Somatic Symptom and Somatic Symptom and Related Dissociative Disorders Disorders

Tiffany Daniels, M.S.

Somatic Symptom and Related Somatic Symptom and Related Disorders Disorders • All of the disorders in this category (DSM-5 • Somatic Symptom Disorders can also Chapter) share a common feature: the accompany diagnosed medical disorders. prominence of somatic symptoms associated with significant distress and impairment. • When genuine medical conditions are present, the person’s reaction is in excess of what would • Individuals with these disorders are commonly typically be expected. encountered in primary care and other medical settings but are less commonly encountered in settings.

Distinguishing Somatic Symptom Distinguishing Somatic Symptom from Other Stuff from Other Stuff

• Do you recall from PSY2012 the other name • In contrast, Psychosomatic-Actual physical for the cell body of a neuron? illness in which psychological factors • Soma = Body contribute (e.g., hypertension where anxiety • So to help you remember….somatic and eating make the symptoms symptom disorders are those involving the worse). body

1 Somatic Symptom Disorder 1. Disproportionate and persistent thoughts about • A person with Somatic Symptom Disorder the seriousness of one’s symptoms. has one or more somatic complaints that are distressing and result in significant disruption of 2. Persistently high level of anxiety about health daily life. or symptoms. 3. Excessive time and energy devoted to these symptoms or health concerns. • Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by AT LEAST • Although any one somatic symptom may not one of the following: be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Somatic Symptom Disorder • There is often a high level of medical care utilization, which rarely alleviates the individual’s concerns.

• Consequently, the patient may seek care from multiple doctors for the same symptoms. • These individuals often seem unresponsive to • People who complain primarily of pain are medical interventions, and frequently feel as given a diagnosis of Somatic Symptom though their medical assessment and treatment Disorder With Predominant Pain. have been inadequate.

Somatic Symptom Disorder Causes of Somatic Symptom • Prevalence may be around 5-7%, females Disorder >males. • More frequent in individuals with few years of • A cognitive theory of Somatic Symptom education and low SES and in those who Disorder suggests that persons with these have recently experienced stressful life disorders tend to experience bodily events. sensations more intensely than other people, pay more attention than others to their • Presentation varies by culture. physical symptoms, and catastrophize their • Associated with high rates of comorbidity symptoms. with medical disorders as well as anxiety and depressive disorders.

2 Treatments for Somatic Symptom Illness Disorder • The primary distinction between Illness Anxiety Disorder (formerly known as • Explaining to people that they have a Somatic ) and Somatic Symptom Symptom Disorder is not easy. Disorder is that people with Illness Anxiety Disorder WORRY excessively that they have a • SSRI’s have some benefit. serious illness, but actual somatic symptoms are not present or, if present, are only mild in intensity. • Chronic Pain Rehabilitation Programs • Not easily treatable, and hard to convince people with this disorder that their problems are caused by psychological factors.

Illness Anxiety Disorder Illness Anxiety Disorder • Has a Care-Seeking Type and Care-Avoidant Type

• Prevalence rate not completely clear since diagnosis has changed since DSM-IV-TR, with a lot of people (75%) previously diagnosed with Hypochondriasis now not better fitting Somatic Symptom Disorder rather than Illness Anxiety Disorder. Could be between 1.3% and 10%. • Woody Allen’s characters in almost every • Significant cultural variance. movie (though Hannah and Her Sisters would probably be the best example) often appear to have Illness Anxiety Disorder.

Causes of Illness Anxiety Disorder Treatment of Illness Anxiety Disorder • Faulty interpretation of physical signs & sensations • Reassurance and education regarding the • Heightened arousal & attention to every little true meaning of bodily sensations is effective sensation in the body can create anxiety, • CBT that focuses on challenging illness- which can create more bodily sensations… related misinterpretations and showing it’s a vicious cycle patients how they are creating symptoms by • Runs in families, can be a learned response, focusing attention on specific body areas can develop in response to stressful life • Antidepressants such as Paxil (an SSRI) events, can develop as a need for increased shown to be effective attention in one’s life

3 Treatment of Illness Anxiety Disorder • In a study conducted by Greeven and • People with conversion disorder (also known colleagues (2007), 45% of patients as Functional Neurological Symptom Disorder) responded to CBT, 30% to Paxil, and have one or more symptoms of altered 14% to Placebo. voluntary motor or sensory functioning • Thoughts on prescribing meds to those with Illness Anxiety Disorder?? • Clinical findings provide evidence of • Do you think IAD patients respond to incompatibility between the symptom and placebo at a greater rate than the general recognized neurological or medical conditions. population?

Conversion Disorder Conversion Disorder • Glove anesthesia- Unique example of a • Prevalence unknown, though approximately 5% Conversion Disorder in which people lose all of referrals to neurology clinics qualify for this sensory feeling in only one hand. diagnosis. • Psychogenic Non-Epileptic Seizures • 2-3 times more common in females. • Other examples can include weakness • Changes resembling Conversion Disorder are (paresis), paralysis, abnormal movements (e.g., common in certain culturally sanctioned rituals. tremor, dystonia, myoclonus, gait disturbance), swallowing symptoms (dysphagia), speech • Anxiety Disorders, ESPECIALLY Panic symptoms (e.g, dysphonia, slurring), other Disorder, and depressive disorders commonly forms of anasthesia or sensory loss. co-occur with Conversion Disorder.

Diagnosis Example: Andria • For a Conversion Disorder to be diagnosed, it must be demonstrated definitively that the From left to • A good friend of mine was involved right: Patrick, symptoms of such disorders are not Andria, and Me consistent with medical pathophysiology. in an accident where, during surgery, an inadequately • A difficult, often overdiagnosed disorder. anesthetized horse she was • Many doctors falsely presume that because operating on bucked and kicked her, they (or current science) can’t figure out knocking her backwards, where she what’s wrong with you, it must be slammed her head into a set of psychological. double doors. Shortly after the event, she began having seizures.

4 Example: Andria Example: Andria

• Doctors could initially find no evidence (such • Another (presumably more qualified) as brain damage) that would be causing her neurologist performed a full workup on her, seizures, and one doctor suggested that she including 24 hour epilepsy monitoring, and had conversion disorder. He also told her did in fact find her seizures to be epileptic in that she was latently homosexual and would nature, of a generalized, and consistent with need years of therapy to cope with these the damage caused by her accident. facts (sounds pretty psychoanalytic, huh?) • Moral of the story: Tread lightly before diagnosing conversion disorder!

Causes of Conversion Disorder Causes of Conversion Disorder, according to our dear friend, Freud Freud cont. • 3) The anxiety continues to increases, • According to Freud, 4 Basic threatening to emerge into consciousness, Processes lead to the development thus the person “converts” it into physical of conversion disorder: symptoms, reducing the anxiety & pressure of • 1) Individual experiences traumatic having to deal with the conflict (primary gain) event • 4) The individual receives greatly increased • 2) Because the conflict and attention and sympathy from loved ones and resulting anxiety are unacceptable, may also be allowed to avoid a difficult the person represses the conflict, situation or task (secondary gain) making it unconscious

Other Potential Causes of Other Potential Causes of Conversion Disorder Conversion Disorder • Social & cultural influences also contribute • For example, CD tends to occur among • Behaviorists would say that prior experience individuals who are less educated, and come with real physical problems can lead to CD from lower socioeconomic status groups where knowledge about disease & medical • Biological vulnerability; there is a connection illness not well developed between the amygdala & conversion disorder, more research needed

5 Treatment of Conversion Disorder Distinguishing Somatoform from Other Stuff • Behavioral treatments focus on relieving the person’s anxiety around the initial trauma • Malingering- Deliberate faking of physical that caused the conversion symptoms and symptoms for SECONDARY GAIN, such as on reducing any benefits the person is avoidance of military service, criminal receiving from the conversion symptoms. prosecution, or trying to get money from an insurance company. • Factitious Disorders- Deliberate faking of physical illness to gain medical/personal attention from others.

Factitious Disorder

• Factitious Disorder, sometimes referred to by it’s former name of Munchausen’s syndrome, is a where a person fakes illnesses/symptoms in order to gain medical attention.

• Specified as Factitious Disorder Imposed on Self, in contrast with…

Factitious Disorder Imposed on Factitious Disorder Imposed on Another Another

• In these cases, parents fake or deliberately cause illnesses in their children to gain attention/sympathy from others as being the caring and diligent parent. • In The Sixth Sense, Mischa Barton played a • People with Factitious Disorders were often little girl whose mother intentionally kept her abused as children, and also are often involved sick (and eventually killed her because of it) in in the medical profession in some capacity. order to get sympathy from others. In real life, this mother would be diagnosed with Factitious Disorder Imposed on Another.

6 Other Somatic Symptom Disorders

• Pseudocyesis- A false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy. • Otherwise known as “hysterical pregnancy”

Dissociative Disorders Dissociative Disorders • Dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, , identity, emotion, perception, body representation, motor control, and behavior.

• All of these disorders involve frequent experiences in which various aspects of a What do all of these person’s “self” are split off from each other and characters have in common? felt as separate.

Dissociative Disorders Dissociative Identity Disorder • Frequently found in the aftermath of trauma.

• In the DSM-5, the Dissociative disorders are placed next to the chapter on Trauma and Stressor-related Disorders to reflect the close relationship between these two diagnostic categories

• Both and PTSD include some occurrence of Dissociative symptoms.

7 Dissociative Identity Disorder (DID) Dissociative Identity Disorder (DID)

• Dissociative Identity Disorder (DID), • The disruption involves formerly known as Multiple Personality marked discontinuity in sense Disorder, involves a disruption of identity of self and sense of agency, characterized by two or more distinct accompanied by related personality states, which may be described alterations in affect, behavior, in some cultures as an experience of consciousness, memory, possession. perception, cognition, and/or sensory-motor functioning.

Dissociative Identity Disorder (DID) DID • Recurrent gaps in the recall of everyday events, • People with DID have more than one important personal information, and/or distinct identity or personality, and many people have more than a dozen traumatic events that are inconsistent with personalities. ordinary forgetting. • These personalities are called alters. • A person’s different alters can have • One of the most fascinating and EXTREMELY different ages, genders, features, and CONTROVERSIAL mental disorders (more on interpersonal features. the controversy later).

Types of Alters Types of Alters

• Child alters are the most • Persecutor Personality- These alters inflict common type. They do not pain or punishment on the other personalities age as the individual ages. by engaging in self-mutilating behaviors, • Unsurprising since such as self-cutting or suicide attempts. childhood trauma is often • Helper Personality- These types offer advice associated with DID, and to other personalities or provide functions the this child alter could be host personality is unable to perform. created during/immediately • People with DID often claim to have after the event as a means for events that occur while other alters are in of coping with it. control.

8 DID Statistics DID Statistics • A history of interpersonal physical/sexual abuse among those with DID is about 90% • Average number of alters: 15 (perhaps DID is a coping mechanism?) • Ratio of females to males diagnosed 9:1 • Influenced by individual’s cultural background. • Onset almost always in childhood • Over 70% of outpatients with DID have • Disorder tends to last a lifetime, although attempted suicide. frequency of switching between alters • To this day, a lot of of mental health decreases professionals are reluctant to give this • Exact prevalence unknown, suspected to diagnosis (more on the controversy in a few occur in about 1% of general population slides).

Diagnosis Treatment of DID

• Treating DID can be VERY challenging. • Was rarely diagnosed before 1980, but increased significantly since then for a few • The goal of treatment is to integrate all of the reasons: alter personalities into one coherent personality. • 1)DID included in 1980 DSM Edition • This is done by identifying the functions of • 2) criteria became more each personality and helping each one specific, helping to separate the two better. confront and work through the trauma and • 3)Lots of articles on DID were published negotiating with the personalities to fuse into around that time. one personality.

DID Controversies DID Controversies

• People who develop DID tend to be highly • A Swiss study found that 90 percent of suggestible and hypnotizable and may Swiss psychiatrists had never seen a case use self-hypnosis to dissociate and of DID escape their traumas. • Conversely, 6 out of the 655 psychiatrists • Fewer than one quarter of U.S. and surveyed had noted that they had seen over Canadian psychologists feel dissociative 20 DID cases. These 6 psychiatrists disorders like DID are valid diagnoses. accounted for over 2/3 of the DID diagnoses given in Switzerland.

9 DID Controversies Dissociative Amnesia • The take home message is that DID is an EXTREMELY RARE, not well understood disorder that most professionals questions the actual existence of in the first place.

• FYI - One of the most common mistakes made in the media is to confuse DID with schizophrenia.

General Psychology Flashback Dissociative Amnesia

• Retrograde involve memory loss for • Dissociative Amnesia involves an inability to events in the past. recall important autobiographical information, usually of a traumatic or stressful nature, that is • Anterograde amnesias involve an impairment in inconsistent with ordinary forgetting. the ability to make new . NOTE: Dissociative amnesia most often consists of localized or for a • Pop Culture comparison: The Bourne Identity () vs. Memento specific event or events, or generalized (Anterograde Amnesia). amnesia for identity and life history.

Dissociative Amnesia Dissociative Amnesia • Localized amnesia- can’t recall events from • Dissociative Amnesia is a psychogenic circumscribed period of time amnesia, which arises in the absence of any • Selective amnesia- can recall some, but not all, brain injury or disease (those are called organic events from a circumscribed period of time amnesias) and is thought to have psychological • Generalized amnesia- a complete loss of causes. memory for one’s life history (“Soap Opera • Psychogenic amnesias are usually retrograde Amnesia;” very rare) amnesias, and very rarely involve any • Systematized amnesia- memory loss for a anterograde amnesia component. specific category of information • Prevalence- Rare, though greater for females • Continuous amnesia- an individual forgets each new event as it occurs

10 Explanations for Dissociative Dissociative Fugue Amnesia • 1) Dissociation used to cope with traumatic • Dissociative Fugue is a specialty subtype of stressor/memory Dissociative Amnesia that involves apparently • 2) Might occur because individuals were in purposeful travel (or, alternative, sometimes such a state of arousal during particular events bewildered ) that is associated with that they couldn’t encode and store information amnesia for identity or for other important during that period. autobiographical information. • 3) Information about those events is stored successfully at the time of the event but can’t be recalled later due to its association with painful emotion.

Dissociative Fugue Dissociative Fugue

• A person in the midst of a dissociative fugue • Just as suddenly, the person can will suddenly pick up and move to a new return to their previous identity and place, assume a new identity, and have no home, resuming their life as if nothing memory for their previous identity. had happened, with no memory of what they did during the fugue. A • They may behave quite normally in their new fugue state can last for days, months, environment, and it might not seem odd to even years, and a person may them that they can’t remember anything from experience repeated fugue states of their past. sometimes just a single episode.

Depersonalization / Disorder

• Depersonalization/Derealization Disorder involves the presence of persistent or recurrent (frequent) experiences of depersonalization, derealization, or both.

• During the depersonalization or derealization experiences, reality testing remains intact.

11 Depersonalization/Derealization Depersonalization/Derealization Disorder Disorder • Depersonalization- Experiences of unreality, • Derealization- Experiences of unreality or detachment, or being an outside observer with detachment with respect to one’s respect to oneself, including one’s thoughts, surroundings, that is, the external world feelings, sensations, body, or actions (e.g., (e.g., other individuals or objects are perceptual alterations, distorted sense of time, experiences as unreal, dreamlike, foggy, unreal or absent self, emotional and/or physical lifeless, or visually distorted). numbing).

Depersonalization/Derealization Depersonalization/Derealization Disorder Disorder • Transient feelings of depersonalization/ derealization lasting hours to days are common • Volitionally-induced within the general population. experiences of depersonalization/ • Can you think of an example of when you might have felt one of these symptoms? derealization can be a part of meditative practices that are • Prevalence for the actual disorder, which prevalent in many religions involves these being persistent or recurrent, is and cultures and should not unknown, though no gender difference is be diagnosed as a disorder. evident.

Other Specified Dissociative Disorders • Other specifiable Dissociative Disorders might include changes in Identity disturbance due to prolonged and intensive coercive persuasion. • E.g., Sgt. Nicholas Brody from Homeland

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