Dissociative disorders and somatic symptoms and related

Dissociative Identity Disorder

• In which a person has two or more distinct or alternate personalities, that may or may not be aware of each other.

• recurrent gaps in memory

• 90% report early neglect and childhood abuse

Controversies of DID

Surveys in Canada and the United States reveal that many mental health professionals are skeptical of the validity of the concept of dissociative identity disorder

Role playing model of DID

Accustomed to playing games of “make believe,” they may readily adopt alternate identities—especially if they learn how to enact the multiple personality role and there are external sources of validation such as a clinician’s interest and concern.

Risk factors for DID

Ninety percent of cases in Canada, the United States and Europe report histories of physical and sexual abuse, and over 70% have attempted suicide

Alternate personalities variations:

• shifting sexual orientations

• sometimes 2 personalities vie for control

• represent different genders

• age

• interests

• memories

Dissociative amnesia

• type of dissociative disorder where in which a person experiences memory losses in the absence of any identifiable organic cause.

• General knowledge and skills are usually retained.

• with or without dissociative fugue

Recall of memories in dissociative amnesia

• Recall of dissociated memories may happen gradually but often occurs suddenly and spontaneously

• Although it may last for days, weeks, or even years to recover

types of dissociative amnesia

localized amnesia, systemized amnesia and generalized amnesia

Systemized amnesia

loss of recall for category of information

selective/localized amnesia

people forget only the disturbing particulars that take place during a certain time period.

generalized amnesia

• people forget their entire lives—who they are, what they do, where they live, and with whom they live

• They tend to retain their habits, tastes, and skills.

Debate between dissociative amnesia and brain injury

Some researchers argue that true dissociative amnesia is very rare, and many cases may actually be caused by brain injury or disease rather than psychological factors.

Malingering

faking illness to avoid or escape work or other duties, or to obtain benefits

depersonalization

• feelings of unreality or detachment from one’s self or one’s body, as if one were a robot or functioning on automatic pilot or observing oneself from outside

derealization

• loss of the sense of reality of one’s surroundings, experienced in terms of strange changes in one’s environment.

• It often involves perceiving the world as dreamlike or distorted, leading to feelings of detachment from reality.

depersonalization/ derealization disorder

disorder characterized by persistent or recurrent episodes of depersonalization

• During these experiences, reality testing remains intact

• 1/3 discrete episodes, 1/3 continuous,1/3 discrete becomes continuous

• Most people will experience an episode lasting hours to days, particularly when stressed – needs to be more persistent/problematic for diagnosis

Psychodynamic explanations for dissociative amnesia

the ego protects itself from becoming flooded with anxiety by blotting out disturbing memories or by dissociating threatening impulses of a sexual or aggressive nature.

Psychodynamic explanations for dissociative identity disorder

people may express these unacceptable impulses through the development of alternate personalities.

Psychodynamic explanations for depersonalization

Dissociative disorders result from intense repression – individual ”splits off” from consciousness unacceptable impulses and painful memories

• Protects first identify from distress

• May allow unacceptable impulses to be expressed

Learning and cognitive theory- explanations for dissociative disorders

• Learning and cognitive theorists view dissociation as a learned response that involves not thinking about disturbing acts or thoughts to avoid feelings of guilt and shame evoked by such experiences.

Diathesis-stress model and dissociative disorders

These personality traits themselves do not lead to dissociative disorders, but they might increase the risk that people who experience severe trauma will develop dissociative phenomena as a survival mechanism.

Biological approaches to dissociative disorders

Biological approaches focus on the use of drugs to treat the anxiety and depression often associated with the disorder, but drugs have not been able to bring about reintegration of the personality.

Research suggests that the childhood experience most strongly associated with the development of dissociative identity disorder is

sexual/or physical abuse

somatic symptom and related disorder

Disorders in which people complain of physical (somatic problems although no physical abnormality can be found

Functional neurological symptom disorder (conversion disorder)

A disorder characterized by symptoms or deficits that affect the ability to control voluntary movements or that impair sensory functions and that are inconsistent or incompatible with known medical conditions or diseases

illness anxiety disorder

A disorder characterized by a preoccupation with the fear of having or the belief that one has a serious medical illness, but no medical basis for the complaints can be found

subtypes of illness anxiety disorder

1. care-avoidant subtype

2. care-seeking subtype

illness anxiety disorder: care-avoidant subtype

applies to people who postpone or avoid medical visits or lab tests because of high levels of anxiety about what might be discovered

illness anxiety disorder: care-seeking subtype

describes people who go doctor shopping, basically jumping from doctor to doctor in the hope of finding the one medical professional who might confirm their worst fears.

Somatic symptom disorder

A disorder involving one or more somatic symptoms that cause excessive concern to the extent that it affects the individual’s thoughts, feelings, and behaviours in daily life

diagnosis of somatic symptom

• requires that physical symptoms be persistent, lasting typically for a period of six months or longer (though any one symptom may not be continuously present),

• they are associated with either significant personal distress or interference with daily functioning.

Factitious disorder

Type of psychological disorder characterized by the intentional fabrication of psychological physical symptoms for no apparent gain

The two major subtypes of factitious disorder

1. factitious disorder on self

2. factitious disorder imposed on another

Factitious disorder on self (Munchausen syndrome)

• The syndrome is a form of feigned illness in which the person either fakes being ill or makes him- or herself ill (e.g., by ingesting toxic substances such as rat poison or injecting themselves with bacteria).

• no obvious gain, apart from assuming the role of a medical patient and receiving sympathy and support from others.

Factitious disorder imposed on another (Munchausen by proxy syndrome)

Often involves a parent who feigns or induces illness in a child (Ayoub, 2006). For example, the parent may attempt to poison the child in order for the child (and, by proxy, the parent) to receive medical attention.

Why do patients with factitious disorder feign illness

This syndrome represents an extreme need for nurturance or attention (Slovenko, 2006), although the underlying reasons for this need are unclear.

Learning theory and somatic disorder

• People with these disorders may be relieved of chores and responsibilities such as going to work or performing household tasks. Being sick also usually earns sympathy and support.

• People who received such reinforcers during past illnesses are likely to learn to adopt a sick role even when they are not ill.

cognitive theory on somatic disorder

• They misinterpret relatively minor physical complaints as signs of a serious illness, creating anxiety and leading them to chase down one doctor after another in an attempt to uncover the dreaded disease they fear they have.

• The anxiety itself may lead to unpleasant physical symptoms, which are likewise exaggerated in importance, leading to more worrisome thoughts.

dissociative fugue

travelling purposefully or wandering related to dissociative amnesia

is dissociative amnesia due to substance use, neurological or medical condition?

False

Behavioural explanation for DID

DID may arise from social learning/ reinforcement – individual observes certain roles than integrates them into personality

Treatment for Dissociative disorder

Typically use psychodynamic therapy while integrating other approaches (e.g., CBT, hypnosis). Medication may help with comorbidities.

• Research support for effective therapies is weak

• Difficulties with treatment and research = long treatment duration, eclectic approaches (mixing therapies), frequent comorbidities, rareness of disorder

conversion disorder symptoms

• conversion symptoms mimic neurological or general medical conditions involving problems with voluntary motor (movement) or sensory functions.

• paralysis, epilepsy, problems in coordination, blindness and tunnel vision, loss of the sense of hearing or of smell, or loss of feeling in a limb (anaesthesia)

Conversion disorder

• one or more altered voluntary motor or sensory functions

• not explained by other diagnosis

• causes functional impairment

Psychodynamic theory-somatic symptom

When ego protects conscious from id’s unacceptable impulses through defense mechanisms, some anxiety may be converted into physical symptoms.

• Primary gains: keep internal conflicts repressed

• Secondary gains: avoid further dangers

CBT- somatic symptom disorders

• Sick role is reinforced, the person “learns” to adopt sick role even when not ill

• Distorted thinking such as tendency to catastrophize/misinterpret bodily symptoms

→ illness anxiety disorder (or panic disorder)

Treatments somatic symptom disorder

Many respond well to treatment.

• Psychodynamic therapy – as unconscious conflicts become conscious, physical symptoms may resolve

• CBT – change reinforcement (have client and family member reduce secondary gains). Learn adaptive ways to cope with physical symptoms, anxiety, and unhelpful thoughts.

• SSRIs for illness anxiety disorder and somatic symptom disorder

• Factitious disorder difficult to treat; poor prognosis