Chapter 8

Question 1

Depersonalization/derealization
disorder

Answer 1

Experience of detachment from the self and reality

Question 2

Dissociative amnesia

Answer 2

Lack of conscious access to memory, typically of a
stressful experience. The fugue subtype involves traveling
or wandering coupled with loss of memory of one’s
identity or past.

Question 3

Dissociative identity disorder

Answer 3

At least two distinct personality states that act independently of each other

Question 4

The core feature of each dissociative disorder, involves …

Answer 4

some aspect of emotion, memory or experience being inaccessible consciously

Question 5

What distinguishes common dissociative experiences from dissociative disorders, and what are the main types of dissociative disorders?

Answer 5

Common dissociation (e.g., zoning out while studying or driving) is harmless and brief. In contrast, dissociative disorders involve more severe disruptions in consciousness or identity. Types include:

Depersonalization/Derealization Disorder: feeling detached from self or surroundings, like being in a dream.

Dissociative Amnesia: inability to recall important personal information.

Dissociative Identity Disorder (DID): memory gaps so extensive that a unified identity is lost.

Question 6

What are potential causes of dissociative disorders, and why are they controversial?

Answer 6

Dissociation may be an avoidance response to stress or trauma, supported by links to military stress, mood disorders, sleep problems, and even ketamine use. Trauma may disrupt sleep, which then triggers dissociation. However, controversies remain—some symptoms are so rare they may reflect exaggeration or confusion, and there’s limited consensus on causes or best treatments. Research is ongoing and complex.

Question 7

What are the key features of depersonalization/derealization disorder, and how is it different from other dissociative disorders?

Answer 7

his disorder involves persistent or recurrent feelings of detachment:

Depersonalization: feeling detached from oneself (e.g., as if observing from outside the body).

Derealization: feeling detached from the environment (e.g., surroundings feel unreal or foggy).
Unlike other dissociative disorders, it does not involve memory disturbances. It often begins in adolescence and may persist for years.

Question 8

What are common triggers, risk factors, and differential diagnoses for depersonalization/derealization disorder?

Answer 8

Triggers include stress and childhood trauma, and symptoms may arise suddenly or gradually. It’s often comorbid with personality disorders, anxiety, and depression. The disorder must be distinguished from other conditions like schizophrenia, PTSD, borderline personality disorder, and substance intoxication (e.g., marijuana, ketamine). Though fleeting episodes are common (especially in students), diagnosis requires persistence and significant distress.

Question 9

What are the defining features of dissociative amnesia, and how does the fugue subtype differ?

Answer 9

Dissociative amnesia involves the inability to recall important autobiographical information, usually linked to trauma or stress, and is too extensive to be normal forgetfulness.

Memory loss can last from hours to years and usually resolves suddenly.

Dissociative fugue subtype includes more extensive memory loss, often involving bewildered wandering or even adopting a new identity, home, and lifestyle.

During the episode, procedural memory (skills) is intact, and behavior may appear normal apart from disorientation. After recovery, memory returns, excluding events during the fugue.

Question 10

What are the leading theories about the causes of dissociative amnesia, and what challenges exist in explaining it?

Answer 10

Psychodynamic theory suggests traumatic memories are repressed to avoid conscious pain.

However, cognitive research finds that trauma usually enhances memory for central features (not suppresses it), often through norepinephrine-driven arousal.

An alternative view proposes extreme stress may impair memory encoding by disrupting attention or flooding the brain with stress hormones.

The condition raises questions about how memory and attention operate under extreme stress, and debate continues about the validity of repression and the mechanisms behind memory loss in trauma.

Question 11

What are the key features of Dissociative Identity Disorder (DID), and how do they affect a person’s experience of self and memory?

Answer 11

DID is marked by a disrupted sense of identity, involving two or more distinct personality states or modes of being that exist independently and alternate control. Each identity can have its own behavior, emotions, and memory, often leading to amnesia for actions done by other identities. The person may feel confused, hear internal voices, or be unaware of lost time.

Question 12

Why did the diagnosis of DID increase dramatically in the 1970s, and what are the controversies surrounding its validity?

Answer 12

Increased diagnoses may stem from greater media exposure (e.g., Sybil, The Three Faces of Eve) and the formal inclusion in DSM-III in 1980. Some critics argue that suggestive therapy, especially using hypnosis, may have contributed to false or therapist-induced cases. While clinicians can reliably describe DID, debate continues over whether it’s an iatrogenic condition or a legitimate disorder.

Question 13

How does culture shape the diagnosis or interpretation of DID, especially in contexts involving possession?

Answer 13

In some cultures, shifts in identity are framed as spiritual possession and are considered normative or even valued. In such cases, a diagnosis of DID is not appropriate. This underscores how cultural beliefs about the self and consciousness influence whether such symptoms are pathologized or spiritually integrated.

Question 14

How does DID compare in severity and comorbidity to other dissociative disorders, and what common co-occurring conditions are observed?

Answer 14

DID is more severe than other dissociative disorders and commonly co-occurs with PTSD, depression, somatic symptom disorder, and borderline personality disorder. Symptoms can include hallucinations, self-injury, and suicide attempts. Most people diagnosed with DID report a long history of symptoms, often dating back to childhood.

Question 15

What brain-related factors contribute to depersonalization/derealization disorder, and how might they explain the symptoms?

Answer 15

The disorder may stem from dysfunction in how the brain integrates sensory and bodily signals. PET studies show underactivity in sensory integration regions, and mismatched sensory input (e.g., distorted goggles) can induce temporary symptoms in healthy people. Reduced activity in emotion-processing areas (like the anterior cingulate cortex) may also lead to emotional numbing.

Question 16

What does the posttraumatic model propose about the origins of DID, and what evidence supports it?

Answer 16

This model suggests DID results from extreme trauma (often childhood abuse), with dissociation used as a coping mechanism. Studies show abused children are more likely to dissociate and develop symptoms later. However, evidence is mixed on whether objectively verified abuse leads to adult dissociation, possibly due to recall bias.

Question 17

What is the sociocognitive model of DID, and how might it explain the emergence of symptoms?

Answer 17

This model suggests DID is influenced by therapist suggestion, cultural exposure (e.g., media), and patient suggestibility. It may be iatrogenic, meaning unintentionally caused by treatment. Therapists using hypnosis or reinforcing identity states may encourage the development of alternate personalities, even without intent to deceive.

Question 18

How do implicit memory tests challenge the idea that personalities in DID are completely separate?

Answer 18

Even when personalities report amnesia, implicit memory tests (e.g., word priming) show shared memory between them. This suggests that memories persist across states, contradicting the idea that identities operate with total independence.

Question 19

What evidence supports the idea that DID symptoms can be influenced or reinforced by therapy or suggestion?

Answer 19

People can role-play DID convincingly in lab settings, producing distinct personality profiles. Many patients only discover alternate personalities after starting therapy. The number of identities often increases during treatment, especially when suggestive techniques are used. Notably, therapists who use hypnosis or probing techniques tend to diagnose more DID cases.

Question 20

What are the key principles in the treatment of Dissociative Identity Disorder (DID), given the lack of strong evidence for specific treatments?

Answer 20

Key principles include:

1. Empathy and gentleness: Establishing trust and a non-threatening environment.
2. Integration of personalities: Helping the person understand that splitting into different personalities is no longer needed.
3. Coping skills: Teaching more effective ways to manage stress and emotions.
4. Psychoeducation: Educating the person on dissociation and its triggers.
5. Intensive care: Hospitalization may be required to prevent self-harm.

Question 21

Why can psychodynamic treatment using hypnosis for DID be problematic?

Answer 21

Psychodynamic treatment aims to uncover repressed memories of trauma using hypnosis and age regression. However, these techniques can exacerbate DID symptoms by suggesting false memories or intensifying dissociation. More than 100 patients have sued therapists for harm caused by this approach, leading to a decline in the use of hypnosis in treatment.

Question 22

Somatic symptom disorder

Answer 22

Excessive thought, distress, and behavior related to somatic symptoms

Question 23

Illness anxiety disorder

Answer 23

Unwarranted fears about a serious illness in the absence of any significant somatic symptoms

Question 24

Functional neurological symptom
disorder

Answer 24

Neurological symptom(s) that cannot be explained by
medical disease or culturally sanctioned behavior

Question 25

Factitious disorder

Answer 25

Falsification of psychological or physical symptoms, without evidence of gains from those symptoms

Question 26

Malingering

Answer 26

Intentionally faking psychological or somatic symptoms to gain from those symptoms

Question 27

What are the key characteristics of Somatic Symptom Disorder (SSD)?

Answer 27

SSD is defined by excessive worry, energy, or behavior focused on somatic symptoms for at least 6 months. The person experiences distress about their health and perceives even minor physical concerns as signs of a serious illness. Despite extensive medical evaluations, symptoms often remain unexplained, and the distress is authentic, not feigned.

Question 28

What is the difference between Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder (IAD)?

Answer 28

SSD involves excessive worry about existing somatic symptoms (physical concerns), while IAD involves intense fear of having or developing a serious illness despite little or no symptoms. SSD has more tangible physical symptoms, whereas IAD focuses on fear of disease without significant somatic evidence.

Question 29

How do individuals with Somatic Symptom Disorder (SSD) typically engage with the medical system, and what are the consequences?

Answer 29

Individuals with SSD often seek frequent and extensive medical treatments, visiting multiple physicians, demanding tests, and sometimes even surgeries. Despite dissatisfaction with medical explanations, they continue seeking new treatments. This can result in significant medical costs, potential dependency on painkillers, and difficulties in working or functioning due to the severity of their concerns.

Question 30

What are some criticisms of the diagnostic criteria for Somatic Symptom Disorder (SSD)?

Answer 30

Critics argue that the threshold for diagnosing SSD is subjective, as up to 80% of the general population reports somatic symptoms at some point. The new DSM-5-TR criteria have made it harder to differentiate between normal health concerns and the disorder, and patients often find the diagnosis stigmatizing.

Question 31

What is the typical course and common comorbidities of Somatic Symptom Disorder (SSD)?

Answer 31

SSD typically develops in early adulthood and tends to be chronic, with less than half of patients achieving full remission within five years. It often co-occurs with anxiety disorders, mood disorders, and personality disorders. Symptoms may fluctuate in severity but can persist long-term.

Question 32

What are the key characteristics of Illness Anxiety Disorder (IAD)?

Answer 32

IAD is characterized by excessive preoccupation with fears of having a serious disease despite no significant somatic symptoms. This includes excessive care-seeking behaviors or maladaptive avoidance, lasting for at least 6 months. Individuals are easily alarmed about their health, often worried about conditions like cancer, heart attacks, AIDS, and strokes, and experience anxiety even when hearing about illnesses in others. Their fears are persistent and difficult to alleviate.

Question 33

What are the key characteristics of Functional Neurological Symptom Disorder (FNSD)

Answer 33

FNSD involves sudden onset of neurological symptoms like blindness, seizures, or paralysis, with no medical explanation from tests. Symptoms include partial or complete paralysis, sensory disturbances, and visual impairments (e.g., tunnel vision or blindness). Symptoms can occur without awareness of their connection to stress or conflict. While some patients might exaggerate their symptoms, many do not, and symptom amplification may be unconscious. Diagnosis involves ruling out true neurological causes, and the disorder is more common in women and patients visiting neurology clinics. Onset is rapid, and many individuals experience disability.

Question 34

How does brain activity relate to somatic symptoms in individuals with health anxiety?

Answer 34

In people with health anxiety, heightened activity in the rostral anterior insula and the anterior cingulate cortex (ACC) leads to an increased focus on unpleasant body sensations. This brain activity is linked to a greater tendency to experience and perceive somatic symptoms as more distressing (Price et al., 2009). These regions are involved in both pain and emotional processing, which can explain why stress or anxiety may amplify physical sensations

Question 35

What role do anxiety, depression, and stress hormones play in somatic symptoms?

Answer 35

Anxiety and depression can heighten the perception of somatic symptoms by increasing activity in the ACC, a brain region involved in both emotional and physical pain processing (Shackman et al., 2011). Stress hormones and emotional pain can make physical sensations feel more intense, contributing to the distress experienced by those with somatic symptom disorders (Rief & Martin, 2014).

Question 36

How can functional MRI feedback help individuals with somatic symptoms?

Answer 36

Real-time fMRI feedback can help people learn to control activity in the ACC, which is involved in pain perception. In a study, individuals who learned to control their ACC activity reported reduced pain intensity, suggesting that the ACC plays a significant role in the experience of pain (deCharms et al., 2005).

Question 37

How do cognitive processes contribute to health anxiety and somatic symptom disorders?

Answer 37

Cognitive biases like focusing on bodily sensations and interpreting them catastrophically (e.g., thinking a small pain is a sign of cancer) can amplify anxiety and distress. This leads individuals to focus on symptoms, which in turn intensifies their experience of those symptoms (Du et al., 2022; Witthöft et al., 2018).

Question 38

How do individuals with somatic symptom disorders react to physical symptoms?

Answer 38

People with somatic symptom disorders tend to pay excessive attention to bodily sensations, especially when in a negative mood. They often interpret these sensations as signs of serious illness, which escalates anxiety and distress. This creates a cycle where anxiety about symptoms makes the symptoms feel worse (Shi et al., 2022; Du et al., 2022).

Question 39

What is the role of avoidance and safety behaviors in health anxiety?

Answer 39

Avoidance behaviors (e.g., avoiding exercise or social activities) and safety behaviors (e.g., seeking reassurance or doing self-exams) are common in health anxiety. While these may provide temporary relief, they can reinforce the belief that something is wrong with one’s health and intensify distress over time (Brown, Skelly, & Chew-Graham, 2020). Safety behaviors prevent individuals from confronting their fear of symptoms, which prevents the fear from diminishing.

Question 40

How do safety behaviors contribute to worsening health anxiety?

Answer 40

Engaging in safety behaviors like frequent self-exams or excessive reassurance-seeking can reinforce the belief that health is fragile, thus increasing anxiety. A study showed that participants who engaged in safety behaviors developed new symptoms and worries about health, indicating that these behaviors can amplify anxiety (Olatunji et al., 2011).

Question 41

How do cognitive biases in somatic symptom disorders compare to panic disorder and obsessive-compulsive disorder (OCD)?

Answer 41

Similar to panic disorder (where physiological symptoms are interpreted as signs of immediate threat), individuals with somatic symptom disorder interpret bodily sensations as signs of long-term, serious illness. In OCD, individuals may have obsessions about disease but typically recognize their fears as irrational, unlike those with somatic symptom disorders (Du et al., 2022).

Question 42

How can watching a documentary influence somatic symptoms?

Answer 42

In an experiment, participants who watched a documentary about Wi-Fi signals causing physical symptoms (like skin tingling) reported more somatic symptoms after being exposed to a sham Wi-Fi signal. This shows that beliefs and anxieties about health can create or exacerbate symptoms, especially for those already anxious (Witthoft & Rubin, 2013).

Question 43

What are common triggers of Functional Neurological Symptom Disorder (FNSD)?

Answer 43

Stress and difficulty coping with emotions are potential triggers for FNSD. Many individuals report major life stressors and childhood neglect/abuse before symptom onset. However, not all individuals with FNSD have these stress histories. Studies show inconsistent findings regarding coping styles and emotions in FNSD patients.

Question 44

How do psychodynamic theories explain the symptoms of Functional Neurological Symptom Disorder (FNSD)?

Answer 44

Psychodynamic theory suggests that FNSD symptoms are responses to unconscious psychological conflicts. For example, a person may have an unconscious conflict leading to symptoms like paralysis (e.g., inability to move a limb) despite a lack of physical cause.

Question 45

How does neuroscience support the idea that FNSD symptoms can occur outside of conscious awareness?

Answer 45

Neuroscience shows that perceptual processing can occur unconsciously. For example, in unexplained blindness, brain regions involved in processing basic visual information may be active, but higher-level processing (like seeing an object as a whole) may be impaired. Involuntary tremors are another example, where brain regions responsible for motor awareness may not process the tremor consciously, causing the person to experience it as involuntary.

Question 46

What role does the amygdala play in Functional Neurological Symptom Disorder?

Answer 46

The amygdala (emotion-processing region) might interact with motor control regions, influencing symptoms like tremors. Studies suggest that differential connectivity between the amygdala and motor regions might contribute to emotion-induced motor symptoms in FNSD.

Question 47

What are some social and cultural influences on the development of Functional Neurological Symptom Disorder?

Answer 47

People from rural areas or those with lower socioeconomic status are more likely to develop FNSD. Mass hysteria cases, like the 1787 cotton-processing facility seizure outbreak, suggest that social contagion can play a role. In such cases, individuals in close-knit social settings may develop symptoms after exposure to others' symptoms.

Question 48

What are common treatment strategies for Somatic Symptom Disorder (SSD) and Illness Anxiety Disorder (IAD)?

Answer 48

Doctor-patient relationship: Strengthening trust and providing reassurance is essential. Cognitive-Behavioral Therapy (CBT): Includes: Identifying and changing emotions that trigger concerns about somatic symptoms. Changing negative thoughts about bodily symptoms. Encouraging healthy behaviors and improving social interactions. Mindfulness helps patients disengage from excessive focus on symptoms and reduces health anxiety.

Question 49

How can Cognitive Behavioral Therapy (CBT) be applied to treat Functional Neurological Symptom Disorder (FNSD)?

Answer 49

In one study, patients with gait disorders (e.g., limping or dragging their foot) were given CBT along with physical training. The two CBT components were: Reinforcing participation in training. Ignoring the symptoms to prevent reinforcing them. This approach led to significant improvements in mobility, independence, and quality of life, with benefits lasting up to 1 year.

Question 50

What other treatments work for Somatic Symptom Disorder with a focus on pain management?

Answer 50

Low-dose antidepressants and hypnosis are effective in treating pain-related SSD. Acceptance and Commitment Therapy (ACT) helps patients accept pain as a natural part of life instead of trying to avoid or fight it. Opioid alternatives: These treatments are preferred over opioid medications, which can be highly addictive.

Question 51

Why might internet-based CBT be beneficial for Somatic Symptom Disorder and Illness Anxiety Disorder?

Answer 51

Internet-based CBT can be effective, especially with brief clinician guidance. Studies show improvements sustained at follow-up assessments. This treatment provides flexibility and accessibility, particularly for individuals unable to attend in-person sessions.

Question 52

How does family therapy play a role in treating Somatic Symptom Disorder?

Answer 52

Family therapy can address reinforcement of sick-role behaviors within the family. If family members are unintentionally reinforcing the patient’s avoidance behaviors or illness symptoms, therapy can educate them on how to reduce these behaviors to prevent symptom escalation.

Question 53

How effective is CBT compared to other treatments for Somatic Symptom Disorder?

Answer 53

CBT has been found to be more effective than standard medical care and psychodynamic treatment in reducing health concerns, anxiety, and depression. Benefits from CBT for SSD and IAD are sustained long-term (up to 8 years). CBT is also as effective as antidepressants in treating illness anxiety symptoms.

Question 54

What is mass hysteria, and how does it relate to Functional Neurological Symptom Disorder?

Answer 54

Mass hysteria refers to a group of individuals in close contact (e.g., coworkers or students) developing inexplicable medical symptoms simultaneously. This phenomenon suggests that social and cultural influences can contribute to the spread and development of FNSD, with modeling and social contagion shaping the symptoms.