{"id":4193,"date":"2018-09-18T17:15:54","date_gmt":"2018-09-18T21:15:54","guid":{"rendered":"https:\/\/www.amyork.ca\/academic\/zz\/?p=4193"},"modified":"2019-05-26T00:20:11","modified_gmt":"2019-05-26T04:20:11","slug":"dissociative-disorders-and-somatic-symptom-related-disorders","status":"publish","type":"post","link":"https:\/\/www.amyork.ca\/academic\/zz\/abnormal-psychology\/dissociative-disorders-and-somatic-symptom-related-disorders\/","title":{"rendered":"Dissociative Disorders and Somatic Symptom-Related Disorders"},"content":{"rendered":"<ul>\n<li>Dissociative<\/li>\n<\/ul>\n<p>\uf0e0 experience disruptions of consciousness, lose track of self-awareness, memory and identity<\/p>\n<ul>\n<li>Somatic symptom-related<\/li>\n<\/ul>\n<p>\uf0e0 complains of bodily symptoms that suggests a physical defect\/dysfunction *often no physiological basis can be found<\/p>\n<ul>\n<li>Both are related to stress, they both tend to be comorbid<\/li>\n<\/ul>\n<ol>\n<li><strong> Dissociative Disorders <\/strong><\/li>\n<\/ol>\n<ul>\n<li>1) Depersonalization\/derealization: alteration in the experience of the self and reality<\/li>\n<li>2) Dissociative amnesia: lack of conscious access to memory, typically of a stressful experience<\/li>\n<\/ul>\n<p>(7.5%) o The fugue subtype involves travelling or wandering coupled with loss of memory for one\u2019s identity or past<\/p>\n<ul>\n<li>3) Dissociative identity disorder (DID): at least 2 distinct personalities that act independently of each other (1-3%)<\/li>\n<li><strong>Dissociation<\/strong> is the core feature = involves some aspect of emotion, memory, or experience being inaccessible consciously<\/li>\n<li>Dissociation is an avoidance response that protects a person from consciously experiencing stressful events o Can also be result of sleep deprivation<\/li>\n<\/ul>\n<p>Memory<\/p>\n<ul>\n<li>Interference memory formation \u2013 not accessible to awareness later<\/li>\n<li>Memory deficits in EXPLICIT but not implicit memory (with dissociative disorder)\n<ul>\n<li><strong>Explicit memory<\/strong> = involves conscious recall of experiences (factual)<\/li>\n<li><strong>Implicit memory<\/strong> = underlies behaviours based on experiences that cannot be consciously recalled (e.g. playing tennis)<\/li>\n<\/ul>\n<\/li>\n<li>Distinguishing other causes of memory loss from dissociation:\n<ul>\n<li><strong>Dementia<\/strong> \u2013 memory fails slowly over time *not linked to stress (brain dysfunction)\n<ul>\n<li>Accompanied by other cognitive deficits (e.g. processing speed)<\/li>\n<li>Inability to learn\/code new information o Memory loss after brain injury o Substance abuse<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol>\n<li><strong>Depersonalization\/Derealization Disorder<\/strong> (DDD) DSM-5 Criteria:\n<ul>\n<li>= Involves a disconcerting and disruptive sense of detachment from one\u2019 self or surroundings<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<p>1) <strong>Depersonalization<\/strong> = sense of being detached from one\u2019s self &#8211; OR:<\/p>\n<p>2) <strong>Derealization<\/strong> = sense of detachment from one\u2019s surroundings, surroundings seem unreal o Outside their bodies, viewing themselves from a distance, looking at the world through fog o Feel mechanical, like robots<\/p>\n<p>3) Reality testing remains intact<\/p>\n<p>4) Symptoms are not explained by substances, another dissociative disorder, another psyc disorder, or by a medical condition<\/p>\n<ol>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Symptoms usually triggered by stress, no disturbance in memory or psychosis<\/li>\n<li>Usually begins in adolescence, abruptly or insidiously<\/li>\n<li>Symptoms often continually present for years<\/li>\n<li>Comorbid personality disorders are frequent, 90% experience anxiety and depression \uf0b7 Childhood trauma often reported<\/li>\n<li>Symptoms can co-occur with other disorders but cannot be entirely explained by them<\/li>\n<\/ul>\n<\/li>\n<li><strong>Dissociative Amnesia<\/strong>DSM-5 Criteria:\n<ul>\n<li>1) Inability to remember important autobiographical information, usually of a traumatic or stressful nature, that is too extensive to be of ordinary forgetfulness<\/li>\n<li>2) The amnesia is not explained by substances, or by other medical or psychological conditions<\/li>\n<li>3) Specify dissociative fugue subtype if the amnesia is associated with bewildered or apparently purposeful wandering<\/li>\n<li>Information is not permanently lost but cannot be retrieved during episode of amnesia (several hours \u2013 several years)<\/li>\n<li>Amnesia usually disappears as suddenly as it began<\/li>\n<li>Complete recovery and only small chance of reoccurrence<\/li>\n<li>Procedural memory remains intact<\/li>\n<li><strong>Fugue<\/strong> = memory loss is more extensive, the person typically disappears from home and work o May take on new name\/job\/personality *identity\n<ul>\n<li>Inability to recall one\u2019s past o Brief duration, remits spontaneously \uf0b7 Psychodynamic theory:<\/li>\n<li>Traumatic experiences are repressed *hippocampus is vulnerable to stress, memories are forgotten because they are so aversive<\/li>\n<\/ul>\n<\/li>\n<li>Cognitive: extreme stress usually enhances rather than impairs memory o Norepinephrine (associated with heightened arousal) enhances memory consolidation and retrieval<\/li>\n<li>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\n<ul>\n<li>Retain emotionally relevant information rather than neutral details<\/li>\n<\/ul>\n<\/li>\n<li>Perhaps extremely high levels of stress hormones interfere with memory formation <strong> Dissociative Identity Disorder <\/strong>(DID) *formerly Multiple Personality Disorder DSM-5 Criteria:<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<p>1) Disruption of identity characterized by 2 or more distinct personality states (alters) or an experience of possession<\/p>\n<p>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<\/p>\n<p>This disruption may be observed by others or reported by the patient<\/p>\n<p>2) Recurrent gaps in memory for events or important personal information that are beyond ordinary functioning<\/p>\n<p>3) Symptoms are not part of a broadly accepted cultural or religious practice<\/p>\n<p>4) Symptoms are not due to drugs or a medical condition<\/p>\n<p>5) In children, symptoms are not better explained by an imaginary playmate or by fantasy play<\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Each alter determine the person\u2019s nature and activities when it is in command<\/li>\n<li>Primary alter may not be aware that any other alter exists *it is the primary alter than usually seeks treatment<\/li>\n<li>Most often 2-4 alters are identified when diagnosed<\/li>\n<li>Personalities of alters are quite different from one another<\/li>\n<li>Rarely diagnosed until adulthood, can recall symptoms dating back to childhood<\/li>\n<li>More severe and extensive than other dissociative disorders *less complete recovery<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>More common in women than in men<\/p>\n<p>Other diagnoses are often present: PTSD, MDD, somatic symptom disorders, personality disorders No thought disorder or behavioural disorganization<\/p>\n<ul>\n<li>Accompanied by other symptoms: headaches, hallucinations, suicide attempts, self-injurious behaviour, amnesia, depersonalization<\/li>\n<\/ul>\n<p>Epidemiology: Increases over time<\/p>\n<ul>\n<li>Almost no reports of DID or dissociative amnesia before 1800<\/li>\n<li>1-3% prevalence estimate<\/li>\n<li>Heightened professional media attention may had led some therapists to suggest strongly to clients that they had DID<\/li>\n<li>Sometimes use hypnosis to probe for alters<\/li>\n<li>Diagnosis criteria was more explicit in DSM-III<\/li>\n<li>Appearance of DID in pop culture (Sybil, 3 faces of eve)<\/li>\n<\/ul>\n<p>Etiology<\/p>\n<ul>\n<li>Almost all patients in therapy report severe childhood abuse \uf0b7 Posttraumatic Model:\n<ul>\n<li>Some people are particularly likely to use dissociation to cope with trauma o Children who are abused are at risk for developing dissociative symptoms<\/li>\n<li>Evidence that children who dissociate are more likely to develop psychological symptoms after trauma<\/li>\n<\/ul>\n<\/li>\n<li>Sociocognitive Model:\n<ul>\n<li>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<\/li>\n<li><strong>Iatrogenic<\/strong> = created within treatment \uf0e0 the person learns to role-play these symptoms within treatment<\/li>\n<\/ul>\n<\/li>\n<li>DID symptoms can be role-played:\n<ul>\n<li>Usually under hypnosis<\/li>\n<\/ul>\n<\/li>\n<li>Alters share memories, even when they report amnesia:\n<ul>\n<li>Defining feature: inability to recall information experienced by one alter when a different alter is present<\/li>\n<li>Implicit memory seems to be intact and shared<\/li>\n<\/ul>\n<\/li>\n<li>Symptoms may only emerge after therapy begins<\/li>\n<\/ul>\n<p>Treatment<\/p>\n<ul>\n<li>Important to have an empathic, gentle stance<\/li>\n<li>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<\/li>\n<li>Teach more effective ways of coping with stress *emotional regulation strategies<\/li>\n<li>Psychoeducation \u2013 help understand why dissociation occurs, identify triggers<\/li>\n<li>Psychodynamic treatment \u2013 goal to overcome repressions o Use hypnosis to help client gain access to repressed material\n<ul>\n<li><strong>Age regression<\/strong> = encourage client to go back in his\/her mind to traumatic events in childhood<\/li>\n<li>Help realize that childhood threats are no longer present o Can possibly worsen DID symptoms<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Often comorbid with anxiety and depression, use antidepressants to lessen *have no effect on DID itself<\/p>\n<ol start=\"2\">\n<li><strong> Somatic Symptom and Related Disorders <\/strong>(previously known as somatoform disorders)<\/li>\n<\/ol>\n<p>1) <strong>Somatic symptom disorder<\/strong>: excessive thought, distress, and behaviour related to somatic symptoms<\/p>\n<p>2) <strong>Illness anxiety disorder<\/strong>: unwarranted fears about a serious illness in the absence of any significant somatic symptoms<\/p>\n<p>3) <strong>Conversion disorder<\/strong>: neurological symptoms that cannot be explained by medical disease or culturally sanctioned behaviour<\/p>\n<p>4) <strong>Malingering<\/strong>: intentionally faking psychological or somatic symptoms to gain from those symptoms<\/p>\n<p>5) <strong>Factitious disorder<\/strong>: falsification of psychological or physical symptoms, without evidence of gains from those symptoms<\/p>\n<p>Defined by excessive concerns about physical symptoms or health<\/p>\n<ul>\n<li><strong>Hypochondriasis<\/strong> = chronic worries about developing a serious medical illness **not a DSM-5 diagnosis<\/li>\n<li>Seek frequent medical treatment, hospitalizations and surgery are common<\/li>\n<li>Conditions are remarkably varied<\/li>\n<li>Health concerns are cause of excessive anxiety or involve too much expenditure of time and energy *very subjective criteria<\/li>\n<li>Diagnosis of these disorders often is found to be stigmatizing<\/li>\n<li>New to DSM-5: somatic symptom disorder does not have to be medically unexplained<\/li>\n<li>Tend to develop in early adulthood, wax and wane over time, recovery can occur naturally<\/li>\n<li>Tend to co-occur with anxiety disorders, mood disorder, substance use disorders &amp; personality disorders<\/li>\n<li>More common in women than in men<\/li>\n<\/ul>\n<ol>\n<li><strong> Somatic Symptom Disorder<\/strong> (SSD)<\/li>\n<\/ol>\n<p>DSM-5 Criteria<\/p>\n<p>1) At least one somatic symptom that is distressing or disrupts daily life<\/p>\n<p>2) Excessive thought, distress and behaviour related to somatic symptoms or health concerns, as indicated by at least one of the following:<\/p>\n<p>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<\/p>\n<p>3) Specify if predominant pain<\/p>\n<ul>\n<li>Diagnosed regardless of whether symptoms can be explained medically<\/li>\n<li>DSM-5 label \u201cPsychological Factors Affecting Other Medical Conditions\u201d used when psychological factors are the cause of symptoms<\/li>\n<li>May begin\/intensify after some conflict or stress<\/li>\n<li>Might seem that the person is using the symptom to avoid some unpleasant activity or to get attention\/sympathy<\/li>\n<li>Experience symptoms as completely physical<\/li>\n<li>3x as common as illness anxiety disorder <strong> Illness Anxiety Disorder <\/strong>(IAD) DSM-5 Criteria:<\/li>\n<\/ul>\n<p>1) Preoccupation with and high level of anxiety about having or acquiring a serious disease<\/p>\n<p>2) Excessive illness behaviour (e.g. checking for signs of illness, seeking reassurance) or maladaptive avoidance (avoiding medical care)<\/p>\n<p>3) No more than mild somatic symptoms are present<\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Not explained by other psychological disorders<\/li>\n<li>Preoccupation lasts at least 6 months<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Often co-occurs with anxiety and mood disorders<\/p>\n<p><strong>III. Conversion Disorder<\/strong> (CD) DSM-5 Criteria:<\/p>\n<p>1) One or more symptoms affecting voluntary motor or sensory function<\/p>\n<p>2) The symptoms are incompatible with recognized medical disorder<\/p>\n<p>3) Symptoms cause significant distress or functional impairment or warrant medical evaluation<\/p>\n<ul>\n<li>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)<\/li>\n<li>May become partially\/completely blind, tunnel vision<\/li>\n<li><strong>Aphonia<\/strong> = loss of the voice other than whispered speech<\/li>\n<li>Many do not connect medical symptoms with stressful situations<\/li>\n<li><strong>Hysteria<\/strong> = 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<\/li>\n<\/ul>\n<p>\uf0a7 Originally known as hysteria (Greek word for uterus) o Symbolized the longing of the women\u2019s body for a child<\/p>\n<ul>\n<li>Conversion originated from Freud, thought anxiety and psyc conflict were converted into physical symptoms (Anna O)<\/li>\n<li>Genuinely physical problems are misdiagnosed as conversion disorder 4% of the time<\/li>\n<li>Symptoms usually develop in adolescence or early adulthood, typically after a major life stressor<\/li>\n<li>Episode may end abruptly, likely to return<\/li>\n<li>Less than 1% prevalence rate, more women diagnosed than men<\/li>\n<li>Likely to meet criteria for other somatic symptom disorder, \u00bd meet criteria for dissociative disorder \uf0b7 Other common comorbid disorders: MDD, substance use disorders, personality disorders<\/li>\n<\/ul>\n<p>Etiology (CD)<\/p>\n<ul>\n<li>Psychodynamic perspectives:\n<ul>\n<li>Clear role of unconscious o Physical symptom is a response to an unconscious psychological conflict o Conversion disorder involving blindness might involve:<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>1) Unconscious processing of perceptual stimuli<\/p>\n<p>2) Motivation to be symptomatic \uf0b7 Social and Cultural Factors:<\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li>Shape the symptoms *more common among people from rural areas and of lower SES<\/li>\n<li>Modeling and social factors shape how conversion symptoms unfold<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong>Etiology of Somatic Symptom-Related Disorders<\/strong><\/p>\n<ul>\n<li>Little evidence for heritability<\/li>\n<\/ul>\n<ol>\n<li>Neurobiological Factors that increase awareness and distress over somatic symptoms:<\/li>\n<\/ol>\n<ul>\n<li>Focus is on brain regions activated by unpleasant body sensations *<strong>anterior insula<\/strong> and <strong>anterior cingulate<\/strong> <strong>cortex<\/strong> (ACC) o Have strong connections with the somatosensory cortex \u2013 involved in processing body sensations<\/li>\n<li>Some people may have hyperactive brain regions that are involved in evaluating the unpleasantness of body sensations<\/li>\n<\/ul>\n<p>Depression and anxiety related to increased activity in ACC and also related to increase in somatic symptoms &amp; pain o Emotional pain can also activate the ACC and anterior insula<\/p>\n<ul>\n<li>No support for genetic influence (concordance rates in MZ twins don\u2019t differ from DZ twins) II. Cognitive Behavioural Factors that increase awareness and distress over somatic symptoms:<\/li>\n<li>Focus on mechanisms that could contribute to the excessive focus on and anxiety over health concerns<\/li>\n<li>Once a somatic symptom develops, 2 cognitive variables appear important:\n<ul>\n<li>Attention to body sensations &amp; interpretation (attributions) of those sensations<\/li>\n<\/ul>\n<\/li>\n<li>Use version of emotion Stroop task \u2013 people with somatic symptom-related disorders had more difficulty ignoring words related to physical health<\/li>\n<li>Believe symptoms are a sign of an underlying long-term disease \uf0b7 2 behavioural consequences:\n<ul>\n<li>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<\/li>\n<li>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<\/li>\n<\/ul>\n<\/li>\n<li>Psychodynamic Perspective\n<ul>\n<li>Unconscious psychological factor cause<\/li>\n<li><strong>Blindsight<\/strong> = not consciously aware of visual input (implicit component still often intact) o Failure to be explicitly aware of sensory information<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol>\n<li>Social &amp; Cultural Factors\n<ul>\n<li>Decrease in incidence of conversion disorder since last half of 19<sup>th<\/sup> century o Higher incidence may have been due to more repressed sexual attitudes or low tolerant for anxiety symptoms<\/li>\n<li>More prevalent: in rural areas, in individuals of lower SES, in non-Western cultures<\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<p><strong>Treatment<\/strong><\/p>\n<ul>\n<li>Most people with these disorders usually want medical care, not mental health care<\/li>\n<li>Most somatic and pain concerns have both physical and psychological components<\/li>\n<\/ul>\n<p>Interventions in Primary Care<\/p>\n<ul>\n<li>Teach primary care teams to tailor care for people with osmatic symptom-related disorders<\/li>\n<li>Goal: to establish a strong doctor-patient relationship to bolster the patient\u2019s sense of trust\/comfort so the patient will feel more reassured about his\/her health<\/li>\n<li>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<\/li>\n<\/ul>\n<p>Cognitive Behavioural Treatment<\/p>\n<p>1) Help people identify and change the emotions that trigger their somatic concerns<\/p>\n<p>2) Help people change their cognitions regarding their somatic symptoms<\/p>\n<p>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<\/p>\n<ul>\n<li>Treating anxiety and depression will help reduce somatic symptoms *antidepressant: <strong>Tofranil<\/strong> = effective even at low dosages that do not alleviate depression symptoms<\/li>\n<li>Psychoeducation programs help patients recognize links between negative moods and somatic symptoms<\/li>\n<li>Train people to pay less attention to their body<\/li>\n<li>Help people identify and challenge negative thoughts about their bodies<\/li>\n<li>Help people resume healthy activities and build a lifestyle that has been damaged by too much focus on illness-related concerns<\/li>\n<\/ul>\n<p>Family therapy to change patient\u2019s reliance on playing the role of a sick person<\/p>\n<p>CBT helps reduce distress about symptoms, less able to reduce the actual symptoms Internet based CBT not strong enough to reduce health anxiety<\/p>\n<ul>\n<li>Mindfulness helps reduce health anxiety<\/li>\n<\/ul>\n<p>Treatment for Somatic Symptom Disorder with Pain<\/p>\n<ul>\n<li>Hypnosis helps reduce pain levels, influences brain regions involved in experiencing and interpreting pain<\/li>\n<li><strong>Acceptance and commitment therapy<\/strong> (ACT) \u2013 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<\/li>\n<li>Antidepressants can also be helpful (low doses can reduce pain)<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>Dissociative \uf0e0 experience disruptions of consciousness, lose track of self-awareness, memory and identity Somatic symptom-related \uf0e0 complains of bodily symptoms that suggests a physical defect\/dysfunction *often no physiological basis&hellip; <a class=\"continue\" href=\"https:\/\/www.amyork.ca\/academic\/zz\/abnormal-psychology\/dissociative-disorders-and-somatic-symptom-related-disorders\/\">Continue Reading<span> Dissociative Disorders and Somatic Symptom-Related Disorders<\/span><\/a><\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[104],"tags":[],"_links":{"self":[{"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/posts\/4193"}],"collection":[{"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/comments?post=4193"}],"version-history":[{"count":2,"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/posts\/4193\/revisions"}],"predecessor-version":[{"id":4904,"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/posts\/4193\/revisions\/4904"}],"wp:attachment":[{"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/media?parent=4193"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/categories?post=4193"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.amyork.ca\/academic\/zz\/wp-json\/wp\/v2\/tags?post=4193"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}