Chapter Six

1. Chapter Six Somatic Symptom and Dissociative Disorders

2. Somatic Symptom Disorders • Disorders that involve physical symptoms or anxiety over illness • Somatic symptom disorder (SSD) • Illness anxiety disorder • Conversion disorder (functional neurological symptoms disorder) • Factitious disorder

3. Somatic Symptom Disorders (cont’d.)

4. Somatic Symptom Disorder • Pattern of reporting distressing physical symptoms combined with extreme concern about health or fears of undiagnosed medical conditions • Symptoms must be present for at least six months • Symptoms not under voluntary or conscious control • Psychological in nature but often accompanied by medical conditions

5. Somatic Symptom Disorder (cont’d.) • SSD with predominantly somatic complaints: • Chronic complaints of specific bodily symptoms that have no physical basis • SSD with pain features: • Severe or lingering pain that appears to have no physical basis

6. Illness Anxiety Disorder • Previously called hypochondriasis • Persistent health anxiety and concern that one has an undetected physical illness with no or minimal somatic symptoms • Symptoms must be present for at least six months

7. Illness Anxiety Disorder (cont’d.) • Individuals with illness anxiety concerns: • Catastrophize • Overgeneralize • Display all-or-none thinking • Show selective attention • Cognitively based disorder

8. Illness Anxiety Disorder (cont’d.)

9. Conversion Disorder • Also known as functional neurological symptom disorder • Sensory or motor impairment suggestive of a neurological disorder, but with no underlying medical cause • Symptoms are not consciously being faked • Individual is not malingering, but rather believes there is a genuine problem

10. Conversion Disorder (cont’d.) • Most common symptoms: • Psychogenic movement • Originating from psychological cause • Disturbances of stance and walking • Sensory symptoms • Blindness, loss of voice, motor tics, and dizziness • Psychogenic seizures • Some symptoms are easily diagnosed, while others require extensive neurological and physical examination

11. Factitious Disorders • Factitious disorder: • Symptoms of illness are deliberately induced, simulated, or exaggerated, with no apparent external incentive • Differs from malingering: • Faking a disorder to achieve some goal, such as an insurance settlement • In factitious disorder, the individual is usually unaware of the motivation for the behavior

12. Factitious Disorders (cont’d.) • Factitious disorder imposed on another: • Pattern of falsification or production of physical or psychological symptoms in another individual • Relatively new diagnostic category and as a result, little information is available on prevalence, age of onset, or familial pattern • Diagnosis of this condition is difficult

13. Etiology of Somatic Symptom Disorders Figure 6-2 Multipath Model for Somatic Symptom Disorders The dimensions interact with one another and combine in different ways to result in a specific somatic symptom disorder.

14. Etiology of Somatic Symptom Disorders (cont’d.) • Biological dimensions: • Modest contribution of genetic factors • Biological predisposition hardwired into central nervous system can result in: • Hypervigilance or exaggerated focus on bodily sensation • Increased sensitivity to mild bodily changes • Tendency to react to somatic sensations with alarm • Repetitive activation of nervous system can lead to increased sensitivity of pain nerves

15. Etiology of Somatic Symptom Disorders (cont’d.) • Psychological dimension: • Role of reinforcement, modeling, catastrophic cognitions, or combination of these • Cognitive factors: • Somatic disorders may develop in predisposed individuals • Unrealistically interpret and overestimate dangerousness of bodily symptoms

16. Etiology of Somatic Symptom Disorders (cont’d.) • Social dimension: • Societal restrictions on women • Rejection or abuse from family members and feeling unloved • History of sexual abuse or rape • Parental modeling • Sociocultural dimension: • Societal restrictions on women • Cultural factors, including lower educational levels, ethnicity, and immigrant status

17. Treatment of Somatic Symptom Disorders • Biological: • Antidepressant medications such as SSRIs are used to treat somatic symptoms disorder ad illness anxiety disorder • Increased physical activity is recommended for conversion disorder

18. Treatment of Somatic Symptom Disorders (cont’d.) • Psychological: • Focus is understanding client’s view regarding problem • Demonstrate empathy • View disorders within social context • Cognitive-behavioral approaches • Correct cognitive distortions • Interoceptive exposure

19. Dissociative Disorders • Involves some sort of dissociation, or separation, of a part of a person’s consciousness, memory, or identity • Dissociative amnesia • Depersonalization/derealization disorder • Dissociative identity disorder • Relatively rare • No objective assessment: • Possibility of feigning

20. Dissociative Amnesia • Sudden partial or total loss of important personal information or recall of events due to psychological factors or stressors • May occur following a traumatic event or stressful circumstances • May also involve a fugue state

21. Dissociative Amnesia (cont’d.) • Localized amnesia: • Lack of memory for a specific event or events • Individuals may have selective amnesia or systematized amnesia • May occur after a repressed memory comes to light • Dissociative fugue: • Episode of complete loss of memory of one’s life and identity , unexpected travel to new location, or assumption of new identity • Recovery is often abrupt and complete

22. Depersonalization/Derealization Disorder • Characterized by feelings of unreality concerning the self and the environment • Depersonalization is the most common dissociative disorder • Diagnosis given only when feelings of unreality and detachment cause major impairment in social or occupational functioning

23. Dissociative Identity Disorder (DID) • Formerly called multiple personality disorder • Two or more relatively independent personality states appear to exist in one person, including experiences of possession • Diagnostic controversy

24. Etiology of Dissociative Disorders Figure 6-4 Multipath Model of Dissociative Identity Disorder The dimensions interact with one another and combine in different ways to result in dissociative identity disorder.

25. Etiology of Dissociative Disorders (cont’d.) • Diagnosis depends on self-report, making it difficult to differentiate between genuine and faked cases • Two most influential models, post-traumatic and sociocognitive, are not sufficient to explain why only some develop disorders • Must look at vulnerabilities in biological, psychological, social, and sociocultural dimensions

26. Etiology of Dissociative Disorders (cont’d.) • Biological dimension: • Atypical brain functioning • Inhibited activity in hippocampus and hypometabolism in area of prefrontal cortex • Variations in brain activity when comparing different personalities • Difficult to interpret patterns of brain activity • Permanent structural changes in brain due to trauma may play a role • Reduction in amygdalar and hippocampal volumes

27. Etiology of Dissociative Disorders (cont’d.) • Psychological dimension: • Psychodynamic theory • Repression blocks unpleasant or traumatic events from consciousness • Protects individuals from painful memories or conflicts • DID results from severe childhood abuse

28. Etiology of Dissociative Disorders (cont’d.) • Psychological dimension: (cont’d.) • Four factors necessary for development of DID according to posttraumatic model (PTM) • Exposure to overwhelming childhood stress • Capacity to dissociate • Encapsulating or walling off the experience • Developing different memory systems • DID results from these factors if supportive environment is unavailable or if personality is not resilient

29. Etiology of Dissociative Disorders (cont’d.) Figure 6-5 The Post-Traumatic Model of Dissociative Identity Disorder Note the importance of each of the factors in the development of dissociative identity disorder. Source: Adapted from Kluft (1987); Loewenstein (1994).

30. Etiology of Dissociative Disorders (cont’d.) • Social and sociocultural dimension: • Sociocognitive model (SCM): • Displays of role enactments that have been created, legitimized, and maintained by social reinforcement • Patients learn about phenomenon and its characteristics from mass media, cues provided by therapist, personal experiences, and observation • Iatrogenic disorder: unintentionally produced by therapists actions and treatment strategies • High levels of hypnotizability and suggestibility

31. Treatment of Dissociative Disorders • Variety of treatments, including: • Supportive counseling • Hypnosis • Personality reconstruction • Currently no specific medication for dissociative disorders, but used to treat accompanying anxiety or depression

32. Treatment of Dissociative Disorders (cont’d.) • Dissociative amnesia and fugue: • Symptoms usually spontaneously end, but often associated with depression and/or stress • Treating dissociative disorders indirectly by alleviating depression and stress • Antidepressants or cognitive-behavioral therapy for depression • Stress-management techniques for stress

33. Treatment of Dissociative Disorders (cont’d.) • Depersonalization/derealization disorder: • Also subject to spontaneous remission, but at a much slower rate • Treatment focuses on alleviating feelings of depression, anxiety, or fear of going insane • Antidepressants and antianxiety medications

34. Treatment of Dissociative Disorders (cont’d.) • Dissociative identity disorder: • Major goal is use of trauma-based therapy to develop healthier ways of dealing with stressors • Hierarchical treatment approach involves: • Working on safety issues, stabilization, and symptom reduction • Reducing cognitive distortions • Identifying and working through traumatic memories • Stabilizing and learning to deal with stressors • Developing healthy relationships and practicing self-care

35. Treatment of Dissociative Disorders (cont’d.) • Dissociative identity disorder (cont’d.): • Treatment is not always successful • Greatest reduction in symptoms when individuals are able to integrate personalities

36. Treatment of Dissociative Disorders (cont’d.) ABC Video: Robert Oxnam (Dissociative Identity Disorder)