chapter 8 abnormal psychology

factitious disorder

. Also placed in the somatic symptoms and related disorders category in DSM-5 is factitious disorder. In factitious disorder the person intentionally produces psychological or physical symptoms (or both). Although this may strike you as strange, the person's goal is to obtain and maintain the benefits that playing the "sick role" (even to the extent of undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel. In DSM-IV, factitious disorder was in a category of its own. In DSM-5 it has been moved into the category of somatic symptom and related disorders. The reason for the move is because in most cases of factitious disorder, the person presents with somatic symptoms and with expressed belief that he or she is ill. However, many regard the inclusion of factitious disorder in the somatic symptom and related disorders category as very unfortunate. These disorders have a history of being stigmatized and many doctors do not take them very seriously. To group them now with a disorder that is characterized by deliberately feigning illness runs the risk of further perpetuating these negative stereotypes. In factitious disorder, patients may surreptitiously alter their own physiology—for example, by taking drugs—in order to simulate various real illnesses. Indeed, they may be at risk for serious injury or death and may even need to be committed to an institution for their own protection. The prevalence of factitious disorder is not well established, although it is probably in the region of 0.5 to 0.8 percent of patients in general hospital settings. The disorder is also thought to be more common in women than it is in men. Systematic research on this disorder is lacking and there is currently no theoretical model of why it develops. Some of the social gains that come from being in a patient role are thought to be involved, however.

Treatment of Somatic Symptom Disorder

. In the case of Richard, the patient you met at the beginning of this chapter, for example, the cognitive components of this treatment approach might focus on assessing his beliefs about illness and modifying misinterpretations of his bodily sensations. Behavioral techniques might include having Richard induce innocuous symptoms by intentionally focusing on parts of his body so that he could learn that selective perception of his own bodily sensations could play a major role in his symptoms. Sometimes patients treated with CBT are also directed to engage in response prevention by not checking their bodies as they usually do and by stopping their constant seeking of reassurance. Generally, the duration of CBT is relatively brief (6 to 16 sessions). Sessions can also be delivered in a group format. In addition to helping reduce physical symptoms and anxiety about symptoms, CBT approaches can also reduce levels of anxiety and depression more generally. Not surprisingly, patients do better if they receive more sessions of treatment. In a recent study, patients also reported that considering alternative reasons for the presence of their bodily symptoms (for example, a headache doesn't necessarily signal the presence of a brain tumor) was the most valuable aspect of CBT Cognitive-behavioral techniques are also widely used in the treatment of somatic symptom disorder that involves pain. Treatment programs generally include relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of "no-pain" behaviors. Patients receiving such treatments tend to show substantial reductions in disability and distress, although changes in the intensity of their pain tend to be smaller in magnitude. In addition, antidepressant medications (especially the tricyclic antidepressants) and certain selective serotonin reuptake inhibitors have been shown to reduce pain intensity in a manner independent of the effects the medications may have on mood

factitious disorder imposed on another

A dangerous variant of factitious disorder is factitious disorder imposed on another (sometimes referred to as Munchausen's syndrome by proxy). Here, the person seeking medical help has intentionally produced a medical or psychiatric illness (or the appearance of an illness) in another person. This person is usually someone (such as a child) who is under his or her care In a typical instance, a mother presents her own child for treatment of a medical condition she has deliberately caused. To produce symptoms, the mother might withhold food from the child, add blood to the child's urine, give the child drugs to make him or her throw up, or heat up thermometers to make it seem as if the child has a fever. If the child is hospitalized, the mother might deliberately infect an intravenous (IV) line to make the child more ill. Of course, the health of the victims is often seriously endangered by this form of child abuse and the intervention of social service agencies or law enforcement is sometimes necessary. In as many as 10 percent of cases, the actions of the mother may lead to a child's death This disorder may be suspected when the victim's clinical presentation is atypical, when lab results are inconsistent with each other or with recognized diseases, or when there are many frequent returns or increasingly urgent visits to the same hospital or clinic. The perpetrators (who often have extensive medical knowledge) tend to be highly resistant to admitting the truth about what they are doing They also appear to be devoted to their child, making it hard for health care providers to suspect that they are the cause of the child's problems. It has been estimated that the average length of time to confirm the diagnosis is 14 months If the perpetrator senses that the medical staff is suspicious, he or she may abruptly terminate contact with that facility, only to show up at another one to begin the entire process anew. Compounding the problem of detection is the fact that health care professionals who realize they have been duped may be reluctant to acknowledge their fallibility for fear of legal action. Misdiagnosing the disorder when the parent is in fact innocent can also lead to legal difficulties for the health care professionals One technique that has been used with considerable success is covert video surveillance of the mother and child during hospitalizations. In one study, 23 of 41 suspected cases were finally determined to have factitious disorder by proxy, and in 56 percent of those cases video surveillance was essential to the diagnosis

sociocognitive theory

According to this theory, DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities, mostly because clinicians have inadvertently suggested, legitimized, and reinforced them and because these different identities are geared to the individual's own personal goals It is important to understand that the sociocognitive perspective does not view this as being done intentionally or consciously by the person involved. Rather, it occurs spontaneously with little or no awareness The suspicion is that overzealous clinicians, through fascination with the clinical phenomenon of DID and unwise use of such techniques as hypnosis, are themselves largely responsible for eliciting this disorder in highly suggestible, fantasy-prone people In an early examination of the sociocognitive hypothesis, Spanos et al. (1985) demonstrated that otherwise ordinary college students can be induced by suggestion under hypnosis to exhibit some of the phenomena seen in DID. These included the adoption of a second identity with a different name that showed a different profile on a personality inventory. Spanos and colleagues thus demonstrated that people can enact a second identity when situational forces encourage it. Related situational forces that may affect the individual outside the therapist's office include memories of one's past behavior (e.g., as a child), observations of other people's behavior (e.g., others being assertive and independent, or sexy and flirtatious), and media portrayals of DID Sociocognitive theory is also consistent with evidence that most DID patients do not show unambiguous signs of the disorder before they enter therapy and with evidence that the number of identities often increases (sometimes dramatically) with time spent in therapy

changes in the prevalence of DID

Also consistent with the sociocultural perspective are changes in the prevalence of DID. Owing to their dramatic nature, cases of DID receive a great deal of attention and publicity in fiction, television, and movies. But until relatively recently, however, DID was extremely rare—or at least rarely diagnosed—in clinical practice. At about the same time, the diagnostic criteria for DID (then called multiple personality disorder) were clearly specified for the first time with the publication of DSM-III in 1980.This seems to have led to increased acceptance of the diagnosis by clinicians, which may have encouraged reporting of it in the literature (not due to media portrayls) In addition, beginning in about 1980, prior scattered reports of instances of childhood abuse in the histories of adult patients began building into what would become a crescendo. As we will see later, many controversies arose regarding how to interpret such findings, but it is definitely true that these reports of abuse in patients with DID attracted a great deal of attention to this disorder, which in turn may have increased the rate at which it was being diagnosed. Prior to 1979, only about 200 cases could be found in the entire psychological and psychiatric literature worldwide. By 1999, however, over 30,000 cases had been reported in North America alone. Prevalence estimates in the general population are hard to come by and it is possible that no such estimates are valid, given how hard it is to make this diagnosis reliably. However, one study of 658 people in upstate New York has estimated a 1.5 percent prevalence

DSM-5 Criteria for... Dissociative Amnesia

An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting. NOTE: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol or other drug of abuse, a medication) or a neurological or other medical condition (e.g., partial complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic brain injury, other neurological condition). The disturbance is not better explained by dissociative identity disorder, posttraumatic stress disorder, acute stress disorder, somatic symptom disorder, or major or mild neurocognitive disorder.

Conversion Disorder (Functional Neurological Symptom Disorder)

Another disorder within the diagnostic category of somatic symptom and related disorders is conversion disorder. The term conversion disorder is relatively recent. Historically this disorder was one of several disorders that were grouped together under the term hysteria. In other words, the patient has symptoms or deficits affecting the senses or motor behavior that strongly suggest a medical or neurological condition. However, the pattern of symptoms or deficits is not consistent with any neurological disease or medical problem. A few typical examples include partial paralysis, blindness, deafness, and episodes of limb shaking accompanied by impairment or loss of consciousness that resemble seizures. Of course, the diagnosis can only be made after a full medical and neurological workup has been conducted. It is also important to emphasize that the person is not intentionally producing or faking the symptoms. Rather, psychological factors are often judged to play an important role because symptoms usually either start or are exacerbated by preceding emotional or interpersonal conflicts or stressors. Early observations dating back to Freud suggested that most people with conversion disorder showed very little of the anxiety and fear that would be expected in a person with a paralyzed arm or loss of sight. This seeming lack of concern was known as la belle indifférence—French for "the beautiful indifference." For a long time it was thought to be an important diagnostic criterion for conversion disorder. However, la belle indifférence occurs only in about 20 percent of patients. Lack of concern about symptoms or their implications is also not specific to conversion disorder. For these reasons, this phenomenon has become de-emphasized in more recent editions of the DSM

Seizures in conversion disorder

Another relatively common form of conversion symptom involves seizures. These resemble epileptic seizures, although they are not true seizures For example, patients do not show any EEG abnormalities and do not show confusion and loss of memory afterward, as patients with true epileptic seizures do. Moreover, patients with conversion seizures often show excessive thrashing about and writhing not seen with true seizures, and they rarely injure themselves in falls or lose bowel or bladder control as patients with true seizures frequently do.

depersonalization/derealization disorder

As many as 50 to 74 percent of us have such experiences in mild form at least once in our lives, usually during or after periods of severe stress, sleep deprivation, or sensory deprivation But when episodes of depersonalization or derealization become persistent and recurrent and interfere with normal functioning, depersonalization/derealization disorder may be diagnosed In this disorder, people have persistent or recurrent experiences of feeling detached from (and like an outside observer of) their own bodies and mental processes. They may even feel they are, for a time, floating above their physical bodies, which may suddenly feel very different—as if drastically changed or unreal. During periods of depersonalization, unlike during psychotic states, reality testing remains intact. The related experience of derealization, in which the external world is perceived as strange and new in various ways, may also occur. In keeping with such reports, research has shown that emotional experiences are attenuated or reduced during depersonalization—both at the subjective level and at the level of neural and autonomic activity that normally accompanies emotional responses to threatening or unpleasant emotional stimuli In DSM-IV, derealization and depersonalization were treated as two distinct conditions. In DSM-5 they have been combined. This is because research suggests that people who have prominent derealization or prominent depersonalization look rather similar in terms of demographic characteristics, the course and severity of their problems, and their comorbid conditions As we noted earlier, transient symptoms of depersonalization or derealization are very common in the general population. This is why, to qualify for a diagnosis, episodes of depersonalization or derealization must be persistent or recurrent. Occasional depersonalization/derealization symptoms are also sometimes reported by people with schizophrenia, borderline personality disorder, panic disorder, acute stress disorder, and posttraumatic stress disorder

disorders in the somatic symptom and related disorders category

As we have already noted, experiencing bodily sensations or symptoms is very common. In most cases, these symptoms go away spontaneously. But in about 25 percent of cases, the symptoms persist for a longer period, prompting people to visit their doctors. Studies conducted throughout the world show that somewhere between 20 and 50 percent of the physical symptoms that cause people to seek medical care are medically unexplained. In other words, no medical cause can be found For many people that is the end of it. They are satisfied when told that all the tests that they have had are negative. But a subset of patients (like Richard) will continue to be very worried that something is seriously wrong—that they have a not-yet-diagnosed disease. These people tend to continue to seek help for their physical problems, asking for and undergoing more and more tests. In other words, they become preoccupied with some aspect of their health to the extent that they show significant impairments in functioning. As you might expect, such patients are much more commonly found in medical settings than in mental health clinics. It is estimated that about 20 percent of doctor visits are caused by complaints of this sort An important change in DSM-5 is that no distinction is now made between medically explained and medically unexplained symptoms. This idea is less prominent, because it is recognized that medicine is fallible and that a medical explanation for symptoms cannot always be provided. Whether symptoms are deemed to have a medical cause or not could also depend on the personality of the doctor or on his or her predominant cultural beliefs Equally key to these disorders is the fact that the affected patients have no control over their symptoms. They are also not intentionally faking symptoms or attempting to deceive others. For the most part, they genuinely believe something is terribly wrong with them. In our discussion, we focus specifically on the four most important disorders in the somatic symptom and related disorders category. These are (1) somatic symptom disorder, (2) illness anxiety disorder, (3) conversion disorder, and (4) factitious disorder.

Important Issues in Diagnosing Conversion Disorder

Because the symptoms in conversion disorder can simulate a variety of medical conditions, accurate diagnosis can be extremely difficult. It is crucial that a person with suspected conversion symptoms receive a thorough medical and neurological examination. Nevertheless, as medical tests (especially brain imaging) have become increasingly sophisticated, the rate of misdiagnoses has declined substantially from in the past, with estimates of misdiagnoses in the 1990s at only 4 percent, down from nearly 30 percent in the 1950s Several other criteria are also commonly used for distinguishing between conversion disorders and true neurological disturbances: The frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease or disorder simulated. For example, little or no wasting away or atrophy of a "paralyzed" limb occurs in conversion paralyses, except in rare and long-standing cases. The nature of the dysfunction is highly selective. As already noted, in conversion blindness the affected individual does not usually bump into people or objects, and "paralyzed" muscles can be used for some activities but not others. Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms can usually be removed, shifted, or reinduced at the suggestion of the therapist. Similarly, a person abruptly awakened from a sound sleep may suddenly be able to use a "paralyzed" limb.

Are Recovered Memories of Abuse in DID Real or False?- controversy 3

Case reports of the cruelty and torture that some patients with DID experienced as children are heart-breaking to read or hear. However, the accuracy and trustworthiness of these reports of widespread sexual and other forms of childhood abuse in DID have become a matter of major controversy. Critics (who are often proponents of sociocognitive theory) argue that many of these reports of patients with DID, which generally come up in the course of therapy, may be the result of false memories, which are in turn a product of highly leading questions and suggestive techniques applied by well-meaning but inadequately skilled and careless psychotherapists It seems quite clear to many investigators that this sort of thing has happened, often with tragic consequences. Innocent family members have been falsely accused by patients with DID and have sometimes been convicted and imprisoned. But it is also true that brutal abuse of children occurs far too often and that it can have very adverse effects on development, perhaps encouraging pathological dissociation In such cases, prosecution of the perpetrators of the abuse is indeed appropriate. Of course, the real difficulty here is in determining when the recovered memories of abuse are real and when they are false (or some combination of the two). One way to document that particular recovered memories are real might be if some reliable physiological test could be developed to distinguish between them. Researchers are currently trying to determine whether there are different neural correlates of real and false memories that could be used to make this determination reliably. Another somewhat easier way to document whether a particular recovered memory is real would be to have independent verification that the abuse had actually occurred, such as through physician, hospital, and police records. A number of studies have indeed reported that they have confirmed the reported cases of abuse, but critics have shown that the criteria used for corroborating evidence are almost invariably very loose and suspect as to their validity.

Sensory Symptoms or Deficits in conversion disorder

Conversion disorder can involve almost any sensory modality, and it can often be diagnosed as conversion disorder because symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate. Today the sensory symptoms or deficits are most often in the visual system (especially blindness and tunnel vision), in the auditory system (especially deafness), or in the sensitivity to feeling (especially the anesthesias). In the anesthesias, the person loses her or his sense of feeling in a part of the body. One of the most common is glove anesthesia, in which the person cannot feel anything on the hand in the area where gloves are worn, although the loss of sensation usually makes no anatomical sense. With conversion blindness, the person reports that he or she cannot see and yet can often navigate about a room without bumping into furniture or other objects. With conversion deafness, the person reports not being able to hear and yet orients appropriately upon "hearing" his or her own name. Such observations lead to obvious questions: In conversion blindness (and deafness), can affected people actually not see (or hear), or is the sensory information received but screened from consciousness? In general, the evidence supports the idea that the sensory input is registered but is somehow screened from explicit conscious recognition (explicit perception).

Causes of Conversion Disorders-psychoanalytic theory of thought

Conversion disorders are thought to develop as a result of stress or internal conflicts of some kind. Freud used the term conversion hysteria for these disorders (which were fairly common in his practice) because he believed that the symptoms were an expression of repressed sexual energy—that is, the unconscious conflict that a person felt about his or her repressed sexual desires. However, in Freud's view, the repressed anxiety threatens to become conscious, so it is unconsciously converted into a bodily disturbance, thereby allowing the person to avoid having to deal with the conflict. This is not done consciously, of course, and the person is not aware of the origin or meaning of the physical symptom. Freud also thought that the reduction in anxiety and intrapsychic conflict was the "primary gain" that maintained the condition, but he noted that patients often had many sources of "secondary gain" as well, such as receiving sympathy and attention from loved ones. Freud's theory that conversion symptoms are caused by the conversion of sexual conflicts or other psychological problems into physical symptoms is no longer accepted outside psychodynamic circles. However, many of Freud's astute clinical observations about primary and secondary gain are still incorporated into contemporary views of conversion disorder. For example, when cast in terms of learning theory, the physical symptoms can be seen as providing negative reinforcement (relief or removal of an aversive stimulus) because being incapacitated in some way may enable the individual to escape or avoid an intolerably stressful situation without having to take responsibility for doing so. In addition, they may provide positive reinforcement in the form of care, concern, and attention from others. It is the case that, in some cultures, expressing intense emotions is not socially acceptable. When viewed through a sociocultural lens, a diagnosis of conversion disorder can therefore be seen as a more socially sanctioned way of expressing distress and escaping an unpleasant situation. However, although becoming sick or disabled is more socially acceptable, it is important to keep in mind that the person is not deliberately choosing to lose his or her sight or become unable to walk. Instead, unconscious processes are thought to be at work. One study compared the frequency of stressful life events in the recent past in patients with conversion disorder and depressed controls and did not find a difference in frequency between them. However, the greater the negative impact of the preceding life events, the greater the severity of the conversion disorder symptoms. Another study compared levels of a neurobiological marker of stress (lower levels of brain-derived neurotropic factor) in individuals with conversion disorder versus major depression versus no disorder. Both those with depression and those with conversion disorder showed reduced levels of this marker relative to the nondisordered controls

Prevalence and Demographic Characteristics of conversion disorder

Conversion disorders were once relatively common in civilian and (especially) military life. In World War I, conversion disorder was the most frequently diagnosed psychiatric syndrome among soldiers; it was also relatively common during World War II. Conversion disorder typically occurred under highly stressful combat conditions and involved men who would ordinarily be considered stable. Here, conversion symptoms—such as paralysis of the legs—enabled a soldier to avoid an anxiety-arousing combat situation without being labeled a coward or being subject to court-martial. Interestingly, this decreased prevalence seems to be closely related to our growing sophistication about medical and psychological disorders: A conversion disorder apparently loses its defensive function if it can be readily shown to lack a medical basis. When it does occur today, it is most likely to occur in people who are medically unsophisticated. For example, a highly unusual "outbreak" of cases of severe conversion disorder involving serious motor weakness and wasting symptoms was reported in five 9- to 13-year-old girls living in a small, poor, rural Amish community. Each of these girls had experienced substantial psychosocial stressors including behavioral problems, dysfunctional family dynamics, and significant community stress from a serious local church crisis. Conversion disorder occurs two to three times more often in women than in men. It can develop at any age but most commonly occurs between early adolescence and early adulthood. It generally has a rapid onset after a significant stressor and often resolves within 2 weeks if the stressor is removed, although it commonly recurs. ike most other somatic symptom disorders, conversion disorder frequently occurs along with other disorders, especially major depression, anxiety disorders, and other forms of somatic symptom or dissociative conditions.

comorbidity with did/prevalance

Depressive disorders, PTSD, substance-use disorders, and borderline personality disorder are the most common comorbid diagnoses One recent study found that among patients with diagnoses of DID, the average number of comorbid diagnoses (based on structured diagnostic interviews) was five, with PTSD being the most common DID usually starts in childhood, although most patients are in their teens, 20s, or 30s at the time of diagnosis. Approximately three to nine times more females than males are diagnosed as having the disorder, and females tend to have a larger number of alters than do males. Some believe that this pronounced gender discrepancy is due to the much greater proportion of childhood sexual abuse among females than among males, but this is a highly controversial point.

DSM-5 Criteria for... Dissociative Identity Disorder

Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not a normal part of a broadly accepted cultural or religious practice. NOTE: In children, the symptoms are not better explained by imaginary playmates or other fantasy play. The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

prevelance of depersonalization/derealization disorder

Dissociative disorders have not been included in the major epidemiological surveys that have been conducted to date, so we have no exact prevalence data. It is estimated that the lifetime prevalence of depersonalization/derealization disorder is around 1 to 2 percent of the population with equal numbers of males and females being affected Although the disorder can start in childhood, the mean age of onset is around age 16, with only a minority of people developing it after age 25 Moreover, in nearly 80 percent of cases, the disorder has a fairly chronic course with little or no fluctuation in intensity. Comorbid conditions can include mood or anxiety disorders. Avoidant, borderline, and obsessive-compulsive personality disorders are also elevated in people with depersonalization and derealization experiences

DSM-5 Criteria for... Factitious Disorder

Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents himself or herself to others as ill, impaired, or injured. The deceptive behavior is evident even in the absence of obvious external rewards. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

criticisms of sociocognitive theory

For example, Spanos and colleagues' demonstration of role-playing in hypnotized college students is interesting, but it does not show that this is the way DID is actually caused in real life. For example, someone might be able to give a convincing portrayal of a person with a broken leg, but this would not establish how legs are usually broken. Moreover, the hypnotized participants in this and other experiments showed only a few of the most obvious symptoms of DID (such as more than one identity) and showed them only under short-lived, contrived laboratory conditions. Thus, although some of the symptoms of DID could be created by social enactment, this is not the same thing as demonstrating that the disorder can be created this way

Motor Symptoms or Deficits in conversion disorder

For example, conversion paralysis is usually confined to a single limb such as an arm or a leg, and the loss of function is usually selective for certain functions. For example, a person may not be able to write but may be able to use the same muscles for scratching, or a person may not be able to walk most of the time but may be able to walk in an emergency such as a fire where escape is important. The most common speech-related conversion disturbance is aphonia, in which a person is able to talk only in a whisper although he or she can usually cough in a normal manner. (In true, organic laryngeal paralysis, both the cough and the voice are affected.) Another common motor symptom, called globus, involves the sensation of a lump in the throat

did treatment

For people diagnosed with DID, most current therapeutic approaches are based on the assumption of posttraumatic theory that the disorder was caused by abuse Most therapists set integration of the previously separate alters, together with their collective merging into the host personality, as the ultimate goal of treatment. There is often considerable resistance to this process by patients with DID, who consider dissociation as a protective device If successful integration occurs, the patient eventually develops a unified personality, although it is not uncommon for only partial integration to be achieved. But it is also very important to assess whether improvement in other symptoms of DID and associated disorders has occurred. Indeed, it seems that treatment is more likely to produce symptom improvement, as well as associated improvements in functioning, than to achieve full and stable integration of the different alter identities Typically the treatment for DID is psychodynamic and insight oriented, focused on uncovering and working through the trauma and other conflicts that are thought to have led to the disorder Most patients with DID are hypnotizable and when hypnotized are able to recover past unconscious and frequently traumatic memories, often from childhood. Then these memories can be processed, and the patient can become aware that the dangers once present are no longer there. Through the use of hypnosis, therapists are often able to make contact with different identities and reestablish connections between distinct, seemingly separate identity states. An important goal is to integrate the personalities into one identity that is better able to cope with current stressors. Clearly, successful negotiation of this critical phase of treatment requires therapeutic skills of the highest order; that is, the therapist must be strongly committed as well as professionally competent. Regrettably, this is not always the case. In general, it has been found that (1) for treatment to be successful, it must be prolonged, often lasting many years, and (2) the more severe the case, the longer that treatment is needed

Illness Anxiety Disorder

Illness anxiety disorder is new to DSM-5. In this newly identified disorder, people have high anxiety about having or developing a serious illness. This anxiety is distressing and/or disruptive, but there are very few (or very mild) somatic symptoms It is estimated that around 25 percent of people who would have been diagnosed with hypochondriasis in DSM-IV will be diagnosed with illness anxiety disorder in DSM-5 The remaining 75 percent will be diagnosed as having somatic symptom disorder. When hypochondriasis is accompanied by significant physical symptoms, the diagnosis will be somatic symptom disorder. When there is hypochondriasis without any physical symptoms (or with very mild ones), the diagnosis will be illness anxiety disorder.

physicans treating/interacting with patients with somatic disorder

In addition to CBT, a certain type of medical management may provide some further benefits. General practitioners can be educated in how to better manage and treat patients with these disorders so that they are less frustrated by them One moderately effective treatment involves identifying one physician who will integrate the patient's care by seeing the patient at regular visits (thereby trying to anticipate the appearance of new problems) and by providing physical exams focused on new complaints (thereby accepting all symptoms as valid). At the same time, however, the physician avoids unnecessary diagnostic testing and makes minimal use of medications or other therapies

What Can Neuroimaging Tell Us about Conversion Disorder?

In one interesting study, three patients with sensory loss (involving numbness in the hand or foot) received brain scans while a vibrating stimulus was applied to their right and left hands (or feet). When the stimulus was applied to the side that had sensation and was unaffected, the brain scans revealed the expected findings. In other words, there was activation in somatosensory areas of the brain on the opposite side to the side being stimulated. (This is because most human motor and sensory fibers cross the midline and so stimulation of the right side of the body affects the left side of the brain.) However, when tactile stimulation was applied to the affected (numb) body part, there was no activation in the contralateral area of the sensory cortex. Again, the findings suggest that when the anesthetic body part is stimulated, there is decreased activation in the somatosensory cortex but increased activation in areas such as the anterior cingulate cortex, insula, and other brain areas implicated in emotion processing. All of this is consistent with the idea that sensory areas may perhaps be being inhibited by overactive emotion-based processing. Strange as it may seem, what may be happening in patients with conversion disorders is that abnormal activation in limbic areas (or areas connected to them) might be overriding activation in motor or sensory areas, shutting off the person's ability to detect stimuli (in the case of anesthesia) or move a limb (in the case of paralysis). Although much more needs to be learned, there is some possibility that neuroimaging research may actually be supporting some of Freud's thinking about the origins of conversion disorders!

dissociative fugue

In rare cases a person may retreat still further from real-life problems by going into an amnesic state called a dissociative fugue, which, as the term implies (the French word fugue means "flight"), is a defense by actual flight—a person is not only amnesic for some or all aspects of his or her past but also departs from home surroundings. This is accompanied by confusion about personal identity or even the assumption of a new identity (although the identities do not alternate as they do in dissociative identity disorder). During the fugue, such individuals are unaware of memory loss for prior stages of their life, but their memory for what happens during the fugue state itself is intact Their behavior during the fugue state is usually quite normal and unlikely to arouse suspicion that something is wrong. However, behavior during the fugue state often reflects a rather different lifestyle from the previous one (the rejection of which is sometimes fairly obvious). Days, weeks, or sometimes even years later, such people may suddenly emerge from the fugue state and find themselves in a strange place, working in a new occupation, with no idea how they got there. In other cases, recovery from the fugue state occurs only after repeated questioning and reminders of who they are. In either case, as the fugue state remits, their initial amnesia remits—but a new, apparently complete amnesia for their fugue period occurs. In DSM-5 dissociative fugue is considered to be a subtype of dissociative amnesia rather than a separate disorder as it was in DSM-IV.

host identity

In the prototypical case of DID, however, there are different personalities that emerge and are apparent to an outside observer. Each identity may appear to have a different personal history, self-image, and name, although there may be some identities that are only partially distinct and independent from other identities. In most cases the one identity that is most frequently encountered and carries the person's real name is the host identity. Also in most cases, the host is not the original identity, and it may or may not be the best-adjusted identity.

research into memory of those with dissassociative disorders

Indeed, several studies using brain imaging techniques have confirmed that when people with dissociative amnesia are presented with autobiographical memory tasks, they show reduced activation in their right frontal and temporal brain areas relative to normal controls doing the same kinds of tasks In a review of nine cases of dissociative amnesia for which brain imaging data were available, the authors concluded there was evidence of significant changes in the brains of these patients, mostly centered on subtle loss of function in the right anterior hemisphere—changes similar to those seen in the brains of patients with organic memory loss

Distinguishing Between Different Types of Somatic Symptom and Related Disorders

It is sometimes possible to distinguish between a conversion (or other somatic symptom) disorder and malingering, or factitiously "sick-role-playing," with a fair degree of confidence, but in other cases it is more difficult to make the correct diagnosis. Persons engaged in malingering (for which there are no formal diagnostic criteria) and those who have factitious disorder are consciously perpetrating frauds by faking the symptoms of diseases or disabilities, and this fact is often reflected in their demeanor. In contrast, individuals with conversion disorders (as well as with other somatic symptom disorders) are not consciously producing their symptoms, feel themselves to be the "victims of their symptoms," and are very willing to discuss them, often in excruciating detail When inconsistencies in their behaviors are pointed out, they are usually unperturbed. Any secondary gains they experience are by-products of the conversion symptoms themselves and are not involved in motivating the symptoms. On the other hand, persons who are feigning symptoms are inclined to be defensive, evasive, and suspicious when asked about them; they are usually reluctant to be examined and slow to talk about their symptoms lest the pretense be discovered. Should inconsistencies in their behaviors be pointed out, deliberate deceivers as a rule immediately become more defensive.

DID, Schizophrenia, and Split Personality: Clearing Up the Confusion

It is very important to remember that people diagnosed with schizophrenia do not have multiple distinct identities that alternately take control over their mind and behavior. They may have a delusion and believe they are someone else, but they do not show the changes in identity accompanied by changes in tone of voice, vocabulary, and physical appearance that are often seen when identities "switch" in DID. Furthermore, people with DID (who are probably closer to the general public's notion of "split personality") do not exhibit such characteristics of schizophrenia as disorganized behavior, hallucinations coming from outside the head, and delusions, or incoherent and loose associations

If Abuse Has Occurred, Does It Play a Causal Role in DID?- controversy 4

Let us put the previous controversy about the reality of recovered memories of abuse aside for a moment and assume that severe abuse has occurred in the early childhood backgrounds of many people with DID. How can we determine whether this abuse has played a critical causal role in the development of DID? Unfortunately, many difficulties arise in answering this question. For example, child abuse usually happens in family environments plagued by many other sources of adversity and trauma (such as psychopathology, extreme neglect, and poverty). One or more of these other, correlated sources of adversity could actually be playing the causal role Another difficulty of determining the role of abuse is that people who have experienced child abuse as well as symptoms of DID may be more likely to seek treatment than people with symptoms of DID who did not experience abuse. Thus, the individuals in most studies on the prevalence of child abuse in DID may not be representative of the population of all people who suffer from DID. Finally, childhood abuse has been claimed by some to lead to many different forms of psychopathology including depression, PTSD, eating disorders, somatic symptom disorder, and borderline personality disorder, to name just a few. Perhaps the most we will ever be able to say is that childhood abuse may play a nonspecific role for many disorders, with other, more specific factors determining which disorder develops

controversy 2-If DID Is Not Faked, How Does It Develop: Posttraumatic Theory or Sociocognitive Theory?

Many professionals acknowledge that, in most cases, DID is a real syndrome (not consciously faked), but there is marked disagreement about how it develops and how it is maintained. In contemporary literature, the original major theory of how DID develops is posttraumatic theory. The vast majority of patients with DID (over 95 percent by some estimates) report memories of severe and horrific childhood abuse. According to posttraumatic theory, DID starts from the child's attempt to cope with an overwhelming sense of hopelessness and powerlessness in the face of repeated traumatic abuse. Lacking other resources or routes of escape, the child may dissociate and escape into a fantasy, becoming someone else. This escape may occur through a process like self-hypnosis. and if it helps to alleviate some of the pain caused by the abuse it will be reinforced and occur again in the future. Sometimes the child simply imagines the abuse is happening to someone else. If the child is fantasy prone, and continues to stay fantasy prone over time, the child may unknowingly create different selves at different points in time, possibly laying the foundation for dissociated identities. But only a subset of children who undergo traumatic experiences are prone to fantasy or self-hypnosis, which leads to the idea that a diathesis-stress model may be appropriate here. That is, children who are prone to fantasy and those who are easily hypnotizable may have a diathesis for developing DID (or other dissociative disorders) when severe abuse occurs Increasingly, those who view childhood abuse as playing a critical role in the development of DID are beginning to see DID as perhaps a complex and chronic variant of posttraumatic stress disorder, which by definition is caused by exposure to some kind of highly traumatic event(s), including abuse Moreover, some (but not all) investigators have estimated that a very high percentage of individuals diagnosed with DID have a comorbid diagnosis of PTSD, suggesting the likelihood of some important common causal factors

implicit memory

Much of our mental life involves automatic nonconscious processes that occur below the radar of deliberate, self-awareness and monitoring. Such unaware processing extends to the areas of implicit memory and implicit perception; all people routinely show indirect evidence of remembering things they cannot consciously recall

why abandon the term mutliple personality disorder?

Much of the reason for abandoning the older diagnostic term multiple personality disorder in favor of DID was the growing recognition that it had misleading connotations, suggesting multiple occupancy of space, time, and people's bodies by differing, but fully organized and coherent, "personalities." In fact, alters are not in any meaningful sense personalities but rather reflect a failure to integrate various aspects of a person's identity, consciousness, and memory Alter identities take control at different points in time, and the switches typically occur very quickly (in a matter of seconds), although more gradual switches can also occur. When switches occur in people with DID, it is often easy to observe the gaps in memories for things that have happened—often for things that have happened to other identities. But this amnesia is not always symmetrical; that is, some identities may know more about certain alters than do other identities. In sum, DID is a condition in which normally integrated aspects of memory, identity, and consciousness are no longer integrated. Additional symptoms of DID include depression, self-injurious behavior, frequent suicidal ideation and attempts, erratic behavior, headaches, hallucinations, posttraumatic symptoms, and other amnesic and fugue symptoms

dissociative amnesia

On the other hand, dissociative amnesia is usually limited to a failure to recall previously stored personal information (retrograde amnesia) when that failure cannot be accounted for by ordinary forgetting The gaps in memory most often occur following intolerably stressful circumstances—wartime combat conditions, for example, or catastrophic events such as serious car accidents, suicide attempts, or traumatic experiences In this disorder, apparently forgotten personal information is still there beneath the level of consciousness. It sometimes becomes apparent in interviews conducted under hypnosis or narcosis (induced by sodium amytal, or so-called truth serum) and (obviously) in cases where the amnesia spontaneously clears up. Amnesic episodes usually last between a few days and a few years. Although many people experience only one such episode, some people have multiple episodes in their lifetimes In typical dissociative amnesic reactions, individuals cannot remember certain aspects of their personal life history or important facts about their identity. Yet their basic habit patterns—such as their abilities to read, talk, perform skilled work, and so on—remain intact, and they seem normal aside from the memory deficit Thus, the only type of memory that is affected is episodic (pertaining to events experienced) or autobiographical memory (pertaining to personal events experienced). The other recognized forms of memory—semantic (pertaining to language and concepts), procedural (how to do things), and short-term storage—seem usually to remain intact, although there is very little research on this topic. Usually there is no difficulty encoding new information

DSM-5 Criteria for... Somatic Symptom Disorder

One or more somatic symptoms that are distressing or result in significant disruption of daily life. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: Disproportionate and persistent thoughts about the seriousness of one's symptoms. Persistently high level of anxiety about health or symptoms. Excessive time and energy devoted to these symptoms or health concerns. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

DSM-5 Criteria for... Conversion Disorder

One or more symptoms of altered voluntary motor or sensory function. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. The symptom or deficit is not better explained by another medical or mental disorder. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Current Perspectives on DID

Overall, however, they provide somewhat more support for the sociocognitive model than for the trauma model. One way in which simulators and diagnosed patients differ is that diagnosed patients show more symptoms of DID than simulators do. This, of course, could be related to the quality of training the simulators had. Another potentially more important difference is that, compared to simulators, patients with DID show more cognitive processing problems. Deficits in performance are apparent on tasks involving recognition of previously seen material, as well as on recall and reaction time tasks. However, cognitive problems (compared to healthy controls) are seen in patients with many types of disorders (including anxiety disorders, mood disorders, and schizophrenia). So they could be a result of psychopathology in general rather than DID in particular. We also have no way of knowing whether these cognitive problems resulted from the DID or predated it, perhaps functioning as a preexisting vulnerability factor. There are also many similarities between simulators and diagnosed patients with DID. Of these, perhaps the most important concerns the transfer of memory across personalities. Interidentity amnesia is a key feature of DID. Most people with DID have at least some identities that seem completely unaware of the existence and experiences of certain other identities. This then raises the question of what happens when information is presented to one identity and the person switches to another identity—one who is not supposed to have any knowledge of the other identity. Does any information transfer from one identity to another? What does the lack of evidence of complete amnesia in DID mean for our understanding of the disorder? The fact that simulators and diagnosed patients are similar in this regard might argue against the validity of the DID diagnosis. However, we know little about how the memories of people with DID can or should function. As Boysen and VanBergen (2014) note, in DID memory may be available but not be subjectively accessible. Our brains naturally integrate and incorporate new material. But there may be an important difference between what our brains know and what we are aware that we know. Advocates of posttraumatic theory are acknowledging that some cases are faked and that some may be inadvertently caused by unskilled therapists in the course of treatment. There is also a growing appreciation that both real and false memories do occur in these patients, combined with a recognition of the critical need for new methods to be developed to help determine which is which. On the other side, advocates of sociocognitive theory have acknowledged that some people with DID may have undergone real abuse, although they believe it occurs far less often, and is less likely to play a real causal role, than the trauma theorists maintain

DSM-5 Criteria for... Illness Anxiety Disorder

Preoccupation with having or acquiring a serious illness. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals). Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

Somatic symptom disorder

Somatic symptom disorder is regarded as the most major diagnosis in its category. This new diagnosis includes several disorders that were previously considered to be separate diagnoses in DSM-IV. The old disorders of (1) hypochondriasis, (2) somatization disorder, and (3) pain disorder have all now disappeared. Most of the people who would in the past have been diagnosed with any one of these disorders will now be diagnosed with somatic symptom disorder. For example, it is estimated that approximately 75 percent of people previously diagnosed with hypochondriasis (where individuals are preoccupied either with fears of contracting a serious disease or with the idea that they have a disease even though they do not) will now be diagnosed with somatic symptom disorder in DSM-5 The diagnosis of somatic symptom disorder is a descriptive one. It contains no assumptions about cause. The name of the diagnosis was chosen to reduce some of the negative connotations associated with older diagnostic terms such as hypochondriasis, as well as ideas that disorders such as these were "all in the mind For the diagnosis of somatic symptom disorder to be made, individuals must be experiencing chronic somatic symptoms that are distressing to them. They must also be experiencing dysfunctional thoughts, feelings, and/or behaviors. The addition of this psychological component is new. In DSM-IV all that was required was that people be experiencing somatic symptoms that were medically unexplained. In other words, no psychological features were required. This was a rather strange omission because a common characteristic of DSM mental disorders is that there are psychological features in addition to other signs and symptoms. Another radical change is that, as we noted earlier, the physical symptoms no longer need to be medically unexplained. Another diagnostic change that has occurred is that, in DSM-5 only one somatic symptom is required. In other words, if a person has any physical problem that they find distressing (even if it involves only a single symptom and is medically explained), the diagnosis of somatic symptom disorder is possible. Estimates are that the prevalence of somatic symptom disorder in the general population will be around 5 to 7 percent. However, there has been much criticism that the new diagnostic criteria are far too loose and will lead to many people being mislabeled as having a mental disorder. It has also been suggested that women will be disproportionately affected because they are more frequent users of medical services and because they are most at risk of being dismissed by their doctors as "catastrophizers" As they now stand, the current DSM-5 criteria may result in a wide range of patients being assigned the same diagnosis. Some will have many symptoms and some will have very few. Some will have symptoms that have a medical cause; others will not. Unknown at this time is whether this broad grouping of clinical conditions will impede the successful development of new treatments. Should patients with medically explained symptoms (like Ellen or Jane) be treated with the same approaches used for patients who have medically unexplained symptoms (like Richard)? Can we assume that there are similar mechanisms at work in both cases? For those who seek to develop new treatments, the changes in DSM-5 may present some interesting challenges.

Treatment of Conversion Disorder

Some hospitalized patients with motor conversion symptoms have been successfully treated with a behavioral approach in which specific exercises are prescribed in order to increase movement or walking, and then reinforcements (e.g., praise and gaining privileges) are provided when patients show improvements. Any reinforcements of abnormal motor behaviors are removed in order to eliminate any sources of secondary gain. In one small study using this kind of treatment for 10 patients, all had regained their ability to move or walk in an average of 12 days, and for seven of the nine patients available at an approximately 2-year follow-up, the improvements had been maintained Some studies have used hypnosis combined with other problem-solving therapies, and there are suggestions that hypnosis, or adding hypnosis to other therapeutic techniques, can be useful.

controversy 1-Is DID Real or Faked?

The issue of possible factitious or malingering origins of DID has dogged the diagnosis of DID for at least a century. One obvious situation in which this issue becomes critical is when it has been used by defendants and their attorneys to try to escape punishment for crimes ("My other personality did it"). In other words, some cases of DID may involve complete fabrication orchestrated by criminal or other unscrupulous persons seeking unfair advantages, and not all prosecutors have as clever and knowledgeable an expert witness as Martin Orne to help detect this. Nevertheless, most researchers think that factitious and malingering cases of DID (such as the Bianchi case or cases in which the person has a need to be a patient) are relatively rare.

What is the difference between factious disorder and malingering?

The key difference is that, in factitious disorder, the person receives no tangible external rewards. In contrast, the person who is malingering is intentionally producing or grossly exaggerating his or her physical symptoms and is motivated by external incentives such as avoiding work or military service or evading criminal prosecution

number of alter identities in DID

The number of alter identities in DID varies tremendously and has increased over time One early review of 76 classic cases reported that two-thirds of these cases had only two personalities and most of the rest had three More recent estimates are that about 50 percent now show over 10 identities with some respondents claiming as many as a hundred. This historical trend of increasing multiplicity suggests the operation of social factors, perhaps through the encouragement of therapists, as we discuss below. Another recent trend is that many of the reported cases of DID now include more unusual and even bizarre identities than in the past (such as being an animal) and more highly implausible backgrounds (e.g., ritualized satanic abuse in childhood).

dissassociative/conversion disorder similarities

The pattern in dissociative amnesia is essentially similar to that in conversion symptoms, except that instead of avoiding some unpleasant situation by becoming physically dysfunctional, a person unconsciously avoids thoughts about the situation or, in the extreme, leaves the scene Thus, people experiencing dissociative amnesia are typically faced with extremely unpleasant situations from which they see no acceptable way to escape. Eventually the stress becomes so intolerable that large segments of their personalities and all memory of the stressful situations are suppressed.

DSM-5 Criteria for... Depersonalization/Derealization Disorder

The presence of persistent or recurrent experiences of depersonalization, derealization, or both: Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). During the depersonalization or derealization experiences, reality testing remains intact. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures). The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder.

Cultural Factors in Dissociative Disorders

There seems little doubt that the prevalence of dissociative disorders, especially their more dramatic forms such as DID, is influenced by the degree to which such phenomena are accepted or tolerated either as normal or as legitimate mental disorders by the surrounding cultural context. Indeed, in our own society, the acceptance and tolerance of DID as a legitimate disorder have varied tremendously over time. Many related phenomena, such as spirit possession and dissociative trances, occur frequently in many different parts of the world where the local cultures sanction them. uch experiences are not necessarily problematic when they are volitional, transient, and occur as a normal part of religious or spiritual practices. However, when they are involuntary and cause distress, possession states are considered to be pathological. The features of pathological possession are very similar to DID. They include distinct changes in identity as well as full or partial amnesia for the event. In pathological possession, however, the other identity is not experienced as another internal personality state but as an external spirit, power, or deity. The inclusion of pathological possession into the diagnostic criteria for DID in DSM-5 has made the diagnosis more applicable to people from a wide range of cultural backgrounds. The inclusion of pathological possession also acknowledges that DID can present in two different forms: a possession form and a nonpossession form. In other words, how the disorder presents may be very much determined by cultural factors Understanding how pathological possession is treated by indigenous healers may also provide new perspectives that could be valuable overall. Interestingly, treatments by indigenous healers and therapists operating within Western culture have many similarities. Both, for example, emphasize addressing different aspects of the person's identities, allowing each to have a voice through which that identity's point of view and distress can be clarified. In contrast, however, in the majority of cases, culturally sanctioned attempts to remove or exorcise the alternate identity typically lead to poor outcomes. There are also cross-cultural variants on dissociative disorders, such as amok, which is often thought of as a rage disorder. Amok occurs when a dissociative episode leads to violent, aggressive, or homicidal behavior directed at other people and objects. It occurs mostly in men and is often precipitated by a perceived slight or insult. The person often has ideas of persecution, anger, and amnesia, often followed by a period of exhaustion and depression. Amok occurs in places such as Malaysia, Laos, the Philippines, Papua New Guinea, Puerto Rico, and among Navajo Indians.

Treatment and Outcomes in Dissociative Disorders

Unfortunately, virtually no systematic, controlled research has been conducted on treatment of depersonalization disorder and dissociative amnesia.Numerous case histories, sometimes presented in small sets of cases, are available, but without control groups who are assessed at the same time or who receive nonspecific treatments, it is impossible to know the effectiveness of the varied treatments that have been attempted In general, depersonalization/derealization disorder may be fairly resistant to treatment, although treatment may be useful for associated problems such as anxiety and depressive disorders. Some think that hypnosis, including training in self-hypnosis techniques, may be useful because patients with depersonalization disorder can learn to dissociate and then "reassociate," thereby gaining some sense of control over their depersonalization and derealization experiences Many types of antidepressant, antianxiety, and antipsychotic drugs have also been tried and some have had modest effects A recent treatment showing some promise for the treatment of dissociative disorders involves administering rTMS-repetitive transcranial magnetic stimulation In dissociative amnesia, it is important for the person to be in a safe environment, and simply removing her or him from what he or she perceives as a threatening situation sometimes allows for spontaneous recovery of memory. Hypnosis, as well as drugs such as benzodiazepines, barbiturates, sodium pentobarbital, and sodium amobarbital, is often used to facilitate recall of repressed and dissociated memories. fter memories are recalled, it is important for the patient to work through the memories with the therapist so that the experiences can be reframed in new ways.

Dissociative disorders

a group of conditions involving disruptions in a person's normally integrated functions of consciousness, memory, identity, or perception Included here are some of the more dramatic phenomena in the entire domain of psychopathology: people who cannot recall who they are or where they may have come from, and people who have two or more distinct identities or personality states that alternately take control of the individual's behavior. In people with dissociative disorders, this normally integrated and well-coordinated multichannel quality of human cognition becomes much less coordinated and integrated. When this happens, the affected person may be unable to access information that is normally in the forefront of consciousness, such as his or her own personal identity or details of an important period of time in the recent past. That is, the normally useful capacity of maintaining ongoing mental activity outside of awareness appears to be subverted, sometimes for the purpose of managing severe psychological threat. When that happens, we observe the pathological symptoms that are the cardinal characteristic of dissociative disorders. Like somatic symptom disorders, dissociative disorders appear mainly to be ways of avoiding anxiety and stress and of managing life problems that have overwhelmed the person's usual coping resources. Both types of disorders also enable the individual to deny personal responsibility for his or her "unacceptable" wishes or behavior. In the case of DSM-defined dissociative disorders, the person avoids the stress by pathologically dissociating—in essence, by escaping from his or her own autobiographical memory or personal identity. The DSM-5 recognizes several types of pathological dissociation. These include depersonalization/derealization disorder, dissociative amnesia, and dissociative identity disorder. The dissociative disorders are placed in DSM-5 immediately after trauma and stressor-related disorders, to reflect the close relationship that exists between them.

Causes of Somatic Symptom Disorder

core features tend to be quite similar. First, there is a focus of attention on the body. In other words, the person is hypervigilant and has an increased awareness of bodily changes. Second, the person tends to see bodily sensations as somatic symptoms, meaning that physical sensations are attributed to illness. Third, the person tends to worry excessively about what the symptoms mean and has catastrophizing cognitions. Fourth, because of this worry, the person is very distressed and seeks medical attention for his or her perceived physical problems According to this formulation, somatic symptom disorder can be viewed as disorder of both perception (noticing benign sensations such as one's heart skipping a beat) and cognition ("Does this mean I have a serious heart problem?"). Individuals who are especially anxious about their health tend to believe that they are very aware of and sensitive to what is happening in their bodies. But this does not seem to be the case. Rather, experimental studies show that these individuals have an attentional bias for illness-related information In other words, top-down (cognitive) processes, rather than bottom-up processes (such as differences in bodily sensations), seem to account for the problems that they have. Although their physical sensations probably do not differ from those of normal controls. They also perceive their symptoms as more dangerous than they really are and judge a particular disease to be more likely or dangerous than it really is. Once they have misinterpreted a symptom, they tend to look for confirming evidence and to discount evidence that they are in good health; in fact, they seem to believe that being healthy means being completely symptom free They also perceive their probability of being able to cope with the illness as extremely low. and see themselves as physically weak and unable to tolerate physical effort or exercise. All this tends to create a vicious cycle in which their anxiety about illness and symptoms results in physiological symptoms of anxiety, which then provide further fuel for their convictions that they are ill. It is also believed that an individual's past experiences with illnesses (in both him- or herself and others, and also as observed in the media) contribute to the development of a set of dysfunctional assumptions about symptoms and diseases that may predispose a person to developing a somatic symptom disorder. These dysfunctional assumptions might include notions such as, "Bodily changes are usually a sign of serious disease, because every symptom has to have an identifiable physical cause" or "If you don't go to the doctor as soon as you notice anything unusual, then it will be too late" Negative affect is regarded as a risk factor for developing somatic symptom disorder. However, negative affect alone is not sufficient. Many people tend to be rather gloomy in their personalities, but only a subset of these people will also be habitual reporters of physical symptoms. Other characteristics that may be important are absorption and alexithymia. Absorption is a tendency to become absorbed in one's experiences and is often associated with being highly hypnotizable. Alexithymia, on the other hand, refers to having difficulties identifying one's feelings. People who report many symptoms but who do not have any medical conditions tend to score high on all of these three traits High levels of functional impairment are also common and many patients are severely disabled by their physical symptoms. Patients with somatic symptom disorder are more likely to be female and to have high levels of comorbid depression and anxiety. Although somatic symptom disorders are often accompanied by a lot of misery and suffering, they may be maintained to some degree by secondary reinforcements. Most of us learn as children that when we are sick we get special comforts and attention, as well as being excused from school or other responsibilities. In the case of the DSM-IV disorder of hypochondriasis, Barsky and colleagues (1994) found that their patients reported much childhood sickness and missed a lot of school. People with hypochondriasis also tend to have an excessive amount of illness in their families while growing up, which may lead to strong memories of being sick or in pain Having said this, it is important to keep in mind that people with somatic symptom disorders are not malingering—consciously faking symptoms to achieve a specific goal such as winning a personal injury lawsuit. They experience physical problems that cause them great concern. As described earlier, these symptoms may be caused by brain processes that occur below the radar of the person's conscious awareness.

Dissociative identity disorder (DID)

formerly known as multiple personality disorder, is a dramatic dissociative disorder. It has long provided a melodramatic focus in movies (Sybil, Mr. Brooks, Raising Cain, Dressed to Kill), as well as in the media. In DSM-IV, it was required that the person manifest two or more distinct identities (or personality states) that alternated in some way in taking control of behavior. This was accompanied by an inability to recall important personal information that could not be explained by ordinary forgetting. In DSM-5 there has been a subtle shift of emphasis. What is now required is that there be a disruption of identity characterized by two or more distinct personality states as well as recurrent episodes of amnesia. Importantly, this disruption in identity can either be self-reported or observed by others. In other words, DID can now be diagnosed without other people witnessing the different personalities. Another change in DSM-5 is the inclusion of pathological possession in the diagnostic criteria for DID.Pathological possession is a common form of DID in Africa, Asia, and many other non-Western cultures.

alter identities

he alter identities may differ in striking ways involving gender, age, handedness, handwriting, sexual orientation, prescription for eyeglasses, predominant affect, foreign languages spoken, and general knowledge. For example, one alter may be carefree, fun loving, and sexually provocative, and another alter quiet, studious, serious, and prudish. Needs and behaviors inhibited in the primary or host identity are usually liberally displayed by one or more alter identities. Certain roles such as a child and someone of the opposite sex are extremely common.

depersonalization

ne's sense of one's own self and one's own reality is temporarily lost

derealization

one's sense of the reality of the outside world is temporarily lost

implicit perception

respond to sights or sounds as if they had perceived them even though they cannot report that they have seen or heard them This type of responding also occurs in conversion disorders where people who say that they cannot see nonetheless are able to respond to some visual stimuli.

trance/possession trance

s said to occur when someone experiences a temporary marked alteration in state of consciousness or identity. It is usually associated with either a narrowing of awareness of the immediate surroundings, or stereotyped behaviors or movements that are experienced as beyond one's control. A possession trance is similar except that the alteration of consciousness or identity is replaced by a new identity that is attributed to the influence of a spirit, deity, or other power. In both cases amnesia is typically present for the trance state. When entered into voluntarily for religious or spiritual reasons, trance and possession states are not considered pathological. However, when they occur involuntarily, outside accepted cultural contexts, and cause distress, this is a serious problem.

Retrograde amnesia

the partial or total inability to recall or identify previously acquired information or past experiences; by contrast

anterograde amnesia

the partial or total inability to retain new information

dissociation concept

was first promoted over a century ago by the French neurologist Pierre Janet (1859-1947). Dissociation can be defined as "a disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including—but not limited to—memory, identity, consciousness, perception and motor control We all dissociate to a degree some of the time. Mild dissociative symptoms occur when we daydream or lose track of what is going on around us, when we drive miles beyond our destination without realizing how we got there, or when we miss part of a conversation we are engaged in. As these everyday examples suggest, there is nothing inherently pathological about dissociation itself. Dissociation only becomes pathological when the dissociative symptoms are "perceived as disruptive, invoking a loss of needed information, as producing discontinuity of experience" or as "recurrent, jarring involuntary intrusions into executive functioning and sense of self