Chapter 6 - Dissociative & Somatoform Flashcards
Define Dissociation
a disruption in the usually integrated functions of consciousness, memory, identity, or perception.
Example of mild dissociation
Mild - deja vu, absorption, daydreaming
Historical rise and fall of interest in dissociation
late 1800 - high
early 20th C - low
1990s - high
Today - low again (over-diagnosis, exaggerated claims, false memory syndrome)
List DSM-IV Dissociative Disorders
1) Dissociative Amnexia
2) Dissociative Fugue
3) Dissociative Identity Disorder (DID; fmr multiple personality)
4) Depersonalization Disorder
List DSM-V changes in Dissociative disorders
1) Dissociative Identity Disorder
2) Dissociative Amnesia (fugue no longer separate)
3) Depersonalization/derealization disorder
Types of Dissociative Amnesia
- suppressed memories
1) Localized (circumscribed period of time)
2) Selective (not all events during specific time period)
3) Generalized (loss of memory for entire life, but not general knowledge)
4) Continuous (loss of memory from a specific time to present. not general knowledge)
5) Systematized (specific categories of information)
Which type of dissociative amnesia is most rare? Why?
Continuous. Rare because typically organic. no general knowledge in this case.
Dissociative is to ____ amnesia as Fugue is to ____
Anterograde, Retrograde
Features of dissociative amnesia
- forget personal info
- autobiographical not general knowledge
- after stress
- spontaneously remits
- sometimes chronic or recurrent
Differential diagnosis of amnesia
- not organic like Alzheimer, dementia or blow to the head
- those typically forget all info including general knowledge
Describe Dissociative Fugue
- Fugue: from latin word for fleeting/running away/flight
- sudden unexpected travel AND forget past
- occasional assume new identity
- hours, months, years
- stress induced
- spontaneous recovery
- Rare (.2%)
- comorbid: mood disorders, substance abuse
What makes depersonalization unique
- no loss of memory
- short time
Features of depersonalization
- detached from mental process or body
- in a dream, observe one’s self. robot or machine
- diff’t from out of body - present but not in control
- reality testing remains intact (no delusions, hallucinations)
- self and world around is unreal
- common at mild levels (50%)
- adolescence, life-treat, stress
- symptom of other disorders: PTSD, depression, panic disorder
- only diagnosed if can’t meet criteria which it is symptom AND severe enuf to cause distress, impairment
Relation between depersonalization and PTSD
- dissociation as symptom
Define Somatoform disorders (DSM-IV)
- Physical symptoms not explained by a medical conditions
How is Somatoform different from:
- Psychophysiological conditions
- Malingering
Factitious disorders
Psychophysiological = psychosomatic
- Psych factors exacerbate illness
- anxiety, depression, maladaptive coping style
Malingering
- really faking, aware of doing so
Factitious
- create symptoms
- javex under skin
- want to go to hospital
Types of Somatoform disorders
1) Conversion disorder
2) Somatization disorder
3) Pain disorder
4) Body dysmorphic disorder
5) Hypochondriasis
Describe difference between Psychosomatic and Somatoform disorders
Psychosomatic = med + psychological Somatoform = purely psychological
Features of Conversion disorder
- inner body conflict is intolerable becomes bodily symptom
- affects voluntary or sensory function
- mimic neurological condition
- doesn’t conform to physiological patterns
- “La belle indeference” (patient not concerned) used 2b diagnostic sign
- lifetime prevalence 1%-3%
- Women > Men
- Late childhood to early adulthood
- symptoms: blindness, paralysis, seizures, visceral (lump in throat, coughing), loss of smell
Test for conversion disorder
- raise hand over head, drop it
- conversion: misses head
- real: smacks head
- thus: some control just not conscious
Other name for conversion disorder
Psychogenic illness
Criteria for Somatization disorder
- different body complaints different time
- many diff’t complaints over several years, starts before 30, many organs
- 4 pain symptom in different locations
- 2 GI
- 1 sexual not pain (no orgasm or erection)
- 1 psychdoneurological
- not explained medically
- not intention
- doctor shopping
Features of somatization disorder
- DSM-V: Somatic Symptom disorder
- comorbid: depression, anxiety, alcohol/substance, personality
- chaotic lives: suicide threats, relationship problems
- low psychological insight, awareness
- complications: unnecessary tests, meds, $ to HC system
Treatment for somatization disorder
- understand underlying emotions, alternative coping, expressing feelings
Pain Disorder
- DSM-V: “Somatic symptom disorder”
- not always real medical basis for pain
- one or more sites in body
- psych factors: in onset, severity, exacerbation, mtce of pain
- impair: work, relationships, family, overuse meds, HC system
Prevalence of Somatization disorder
- .2 - 2%
- women > men, except in some cultures (Greece)
Describe Body dysmorphic disorder
- preoccupied w imagined deficit in appearance
- clinically significant distress (required)
- frequent: suicide thoughts, delusions, depression, alcohol/substance abuse
- –> social isolation, social phobia
- frequent “checking”
- plastic surgery
- prevalence: Men = women (like OCD)
- adolescence onset
Where is body dysmorphic disorder in DSM-V? Why?
- moved to OCD Spectrum disorders
- distinct (if focus is on weight instead is Anorexia)
- BDD: more severely disturbed than OCD
Describe Hypochondriasis
- preoccupation w fears of having serious disease
- misinterpret bodily symptoms
- like panic disorder (symptoms exacerbate)
- continues despite Dr reassurance
Criteria: 6mos+ - doctor shopping
- men = women
- prevalence 1-5% (more common in med practice
Comorbid: anxiety, depression, relationship problems
Where is hypochondriasis in DSM-V?
- Illness anxiety disorder
%age of ppl in dr office presenting w hypochondriasis
25% per day
Describe Factitious disorder
- create or feign physical or psych signs or symptoms
- often self-harm
- motivation: assume sick role, be cared for
- external incentives are absent
- not malingering: which is typically to get out of something
- Munchausen
Etiology of Somatoform disorders
Psychodynamic - defense against neurotic anxiety (conversion, displacement) Bio - little evidence of genetic factors - stress -> more cortisol -> general malaise, fatigue, pain Social - history of physical or sexual abuse, trauma Personality traits - health anxiety, neuroticism Cog-Beh - Negative or positive reinforcement - miss-attributions of symptoms - early learning experiences - coping deficits
Draw cognitive model of Hypochondriasis
- see Word doc
- like panic model
- catastrophizing
Difference between hypochondriasis and Panic disorder
Hypocondriasis: long term concern
Panic: immediate issue
Treatments for somatic disorder
- therapeutic relationship is key
- Cog/Beh (similar to anxiety
- exposure
- coping strategies
- cognitive restructuring
- social reinforcement
- treat comorbid: depression, anxiety
Diagnostic criteria for Dissociative identity disorder
1) 2 or more distinct identities or personality states (alters)
- each has own enduring pattern of perceiving, relating to environment, self
2) take turns at controlling behavior
3) forget personal info
4) Rule out - physiological or substance or general medical condition
Associated features of Dissociative identity disorder
- history of severe childhood abuse
- post-traumatic symptoms
- highly comorbid: depression, anxiety, BPD, suicide, drugs, PTSD, eating disorders
- self-mutilation, suicide, aggression
- destructive relationships
- easily hypnotizable, dissociative tendencies
- switching - response to stressful situation or therapist requests
Course of DID
- chronic, recurrent
- Women 3x than men, also more alters
- childhood trauma -> first symptoms early 20’s -> diagnosis early 30’s
History of DID
1957 - Three Faces of Eve 1970s - Sybil 1980s - wild upswing multi personality, clinical interest 1990s - false memory syndrome, lawsuits 2000s - dramatic drop off
Trauma Theory of DID
- event -> manifestation of disorder
- alters as way of coping w trauma
- one alter is likely age when trauma occurred, need something to retreat to
- insecure attachment
STRESS: childhood, severe trauma, abuse
DIATHESIS: high dissociative ability, hypnotizability - those low in dissociative tendencies will develop anxious, intrusive thoughts rather than dissociative reaction
Treatment of DID
- long term therapy - often includes hypnosis
- thera relationship key (trust)
- effective coping skills
- integrate personalities
- draw out abuse, alter no longer needed
Criticisms of Trauma theory
- sometimes no evidence of childhood trauma
- abuse not recalled ‘till start of therapy
- alters emerge after therapy starts
- some specialists diagnose (tho may be due to expertise)
- no evidence of DID in kids
- upswing after media attention
- NAmerican thing, rare in other countries
Socio-Cognitive theory
- alter as social role (rule-governed social construct established, legitimized and maintained thru social interaction
- often iatrogenic (caused by therapy)
- highly suggestible patients
- not malingering: have severe psych probs
- Social hysteria: like belief in possession in prev centuries
Define iatrogenic
caused by therapy
Difference between dissociative and somatoform
Dissociative: severe disruptions in consciousness, memory and identity
Somatoform: believe serious illness despite medical reassurance to contrary
Similar: maladaptive ways of coping w extreme stress
Why were they once categorized together? Name of category
Hysteria
- due to underlying anxiety
History of dissociation and somatization
- wandering womb
- demonic posession (exorcism)
- Charcot: pathological breakdown of integration of mental processes (due to trauma)
- Freud: Trauma established relationship between dissociation and hypnotic-like states
- Dissociation: Unacceptable sexual impulses
- Conversion: expression of unconscious psych conflicts
- Behaviourism: ignore internal states (thus drop off in diagnosis)
- Increase: media attention, research consciousness/hypnosis
Describe primary and secondary gains
Primary gain: avoidance of conflict, reinforcement to maintain somatoform disorders
Secondary gain: avoid responsibility, get attention and sympathy
Who else championed socio-cognitive model (alters as role-playing)
- Merskey from UWO
- iatrogenic
- roles be satisfy therapists concept
Sodium amaytal is also known as
truth serum (causes drowsiness)
Idea of reference is also known as
Body dysmorphic disorder
fMRIs help uncover what in conversion disorder
- dynamic reorganization of brain circuits that link volition, movement, perception
- inhibition of normal cortical activity
Similarity between Conversion disorder and dissociative disorder, reason for not including
- Conversion (somatic) and dissociative (cognitive)
- similar: lack of integration between conscious awareness and sensory processes or voluntary control over physical symptoms
- not included: unproven hypothesis, benefit from treatment
What’s Dhat syndrome?
- indian men fearing loss of semen
Somatization disorder is to ___ as hypochondriasis is to ___
Somatization = personality disorder Hypochondriasis = anxiety disorder
Reason for keeping somatic disorders together
- clinical utility: more common presented to general medical
Chronic stress activates which area of the brain? what does that area do?
- HPA: hypothalamic-pituitary-adrenal axis
- produces high cortisol -> immune system -> fatigue, pain, malaise
- stress misattributed as illness
Treatment of somatoform
1) therapeutic alliance: acknowledge concerns, all symptoms are real
2) negotiate treatment goal (tolerate some pain)
3) shift attention from soma to life stresses exacerbate
4) symptom management, rehab
5) treat comorbid
- antidepressants: hypochondriasis and BDD
