a serious disease and become disabled by constant worry, anxiety, and excessive time and energy devoted to their health concerns.
Patients view themselves of having a
Medical disease or illness rather than a psychological disorder, and they are much more likely to seek help from a physician in general medicine than from a psychologist or psychiatrist.
Early versions of the DSM- disorder was called
somatoform disorders and an important criterion for diagnosis was that the bodily complaints of these individuals did not have a physiological basis or medical explanation.
-traumatic experiences or unresolved emotional distress. Because of the implication that their physical symptoms were “all in their head,” many patients viewed these diagnoses as demeaning and pejorative.
Somatic symptoms Disorder
One or more somatic symptoms (e.g., chronic pain, fatigue) that are distressing or cause significant disruption of daily life, accompanied by disproportionate concerns about seriousness, anxiety, and/or excessive time and energy devoted to health concerns; a diagnosed medical illness may or may not be present
Illness Anxiety Disorder
Preoccupation, anxiety, and worry about having or acquiring a serious illness in the absence of significant somatic symptoms and despite the fact that thorough evaluation fails to identify a serious medical condition
Functional Neurological symptom Disorder
Symptoms affecting voluntary motor or sensory functions (e.g., blindness, paralysis, loss of feeling) that are incompatible with recognized neurological or medical conditions
Psychological factors affecting other medical conditions
The individual has a medical condition (e.g., asthma, heart disease, diabetes) that is adversely affected by psychological or behavioural factors (e.g., anxiety exacerbating asthma symptoms, stressful work environment causing high blood pressure)
Factitious disorder
Faking or inducing symptoms of illness to gain sympathy, medical care, and attention (e.g., taking excessive laxatives, contaminating urine samples, intentionally injuring oneself)
Diagnosis
(recurring, multiple, and current significant complaints about bodily symptoms) as well as most cases of hypochondriasis (excessive anxiety about personal health, often fearing a serious disease).
Functional Neurological Symptom Disorder (Conversion disorder)
Individuals with this disorder have a loss of functioning in a part of their body that appears to be due to a neurological or other medical cause, but without any underlying medical abnormality to explain it. They may have motor deficits such as paralysis or localized weakness, impaired coordination or balance, inability to speak, difficulty swallowing or the sensation of a lump in the throat, and urinary retention. Behaviour resembling seizures or convulsions may also occur. In other cases, individuals have sensory deficits such as loss of touch or pain sensation, double vision, blindness, or deafness.
Causes pf Functional Neurological Symptom Disorer
conflict or stress, are presumed to be associated with the onset or exacerbation of the condition. Patients with conversion disorder often have other diagnosable psychological disorders, such as depression and anxiety
Diagnose
clinicians often look for particular signs that help to distinguish these symptoms from those with an organic origin
-electroencephalographic recordings might show that a patient’s seizures are not accompanied by the distinctive brainwave activity seen in epilepsy
-show inconsistencies over time (e.g., inadvertently moving a “paralyzed” limb when attention is directed elsewhere) or unusual symptom patterns (e.g., unusual head movements during seizures).
Glove Anaesthesia
A sensory symptom of conversion disorder involving a loss of feeling in the whole hand and wrist. Since this pattern is incompatible with the way nerves extend from the arm into the hand, it is clearly psychogenic in origin.
Le belle indifference
A surprising nonchalance or lack of concern about the severity of one’s symptoms, which was previously thought to be evidence of a conversion disorder.
Brain and conversion
dynamic reorganization of the brain circuits that link volition, movement, memory, and perception, leading to an inhibition of normal cortical activity
Conversion and dissociative disorders were grouped together under the concept of
hysteria
Conversion disorders involve
a process of dissociation in which there is a lack of integration between conscious awareness and sensory processes or voluntary control over physical symptoms.
Somatic Symptom Disorder
typically have multiple, recurrent somatic symptoms such as pain, fatigue, nausea, muscle weakness, numbness, or indigestion. These symptoms, which may or may not be due to a diagnosed medical disease or illness, must be very distressing to the individual and result in significant disruption of daily life.
-great deal of anxiety about health and symptoms
They become upset when
strongly resist suggestions that psychological or social factors might contribute to their illness or disability, and they become quite upset at the suggestion to see a psychologist or psychiatrist.
Patients are in danger because
Their accounts can be very persuasive and potentially expose them to danger as a result of invasive or risky diagnostic procedures (e.g., X-ray examinations or invasive probes), surgery, hospitalization, side effects from potent medications, or treatment by several physicians at once, perhaps leading to complicated or even hazardous care
They need to test
-physicians need to test for the possible presence of medical conditions for which there can be vague, multiple, and confusing somatic symptoms (e.g., systemic lupus, multiple sclerosis, or chronic parasitic disease).
-psychologists need to assess emotional, cognitive, behavioural, and social issues.
They are very sensitive to
minor bodily symptoms. The patient may be alarmed by their heartbeat, breathing, or sweating; become apprehensive about a small sore; or worry about a minor cough.
Difference between panic disorder and immediate symptom related disorders
panic disorder typically fear immediate symptom-related disasters that might occur during the panic attack itself, whereas individuals with somatic symptom disorder focus on the long-term process of illness and disease.
Somatic symptom disorder with predominant pain
A subtype of somatic symptom disorder in which the presenting bodily symptom involves pain (called pain disorder in previous editions of DSM).
Illness Anxiety Disorder
applies to a subset of the individuals who would previously have been diagnosed with hypochondriasis. People with illness anxiety disorder are preoccupied with the fear that they may have a serious medical disease, despite the fact that thorough medical examination reveals that there is nothing seriously wrong with them
Difference between illness anxiety disorder and somatic symptom disorder
individuals with illness anxiety disorder do not have any significant bodily symptoms and are primarily concerned with the idea that they are ill, whereas those with somatic symptom disorder have significant symptoms such as pain and may actually have a diagnosed medical illness
Signs of this disorder
People with illness anxiety disorder tend to be highly anxious about their health and become easily alarmed about illness-related events, such as hearing that a friend has become ill or watching a health-related news story on TV. They tend to examine themselves frequently (e.g., taking their temperature or examining their throat in a mirror), and they search the internet excessively to research their suspected disease. Illness becomes central to their self-identity, affecting their daily activities, and a major focus of their conversations with friends and family
Tend to seek help from
general medical practitioner than from a psychologist or psychiatrist, and they tend to become quite upset when it is suggested that they might benefit from psychological intervention.
In order to be diganosed
he illness preoccupation must have been present for at least six months, although the particular illness that is feared may have changed during that time.
Since anxiety is the predominant symptom of this disorder
some researchers believe that illness anxiety disorder would be more appropriately categorized as an anxiety disorder than a somatic symptom disorder
Factitious disorder/Munchausen syndrome
deliberately fake or generate the symptoms of illness or injury to gain medical attention. For example, they might surreptitiously take excessive amounts of laxatives, contaminate urine samples with fecal matter, or inject cleaning fluids into their skin to make it appear that they have a serious illness.
In order to be diagnosed
there must not be any obvious external rewards for this behaviour, such as receiving insurance money, evading military service, or avoiding an exam. Instead, the motivation of these individuals seems to be to gain sympathy, care, and attention that accompany the sick role.
Factitious disorder imposed on another
ndividual falsifies illness in another person, most commonly the person’s own child. The news media occasionally report tragic cases of mothers producing life-threatening symptoms in their children, such as injecting them with a noxious substance or smothering them with a pillow to induce unconsciousness.
-Gypsy rose
Intergrative biopsychosocial model
a number of physiological, psychological, and social factors may interact in a series of vicious cycles, with different somatic symptom disorders resulting from different patterns of interaction.
Some genetic factors, but more of an influence of physiological factors
chronic stress produces activation of the hypothalamic-pituitary-adrenal (HPA) axis, producing high levels of cortisol, which can adversely affect the immune system and also produce feelings of fatigue, pain, and general malaise
-cause individuals to perceive themselves as having a physical illness when they are actually experiencing stress.
The brain
neuroimaging studies have also found that brain networks related to cognitive control, emotion regulation, stress, motor control, and somatic-visceral perception are affected in individuals with these disorders
Cognitive factors
individuals with somatic symptom disorders spend substantial time monitoring their bodies and thus they are more likely to notice the various changes that take place. People with these disorders also tend to interpret bodily sensations in a distorted manner, magnifying their seriousness or importance and attributing them to serious illnesses, leading to increased distress and further physiological arousal
Cognitive behavioural model of health and anxiety
we all develop beliefs and attitudes about our physical well-being through personal experiences with illness and information from others about their experiences
Other causes/factors
-individual differences in various personality traits, such as negative affectivity and emotion regulation deficits, have also been proposed as contributors to the development of somatic symptom and related disorders
-Early life experiences and social learning also likely play a role in the etiology of somatic symptom and related disorders
Children and social learning perspective
children observe and internalize the health-related opinions and behaviours of close others, such as how parents perceive illness and respond to bodily symptoms
Medication
-Antidepressant medciation
-identification and treatment of comorbid anxiety and depressive disorders is a vital part of treatment, for which pharmacotherapeutic interventions are often prescribed.
Psychotherapy
, including establishing the position that all symptoms are “real” and distressing, negotiating a mutually acceptable treatment goal (e.g., tolerance of reasonable uncertainty about health), shifting attention from somatic symptoms to life stresses or affective states that may provoke or exacerbate symptoms, and focusing on symptom management and rehabilitation rather than medical diagnosis and cure.
Cognitive behavioural approach
involves restructuring morbid thoughts and preoccupations, and works to bring dysfunctional behaviour patterns under control. Many reviews of the existing research indicate that cognitive-behavioural therapy (CBT) is an effective method for treating patients with these disorders
The reason these people struggle are due to the fact that
many patients do not seek psychological treatment, insisting that their problems are physical even after extensive medical testing indicates otherwise.
