Lecture 10: Somatic Symptom and Dissociative Disorder

DSM-IV to DSM-5 Changes - Dissociative Disorders

• Dissociative Fique was removed in DSM-5

• Depersonalisation and Derealisation Disorder were separate in DSM-IV and combined in DSM-5

Dissociative Identity Disorder (DID): DSM-5 Criteria

A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The disturbance is not a normal part of a broadly accepted cultural or religious practice.

E. The symptoms are not attributable to the physiological effects of substance (e.g., blackouts or chaotic behaviour during alcohol intoxication) or another medical condition (e.g., complex partial seizures)

DID Controversies

1. Most cases are diagnosed by a small number of ‘ardent’ clinicians and there are low case numbers

2. They rarely occur outside of USA & Canada

   • this is unusual for this type of psychopathology as we would typically expect that disorders would not be geographically bound in this way

3. The frequency of dissociative disorders (DID in particular) increased rapidly after release of book

4. The no. identities that are being reported has grown rapidly

5. Symptoms of DDs are more extreme than those found in measures of dissociation

6. Is DID real or faked? And if it is real, can it still be faked?

   1. Faking might happen through Iatrogenesis (clinicians suggesting treatment or diagnosis but causing more harm to the individual - therapist unwittingly shift or shapes the narrative

DID in Queensland

• A study conducted in Queensland on DID aimed to characterise the history of 62 people with DID

• Results and conclusions:

  • DID was found in inpatient and outpatient settings in Brisbane

  • Dissociation was viewed as a component of a ‘complex syndrome associated with a history of severe ongoing developmental trauma from early childhood’

  • DID is being underdiagnosed and should change as people with DID not only experience different personalities but spouses of people with undiagnosed DID notice and describe these distinct personality states or report unusual behaviours

    • Because of this people with DID are at high risk of being misdiagnosed
      

DID Etiology - Theories

• biological correlates are not widely documented

• Historically dominant model that explains dissociation disorders are based on trauma theory which suggests that DID is a response to early childhood trauma

  • it is a means of coping with an overwhelming experience of hopelessness and powerlessness arising in face of repeated abuse - supported by high rates of childhood trauma in DID

• Diathesis-stress variant: is another theory which suggests that a proneness to fantasy (diathesis) and trauma exposure (stress) can lead to dissociative disorders

• Socio-cognitive theory: suggests DID occurs when a highly suggestible person learns to adopt and enact multiple identities, mostly because this has been suggested (cued), legitimised and reinforced by the therapist, the enacted identities serve a client’s personal goal → not a deliberative act by client but a result of ideas beeing seeded and accepted by client

  • supported by a hypnotisable person expressing a second identity when instructed to do so, and when hypnotised, the disorder timeline emerges after entering therapy

• Trauma-model supporters have put the view that DID could be better understood
  as a form of PTSD - due to symptom overlap; also, high comorbidity of DID &
  PTSD.

• A current perspective is that trauma is important in DID as are other factors
  including suggestive media, fantasy-proneness, sleep disturbances, and
  “problematic psychotherapeutic techniques” etc.

DID Treatments

• Poorly evaluated at this time - no systematic or controlled research

• However, the ultimate goal in treating DID (assuming trauma-based etiology), is the integration of the identities or partial fusion and cooperative arrangement among the alters

  • Can possibly be achieved by uncovering the trauma about which the person might not even be aware of, through psychodynamic and insight-oritented approaches, and using this information to educate and support ‘reintegration’

• Without the trauma-lense, the approach might emphasise adaptive coping for trauma/stress exposures

• Successful treatment may need to be long term e.g., for years, and for severe illness, even longer

Somatic Symptom Disorders (SSDs)

Essential features of SSDs

• physical symptoms in the absence of medical cause that are psychologically distressing/impairing - experienced as bodily and real

• associated with numerous, evolving, and non-specific complaints such as chronic pain, upset stomach, dizziness

• a key distinction of SSDs and other psychopathologies are the physical symptoms in SSDs and its association with ‘abnormal’ psychology

• In the DSM-5 there are the following disorders under SSDs:

  • Somatic symptom disorder

  • Conversion Disorder (formerly in DDs)

  • Psychological factors affecting other medical conditions

  • Factitious Disorder

Conversion Disorder (Functional Neurological Symptom Disorder): Diagnostic Criteria

A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

C. The symptom or deficit is not better explained by another medical or mental disorder.

D.The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Prevalence of SSDs

• Actual prevalence unknown, but typically considered

• Relatively rare in the general population (<1%)

• More common among women (~3Xtimes) than men, and in people w
  lower SES/education

• With onset in adolescence or early adulthood

• More common in medical /neurological settings than mental health
  settings (estimated that 5% of “neurology” patients have CD”).

• Comorbidities:

  • Depression, anxiety, antisocial personality disorder

Theorised causes of SSDs

• Aetiology is under-researched however some possibilities include:

  • Biological: a missed organic explanatation for the symptoms - mimicking of medical conditions warrant careful medical testing to rule out a medical cause

  • Psychological:

    • underlying trauma or identity issues

    • Difficulty with emotional/psychological expression

    • Primary and secondary gain

    • Cognitive tendencies

    • Responses to ‘stressor’ exposure

Psychological treatments for SSDs

Limited evaluation, but some examples:

• If symptoms incl. pain, operant (behavioural) approaches might be tried
  (e.g., rewarding successful coping and adaptation)

• Changing the cognitive overlay/interpretation/meaning of symptoms (e.g.,
  cognitive behavioural therapy; cognitive restructuring)

• Interpersonal psychotherapy (addressing presumed underlying
  trauma/psychological conflict/identity reintegration – historically, “cathartic”
  therapies for CD –promoting emotional expression/recognition