Psyc 2151- Exam 2 (Ch 8)

People with depersonalization and/or derealization experience

persistent or recurrent experiences of feeling detached from/like an outside observer of their own bodies and mental processes. Attenuated or reduced emotional experiences Higher levels of subjective and objective memory fragmentation

Host identity (DID)

the one identity most frequently encountered and who carries the person's real name

Retrograde amnesia (dissociative amnesia)

the partial or total inability to recall or identify previously acquired information or past experiences.

Anterograde amnesia (dissociative amnesia)

the partial or total inability to retain new information.

Factitious Disorder

the person intentionally produces psychological or physical symptoms (or both) Goal is to obtain and maintain the benefits that playing the "sick role" may provide, including the attention and concern of family and medical personnel In DSM-5 has been moved into the category of somatic symptom and related disorders. It is viewed as unfortunate by some because these disorders have a history of being stigmatized; many doctors do not take them very seriously

Current prevalence estimate of DID is between __ and __ percent

1 1.5

The four most important disorders in the somatic symptom and related disorders category are:

1) somatic symptom disorder 2) illness anxiety disorder 3) conversion disorder 4) factitious disorder

Suggested Revised Diagnostic Criteria for Somatic Symptom Disorder

A) One or more prominent physical symptoms. B) Excessive and maladaptive thoughts, feelings, and behaviors related to the physical symptoms. All three of the following must be present: (a) clearly disproportionate and intrusive worries about the seriousness of the symptoms, (b) extreme anxiety about the symptoms, and (c) excessive time and energy devoted to the symptoms or health concerns. C) The excessive concerns have persisted at a clearly problematic level for at least 6 months. D) The excessive concerns about physical symptoms are pervasive and cause significant disruption and impairment in daily life. E) If a diagnosed medical condition is present, the thoughts, feelings, and behaviors are grossly in excess of what would be expected, given the nature of the medical condition. F) If no medical diagnosis has been made, a thorough medical workup has been performed to rule out possible causes and is repeated at suitable intervals to uncover medical conditions that may declare themselves with the passage of time. G) The physical symptom or concern is not better accounted for by another mental disorder (e.g., anxiety, depressive, or psychotic disorder).

Important Issues in Diagnosing Conversion Disorder

Accurate diagnosis is difficult; symptoms can mimic a variety of medical conditions Criteria used to distinguish between conversion disorders and true neurological disturbances include: -Frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease or disorder simulated -Nature of the dysfunction is highly selective -Under hypnosis or narcosis, the symptoms can usually be removed, shifted, or reinduced at the suggestion of the therapist

Distinguishing Between Different Types of Somatic Symptom and Related Disorders

Can be difficult to distinguish between the disorders and make a correct diagnosis Difference in terms of willingness to discuss symptoms: -Individuals with conversion disorders (and other somatic symptom disorders) are not consciously producing their symptoms (very willing to discuss them and usually unperturbed when inconsistencies are pointed out) -People who are malingering and those who have factitious disorder are consciously perpetrating fraud—faking symptoms of diseases or disabilities (defensive, evasive, and suspicious when asked about inconsistencies)

Treatment of Somatic Symptom Disorder

Cognitive-behavioral treatments are widely used to treat these disorders Treatment focuses on assessing the patient's beliefs about illness and modifying misinterpretations of bodily sensations Techniques might include having the patient induce innocuous symptoms by intentionally focusing on parts of the body to learn that selective perception of bodily sensations could play a major role in symptoms Sometimes patients are directed to engage in response prevention (ex: not checking their bodies as they usually do or stopping their constant seeking of reassurance) Cognitive-behavioral techniques are also widely used in the treatment of somatic symptom disorder that involves pain (ex: Relaxation training, Support and validation that the pain is real, Scheduling of daily activities, Cognitive restructuring, and Reinforcement of "no-pain" behaviors)

Conversion Disorder (Functional Neurological Symptom Disorder)

Conversion disorder is characterized by the presence of neurological symptoms in the absence of a neurological diagnosis Historically, was grouped under the term hysteria Patient has symptoms or deficits affecting either the senses or motor behavior Examples include partial paralysis, blindness, deafness, and episodes of limb shaking accompanied by impairment or loss of consciousness that resemble seizures The greater the negative impact of preceding life events, the greater the severity of the conversion disorder symptoms Individuals with depression and individuals with conversion disorder showed reduced levels of brain-derived neurotrophic factor relative to nondisordered controls

sociocognitive theory (DID)

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 Theory is consistent with evidence of no clear DID symptoms prior to entering therapy and the fact that the number of alters increases as therapy progresses Theory is also consistent with increased DID, as therapists became more aware of the condition

DSM-5 recognizes several types of pathological dissociation, including:

Depersonalization/derealization disorder Dissociative amnesia Dissociative identity disorder

Illness Anxiety Disorder

Disorder is new to DSM-5. People with illness anxiety disorder havehigh anxiety about having or developing a serious illness. This anxiety is distressing or disruptive, but there are very few (or very mild) somatic symptoms. The main difference between illness anxiety disorder and somatic symptom disorder is the severity: people with somatic symptom disorder have more comorbid conditions and visit doctors more frequently.

Somatic Symptom Disorder

For diagnosis to be made, individuals must be experiencing chronic somatic symptoms that are distressing to them, as well as dysfunctional thoughts, feelings, and/or behaviors. Regarded as the most major diagnosis in its category Diagnostic criteria for somatic symptom disorder likely to be modified over time Prevalence in the general population estimated at around 5 to 7 percent Somatic symptom disorder can be viewed as disorder of both perception and cognition Studies show these individuals have an attentional bias for illness-related information May be predisposed by past experiences with illness and dysfunctional assumptions about symptoms and diseases Negative affect is regarded as a risk factor, as well as absorption and alexithymia Patients are more likely to be female and to have high levels of comorbid depression and anxiety Somatic symptom disorders may be maintained to some degree by secondary reinforcements People with somatic symptom disorders are not malingering (consciously faking symptoms to achieve a specific goal such as winning a personal injury lawsuit)

In DSM-__, derealization and depersonalization were treated as two distinct conditions; in DSM-5, they are combined.

IV

Identifying Factitious Disorder

In factitious disorder, the person receives no tangible external rewards Different from malingering: Intentionally producing or grossly exaggerating physical symptoms Motivated by external incentives (avoiding work or military service, evading criminal prosecution) Patients may surreptitiously alter their own physiology to simulate real illnesses

Treatment of Conversion Disorder

Knowledge of how to treat conversion disorder is limited because few well-controlled studies have been conducted Behavioral approach: specific exercises prescribed to increase movement or walking; reinforcements (e.g., praise) provided when patients show improvements Hypnosis combined with other problem-solving therapies can also be useful

Treatment and Outcomes in Dissociative Disorders

Little is known about how to treat these disorders successfully -Hypnosis (including self-hypnosis techniques) may be useful -Some modest effects from medications Treatment is typically 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 current approaches are based on assumption of abuse as cause -Integration of the previously separate alters and their merging into the host personality is seen as the ultimate goal of treatment -Treatment must be prolonged to be successful; often years-long

Research on Dissociative Disorder and Fugue

Little systematic research has been conducted on individuals with dissociative amnesia and fugue. -Individuals' semantic knowledge seems to be intact; primary deficit is their compromised episodic or autobiographical memory -Several cases have suggested that implicit memory is intact. -Studies show reduced activation in right frontal and temporal brain areas -Some memory deficits in dissociative amnesia and fugue have been compared to related deficits in explicit perception that occur in conversion disorders

Prevalence and Demographic Characteristics

Most frequently diagnosed psychiatric syndrome among soldiers in World War I; also common during World War II Found in approximately 5 percent of people referred for treatment at neurology clinics Prevalence in general population is unknown -More common among rural populations from lower socioeconomic circles -Occurs two to three times more often in women than in men Rapid onset after a significant stressor; often resolves within two weeks if stressor is removed

Cultural Factors in Dissociative Disorders

Prevalence of dissociative disorders is influenced by degree to which they are accepted either as normal or as legitimate mental disorders by the surrounding cultural context -Related phenomena such as spirit possession and dissociative trances are sanctioned in other cultures when they occur Inclusion of pathological possession in the diagnostic criteria for DID has made the diagnoses more applicable to people from a wide range of cultural backgrounds -Cross-cultural variants on dissociative disorders include amok

Siezures (of Conversion Disorder)

Resemble epileptic seizures, but are not true seizures Patients show no EEG abnormalities and no confusion or memory loss afterwards

Causes of Conversion Disorders

Thought to develop as a result of stress or internal conflicts Freud used the term conversion hysteria for these disorders; believed that the symptoms were an expression of repressed sexual energy -Repressed anxiety threatens to become conscious, so it is unconsciously converted into bodily disturbance -Primary gain: reduction in anxiety and intrapsychic conflict -Secondary gain: receiving sympathy and attention from loved ones -Theory is no longer accepted, but many of this clinical observations about primary and secondary gain are reflected in contemporary views of conversion disorder

Causes of Somatic Symptom Disorder

Used to think symptoms developed as a defense mechanism against unresolved or unacceptable unconscious conflicts. Current views take a much more cognitive-behavioral approach. Several different models; similar core features: -Focus of attention on the body; person is hypervigilant, has an increased awareness of bodily changes -Person tends to see bodily sensations as somatic symptoms, attributes them to illness -Person worries excessively about what the symptoms mean, has catastrophizing cognitions -Because of this worry, the person is very distressed and seeks medical attention for their perceived physical problems People with somatic symptom disorder tend to have a cognitive style that leads them to be hypersensitive to their bodily sensations. They also experience these sensations as intense, disturbing, and highly aversive. They also tend to overestimate the medical severity of their condition.

Sensory Symptoms of Conversion Disorder

Visual system deficits (especially blindness and tunnel vision), the auditory system deficits (especially deafness), and deficits in sensitivity to feeling (especially the anesthesias) Anesthesias: person loses feeling in a part of the body Conversion blindness: person reports being unable to see, yet navigates spaces without problems Conversion deafness: person reports not being able to hear and yet orients appropriately upon "hearing" his or her own name

Dissociative Disorders

a group of conditions involving disruptions in a person's normally integrated functions of consciousness, memory, identity, or perception. Dissociation only becomes pathological when the dissociative symptoms are perceived as disruptive or as "recurrent, jarring involuntary intrusions into executive functioning and sense of self." Affected person may be unable to access information that is normally in the forefront of consciousness

People with somatic symptom disorders experience __ symptoms that cause them significant psychological distress and impairment.

bodily

soma means "__"

body

Motor Symptoms of Conversion Disorder

conversion paralysis, usually confined to a single limb aphonia, a speech-related conversion disturbance globus, the sensation of a lump in the throat

Factitious disorder imposed on another (sometimes referred to as Munchausen's syndrome by proxy):

dangerous variant of factitious disorder in which the person seeking medical help has intentionally produced a medical or psychiatric illness (or its appearance) in another person usually the person is under their care, such as a child

__ and __ disorder may be diagnosed when episodes become consistent and recurrent and interfere with normal functioning.

depersonalization derealization

Dissociative Amnesia

failure to recall previously stored personal information when that failure cannot be accounted for by ordinary forgetting. Gaps in memory most often occur following intolerably stressful circumstances (wartime combat conditions, catastrophic events, traumatic experiences). In typical reactions, individuals cannot remember certain aspects of their personal life history or important facts about their identity. The only types of memory affected are episodic (events experienced) or autobiographical (personal events experienced)

Alter identities (DID)

fragments of a single person -Some alters may have more knowledge than others -Alter identities take control at different points in time; switches typically occur very quickly

depersonalization (dissociative disorder)

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

Old disorders of __, __ disorder, and __ disorder are gone. Most people who would have previously been diagnosed with one of these disorders will now be diagnosed with somatic symptom disorder.

hypochondriasis somatization pain

derealization (dissociative disorder)

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

Dissociative fugue (dissociative amnesia)

is a defense by actual flight: the person is not only amnesic for some or all aspects of their past, but also they depart from home surroundings. Accompanied by confusion about personal identity or even assumption of a new identity Individuals unaware of memory loss for prior stages of their life Memory of what happens during the fugue stage is intact Behavior is usually quite normal and unlikely to arouse suspicion but reflects a rather different lifestyle from the previous one In DSM-5, it is considered to be a subtype of dissociative amnesia, rather than a separate disorder as in DSM-IV

Dissociative Identity Disorder (DID)

is a disruption of identity characterized by two or more distinct personality states as well as recurrent episodes of amnesia. DSM-5 included pathological possession in the diagnostic criteria for DID. -A trance occurs when someone experiences a temporary marked alteration in state of consciousness or identity. -In a possession trance, alteration of consciousness or identity is replaced by a new identity that is attributed to the influence of a spirit, deity, or other power. -Pathological possession is a common form of DID. Usually starts in childhood; most patients are in their teens, 20s, or 30s at time of diagnosis Approximately 3-9 times more females than males are diagnosed with the disorder Females tend to have more alters than males. Gender difference believed to be due to greater proportion of childhood sexual abuse among females (controversial point) Number of alter identities varies tremendously and has increased over time. Another recent trend is bizarre and unusual identities.

somatic symptom disorder

may be diagnosed when concern about somatic symptoms is severe and leads to significant distress or impairment

dissociative disorder

may be diagnosed when feelings of "being out of it" become so persistent and recurrent that the person has profound and unusual memory deficits

Dissociative identity disorder was formally known as

multiple personality disorder

somatic system disorders and dissociative disorders were considered to be forms of __

neurosis

Mild dissociative or somatic symptoms are experienced at least __ by almost everyone

occasionally

implicit memory (dissociative disorders)

remembering things an individual cannot consciously recall

Reflects an attempt to cope with an overwhelming sense of hopelessness and powerlessness in the face of __ traumatic abuse

repeated

implicit perception (dissociative disorders)

responding to sights and sounds as if they had been perceived, even though the individual cannot report that they have seen or heard them

somatic system disorders used to be called

somatoform disorders

Symptoms of DID

symptoms include depression, self-injurious behavior, frequent suicidal ideation and attempts, erratic behavior, headaches, hallucinations, posttraumatic symptoms, and other amnesic and fugue symptoms

Symptoms of dissociation are __, or associated with many different forms of psychopathology

transdiagnostic

According to __ theory, DID starts from early childhood traumatization

trauma