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Chapter 6

Ch. 6 Dissociative and Somatoform Disorders.pdf

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PSYC 3230
James Alcock

6. Dissociative and Somatoform Disorders Monday, February 11, 2019:00 AM Learningobjectives 1) Describe the symptoms and clinical features of the major dissociative disorders. 2) Compare and contrast two competing theories of the etiology of dissociative identity disorder. 3) Describe the symptoms and clinical features of the major somatoform disorders. 4) Explain how biological, psychological, and social-environmental factors can work together to cause somatoform disorders. 5) Discuss the goals and methods of contemporary psychological treatments for somatoform disorders. Introduction • Dissociative disorders include a wide range of different symptoms that involve severe disruptions in consciousness, memory, and identity • Somatoform disorders include conditions in which individuals complain about a physical defect or dysfunction for which no medical explanation can be found • Many clinicians and researchers believe that these disorders result from maladaptive ways of coping with extreme stress • Although dissociative and somatoform disorders are classified as two separate diagnostic categories in the DSM-IV-TR, they are strongly linked historically and share common features Historicalperspective • The dissociative and some of the somatoform disorders were once viewed as expressions of hysteria-- a term used to describe a symptom pattern characterized by emotional excitability and physical symptoms (e.g., convulsions, paralyses, numbness, loss of vision) in the absence of any evident organic cause • Plato believed these symptoms were caused in women by a wandering womb • With the rise of Christianity, organic theories of hysteria were replaced by supernatural explanations: dissociations and related complaints were now seen as the result of demonic possession, and exorcism was the favored treatment • Josef Breuer and Freud posited that trauma, often sexual, was a predisposing factor for hysteria and established a relationship between dissociation and hypnotic-like states • Freud believed that dissociation and other intrapsychic defenses developed in order to protect individuals from their unacceptable sexual impulses, not from real traumatic memories • Freud suggested 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 called primary gain (primary reinforcement for somatoform symptoms) ○ Secondary gain-- the benefits of assuming a sick role (i.e., attention and sympathy) • Many researchers now believe that dissociative disorders were overdiagnosed in recent decades (1970s-1990s) when they enjoyed a brief "bubble" of fashion that has now declined Dissociativedisorders • Dissociative disorders-- characterized by severe maladaptive disruptions or alterations of identity, memory, and consciousness that are experienced as being beyond one's control and consciousness that are experienced as being beyond one's control • Dissociation-- the defining symptom of these disorders; the lack of normal integration of thoughts, feelings, and experiences in consciousness and memory • Dissociation itself is not necessarily pathological, but becomes problematic when one is unable to control these drifts of consciousness or behavior and they affect one's ability to function in everyday life (i.e., the person cannot "snap out of it") • Two groups of dissociative experiences 1) Mild, non-pathological forms of dissociation, such as absorption and imaginative involvement, that are normally distributed on a continuum across the general population 2) More severe, pathological types of experiences, such as amnesia, derealization, depersonalization, and identity alteration, that do not normally occur in the general population and that form a discrete category or taxon  Psychological trauma and emotional distress are commonly viewed as causal factors • 4 dissociative disorders: ○ Dissociative amnesia ○ Dissociative fugue ○ Depersonalization disorder ○ Dissociative identity disorder (formerly multiple personality disorder) • False memory syndrome-- a proposed condition in which people are induced by therapists to remember events that never occurred (e.g., childhood sexual abuse) Prevalence • As many as 15 to 21% of inpatients in Canada have some kind of dissociative disorder • 9.1% of general population • No differences in prevalence between men and women • More common in younger than older adults • High rates of comorbidity with other psychological disorders, including anxiety disorders, mood disorders, and personality disorders Dissociativeamnesia • The primary symptom is the inability to recall significant personal information in the absence of organic impairment • Typically occurs following a traumatic event, such as an automobile accident or battlefield experiences during wartime • Usually have no memory of the precipitating event • May be unable to recall autobiographical information, while retaining general knowledge • 5 patterns of memory loss: 1) Localized amnesia-- information is lost from a very specific time period 2) Selective amnesia-- parts of the trauma are forgotten while other parts are remembered 3) Generalized amnesia-- the person forgets all personal information from his or her past 4) Continuous amnesia-- the individual forgets information from a specific date until the present 5) Systematized amnesia-- only certain categories of information are forgotten, such as certain people or places • The latter three types of amnesia are less common and usually associated with dissociative identity disorder Dissociativefugue • Extremely rare and unusual condition in which an individual travels suddenly and unexpectedly away from • Extremely rare and unusual condition in which an individual travels suddenly and unexpectedly away from home, accompanied by a loss of memory for one's past and personal identity • Frequently, the individual has left behind an intolerable situation • Usually lasts a few days to a few weeks • Individuals are able to function and may even successfully adopt a new identity and occupation if the disorder is prolonged • May end abruptly or gradually • Often, those who have recovered from the disorder report no memory of what occurred during the fugue state • Incidence increases during times of greater stress, such as wartime or following a natural disaster • DSM-5: No longer a separate diagnosis, part of dissociative amnesia Depersonalizationdisorder • Depersonalization is an experience in which individuals feel a sense of unreality and detachment from themselves • Relatively common, approximately half the general population reports such symptoms, often during times of stress • Depersonalization is the third most commonly reported clinical symptom among psychiatric disorders, after depression and anxiety • Depersonalization disorder is diagnosed only when severe depersonalization is the primary problem, and when the symptoms are persistent and cause clinically significant impairment or distress • Recurrent episodes of depersonalization, in which the individual fells as though they are living in a dream, observing their own mental processes or body from the outside, or as if time is moving slowly • Derealization-- an experience of detachment and altered relationship to the surrounding world, in which the person perceives people and objects in the environment as unreal, dreamlike, distant, or distorted • Unlike other dissociative disorders, depersonalization disorder does not tend to be characterized by memory impairment or identity confusion • Typically begins in adolescence, chronic in nature • Related to a history of trauma, particularly emotional abuse • Reduced emotional reactivity to stressful or emotionally arousing stimuli Dissociativeidentitydisorder • Dissociative identity disorder (DID)-- diagnosed when the patient presents with two or more distinct personality states that regularly take control of the patient's behavior • Typically, one the personalities is identified as the "host," and subsequent personalities are identified as alters • Each personality is distinct and presents with different memories, personal histories, and mannerisms • Different personalities may be male, female, adult, child, or even animal • The host personality may or may not be aware of the presence of one or more of the alters • Average number of alters is typically 13-16 • Switching-- the process of changing from one personality to another ○ Often occurs in stressful situations • 3 to 9 times more frequent in women • Average age of diagnosis is 29-35 • Self-destructive behavior is common • 4 diagnostic criteria: 1) Presence of two or more distinct identities or personality states 2) At least two of these identities or personality states recurrently take control of the person's behavior 2) At least two of these identities or personality states recurrently take control of the person's behavior 3) Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness 4) Not due to a substance or medical condition • Debate among mental health professionals about the prevalence and legitimacy of the diagnosis Etiology • Knowledge of etiology is minimal compared to other Axis I disorders • Two competing explanatory models: ○ Trauma model-- dissociative disorders result from severe childhood trauma, including sexual, physical, and emotional abuse, accompanied by personality traits that predispose the individual to employ dissociation as a defense mechanism or coping strategy  Certain personality traits, such as high hypnotizability, fantasy proneness, and openness to altered states of consciousness may represent a diathesis, predisposing some individuals to develop dissociative experiences in the face of trauma  There may be a genetic heritability component to these personality traits that make some individuals more vulnerable to dissociative disorders  Attachment theory can also help to explain why some people are more vulnerable to dissociative disorders than others; disorganized attachment may be a risk factor for the development of pathological dissociation in adult life ○ Socio-cognitive model-- multiple personality disorder is a form of role-playing in which individuals come to construe themselves as possessing multiple selves and then begin to act in ways consistent with their own or their therapist's conception of the disorder  Individuals are not faking or malingering their illness, but it is entirely possible to alter one's personal history so that it is consistent with the belief that one has DID  Accepted by mental health professionals who do not accept DID as a legitimate disorder  Iatrogenic condition-- literally a condition "caused by treatment" • A critical issue dividing these two theories is whether or not DID actually develops in childhood as a result of abuse ○ DID is usually diagnosed in adults and almost never observed during childhood when it is supposed to begin Treatment Psychotherapy • Most psychotherapies for dissociative disorders focus on helping patients resolve emotional distress associated with past traumas and learn more effective ways of coping with stress in their lives • The first stage of therapy involves the establishment of a trusting, safe environment for the patient to discuss emotionally charged memories of past traumas • The next stage involves helping patients develop new coping skills that will be required when discussions of past history of abuse take place • The final stage in the treatment of DID involves the integration of the personalities Hypnosis • The use of
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