LECTURE NOTES 5 : Dissociative and Somatoform Disorders

Dissociative Disorders

Is when individuals feel detached from themselves and their surroundings, almost as if they were dreaming or living in slow motion. The person cannot integrate consciousness, memory, and personal identity

1. The experience is usually characterized by derealization and or depersonalization Derealization is where your sense of the reality of the external world is lost. With Depersonalization it is often accompanied by a serious set of conditions, where reality, experience, and, even one's identity disintegrates.
2. Dissociation in general is not being able to remember personal experiences, becoming confused about an identity or acting as if they had a new identity. They feel like objects around them are not real, and emotionally feeling like they are watching a movie.

Types of Dissociative Disorders-some selected types

Depersonalization Disorder - very rare

These experience may be part of many different disorders with derealization and depersonalization- examples would be a panic disorder or acute stress disorder. Also found to exist with depression and schizophrenia

1. This disorder includes both derealzation and depersonalization.
2. The person feels like they are a robot or in a movie- the person feels like they are cut off from their body as if they are operating mechanically.
3. Movement and speech not within their control
4. The diagnosis may be in error taken for very brief periods of depersonalization, therefor it must be severe with or without trauma and persistent enough to disrupt the persons life to be considered a disorder.
5. The person is unable to match current experience with past experiences or may experience a deja vu or the opposite- have been their before - or- it may seem totally new and strange.
6. People afflicted will not lose touch with reality and actually understand the experience is happening and that their perceptions are wrong but feel that they are going insane

Dissociative Amnesia

Easiest to understand among the severe dissociative disorders because it is closely linked with people who are unable to remember anything, including who they are called a generalized amnesia - It may be caused by a blow to the head or a number of brain disorders.

1. far more common than general amnesia is localized or selective amnesia - a failure to recall specific events, usually traumatic, that occur during a specific period of time.
2. Is very common during wartime
3. In most cases the dissociative amnesia, is forgetting very selective traumatic events or memories rather than generalized.
4. Is distinguishable from an organic amnesia in that the events or memory is recovered under hypnosis or sodium amytal( a barbiturate).
5. usually does not happen before adolescence or in adulthood

Dissociative fugue

Is related to amnesia only the fugue literally means "flight" like fugitive.

1. In this case the memory loss revolves around a specific incident- an unexpected trip (or trips ).
2. Typically people just take off, and later find themselves in a new place, unable to remember why or how they got there
3. Also happens in adolescence or adulthood and even more likely near the age of 50 and above.
4. Occurs twice as often in men than women.
5. Those afflicted usually recover quickly and abruptly, and recurrence is rare.

Dissociative Identity Disorder ( DID )- includes both amnesia and dissociative fugue - Formerly Multiple Personality Disorder

1. Those afflicted may adopt as many as 100 new identities, all simultaneously coexisting inside one body and mind.
2. In some cases the identities are complete, each with its own behavior, tone of voice, and physical gestures- but in may cases their identities are partially complete not independent.
3. Similar to multiple personality disorder but may be slightly different when the identities are fragmented and that only certain aspects of the person's identity are dissociative.- However for most purposes DID and Multiple personality Disorder are the same
4. Some interesting biological evidence of the disorder include;
   1. alter (other identity) are right handed, while the host(true identity) are left handed
   2. Some alters need glasses, and host does not
   3. Host is color blind, with alter seeing colors.
      1. When seeking treatment the host will initiate and quickly disappear. Host reappears later
         1. examples are famous cases- The Three Faces of Eve, Sybil
         2. Male and female alter personalities may exist within one individual
         3. Common characteristic is switching - process of changing from one personality to another- usually stimulated by anxiety, and flashbacks of prior traumas.

   Statistics on DID

   1. average number of personalities is close to 15.
   2. Ratio of females to males is 9 to 1.

Additional Statistics:

1. Onset almost always in childhood, often as young as 4 years of age, but rarely identified before the age of 7.
2. Last a lifetime if not treated
3. Prevalence estimated between 1 and 6% depending on who quoted the study.
4. Confusing disorder because the patents with DID often have differentially developed other disorders with it such as substance abuse, depression, somatisization disorders, borderline personalities, panic attacks, and eating disorders.

Causes and treatment of Dissociative Disorders

MAJOR ISSUES WITH DISSOCIATIVE DISORDERS IS THE QUESTION OF SUGGESTIBILITY AND POSSIBILITY OF FALSE MEMORY SYNDROME.

1. many conflicting studies exist concerning the evidence as to whether early trauma can be repressed and recovered correctly.
2. More likely dissociative amnesia can occur with preschoolers in terms of traumatic events although the findings are inconclusive.
3. Are people who are more vulnerable to suggestion likely candidates for dissociative disorders and amnesia? A) If abused during childhood are they more apt to have active fantasy lives B) believing in these active fantasies or factitious events makes it more real with repetition.
4. Dissociative persons are higher on measures of hypnotic sensitivity.

Most Recent Findings on Causes of DID

1. Linked to childhood abuse
2. Sexual abuse particularly incest, most commonly reported
3. Ritualistic , repetitive, and sadistic and lurid abuse.

Conversion Disorder

In this disorder a psychosocial conflict or need is converted into dramatic physical symptoms that affect motor or sensory functioning.

Symptoms often seem neurological: paralysis, blindness, or a loss of feeling, or difficulty speaking without any physical or organic pathology.

These symptoms can actually mimic the full neurological malfunctioning.

Some closely related disorders to Conversion are Malingering( faking)

Which must be substantiated usually where no stressful events precipitated the impairment or a Factitious Disorder which are feigned or under voluntary control for no reason other than assuming a sick role for increased attention.- This factitious disorder can also be categorized as a factitious disorder by proxy or Munchausen's syndrome by proxy

Prevalence and Causes of Conversion

1. Prevalence
   1. begins in late childhood and early adulthood
   2. twice as often in women
   3. Conversion is not uncommon in men during military combat however.
   4. The conversion reactions in religious or fundamentalist rituals do not constitute the conversion disorder
2. Causes of Conversion
   1. Freud described 4 basic processes of conversion;
      1. Individual experiences a traumatic event- unacceptable unconscious conflict.
      2. The conflict is then repressed
      3. Since the conflict reappears increasing the anxiety the "conversion" occurs into the form of physical symptoms relieving the pressure having to deal with the conflict.
      4. The individual receives increased attention and sympathy from loved ones and may also be allowed to avoid a difficult situation or task. Thus reinforcing a secondary gain

Treatment of Conversion

Treatment similar to somatization disorders

1. Attend to the stressful life event, if still present and remove the sources of secondary gain.
2. Removing the stress is done by assisting the patient " reliving " or reexperiencing the event.
3. Remove reinforcers or supportive consequences.
4. Pain disorder

Little is known about this disorder where psychosocial factors play a central role in the onset, severity, or continuation of pain.

In this disorder a physical reasons for pain may have initially existed, but psychological factors play a role in maintaining it.

An important feature of the disorder is that pain does exist and it hurts, regardless of the cause.

Body Dysmorphic Disorder

Is where a person is preoccupied with some imagined defect in appearance who actually looks reasonably normal.

The disorder has been referred to as imagined ugliness

1. Is so all consuming the person avoids social contact
2. They repeatedly checking look at body part in mirror or avoids mirrors at all cost.
3. Spends hours each day in self devised remedies to correct the problem.
4. Sometimes difficult to separate from delusional disorder; somatic type

Prevalence Cause and treatment of body dysmorphic disorder

By its very nature it tends to be kept secret making it difficult to estimate.

1. unfortunately tends to run a lifelong course
2. found common in mild forms among 70% of college students. With close to 28% meeting all criteria for the disorder.
3. only slightly more females than males affected in the U.S.
4. few people with the disorder get married and peak during adolescence.
5. little is known about etiology or treatment except that there is comorbidity - with other disorders such as OCD - intrusive thoughts about one's appearance being ugly or disfigured
6. some relief has been reported with serotonum reuptake inhibitors(antidepressants such as clomipramine(Anafranil).
7. Some success also with cognitive behavior therapy as with OCD.- exposure and response prevention.
8. Plastic surgery has also been successful when it is the head or facial areas-
9. Michael Jackson possible candidate- but most body dysmorphic patients are not really satisfied with the results.