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Chapter 6

PS280 Chapter 6 - Dissociative and Somatoform Disorders.docx

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Camie Condon

ABNORMAL PSYCH Chapter 6 – Dissociative and Somatoform Disorders  Dissociative disorders as a group include a wide range of different symptoms that involve severe disruptions in consciousness, memory and identity. o One of the most severe types of dissociative disorders is known as “dissociative identity disorder”. This is when the individual has 2 or more distinct identities that alternate control of the person’s behaviour.  Somatoform disorders as a group include conditions whereby individuals complain about a physical defect or dysfunction for which no physiological basis can be found.  An example of this is “hypochondria” in which people have long standing beliefs that they have a serious illness despite medical reassurance that they do not.  Many doctors believe that both these types of disorders result from maladaptive ways of coping with extreme stress.  Although there are many thoughts and theories on the causes and symptoms of these disorders, our knowledge is still quite limited.  Although dissociative and somatoform disorders are classified in separate categories now, they share common features historically. They used to be classified together in the anxiety disorders under neuroses since it was assumed anxiety was the underlying feature.  Classification of disorders later shifted in emphasis from etiology to observable behaviour. Historical Perspective  Dissociative disorders along with some somatoform disorders were once seen as expression of hysteria (Greek term meaning – a symptom or pattern characterized by emotional excitability and physical symptoms with no evident organic cause)  Plato believed these symptoms were caused in women when their womb remained inactive for too long. Described the womb like an animal that desired to reproduce and when this didn’t happen it became angry and wandered around the body.  Christianity blamed hysteria with supernatural explanations. Thought it was a result of demonic possession and that exorcism was only treatment.  Pierre Janet was first to systematically study the concept of dissociation, which we saw as a pathological breakdown of the normal integration of mental processes occurring as a result of traumatic experiences.  Josef Breuer and Sigmund Freud thought that trauma, usually of a sexual nature, was a predisposing factor for hysteria and established a relationship between dissociation and hypnotic-like states.  Freud began to doubt retrospective reports of his patients traumatic sexual experiences and decided their memories of trauma were only fantasized. He believed the dissociation and other intrapsychic defenses developed to protect the individual from unacceptable sexual impulses, not from real traumatic memories.  He suggested too that “conversion” of anxiety to more acceptable physical symptoms relieved the pressure of having to deal directly with the conflict.  This avoidance of conflict was named “primary gain” and was viewed as the primary reinforcement maintaining the somatoform symptoms.  “Secondary gains” of the symptoms were the fact that hysterical symptoms could allow patients to avoid responsibility and gain both attention and sympathy.  Interest in dissociative processes drops and rises in level of interest  Lately in the 1970’s-90’s there was a lot of interest brought on by cases of multiple personality being brought into public eye, new research in hypnosis etc. Recently interest in dissociative disorders has waned once again. Dissociative Disorders  Characterized by serious maladaptive disruptions or alterations of identity, memory, and consciousness that are experienced as being beyond one’s control.  The defining symptom is dissociation, which is the lack of normal integration of thoughts, feelings and experiences in consciousness and memory.  Simple things such as knowing who we are, our names, where we live etc are all bizarrely disturbed and remain un-integrated for people with these disorders.  It is possible to have very mild cases of dissociative disorders. These would be for instance when you daydream or get lost in thought and forget about your surroundings or the passing of time. As long as you can snap out of it then there is no reason for concern.  The problem is when people are unable to control these drifts of consciousness or they affect ability to function in daily life.  Research by Waller, Putnam, and Carlson indicated that dissociative disorders fall into 2 groups: o The first group involves mild, non-pathological forms of dissociation, such as things that are normally distributed across the general population on a continuum of sorts. o Second group involves more serious, pathological types of experiences, such as amnesia, identity alteration, depersonalization, that do not occur normally across the population.  Psychological trauma and emotional distress are causal factors  Four main types of dissociative disorders that will be discussed in this chapter are: dissociative amnesia, dissociative fugue, depersonalization disorder, and dissociative identity disorder.  To determine the prevalence in the general population doctors constructed structured clinical interviews with a representative sample of adults. 9.1% could be diagnosed with dissociative disorder. There was no difference between men and women, but it was slightly more common in younger vs older people. Dissociative Amnesia  Primary symptom is the inability to recall significant personal information in the absence of organic impairment.  Typically occurs following a traumatic event  Individuals typically have no memory of the traumatic event and may not be able to recall own name, occupation or other facts about themselves even though they might be able to retain general knowledge of world events.  Sometimes after being in a safe environment for a few days the person’s amnesia stops, other times it can be more chronic or recurrent.  5 patterns of memory loss characteristic of dissociative amnesia are: 1. Localized amnesia – person fails to recall information from a very specific time period 2. Selective Amnesia – only parts of the trauma are forgotten, while others are remembered. 3. Generalized Amnesia – person forgets all personal information from their past 4. Continuous Amnesia – individual forgets information from specific date until the present 5. Systematized Amnesia – individual only forgets certain categories of information such as certain people or places.  The first two are the most common types  False memory syndrome  a proposed syndrome where people are influenced by their therapists to remember events that never occurred. Dissociative Fugue  An extremely rare and unusual condition where the individual travels suddenly and unexpectedly and later discovers that they are in a new place; unable to remember why or how they got there.  Usually only last a few days or weeks, but sometimes individual disappears for long amounts of time.  They tend to take on a new identity and occupation  Confusion will only happen if they are questioned about their personal history, other than that they tend to function reasonably well.  When they recover from this state, the report having no memory of what occurred  Incidences seem to occur for many more people after times of high stress, such as war or a natural disaster. Depersonalization Disorder  Depersonalization is an experience in which individuals feel a sense of unreality and detachment from themselves.  Feelings like this are relatively common among population (about half the general population reports such symptoms…especially when under stress)  A diagnosis is only made when symptoms are persistent and cause clinically significant impairment or distress.  Depersonalization Disorder is experiencing recurrent episodes of depersonalization, describing the experiences as if they are living in a dream  Describe it commonly as feeling like a robot that can respond to the environment but with no feeling of connection.  Often combined with episodes of derealization – an experience of detachment, unreality, and altered relationship to the outside world  Depersonalization disorder is only diagnosed when severe depersonalization and derealization are the primary problem  Typically begins in adolescence and is chronic  Highly related to trauma, specifically emotional abuse  Brain abnormalities in perceptual pathways may play a role in the mechanisms for these deficits Dissociative Identity Disorder (DID)  Formerly known as multiple personality disorder  It’s diagnosed when the patient presents with two or more distinct personality states that regularly take control of the patient’s behaviour.  The individuals inability to recall information is too extensive to be explained by normal forgetting  Typically in DID one of the personalities is identified as the “host” whereas other personalities are identified as “alters”  Each personality is distinct and presents with different memories, personal histories, and mannerisms  Personalities can identify themselves as male, female, child, adult, or animals  Host personality may or may not be aware of the presence of one or more of the alters and may report strange occurrences such as strangers claiming to know them.  Average number of personalities an individual has is 13-16  Process of changing from one personality to another is simply referred to as switching. Often occurring in response to a stressful situation  Change in the personalities may lead to change of tone of voice, demeanor, or posture of the individual  Average age of diagnosis is 29-35 years  Self-destructive behaviour is common, over 75% have suicide attempts and 90% report recurrent suicidal thoughts Etiology  Two competing explanatory models have been proposed: the trauma model and the socio-cognitive model.  Trauma Model  is a diathesis-stress formulation, has a long history and continues to be widely accepted. According to this dissociative disorder are a result of severe childhood trauma accompanied by personality traits that predispose the individual to employ dissociation as a defense mechanism or coping strategy.  The defense mechanism is no longer adaptive when it is maintained as a habitual way of coping throughout adulthood.  People who are low in dissociative tendencies may develop anxious, intrusive thoughts rather than a dissociative reaction.  Might be a genetic heritability component to these personality traits makes some people more vulnerable.  Attachment theory can also help explain why some are more vulnerable  Sensitive responding by the parent to an infant’s needs results in a child who demonstrates secure attachment, developing the skills
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