Transcript What is Dissociation? - University of Delaware

Somatoform and
Dissociative Disorders
Somatoform Disorders
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Concerns with appearance or functioning of body
Absence of medical condition
Hypochondriasis
Somatization Disorder
Conversion Disorder
Pain Disorder
Body Dysmorphic Disorder
Hypochondriasis
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Anxiety over belief one has a disease,
without evident cause
Reassurance from doctors no help, in the
long-term
Misinterpretation of bodily signals as disease
Disorder realized after physician visits
Hypochondriasis - Statistics
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Little information
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Prevalence estimate 3%
Equal in men and
women, age groups
Causes of Hypochondriasis
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Faulty thoughts/interpretation of physical
signs (cognition)
Enhanced sensitivity to illness cues
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Increased awareness and fright
Family/genetic influences
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Might be unspecific anxiety
Children report symptoms of parents
Causes of Hypochrondriasis
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Context of stressful life events - often
involving death or illness
Disproportionate incidence of disease in
family
Social influence
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Attention paid to sick relatives
Treatment of Hypochrondriasis
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Little information
regarding treatment
Cognitive therapy
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Exposure to symptoms
Decreased reassurance
seeking re: symptoms
Stress management
program
Somatization Disorder
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History of physical
complaints, occurring over
years
Result in treatment being
sought or impairment
4 pain symptoms
2 GI symptoms
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1 sexual symptom
1 pseudo-neurologic
symptom
Not explained by
medical condition
Complaints not
intentionally produced
or feigned
Somatization Disorder Statistics
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Rare
Continuum
20% estimated
prevalence in primary
care settings
Adolescent age of
onset
Causes and Treatment
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History of family illness
Few research studies
Genetic link with Antisocial PD
Difficult to treat
Conversion Disorder
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Physical malfunctioning, suggesting
neurological impairment, with no medical
cause
E.g., blindness, paralysis
Rare
Causes - trauma
Insight focused treatment, identifying trauma
Pain Disorder
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True pain
Psychological factors play role
May have been original physical cause
Body Dysmorphic Disorder
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Preoccupation with imagined defect in
appearance
Suicidality common
Focused on self and defect (similar to social
anxiety)
Can significantly disrupt life
Body Dysmorphic Disorder Statistics
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Difficult to estimate prevalence
Chronic course
Often seek plastic surgery or other medical
attention
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2% of plastic surgery patients?
Little information on cause
Link with OCD
Conversion Disorder vs.
Malingering
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Conversion patients are indifferent to
symptoms
Precipitated by stress - 52-93% cases
Can function normally, but often unaware of
this ability or sensory input
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E.g., avoiding objects in visual field
Dissociative Disorders
What is Dissociation?
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Derealization: Losing sense of reality of the
external world
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Common to some degree for everyone (a
great example of dimensionality)
Dissociative Disorders
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Incredibly puzzling category of mental
disorder
Disruption of normal integration of:
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Consciousness
Memory
Perception
Separating from identity
Types of Dissociative
Disorders
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Depersonalization Disorder
Dissociative Amnesia
Dissociative Fugue
Dissociative Trance Disorder**
Dissociative Identity Disorder
1. Depersonalization Disorder
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Feelings of detachment from self
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“living in a dream” or “going through the motions”
Feeling of watching self
Can include disconnection from body
Knows this is a feeling, does not believe
Common with other disorders (up to 40%)
Prevalence unknown
Common reaction to stress/burnout
Treating Depersonalization
Disorder
No controlled studies; lots of books
Supportive + insight-oriented therapy
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Recognize source
Reconnect with others & life
Discuss abuse (if present)
Medication for certain symptoms
(depression)
Progressive relaxation - increase anxiety?
2. Dissociative Amnesia
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Loss of autobiographical memory
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E.g. the loss of one event memory
Not due to brain damage
Usually in response to trauma (which is
forgotten)
Spontaneous recovery
Prevalence unknown
Controversy over existence
3. Dissociative Fugue
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Amnesia for past + sudden moving
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Most are not very long-term
Confusion re: identity
Assumption of a new identity
May last: hours to months
Prevalence estimated: 1 in 500
Usually in response to stressor
Treating Dissociative Amnesia
and Fugue
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Supportive therapy
Usually recover on own
Fugue often needs couples/family therapy
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Feelings of abandonment
At risk of relapse when stressed
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Preventive approaches helpful
Stress management skills
5. Dissociative Identity
Disorder
*Formerly Multiple Personality Disorder
 Presence of 2+ distinct identities
 Recurrently control an individual
 “Alters” & “Host Personality”
 Alters & Host Personality may/may not be
aware of what is going on
Dissociative Identity Disorder
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Alters who are unaware have lapses in
memory unaccounted for
Own constellation of behavior, voice tone,
gestures
Different reactions to medications, eyeglass
prescriptions
May claim to be different in age, gender,
race, family history
Alters’ Awareness of Each
Other
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Mutually amnesic
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Mutually cognizant
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One-way amnesic
Dissociative Identity Disorder
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Preceded by headaches
Rare: 1% of general population
Few believe prevalence is that high
Higher rates of diagnosis?
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Better identification?
Overused?
Iatrogenic?
Dissociative Identity Disorder
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Course is unpredictable and varies
May be long time b/w treatment & diagnosis
(e.g. 6-7 years)
Little insight
Chronic or episodic
What Causes Dissociative
Disorders?
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Trauma (child abuse, etc)
Derealization
Child abuse as first onset -> coping in
children
Common in reporters of child abuse
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90% of patients report child abuse
Psychodynamic Perspective
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DID results from defense mechanisms
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Massive repression
Recent work suggests adult stress may also
be a risk factor, not just childhood
experiences
Trauma & Dissociation
Problem: reports are
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Self-report
Retrospective
1/3 report abuse prior to age 3
Autobiographical memory rarely accurate
before 5
Why no evidence of alters during
childhood?
Causes of Dissociative
Disorders
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Suggestibility
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How are people who develop dissociative
disorders different from those who develop
PTSD?
Those who develop are better @ dissociating
Suggestibility = personality trait re: ease of
accepting ideas proposed by others
Suggestibility
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Highly suggestible people:
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Have more detailed fantasy lives
Respond more dramatically to hypnosis
The Autohypnotic Model of DID
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Select people use self-hypnosis as defense
against emotional trauma
Retreat into a trance during trauma that is
protective and provides amnesia
Autohypnotic Model of DID
Trauma
(Repeated)
Self-hypnosis
Suggestible
Personality
Alters
Form
Flaws in the Autohypnotic
Model
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Why develop only with abuse?
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Not war related. Not in bullying
Involves a betrayal of trust?
How exactly do alters develop from hypnotic
state?
May be little/no evidence of alters until
adulthood
Treating DID
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No controlled treatment studies
Agree: People cannot function well with alters
Disagree: How to integrate alters
Identify & map alters, then integrate
Mapping alters may create more?
Others argue - ignore, and will go away
Treating DID
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Important to establish trust
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Usually unsuccessful treatment history
Secretive about symptoms
Skepticism from other providers
Culture and DID
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Rare until late 1980s
 1st case 1817, by 1960s lit review = 77
cases
 1970s = 300 cases, doubled in 1980s
 Why the rapid increase? Is it real?
Increase is largely North American
 Rare in France, where theorists played a
big role
Controversies Surrounding
DID
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Could Therapists Shape DID?
Sociocognitive model of DID (Spanos, 1994)
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Symptoms shaped by available info & therapist responses
To avoid responsibility?
Interest due to rarity
Normal social reinforcement
Ignore to treat
Controversies Surrounding
DID
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Recovered Memories
Use recovered memory
techniques to assess
People repress painful
memories of abuse
Therapists encourage
recovery of memory
Evidence Against Recovered
Memories
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Little scientific evidence for repressed
memories
Can implant false memories in
children/adults
Techniques used to implant same as
therapists use to “recover”
Recovered Memories in Court
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Some therapists held liable for harmful
techniques
Courts increasingly rejecting recovered
memories
Continues to be an intense controversy