Week 10 - Ch 8 - Dissociative Disorders and Somatic Symptoms (DN) Flashcards
Why are dissociative & somatic symptom disorders covered in the same chapter?
because both are hypothesised to relate to some stressful experience
yet symptoms do not involve direct expressions of anxiety
Learning Goals
- define symptoms of the dissociative and somatic disorders
- summarize current debate regarding etiology of DID
- explain etiological models of the somatic symptom disorders
- describe available treatments for dissociative and somatic symptom disorders
What are the defining features of dissociative & somatic symptoms disorder?
dissociative disorders - disruptions of consciosness, loses track of self awareness, memory & identity
somatic symptoms disorder - bodily symptoms suggesting physical defect/dysfunction. No physiological basis may be found or psychological reaction to symptoms appear excessive
Name the 3 major dissociative disorders
- dissociative amnesia
- depersonalisation/derealisation disorder
- disocciative identity disorder
p228
Dissociative Amnesia
Lack of conscious access to memory (typically stressful one)
- Fugue subtype = loss of memory for entire past or identity
(used to be a separate classification in DSM-IV, became subtype in DSM-5)
Depersonalization/Derealization Disorder
- alteration in experience of self & reality
(derealization added in DSM-5)
p228
Dissociative Identity Disorder
- at least 2 distinct personalities
- act indepently of each other
DSM-5 added
(not part of accepted cultural/religious paractice)
Is the memory loss more severe in dissociative amnesia or in its subtype fugue?
fugue
p231
Is complete recovery possible in Dissociative Amnesia & its subtype Fugue?
If so, does recovery from these disorders differ?
Complete recovery usually occurs in both
Dissociative Amnesia:
amnesia disappears as quick as it began & only small chance of recurrence
Memories not completely lost but can’t be retrieved during the amnesia
Fugue:
Memory loss is more extensive in fugue
Recovery takes varying amounts of time. Full memory of life & experiences return except for those during fugue
p231
What kind of memories are typically affected in Dissociative Amnesia & Dissociative Fugue?
Explicit memories (requiring conscious recall)
p231
What is a hotly debated component of Dissociative Disorders
Memory
Memories with emotional power are more salient
Although research has shown even false memories can have painful physiological responses
Repression: is it responsible for failure to report events
if so more severe events should limit recall (not the case)
Recovered memories of Child abuse & highly painful events
- are these memories real, or are they false memories
- therapists suggestion (hypnosis, guided imagery etc)
Getting this wrong :
Injustice to either accused or the accuser
p229-230 Focus on Discovery
Depersonalization/Derealization Disorder
- No disturbance of memory
- suddenly lose/altered sense of self & perception of surroundings
- bizarre sensory experiences
- usually triggered by stress
- not explained by substances, another disorder or medical condition
Derealization added to DSM-5
(refers to sensation that world has become unreal)
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When does Depersonalization/Derealization disorder usually begin?
How does it normally begin & what is its time course?
- adolescence
- begins either abruptly or insidiously
- chronic time course
Wh common symptom of panic attacks may trigger depersonalization?
hyperventilation
p232
When does Dissociative Identity Disorder usually begin?
Childhood, but rarely diagnosed until adulthood
Which is the most severe and extensive of the dissociative disorders?
How does its recovery compare?
Dissociative identity disorder
recovery is also less complete than the other dissociative disorders
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What are cases of DID sometimes mislabelled as in the popular press?
Why the confusion?
schizophrenia
schizo - splitting away from
however a split into 2 or more separate & coherent personalities is entirely different from symptoms of schizophrenia
p233
What are some possible explanations in the increase in DID symptoms over time?
- possible that more people are actually experiencing it
or - possible increased diagnosis coincided with DSM-3 (1980’s) inclusion of it (e.g., China DID is not officially recognised - rates are less than one tenth than countries where it is recognised)
- Highly popularised by media e.g., Sybil / Three Faces of Eve
- Therapists suggestions
Describe the two major theories of DID?
Posttraumatic model - some are likely to dissociate in response to trauma
Sociocognitive model - DID result of learning social roles. Alters appear by - therapist’s suggestion, media exposure, cultural influences
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Does the socio-cultural model imply that DID is a conscious deception?
No, this models focus is not on whether DID is real, but how it actually develops
p234
What has evidence demonstrated with regard to role-playing and DID?
What caution should be taken when interpreting this evidence?
people can adopt a 2nd personality (when the situation demands)
caution: this does not mean that DID results from role-playing
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What is one of the defining deatures of DID?
the inability to recall information experienced by one alter when a different alter is present
p235
Which principles of DID treatment are widely agreed upon regardless of clinician orientation?
Empathic, gentle approach
Goal:
- to help client function as one wholly integrated person
- show person that splitting is no longer needed to deal with trauma
- teach person more effective ways to cope with stress
p237
What are some important concerns particularly with psychodynamic approaches to DID treatment?
Psychodynamic approach: goal is to overcome repression (repressed trauma believed to contribute to DID)
- Often use hypnosis & age regression which can worsen symptoms of DID
p237
What is age regression?
What is its goal?
- a technique often used in the psychodynamic approach to treating DID
- client hypnotised and asked to go back in mind to traumatic events in childhood
goal: access traumatic memories to allow person to realise childhood threats are no longer present - that coping mechanisms needed then are not useful as an adult
What is the treatment course (time frame) for DID?
What comorbidities often exist with DID?
Treatment course:
- 2 years plus (Kluft)
- within 10 years (Coons & Bowman)
- more alters, longer treatment
Comorbid:
- anxiety & depression - lessened with medication
- medication does not effect the DID itself
p237
Who is Richard Kluft?
a highly experienced DID therapist
- achieve 84% stable integration
- 10% at least better functioning
p237
What bold step was taken in DSM-5 with the criteria for Somatic Symptom Disorders?
the requirement that symptoms be medically unexplainable was removed
- because it became clear over thime that it is close to impossible to distinguish whether some symptoms are biologically caused
p238
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What was Somatic Symptom Disorders previously called in DSM-IV-TR?
Somatoform
to capture fact that symptoms were bodily sensations
What are three criticisms of the somatic symptom disorders?
- diversity in basis of condition (e.g., some in context of anxiety/depression, others not)
- subjective criteria
(i.e., somatic symptom disorder & illness anxiety disorder defined by causing ‘excessive’ anxiety or involving ‘too much’ time & energy) very subjective thresholds - stigma associated with diagnosis > lack of clinical diagnoses
removal of ‘medical unexplained’ requirement - was hoped to reduce stigma & address hesitation to diagnosis in clinical practise
What are the ‘Somatic Symptom & Related Disorders’?
DSM-5
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion (Functional Neurological Symptom Disorder)
taken from lecture slides & DSM-5 p309, as text book DSM-5 predictions differed
What is the clinical description of Somatic Symptom Disorder?
three core criteria:
- 1 or more symptoms casuing distress/disruption
- excesive anxiety, concern, time & energy devoted to somatic concern
- at least 6 months
p240
What is the clinical description of Illness Anxiety Disorder?
main feature:
- preoccupation with fears of having serious disease, despite no significant symptoms
- excessive care-seeking
- at least 6 months
p240
What is the clinical description of Conversion Disorder (Functional Neurological Symptom Disorder)?
- sudden development of neurological symptoms (e.g., blindness, paralysis)
- illness suggests neuro damage, but medical tests indicate organs & nervous system are fine
What are some symptoms of Conversion Disorder (Functional Neurological Symptom Disorder)?
Paralysis: partial or complete (arms, legs)
Seizures
Coordination disturbance
Skin sensations (prickling, crawling, insensitivity to pain)
Vision: seriously impaired, completely blind, tunnel vision
Aphonia: loss of voice other than a whisper
Anosmia: loss of sense of smell
What etiological factors have been proposed to increase awareness & distress over somatic symptoms in Somatic Symptom Disorders?
Neurobiological Factors
Cognitive Behavioural Factors
What two brain regions have Neurobiological models of somatic symptom disorder focussed on?
What other disorders are connected to these regions?
- Anterior Insula & Anterior Cingulate
these regions are activated by unpleasant body sensations (e.g., heat) - both regions have strong connections with somatosensory cortex (involved in processing bodily sensations)
- Depression & Anxiety - directly related to anterior cingulate
- Emotional pain - can activate both regions
What may the involvement of the anterior insula & anterior cingulate help explain with regard to painful physical & emotional experiences?
their activation in depression, anxiety & physical sensations
may explain why emotions and depression can intensify experiences of pain
p245
How does the cognitive process in Somatic Symptom Disorder differ to that in Panic Disorder?
Underlying Belief:
Panic Disorder: interpret symptoms are sign of ‘immediate’ threat (heart attack)
Somatic Disorder: interpret symptoms as sign of underlying ‘long-term’ disease (cancer, aids)
Physical Cues
Panic Disorder: focuses on symptoms that actually become worse as they become more anxious
Somatic Disorder: cannot actually increase symptoms (e.g., make sun spot on arm bigger)
What is the underlying feature of the Cognitive Behavioural model of Somatic Symptom Disorder?
Cognitive Bias
- focus on health cues
- worst possible negative interpretations of symptoms
What can result from the Cognitive Biases in Somatic Symptom Disorder?
elevated anxiety and cortisol may exacerbate somatic symptoms & distress over those symptoms
p245
What two behavioural consequences of fear that bodily sensations signify illness?
What suggestion has been made as to why people with these disorders seek socially reinforcing interactions in this way?
- Assuming the ‘sick role’
- help-seeking behaviour (which may reinforce if attention or sympathy are given)
- people with Somatic Symptom Disorders often have trouble identifying their emotions and describing them directly
p245
What does the apparent decrease in incidence of functional neurological disorder suggest?
a possible role for social & cultural factors
i.e., Freud & charcot saw lots of females with this disorder yet
contemporary clinicians rarely see it
- studies show decline in western societies but more common in countries that place less emphasis on ‘psychologizing’ distress (e.g., Libya, China, India)
- suggesting individuals who do not process distress psychologically, may have it manifest neurologically (DN made this last sentence up)
p247
What is one of the major obstacles to treatment with somatic symptom disorders?
- most do not want to consult mental health professionals
- patients may resent referrals, interpreting it as a sign doctor thinks its ‘all in their head’
Convincing a patient that somatic symptoms are psychological is not a good idea, what alternatives do GP’s have?
- coaching GP’s & their treatment teams to provide care
- high level support has better outcomes over 6 weeks than low level support
- goal: establish strong relationship, building trust & comfort in patient, feeling more reassured about health
p248
What are some CBT treatments that have been applied to somatic symptom disorders?
Help people to
1) identify & change emotions that trigger emotional concerns
2) change cognitions regarding somatic symptoms
3) change their behaviours so they stop playing ‘sick role’ & gain reinforcement for engaging in other types of social interactions
How can psychoeducation programmes help people with somatic symptom disorders?
help them recognize the links between their negative moods & somatic symptoms
What other techniques/approaches have proven successful in reducing somatic symptoms?
- treating comorbid anxiety & depression
- relaxation training
- teaching patients to reframe their experience of a somatic symptom
behavioural tehniques
- encourage activities to rebuild healthy lifestyle
- exposure therapy, cognitive restructuring
- assertiveness training, social skills training
family approaches
- operant conditioning (reduce focus given to somatic symptoms)
antidepressant treatment
- (low dose) helps reduce pain
