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  • We all dissociate all the time -when we do one thing (make a left hand turn) while thinking about another (talking on the phone). We all are capable of splitting our consciousness in different directions and the ability to do so is not necessarily abnormal. In dissociative disorders, normal, adaptive ability to dissociate is misused for the purposes of managing severe psychological threat. Without conscious effort, the individual splits consciousness or memory in order to manage a severe psychological threat.
  • Amnesia caused by brain pathology normally involves inability to retain information. In psychogenic amnesia, the information is retained by cannot be recalled. In psychogenic amnesia, the person may recall material under hypnosis or with the use of sodium amytal. In typical dissociative amnesia, individuals don’t remember where they live, their name, parents, family, spouse, etc., but do not forget how to do things or how to read, etc. EPISODIC memory tends to be affected. Semantic, procedural and short tem memory typically do not.
  • The fugue state may last hours, weeks or years. May involve just going to see a bunch of movies (as suggested in the text) or traveling to a new state, assuming a new occupation and starting a new family. Amnesia, in this case, often involves that material which is stressful or threatening. If the stressful situation is the home, all information related to the home may be forgotten.
  • Tends to occur in unstable individuals with many other problems, including personality disorders (namely avoidant, borderline and obsessive-compulsive. It is often very resistant to treatment. MAY be early manifestation of psychotic states (schizophrenia)
  • A person normally develops DID only after extreme trauma or stress - often multiple factors precipitate this disorder. Psychologists no longer speak of alters as distinct personalities - instead they are conceptualized as pretended, fragmented parts of a single person that are used to manage stress. Of course, this use of alters is not a conscious process. Ross (1997) says the patient pretends to be several different people so convincingly that he or she believes it herself. Common alters include child, protector, persecutor and opposite sex. Alters normally know of the host personality and of each other, but the host personality does not generally have knowledge of the alters. There may be amnesia for the actions of some alters by others, but there is usually one alter which is aware of the actions of all the alters and may be therapeutically useful. Brain scans of different alters are often different, however. Note that before DID was popularized in the media, there were fewer than 100 cases of the disorder ever reported. Most patients are in their 20s and 30s when diagnosed and females outnumber males 3 to 1. There is strong evidence of REPORTED history of significant abuse - however this may be either a cause or effect (memory construction) of underlying pathology. Additionally, DID may be diagnosis given to pathological individuals who have been induced by the power of suggetion . (note that normal college students were led by suggestion to exhibit sx of DID in less than two weeks through the power of suggestion alone) (Spanos et. al., 1985) Could be thought of as severe disruption in memory, identity and behavior In terms of the controversy… Many psychologists no longer believe that individuals with DID truly develop distinct personalities. Your instructor conceives of this disorder as a case of dissociating too often and too much, to the point where functioning is affected.
  • Because DID often occurs after extreme stress, evidence suggests it may be a type of PTSD. Sociocultural factors include the fact that the incidence and diagnosis of these disorders seems strongly related to the current level of awareness and acceptance of this as a disease state.
  • Formerly called Briquet’s syndrome, 10X more common among women than men. More common among lower socioec. Classes; may be that the same underlying predisposition leads men to antisocial beh. And women to somatization disorders (based on familial research). At least four pain symptoms: ex., head, abdomen, back, joints, or during sexual intercourse, menstruation or urination At least two gastrointestinal symptoms- not including pain; can be multiple food intolerances, bloating, or vomiting (other than during pregnancy At least one sexual symptom: sexual indifference or dysfunction, menstrual irregularity, vomiting throughout pregnancy One pseudoneurological symptom: sx which mimic sensory impairments, or anomalies of consciousness and memory
  • Originally known as hysteria; Freud thought it resulted from a wandering (frustrated) uterus and could be solved by marriage.Allow an individual to escape an intolerable or stressful situation. Was commonly diagnosed during WWI and II(eg, paralysis of the legs) but its incidence seems to be decreasing.Sensory symptoms may include anesthesia (loss of sensitivity), Hypesthesia (partial loss of sensitivity) Hyperesthesia (excessive sensitivity) and analgesia (loss of sensitivity to pain).DSM IV is not clear about why this is a separate category- I think it’s because the symptoms obviously serve a secondary purpose and because they are often pseudoneurological Paralysis functions are usually combined to a single limb and are usually selective (can use limb for somethings, but not others. Sx may also include tics and contractures (when muscles, limbs or joints are flexed and/or rigid). Astasia-abasia (px can control limbs when sitting or lying down, but can’t control them when walking (walk may be grotesque) Aphonia (only talk in a whisper) common -and mutism (rare) may also occur Visceral sx may include lump in the throat, choking sensations, coughing spells, difficulty breathing, belching, cold, clammy extremities, nausea, vomiting, hiccoughing, sneezing - may very closely mimic actual organic conditions. Pseudopregnancy and conversion cases of malaria and tuberculosis may closely mimic the actual disease (with fever, weight loss, night sweats or loss of menstruation, enlarged breasts, etc.)
  • Common among psychiatric patients and more common among women than men Reported level of pain seems to be related to current level of stress. May lead to assumption of the sick role, interfering with productivity and responsibility. May also lead to doctor shopping. How is this different from hypochondriasis or somatization disorder? Predominant symptom is pain DISTINGUISH BETWEEN: Factitious Disorder : goal is generally maintaining personal benefits provided by the “sick role”-including attention and concern from Medical personnel. This is also called Munchausen syndrome - and may involve consciously feigning symptoms by taking drugs, etc. Malingering: the person is seeking a specific outcome, such as a monetary reward or avoidance of a specific duty or obligation. This is a conscious effort to gain more than just attention but some specific results.
  • Complaints may be in the general area of the stomach, chest, head, genitals or anywhere Usually do not give a precise description of symptoms and are not relieved by being told there is nothing wrong with them do Not normally show the intense fear or anxiety expected of people actually suffering from serious illnesses. Often overly concerned with digestive and excretory functions Often desire more attention from others OR want to escape expectations of performance or responsibility. Most also have Axis I diagnoses and ten to show needful interpersonal communication (appear needy).
  • Psychosocial factors usually include neuroticism as a personality trait (anxiety, angry hostility, depression, self-consciousness, impulsiveness, vulnerability. Also exists evidence of relationship between somatoform disorders and serious abuse as a child. Biological factors are not clearly defined - does seem to be some familial evidence but this may be the result of learning. Sociocultural factors appear to be significant as the prevalence varies among differing cultures (also note increase in conversion disorder for soldiers at war). Antianxiety and antidepressant medications are sometimes effective. Pseudomedical treatment (with support and attention) may be the answer to pseudomedical problems, however, prognosis for a full recovery from somatoform disorders is not encouraging. Cognitive Behavioral therapy may be the most effective.

    1. 1. Essentials of Understanding Abnormal Behavior Chapter Five Dissociative Disorders and Somatoform Disorders
    2. 2. Dissociative Disorders and Somatoform Disorders <ul><li>Dissociative disorders: Mental disorders in which a person’s identity, memory, and consciousness are altered or disrupted </li></ul><ul><li>Somatoform disorders: Involve physical symptoms or complaints that have no physiological basis </li></ul>
    3. 3. Dissociative Disorders <ul><li>Dissociative disorders: Mental disorders in which a person’s identity, memory, or consciousness is altered or disrupted: </li></ul><ul><ul><li>Dissociative amnesia </li></ul></ul><ul><ul><li>Dissociative fugue </li></ul></ul><ul><ul><li>Dissociative identity disorder (DID, formerly Multiple Personality Disorder) </li></ul></ul><ul><ul><li>Depersonalization disorder </li></ul></ul>
    4. 4. Figure 6.1: Disorders Chart: Dissociative Disorders
    5. 5. Figure 6.1: Disorders Chart: Dissociative Disorders (cont’d)
    6. 6. Dissociative Amnesia <ul><li>Dissociative amnesia : Partial or total loss of important personal information, may occur suddenly after stressful/traumatic event </li></ul><ul><ul><li>Localized: Failure to recall all the events that happened during a specific period </li></ul></ul><ul><ul><li>Selective: Inability to remember certain details of an incident </li></ul></ul>
    7. 7. Dissociative Amnesia (cont’d) <ul><ul><li>Generalized: Inability to remember anything about one’s past life </li></ul></ul><ul><ul><li>Systematized: Loss of memory for selected types of information </li></ul></ul><ul><ul><li>Continuous: Inability to recall events occurring between specific time in the past and the present </li></ul></ul>
    8. 8. Dissociative Amnesia (cont’d) <ul><li>Possibly due to repression (or closely related process) of a traumatic event: </li></ul><ul><ul><li>Posthypnotic amnesia : Individual cannot recall events occurring during hypnosis with hypnotist suggesting what is to be forgotten </li></ul></ul><ul><ul><li>Dissociative amnesia : Both the source and content of the amnesia are unknown </li></ul></ul><ul><ul><li>In posthypnotic and dissociative amnesia, lost material can sometimes be retrieved with professional help. </li></ul></ul>
    9. 9. Dissociative Fugue <ul><li>Confusion over personal identity, together with unexpected travel away from home </li></ul><ul><li>Also called “fugue state” </li></ul><ul><li>Usually involves only short periods of time with incomplete change of identity </li></ul><ul><li>In the classic presentation of this disorder: </li></ul><ul><ul><li>Individual travels from home and assumes a partial or complete new identity. </li></ul></ul><ul><ul><li>Results from an urgent wish to escape an unbearable situation </li></ul></ul><ul><ul><li>During the fugue state, the individual has amnesia for his or her previous life </li></ul></ul><ul><ul><li>After recovering from the fugue state, the individual has amnesia for activities during the fugue state </li></ul></ul>
    10. 10. Depersonalization Disorder <ul><li>A dissociative disorder in which feelings of unreality concerning the self or the environment cause major impairment in social or occupational functioning </li></ul><ul><li>Depersonalization is the most common dissociative disorder </li></ul><ul><li>occurs mostly in adolescents and young adults. </li></ul><ul><li>Includes loss of the sense of self. </li></ul><ul><li>Individuals feel they are suddenly different- for example, </li></ul><ul><li>that their bodies have changed </li></ul><ul><li>Often accompanied by derealization - during which the external world is perceived as distorted or “out of body” experiences </li></ul><ul><li>Precipitated by physical or psychological stress; evidence that it may be related to emotional abuse, especially by parents </li></ul>
    11. 11. Culture-Bound Syndromes <ul><li>Koro : Intense fear that genitalia are receding into the body </li></ul><ul><li>Latah : Mimicking or following instructions or behaviors of others, plus trancelike states </li></ul><ul><li>Brain fag : Fatigued brain, neck, or head pain or blurred vision related to difficult coursework </li></ul><ul><li>Dhat : Problems related to semen discharge </li></ul>
    12. 12. Culture-Bound Syndromes (cont’d) <ul><li>Nervios : Somatic symptoms and anxiety </li></ul><ul><li>Pibloktoq : Dissociative episode, plus extreme excitement followed by convulsions and coma </li></ul><ul><li>Zar : Sense of spirit possession </li></ul>
    13. 13. Dissociative Identity Disorder (DID) <ul><li>Formerly called Multiple Personality Disorder </li></ul><ul><li>Dissociative disorder in which two or more relatively independent personalities appear to exist in one person, with only one evident at a time </li></ul><ul><li>Originates in childhood: Reports of extreme physical or sexual abuse </li></ul><ul><ul><li>Comorbid with conversion symptoms, depression, and anxiety </li></ul></ul><ul><li>Highly controversial </li></ul>
    14. 14. Figure 6.2: Comparison of Characteristics of Reported Cases of Dissociative Identity Disorder (Multiple Personality Disorder)
    15. 15. Causal Factors in Dissociative Disorders <ul><li>Little information about causal factors of dissociative amnesia, fugue and depersonalization disorder </li></ul><ul><li>Ross suggests DID may arise from childhood abuse or neglect, or the disorder may be factitiously created, or created iatrogenically (as a result of treatment for other disorders). </li></ul><ul><li>There appear to be no biological causes </li></ul><ul><li>Psychosocial causes (stressors) are valid </li></ul>
    16. 16. Etiology of Dissociative Disorders <ul><li>Difficult to differentiate between genuine and faked cases </li></ul><ul><li>Psychodynamic perspective: Repression blocks unpleasant/traumatic events from consciousness </li></ul><ul><ul><li>Amnesia and fugue: Part of personal identity blocked </li></ul></ul><ul><ul><li>DID: Conflicts in personality structure; opposing personality components disable ego’s ability to control incompatible elements </li></ul></ul>
    17. 17. Figure 6.3: Psychodynamic Model for Dissociative Identity Disorder
    18. 18. Etiology of Dissociative Disorders (cont’d) <ul><li>Behavioral perspective: Indirect avoidance of stress </li></ul><ul><ul><li>Sociocognitive model: Rule-governed/goal-directed experiences and displays created, legitimized, and maintained by social reinforcement </li></ul></ul><ul><ul><li>Learn behaviors from observing what works for others </li></ul></ul><ul><ul><li>Iatrogenic: Created by the therapeutic situation (hypnotic suggestibility) </li></ul></ul>
    19. 19. Treatment of Dissociative Disorders <ul><li>Medications treat accompanying anxiety or depression. </li></ul><ul><li>Survivors of childhood sexual abuse who have dissociated are often treated with psychoeducation, use of group resources, and cognitive/social skills training. </li></ul><ul><li>Amnesia and fugue (usually spontaneously remit): </li></ul><ul><ul><li>Supportive counseling </li></ul></ul><ul><ul><li>Treat depression and stress </li></ul></ul>
    20. 20. Treatment of Dissociative Disorders (cont’d) <ul><li>Depersonalization disorder (slower spontaneous remission) </li></ul><ul><ul><li>Alleviate feelings of anxiety, depression, fear of going insane </li></ul></ul><ul><ul><li>Occasionally behavioral therapy (reinforcement of appropriate responses) </li></ul></ul>
    21. 21. Treatment of Dissociative Disorders (cont’d) <ul><li>Dissociative identity disorder (DID): </li></ul><ul><ul><li>Controversial treatments, not always successful </li></ul></ul><ul><ul><li>Psychotherapy and hypnosis </li></ul></ul><ul><ul><ul><li>Personalities introduce selves to patient and recall traumatic experiences/memories </li></ul></ul></ul><ul><ul><ul><li>Therapist suggests personalities served a purpose but now alternative coping strategies will be more effective </li></ul></ul></ul><ul><ul><ul><li>Integrate personalities </li></ul></ul></ul>
    22. 22. Treatment of Dissociative Disorders (cont’d) <ul><li>Dissociative identity disorder (DID) (cont’d) : </li></ul><ul><ul><li>Progress in therapy: </li></ul></ul><ul><ul><ul><li>Better assessment, greater understanding of DID, progress in handling controversial issues, and treatment to achieve quick resolution of acute symptoms </li></ul></ul></ul><ul><ul><ul><li>Problem-focused therapy to improve functioning </li></ul></ul></ul><ul><ul><ul><li>Cognitive behavior strategies </li></ul></ul></ul>
    23. 23. Somatoform Disorders <ul><li>Physical symptoms that mimic medical conditions with no physiological basis </li></ul><ul><li>Symptoms are not under voluntary or conscious control </li></ul><ul><li>Somatoform disorders: </li></ul><ul><ul><li>Somatization disorder </li></ul></ul><ul><ul><li>Conversion disorder </li></ul></ul><ul><ul><li>Pain disorder </li></ul></ul><ul><ul><li>Hypochondriasis </li></ul></ul><ul><ul><li>Body dysmorphic disorder </li></ul></ul>
    24. 24. Somatoform Disorders <ul><li>Involve physical complaints or disabilities that occur without any evidence of physical cause </li></ul><ul><li>Patients are NOT faking </li></ul><ul><li>Individuals suffering from somatoform disorders are typically preoccupied with their health, but believe they are genuinely ill. </li></ul>
    25. 25. Figure 6.4 Disorders Chart: Somatoform Disorders
    26. 26. Figure 6.4: Disorders Chart: Somatoform Disorders (cont’d)
    27. 27. Table 6.1: Variables that Distinguish Subgroups of Confirmed Somatoform Disorder
    28. 28. Somatoform Disorders (cont’d) <ul><li>Comorbid disorders: Mood, personality, and substance use disorders </li></ul><ul><li>Differentiate from: </li></ul><ul><ul><li>Malingering : Faking a disorder to achieve some goal, such as an insurance settlement </li></ul></ul><ul><ul><li>Factitious disorder : Symptoms of physical or mental illness are deliberately induced or simulated with no apparent incentive </li></ul></ul><ul><li>Cultural differences: Psychosomatic versus somatopsychic perspectives </li></ul>
    29. 29. Somatization Disorder <ul><li>Chronic complaints of many bodily symptoms with no physical basis </li></ul><ul><li>Complaints include at least four pain symptoms in different sites (DSM-IV-TR): </li></ul><ul><ul><li>Two gastrointestinal </li></ul></ul><ul><ul><li>One sexual </li></ul></ul><ul><ul><li>One pseudoneurological </li></ul></ul><ul><li>Undifferentiated somatoform disorder </li></ul><ul><li>Relatively rare diagnosis world-wide </li></ul>
    30. 30. Conversion Disorder <ul><li>Complaints of physical problems or impairments of sensory or motor functions controlled by voluntary nervous system, suggesting neurological disorder, with no underlying physical cause; often related to stress </li></ul>
    31. 31. Conversion Disorder (cont’d) <ul><li>Most common conversion symptoms: </li></ul><ul><ul><li>Psychogenic pain </li></ul></ul><ul><ul><li>Disturbances of stance and gait </li></ul></ul><ul><ul><li>Sensory symptoms </li></ul></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Psychogenic seizures </li></ul></ul><ul><li>Some symptoms are easily diagnosed as conversion disorders, while others require extensive neurological and physical examination. </li></ul>
    32. 32. Figure 6.5: Glove Anesthesia
    33. 33. Pain Disorder <ul><li>Reports of severe pain, but: </li></ul><ul><ul><li>No physiological or neurological basis (vague descriptions) </li></ul></ul><ul><ul><li>Pain is greatly in excess of that expected with an existing condition, OR </li></ul></ul><ul><ul><li>Pain lingers long after a physical injury has healed </li></ul></ul><ul><li>Frequent visits to doctors with numerous physical complaints; potential for drug or medication abuse </li></ul>
    34. 34. Figure 6.6: Physical Complaints: A Comparison of Individuals with Pain Disorder Versus Healthy Controls
    35. 35. Hypochondriasis <ul><li>Persistent preoccupation with one’s health and physical condition, despite physical evaluations that reveal no organic problems </li></ul><ul><li>Prevalence: 2-7% of general medical population </li></ul>
    36. 36. Hypochondriasis (cont’d) <ul><li>Predisposing factors: </li></ul><ul><ul><li>History of physical illness </li></ul></ul><ul><ul><li>Parental attention to somatic symptoms </li></ul></ul><ul><ul><li>Low pain threshold </li></ul></ul><ul><ul><li>Greater sensitivity to somatic cues </li></ul></ul><ul><ul><li>Anxiety/stress-arousing event , plus perception of somatic symptoms, plus fear that sensations reflect disease = greater attention to somatic cues </li></ul></ul>
    37. 37. Body Dysmorphic Disorder <ul><li>Preoccupation with imagined physical defect in a normal-appearing person, or excessive concern with slight physical defect </li></ul><ul><li>May be underdiagnosed due to embarrassment to discuss the problem </li></ul><ul><li>Comorbid: Functional impairment, mood disorders, social phobia, low self-esteem; may be suicidal </li></ul><ul><li>Possibly related to obsessive-compulsive disorder </li></ul>
    38. 38. Figure 6.7: Imagined Defects in Patients with Body Dysmorphic Disorder
    39. 39. Etiology of Somatoform Disorders <ul><li>Diathesis-stress models: </li></ul><ul><ul><li>Predisposition may be learned or “hard-wired” </li></ul></ul><ul><ul><li>Predisposition involves hypervigilance or exaggerated focus on bodily sensations, increased sensitivity to weak bodily sensations, and disposition to react to somatic sensations with alarm </li></ul></ul><ul><ul><li>Predisposition becomes fully developed disorder when person can’t deal with trauma or stress </li></ul></ul><ul><li>Precipitating Circumstances (Antecedents) </li></ul><ul><ul><li>Desire to escape an unpleasant situation </li></ul></ul><ul><ul><li>Fleeting wish to be sick in order to escape (wish is quickly suppressed) </li></ul></ul><ul><ul><li>Appearance of physical ailment </li></ul></ul><ul><ul><li>Patient sees no relation between physical symptoms and stress situation </li></ul></ul>
    40. 40. Figure 6.8: Diathesis-Stress Model for Somatoform Disorders
    41. 41. Etiology of Somatoform Disorders (cont’d) <ul><li>Psychodynamic perspective: Somatic symptoms defend against awareness of unconscious emotional issues </li></ul><ul><ul><li>Freud: Hysterical reactions result from repression of conflict (usually sexual) </li></ul></ul><ul><ul><li>Two mechanisms produce and sustain symptoms: </li></ul></ul><ul><ul><ul><li>Primary gain (protection from anxiety) </li></ul></ul></ul><ul><ul><ul><li>Secondary gain (dependency needs fulfilled) </li></ul></ul></ul>
    42. 42. Etiology of Somatoform Disorders (cont’d) <ul><li>Behavioral perspective: </li></ul><ul><ul><li>Reinforcement </li></ul></ul><ul><ul><li>Modeling </li></ul></ul><ul><ul><li>Cognitive styles </li></ul></ul><ul><ul><li>Combination of all three </li></ul></ul><ul><li>Sociocultural perspective: </li></ul><ul><ul><li>Societal restrictions on women </li></ul></ul>
    43. 43. Etiology of Somatoform Disorders (cont’d) <ul><li>Biological perspective: </li></ul><ul><ul><li>There may be innate physical bases </li></ul></ul><ul><ul><li>Hypochondriacs are more sensitive to bodily sensations </li></ul></ul>
    44. 44. Treatment of Somatoform Disorders <ul><li>Psychodynamic: Psychoanalysis and hypnosis to help person relive feelings associated with repressed trauma </li></ul><ul><li>Behavioral: Many strategies, including exposure and response prevention (extinction and nonreinforcement of complaints); systematic desensitization </li></ul><ul><li>Cognitive-behavioral: Correct cognitive distortions and reattribution training </li></ul>
    45. 45. Treatment of Somatoform Disorders (cont’d) <ul><li>Biological: Antidepressant medications, increased physical activity, SSRIs </li></ul><ul><li>Family systems treatment: Place identified patient’s disorder in perspective, teach family adaptive ways of support, prepare family members to deal with problems </li></ul>
    46. 46. Checkpoint Review <ul><li>When do physical complaints become a type of disorder? </li></ul><ul><li>What are the causes of these conditions? </li></ul><ul><li>What treatments are used for these conditions? </li></ul>