| Psy302 Lecture Notes Week 3 SOMATOFORM DISORDERS These are closely related to anxiety disorders and person tends to suffer from poor insight - does not recognise that concerns are excessive or unreasonable and reassurance from others, including Drs. is not helpful. HYPOCHONDRIASIS A disorder of cognition or perception with strong emotional contributions. SOMATIZATION DISORDER Linked to antisocial, or psychopathic, personality disorder and might have a heritable component. PAIN DISORDER Could be psychologically or medically related. BODY DYSMORPHIC DISORDER "Imagined Ugliness" DIAGNOSTIC CRITERIA FOR HYPOCHONDRIASIS l. Preoccupation with fears of having, or ideas that one has, a serious disease based on the person's misinterpretations of bodily symptoms. 2. The preoccupation persists despite appropriate medical evaluation and reassurance. 3. The belief (Criterion 1) is not of delusional intensity and is not restricted to a circumscribed concern about body appearance. 4. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 5. The duration of the disturbance is at least 6 months. 6. The preoccupation is not better accounted for by Generalised Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder HYPOCHONDRIASIS CLINICAL DESCRIPTION l. ANXIETY DISORDER - Person develops severe anxiety focused on possibility of having a serious disease. 2. Possibility is so real that even medical reassurance will not help. 3. Key feature : concern or preoccupation with physical symptoms. 4. Core feature : disease conviction. 5. Prevalence in Population : 4% to 9% higher in elderly. Ration men to women 50/50. 6. Reinforcers/Contributors : a. society - is socially approved and at times even rewarded. b. fear of having illness increases anxiety, which increases symptom perception, etc. - vicious cycle. c. enhanced perceptual sensitivity to illness cues, causing them to interpret as dangerous and threatening any stimuli, no matter how minor or ambiguous. d. past background of trauma or disproportionate incidences of illness when a child. 7. Symptom variety dependent on cultural believes. 8. Assessment must look at: a. Rule out physical cause for complaint. b. Its association with a specific somatoform disorder or part of some other psychopathological disorder or syndrome. c. Cultural and subcultural awareness. HYPOCHONDRASIS TREATMENT l. Focus on illness preoccupaiton. 2. Focus directly on the anxiety. 3. Cognitive Behavioural approaches. 4. Psychopharmacological treatments. 5. Direct reassurance. 5. REM 6. Relaxation and guided imagery techniques. 7. Hypnosis/self hypnosis. 8. Group therapy. 9. Support Groups. SOMATIZATION DISORDER CRITERIA FOR SOMATIZATION DISORDER l. History of many physical complaints beginning before age 30 that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. 2. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: a. Four pain symptoms: A history of pair related to at least four different sites or functions (such as head, abdomen, back, joints, extremities, chest, rectum, during sexual intercourse, during menstruation, or during urination. b. Two gastrointestinal symptoms: A history of at least two gastrointestinal symptoms other than pain (such as nausea, diarrhoea, bloating, vomiting other than during pregnancy, or intolerance of several different foods). c. One sexual symptom: A history of at least one sexual or reproductive symptom other than pain (such as sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy. d. One pseudoneurologic symptom: A history of at least one symptom or deficit suggesting a neurological disorder not limited to pain (conversion symptoms such as blindness, double vision, deafness, loss of touch or pain sensation, hallucinations, aphonia, impaired coordination or balance, paralysis or localised weakness, difficulty swallowing, difficulty breathing, urinary retention, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting) SOMATIZATION DISORDER CLINICAL DESCRIPTION 1. Long list of somatic complaints with no medical basis. 2. Preoccupation persists despite appropriate medical evaluation and reassurance. Clients return with some variations to initial complaint. 3. Focus on symptom itself and not what the symptom means. Life itself may revolve around the symptom, as well as relationships. 4. Prevalence in Population: to 0.7% - on a continuum of impairment because of disorder. Tendency for somewhat higher incidence in females. 6. Reinforcers/Contributors: a. society - is socially approved and at times even rewarded. b. past background of disproportionate incidence of illness or injury while growing up. c. linked to heredity and to antisocial behaviour characteristics; including vandalism, persistent lying, theft, irresponsibility with finances and at work, and outright physical aggression. Insensitivity to punishment or negative consequences of behaviour is also a characteristic, as is little anxiety or guilt over their aggression or criminal behaviour. d. Neurobiologically based disinhibition syndrome, as found in antisocial personality disorders that is incapable of exerting sufficient control over the behavioural activation system. SOMATIZATION DISORDER TREATMENT l. Provide reassurance 2. Focus on the stress associated with the disorder. 3. Focus on reducing the help-seeking behaviour 4. Reducing any reinforcing or supporting consequences of relating to significant others on the basis of physical symptoms alone. 5. Group Therapy 6. Cognitive Behavioural approaches 7. REM 8. Hypnosis/self hypnosis CONVERSION DISORDER CRITERIA FOR CONVERSION DISORDER l. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or general medical condition. 2. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. 3. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). 4. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behaviour or experience. 5. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. 6. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder. CONVERSION DISORDER CLINICAL DESCRIPTION 1. Generally refers to physical malfunctioning, such as a paralysis, blindness, or difficulty speaking (aphonia), without any physical or organic pathology what would account for the malfunction. 2. Anxiety resulting from an unconscious conflict and needing to express itself "convert" itself into physical symptoms. 3. Key features : a. at times perceived to be indifferent to the symptom. b. precipitated by some marked stress. c. people usually function normally, but are unaware of this ability or of the sensory input. d. usually not trying "to get out of something" like malingerers. e. not like "factitious disorder" (eg. Munchausen or Munchausen by roxy), who feign illness but who have no obvious good reason to be sick. 4. Prevalence in Population : 1% to 30%; primarily found in women, in adolescence and thereafter, tough frequently seen in men enduring great stress and trauma, such as combat soldiers. Tends to occur in less educated, lower socioeconomic groups where knowledge about disease and medical illness is not as well developed. Other member's experience with illness may influence disorder chose (patients tend to "pick-up" symptoms). 5. Reinforcers/Contributors: a. First, The experience of a traumatic event (Freud believed it to be some unacceptable, unconscious conflict)that must be avoided at all cost. Second, conflict repressed or made unconscious because conflict is unacceptable and creates anxiety Third, as anxiety increases, threatening to emerge into consciousness, person "converts" it into physical symptoms, thus relieving pressure to deal with it directly (the primary gain or primary reinforcers maintaining disorder). Fourth, individual receives increased attention and sympathy from loved ones and may even avoid or escape dealing with some difficult situations (the secondary gain or secondary reinforcer of disorder). b. is a substitute for "running away" which is not acceptable socially and illness is detached/dissociated because getting sick on purpose is also unacceptable. c. success of "conversion" maintains condition until the underlying problem or set of maintaining factors is resolved. d. Seem to be part of a larger constellation of psychopathology and vulnerability under stress. CONVERSION DISORDER TREATMENT l. Attention to traumatic or stressful life event, if present, by "reliving" the event first, (catharsis) and removing source of secondary gains. 2. Reduction of any reinforcing or supportive consequences of the symptom (the primary gains). This needs strong collaboration for family and social structure of the client. 3. REM 4. Hypnosis/self-hypnosis 5. Cognitive Behaviour therapies PAIN DISORDER DIAGNOSTIC CRITERIA 1. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. 2. The pain causes clinically significant distress or impairment i social, occupational, or other important areas of functioning. 3. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. 4. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). 5. The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia. ACUTE: less 6 mo. CHRONIC: 6 mo. or more PAIN DISORDER CLINICAL DESCRIPTIONS l. Very difficult to assess if pain is primarily psychological or if causes are primarily physical. 2. Important feature: pain is real whether psychological or physical. TREATMENT l. Better treated in a multidisciplinary clinic. 2. Cognitive Behaviour therapies. 3. Pharmacology 4. Biofeedback 5. Group and Individual therapy BODY DYSMORPHIC DISORDER CRITERIA FOR BODY DYSMORPHIC l. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive. 2. The preoccupation causes significant distress or impairment in social, occupational, or other important areas of functioning. 3. The preoccupation is not better accounted for by another mental disorder (e.g. dissatisfaction with body shape and size in anorexia nervosa). BODY DYSMORPHIC DISORDER CLINICAL DESCRIPTION 1. "Imagined ugliness" and "mirror fixation" either phobic avoidance or frequent checks to see if changes have occurred. 2. Usually accompanied by suicidal ideation, and suicide attempts. 3. Possible association to defensive mechanism of displacement - underlying unconscious conflict is too anxiety provoking - "displaced" to a body part. 4. Association to somatoform disorder. 5. Related to anxiety. 6. Frequently co-occurs obsessive-compulsive disorders. This is also found in family members of BDD sufferers. 7. "Ideas of Reference" - everything that goes on in the world related to their imagined defect. 8. Prevalence in population: Greater than thought . Up to 70% of college students had some degree of dissatisfaction with their bodies. About equal male to female ration, with slightly more females in Western World (62% males noted in Japan). Starts around adolescence, peaking at l9 y.o. Very few sufferers get married. 9. Reinforcers/Contributors: a. societal beauty values b. cultural standards/desirability factor c. family/partners values DYSMORPHIC DISORDER TREATMENT l. Only one treatment so far found successful: drugs that block the reuptake of serotonin, such as clomipramine and fluoxide. This same drug has effect on obsessive-compulsive disorders. Plastic Surgery usually used by these sufferers, but they are never satisfied and keep returning for more surgery or file malpractice law suits. Studies have also shown preoccupation with imagined ugliness increases in many cases. DISSOCIATIVE DISORDER Description: Individual feels detached of surrounding and/or themselves - as if in a dream or living life in slow motion. Any body can feel this at times of great stress/trauma/accident or when very tired or extremely stressed mentally or physically. CLINICAL PRESENTATIONS Feelings created by experience of unreality: - depersonalisation - temporary loss of sense of owns reality due to alteration in perception. - derealization - loss of sense of "realness" of external world. Symptoms of unreality are prevalent: dissociation from reality. It can be part of a more serious set of conditions where reality, experience, and even one's identity disintegrate. DEPERSONALISATION DISORDER CRITERIA FOR DEPERSONALISATION l. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream). 2. During the depersonalisation experience, reality testing remains intact. 3. The depersonalisation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 4. The depersonalisation experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder, and is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g. temporal lobe epilepsy). DEPERSONALISATION DISORDER CLINICAL DESCRIPTION l. Feelings of being unreal or detached are so severe and frightening that they dominate the individual's life and prevents normal functioning. 2. Is not associated, or is not, the major problem of another disorder. DISSOCIATIVE AMNESIA CLINICAL DESCRIPTION l. Generalised amnesia : unable to remember anything, including who they are (from l y. prior to onset to forever). 2. Localised amnesia (more common) : failure to recall specific events that occur during a specific period of time. DISSOCIATIVE AMNESIA DIAGNOSTIC CRITERIA l. The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. 2. The disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue, posttraumatic stress disorder, acute stress disorder, or somatization disorder and is not due to the direct physiological effects of a substance (e.g. , a drug abuse, a medication) or a neurological or other general medical condition (e.g., amnestic disorder due to head trauma). 3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. DISSOCIATIVE FUGUE Description: "Flight" - not only is there memory loss but it revolves around a very specific incident, where the individual "takes off" and later finds her/himself in some new place, usually leaving behind some very difficult situation they find intolerable. During these "flights" the individual sometimes takes on a new identity or becomes confused about the old one. CLINICAL PRESENTATIONS l. Usually do not appear until adolescence; more commonly in adults. Rare after age 50. 2. Usually end rather abruptly and the individual returns home recalling most of what happened. 3. Disorder goes beyond memory loss. It involves some disintegration of identity to the adoption of a completely new one. DISSOCIATIVE FUGUE CRITERIA FOR DISSOCIATIVE FUGUE l. The predominant disturbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's past. 2. Confusion about personal identity or assumption of new identity (partial or complete). 3. The disturbance does not occur exclusively during the course of dissociative identity disorder and is not due to the direct physiological effects of a substance (e.g., drug abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy). 4. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. DISSOCIATIVE TRANCE DISORDER Characteristics: culturally determined trance possession Symptoms: dissociative symptoms such as sudden changes in personality. Changes attributed to possession by a spirit, which is culturally defined. Prevalence in Population: More common in women, except for "amok". Contributor: Associated with some life stress or trauma. Stress or trauma is current. Cultural or traditional practice (then, not considered an abnormality, unless seen as undesirable or pathological by culture/tradition). DISSOCIATIVE TRANCE DISORDER CRITERIA FOR TRANCE AND POSSESSION A. Either (1) or (2): l. Trance, i.e., temporary marked alteration in the state of consciousness or loss of customary sense of personal identity without replacement by an alternate identity, associated with at least one of the following: a. narrowing of awareness of immediate surroundings, or unusually narrow and selective focusing on environmental stimuli. b. stereotyped behaviours or movements that are experienced as being beyond one's control. 2. Possession trance, a single or episodic alteration in the state of consciousness characterised by the replacement of customary sense of personal identity by a new identity. This is attributed to the influence of a spirit, power, deity, or other person, as evidenced by one (or more) of the following: a. stereotyped and culturally determined behaviours or movements that are experienced as being controlled by the possessing agent. b. full or partial amnesia of the event. B. The trance or possession state is not accepted as a normal part of a collective cultural or religious practice. C. The trance or possession state causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The trance or possession trance state does not occur exclusively during the course of a Psychotic Disorder (including Mood Disorder With Psychotic Features and Brief Reactive Psychosis) or Dissociative Identity Disorder and is not due to the direct physiological effects of a substance or a general medical condition. DISSOCIATIVE TRANCE DISORDER CLINICAL DESCRIPTION 1. Differ greatly across cultures (trance or possession). 2. Symptoms: dissociative symptoms such as sudden changes in personality but attributed to possession by a spirit known by the culture of the person. if part of some traditional religious or cultural practice it is then considered normal. If undesirable and considered pathological by culture, then it is considered a disorder. 3. Prevalence in population: more common in women. 4. Reinforces/Contributors: associated to a present stress or trauma. DISSOCIATIVE IDENTITY DISORDER MULTIPLE PERSONALITY DISORDER CRITERIA FOR DISSOCIATIVE IDENTITY DISORDER 1. The presence of two or more distinct identities or personality stated (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self). 2. At least two of the above recurrently take control of the person's behaviour. 3. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness. 4. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts on chaotic behaviour during alcohol intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play. DISSOCIATIVE IDENTITY DISORDER CLINICAL DESCRIPTION 1. Characteristics: a. Person may adopt from one to l00 or more identities (alters) that coexist within mind and body. b. Each personality may be completely different to the other in voice, gestures, behaviours, believes, postures, physical disabilities, even pattern of facial, number of changes in optical functioning wrinkles and handedness, or be partially dependent of each other and to be cross gendered. c. Personalities score different in personality and other tests. d. There is usually a "host" identity (the client, which is seldom the first one to seek treatment), which tends to develop later. e. Each personality has a different role. One is usually impulsive and another one has knowledge of all others. f. Switch - transition from one personality to another, can be instantaneous and physical transformations can take place during these switches. g. Number of personalities in an individual is l5 on the average. h. Onset: around 7 yo, but as young as 4 yo. i. Duration - usually a lifetime if not treated. Form of disorder remains the same throughout life but switching decreases with age. Different personalities appear over years in reaction to new life situations. j. Additional accompanying disorders: substance abuse, depression, somatization disorder, borderline personality disorder, panic attacks and eating disorders. 2. Symptoms: fragmented identity (parts of person's identity become detached or dissociated), dissociative amnesia and dissociative fugue. 3. Symptoms shared with other disorders, such as with borderline,: self-destructive, sometimes suicidal behaviours and emotional instability, are due to severity of reaction to usually horrible childhood abuse. DID also has much similarity with PTSD - severe and strong emotional reactions to experiencing severe trauma, to point that there is a believe DID is an extreme case of PTSD, with emphasis on process of dissociation rather than symptoms of anxiety. 4. Prevalence in Population: Not known in population at large, but more common than thought previously. There are about 9 females to 1 male. 5. Suggestibility is great in these individuals. Because of this, at times it is difficult to assess if DID is real, fake, or suggested by therapist's leading questions. 6. Veracity Tests can include: a. optical changes such as in measures of visual acuity, manifest refraction, and eye muscle balance, which are difficult to fake. b. different physiological responses to emotionally laden words (GRS and EEG)). c. developmental history that suggests early onset. d. failure to attain substantive information from relatives and friends. e. failure to create more personalities under suggestion (escalation when under investigation). f. lack of test response differentiation amongst personalities. g. assessment indicates no gains received from having disorder. h. "faking tests" with symptoms shown by some of the personalities. 7. Reinforcers/ Contributors: a. horrible child abuse, bizarre and sadistic. b. satanic or ritual abuse. c. witnessing a traumatic event, such as the murder of loved ones. d. being forced to commit a crime or sacrifice loved one,(eg satanic sacrifice). e. DID is rooted in a natural, normal tendency to escape or "dissociated" from the unremitting negative affect associated with severe abuse. f. lack of social support during or after abuse. g. suggestibility and hypnotisability traits which makes them able to use dissociation as a defence against extreme trauma. SEIZURES AND DISSOCIATIVE SYMPTOMS Description: A biological vulnerability to reacting with a seizure to trauma. A Possible Explanation for this disorder could be based on an abnormal electrical activity of the brain. Neurological seizure sufferers experience a lot of dissociative symptoms (6% of temporal lobe report "out of body experiences"; 50% of temporal lobe display some kind of dissociative symptoms, such as alternate identities or identity fragments. Yet, there are differences between dissociative disorder patients who have seizures and those who do not. Also, in seizure patients. dissociative symptoms develop in adulthood and are not associated with trauma. TREATMENT FOR DISSOCIATIVE DISORDERS Episodes of dissociative amnesia or fugue state: Individual usually gets better on their own and go back to their homes or "remember". If memories do not return, therapy focus on uncovering forgotten information and to confront it, integrating it into their experience. Therapeutic resolution of stressful situation. Increasing strength of coping mechanisms. REM Dissociative Identity Disorder: Treatment for Dissociative Disorders Long-term psychotherapy to reintegrate identities (successful only in 5 of 20). Goal is to confront and relive early trauma in a way that the individual gains control over the horrible events, as they continue to occur in patient's mind in the present and to make the trauma simply a terrible memory of a particular past period. Hypnosis, particularly for "unconscious" memories and to bring forth "alters" Same treatment procedures as used in PTSD. pharmacology strategies to gradually confront feared situations and do reality testing gradual exposures paired with relaxation exercises panic control treatment techniques - the recreation of feelings felt during past, traumatic and feared experiences, during treatment paired with CBT techniques relaxation and breathing exercises to help cope with stress of memories REM Note: l. reemerging memories of the trauma may trigger further dissociation. Therapist must be vigilant 2. very important in therapy are therapeutic relationship and sense of trust 3. Medication, not yet proven to be helpful there are indications that antidepressant drugs help. 4. VERY IMPORTANT IN TREATMENT: a. Setting treatment plan that will define: safety area which personality would like to meet therapist first assessment of past treatment(s) and what helped/did not help assessment of developmental/past history: - when aware of dissociations - memories held - gaps in memories - affects in daily life and job getting names of each personality or identity and their roles genesis of each personality state and duration of time it has executive control of the body why did each personality state appear, in terms of precipitatives and perpetuating events associated with its development and why it is present at this time in life where was client at time of each personality state's creation, where each personality state fits in the power structure, and where each personality state fits into the system of the client's personality the function of each personality state and how he or she aids the system as a whole b. Making a Contract (or hospitalise): - Type and regularity of treatment - No set time for duration of sessions or of treatment - Use of specific procedures (eg, hypnosis) No self hurt, suicide or homicide (eg: " I will not hurt myself or kill myself, nor anyone else external or internal, either accidentally or on purpose at any time." c. taping sessions and taking good notes - clients tend to not remember great parts of the session because of shifts and defence mechanisms. d. giving client copy of notes to remember session and when ready, with therapist present, go over tapes (helpful to get to know other personalities). e. therapist must have great sensitivity to client's reactions during therapy and must ensure client leaves in a well state. f. therapist must be very aware of him/herself and reactions to horrific revelations and be able to deal with these, without showing disturbance or fear as personalities will realise therapist's inability to deal with issues and stop making themselves available to therapy and stop memory recovery process. g. therapist must be available 24 hrs. a day for emergencies as clients, once memory starts to reemerge, will have flashbacks during sleep and waking - at any time and will not be able to deal with these without help. [Submitted by: Tania Lioulios (tania.lioulios@anu.edu.au) Mon, 25 Mar 1996 14:17:44 +1000] | |
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