Chapter 5: Somatoform and Dissociative Disorders (focus on dissociative disorders)

Dissociative Disorders are disorders in which individuals feel detached from themselves or their surroundings, and reality, experience and identity may disintegrate.

Derealisation is a situation in which the individual loses his or her sense of the reality of the external world (things may change in shape or size and people may seem dear or mechanical).

Types of Dissociative Disorders

1) Depersonalisation Disorder

Definition: dissociative disorder in which feelings of depersonalization are so severe they dominate the client’s life and prevent normal functioning.

Defining features:
- Severe depersonalisation and derealisation.
- Easily distracted and have problems perceiving 3-dimensonal objects.
- Frequent experience of “tunnel vision” (perceptual distortions) and “mind emptiness” (difficulty in absorbing new information).

Statistics:
- Mean age of onset: 16.1 years old.
- Chronic course, averaging 15.7 years.
- More than 50% suffered from additional mood and anxiety disorders.

2) Dissociative Amnesia

Definition: Dissociative disorder featuring te inability to recall personal information, usually of a stressful or traumatic nature.

Defining features:

- Generalised amnesia: condition in which the person loses memory of all personal information, including his or her own identity.
- Localised amnesia: memory loss limited to specific times and events, particularly traumatic events. Also known as selective amnesia.
- Memory loss need not be isolated to simply the events, but the intense emotional reactions to the events as well.

Statistics:
- Could be life long or episodic (6 months or a year).
- Localised amnesia is more common.

3) Dissociative Fugue

Definition: Dissociative disorder featuring sudden, unexpected travel from home, along with an inability to recall one’s past, sometimes with assumption of a new identity.

Defining features:
- Leaving behind an intolerable situation.
- Becomes confused about old identity.
- Running syndromes: individual enters a trancelike state and suddenly imbued with a mysterious source of energy , runs or flees for a long time.
- Amok (a type of running syndrome): individuals enters a trancelike state and often brutally assault and sometimes kill people of animals. If the person is not killed himself, he will probably not remember the episode.

Statistics:
- Usually occur in adulthood.
- Chronic course.
- Fugues states usually end rather abruptly.

4) Dissociative Trance Disorder (DTD)

Definition: Altered state of consciousness in which the person believes firmly that he or she is possessed by spirits; considered to be a disorder only where there is distress and dysfunction.

Defining features:
- Common part of some traditional religious and cultural practices and are not considered abnormal in that context.
- Possession trance: a single or episodic alteration in the state of consciousness characterised by the replacement of customary sense of personal identity b a new identity, often a spirit, power, deity or other person.
- Only when the state is undesirable and considered pathological by members of the culture is it defined as DTD.

Statistics:
- Most common in women.
- Often associated with stress or trauma (current).

5) Dissociative Identity Disorder (DID)

Definition: Dissociative disorder in which as many as 100 personalities or fragments of personalities coexist within one body and mind. Formerly known as multiple personality disorder.

Clinical description:
- DSM-IV criteria include amnesia, as in dissociative amnesia and dissociative fugue.
- Certain aspects of the person’s identity are dissociated.
- Alters: shorthand term for alter egos, the different personalities or identities in DID (could be cross gendered).
- Host identity: Person who becomes the patient and asks for treatment is usually the, which is the identity that keeps the other identities together but end up being overwhelmed.
- Switch: Transition from one personality to another (there could be physical transformations).

Statistics:
- Average number of identities is close to 15.
- Ratio is 9:1 females.
- Onset is always in early childhood, as early as 4 years of age.
- Chronic course without treatment.
- Different personalities can emerge in response to new life situations.
- Comorbid with substance abuse, depression, somatization disorder, borderline personality disorder, panic attacks and eating disorders.
- Often misdiagnosed as psychotic disorder since DID patients usually experience hallucinations (voices in their head motivating them to do something against their will) and are aware of it.

Etiology:
- Child abuse, usually sexual and physical abuse.
- Traumatic experience.
- Hence, DID as an escape mechanism.
- Diathesis-stress model: DID similar to posttraumatic stress disorder (PTSD) in that only people who are biologically and psychologically vulnerable to anxiety are at risk for developing PTSD in response to moderate levels of trauma or stress.
- Suggestability: susceptibility or responsiveness to suggestion.
- Autohypnotic model: people who are suggestible may be able to use dissociation as a defense against extreme trauma.

Treatment:
- Long term psychotherapy to reintegrate identities.
- Prognosis remains guarded nevertheless.
- Catharsis: identify cues or triggers that provoke memories of trauma and/or dissociation and to neutralise them.
- Hence, hypnosis.
- However, reemergence of memories of trauma may trigger further dissociation, which emphasizes the importance of trust in a therapeutic relationship.
- Antidepressant drugs.

Malingerers of DID:
- No changes in physiological responses.
- Recent up-to-date MRI procedures showed changes in hippocampal and medial temporal activity after switch.
- Eager to demonstrate symptoms and do so in a fluid fashion, as opposed to real DID patients who usually attempt to hide symptoms.

Real Memories and False Memories:
- Controversial issue: extent to which memories of early trauma, particularly sexual abuse, are accurate.
- Memories could be a result of strong suggestions by careless therapists.
- If sexual abuse occurred by is forgotten due to amnesia/repression, catharsis is crucial to relief suffering (under direction of a skilled therapist) and perpetrators must be punished.
- However, false memories may result in false accusations.

Chapter 5: Somatoform and Dissociative Disorders (focus on somatoform disorders)

Somatoform Disorders (soma means body) refer to pathological concerns of individuals with the appearance of functioning of their bodies, usually in the absence of any identifiable medical condition.

Types and Characteristics of Somatoform Disorders.

1) Hypochondriasis

Definition: Somatoform disorder involving severe anxiety over the belief that one has a disease process without any evident physical cause.

Clinical Descripion:
- Usually comorbid with anxiety and mood disorders, panic disorder in particular.
- Preoccupation with bodily symptoms, misinterpreting them as indicative of illness or disease (eg. Increase in heart rate and perspiration indicates heart attack and headache indicates brain tumour).
- Preoccupation persists despite appropriate medical evaluation and reassurance.
- Distinction from illness phobia: individuals have marked fear of developing a disease. Hypochondriacs have high disease conviction. Illness phobic individuals have lower rates of checking behaviours and trait anxiety and earlier age of onset.
- Illness phobics can later on develop hypochondriasis and panic disorder.

Statistics:
- Prevalence is unclear: 1%-14%. Recent studies show 3%.
- Sex ratio is 50-50.
- Onset is possible at any time of life, with peak periods in adolescence, 40s and 50s and after 60s.
- Culture-specific syndromes such as koro (belief, accompanied by severe anxiety and panic that genitals are retracting into abdomen, common in Chinese cultures) and dhat (anxious concern about losing semen, common in India).

Etiology:
- Cognitive and perception distortion.
- Vicious cycle: increase focus on self increases arousal and makes physical sensations more intense than they are. With further misinterpretation as illness, anxiety is increased with additional physical symptoms.
- Better safe than sorry: restrictive concept of heath as being totally symptom free.
- Tendency to overrespond to stress, view life negatively and hence, importance of being guarded.
- Learned from family members.
- Stressful life event and memories of illness by family members.
- Secondary gain of increased attention.

Treatment:
- Cognitive-behavioral therapy (CBT)
- General stress management
- Effective and sensitive reassurance form mental health professionals (as opposed to family doctors).
- Antidepressants (for anxiety and depression).

2) Somatization Disorder (Briquet’s Symdrome)

Definition: Somatoform disorder involving extreme and long lasting focus on multiple physical symptoms for which no medical cause is evident.

Clinical Description:
- History of many physical complaints beginning before 30 that occur over the years, resulting in treatment being sought or significant impairment in important areas of functioning.
- Physical complaints cannot be fully explained by a known medical condition or effects of substance (medication or drug abuse).
- Complaints and impairment are not malingered.

Statistics:
- 8 symptoms required for DSM-IV diagnosis (but usually fewer than eight, ie. 4-6).
- Onset begins early in life.
- Chronic course.
- Greater tendency for single women from lower socioeconomic groups.
- Sex ratio for somatic complaints are uniform but that of somatic disorder is approximately 2:1 female.

Etiology:
- Strongly linked to antisocial personality disorder (from family and genetic studies).
- Associated with marital discord, drug and alcohol abuse, suicide attempts etc.
- Learned in a maladaptive family setting.
- Impulsive behaviour with aims at secondary gains of attention, but usually ignored eventually.
- Pleasure seeking and desire short term gratification (eg. provocative sexual behaviour).
- Sociocultural factors: strong degree of dependence in women as opposed to men (possibly as a result of socialization of gender roles).

Treatment:
- No treatment with proven effectiveness as of now.
- Possible to concentrate on providing reassurance, reducing stress and frequency of help-seeking behaviours.
- CBT and antidepressants.

3) Conversion Disorder

Definition: Physical malfunctioning, such as blindness or paralysis, suggesting neurological impairment but with no organic pathology to account for it.

It was backed by strong Freudian beliefs that anxiety resulting from unconscious conflicts somehow was “converted” into physical symptoms to find expression (displacement defense mechanism).

Clinical description:
- Physical malfunctioning such as blindness, paralysis and aponia (difficulty in speaking), total mutism (refusal/inability to speak), loss of sense of touch, seizures, globus hystericus (sensation of lump in throat which inhibits swallowing, eating and speech) etc.
- La belle indifference (to distinguish from malingering).
- Precipitated by marked stress.
- Can usually function normally but unaware of the ability or sensory input.
- Misdiagnosis of physical problems for conversion disorder (5-10%).
- Factitious disorder: non existent physical or psychological disorder deliberately faked for no apparent gain except possibly sympathy and attention.
- Factitious disorder or Munchausen syndrome by proxy: when an individual deliberately makes someone sick.

*To distinguish between real unconscious process and malingering, people with conversion disorders are usually able to perform well on tasks requiring the use of their supposedly impaired body functions under, perhaps, hypnosis where they are dissociated from their awareness. Malingerers usually perform poorly, especially those with factitious disorders who would probably do everything at all costs to prove their impairment.

Statistics:
- Commonly comorbid with anxiety and mood disorders.
- Prevalence vary from 1%-30%.
- Found primarily in women.
- Onset typically during adolescence and slightly after.
- Frequent in males under extreme stress (eg. soldiers exposed to combat).
- Occur in less educated, lower socioeconomic groups.
- In some cultures, such symptoms are common aspects of religious or healing rituals and even seen as contact with God. In these cases, they would not meet the criteria as a disorder since it is culturally accepted and seemingly does not interfere with the individual’s functioning.

Etiology:
- Psychanalytic view: individual experiences a traumatic event which represents an unccepted and unconscious conflict, hence repressed. As anxiety increases and threatens to emerge into consciousness, the person converts it into physical symptoms, so direct dealing with the conflict can be avoided. Such reduction of anxiety is considered the primary gain or reinforcing even that maintains the conversion symptom.
- Major mood disorders and environmental stress, especially sexual abuse.
- Learned from family members with such disorder (secondary gain).

Treatment:
- Carthasis: to recall and relive emotional trauma that has been made unconscious and to release the accompanying tension (chapter 1).
- Treatments as used in somatization disorder.
- Reduce reinforcing or supportive consequences of conversion symtoms, especially the secondary gains.

4) Pain disorder

Definition: Somatoform disorder featuring true pain but for which psychological factors play an important role in onset, severity or maintenance.

Clinical description:
- Pain is real and hurts, regardless of causes.
- Presence of pain in one or more anatomical sites.
- Causes significant distress or impairment in functioning.
- Psychological factors judged to play primary role in onset, severity, exacerbation (worsening of symptoms) or maintenance of the pain.
- Pain is not malingered.

More on causes and treatment in chapter 7.

5) Body Dysmorphic Disorder (BDD)

Definition: Somatoform disorder featuring a disruptive preoccupation with some imagined defect in appearance.

Clinical description:
- Preoccupation with imagined defect in appearance.
- Eg. fixation on mirrors or phobia of mirrors.
- Suicide attempts as common consequences of disorder.
- Ideas of reference: perception that everything that goes on in their world is somehow related to them, ie. their imagined defect.
- Similar to OCD (obsessive-compulsive disorder), individuals with BDD believe that their imagined bodily defect is a real and reasonable source of concern (delusional? Remains controversial till now).

Statistics:
- Prevalence is hard to estimate because BDD patients usually attempt to keep it secret.
- Life-long course without treatment.
- Onset ranges from early adolescence through the 20s, peaking at 18 or 19.
- Most people with BDD seek help from plastic surgeons and dermatologists.
- High percentage of suicide attempts.

Etiology:
- Little is known, but it tends to run in families.
- Comorbid with OCD (similar age of onset and course).

Treatment:
- Drugs that block the reuptake of serotonin.
- CBT: exposure and response prevention.
- Generally similar to treatments of OCD.
- Plastic surgery, but severity of disorder and distress is usually increased after which.