Transcript AP8_Lecture_7 - Forensicconsultation.org

Disorders Focusing on
Somatic and Dissociative
Symptoms
Chapter 7
Slides & Handouts by Karen Clay Rhines, Ph.D.
American Public University System
Comer, Abnormal Psychology
DSM-5 Update, 8e
Disorders Focusing on Somatic and
Dissociative Symptoms

In addition to disorders covered earlier,
stress and anxiety also contribute to several
other kinds of disorder, particularly
disorders that focus on somatic and
dissociative symptoms
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Disorders Focusing on Somatic
Symptoms

In these disorders, the somatic symptoms
are primarily caused by psychosocial
factors or the symptoms trigger excessive
anxiety and concern

These disorders are different than
psychophysiological disorders, in which
psychosocial factors interact with genuine
physical ailments
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Disorders Focusing on Dissociative
Symptoms

Dissociative disorders are each
characterized by significant memory loss or
identity disruption
Comer, Abnormal Psychology,8e
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Disorders Focusing on Somatic and
Dissociative Symptoms
Disorders that focus on somatic symptoms and
those that focus on dissociative symptoms have
much in common:


Both may occur in response to severe stress

Both have traditionally been viewed as forms of
escape from stress

A number of individuals suffer from both a somaticrelated and a dissociative disorder

Theorists and clinicians often explain and treat the
two groups of disorders in similar ways
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Disorders Focusing on Somatic
Symptoms

DSM-5 lists a number of disorders in which
bodily symptoms or concerns are the
primary features
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Factitious Disorder

Sometimes when physicians cannot find a
medical cause for a patient’s symptoms, he or
she may suspect other factors are involved.

Patients may malinger, intentionally fake illness to
achieve external gain (e.g., financial
compensation, military deferment)

Patients may be manifesting a factitious disorder intentionally producing or faking symptoms
simply out of a wish to be a patient
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Factitious Disorder

Known popularly as Munchausen
syndrome, people with a factitious disorder
often go to extremes to create the
appearance of illness

Many secretly give themselves medications to
produce symptoms

Patients often research their supposed
ailments and are impressively knowledgeable
about medicine
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Factitious Disorder

Clinical researchers have a hard time
determining the prevalence of this disorder
as patients hide the true nature of their
problem

Overall, the pattern appears to be more
common in women than men and the disorder
usually begins during early adulthood
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Factitious Disorder

Factitious disorder seems to be particularly
common among people who (a) received
extensive medical treatment as children,
(2) carry a grudge against the medical
profession, or (3) have worked as a nurse,
lab technician, or medical aide
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Factitious Disorder

The precise causes of factitious disorder are
not understood, although clinical reports
have pointed to factors such as depression
unsupportive parental relationships, and an
extreme need for social support
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Factitious Disorder

Psychotherapists and medical practitioners
often become angry at people with a
factitious disorder, feeling that they are
wasting their time

People with the disorder, however, feel they
have no control over their problems and often
experience great distress
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Factitious Disorder

In a related pattern, factitious disorder
imposed on another, known popularly as
Munchausen syndrome by proxy, parents
make up or produce physical illnesses in
their children
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Conversion Disorder

Conversion disorder

People with this disorder display physical
symptoms that affect voluntary motor or
sensory functioning, but the symptoms are
inconsistent with known medical diseases

In short, the individuals experience neurologicallike symptoms – blindness, paralysis, or loss of
feeling – that have no neurological basis
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Conversion Disorder

Conversion disorder often is hard to
distinguish from genuine medical problems


It is always possible that a diagnosis of conversion
disorder is a mistake and the patient’s problem has
an undetected medical cause
Physicians sometimes rely on oddities in the
patient’s medical picture to help distinguish
the two

For example, conversion symptoms may be at odds
with the known functioning of the nervous system,
as in cases of glove anesthesia
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Conversion Disorder

Unlike people with factitious disorder,
those with conversion disorder don’t
consciously want or produce their
symptoms

This pattern is called “conversion” disorder
because clinical theorists used to believe that
individuals with the disorders are converting
psychological needs into neurological
symptoms
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Conversion Disorder

Conversion disorder usually begins
between late childhood and young
adulthood

It is diagnosed in women twice as often as in
men

It typically appears suddenly, at times of stress

It is thought to be rare, occurring in at most 5
of every 1,000 persons
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Somatic Symptom Disorder

People with somatic symptom disorder
become excessively distressed, concerned,
and anxious about bodily symptoms that
they are experiencing

Two patterns of somatic symptom disorder
have received particular attention:

Somatization pattern

Predominant pain pattern
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Somatic Symptom Disorder

People with a somatization pattern experience
many long-lasting physical ailments that have
little or no organic basis


Also known as Briquet’s syndrome
A sufferer’s ailments often include pain
symptoms, gastrointestinal symptoms, sexual
symptoms, and neurological symptoms

Patients usually go from doctor to doctor in search
of relief
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Somatic Symptom Disorder

Somatization pattern

Patients with this pattern often describe their
symptoms in dramatic and exaggerated terms

Most also feel anxious and depressed

The pattern typically lasts for many years

Symptoms may fluctuate over time but rarely
disappear completely without therapy
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Somatic Symptom Disorder

Somatization pattern

Between 0.2% and 2% of all women in the U.S.
experience a somatization pattern in any given
year (compared with less than 0.2% of men)

The pattern often runs in families and begins
between adolescence and young adulthood
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Somatic Symptom Disorder

Predominant pain pattern


If the primary feature of somatic symptom
disorder is pain, the individual is said to have a
predominant pain pattern
Although the precise prevalence has not been
determined, this pattern appears to be fairly
common


The pattern often develops after an accident or illness
that has caused genuine pain
The pattern may begin at any age, and more
women than men seem to experience it
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What Causes Conversion and
Somatic Symptom Disorders?

For many years, conversion and somatic symptom
disorders were referred to as hysterical disorders


This label was to convey the prevailing belief that
excessive and uncontrolled emotions underlie the
bodily symptoms
Today’s leading explanations come from the
psychodynamic, behavioral, cognitive, and
multicultural models

None has received much research support, and the
disorders are still poorly understood
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What Causes Conversion and
Somatic Symptom Disorders?

The psychodynamic view

Freud believed that hysterical disorders
represented a conversion of underlying
emotional conflicts into physical symptoms

Because most of his patients were women,
Freud centered his explanation on the
psychosexual development of girls and focused
on the phallic stage (ages 3 to 5)…
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What Causes Conversion and
Somatic Symptom Disorders?

The psychodynamic view




During this stage, girls develop a pattern of sexual desires
for their fathers (the Electra complex) and recognize that
they must compete with their mothers for his attention
Because of the mother’s more powerful position, however,
girls repress these sexual feelings
Freud believed that if parents overreact to such feelings, the
Electra complex would remain unresolved and the child
might re-experience sexual anxiety throughout her life
Freud concluded that some women unconciously hide their
sexual feelings in adulthood by converting them into
physical symptoms
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What Causes Conversion and
Somatic Symptom Disorders?

The psychodynamic view

Today’s psychodynamic theorists take issues
with parts of Freud’s explanation

They continue to believe that sufferers of these
disorders have unconscious conflicts carried from
childhood
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What Causes Conversion and
Somatic Symptom Disorders?

The psychodynamic view

Psychodynamic theorists propose that two
mechanisms are at work in hysterical
disorders:

Primary gain: bodily symptoms keep internal
conflicts out of conscious awareness

Secondary gain: bodily symptoms further enable
people to avoid unpleasant activities or receive
sympathy from others
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What Causes Conversion and
Somatic Symptom Disorders?

The behavioral view

Behavioral theorists propose that the physical
symptoms of hysterical disorders bring rewards
to sufferers

May remove individual from an unpleasant
situation

May bring attention from other people
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What Causes Conversion and
Somatic Symptom Disorders?

In response to such rewards, people learn to
display symptoms more and more

This focus on rewards is similar to the
psychodynamic idea of secondary gain, but
behaviorists view the gains as the primary
cause of the development of the disorder

Like the psychodynamic explanation, the
behavioral view of these disorders has
received little research support
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What Causes Conversion and
Somatic Symptom Disorders?

The cognitive view

Some cognitive theorists propose that
hysterical disorders are a form of conversion
and somatic symptom disorder, providing a
means for people to express difficult emotions
Comer, Abnormal Psychology,8e
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What Causes Conversion and
Somatic Symptom Disorders?

Like psychodynamic theorists, cognitive
theorists hold that emotions are being
converted into physical symptoms

This conversion is not to defend against
anxiety but to communicate extreme feelings

Like the other explanations, this cognitive view
has not been widely tested or supported by
research
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What Causes Conversion and
Somatic Symptom Disorders?

The multicultural view

Some theorists believe that Western clinicians
hold a bias that sees somatic symptoms as an
inferior way of dealing with emotions

The transformation of personal distress into somatic
complaints is the norm is many
non-Western cultures

The lesson to be learned from multicultural findings is
that both bodily and psychological reactions to life
events are often influenced by one's culture
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What Causes Conversion and
Somatic Symptom Disorders?

A possible role for biology

The impact of biological processes on somatoform
disorders can be understood through research on
placebos and the placebo effect

Placebos: substances with no known medicinal value

Treatment with placebos has been shown to bring
improvement to many – possibly through the power of
suggestion but likely because expectation triggers the release
of endogenous chemicals

Perhaps traumatic events and related concerns or needs can
also trigger our “inner pharmacies” and set in motion the
bodily symptoms of hysterical somatoform disorders
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How Are Conversion and Somatic
Symptom Disorders Treated?

People with these disorders usually seek
psychotherapy only as a last resort
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How Are Conversion and Somatic
Symptom Disorders Treated?

Many therapists focus on the causes of the
disorders and apply techniques including:

Insight – often psychodynamically oriented

Exposure – client thinks about traumatic
event(s) that triggered the physical symptoms

Drug therapy – especially antidepressant
medication
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How Are Conversion and Somatic
Symptom Disorders Treated?

Other therapists try to address the physical
symptoms of these disorders, applying techniques
such as:




Suggestion – usually an offering of emotional support
that may include hypnosis
Reinforcement – a behavioral attempt to change
reward structures
Confrontation – an overt attempt to force patients out
of the sick role
Researchers have not fully evaluated the effects of
these particular approaches on these disorders
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Illness Anxiety Disorder

People with illness anxiety disorder,
previously known as hypochondriasis,
experience chronic anxiety about their
health and are concerned that they are
developing a serious medical illness,
despite the absence of somatic symptoms
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Illness Anxiety Disorder

They repeatedly check their bodies for
signs of illness and misinterpret bodily
symptoms as signs of a serious illness


Often their symptoms are merely normal bodily
changes, such as occasional coughing, sores, or
sweating
Although some patients recognize that their
concerns are excessive, many do not
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Illness Anxiety Disorder

Although this disorder can begin at any
age, it starts most often in early adulthood,
among men and women in equal numbers

Between 1% and 5% of all people experience
the disorder

For most patients, symptoms rise and fall over
the years
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Illness Anxiety Disorder

Theorists explain this disorder much as
they explain various anxiety disorders:

Behaviorists: classical conditioning or
modeling

Cognitive theorists: oversensitivity to bodily
cues
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Illness Anxiety Disorder

Individuals with illness anxiety disorder
typically receive the kinds of treatments
applied to OCD:

Antidepressant medication

Exposure and response prevention (ERP)

Cognitive-behavioral therapies
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Body Dysmorphic Disorder

People with this disorder, also known as
dysmorphobia, become deeply concerned
about some imagined or minor defect in
their appearance

Most often they focus on wrinkles, spots, facial
hair, swelling, or misshapen facial features
(nose, jaw, or eyebrows)
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Body Dysmorphic Disorder


As many as half of people with this disorder
seek plastic surgery or dermatology treatment,
and often they feel worse rather than better
afterward
Most cases of the disorder begin in
adolescence but are often not revealed until
adulthood

Up to 5 percent of people in the United States
experience BDD, and it appears to be equally
common among women and men
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Body Dysmorphic Disorder

Theorists typically account for BDD by using
the same kinds of explanations – both physical
and psychological – that have been applied to
anxiety disorders and OCD

Similarly, clinicians typically treat clients with
this disorder by applying the kinds of
treatment used with OCD, particularly antidepressant drugs, exposure and response
prevention, and cognitive therapy
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Dissociative Disorders

The key to our identity – the sense of
who we are and where we fit in our
environment – is memory

Our recall of past experiences helps us to react
to present events and guides us in making
decisions about the future

People sometimes experience a major
disruption of their memory
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Dissociative Disorders

When such changes in memory lack a clear
physical cause, they are called
“dissociative” disorders

In such disorders, one part of the person’s
memory typically seems to be dissociated, or
separated, from the rest
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Dissociative Disorders


There are several kinds of dissociative
disorders, including:

Dissociative amnesia

Dissociative identity disorder (multiple personality
disorder)

Depersonalization-derealization disorder
These disorders are often memorably
portrayed in books, movies, and television
programs
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Dissociative Amnesia

People with dissociative amnesia are
unable to recall important information,
usually of an upsetting nature, about their
lives

The loss of memory is much more extensive
than normal forgetting and is not caused by
physical factors

Often an episode of amnesia is directly
triggered by a specific upsetting event
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Dissociative Amnesia

Dissociative amnesia may be:

Localized – most common type; loss of all memory
of events occurring within a limited period

Selective – loss of memory for some, but not all,
events occurring within a period

Generalized – loss of memory beginning with an
event, but extending back in time; may lose sense
of identity; may fail to recognize family and friends

Continuous – forgetting continues into the future;
quite rare in cases of dissociative amnesia
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Dissociative Amnesia

All forms of the disorder are similar in that
the amnesia interferes mostly with a
person’


Memory for abstract or encyclopedic
information – usually remains intact
Clinicians do not known how common
dissociative amnesia is, but many cases
seem to begin serious threats to health and
safety
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Dissociative Fugue

An extreme version of dissociative amnesia is
dissociative fugue



People with dissociative fugue not only forget their
personal identities and details of their past, but
also flee to an entirely different location
For some, the fugue is brief – a matter of hours or
days – and ends suddenly
For others, the fugue is more severe: people may
travel far from home, take a new name and
establish new relationships, and even a new line of
work; some display new personality characteristics
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Dissociative Fugue

~0.2% of the population experience
dissociative fugue


It usually follows a severely stressful event
Fugues tend to end abruptly

When people are found before their fugue has
ended, therapists may find it necessary to
continually remind them of their own identity

The majority of people regain most or all of their
memories and never have a recurrence
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Dissociative Identity Disorder
(Multiple Personality Disorder)

A person with dissociative identity disorder
(DID; formerly multiple personality
disorder) develops two or more distinct
personalities (subpersonalities) each with a
unique set of memories, behaviors,
thoughts, and emotions
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Dissociative Identity Disorder
(Multiple Personality Disorder)

At any given time, one of the
subpersonalities dominates the person’s
functioning

Usually one of these subpersonalities – called
the primary, or host, personality – appears
more often than the others

The transition from one subpersonality to the
next (“switching”) is usually sudden and may
be dramatic
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Dissociative Identity Disorder
(Multiple Personality Disorder)

Cases of this disorder were first reported
almost three centuries ago

Many clinicians consider the disorder to be
rare, but some reports suggest that it may be
more common than once thought
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Dissociative Identity Disorder
(Multiple Personality Disorder)

Most cases are first diagnosed in late
adolescence or early adulthood

Symptoms generally begin in childhood after
episodes of abuse


Typical onset is before age 5
Women receive the diagnosis three times
as often as men
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Dissociative Identity Disorder
(Multiple Personality Disorder)

How do subpersonalities interact?

The relationship between or among
subpersonalities varies from case to case

Generally there are three kinds of relationships:



Mutually amnesic relationships – subpersonalities have no
awareness of one another
Mutually cognizant patterns – each subpersonality is well
aware of the rest
One-way amnesic relationships – most common pattern;
some personalities are aware of others, but the awareness is
not mutual
 Those who are aware (“co-conscious subpersonalities”)
are “quiet observers”
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Dissociative Identity Disorder
(Multiple Personality Disorder)

How do subpersonalities interact?

Investigators used to believe that most cases of
the disorder involved two or three
subpersonalities

Studies now suggest that the average number is
much higher – 15 for women, 8 for men

There have been cases of more than 100!
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Dissociative Identity Disorder
(Multiple Personality Disorder)

How do subpersonalities differ?

Subpersonalities often display dramatically
different characteristics, including:

Identifying features


Subpersonalities may differ in features as basic as age, sex,
race, and family history
Abilities and preferences


Although encyclopedic information is not usually affected by
dissociative amnesia or fugue, in DID it is often disturbed
It is not uncommon for different subpersonalities to have
different abilities, including being able to drive, speak a
foreign language, or play an instrument
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Dissociative Identity Disorder
(Multiple Personality Disorder)

How do subpersonalities differ?

Subpersonalities often display dramatically
different characteristics, including:

Physiological responses

Researchers have discovered that subpersonalities may
have physiological differences, such as differences in
autonomic nervous system activity, blood pressure levels,
and allergies
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Dissociative Identity Disorder
(Multiple Personality Disorder)

How common is DID?

Traditionally, DID was believed to be rare

Some researchers even argue that many or all cases
are iatrogenic; that is, unintentionally produced by
practitioners

These arguments are supported by the fact that many
cases of DID first come to attention only after a person is
already in treatment

Not true of all cases
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Dissociative Identity Disorder
(Multiple Personality Disorder)

How common is DID?


The number of people diagnosed with the disorder has
been increasing
Although the disorder is still uncommon, thousands of
cases have been documented in the U.S. and Canada
alone

Two factors may account for this increase:



A growing number of clinicians believe that the disorder does exist
and are willing to diagnose it
Diagnostic procedures have become more accurate
Despite changes, many clinicians continue to question
the legitimacy of this category
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How Do Theorists Explain
Dissociative Disorders?

A variety of theories have been proposed to
explain dissociative disorders

Older explanations have not received much
investigation

Newer viewpoints, which combine cognitive,
behavioral, and biological principles, have
captured the interest of clinical scientists
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How Do Theorists Explain
Dissociative Disorders?

The psychodynamic view

Psychodynamic theorists believe that
dissociative disorders are caused by repression,
the most basic ego defense mechanism

People fight off anxiety by unconsciously preventing
painful memories, thoughts, or impulses from
reaching awareness
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How Do Theorists Explain
Dissociative Disorders?

The psychodynamic view

In this view, dissociative amnesia and fugue are
single episodes of massive repression

DID is thought to result from a lifetime of
excessive repression, motivated by very
traumatic childhood events
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How Do Theorists Explain
Dissociative Disorders?

The psychodynamic view

Most of the support for this model is drawn
from case histories, which report brutal
childhood experiences, yet:

Some individuals with DID do not seem to have
these experiences of abuse

Further, why might only a small fraction of abused
children develop this disorder?
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How Do Theorists Explain
Dissociative Disorders?

The behavioral view

Behaviorists believe that dissociation grows from
normal memory processes and is a response learned
through operant conditioning:



Momentary forgetting of trauma leads to a drop in anxiety,
which increases the likelihood of future forgetting
Like psychodynamic theorists, behaviorists see dissociation as
escape behavior
Also like psychodynamic theorists, behaviorists rely
largely on case histories to support their view of
dissociative disorders

Moreover, these explanations fail to explain all aspects of
these disorders
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How Do Theorists Explain
Dissociative Disorders?

State-dependent learning

If people learn something when they are in a
particular state of mind, they are likely to
remember it best when they are in the same
condition

This link between state and recall is called statedependent learning

This model has been demonstrated with substances
and mood and may be linked to arousal levels
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How Do Theorists Explain
Dissociative Disorders?

State-dependent learning

People who are prone to develop dissociative
disorders may have state-to-memory links that
are unusually rigid and narrow; each thought,
memory, and skill is tied exclusively to a
particular state of arousal, so that they recall a
given event only when they experience an
arousal state almost identical to the state in
which the memory was first acquired
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How Do Theorists Explain
Dissociative Disorders?

Self-hypnosis

Although hypnosis can help people remember
events that occurred and were forgotten years ago,
it can also help people forget facts, events, and
their personal identity

Called “hypnotic amnesia,” this phenomenon has been
demonstrated in research studies with word lists

The parallels between hypnotic amnesia and dissociative
disorders are striking and have led researchers to
conclude that dissociative disorders may be a form of
self-hypnosis
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How Are Dissociative
Disorders Treated?

People with dissociative amnesia often recover
on their own


Only sometimes do their memory problems linger
and require treatment
In contrast, people with DID usually require
treatment to regain their lost memories and
develop an integrated personality

Treatment for dissociative amnesia tends to be
more successful than treatment for DID
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How Are Dissociative
Disorders Treated?

How do therapists help people with dissociative
amnesia?

The leading treatments for these disorders are
psychodynamic therapy, hypnotic therapy, and drug
therapy



Psychodynamic therapists guide patients to search their
unconscious and bring forgotten experiences into consciousness
In hypnotic therapy, patients are hypnotized and guided to recall
forgotten events
Sometimes intravenous injections of barbiturates are used to help
patients regain lost memories

Often called “truth serums,” the key to the drugs’ success is their ability
to calm people and free their inhibitions
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How Are Dissociative
Disorders Treated?

How do therapists help individuals with
DID?

Unlike victims of dissociative amnesia, people
with DID do not typically recover without
treatment

Treatment for this pattern, like the disorder itself, is
complex and difficult
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How Are Dissociative
Disorders Treated?

How do therapists help individuals with DID?

Therapists usually try to help the client by:

Recognizing the disorder

Once a diagnosis of DID has been made, therapists try to
bond with the primary personality and with each of the
subpersonalities

As bonds are forged, therapists try to educate the patients
and help them recognize the nature of the disorder


Some use hypnosis or video as a means of presenting
other subpersonalities
Many therapists recommend group or family therapy
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How Are Dissociative
Disorders Treated?

How do therapists help individuals with
DID?

Therapists usually try to help the client by:

Recovering memories

To help patients recover missing memories, therapists use
many of the approaches applied in other dissociative
disorders, including psychodynamic therapy,
hypnotherapy, and drug treatment

These techniques tend to work slowly in cases of DID
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How Are Dissociative
Disorders Treated?

How do therapists help individuals with DID?

Therapists usually try to help the client by:

Integrating the subpersonalities

The final goal of therapy is to merge the different
subpersonalities into a single, integrated identity

Integration is a continuous process; fusion is the final
merging


Many patients distrust this final treatment goal and their
subpersonalities see integration as a form of death
Once the subpersonalities are integrated, further therapy is
typically needed to maintain the complete personality and to
teach social and coping skills to prevent later dissociations
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Depersonalization-Derealization
Disorder

DSM-5 categorizes depersonalizationderealization disorder as a dissociative
disorder, even though it is not
characterized by memory difficulties
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Depersonalization-Derealization
Disorder

The central symptom is persistent and
recurrent episodes of depersonalization (a
change in one’s experience of the self in
which one’s mental functioning or body
feels unreal or detached) and/or
derealization (the sense that one’s
surroundings are unreal or detached)
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Depersonalization-Derealization
Disorder

People with this disorder feel as though
they have become separated from their
body and are observing themselves from
outside

This sense of unreality can extend to other
sensory experiences and behavior
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Depersonalization-Derealization
Disorder

In contrast to depersonalization,
derealization is characterized by the feeling
that the external world is unreal and
strange
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Depersonalization-Derealization
Disorder

Depersonalization and derealization
experiences by themselves do not indicate a
disorder

Transient depersonalization or derealization
reactions are fairly common

The symptoms of a depersonalizationderealization disorder are persistent or recurrent,
cause considerable distress, and interfere with
social relationships and job performance
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Depersonalization-Derealization
Disorder

The disorder occurs most frequently in
adolescents and young adults, hardly ever
in people older than 40


The disorder comes on suddenly and tends to
be long-lasting
Few theories have been offered to explain
this disorder
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