Chapter Six

1
Chapter Six

• Somatic Symptom and Dissociative Disorders

2
Somatic Symptom Disorders

• Disorders that involve physical symptoms or
  anxiety over illness
• Somatic symptom disorder (SSD)
• Illness anxiety disorder
• Conversion disorder (functional neurological
  symptoms disorder)
• Factitious disorder

3
Somatic Symptom Disorders (contd.)
4
Somatic Symptom Disorder

• Pattern of reporting distressing physical
  symptoms combined with extreme concern about
  health or fears of undiagnosed medical conditions
• Symptoms must be present for at least six months
• Symptoms not under voluntary or conscious control
• Psychological in nature but often accompanied by
  medical conditions

5
Somatic Symptom Disorder (contd.)

• SSD with predominantly somatic complaints
• Chronic complaints of specific bodily symptoms
  that have no physical basis
• physical complaints such asvdiscomfort in
  different parts of the body gastrointestinal
  symptoms, sexual symptoms such as sexual
  indifference, irregular menses, or erectile
  dysfunction and pseudoneurological symptoms such
  as amnesia or breathing difficulties
• SSD with pain features
• reports of severe pain that (a)appears to have no
  physiological or neurological basis,(b)seems
  significantly greater than would be expected with
  an existing physical condition, or(c)lingers long
  after a physical injury has healed.

6
Illness Anxiety Disorder

• Previously called hypochondriasis
• Persistent health anxiety and concern that one
  has an undetected physical illness with no or
  minimal somatic symptoms
• Symptoms must be present for at least six months

7
Illness Anxiety Disorder (contd.)

• Individuals with illness anxiety concerns
• Catastrophize
• Overgeneralize
• Display all-or-none thinking
• Show selective attention
• Cognitively based disorder

8
Illness Anxiety Disorder (contd.)
9
Conversion Disorder

• Also known as functional neurological symptom
  disorder
• Sensory or motor impairment suggestive of a
  neurological disorder, but with no underlying
  medical cause
• Symptoms are not consciously being faked
• Individual is not malingering, but rather
  believes there is a genuine problem

10
Conversion Disorder (contd.)

• Most common symptoms
• Psychogenic movement
• Originating from psychological cause
• Disturbances of stance and walking
• Sensory symptoms
• Blindness, loss of voice, motor tics, and
  dizziness
• Psychogenic seizures
• Some symptoms are easily diagnosed, while others
  require extensive neurological and physical
  examination

11
Factitious Disorders

• Factitious disorder
• Symptoms of illness are deliberately induced,
  simulated, or exaggerated, with no apparent
  external incentive
• Differs from malingering
• Faking a disorder to achieve some goal, such as
  an insurance settlement
• In factitious disorder, the individual is usually
  unaware of the motivation for the behavior

12
Factitious Disorders (contd.)

• Factitious disorder imposed on another
• Pattern of falsification or production of
  physical or psychological symptoms in another
  individual
• Relatively new diagnostic category and as a
  result, little information is available on
  prevalence, age of onset, or familial pattern
• Vast majority involve apparently loving and
  attentive mother
• Diagnosis of this condition is difficult
• A mortality rate of up to 9 percent of those
  targeted

13
Etiology of Somatic Symptom Disorders

• Figure 6-2 Multipath Model for Somatic Symptom
  Disorders The dimensions interact with one
  another and combine in different ways to result
  in a specific somatic symptom disorder.

14
Etiology of Somatic Symptom Disorders (contd.)

• Biological dimensions
• Modest contribution of genetic factors
• Biological predisposition hardwired into central
  nervous system can result in
• Hypervigilance or exaggerated focus on bodily
  sensation
• Increased sensitivity to mild bodily changes
• Tendency to react to somatic sensations with
  alarm
• Repetitive activation of nervous system can lead
  to increased sensitivity of pain nerves

15
Etiology of Somatic Symptom Disorders (contd.)

• Psychological dimension
• Role of reinforcement, modeling, catastrophic
  cognitions, or combination of these
• allows them to escape unpleasant circumstances or
  to avoid responsibilities
• Cognitive factors
• Somatic disorders may develop in predisposed
  individuals
• Unrealistically interpret and overestimate
  dangerousness of bodily symptoms, which leads to
  a cycle (catastrophic thoughts -gt bodily
  sensations, which are interpreted as a threat,
  which -gt more bodily sensations.

16
Etiology of Somatic Symptom Disorders (contd.)

• Social dimension
• Rejection or abuse from family members and
  feeling unloved
• History of sexual abuse or rape
• Social isolation/inability to connect with family
  and friends
• Sociocultural dimension
• Cultural factors, including lower educational
  levels, ethnicity, and immigrant status

17
Treatment of Somatic Symptom Disorders

• Biological
• Antidepressant medications such as SSRIs are used
  to treat somatic symptoms disorder ad illness
  anxiety disorder
• Increased physical activity is recommended for
  conversion disorder

18
Treatment of Somatic Symptom Disorders (contd.)

• Psychological
• Focus is understanding clients view regarding
  problem
• Demonstrate empathy
• Develop and improve social network and coping
  skills
• Provide psychoeducation
• Cognitive-behavioral approaches
• Correct cognitive distortions challenge
  irrational beliefs
• Interoceptive exposure (exposure to bodily
  sensations)

19
Dissociative Disorders

• Involves some sort of dissociation, or
  separation, of a part of a persons
  consciousness, memory, or identity
• Dissociative amnesia
• Depersonalization/derealization disorder
• Dissociative identity disorder
• Relatively rare
• No objective assessment
• Possibility of feigning

20
Dissociative Amnesia

• Sudden partial or total loss of important
  personal information or recall of events due to
  psychological factors or stressors
• May occur following a traumatic event or
  stressful circumstances
• May also involve a fugue state

21
Dissociative Amnesia (contd.)

• Localized amnesia
• Lack of memory for a specific event or events
• Individuals may have selective amnesia or
  systematized amnesia
• May occur after a repressed memory comes to light
• selective amnesia Inability to remember certain
  details of an incident.
• systematized amnesia Loss of memory for certain
  categories of information
• Dissociative fugue
• Episode of complete loss of memory of ones life
  and identity , unexpected travel to new location,
  or assumption of new identity Recovery is often
  abrupt and complete

22
Depersonalization/Derealization Disorder

• Characterized by feelings of unreality concerning
  the self and the environment
• Depersonalization is the most common dissociative
  disorder
• Diagnosis given only when feelings of unreality
  and detachment cause major impairment in social
  or occupational functioning
• Can be fairly intense
• May be short-lived or last for decades

23
Dissociative Identity Disorder (DID)

• Formerly called multiple personality disorder
• Two or more relatively independent personality
  states appear to exist in one person, including
  experiences of possession
• Possession was added to the DID definition in
  DSM-5 to provide more cross-cultural utility
• Many individuals with DID also experience trance
  states, sleepwalking, paranormal and possession
  episodes
• Diagnostic controversy
• extremely before media portrayal
• Therapeutic techniques may increase or create
  symptoms

24
Etiology of Dissociative Disorders

• Figure 6-4 Multipath Model of Dissociative
  Identity Disorder The dimensions interact with
  one another and combine in different ways to
  result in dissociative identity disorder.

25
Etiology of Dissociative Disorders (contd.)

• Diagnosis depends on self-report, making it
  difficult to differentiate between genuine and
  faked cases
• Two most influential models, post-traumatic (that
  DID results from attempt to encapsulate trauma)
  and sociocognitive (that individuals are
  reinforced for symptoms, which may be
  iatrogenic/resulting from treatment), are not
  sufficient to explain why only some develop
  disorders
• Must look at vulnerabilities in biological,
  psychological, social, and sociocultural
  dimensions

26
Etiology of Dissociative Disorders (contd.)

• Biological dimension
• Atypical brain functioning
• Inhibited activity in hippocampus and
  hypometabolism in area of prefrontal cortex
• Variations in brain activity when comparing
  different personalities
• Difficult to interpret patterns of brain activity
• Permanent structural changes in brain due to
  trauma may play a role
• Reduction in amygdalar and hippocampal volumes

27
Etiology of Dissociative Disorders (contd.)

• Psychological dimension
• Psychodynamic theory
• Repression blocks unpleasant or traumatic events
  from consciousness
• Protects individuals from painful memories or
  conflicts
• DID results from severe childhood abuse

28
Etiology of Dissociative Disorders (contd.)

• Psychological dimension (contd.)
• Four factors necessary for development of DID
  according to posttraumatic model (PTM)
• Exposure to overwhelming childhood stress
• Capacity to dissociate
• Encapsulating or walling off the experience
• Developing different memory systems
• DID results from these factors if supportive
  environment is unavailable or if personality is
  not resilient

29
Etiology of Dissociative Disorders (contd.)

• Figure 6-5 The Post-Traumatic Model of
  Dissociative Identity Disorder Note the
  importance of each of the factors in the
  development of dissociative identity disorder.
• Source Adapted from Kluft (1987) Loewenstein
  (1994).

30
Etiology of Dissociative Disorders (contd.)

• Social and sociocultural dimension
• Sociocognitive model (SCM)
• Displays of role enactments that have been
  created, legitimized, and maintained by social
  reinforcement
• Patients learn about phenomenon and its
  characteristics from mass media, cues provided by
  therapist, personal experiences, and observation
• Iatrogenic disorder unintentionally produced by
  therapists actions and treatment strategies
• High levels of hypnotizability and suggestibility
  

31
Treatment of Dissociative Disorders

• Variety of treatments, including
• Supportive counseling
• Hypnosis
• Personality reconstruction
• Currently no specific medication for dissociative
  disorders, but used to treat accompanying anxiety
  or depression

32
Treatment of Dissociative Disorders (contd.)

• Dissociative amnesia and fugue
• Symptoms usually spontaneously end, but often
  associated with depression and/or stress
• Treating dissociative disorders indirectly by
  alleviating depression and stress
• Antidepressants or cognitive-behavioral therapy
  for depression
• Stress-management techniques for stress

33
Treatment of Dissociative Disorders (contd.)

• Depersonalization/derealization disorder
• Also subject to spontaneous remission, but at a
  much slower rate
• Treatment focuses on alleviating feelings of
  depression, anxiety, or fear of going insane
• Antidepressants and antianxiety medications

34
Treatment of Dissociative Disorders (contd.)

• Dissociative identity disorder
• Major goal is use of trauma-based therapy to
  develop healthier ways of dealing with stressors
• Hierarchical treatment approach involves
• Working on safety issues, stabilization, and
  symptom reduction
• Reducing cognitive distortions
• Identifying and working through traumatic
  memories
• Stabilizing and learning to deal with stressors
• Developing healthy relationships and practicing
  self-care

35
Treatment of Dissociative Disorders (contd.)

• Dissociative identity disorder (contd.)
• Treatment is not always successful
• Greatest reduction in symptoms when individuals
  are able to integrate personalities