Cogito ergo sum.
I think,
therefore, I am.
Rene Descartes
Lecture 5
Somatoform and Dissociative
Disorders
Dale L. Johnson
The disorders in this section all
have to do with knowing: knowing about one's body and knowing about one's self,
one's past, and one's relations to others. The early French psychiatrists
realized that knowing was central to these disorders, but this realization was
not seen as a cognitive matter until quite recently. "Knowing" in the
earlier theories was about the absence of knowing because of repression and
repression was believed to be the result of intrapsychic conflict.
Somatoform Disorders
Hypochondriasis
Clinical
Description
The person develops severe anxiety
that is focused on the possibility of having a severe disease. The person
regards this as so likely that reassurance from physicians fails to provide
relief.
See the case of Gail in your
textbook.
This has much in common with the
anxiety disorders. This is partly the result of a DSM-IV redefinition of the
disorder which now links it more exclusively to anxiety. The anxiety is about
having the disease, not that one might get the disease.
People with this disorder tend to
misinterpret ambiguous physical signs.
____________________________________________________________
Diagnostic Criteria for
Hypochondriasis
A. Preoccupation wiht fears of having, or the
idea that one has, a serious illness based on the person's misinterpretation of
bodily symptoms.
B. The preoccupation persists despite
appropriate medical evaluation and reassurance.
C. The belief in Criterion A is not of
delusional intensity and is not restricted to
circumscribed concern about appearance.
D. The preoccupation causes clinically
significant distress or impairment in social, occupational or other important
areas of functioning.
E. The duration of the disturbance is at least
6 months.
F. The preoccupation is not better accounted
for by other disorders.
Source: DSM-IV,
APA, 1994.
____________________________________________________________
Statistics
and Course
The prevalence is unknown. Estimates
range from 1% to 14% of medical patients. There are no estimates for the
general population. The sex ratio is
presumed to be equal.
Causes
The person's perception of physical
signs of physical signs is faulty. It is, therefore, a disorder of cognition or
perception. It has been demonstrated that people with this disorder have an
enhanced sensitivity to illness cues. Thus, a minor headache is seen as
equalling a brain tumor. Think of how we ordinarily handle the perception of
our physical well-being. If a new ache develops, we mentally review the ache,
where it is, how intense, when it began, was there ever such an ache before?
Quickly, we do a self-diagnosis and decide, "Aha! I ran 5 miles yesterday
instead of my usual 3 and now I am feeling it." Or, we might decide it is
new and is a warning sign. Perhaps we let it go for awhile and then we seek
help from an expert (if we have health insurance and can afford help).
For some reason, the person with hypochondriasis
makes the same self-check and usually decides that the result is that one has
some awful illness. The signs from the body all point in the direction of dire
consequences.
The predispositions are unknown, but
there may have been a prior trauma or an
illness that has frightened the person. Risk factors for hypochondriasis
are essentially unknown. There is some evidence that it runs in families, and
thus, may be either genetic or learned. If parents place a great emphasis on
physical signs as indicators of illness, the child may develop a sensitivity to
these signs and a tendency to over-interpret their significance.
It is important to keep in mind the
rewards that may be found in discovering that one has an interesting illness.
The reinforcement is treatment by the medical community and family. There are
sick role benefits. We should not discount these behaviors and learn to provide
alternative rewards.
Treatment
Until recently little has been known
about treatment. There have been few controlled studies. One of these (Warwick,
H. M., Clark, D. M, Cobb, A. M., & Salkovskis, P. M. (1996). A controlled
trial of cognitive-behavioural treatment of hypochondriasis. British Journal
of Psychiatry, 169, 189-195.) randomly assigned 32 patients to CBT or to a
no-treatment, waiting list control. At 3 month follow-up, patients who had
received CBT were doing significantly better on measures than patients in the
control group. Two other studies using CBT have had similar positive results.
Reassurance is effective with some
patients and support groups seem to benefit others, but this work has not been
tested with controlled clinical trials.
* * *
Somatization Disorder
Clinical
Description
This disorder was first
termed,Briquet’s syndrome, after the man who defined the disorder in 1859. The
key features are multiple somatic complaints presented in a vague, exaggerated
way. The main difference from hypochoncriasis is that there is less anxiety;
indeed, it is remarkably absent. The focus is on the symptoms and not what they
might mean. Notice the lack of interest in knowing. The disorder has an
obsessive quality. Life is organized around symptoms.
________________________________________________________________________
DSM-IV Criteria for Somatization Disorder
A. A history of many physical complaints
beginning before age 30 that occur over a period of several years and result in
treatment being sought, or impairment in social, occupational or other
important areas of functioning..
B. Each of the following criteria must have
been met, with individual symptoms occurring at any time during the course of
disturbance:
1.
Four pain symptoms. A history of pain related to at least four different
sites or functions of the body.
2.
Two gastrointestinal symptoms. A story of at least two gastrointestinal
symptoms other than pain such as nausea, diarrhea, bloating, vomiting (other
tnan pregnancy),or intolerance of several different foods.
3.
One sexual symptom; e.g., erectile dysfunction, irregular menses, excessive
bleeding.
4.
On pseudoneurological symptom; e.g., deafness, blindness, double vision.
Source: DSM-IV,
APA, 1994.
____________________________________________________________
Statistics
and Course
Very rare. ECA females
0.2% 2/1000
males
0.01% 1/10,000
Used DSM-III
criteria.
The disorder's severity occurs on a
continuum. The number of symptoms reported ranges widely.
Causes
One cause seems to be having been a
witness to injury or traumatic event.
Genetic. Torgerson (Archives of
General Psychiatry 1986) MZ 29%, DZ
10%
Others have
found a genetic component.
It appears to be linked to such
antisocial characteristics as lying, vandalism, theft, and irresponsibility.
There is little anxiety and there may be a manipulative, deceitful component.
Both disorders begin early in life, run a chronic course, and are associated
with many social and interpersonal problems.
What does somatization have in common with antisocial personality
disorder? A neurobehavioral
disinhibition syndrome. This behavioral Activation Syndrome is characterized by
impulsivity and thrill seeking.
The Behavioral Inhibition Syndrome
(BIS) ensures responsivity to threat or danger. We feel anxious when we get
certain signals. People with antisocial personality disorder are less inclined
to be anxious. They are impulsive--responsive to short-term rewards.
BIS brain circuiting involves the
septal area of the brain through the hippocampus to the orbital frontal cortex.
There is dysfunction in this circuitry. This also appears in attention deficit
disorder.
People with somatization disorder
are different for social/cultural reasons. There is a markedly high degree of
dependency. Dependence and lack of physical aggression are feminine characteristics
(which is to say they may appear in men and women and are conceptually in
contrast to masculinity).
Treatment
Somatization disorder is believed to
be difficult to treat (as are antisocial personality disorders). There is only
one (to my knowledge) demonstrably
effective treatment for this disorder. Group therapy for somatization disorder
that is based on short cognitive-behavioural treatment model. (Lidbeck, J.,
1997 Acta Psychiatrica Scandinavica, 96, 14-24.) When results were
analyzed 6 months after treatment, the participants who had received group CBT
were doing significantly better than the control group. Control group patients
did not improve. Certainly, more research is called for, but this study points
to a way of effective treatment.
Warning: some people diagnosed with
this disorder, and the other somatoform disorders, are subsequently found to
have a real physical illness such as multiple sclerosis. Clinicians are warned
to do a searching physical diagnostic examination.
*
* *
Conversion Disorder
Definition
Physical malfunctioning without
physical pathology.
The term “conversion” was used by
Freud who theorized that anxiety arising from unconscious conflicts was
converted from psychological to physical expression. The person could get rid
of the anxiety without confronting it, without acknowledging that it is my
anxiety, that it is my future that is threatened.
What is the difference between
conversion disorder and simple malingering or consciously trying to look bad?
For one thing, in conversion there is indifference (not knowing) to the
disability whereas the malingerer makes a point of proving that he or she is
disabled. Malingerers have an object in mind; they want to get something out of
the disability. They are fully aware of what they are doing. There was a NYPD
episode in which a man faked insanity. He was tricked into revealing himself.
In conversion disorder, the person cannot be tricked into revealing self.
In factitious disorders the symptoms
are faked and under full awareness, but for no apparent reason, except perhaps
to assume the sick role. This may be shared by family and in this case it is a
factitious disorder by proxy.
________________________________________________________________________
DSM-IV Criteria for Conversion Disorder
A. One or more symptoms or deficits affecting
voluntary motor or sensory function that suggest a neurological or general
medical condition.
B. Psychological factors are judged to be
associated with the symptom or deficit because the initiation or exacerbation
of the symptom is preceded by conflicts or other stressors.
C. The symptom is not intentionally produced or
feigned.
D. the symptom 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 behavior or
experience.
E. The symptom causes clinically significant
distress or impairment in social, occupational or other important areas of
functioning.
Source: DSM-IV,
APA, 1994.
____________________________________________________________
Unconscious mental processes come
into play in trying to understand conversion disorders. The case of Anna O. is
a famous example. As Freud described the case she had a conversion reaction, but
records discovered later show that she suffered from tuberculous meningitis
which she contracted from her father. She had nursed her father for a long
time. She may also have had a conversion disorder, but it is impossible to know
in retrospect. Freud failed to acknowledge his misdiagnosis, even though he
knew he had been in error.
One thing is clear. People with this
disorder are not good describers of their physical problem. This has something
to do with cognitive style. There is a remarkable vagueness of the
presentation. I have seen several cases, all in VA hospitals, and I recall that
trying to find out about the problem was a frustrating challenge.
Statistics
and Course
Prevalence: 1% to 30%. These
estimates are absurdly wide. The disorder is almost certainly rare. The
condition seems to be quite chronic.
It seems to occur most often in
women who have a low IQ, low socioeconomic status (SES), isolated environments,
and fundamentalist religion . Basic to all of this is the issue of knowing.
People who develop this disorder are not sophisticated. They do not read the
New York Times or watch PBS.
There is some evidence that the
disorder is declining in incidence. But how can we know without data? Perhaps
if it is declining it is related to the general increase in IQ of the
population that has been underway for several decades. Perhaps with more public
communication (radio, TV) there is growing sophistication.
Treatment
Several forms of treatment are
effective in the short term. This includes hypnosis, faith healing and
psychoanalysis.
Perhaps the most effective treatment
is to attend to the traumatic event and remove opportunities for secondary
gain. It is also necessary to change environmental reinforcers. One might try
behavioral family therapy. There are no controlled studies of treatment
effectiveness.
*
* *
Pain Disorder
Pain experienced beyond expectations
for a physical condition.
*
* *
Body Dysmorphic Disorder
The disorder is based on imagined
ugliness. In some other somatoform disorders there is imagined illness; here
the focus is on beauty or ugliness. it is related to obsessive compulsive
disorder and to anorexia. There is an obsessive quality about the concern which
resists conventional correction. People in general rate themselves as a little
above average in beauty. They do this by focusing on certain features:
"You have lovely eyes." They ignore other features such as big ears
(e.g., Clark Gable).
________________________________________________________________________
DSM-IV Criteria for Body Dysmorphic
Disorder
A. Preoccupation with an imagined defect in
appearance. If a slight physical anomally is preent, the person's concern is
markedly excessive.
B. The preoccupation causes significant
distress or impairment in social, occupational or other important areas of
functioning.
C. The preoccupation is not better accouted for
by other mental disorders.
Source: DSM-IV,
APA, 1994.
____________________________________________________________
Statistics
70% of college students are
dissatisfied with some aspect of their body. But BDD goes beyond wishing to be
more beautiful. See the criteria above: the concern has to be disabling.
There are cultural definitions of
beauty, such as slimness for American women and more roundedness for women in
the Middle East. There is also great cross-cultural agreement. One universal
seems to be that symetry of facial features is associated with beauty.
The prevalence of BDD is unknown.
There maybe a slightly greater prevalence for females, but perhaps men simply
hide their concern more. Age of onset peaks at age 19.
Causes
It was an important discovery that
BDD is related to obsessive-compulsive disorder and that the two disorders
co-occur in families. In OCD the obsession is often about germs; in BDDthe
obsession is about ugliness. They are not so different.
The most effective treatments are
the SSRI anti-depressant medications; especially, Prozac. It may be that the
other SSRIs are equally effective, but research is lacking.
Plastic surgery provides no benefit
because it is never good enough, and the obsession is still present.
Prozac is not the only treatment. I
recall at case at the Winter VA Hospital in Topeka, Kansas. A man came to the hospital with the
complaint that his penis was too small. He had gone shopping, from one VA
hospital to another. His penis was measured and he was always told he did not
have a problem. Finally, at Topeka, his penis was again carefully measured and
found to be in the normal range, but the patient was told it was small. He was
advised that given this limitation he would have to focus on his sexual
technique, and then on his vocational esteem. He was given lessons on sexual
technique, books to read, and homework assignments. At follow-up he was doing well.
*
* * * *
Dissociative Disorders
There are two types of feelings of
unreality: depersonalization, in which
one loses a sense of one's own reality; and derealization, in which the sense
of the realness of the external world is altered.
These forms of awareness have been
the subject of concern by the existential philosophers such as Heidegger and
Sartre. They have analyzed how one is grounded; that is, how one functions in
the ordinary world. For Heidegger, the person in the ordinary world is in care.
In the dissociative disorders, this groundedness has gone wrong. It is as
though they have a tenuous connection with the real world, including the social
world. I recall seeing a play once, the title is forgotten, in which the hero
would wander on stage with "Who am I?" spells. No one could help him.
Depersonalization Disorder
____________________________________________________________
DSM-IV Criteria for
Depersonalization Disorder
A. 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.
B. During the depersonalization experience
reality testing remains intact.
C. The depersonalization causes clinically
significant distress or impairment in social, occupational or other important
areas of functioning.
D. The depersonalization experience is not part
of another disorder.
Source: DSM-IV,
APA, 1994.
____________________________________________________________
Although the text mentions that the
experience tends to be chronic, it also appears more fleetingly, especially in
adolescents. In these one or two time forms of the depersonalization there is
no impairment of functioning and most adolescents view the experiences as part
of the mystery of growing up.
Making a distinction between
depersonalization disorder as distinct from the consequences of substance use
is crucial for the diagnosis.
*
* *
Dissociative Amnesia
____________________________________________________________
DSM-IV Criteria for
Dissociative Amnesia
A. 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.
B. The disturbance does not occur exclusively
during the course of dissociative identity disorder, dissociative fugue, post
traumatic stress disorder, or somatization disorder, and is not due to
substance abuse or medication.
C. The symptoms cause clinically significant
distress or impairment in social, occupational or other important areas of
functioning.
Source: DSM-IV,
APA, 1994.
____________________________________________________________
This disorder must be distinquished
from amnesia associated with acute alcohol intoxication. Some people who abuse
alcohol begin having black-outs, or amnestic periods at about age 30. These may
occur more frequently as drinking proceeds.
*
* *
Dissociative Fugue
____________________________________________________________
DSM-IV Criteria for
Dissociative Fugue
A. The predominant disturbance is
sudden,unexpected travel away from home or one's customary place of work, with
inability to recall one's past.
B. Confusion about personal identity or
assumption of a new name (partial or complete).
C. The symptoms cause clinically significant
stress or impairment in social, occupational or other important areas of
functioning.
Source: DSM-IV,
APA, 1994.
____________________________________________________________
I have never encountered a case of
dissociative fugue that was not characterized by heavy drinking. Even the case
on P. 160 in the text (The Sherif) includes drinking.
On p. 160 the authors of the text
mention cultural variations on this disorder. They refer to frenzy witchcraft
among the Navajo. They neglect to mention that I wrote the first report on that
Navajo disorder. Fame is so elusive!
*
* *
Dissociative Identity Disorder (DID)
This disorder was once called multiple personality disorder and
was popularized in several movies (e.g., Three faces of Eve). Only a short time
ago, after years of almost no research on this disorder, there was a surge of
research and reports appeared on what seemed like a monthly basis. Now, there
are few reports again. What has happened is that for a time, researchers
believed they had identified many cases of DID. The identification procedures
were severely criticized and it became clear that many of the personalities
presented by patients had been suggested by the clinicians. There has been a
reaction and now many researchers doubt that DID even exists. Others think it
is more common than believed earlier.
Clinical
Description
___________________________________________________________
DSM-IV Criteria for Dissociative Identity
Disorder
A.
The presence of two or more identities or personality states (each with
its own relatively enduring pattern of perceiving, relating to, or thinking
about the environment and self).
B. At least two of these identities or personality
states recurrently take control of the person's behavior.
C. Inability to recall personal information
that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due another disorder,
Source: DSM-IV,
APA, 1994.
____________________________________________________________
Characteristics
The first question is what is the host
identity? Who is the original person? What is this person like? Personality? Intelligence? Experiences?
Quite often the person with DID is
described as impulsive, quickly shifting interests or goals.
Another major question is how does
the person switch from one ego to another. Is it really any different from the
way an actress shifts from her home identity to the role she plays on stage or
in a movie? When we saw Helen Hunt in
the movie "What women want" was this the "real" Helen Hunt,
or was she playing a role? She played a role and got paid for it. Is the
switching of the person with DID any different? This issue has not been
resolved.
So, is the behavior real or fake?
Possibly a bit of both. It is possible to be caught up in playing a role. It
becomes real. In fact, however, I do
not know the answer to this question, and I have not seen much research on the
matter.
One problem is that DID seems to
occur in people who are very suggestible. A careless therapist may be assisting
in the creation of multiple identities.
The case of
Sybil was regarded as a valid case of
DID, a book was written and a movie made that was often shown in abnormal
psychology classes. Then, the case was shown to be a fraud. Nevertheless, 40%
of psychology teachers surveyed still regard the case as valid and continued to
use the movie.
A survey of American
psychiatrists found that 67% had serious reservations abou the diagnosis.
Psychiatrists in Israel were also skeptical.
Etiology
Several studies have
reported on the life histories of people with DID. Almost all of the cases were
women. Nearly all reported having been sexually abused by age 5 and nearly all
had developed an ability to retreat into phantasy or trance states. DID does
seem to be a kind of post-traumatic stress disorder. It should be noted that
all of these studies were retrospective case studies. The reported abuse may
not have happened, but may be part of the dramatic role presentation of the
person with DID.
Treatment
The goal of treatment is to bring
the diverse personalities together into one. Many different types of therapies
have been tried, but there have been no controlled treatment trials with
adequate samples,and there is only one follow-up. One study (Coons, 2001, Journal
of Trauma and Dissociation, 2, 73-89) followed25 patients for 10 years.
They had all been in treatment. 12
patients provided follow-up data. 6 had achieved full integration of their
personality states, but 2 of them relapsed into DID. Teen-age patients did
better than older patients. All of the patients reported improvement. Of course, nothing is known about the 13
patients who did not report on their experiences.
True Memories and False
The section on this topic in the
textbook is important and you should read it carefully.
Memory does not exist like the bytes
on a computer hard drive. Human memory is always dynamic. We create our
remembered history as we go along. We also discover our history through the
recollections of others (which are no more accurate) and through such objective
records as photos and home movies. I recall having a distinct recollection of
being with father in some woods along the Missouri river when I was about 4
years of age. Later, while looking through a neglected family photo album, I
saw a picture of me at age 4 with my father in the woods. I remembered the
photo having seen it many times as a child, but I did not remember the actual
event.
Careless and unskilled therapists
have created "memories" in clients who they were treating. As it has
been fashionable to look for signs of child abuse in troubled adults, these
therapist suggested that there was child abuse, and some of their clients then
discovered that they had been abused (even though they had not). A problem is
that objective evidence is nearly always lacking. This is not to say that we
cannot recall events from our childhoods, traumatic and non-traumatic, but it
is certain that we do not have a tape-recorder memory of the events. They are
always contructed to some degree.
Most research now shows that
traumatic events are recalled. They are not repressed and hidden from conscious
awareness.
Doesn't the therapist have to help
the client recover memories that are distressing? The answer is "yes"
if you subscribe to a psychodynamic theory of therapy. It is "no" if
your allegiance is with the cognitive-behavioral approach. In the latter, it is
what is happening now that is of most importance.