Somatoform and Dissociative Disorders

1. Somatoform and Dissociative Disorders

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

3. 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

4. Hypochondriasis - Statistics • Little information • Prevalence estimate 3% • Equal in men and women, age groups

5. Causes of Hypochondriasis • Enhanced sensitivity to illness cues • Increased awareness and fright • Faulty thoughts/interpretation of physical signs(cognition) • Context of stressful life events • often involving death or illness

6. Causes of Hypochrondriasis Family/genetic influences • Might be unspecific anxiety • Children report symptoms of parents • Disproportionate incidence of disease in family • Social influence • Attention paid to sick relatives

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

8. 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

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

10. Causes and Treatment • History of family illness • Few research studies • Difficult to treat

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

12. Conversion Disorder vs. Malingering • Conversion patients are indifferent to symptoms • Precipitated by stress - 52-93% cases • Can function normally, but often unaware of this ability or sensory input • E.g., avoiding objects in visual field

13. Body Dysmorphic Disorder • Preoccupation with imagined defect in appearance • Suicidality common • Focused on self and defect (similar to social anxiety) • Can significantly disrupt life

14. 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

15. Dissociative Disorders

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

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

18. Types of Dissociative Disorders • Depersonalization Disorder • Dissociative Amnesia • Dissociative Fugue • Dissociative Trance Disorder • Dissociative Identity Disorder

19. 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

20. 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

21. 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

22. 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

23. 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

24. Alters’ Awareness of Each Other • Mutually amnesic • Mutually cognizant • One-way amnesic

25. 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?

26. Dissociative Identity Disorder • Course is unpredictable and varies • May be long time b/w treatment & diagnosis (e.g. 6-7 years) • Little insight

27. What Causes Dissociative Disorders? • Trauma (child abuse, etc) • Child abuse as first onset -> coping in children • Massive repression • Commonly report child abuse • 90% of patients report child abuse

28. Problems with Trauma & Dissociation • Reports are • Self-report • Retrospective • 1/3 report abuse prior to age 3 • Autobiographical memory rarely accurate before 5 • Why no evidence of alters during childhood?

29. Causes of Dissociative Disorders • Suggestibility • 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

30. 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

31. Autohypnotic Model of DID Trauma (Repeated) Self-hypnosis Alters Form Suggestible Personality

32. 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

33. Neurobiology & DID • Neurobiology seems to support multiple, distinct states of awareness in one brain • Changes in skin conductance, heartbeat • Allergies • Endocrine function

34. Trauma Narratives & DID (Simone Reinders, University of Groningen) • 11 DID patients - story from life (traumatic vs. nontraumatic) • Recording of subjective & biological reactions

35. Neutral Personality Reacted as if neutral memory Claimed not to remember Trauma Personality Subjective and cardiovascular reaction Different brain activation pattern Reported memory of event

36. Neurobiological Differences (Waldvogel, Ullrich, Strasburger, Munich Germany) • Case study of dissociated patient with 15-years of blind male alter • Sighted personality = EEG reaction to checkerboard pattern • Reduced visual activity in “blind” personality • Neurobiological summary: DID is a lack of integration, cohesiveness?

37. 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

38. Treating DID • Important to establish trust • Usually unsuccessful treatment history • Secretive about symptoms • Skepticism from other providers

39. 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

40. Controversies Surrounding DID • Could Therapists Shape DID? • Sociocognitive model of DID (Spanos) • Symptoms shaped by available info & therapist responses • To avoid responsibility? • Interest due to rarity • Normal social reinforcement • Ignore to treat

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

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