Somatic Symptom and Related Disorders and Dissociative Disorders

Somatic Symptom and Related Disorders and Dissociative Disorders

Chapter 6

Somatic symptom and Related Disorders and Dissociative Disorders

Chapter Overview

This chapter outlines the primary features of somatic symptom and related disorders and dissociative disorders.With respect to the former, the symptoms, prevalence, etiology, and treatment of somatic symptom disorder, illness anxiety disorder, and conversion disorder (functional neurological symptom disorder) are discussed, as well as psychological factors affecting a medical condition.For dissociative disorders, depersonalization-derealization disorder and dissociative amnesia (including dissociative fugue states) are discussed.The chapter also describes the relation between malingering and factitious disorders in the context of conversion reactions and dissociative identity disorder.In addition, the major characteristics of dissociative trance and dissociative identity disorder are described, including available treatment approaches.

Chapter Outline

SOMATIC SYMPTOM AND RELATED DISORDERS

Somatic Symptom Disorder

Illness Anxiety Disorder

Clinical description

Statistics

Causes

Treatment

Psychological Factors Affecting Medical Condition

Conversion Disorder (Functional Neurological Symptom Disorder

Clinical Description

Closely Related Disorders

Unconscious Mental Processes

Statistics

Causes
Treatment

DISSOCIATIVE DISORDERS

Depersonalization-Derealization Disorder

Dissociative Amnesia

Dissociative Identity DisorderClinical Description

Characteristics

Can DID Be Faked?

Statistics

Causes

Suggestibility

Biological Contributions

Real Memories and False

Treatment

Detailed Outline

Somatic Symptom and RelatedDisorders

Individuals with somatic symptom and relateddisorders are pathologically concerned with the appearance or functioning of their bodies and bring these concerns to the attention of health professionals, who usually find no identifiable medical basis for the physical complaints.

There are several types of somatic symptomdisorders. Somatic symptom disorder is characterized by a focus on one or more physical symptoms accompanied by marked anxiety and distress focused on the symptom that is disproportionate to the nature or severity of the physical symptoms. This condition may dominate the individual’s life and interpersonal relationships. Illness anxiety disorder is a condition in which individuals believe they are seriously ill and become anxious over this possibility, even though they are not experiencing any notable physical symptoms at the time. In conversion disorder, there is physical malfunctioning, such as paralysis, without any apparent physical problems. Distinguishing among conversion reactions, real physical disorders, and outright malingering, or faking, is sometimes difficult. Even more puzzling can be factitious disorder, in which the person’s symptoms are feigned and under voluntary control, as with malingering, but for no apparent reason.

Discussion Point:

What are some examples of normal physical symptoms that someone with somatic symptom disordermight interpret catastrophically?

Discussion Point:

How might a psychologist detect the difference between headaches due to physical factors and those that might be conversion symptoms?

The causes of somatic symptomdisorders are not well understood, but seem closely related to anxiety disorders.

Treatment of somatic symptom disorders ranges from basic techniques of reassurance and social support to those meant to reduce stress and remove any secondary gain for the behavior. Recently, specifically tailored cognitive-behavioral therapy has proved successful with these conditions.

Dissociative Disorders

Dissociative disorders are characterized by alterations in perceptions: a sense of detachment from one’s own self, from the world, or from memories.

Dissociative disorders include depersonalization-derealization disorder, in which the individual’s sense of personal reality is temporarily lost (depersonalization), as is the reality of the external world (derealization). In dissociative amnesia, the individual may be unable to remember important personal information. In generalized amnesia, the individual is unable to remember anything; more commonly, the individual is unable to recall specific events that occur during a specific period (localized or selective amnesia). In dissociative fugue, a subtype of dissociative amnesia, memory loss is combined with an unexpected trip (or trips). In the extreme, new identities, or alters, may be formed, as in dissociative identity disorder (DID). The causes of dissociative disorders are not well understood but often seem related to the tendency to escape psychologically from stress or memories of traumatic events.

Discussion Point:

Why might an alter identity develop in an individual?Ask students to generate examples of ways that an alter identity may be adaptive to the person.

Treatment of dissociative disorders involves helping the patient re-experience the traumatic events in a controlled therapeutic manner to develop better coping skills. In the case of DID, therapy is often long term. Particularly essential with this disorder is a sense of trust between therapist and patient.

Key Terms

somatic symptom disorder, 181dissociative amnesia, 197

dissociative disorder, 181generalized amnesia, 197

illness anxiety disorder,183localized or selective amnesia, 197

conversion disorder, 190dissociative fugue, 198

malingering, 190dissociative identity disorder

factitious disorder, 191 (DID), 200

derealization, 196dissociative trance disorder,

derealization- 200

depersonalization disorder, 196alters, 200

Ideas for Instruction

1.Activity: When Have I Assumed the Sick Role?To expose students to characteristics endorsed by people diagnosed with a somatic symptom disorder, including features of malingering or factitious disorders, you could ask students if they have ever used or faked physical symptoms to get out of having to perform important life activities (e.g., exams, classes, work, social functions), including use of such tactics to gain attention and sympathy from others.

2.Activity: Understanding Somatic Symptom Disorder.You could administer the Hypochondriasis Scale of the MMPI-2 to your students.After scoring the scale, you could discuss results and how the test items relate to the DSM-5 diagnosis. To depict the process of a person with somatic symptom disorder, ask your students to keep a log of their bodily sensations for a few days.Examples may include stomach rumblings, headaches, muscle soreness, frequent urination, stiffness, tingling sensations, skin color changes, perspiration, and fatigue among others.Have the students bring in their record and ask them to consider how a person with somatic symptom disorder might interpret these normal sensations.What physical ailment could they represent?Also, discuss with them why anxiety is so prevalent among people with this disorder.(Be sure to remind students that the diagnosis of hypochondriasis has been renamed in DSM-5. This may stimulate a discussion of the stigma associated with certain labels)

3.Activity: “Normal” Dissociations.Before exploring the dissociative disorders, ask your students to identify periods of dissociation that are normal.For example, most students have had the experience of wanting to drive to a friend's house, but ending up at their school or office because they are so used to driving that route. Others have had experiences of driving on the highway only to find that they have no recollection of the last 10 or so miles they have driven, including obvious landmarks they had passed along the way.Alternatively, many have had the experience of dialing a phone number intending to talk to one particular friend, only to have dialed the number of someone else without being consciously aware of doing so.These examples illustrate that one can fail to be conscious of what one is doing, and yet safely guide oneself through a task.Another example occurs when studying.Again, almost every student has had the experience of reading pages of material (perhaps in their Abnormal text!), only to snap out of their “trance” and realize that, although their eyes were moving over the words, they were thinking about very different things besides their textbook material. That is, they get to the bottom of a page and have no idea how they got there. Finally, many students may have experienced some form of trauma in which they felt cutoff from feelings or numb from shock.Highlighting these experiences helps illustrate that dissociative disorders are not as bizarre as they first appear.Emphasizing the continuum of behavior is important here to enhance student empathy for people with this class of disorders.We are all capable of forms of dissociation, and people with severe dissociative disorders may be simply using a natural process to protect themselves from the ongoing onslaught of trauma.

4.Activity: Invited Hypnotist or Pain Specialist.A useful class activity can be to invite a guest lecturer with expertise in hypnotism or the treatment of pain-related disorders to come and speak to your class.

5.Video Activity: Abnormal Psychology, Inside/Out, Vol. 2.This video segment presents the case of Mike, who suffered a brain injury after racing his car and cannot learn or remember new information. After describing dissociative amnesia, play this video segment and ask the class to determine whether Mike would meet diagnostic criteria for a dissociative amnesia.Use this video clip to illustrate important facets of amnesia and the critical features that would not warrant a diagnosis of dissociative amnesia in this case.

6.Dissociative Identity Disorder (DID). Previously referred to as multiple personality disorder (MPD), this dissociative disorder involves a disturbance of identity in which two or more separate and distinct personality states (or identities) control the individual’s behavior at different times.Use to help develop a lecture and discussion of dissociative identity disorder.Show example of dissociative identity disorder.

Supplementary Reading Material

Additional Readings:

(Please note: many of these references use outdated terminology, but may nonetheless be instructive on the basic foundations of somatic symptom and related disorders and dissociative disorders)

Bliss, E. L. (1980).Multiple personalities?:A report of 14 cases with implications for schizophrenia and hysteria.Archives of General Psychiatry, 37, 1388-1397.

Chase, T. (1990).When rabbit howls.New York: Jove.

Ford, C. V. (1995). Dimensions of somatization and hypochondriasis. Special issue: Malingering and conversion reactions. Neurological Clinics, 13, 241-253.

Kellner, R. (1986).Somatization and hypochondriasis.New York: Praeger.

Kellner, R. (1991).Psychosomatic syndromes and somatic symptoms.Washington, DC: American Psychiatric Press.

Kluft, R. P. (1991).Multiple personality disorder.In A. Tasman & S. M. Goldfinger (Eds.), American Psychiatric Press Review of Psychiatry, vol. 10.Washington, DC: American Psychiatric Press.

Loewenstein, R. J. (1991).Psychogenic amnesia and psychogenic fugue: A comprehensive review.In A. Tasman & S.M. Goldfinger (Eds.), American Psychiatric Press Review of Psychiatry, vol. 10.Washington, DC: American Psychiatric Press.

Lynn, S. J., & Rhue, J. W. (1994).Dissociation:Clinical and theoretical perspectives. New York: Guilford.

Miller, M., & Bowers, K. S. (1993).Hypnotic analgesia:Dissociated experience or dissociated control?Journal of Abnormal Psychology, 102, 29-38.

Putnam, Frank W., et al. (1986). The clinical phenomenology of multiple personality disorder: A review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293.

Spanos, N. P. (1997).Multiple identities and false memories:A sociological perspective.Washington, DC:American Psychological Association.

Thigpen, C. H., & Cleckley, H. M. (1957).The three faces of Eve.New York: McGraw- Hill.

Waites, E. A. (1993).Trauma and survival: Post-traumatic and dissociative disorders in women. New York: Norton.

Weintraub, M. I. (1983).Hysterical conversion reactions: A clinical guide to diagnosis and treatment.New York: SP Medical and Scientific Books.

Suggested Videos

Abnormal Psychology, Inside/Out.(Available through your Cengage Learning representative).The video segment presents the case of Mike, who suffered a brain injury after racing his car and cannot learn or remember new information. However, he has retained overlearned memories, such as how to build an engine. He carries a notebook with information with him at all times with activities he must do every half hour. He has developed a temper problem, depression, and has lost his job, wife, and home as a result of the trauma. Finally, Mike describes a repetition technique he uses to help remember short-term information.

A second segment provides an overview of the characteristics of dissociative identity disorder (DID), where a female client describes her alters, and what it is like to suffer from DID.This volume of Inside/Out also includes a segment on the relation of early history of child abuse and DID.(5 min)

A Case Study of Multiple Personality: The Three Faces of Eve. (Insight Media). This classic recording of a woman with three distinct personalities includes a case background, actual interview sessions in which the psychiatrist elicits each personality, and scenes with the patient after complete recovery. (30 min)

Agnes of God.Jane Fonda plays a court-appointed psychiatrist who must make sense out of pregnancy and apparent infanticide in a local convent.The film illustrates stigmata as an example of a conversion reaction.

Freud. This film illustrates several clinical manifestations of somatoform disorders (e.g., paralysis, false blindness, and false pregnancy).

Hanna and her sisters.Woody Allen stars as a hopeless hypochondriac who spends his days worry about brain tumors, cancer, and cardiovascular disease.

The devils.This film, adapted from Aldous Huxley’s book, The Devils of Loundun, traces the lives of 17th century French nuns who experienced highly erotic dissociative states attributed to possession by the devil.

Primal fear.The film depicts a man who commits heinous crimes, purportedly as a result of a dissociative disorder.The film raises questions about the problem of malingering and differential diagnosis.

The three faces of Eve.This film portrays a woman with three personalities (i.e., Eve White, Eve Black, and Jane).

Twelve o’clock high.This film depicts a general who develops conversion disorder (i.e., paralysis) in response to his role in the death of several of his subordinates.This film is based on a true story.

OnlineResources

American Society of Clinical Hypnosis

A good resource for research relevant to altered states of consciousness.

Child Abuse:Statistics, Research, and Resources

A good resource for current research and informational links related to child abuse.

Pediatric Conversion Disorder

This article presents material related to conversion disorder, including the history of the diagnosis and current data on prevalence.

International Society for the Study of Trauma and Dissociation

Offers information about diagnosis and treatment of dissociative disorders.

Mental Help Net - Dissociative Disorders

Offers information and connections to other websites related to dissociative disorders.

Recovered Memories of Sexual Abuse

A useful scholarly source of information and links related to recovered memories of sexual abuse.

The Sidran Institute

The website for the Sidran Institute, which focuses on trauma and trauma-related disorders. It provides a glossary of dissociative disorder terms, a brochure on dissociative identity disorder, and tips for survivors as well as an article on the effects of dissociative identity disorder on children of trauma survivors.

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WARNING SIGNSFOR
SOMATIC SYMPTOM DISORDER

Frequent visits to the doctor

Fixation on a disease that no doctor has diagnosed

Rejection of a doctor’s reassurance that there is nothing seriously wrong

Continuous doctor-shopping

Checking your body many times a day/week for peculiarities

Preoccupation with an illness that you see on television or in the newspaper

Excessive concern about fear or pain

Frequent thoughts of death

COPYRIGHT (c) 2015 Cengage Learning

WARNING SIGNS FOR
FACTITIOUS DISORDER IMPOSED ON ANOTHER

Illness that persists in spite of traditionally effective treatments

The child has been to many doctors without a clear diagnosis

The parent (usually the mother) seems eager for the child to undergo additional tests, treatments, or surgeries

The parent is very reluctant to have the child out of her sight

Another child in the same family has had an unexplained illness

Parent has a background in healthcare

Symptoms appear only when the parent is present

(Recall that this diagnosis does not apply exclusively to the victimization of a child, but can involve any dependent individual)

COPYRIGHT (c) 2015 Cengage Learning

WARNING SIGNS

FOR DISSOCIATIVE IDENTITY DISORDER

Two or more distinct personalities exist within one person

Each personality has its own way of thinking about things and relating to others

At least two of the identities take control of the person’s behavior

The person is unable to recall important personal information

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