Lecture 10 - Somatic and Dissociative Disorders Flashcards
Explain the difference between factitious and malingering disorders
- factitious: deliberate feigning of disorder (often about seeking attention from people)
- malingering: recognised incentive for feigning disorder (deception, but also mental illness involved)
What are somatic disorders?
- present with prominent somatic sx, but cannot be explained medically
- mental disorders take the form of physical disorders
- prominent somatic sx associated with distress and impairment
What are dissociative disorders?
- disruption and/or discontinuity in the normal integration of consciousness, identity, memory, emotion, perception, body representation, motor control and behaviour
- can disrupt potentially every area of psych functioning
dissociative sx experienced as:
- intrusions into awareness/behaviour + loss of continuity in subjective experience (i.e. +ve dissociative sx)
- inability to access info/control mental functions that normally are readily amenable to access or control (i.e. -ve dissociative sx)
Explain the history of somatic and dissociative disorders
- Hippocrates: ‘hysteria’ > non-fatal bodily sx in women
- 17th century: ‘hypochondriasis’ > male
- Anna O > looking after father (mute, vision loss, headaches, limb weakness): Freud and Breuer
- “conversion”: transformation of physical/mental excitation into chronic somatic symptoms
What are the 4 somatic disorders and their associated features?
- somatic symptom disorder: freq medical visits; impaired functioning
- illness anxiety disorder: fear of illness persists despite med reassurance; interpret physical sensations as signs of illness
- conversion disorder: emerges in context of stress/conflict
- factitious disorder: sx do not result in any obvious gain; 2 types (imposed on self v. others)
How common are medically unexplained symptoms in general practice?
- very common, up to 30%
- rship b/w the no. of somatic sx someone has and anxiety/depression
Explain the impact of somatic symptoms disorders (4)
- huge disability and handicap problems
- costs to community > days off work
- compensation seeking
- problems to family members (separation difficulties bc children become carers for parents; kids miss school which reduces social opps)
Explain the cultural differences of somatic symptoms
- Western: somatisation abnormal
- some Eastern: somatisation the norm (expressing psych distress is abnormal)
Highlight ongoing debate about mind-body split
- Western: chronic fatigue, IBS
- China: Shenjing shuairuo
- Korea: Hwa-byung
What is illness anxiety disorder?
- preoccupation with having or acquiring a physical illness
- easily alarmed by hearing about illness
- do not respond to appropriate medical reassurance/tests/benign course
- doctors attempts do not alleviate concerns (may heighten them)
- illness concerns assume a prominent place in life, affect daily activities, may lead to invalidism
Differentiate IAD from 5 other disorders
GAD: worry about multiple concerns (one may be health)
IAD: sole focus of worry is health
OCD: fearful of getting disease in future; O+Cs about other things too
IAD: intrusive thoughts about disease associated with compulsions (eg. reassurance)
MDD: may involve health concerns
IAD: illness worry persists after MDE
DELUSIONS: somatic delusions bizarre and rigid
IAD: can usually acknowledge that feared disease not present; illness concerns not real but plausible
PANIC: misinterpretations of bodily sensations > avoid situations; misinterpret anxiety signs; may worry that PA reflects medical illness but worry is acute/episodic
IAD: anticipated harm less imminent than in panic (have time to get med attn and prevent it); health anxiety/fears are persistent and enduring (may have PA resulting from illness concerns)
What are the cog and psych aspects of illness anxiety disorder?
- hypersensitivity to bodily sensations
- heightened anxiety regarding health/illness
- biased thinking about threat/reality of serious disease
- excessive reassurance seeking
- distrust med opinion BUT more help-seeking
- childhood learning experiences of illness behaviour
- catastrophic misinterpretations of benign sings
- optimistic bias towards making judgments about own health risks
What is the treatment of illness anxiety disorder? What are three challenges of this?
- CBT (psych therapy better than med)
CHALLENGES
- help client feel understood
- enable client to consider: non-catastrophic alternative explanation + suggested treatment rationale and strategies that flow from it
- engagement in psych treatment is problematic > they believe they have a physical illness and that the last thing they need it psych treatment
What is conversion disorder? What are the symptoms? What are the specifiers? Give two examples of it.
- altered voluntary motor or sensory function
- no medical/neuro explanation
- often spontaneously remit without treatment
SYMPTOMS
- weakness/paralysis
- abnormal movement (tremor, gait etc.)
- swallowing
- speech
- attack/seizures
- sensory loss
- special sensory sx (visual, olfactory, hearing)
- mixed sx
SPECIFIERS:
- acute v. persistent
- with/without psych stressor
EXAMPLES
- soldiers in wartime
- mass psychogenic disorder/mass hysteria > Melb Airport 2005
What is used to measure dissociative symptoms?
Dissociative Experiences Scale
What is Dissociative Identity Disorder?
- disruption of identity; 2+ distinct personality states
- discontinuity in sense of self and sense of agency
- alterations in: affect, behaviour, consciousness, memory, perception, cognition, sensory-motor function
- recurrent gaps in recall of everyday events, personal info, traumatic events
- not normal given cultural and religious context
Explain the prevalence of Dissociative Identity Disorder
- 1957: “Eve” only case in world
- 1980: approx 200 cases reported internationally
- more recently: 1% of adult population
- large-scale population based studies required
What are the associated features of Dissociative Identity Disorder?
- comorbidities: anxiety, depression, substance use, self-injury, non-epileptic seizures, other
- concealment or non-awareness of disruptions in consciousness, amnesia or other dissociative sx
- dissociative flashbacks
- other experiences of trauma (non-abuse)
- self-mutilation/suicidal behaviour
- high levels of hypnotisability
Explain the aetiology of Dissociative Identity Disorder
- severe childhood trauma (almost always ~90%) > majority with DID have PTSD
ADDITIONAL FACTORS
- capacity to dissociate
- elaboration of alternate identities
- lack of soothing experiences after trauma
Explain the differences in Dissociative Identity Disorder at different age groups
CHILDREN: memory/concentration/attachment problems; usually don’t present with identity changes; present with overlap/interference among mental states
ADOLESCENTS: sudden changes in identity may appear to be just adolescent turmoil or early stages of another disorder
OLDER: present to treatment with what appear to be late-life mood dx, OCD, paranoia, psychotic mood dx, or cog dx
What can trigger overt changes in identity in Dissociative Identity Disorder?
- removal from traumatising situation
- individual’s children reaching same age at which individual was originally abuse or traumatised
- later traumatic experiences (even seemingly inconsequential ones eg. minor car accident)
- death of, or onset of, a fatal illness in abuser(s)
Explain the controversy in Dissociative Identity Disorder
RECOVERED MEMORY DEBATE
- is it possible that a trauma memory of abuse can be repressed so that the memory is inaccessible, but can later be recalled accurately?
- hypnosis/guided imagery treatment if repressed memory thought possible
- careful assessment to minimise likelihood of false recall + use CBT to reduce anx/dep etc. if repressed memory not thought possible
IATROGENIC/SOCIOCOG THEORY
- psychologists play a role in development of DID: suggest possibility of multiple identities and legitimise it
- also: create sx through hypnosis and then shape behaviour through differential reinforcement
- media cases: Eve and Sybil
What is dissociative amnesia? What is the specifier?
- inability to recall important autobiographical memory (usually trauma/stressful memory) inconsistent with normal forgetting
WITH DISSOCIATIVE FUGUE
- purposeful travel/bewildered wandering that is associated with amnesia for identity/for other important autobiographical information
What are the 5 subtypes of dissociative amnesia?
- LOCALISED: memory loss in a circumscribed period of time (may be broader than one single event)
- SELECTIVE: can recall some, but not all, of the events during a circumscribed period of time
- SYSTEMATISED: memory for a specific category of info lost
- CONTINUOUS: forget each new event as it occurs
- GENERALISED: complete loss of life history (personal identity, semantic knowledge, procedural knowledge)
What are the associated features of dissociative amnesia?
- history of trauma (v common)
- difficulty forming and maintaining rships
- dissociative flashbacks (possible)
- depression
- suicide/self-harm (common)
- high levels of hypnotisability
- sexual dysfunction (common)
What is the prev and course of dissociative amnesia?
- 12mth prev: 1.8% (1%M, 2.6%F)
- children, adolescents and adults
COURSE:
- generalised: onset sudden
- localised + selective: less known (rarely evident)
- may have many episodes (one episode can predispose others); may/may not be symptomatic b/w episodes
- any age
What is derealisation/depersonalisation disorder?
- depersonalisation: unreality, detachment or feeling like an outsider with respect to thoughts, feelings, sensations, body, actions (distorted sense of time, perceptual alterations, emotional or physical numbing)
- derealisation: unreality or detachment with respect to surroundings (dream-like, foggy, unreal, lifeless, distorted)
What are the associated features of derealisation/depersonalisation disorder?
- fear ‘going crazy’
- fear ‘brain damage’
- subjectively altered sensation of time (too fast/slow)
- lightheadedness
- extreme rumination or obsessional preoccupation (do I really exist?)
- anxiety + depression
What is the course of derealisation/depersonalisation disorder?
- onset: 16yrs (<20% after 20yrs; 5% after 25yrs)
- onset: range extremely sudden to gradual
- duration of episodes: vary brief (hrs/days) to prolonged (wks, mths, yrs)
- 1/3 cases discrete episodes; 1/3 continuous sx; 1/3 initially episodic then continuous
What is the aetiology of derealisation/depersonalisation disorder?
- childhood interpersonal trauma < association to this not as strong as with other dissociative disorders
- proximal precipitants: severe stress (interpersonal, financial, occupational), depression, anxiety (esp. panic attacks), illicit drug use
Explain the treatment of dissociative disorders
- derealisation/depersonalisation: pharamacotherapy (SSRIs, antipsychotics > limited evidence); CBT?
- dissociative amnesia: imaginal exposure, hypnosis
- DID: treatment guidelines, more empirical research needed
