Comer, Abnormal Psychology DSM-5 Update, 8e Disorders Focusing on Somatic and Dissociative Symptoms...

Comer, Abnormal PsychologyDSM-5 Update, 8e

Disorders Focusing on Somatic and

Dissociative Symptoms

Chapter 7

Slides & Handouts by Karen Clay Rhines, Ph.D.American Public University System

2Comer, Abnormal Psychology,8e

DSM-5 Update

Disorders Focusing on Somatic and Dissociative Symptoms

In addition to disorders covered earlier, stress and anxiety also contribute to several other kinds of disorder, particularly disorders that focus on somatic and dissociative symptoms


DSM-5 Update

Disorders Focusing on Somatic Symptoms

In these disorders, the somatic symptoms are primarily caused by psychosocial factors or the symptoms trigger excessive anxiety and concern These disorders are different than

psychophysiological disorders, in which psychosocial factors interact with genuine physical ailments


DSM-5 Update

Disorders Focusing on Dissociative Symptoms

Dissociative disorders are each characterized by significant memory loss or identity disruption


DSM-5 Update

Disorders Focusing on Somatic and Dissociative Symptoms

Disorders that focus on somatic symptoms and those that focus on dissociative symptoms have much in common:

Both may occur in response to severe stress Both have traditionally been viewed as forms of

escape from stress A number of individuals suffer from both a

somatic-related and a dissociative disorder Theorists and clinicians often explain and treat

the two groups of disorders in similar ways

Disorders Focusing on Somatic Symptoms

DSM-5 lists a number of disorders in which bodily symptoms or concerns are the primary features


DSM-5 Update

Factitious Disorder

Sometimes when physicians cannot find a medical cause for a patient’s symptoms, he or she may suspect other factors are involved. Patients may malinger, intentionally fake

illness to achieve external gain (e.g., financial compensation, military deferment)

Patients may be manifesting a factitious disorder - intentionally producing or faking symptoms simply out of a wish to be a patient


DSM-5 Update

Factitious Disorder

Known popularly as Munchausen syndrome, people with a factitious disorder often go to extremes to create the appearance of illness Many secretly give themselves

medications to produce symptoms Patients often research their supposed

ailments and are impressively knowledgeable about medicine


DSM-5 Update

Factitious Disorder

Clinical researchers have a hard time determining the prevalence of this disorder as patients hide the true nature of their problem Overall, the pattern appears to be more

common in women than men and the disorder usually begins during early adulthood


DSM-5 Update

Factitious Disorder

Factitious disorder seems to be particularly common among people who (a) received extensive medical treatment as children, (2) carry a grudge against the medical profession, or (3) have worked as a nurse, lab technician, or medical aide


DSM-5 Update

Factitious Disorder

The precise causes of factitious disorder are not understood, although clinical reports have pointed to factors such as depression unsupportive parental relationships, and an extreme need for social support


DSM-5 Update

Factitious Disorder

Psychotherapists and medical practitioners often become angry at people with a factitious disorder, feeling that they are wasting their time People with the disorder, however, feel

they have no control over their problems and often experience great distress


DSM-5 Update


DSM-5 Update

Factitious Disorder

In a related pattern, factitious disorder imposed on another, known popularly as Munchausen syndrome by proxy, parents make up or produce physical illnesses in their children

Conversion Disorder

Conversion disorder People with this disorder display

physical symptoms that affect voluntary motor or sensory functioning, but the symptoms are inconsistent with known medical diseases

In short, the individuals experience neurological-like symptoms – blindness, paralysis, or loss of feeling – that have no neurological basis


DSM-5 Update

Conversion Disorder

Conversion disorder often is hard to distinguish from genuine medical problems It is always possible that a diagnosis of

conversion disorder is a mistake and the patient’s problem has an undetected medical cause

Physicians sometimes rely on oddities in the patient’s medical picture to help distinguish the two For example, conversion symptoms may be at

odds with the known functioning of the nervous system, as in cases of glove anesthesia


DSM-5 Update

Conversion Disorder

Unlike people with factitious disorder, those with conversion disorder don’t consciously want or produce their symptoms This pattern is called “conversion”

disorder because clinical theorists used to believe that individuals with the disorders are converting psychological needs into neurological symptoms


DSM-5 Update

Conversion Disorder

Conversion disorder usually begins between late childhood and young adulthood It is diagnosed in women twice as often

as in men

It typically appears suddenly, at times of stress

It is thought to be rare, occurring in at most 5 of every 1,000 persons


DSM-5 Update

Somatic Symptom Disorder

People with somatic symptom disorder become excessively distressed, concerned, and anxious about bodily symptoms that they are experiencing

Two patterns of somatic symptom disorder have received particular attention: Somatization pattern Predominant pain pattern


DSM-5 Update


People with a somatization pattern experience many long-lasting physical ailments that have little or no organic basis Also known as Briquet’s syndrome

A sufferer’s ailments often include pain symptoms, gastrointestinal symptoms, sexual symptoms, and neurological symptoms Patients usually go from doctor to doctor in

search of relief


DSM-5 Update


Somatization pattern Patients with this pattern often describe

their symptoms in dramatic and exaggerated terms

Most also feel anxious and depressed

The pattern typically lasts for many years

Symptoms may fluctuate over time but rarely disappear completely without therapy


DSM-5 Update


DSM-5 Update


Somatization pattern Between 0.2% and 2% of all women in

the U.S. experience a somatization pattern in any given year (compared with less than 0.2% of men)

The pattern often runs in families and begins between adolescence and young adulthood


Predominant pain pattern If the primary feature of somatic symptom

disorder is pain, the individual is said to have a predominant pain pattern

Although the precise prevalence has not been determined, this pattern appears to be fairly common

The pattern often develops after an accident or illness that has caused genuine pain

The pattern may begin at any age, and more women than men seem to experience it


DSM-5 Update

What Causes Conversion and Somatic Symptom Disorders?

For many years, conversion and somatic symptom disorders were referred to as hysterical disorders This label was to convey the prevailing belief

that excessive and uncontrolled emotions underlie the bodily symptoms

Today’s leading explanations come from the psychodynamic, behavioral, cognitive, and multicultural models None has received much research support,

and the disorders are still poorly understood


DSM-5 Update


DSM-5 Update


The psychodynamic view Freud believed that hysterical disorders

represented a conversion of underlying emotional conflicts into physical symptoms

Because most of his patients were women, Freud centered his explanation on the psychosexual development of girls and focused on the phallic stage (ages 3 to 5)…


The psychodynamic view During this stage, girls develop a pattern of sexual

desires for their fathers (the Electra complex) and recognize that they must compete with their mothers for his attention

Because of the mother’s more powerful position, however, girls repress these sexual feelings

Freud believed that if parents overreact to such feelings, the Electra complex would remain unresolved and the child might re-experience sexual anxiety throughout her life

Freud concluded that some women unconciously hide their sexual feelings in adulthood by converting them into physical symptoms


DSM-5 Update


The psychodynamic view Today’s psychodynamic theorists take

issues with parts of Freud’s explanation They continue to believe that sufferers of

these disorders have unconscious conflicts carried from childhood


DSM-5 Update


The psychodynamic view Psychodynamic theorists propose that

two mechanisms are at work in hysterical disorders:

Primary gain: bodily symptoms keep internal conflicts out of conscious awareness

Secondary gain: bodily symptoms further enable people to avoid unpleasant activities or receive sympathy from others


DSM-5 Update


The behavioral view Behavioral theorists propose that the

physical symptoms of hysterical disorders bring rewards to sufferers

May remove individual from an unpleasant situation

May bring attention from other people


DSM-5 Update


In response to such rewards, people learn to display symptoms more and more

This focus on rewards is similar to the psychodynamic idea of secondary gain, but behaviorists view the gains as the primary cause of the development of the disorder

Like the psychodynamic explanation, the behavioral view of these disorders has received little research support


DSM-5 Update


The cognitive view Some cognitive theorists propose that

hysterical disorders are a form of conversion and somatic symptom disorder, providing a means for people to express difficult emotions


DSM-5 Update


Like psychodynamic theorists, cognitive theorists hold that emotions are being converted into physical symptoms This conversion is not to defend against

anxiety but to communicate extreme feelings

Like the other explanations, this cognitive view has not been widely tested or supported by research


DSM-5 Update


The multicultural view Some theorists believe that Western clinicians

hold a bias that sees somatic symptoms as an inferior way of dealing with emotions

The transformation of personal distress into somatic complaints is the norm is many non-Western cultures

The lesson to be learned from multicultural findings is that both bodily and psychological reactions to life events are often influenced by one's culture


DSM-5 Update


A possible role for biology The impact of biological processes on somatoform

disorders can be understood through research on placebos and the placebo effect

Placebos: substances with no known medicinal value Treatment with placebos has been shown to bring

improvement to many – possibly through the power of suggestion but likely because expectation triggers the release of endogenous chemicals

Perhaps traumatic events and related concerns or needs can also trigger our “inner pharmacies” and set in motion the bodily symptoms of hysterical somatoform disorders


DSM-5 Update

How Are Conversion and Somatic Symptom Disorders

Treated? People with these disorders usually

seek psychotherapy only as a last resort


DSM-5 Update


Treated? Many therapists focus on the causes of

the disorders and apply techniques including: Insight – often psychodynamically oriented

Exposure – client thinks about traumatic event(s) that triggered the physical symptoms

Drug therapy – especially antidepressant medication


DSM-5 Update


Treated? Other therapists try to address the physical

symptoms of these disorders, applying techniques such as: Suggestion – usually an offering of emotional

support that may include hypnosis Reinforcement – a behavioral attempt to

change reward structures Confrontation – an overt attempt to force

patients out of the sick role Researchers have not fully evaluated the

effects of these particular approaches on these disorders


DSM-5 Update


DSM-5 Update

Illness Anxiety Disorder

People with illness anxiety disorder, previously known as hypochondriasis, experience chronic anxiety about their health and are concerned that they are developing a serious medical illness, despite the absence of somatic symptoms


DSM-5 Update


They repeatedly check their bodies for signs of illness and misinterpret bodily symptoms as signs of a serious illness

Often their symptoms are merely normal bodily changes, such as occasional coughing, sores, or sweating

Although some patients recognize that their concerns are excessive, many do not


Although this disorder can begin at any age, it starts most often in early adulthood, among men and women in equal numbers Between 1% and 5% of all people

experience the disorder

For most patients, symptoms rise and fall over the years


DSM-5 Update


Theorists explain this disorder much as they explain various anxiety disorders: Behaviorists: classical conditioning or

modeling

Cognitive theorists: oversensitivity to bodily cues


DSM-5 Update


Individuals with illness anxiety disorder typically receive the kinds of treatments applied to OCD: Antidepressant medication

Exposure and response prevention (ERP)

Cognitive-behavioral therapies


DSM-5 Update

Body Dysmorphic Disorder

People with this disorder, also known as dysmorphobia, become deeply concerned about some imagined or minor defect in their appearance Most often they focus on wrinkles,

spots, facial hair, swelling, or misshapen facial features (nose, jaw, or eyebrows)


DSM-5 Update


As many as half of people with this disorder seek plastic surgery or dermatology treatment, and often they feel worse rather than better afterward

Most cases of the disorder begin in adolescence but are often not revealed until adulthood Up to 5 percent of people in the United

States experience BDD, and it appears to be equally common among women and men


DSM-5 Update


Theorists typically account for BDD by using the same kinds of explanations – both physical and psychological – that have been applied to anxiety disorders and OCD

Similarly, clinicians typically treat clients with this disorder by applying the kinds of treatment used with OCD, particularly anti-depressant drugs, exposure and response prevention, and cognitive therapy


DSM-5 Update

Dissociative Disorders

The key to our identity – the sense of

who we are and where we fit in our environment – is memory Our recall of past experiences helps us

to react to present events and guides us in making decisions about the future

People sometimes experience a major disruption of their memory


DSM-5 Update


When such changes in memory lack a clear physical cause, they are called “dissociative” disorders In such disorders, one part of the

person’s memory typically seems to be dissociated, or separated, from the rest


DSM-5 Update


There are several kinds of dissociative disorders, including: Dissociative amnesia Dissociative identity disorder (multiple

personality disorder) Depersonalization-derealization disorder

These disorders are often memorably portrayed in books, movies, and television programs


DSM-5 Update

Dissociative Amnesia

People with dissociative amnesia are unable to recall important information, usually of an upsetting nature, about their lives The loss of memory is much more

extensive than normal forgetting and is not caused by physical factors

Often an episode of amnesia is directly triggered by a specific upsetting event


DSM-5 Update


Dissociative amnesia may be: Localized – most common type; loss of all memory

of events occurring within a limited period Selective – loss of memory for some, but not all,

events occurring within a period Generalized – loss of memory beginning with an

event, but extending back in time; may lose sense of identity; may fail to recognize family and friends

Continuous – forgetting continues into the future; quite rare in cases of dissociative amnesia


DSM-5 Update


All forms of the disorder are similar in that the amnesia interferes mostly with a person’ Memory for abstract or encyclopedic

information – usually remains intact

Clinicians do not known how common dissociative amnesia is, but many cases seem to begin serious threats to health and safety


DSM-5 Update

Dissociative Fugue

An extreme version of dissociative amnesia is dissociative fugue People with dissociative fugue not only forget

their personal identities and details of their past, but also flee to an entirely different location

For some, the fugue is brief – a matter of hours or days – and ends suddenly

For others, the fugue is more severe: people may travel far from home, take a new name and establish new relationships, and even a new line of work; some display new personality characteristics


DSM-5 Update

Dissociative Fugue

~0.2% of the population experience dissociative fugue It usually follows a severely stressful event

Fugues tend to end abruptly When people are found before their fugue has

ended, therapists may find it necessary to continually remind them of their own identity

The majority of people regain most or all of their memories and never have a recurrence


DSM-5 Update

Dissociative Identity Disorder (Multiple

Personality Disorder) A person with dissociative identity

disorder (DID; formerly multiple personality disorder) develops two or more distinct personalities (subpersonalities) each with a unique set of memories, behaviors, thoughts, and emotions


DSM-5 Update


Personality Disorder) At any given time, one of the

subpersonalities dominates the person’s functioning Usually one of these subpersonalities –

called the primary, or host, personality – appears more often than the others

The transition from one subpersonality to the next (“switching”) is usually sudden and may be dramatic


DSM-5 Update


Personality Disorder) Cases of this disorder were first

reported almost three centuries ago Many clinicians consider the disorder to

be rare, but some reports suggest that it may be more common than once thought


DSM-5 Update


Personality Disorder) Most cases are first diagnosed in

late adolescence or early adulthood Symptoms generally begin in childhood

after episodes of abuse Typical onset is before age 5

Women receive the diagnosis three times as often as men


DSM-5 Update


Personality Disorder) How do subpersonalities interact?

The relationship between or among subpersonalities varies from case to case

Generally there are three kinds of relationships: Mutually amnesic relationships – subpersonalities

have no awareness of one another Mutually cognizant patterns – each subpersonality

is well aware of the rest One-way amnesic relationships – most common

pattern; some personalities are aware of others, but the awareness is not mutual

Those who are aware (“co-conscious subpersonalities”) are “quiet observers”


DSM-5 Update


Personality Disorder) How do subpersonalities interact?

Investigators used to believe that most cases of the disorder involved two or three subpersonalities

Studies now suggest that the average number is much higher – 15 for women, 8 for men

There have been cases of more than 100!


DSM-5 Update


Personality Disorder) How do subpersonalities differ?

Subpersonalities often display dramatically different characteristics, including:

Identifying features Subpersonalities may differ in features as basic as

age, sex, race, and family history Abilities and preferences

Although encyclopedic information is not usually affected by dissociative amnesia or fugue, in DID it is often disturbed

It is not uncommon for different subpersonalities to have different abilities, including being able to drive, speak a foreign language, or play an instrument


DSM-5 Update


Personality Disorder) How do subpersonalities differ?

Subpersonalities often display dramatically different characteristics, including:

Physiological responses Researchers have discovered that

subpersonalities may have physiological differences, such as differences in autonomic nervous system activity, blood pressure levels, and allergies


DSM-5 Update


Personality Disorder) How common is DID?

Traditionally, DID was believed to be rare

Some researchers even argue that many or all cases are iatrogenic; that is, unintentionally produced by practitioners

These arguments are supported by the fact that many cases of DID first come to attention only after a person is already in treatment

Not true of all cases


DSM-5 Update


Personality Disorder) How common is DID?

The number of people diagnosed with the disorder has been increasing

Although the disorder is still uncommon, thousands of cases have been documented in the U.S. and Canada alone

Two factors may account for this increase: A growing number of clinicians believe that the disorder

does exist and are willing to diagnose it Diagnostic procedures have become more accurate

Despite changes, many clinicians continue to question the legitimacy of this category


DSM-5 Update

How Do Theorists Explain Dissociative Disorders?

A variety of theories have been proposed to explain dissociative disorders Older explanations have not received

much investigation

Newer viewpoints, which combine cognitive, behavioral, and biological principles, have captured the interest of clinical scientists


DSM-5 Update


The psychodynamic view Psychodynamic theorists believe that

dissociative disorders are caused by repression, the most basic ego defense mechanism

People fight off anxiety by unconsciously preventing painful memories, thoughts, or impulses from reaching awareness


DSM-5 Update


DSM-5 Update


The psychodynamic view In this view, dissociative amnesia and

fugue are single episodes of massive repression

DID is thought to result from a lifetime of excessive repression, motivated by very traumatic childhood events


The psychodynamic view Most of the support for this model is

drawn from case histories, which report brutal childhood experiences, yet:

Some individuals with DID do not seem to have these experiences of abuse

Further, why might only a small fraction of abused children develop this disorder?


DSM-5 Update


The behavioral view Behaviorists believe that dissociation grows from

normal memory processes and is a response learned through operant conditioning:

Momentary forgetting of trauma leads to a drop in anxiety, which increases the likelihood of future forgetting

Like psychodynamic theorists, behaviorists see dissociation as escape behavior

Also like psychodynamic theorists, behaviorists rely largely on case histories to support their view of dissociative disorders

Moreover, these explanations fail to explain all aspects of these disorders


DSM-5 Update


State-dependent learning If people learn something when they are

in a particular state of mind, they are likely to remember it best when they are in the same condition

This link between state and recall is called state-dependent learning

This model has been demonstrated with substances and mood and may be linked to arousal levels


DSM-5 Update


State-dependent learning People who are prone to develop

dissociative disorders may have state-to-memory links that are unusually rigid and narrow; each thought, memory, and skill is tied exclusively to a particular state of arousal, so that they recall a given event only when they experience an arousal state almost identical to the state in which the memory was first acquired


DSM-5 Update


Self-hypnosis Although hypnosis can help people remember

events that occurred and were forgotten years ago, it can also help people forget facts, events, and their personal identity

Called “hypnotic amnesia,” this phenomenon has been demonstrated in research studies with word lists

The parallels between hypnotic amnesia and dissociative disorders are striking and have led researchers to conclude that dissociative disorders may be a form of self-hypnosis


DSM-5 Update

How Are Dissociative Disorders Treated?

People with dissociative amnesia often recover on their own Only sometimes do their memory problems

linger and require treatment

In contrast, people with DID usually require treatment to regain their lost memories and develop an integrated personality Treatment for dissociative amnesia tends to

be more successful than treatment for DID


DSM-5 Update


How do therapists help people with dissociative amnesia? The leading treatments for these disorders are

psychodynamic therapy, hypnotic therapy, and drug therapy

Psychodynamic therapists guide patients to search their unconscious and bring forgotten experiences into consciousness

In hypnotic therapy, patients are hypnotized and guided to recall forgotten events

Sometimes intravenous injections of barbiturates are used to help patients regain lost memories

Often called “truth serums,” the key to the drugs’ success is their ability to calm people and free their inhibitions


DSM-5 Update


How do therapists help individuals with DID? Unlike victims of dissociative amnesia,

people with DID do not typically recover without treatment

Treatment for this pattern, like the disorder itself, is complex and difficult


DSM-5 Update


How do therapists help individuals with DID? Therapists usually try to help the client by:

Recognizing the disorder Once a diagnosis of DID has been made, therapists try to

bond with the primary personality and with each of the subpersonalities

As bonds are forged, therapists try to educate the patients and help them recognize the nature of the disorder

Some use hypnosis or video as a means of presenting other subpersonalities

Many therapists recommend group or family therapy


DSM-5 Update



Recovering memories To help patients recover missing memories, therapists

use many of the approaches applied in other dissociative disorders, including psychodynamic therapy, hypnotherapy, and drug treatment

These techniques tend to work slowly in cases of DID


DSM-5 Update



Integrating the subpersonalities The final goal of therapy is to merge the different

subpersonalities into a single, integrated identity Integration is a continuous process; fusion is the final

merging Many patients distrust this final treatment goal and

their subpersonalities see integration as a form of death Once the subpersonalities are integrated, further therapy is

typically needed to maintain the complete personality and to teach social and coping skills to prevent later dissociations


DSM-5 Update

Depersonalization-Derealization Disorder

DSM-5 categorizes depersonalization-derealization disorder as a dissociative disorder, even though it is not characterized by memory difficulties


DSM-5 Update


The central symptom is persistent and recurrent episodes of depersonalization (a change in one’s experience of the self in which one’s mental functioning or body feels unreal or detached) and/or derealization (the sense that one’s surroundings are unreal or detached)


DSM-5 Update


People with this disorder feel as though they have become separated from their body and are observing themselves from outside This sense of unreality can extend to

other sensory experiences and behavior


DSM-5 Update


In contrast to depersonalization, derealization is characterized by the feeling that the external world is unreal and strange


DSM-5 Update


Depersonalization and derealization experiences by themselves do not indicate a disorder Transient depersonalization or derealization

reactions are fairly common

The symptoms of a depersonalization-derealization disorder are persistent or recurrent, cause considerable distress, and interfere with social relationships and job performance


DSM-5 Update


The disorder occurs most frequently in adolescents and young adults, hardly ever in people older than 40 The disorder comes on suddenly and

tends to be long-lasting

Few theories have been offered to explain this disorder


DSM-5 Update

Comer, Abnormal Psychology DSM-5 Update, 8e Disorders Focusing on Somatic and Dissociative Symptoms...

Documents

Transcript of Comer, Abnormal Psychology DSM-5 Update, 8e Disorders Focusing on Somatic and Dissociative Symptoms...