Clinical psychology
Chapter 8
Dissociative disorders and somatic symptom- related disorders

Introduction

Both types of disorders are hypothesized to be associated with stressful experiences, yet symptoms do not involve direct expressions of anxiety.

• In the dissociative disorders, the person experiences disruptions of consciousness. He or she loses track of self-awareness, memory, and identity
• In the somatic related disorders, the person complains of bodily symptoms that suggest a physical defect or dysfunction, sometimes dramatic in nature. For some of these, no physiological basis can be found, and for others, the psychological reaction to the symptoms appear to be excessive.

Dissociative and somatic symptom-related disorders tend to be comorbid.

Dissociative disorders

The DSM-5 includes three major dissociative disorders:

• Dissociative amnesia
• Depersonalization/derealization disorder
• Dissociative identity disorder

The dissociative disorders are all presumed to be caused by a common mechanism, dissociation. Which results in some aspect of cognition or experience being inaccessible consciously.

Dissociation and memory

Psychodynamic theory suggests that in dissociative disorder traumatic events are repressed.
In this model, memories are forgotten because they are so aversive.

Memory for emotional relevant stimuli is enhanced by stress, while memory for neutral stimuli is impaired.

Dissociative disorders involve unusual ways of responding to stress.
Extremely high levels of stress hormones could interfere with memory formation.
In the face of severe trauma, memories may be stored in such a way that they are not accessible to awareness later when the person has returned to a more normal state.
Dissociative disorders are considered an extreme outcome of this process.

Dissociative amnesia

The person with dissociative amnesia is unable to recall important personal information, usually information about some traumatic experience.
The holes in memory are too extensive to be explained by ordinary forgetfulness.
The information is not permanently lost, but it cannot be retrieved during the episode of amnesia, which may last for as short a period as several hours, or as long as several years.
The amnesia usually disappears as suddenly as it began, with complete recovery and only a small change of recurrence.

Most of the memory loss involves information about some part of a traumatic experience.
More rarely the amnesia is for entire events during a circumscribed period of distress.
During the period of amnesia, the person’s behavior is otherwise unremarkable, except that the memory loss may cause some disorientation.

In a more severe sub-type of amnesia, fugue, the memory loss is more extensive.
The person not only becomes totally amnesic but suddenly leaves home and work.
Recovery is usually complete, although it takes various amounts of time.
After recovery, people are fully able to remember the details of their life and experiences, except for those events that took place during the fugue.

Typically, dissociative disorders involve deficits in explicit memory, but not implicit memory.

In diagnosing dissociative amnesia, it is important to rule out other common causes of memory loss, such as dementia or substance loss.

Amnesia can occur after a person has experienced some severe stress.
But not all amnesias seem to immediately follow trauma.

DSM-5 criteria for dissociative amnesia

• Inability to remember important personal information, usually of a traumatic or stressful nature, that is too extensive to be ordinary forgetfulness.
• The amnesia is not explained by substances, or by other medical or psychological conditions.
• Specify dissociative fugue sub-type if:
  • The amnesia is associated with bewildered or apparently purposeful wandering.

Depersonalization/derealization disorder

The person’s perception of the self or surroundings is disconcertingly and disruptively altered.
The altered perceptions are usually triggered by stress. It involves not disturbance of memory.
People suddenly lose their sense of self. This involves unusual sensory experiences.

Derealization: the sensation that the world has become unreal.

Depersonalization/derealization disorder usually begins in adolescence.
It can start either abruptly or more insidiously.
Once it begins, it has a chronic course, it lasts a long time.
Comorbid personality disorders are frequent.
Childhood trauma is often reported.

Disorders that commonly involve these symptoms:

• Schizophrenia
• Posttraumatic stress disorder
• Borderline personality disorder

Depersonalization also can be triggered by hyperventilzation.

DSM-5 criteria for depersonalization/derealization disorder

• Depersonalization: experiences for detachment from one’s mental processes or body, as through one is in a dream, or
• Derealization: experiences of unreality of surroundings
• Symptoms are persistent or recurrent
• Reality testing remains intact
• Symptoms are not explained by substances, another dissociative disorder, another psychological disorder, or by a medical condition.

Dissociative identity disorder

DSM-5 criteria for dissociative identity disorder

• A. disruption of identity characterized by tow or more distinct personality states (alters) or an experience of possession, as evidenced by discontinuities in sense of self or agency, as reflected in altered cognition, behavior, affect, perceptions, consciousness, memories, or sensory-motor functioning. This disruption may be observed by others or reported by the patient.
• B. recurrent gaps in recalling events or important personal information that are beyond ordinary forgetting.
• C. symptoms are not part of a broadly accepted cultural or religious practice, and are not due to drugs or a medical condition.
• D. In children, symptoms are not better explained by an imaginary playmate or by fantasy play.

Clinical description of DID

Dissociative identity disorder (DID) requires that a person have at least two separate personalities, or alters, different models or being, thinking, feeling, and acting that exist independently of one another and that emerge at different times.
Each determines the person’s nature and activities when it is in command.
The primary alter may be totally unaware that the other alters exist and may have no memory of what those other alters do and experience when they are in control.

Sometimes, there is one primary personality, and this is typically the alter that seeks treatment.
Usually, there are two to four alters at the time a diagnoses is made, but over the course of treatment, others may emerge.
The diagnoses requires that the existence of different alters be chronic.

Each alter may be quite complex, with its own behavior patterns, memories, and relationships. Usually the personalities of the different alters are quite different form one another, even polar opposites.
The alters are all aware of lost periods of time, and the voices of the others may sometimes echo an alter’s consciousness, even though the alter does not know to whom these voices belong.

DID usually beings in childhood, but it is rarely diagnosed until adulthood.
It is more severe and extensive than the other dissociative disorders, and recovery may be less complete.
More common in women.
Other diagnoses are often present, including posttraumatic stress disorder, major depressive disorder, and somatic symptom disorder.
DID is commonly accompanied by other symptoms such as headaches, hallucinations, suicide attempts, and self-injurious behavior, as well as by other dissociative symptoms such as amnesia and depersonalization.

Etiology of DID

Almost all patients with DID report severe childhood abuse.

Two major theories of DID:

• The posttraumatic model
• The sociaocognitive model

Both theories suggest that sever physical or sexual abuse during childhood sets the stage for DID.

The posttraumatic model proposes that some people are particularly likely to use dissociation to cope with trauma, and this is seen as a key factor in causing people to develop alters after trauma.

The sociocognitive model considers DID to be the result of learning to enact social roles.
According to this model, alters appear in response to suggestions by therapists, exposure to media reports of DID, or other cultural influences.

Evidence in the debate:

• DID symptoms can be role-played
• Alters share memories, even when they report amnesia.
• The detection of DID differs by clinician
• Many DID symptoms emerge after treatment starts

Treatment of DID

There seems to be widespread agreement on several principles in the treatment of dissociative identity disorder, whatever the clinician’s orientation.

• An emphatic and gentle stance, with the goal of helping the client function as one wholly integrated person.

The goal of treatment should be to convince the person that splitting into different personalities is no longer necessary to deal with traumas.
DID is conceptualized as a means of escaping from severe stress, treatment can help teach the person more effective ways to cope with stress.

There are also important discrepancies across approaches.
Psychodynamic treatment is probably used more for DID and the other dissociative disorders than for any other psychological disorder.

• Hypnosis as a means of helping patients diagnosed with dissociative disorders to gain access to repressed material. Usually worsen DID symptoms.

DID is often comorbid with anxiety and depression, which can sometimes be lessened with antidepressant medication. These medications have no effect on the DID itself.

Somatic symptom and related disorders

Somatic symptom and related disorders are defined by excessive concerns about physical symptoms or health.
Includes somatic symptoms regardless of whether they can be explained medically.

Three major somatic symptom-related disorders:

• Somatic symptom disorder
  Involves major distress or energy experditure regarding a somatic symptom or symptoms
• Illness anxiety disorder
  Involves fears about having a major medical illness in the absence of somatic symptoms
• Conversation syndrome
  Neurobiological symptoms that are medically unexplained.

People with somatic symptom and related disorders tend to seek frequent medical treatment, sometimes at great expense.
Often dissatisfied with their medical care. For many, no medical explanation or cure can be identified.

Somatic symptom and related disorders have been criticized for several reasons:

• Incredible diversity among people diagnosed with these conditions
• Somatic symptom disorder and illness anxiety disorder are defined by health concerns that are a cause of excessive anxiety or involve too much expenditure of time and energy. Quite subjective criteria.
• The diagnoses of somatic symptom and related disorders are often concerned stigmatizing by patients and clinicians.

Clinical description of somatic symptom disorder

Three core criteria for somatic symptom disorder

• One or more somatic symptoms that are distressing or result in significant disruption in daily life
• Excessive anxiety, concern, or time and energy devoted to the somatic concern
• Duration of at least 6 months

The somatic symptoms may begin or intensify after some conflict or stress.

DSM-5 criteria for somatic symptom disorder

• At least one somatic symptom that is distressing or disrupts daily life
• Excessive thoughts, feelings, and behaviors related to somatic symptom(s) or health concerns, as indicated by at least one of the following:
  • Health-related anxiety
  • Disproportionate and persistent concerns about the medical seriousness of symptoms, and excessive time and energy devoted to health concerns
• Duration of at least 6 months
• Specify if predominant pain.

Clinical description of illness anxiety disorder

The main feature of illness anxiety disorder is a preoccupation with fears of having a serious disease despite having no significant somatic symptoms.
These fears must lead to excessive care seeking or maladaptive avoidance behaviors that persists for at least 6 months.

Illness anxiety disorder often co-occurs with anxiety and mood disorders.

DSM-5 criteria for illness anxiety disorder

• Preoccupation with and high level of anxiety about having or acquiring a serious disease
• Excessive illness behavior or maladaptive avoidance
• No more than mild somatic symptoms are present
• Not explained by other psychological disorders
• Preoccupation lasts at least 6 months

Clinical description of conversion disorder

In conversation disorder, the person suddenly develops neurological symptoms.
The symptoms suggest an illness related to neurological damage, but medical tests indicate that the bodily organs and nervous system are fine.

Aphonia: loss of the voice other than whispered speech.
Amosia: loss of the sense of smell.

Some people with conversion disorder seem complacent or even serene, are not particularly eager to part with their symptoms, and do not connect their symptoms with their stressful situations.

Symptoms of conversion disorder usually develop in adolescence or early adulthood, typically after a major life stressor.
An episode may end abruptly, but sooner or later the disorder is likely to return, either in its original form or with a different symptom.
The prevalence is less than 1 percent.
More women than men.
Patients with conversion disorder are highly likely to meet criteria for another somatic symptom disorder.

• Dissociative disorder
• Major depressive disorder
• Substance use disorders
• Personality disorders

DSM-5 criteria for conversion disorder

• One or more symptoms affecting voluntary motor or sensory function.
• The symptoms are incompatible with recognized medical disorder
• Symptoms cause significant distress or functional impairment or warrant medical evaluation.

DSM-5 criteria for factitious disorder

• Fabrication of physical or psychological symptoms, injury or disease.
• Deceptive behavior is present in the absence of obvious external rewards
• Behavior is not explained by another mental disorder
• The factitious disorder imposed on self, the person presents himself or herself to others as ill, or injured.
• In factitious disorder imposed on another, the person fabricates symptoms in another person and then presents that person to others as ill, impaired, or injured.

Etiology of somatic symptom-related disorders

Somatic symptom disorder and conversion disorder are not heritable.

Neurobiological factors that increase awareness of and distress over somatic symptoms

Pain and uncomfortable physical sensations increase activity in regions of the brain called the anterior insula and the anterior cingulate.
These regions have strong connections with the somatosensory cortex.
Heightened activity in these regions is related to greater propensity for somatic symptoms and more intense ratings of the unpleasantness of a standardized painful stimulus.
Some people may have hyperactive brain regions that are involved in evaluating the unpleasantness of body sensations, which would help explain why they are more vulnerable to experiencing and noticing somatic symptoms and pain.

Pain and somatic symptoms can be increased by anxiety, depression, and stress hormones.
Anxiety and depression are also directly related to activity in the anterior cingulate.
Experiences of emotional pain can also activate the anterior cingulate and the anterior insula.

Cognitive behavioral factors that increase awareness of and distress over somatic symptoms

Cognitive behavioral models focus on the mechanisms that could contribute to the excessive focus on and anxiety over health concerns. .

Once a somatic symptom develops, two cognitive variables appear important:

• Attention to body sensations
• Interpretation of those sensations.

People prone to worries about their health also demonstrate an attributional style that involves interpreting physical symptoms in the worst possible way.
The exact form of the cognitive bias may vary, but once these negative thoughts begin, the resultant elevations of anxiety and cortisol may exacerbate somatic symptoms and distress over those symptoms.

The tendency to be overly concerned about one’s health may have evolved from early experiences of medical symptoms or from family attitudes to physical illness.

Fear that bodily sensation signifies illness is likely to have two behavioral consequences:

• The person may assume the role of being sick and avoid work and social tasks, and this can intensify symptoms by limiting exercise and other healthy behaviors
• The person may seek reassurance from doctors and from family members, and this help-seeking behavior may be reinforced if it results in the person getting attention or sympathy.

Etiology of conversion disorder

Psychodynamic perspective on conversion disorder
On a conscious level, a patient is telling the truth
On a on unconscious level, some psychological factor is at work, making the patient (for example) unable to more her arm despite the absence of any physical cause.

Perceptions formed outside of consciousness can influence behavior.
One way to understand conversion disorder is that there is a disruption in consciousness, such that the person fails to have an explicit awareness of sensory and motor information.
The second stage focuses on motivation. Some people are motivated to appear ill.

Social and cultural factors in conversion disorder
More common in countries that may place less emphasis on psychologizing distress.

Treatment of somatic symptom and related disorders

One of the major obstacles to treatment is that most people with somatic symptom-related disorders do not want to consult mental health professionals.
It is better to work with patients on ways to improve their lives than on debating them about the source of their symptoms.

Cognitive behavioral treatment

Cognitive behavioral therapists have applied many different techniques to help people with somatic symptom-related disorders

• Identify and change the emotions that trigger their somatic concerns
• Change their cognitions regarding their somatic symptoms
• Change their behaviors so they stop playing the role of a sick person and gain more reinforcement for engaging in other types of social interactions.

Treating anxiety and depression often reduces somatic symptoms.

Antidepressant treatment for somatic symptom disorder with pain

Antidepressants are likely to be helpful when pain is a dominant symptom of somatic symptom disorder.