Somatoform and Dissociative Disorders

Somatoform Disorders Concerns with appearance or functioning of body Absence of medical condition 1. Hypochondriasis 2. Somatization Disorder 3. Conversion Disorder 4. Pain Disorder 5. Body Dysmorphic Disorder

Hypochondriasis 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 Little information Prevalence estimate 3% Equal in men and women, age groups

Causes of Hypochondriasis Faulty thoughts/interpretation of physical signs (cognition) Enhanced sensitivity to illness cues Increased awareness and fright Family/genetic influences Might be unspecific anxiety Children report symptoms of parents

Causes of Hypochrondriasis Context of stressful life events - often involving death or illness Disproportionate incidence of disease in family Social influence Attention paid to sick relatives

Treatment of Hypochrondriasis Little information regarding treatment Cognitive therapy Exposure to symptoms Decreased reassurance seeking re: symptoms Stress management program

Somatization Disorder History of physical complaints, occurring over years Result in treatment being sought or impairment 4 pain symptoms 2 GI symptoms 1 sexual symptom 1 pseudo-neurologic symptom Not explained by medical condition Complaints not intentionally produced or feigned

Somatization Disorder - Statistics Rare Continuum 20% estimated prevalence in primary care settings Adolescent age of onset

Causes and Treatment History of family illness Few research studies Genetic link with Antisocial PD Difficult to treat

Conversion Disorder Physical malfunctioning, suggesting neurological impairment, with no medical cause E.g., blindness, paralysis Rare Causes - trauma Insight focused treatment, identifying trauma

Pain Disorder True pain Psychological factors play role May have been original physical cause

Body Dysmorphic Disorder 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 Difficult to estimate prevalence Chronic course Often seek plastic surgery or other medical attention 2% of plastic surgery patients? Little information on cause Link with OCD

Conversion Disorder vs. Malingering Conversion patients are indifferent to symptoms Precipitated by stress % cases Can function normally, but often unaware of this ability or sensory input E.g., avoiding objects in visual field

Dissociative Disorders

What is Dissociation? Derealization: Losing sense of reality of the external world Common to some degree for everyone (a great example of dimensionality)

Dissociative Disorders Incredibly puzzling category of mental disorder Disruption of normal integration of: Consciousness Memory Perception Separating from identity

Types of Dissociative Disorders 1. Depersonalization Disorder 2. Dissociative Amnesia 3. Dissociative Fugue 4. Dissociative Trance Disorder** 5. Dissociative Identity Disorder

1. Depersonalization Disorder Feelings of detachment from self “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 1. Recognize source 2. Reconnect with others & life 3. Discuss abuse (if present) – Medication for certain symptoms (depression) – Progressive relaxation - increase anxiety?

2. Dissociative Amnesia Loss of autobiographical memory 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 Amnesia for past + sudden moving 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 Supportive therapy Usually recover on own Fugue often needs couples/family therapy Feelings of abandonment At risk of relapse when stressed 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 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 Mutually amnesic Mutually cognizant One-way amnesic

Dissociative Identity Disorder Preceded by headaches Rare: 1% of general population Few believe prevalence is that high Higher rates of diagnosis? Better identification? Overused? Iatrogenic?

Dissociative Identity Disorder 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? Trauma (child abuse, etc) Derealization Child abuse as first onset -> coping in children Common in reporters of child abuse 90% of patients report child abuse

Psychodynamic Perspective DID results from defense mechanisms Massive repression Recent work suggests adult stress may also be a risk factor, not just childhood experiences

Trauma & Dissociation Problem: reports are 1. Self-report 2. 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 Suggestibility How are people who develop dissociative disorders different from those who develop PTSD? Those who develop are dissociating Suggestibility = personality trait re: ease of accepting ideas proposed by others

Suggestibility Highly suggestible people: Have more detailed fantasy lives Respond more dramatically to hypnosis The Autohypnotic Model of DID 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) Suggestible Personality Self-hypnosis Alters Form

Flaws in the Autohypnotic Model Why develop only with abuse? 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 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 Important to establish trust Usually unsuccessful treatment history Secretive about symptoms Skepticism from other providers

Culture and DID 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 Could Therapists Shape DID? Sociocognitive model of DID (Spanos, 1994) Symptoms shaped by available info & therapist responses To avoid responsibility? Interest due to rarity Normal social reinforcement Ignore to treat

Controversies Surrounding DID Recovered Memories Use recovered memory techniques to assess People repress painful memories of abuse Therapists encourage recovery of memory

Evidence Against Recovered Memories 1. Little scientific evidence for repressed memories 2. Can implant false memories in children/adults 3. Techniques used to implant same as therapists use to “recover”

Recovered Memories in Court Some therapists held liable for harmful techniques Courts increasingly rejecting recovered memories Continues to be an intense controversy