Chapter 7: Somatic Symptom and Dissociative Disorders Flashcards
What is a somatoform disorder?
A physical condition that is medically unexplained and reflects psychological factors
*soma = body
What significant event related to conversion disorder occurred in 2012?
An outbreak of symptoms in Le Roy, New York, where 18 people developed uncontrollable tics and jerking.
- Psychogenic illness and Mass hysteria are other terms for these types of conversion outbreaks
What conversion symptoms were observed in the Amish girls’ outbreak?
- Motor deficits
- Life-threatening anorexia
- Neck weakness preventing head support
Deemed to be caused by stress from the strict pressure/ecpectations common in Amish girls.
What challenges do professionals face in diagnosing somatoform disorders?
Determining if physical symptoms are due to medical or psychological issues is very challenging.
When there is an absense of a medical cause, a somatoform disorder is considered.
What was the ruling regarding somatoform disorder BEFORE DSM-5?
In earlier DSM versions, somatoform disorder was completely ruled out unless there was no medical explanation.
Conversion and dissociative disorders related to what general type of disorders?
Anxiety disorders
Early DSM versions classified them under anxiety as the predominant factor.
What are dissociative disorders?
Disorders where normal integration of consciousness, memory, or identity is suddenly and temporarily altered.
Ex. dissociative amnesia, dissociative fugue, dissociative identity disorder, and depersonalization disorder
What are somatic symptom disorders?
Psychological problems that take a physical form and are thought to be linked with anxiety and be psychologically caused.
Conversion disorder and somatization are examples.
What are the two DSM-IV-TR categories of somatoform disorders that are no longer distinct in DSM-5?
Pain disorder (complains of severe pain that is not medically explainable - used to avoid an aversive activity or to gain attention)
Hypochondriasis
What is the new term for somatoform disorders in DSM-5?
Somatic symptom disorders.
somatic symptom disorder and conversion disorder are the only two diagnosies in the DSM5
What is the focus of the new classification of somatic symptom disorders in the DSM-5?
The extent to which symptoms cause subjective distress or impairment.
(this removes any confusion of overlap between distinguishing between disorders that all involve physical symptoms)
Explain the summary of Somatoform Disorders in the DSM-IV-TR:
All these disorders in the table are know diagnosed as “somatic symptom disorder” in the DSM-5, with the exception of conversion disorder (which still has it’s own diagnosis.
What is malingering?
Faking a physical or psychological incapacity to avoid responsibility (ex. work) or gain an end (ex. given a large amount of insurance money)
*differs from somatofom disorders as malingering occurs under voluntary control (done on purpose), whereas somatoform disorders is unvoluntary
there is a need for multiple forms of assessment to determine if malingering is happening
What is ‘la belle indifference’? How does show up differently between people with a conversion disorder and malingers?
A relative lack of concern or a blasé attitude toward symptoms.
Both will display this, but in different ways:
conversion disorder = demonstrate this behaviour by willing to talk endlessly/dramatically, but still sort of indifferent about it.
malingers = very gaurded and less open as they consider the interviews as a challenge to maintain their lie.
If la belle indifference is shown genuinely, that is an indicator that a person is not faking it and actually does have a conversion disorder
What is factitious disorder?
A disorder where symptoms appear under voluntary control to assume the role of a sick person.
There is NOT a clear goal (unlike malingering) within these disorders - the motivations are not for an end goal like money, but more from an intrinstic need to be taken care of.
What is ‘factitious disorder by proxy’ or “munchausen syndrome by proxy”?
When a parent produces a disorder in a child.
What was a dramatic example of factitious disorder by proxy?
Kathleen Bush caused her daughter’s illnesses using drugs and contaminating her feeding tube.
Caused 40 surgeries and a cost of over $20 million.
Occured from motivation to appear as an excellent/tireles parent
What is hypochondriasis?
A somatoform disorder where the person misinterprets ordinary physical sensations as fears of having a serious disease.
They use medical services often and likely have mood/anxiety disorders
Overreact to minor abnormalties (stomach ages, coughing, red spot on skin, etc.)
*not easily differentiated from somatization disorder - contributed to the decision to make the overatching somatic symptom disorder diagnoses
In which demographic does hypochondriasis typically begin?
Early adulthood.
(and has a chronic course)
What percentage of the general population is estimated to have hypochondriasis?
About 5%.
What is the new term used in the DSM-5 to replace hypochondriasis?
Illness anxiety disorder.
For the tendency to worry obsessively about illness despite the lack of a physical illness
What is health anxiety?
In general, health-related fears or beliefs of bodily signs and symptoms being connected to serious illnesses.
*not a disorder, but is present in disorders like illness anxiety disorder.
Fill in the blank: Health anxiety would present in both hypochondriasis and an illness ———–.
phobia.
Health anxiety is best thought of as a continum rather than a category.
What are the four factors assessed by the Illness Attitudes Scale (IAS) to assess health anxiety?
- Worry about illness and pain (fears)
- Diseases conviction (beliefs)
- Health habits (safety-seeking)
- Interference with lifestyle
According to twin studies, health anxiety is mostly learned due to ———.
environmental factors.
*health anxiety has been shown to be moderately heritable, but mostly due to environment.
What are the four contributing factors in the cognitive model of the development of health anxiety?
- A critical precipitating incident
- A previous experience of illness and related medical factors
- The presence of inflexible or negative cognitive assumptions
- The severity of anxiety
According to the cognitive model of the development of health anxiety, under what circumstances would health anxiety increase, and under what circumstances would it decrease?
Health anxiety will increase with increases in
(1) the perceived likelihood or probability of illness
(2) the perceived costs/burdens of illness.
Health anxiety will decrease with greater
(1) perceived ability to cope
(2) the perceived presence/effectiveness of medical help.
True or False: Conversion disorder is a somatoform disorder where sensory or muscular functions are impaired despite healthy bodily organs.
True.
*conversion disorder used to be called or known as hysteria (where it only applied to women)
What is anaesthesias?
A loss or impairment of sensations
Occurs within conversion disorders
What is aphonia and anosmia?
Aphonia = loss of the voice or all whispered speach
Anosmia = loss or impairment of sense of smell
What is another name for conversion disorder in the DSM-5?
Functional neurological symptom disorder.
What is glove anesthesia?
A rare syndrome where the individual experiences little or no sensation in the part of the hand that would be covered by a glove.
What is the prevalence of conversion disorder?
Less than 1%.
More women than men are given the diagnoses
Often occurs with mood and anxiety disorders
Often history of physical or sexual abuse
Some misdiagnosises of glove anesthesia can occur, what is one medical issue that seems to produce the same effect as glove anesthesia?
Carpal tunnel syndrome (where nerves in the wrist become swollen)
Many other conversion disorders can be misdiagnosed and actually be true physical problems (but rate is declining)
George Fraser reported two cases of conversion disorder involving “hyserical” blindness that demonstrates the role of ———- in developing conversion disorders
STRESS
In this cases, it was due to the military.
Hysteria is an older term for what?
Conversion disorder
Also dissociative disorders were considered “hysterical states”
Fill in the blank: Somatization disorder is characterized by frequent somatic complaints with no apparent ————.
physical/medical cause.
Characterized by frequent complaints from all over the body, presented in a dramatic fashion.
What diagnostic criteria changes occurred in the DSM-5 for somatic symptom disorder?
- Requires the presence of only ONE physical symptom for diagnosis
(compared to requireing thirteen in DSM-III to have a somatization disorder) - Requires presence of it least ONE psychological feature (ex. health anxiety, repetative thoughts, etc.)
As a result of DSM-5 changes, the prevelance of somatic symptom disorders is increasing!
What memory bias do individuals with somatoform disorders exhibit?
Bias for information that involves physical threat (hyper vigilant)
More sensitive to physical sensations in general
According to the behavioral view, what causes various aches and discomforts in somatoform disorders?
Unrealistic anxiety about bodily systems.
What hypothesis for developing somatoform disorder relates to parental illness?
Hypothesis that illness behaviors might be learned in response to exposure to parental illness and health anxiety in childhood.
Example Study: mother’s with somatization had children who expressed more health and safety needs during play than other children.
What is the psychoanalytic theory of conversion disorder?
Claims that REPRESSED impulses are converted to physical symptoms.
Frued proposed tha conversion disorders occur when a person expereinces great emotional arousal from event and the memory of that event dispears from concious expereince
What complex did Freud associate with conversion disorder in women?
Unresolved Electra complex. (repressed sexual attachment to father)
What is the two-stage defense reaction proposed for hysterical blindness?
- Perceptual representations are blocked from awareness.
- Information is still extracted from perceptual representations.
Explains that hyserically blind people CAN see, but do not know they can see (due to issues in cerebral cortex), making it possible to be truthful in saying they cannot see but provide evidence that they can.
What does the behavioral theory of conversion disorder suggest?
Individuals consciousily and deliberatily adoption of the symptoms as a way of obtaining a desired goal
Person behaves how the person with that disease they are expereincing would act.
What are the two conditions that increase the likelihood of adopting illness behavior
(according to the behavioural theory of conversion disorder)
- Experience with the role
(similar physical problems or witnessed them) - Enactment of the sick role is
(by reducing stress or other positive consequences)
Does research fully support the behavioural interpretation of conversion disorder? (claiming it is a concious act to obtain a goal)
NO
- studies on hysterical blindness do not support this (the person is not “acting” because they demonstrated that they could actually see, which you would not do if it was an act)
What is a common perception from patients with somatoform disorders when they get referrals to psychologists?
They view it as indicating that the illness is just ‘in their head’ and is quite offensive because they genuinely feel pain.
What social factors influence the prevalence of conversion disorder?
More common among lower socio-economic status and rural populations.
Also more common in women.
Has there been an increase or decrease in conversion disorders over the past century? Why?
There has been a large decrease in prevelence!
Some think this is because conversion disorder was so high in 19th century due to repressive sexual attitudes of the time (and there is now lessened anxiety around sexual desires today)
Others think it is because the increase in knowledge about medical diseases over time has decreaseed conversion disorder occurance
What biological factor is associated with conversion disorder symptoms?
Symptoms are more likely to occur on the left side of the body.
*based on evidence of this - we know it is possible to distinguish actual conversion disorder from faking.
What was discovered about brain activation in patients with sensory conversion disorder?
(discovery happened in a case study with 3 women with a sensory form o conversion disorder)
Found that stimulating a numb hand/foot did NOT activate the somatosensory region of the brain.
But stimulating each client’s other hand/food that was not numb DID result in activation of the somatosensory region.
This acts as evidence for how the brain structure works with conversion disorder
What does the biopsychosocial model of conversion disorder consider?
Risk factors (ex. family and socio-cultural factors, cognitive impairment, PTSD)
perpetuating factors (ex. impaired emotional processing, supression of expressing distress)
triggering events (ex. abuse or life stress)
Developed specifically for conversion disorder but can serve to be useful for other somatoform disorders
What are examples of everyday dissociative experiences?
Daydreaming, viewing oneself from outside the body, engaging in a personal narrative
These experiences can occur without significant impairment and are not maladaptive.
What are the 4 dissociative disorders in the DSM-5?
- Dissociative Amnesia
- Depersonalization/Derealization Disoder
- Dissociative identity Disorder
- Other specificed dissociative disorder (ex. dissociative trance - insensitivity to environmental cues)
What does the Dissociative Experiences Scale (DES) indicate about the general population?
Majority of people report a few dissociative experiences; but very few report many of them.
Most people never experience the most pathological items. (only about 3.3% of the study sample had those items)
What are the most common dissociative experiences identified in the study on everyday dissociatve experiences?
- Ignoring pain
- Missing part of a conversation
- Uncertainty about actions or thoughts
These experiences are often not indicative of a disorder.
What are some key factors causing dissociation?
Stress, fatigue, binge drinking, or use of psychoactive drugs
What is dissociative amnesia?
A dissociative disorder where a person cannot recall important personal information
Information is not lost forever (but it cannot be retrived during an episode of amnesia)
This cannot be explained by ordinary forgetfulness.
Why does memory loss during dissociative amnesia typically occur?
Following a traumatic experience
(very rarely does amnesia occur for long periods of time or thoughout the person’s life)
Examples include witnessing death or being sexually assaulted.
Can memory loss during dissociative amnesia last long periods?
Very rarely
An episode can last however for several hours to several years, and usually disappears as suddenly as it came on, with complete recovery and low chance of reoccurance.
During an episode of dissociative amnesia, can the person still recognize their friends and family?
No they cannot
But they are still able to talk, read, and retain talents and knowledge previously aquired
Ex. Dory in finding Nemo accurately protrays “short-term memory loss”, a symptom consistent with amnesia.
What is dissociative fugue? Is it a DSM disorder?
A disorder where a person experiences total amnesia and establishes a new identity
Memory loss is more extensive, making it a specifier of dissociative amnesia.
No longer considered a DSM-5 disorder and is now considered a subtype of dissociative amnesia.
Research trying to identify brain regions involved in dissociative amnesia found what?
- reduced glucose utlization in the right inferolateral predrontal cortex
(likely associated with hypometabolism in this brain region)
What is depersonalization/derealization disorder?
A dissociative disorder where individuals feel unreal and estranged from themselves and surroundings
It disrupts functioning but does not involve memory disturbances.
Does recovery from dissociaitve fugue usually occur?
It varies but does usually occur. The person does not recollect at all what happened during their fugue.
What triggers episodes of depersonalization?
Usually stress
(same for most other dissociative disordes)
Similar episodes can occur in other disordes (PTSD, BPD, schizophrenia)
People may feel as if they are outside their bodies or mechanical (move through the world lost in reality)
What is depersonalization/deralization disorder?
A dissociative disorder in which the individual feels unreal and estranged from the self and surroundings enough to disrupt functioning.
People with this disorder may feel that their extremities have changed in size or that they are watching themselves from a distance.
It involves no disturbances of memory! (makes it controversial to be included as a dissociative disorder)
Which dissociative disorder does not include memory disturbances?
depersonalization/derealization disorder
They instead just feel that they are unreal from the self and surroundings
What changes did DSM-5 make regarding depersonalization disorder?
Included derealization, the loss of the sense that surroundings are real
derealization = “The world does not feel real” (everything seems fake/dreamlike)
depersonalization = “I do not feel real” (watching themselves from a distance)
What is the relationship between depersonalization disorder and traumatic life events?
It is often associated with traumatic events, particularly sexual abuse
Individuals may report feelings of detachment and isolation.
What defines Dissociative Identity Disorder (DID)?
a person has at least two separate ego states or alters (different modes of being and feeling and acting) that exist independently of each other and that come in control at different times.
Alters can have different memories, behaviors, and identities.
There is typically one primary personality (where treatment is sought by the primary alter)
What is common about the alters in DID?
They are usually very different from each other!!
Ex. have very different physical characterisics like glasses with different perscriptions, allergies to different things, and often have different ages
It vaires on the person if they have awareness of their other identities or not (some can switch right away and have no memory, while other people can hear the voices in their head of the other alters while they are their primary alter)
When does DID typically begin and when is it most commonly diagnosed?
Begins in childhood; diagnosed most commonly in adulthood
Diagnosis is more prevalent in women.
In Dissociative Identity Disoder, how do the alters interact with one another?
They do not - gaps in memory always occur because it least 1 alter has no contact with the others
(Alter A has no memory of Alter B or even any knowledge of having an alternative state)
The original and subordinate alters are all aware of lost periods of time → and the voices of other alters may arise in consciousness, but the person does not know who these voices are.
What are common comorbid conditions with DID?
- Substance abuse
- Headaches
- Phobias
- Hallucinations
- Suicide ideation/attempts
- Sexual dysfunction
These symptoms often overlap with dissociative symptoms.
What has research linked to symptoms of dissociation in DID within childhoosd?
Attachment-related trauma in childhood is linked to symptoms of dissociation.
How are cases of DID often misrepresented in the media?
They are frequently mislabeled as schizophrenia
What are the main concerns psychiatrists have about DID being classified as a disorder in the DSM-5?
Concerns about scientific validity and diagnostic legitimacy of DID
Psychoanalytically oriented psychiatrists are MORE accepting of DID than biologically oriented psychiatrists!!!
What impact did the book and movie ‘Sybil’ have on the perception of DID?
The book and movie created an outrage that DID is retained in DSM-5, viewed DID as unscientific
Some critics feel this movie caused therapists to strongly suggest to clients that they have DID (huge problem).
‘Sybil’ presented a dramatic case with 16 personalities.
What has been the trends of DID prevelance over time?
Studies declined (unlike other disorders) until 1970s which caused the claim that dissociative disorders do not have widespread acceptance and there was not many diagonses
Re-emergence of DID in the past 30 years do to either:
- DSM-3 outlining diagnosic criteria for DID for the first time
- OR clinicians always noticed DID but did not report them until interest in DID grew
Why did DID likely decline until the 1970s?
Likely due to the popularity of schizophrenia - where people with DID would get diagnosed with this instead
(even though the disorders are not very similar)
How did the prevalence estimates of DID change over time?
Initially thought to be 1 in 1 million, researchers in one study suggest to be about 1 in 100 people!
In a study looking at dissociative disorders in students, what was some factors in students that report more dissociative experiences?
That those students had greater physical and psychological maltreatment from parents, greater psychopathology, and lower university adjustment.
*only two students in this study deemed to have another diagnosable disorder, but neither of them met the threshold for dissociative disorder.
Where does the concept of “dissociative disordes” come from? What is the early idea of dissociative disorders?
Comes from Pierre Janet (a french neurologist)
Early idea is that consciousness is usually a unified experience, but under stress, memories of trauma may be stored in a way to not be accessible when the person returns to their normal state (where amnesia or fugue is possible).
(the behavioural view is similar to this as it thinks dissociation is an avoidance response from trauamtic events!)
What is the Trauma Model of Dissociation?
(one of the major theories of DID)
Assumes DID begins in childhood due to severe physical or sexual abuse (or other forms of distress) and leads to dissociation as a response to distress.
Person cannot handle the truama so they engage in dissociation
Lots of evidence that this model is accurate!!
What is the Fantasy Model of Dissociation?
(one of the theories of DID)
Assumes people who develop DID are very prone to engage in fantasy.
Less evidence for this model
What did a study on convicted murderers reveal about DID?
14 cases of DID were found in a sample of 150 convicted murderers, with many having symptoms before incarceration and documentation of childhood abuse present in 11 cases.
Ex. several participants showed different hand writing styles well before committing their crimes.
Acts as evidence for the truama model of dissociation (that DID begins in childhood and related to extreme stress)
Who is Nicholas P. Spanos and what is his contribution to the understanding of DID?
Challenged the validity of DID as a distinct psychiatric disorder, advocating it as a socially constructed form of role-playing (learned social roles)
Essentiallt thought it DID is not real.
What 3 things was Nicolas Spanos primarly known for?
(1) He was a leading advocate of the idea that DID basically involves a socially constructed form of role-playing.
(2) Used role-playing studies with students to provide a perspective on the trial of a serial murderer known as the Hillside Strangler.(revealed that people are able to adopt a second personality - and that role-playing of DID is possible).
(3) His research on people who reported seeing UFOs are caused by congitive constructions and false memories
What are the issues of repressed memories of childhood sexual abuse (especially in court cases)
Lots of debate if these recovered memories are valid for court cases
Lots of research reveals that recovered memories are very valid and align with how memory works
But… Canada is the first coutnry in English common law to impose a total ban on post-hyptotic evidence (inclusing those of CSA)
Might be problematic as dissociation is linked to the forgetting of truamatic information from one’s past.
What is a common treatment approach for dissociative disorders?
Psychoanalytic approach is the most common choice of treatment.
This is because dissociative disorders indicate having repressed portions of their life likely due to stress and truama
Therapies for PTSD are also used for dissociative disorders (large overlap in these diagnoses)
Fill in the blank: The decline in reports of DID until the 1970s was likely due to the popularity of ———-.
schizophrenia
What is the role of hypnosis in treating dissociative disorders?
Used to help clients gain access to hidden portions of their personality lost due to trauma.
Idea is to enter a state of mind to events in their childhood (a technique called age regression)
