• Dissociative

 experience disruptions of consciousness, lose track of self-awareness, memory and identity

  • Somatic symptom-related

 complains of bodily symptoms that suggests a physical defect/dysfunction *often no physiological basis can be found

  • Both are related to stress, they both tend to be comorbid
  1. Dissociative Disorders
  • 1) Depersonalization/derealization: alteration in the experience of the self and reality
  • 2) Dissociative amnesia: lack of conscious access to memory, typically of a stressful experience

(7.5%) o The fugue subtype involves travelling or wandering coupled with loss of memory for one’s identity or past

  • 3) Dissociative identity disorder (DID): at least 2 distinct personalities that act independently of each other (1-3%)
  • Dissociation is the core feature = involves some aspect of emotion, memory, or experience being inaccessible consciously
  • Dissociation is an avoidance response that protects a person from consciously experiencing stressful events o Can also be result of sleep deprivation

Memory

  • Interference memory formation – not accessible to awareness later
  • Memory deficits in EXPLICIT but not implicit memory (with dissociative disorder)
    • Explicit memory = involves conscious recall of experiences (factual)
    • Implicit memory = underlies behaviours based on experiences that cannot be consciously recalled (e.g. playing tennis)
  • Distinguishing other causes of memory loss from dissociation:
    • Dementia – memory fails slowly over time *not linked to stress (brain dysfunction)
      • Accompanied by other cognitive deficits (e.g. processing speed)
      • Inability to learn/code new information o Memory loss after brain injury o Substance abuse
  1. Depersonalization/Derealization Disorder (DDD) DSM-5 Criteria:
    • = Involves a disconcerting and disruptive sense of detachment from one’ self or surroundings

1) Depersonalization = sense of being detached from one’s self – OR:

2) Derealization = sense of detachment from one’s surroundings, surroundings seem unreal o Outside their bodies, viewing themselves from a distance, looking at the world through fog o Feel mechanical, like robots

3) Reality testing remains intact

4) Symptoms are not explained by substances, another dissociative disorder, another psyc disorder, or by a medical condition

    • Symptoms usually triggered by stress, no disturbance in memory or psychosis
    • Usually begins in adolescence, abruptly or insidiously
    • Symptoms often continually present for years
    • Comorbid personality disorders are frequent, 90% experience anxiety and depression  Childhood trauma often reported
    • Symptoms can co-occur with other disorders but cannot be entirely explained by them
  2. Dissociative AmnesiaDSM-5 Criteria:
    • 1) Inability to remember important autobiographical information, usually of a traumatic or stressful nature, that is too extensive to be of ordinary forgetfulness
    • 2) The amnesia is not explained by substances, or by other medical or psychological conditions
    • 3) Specify dissociative fugue subtype if the amnesia is associated with bewildered or apparently purposeful wandering
    • Information is not permanently lost but cannot be retrieved during episode of amnesia (several hours – several years)
    • Amnesia usually disappears as suddenly as it began
    • Complete recovery and only small chance of reoccurrence
    • Procedural memory remains intact
    • Fugue = memory loss is more extensive, the person typically disappears from home and work o May take on new name/job/personality *identity
      • Inability to recall one’s past o Brief duration, remits spontaneously  Psychodynamic theory:
      • Traumatic experiences are repressed *hippocampus is vulnerable to stress, memories are forgotten because they are so aversive
    • Cognitive: extreme stress usually enhances rather than impairs memory o Norepinephrine (associated with heightened arousal) enhances memory consolidation and retrieval
    • Nature of attention and memory change during periods of intense stress o Focus on central features of threatening situation o Stop paying attention to peripheral features
      • Retain emotionally relevant information rather than neutral details
    • Perhaps extremely high levels of stress hormones interfere with memory formation Dissociative Identity Disorder (DID) *formerly Multiple Personality Disorder DSM-5 Criteria:

1) Disruption of identity characterized by 2 or more distinct personality states (alters) or an experience of possession

o These disruptions lead to discontinuities in the sense of self or agency, as reflected in altered cognition, behaviour, affect, perceptions, consciousness, memories, or sensory-motor functioning

This disruption may be observed by others or reported by the patient

2) Recurrent gaps in memory for events or important personal information that are beyond ordinary functioning

3) Symptoms are not part of a broadly accepted cultural or religious practice

4) Symptoms are not due to drugs or a medical condition

5) In children, symptoms are not better explained by an imaginary playmate or by fantasy play

    • Each alter determine the person’s nature and activities when it is in command
    • Primary alter may not be aware that any other alter exists *it is the primary alter than usually seeks treatment
    • Most often 2-4 alters are identified when diagnosed
    • Personalities of alters are quite different from one another
    • Rarely diagnosed until adulthood, can recall symptoms dating back to childhood
    • More severe and extensive than other dissociative disorders *less complete recovery

 

More common in women than in men

Other diagnoses are often present: PTSD, MDD, somatic symptom disorders, personality disorders No thought disorder or behavioural disorganization

  • Accompanied by other symptoms: headaches, hallucinations, suicide attempts, self-injurious behaviour, amnesia, depersonalization

Epidemiology: Increases over time

  • Almost no reports of DID or dissociative amnesia before 1800
  • 1-3% prevalence estimate
  • Heightened professional media attention may had led some therapists to suggest strongly to clients that they had DID
  • Sometimes use hypnosis to probe for alters
  • Diagnosis criteria was more explicit in DSM-III
  • Appearance of DID in pop culture (Sybil, 3 faces of eve)

Etiology

  • Almost all patients in therapy report severe childhood abuse  Posttraumatic Model:
    • Some people are particularly likely to use dissociation to cope with trauma o Children who are abused are at risk for developing dissociative symptoms
    • Evidence that children who dissociate are more likely to develop psychological symptoms after trauma
  • Sociocognitive Model:
    • People who have been abused seek explanations for their symptoms and distress, alters appear in response to suggestions by therapists, exposure to media reports of DID or other cultural influences
    • Iatrogenic = created within treatment  the person learns to role-play these symptoms within treatment
  • DID symptoms can be role-played:
    • Usually under hypnosis
  • Alters share memories, even when they report amnesia:
    • Defining feature: inability to recall information experienced by one alter when a different alter is present
    • Implicit memory seems to be intact and shared
  • Symptoms may only emerge after therapy begins

Treatment

  • Important to have an empathic, gentle stance
  • Goal of helping the person function as one holly integrated person o Convince the person that splitting into different personalities is no longer necessary to deal with trauma
  • Teach more effective ways of coping with stress *emotional regulation strategies
  • Psychoeducation – help understand why dissociation occurs, identify triggers
  • Psychodynamic treatment – goal to overcome repressions o Use hypnosis to help client gain access to repressed material
    • Age regression = encourage client to go back in his/her mind to traumatic events in childhood
    • Help realize that childhood threats are no longer present o Can possibly worsen DID symptoms

Often comorbid with anxiety and depression, use antidepressants to lessen *have no effect on DID itself

  1. Somatic Symptom and Related Disorders (previously known as somatoform disorders)

1) Somatic symptom disorder: excessive thought, distress, and behaviour related to somatic symptoms

2) Illness anxiety disorder: unwarranted fears about a serious illness in the absence of any significant somatic symptoms

3) Conversion disorder: neurological symptoms that cannot be explained by medical disease or culturally sanctioned behaviour

4) Malingering: intentionally faking psychological or somatic symptoms to gain from those symptoms

5) Factitious disorder: falsification of psychological or physical symptoms, without evidence of gains from those symptoms

Defined by excessive concerns about physical symptoms or health

  • Hypochondriasis = chronic worries about developing a serious medical illness **not a DSM-5 diagnosis
  • Seek frequent medical treatment, hospitalizations and surgery are common
  • Conditions are remarkably varied
  • Health concerns are cause of excessive anxiety or involve too much expenditure of time and energy *very subjective criteria
  • Diagnosis of these disorders often is found to be stigmatizing
  • New to DSM-5: somatic symptom disorder does not have to be medically unexplained
  • Tend to develop in early adulthood, wax and wane over time, recovery can occur naturally
  • Tend to co-occur with anxiety disorders, mood disorder, substance use disorders & personality disorders
  • More common in women than in men
  1. Somatic Symptom Disorder (SSD)

DSM-5 Criteria

1) At least one somatic symptom that is distressing or disrupts daily life

2) Excessive thought, distress and behaviour related to somatic symptoms or health concerns, as indicated by at least one of the following:

o Health-related anxiety, disproportionate and persistent concerns about the seriousness of symptoms, excessive time and energy devoted to health concerns, duration of at least 6 months

3) Specify if predominant pain

  • Diagnosed regardless of whether symptoms can be explained medically
  • DSM-5 label “Psychological Factors Affecting Other Medical Conditions” used when psychological factors are the cause of symptoms
  • May begin/intensify after some conflict or stress
  • Might seem that the person is using the symptom to avoid some unpleasant activity or to get attention/sympathy
  • Experience symptoms as completely physical
  • 3x as common as illness anxiety disorder Illness Anxiety Disorder (IAD) DSM-5 Criteria:

1) Preoccupation with and high level of anxiety about having or acquiring a serious disease

2) Excessive illness behaviour (e.g. checking for signs of illness, seeking reassurance) or maladaptive avoidance (avoiding medical care)

3) No more than mild somatic symptoms are present

    • Not explained by other psychological disorders
    • Preoccupation lasts at least 6 months

Often co-occurs with anxiety and mood disorders

III. Conversion Disorder (CD) DSM-5 Criteria:

1) One or more symptoms affecting voluntary motor or sensory function

2) The symptoms are incompatible with recognized medical disorder

3) Symptoms cause significant distress or functional impairment or warrant medical evaluation

  • Sensory/motor function impairment with no neurological cause o May experience partial or complete paralysis of arms/legs, seizures and coordination disturbances, sensation of prickling/tingling/creeping on the skin, insensitivity to pain, or anesthesia (loss of sensation)
  • May become partially/completely blind, tunnel vision
  • Aphonia = loss of the voice other than whispered speech
  • Many do not connect medical symptoms with stressful situations
  • Hysteria = term originally used to describe the disorder o Hippocrates considered it to be an affliction limited to women, brought on by the wandering of the uterus

 Originally known as hysteria (Greek word for uterus) o Symbolized the longing of the women’s body for a child

  • Conversion originated from Freud, thought anxiety and psyc conflict were converted into physical symptoms (Anna O)
  • Genuinely physical problems are misdiagnosed as conversion disorder 4% of the time
  • Symptoms usually develop in adolescence or early adulthood, typically after a major life stressor
  • Episode may end abruptly, likely to return
  • Less than 1% prevalence rate, more women diagnosed than men
  • Likely to meet criteria for other somatic symptom disorder, ½ meet criteria for dissociative disorder  Other common comorbid disorders: MDD, substance use disorders, personality disorders

Etiology (CD)

  • Psychodynamic perspectives:
    • Clear role of unconscious o Physical symptom is a response to an unconscious psychological conflict o Conversion disorder involving blindness might involve:

1) Unconscious processing of perceptual stimuli

2) Motivation to be symptomatic  Social and Cultural Factors:

    • Shape the symptoms *more common among people from rural areas and of lower SES
    • Modeling and social factors shape how conversion symptoms unfold

Etiology of Somatic Symptom-Related Disorders

  • Little evidence for heritability
  1. Neurobiological Factors that increase awareness and distress over somatic symptoms:
  • Focus is on brain regions activated by unpleasant body sensations *anterior insula and anterior cingulate cortex (ACC) o Have strong connections with the somatosensory cortex – involved in processing body sensations
  • Some people may have hyperactive brain regions that are involved in evaluating the unpleasantness of body sensations

Depression and anxiety related to increased activity in ACC and also related to increase in somatic symptoms & pain o Emotional pain can also activate the ACC and anterior insula

  • No support for genetic influence (concordance rates in MZ twins don’t differ from DZ twins) II. Cognitive Behavioural Factors that increase awareness and distress over somatic symptoms:
  • Focus on mechanisms that could contribute to the excessive focus on and anxiety over health concerns
  • Once a somatic symptom develops, 2 cognitive variables appear important:
    • Attention to body sensations & interpretation (attributions) of those sensations
  • Use version of emotion Stroop task – people with somatic symptom-related disorders had more difficulty ignoring words related to physical health
  • Believe symptoms are a sign of an underlying long-term disease  2 behavioural consequences:
    • Person may assume the role of being sick and avoid work, exercise and social tasks, these avoidant behaviours in turn can intensify symptoms by limiting other healthy behaviours
    • Person may seek reassurance from doctors and from family members, this help-seeking behaviour may be reinforced if it results in the person getting attention/sympathy
  • Psychodynamic Perspective
    • Unconscious psychological factor cause
    • Blindsight = not consciously aware of visual input (implicit component still often intact) o Failure to be explicitly aware of sensory information
  1. Social & Cultural Factors
    • Decrease in incidence of conversion disorder since last half of 19th century o Higher incidence may have been due to more repressed sexual attitudes or low tolerant for anxiety symptoms
    • More prevalent: in rural areas, in individuals of lower SES, in non-Western cultures

Treatment

  • Most people with these disorders usually want medical care, not mental health care
  • Most somatic and pain concerns have both physical and psychological components

Interventions in Primary Care

  • Teach primary care teams to tailor care for people with osmatic symptom-related disorders
  • Goal: to establish a strong doctor-patient relationship to bolster the patient’s sense of trust/comfort so the patient will feel more reassured about his/her health
  • Informing physicians when a patient appears to be an intensive user of health care services so they can minimize the use of diagnostic tests and medications

Cognitive Behavioural Treatment

1) Help people identify and change the emotions that trigger their somatic concerns

2) Help people change their cognitions regarding their somatic symptoms

3) Help people change their behaviours to stop playing the role of a sick person and to gain more reinforcement for engaging in other types of social interactions

  • Treating anxiety and depression will help reduce somatic symptoms *antidepressant: Tofranil = effective even at low dosages that do not alleviate depression symptoms
  • Psychoeducation programs help patients recognize links between negative moods and somatic symptoms
  • Train people to pay less attention to their body
  • Help people identify and challenge negative thoughts about their bodies
  • Help people resume healthy activities and build a lifestyle that has been damaged by too much focus on illness-related concerns

Family therapy to change patient’s reliance on playing the role of a sick person

CBT helps reduce distress about symptoms, less able to reduce the actual symptoms Internet based CBT not strong enough to reduce health anxiety

  • Mindfulness helps reduce health anxiety

Treatment for Somatic Symptom Disorder with Pain

  • Hypnosis helps reduce pain levels, influences brain regions involved in experiencing and interpreting pain
  • Acceptance and commitment therapy (ACT) – variant of CBT, the therapist encourages the client to adopt a more accepting attitude towards pain, suffering and moments of depression and anxiety, and to view these as a natural part of life o Coached not to struggle intensely to avoid these situations
  • Antidepressants can also be helpful (low doses can reduce pain)