Chapter 6- Somatic Symptom AND Related diagnostic system in 1980 because it was too vague,

applying to almost all nonpsychotic disorders, and because

Disorders and Dissociative Disorders
it implied a specific but unproven cause for these disorders.

“Do you know somebody who’s a hypochondriac?

SOMATIC SYMPTOM AND RELATEDISORDERS
Most of us do. Maybe it’s you! The popular image of
I. SOMATIC SYMPTOM DISORDER
this condition, now called more accurately illness
“In 1859, Pierre Briquet, a French physician, described
anxiety disorder”.
patients who came to see him with seemingly endless
lists of somatic complaints for
Illness anxiety disorder-someone who
which he could find no medical basis. Despite his
exaggerates the slightest physical symptom.
negative findings, patients returned shortly with
-is characterized by high anxiety about one’s health,
either the same complaints or new lists containing
by excessive preoccupation with having an illness or
slight variations.”
acquiring it, and by behaviors associated with the
presumed or feared condition (e.g., repeatedly
“For many years, this disorder was called
checking oneself for possible signs of illness), yet with
Briquet’s syndrome, but now would be
no significant somatic symptoms that would warrant
considered somatic symptom disorder.
such concern.
CASE OF LINDA…FULL-TIME PATIENT
Linda, an intelligent woman in her 30s, came to our
“Their problems fall under the general heading of
clinic looking distressed and pained. As she sat down she
somatic symptom disorders”. noted that coming into the office was difficult for her
Soma=means body, and the problems preoccupying because she had trouble breathing and considerable
these people seem, initially, to be physical disorders. swelling in the joints of her legs and arms. She was also in
Explanation: (Somatic Symptom Disorders) What the some pain from chronic urinary tract infections and might
somatic symptom disorders have in common is that there is have to leave at any moment to go to the restroom, but
an excessive or maladaptive response to physical symptoms she was extremely happy she had kept the appointment.
or to associated health concerns. These disorders are At least she was seeing someone who could help alleviate
sometimes grouped under the shorthand label of medically her considerable suffering. She said she knew we would
unexplained physical symptoms have to go through a detailed initial interview, but she had
Dissociation/Dissociative experiences during these something that might save time. At this point, she pulled
experiences, some people feel as if they are dreaming. out several sheets of paper and handed them over. One
-mild sensations that most people experience section, some five pages long, described her contacts with
occasionally are slight alterations, or detachments, in the health-care system for major difficulties only. Times,
dates, potential diagnoses, and days hospitalized were
consciousness or identity.
noted. The second section, one-and-a-half single-spaced
-partial or total disconnection between memories of
pages, consisted of a list of all medications she had taken
the past, awareness of identity and of immediate
for various complaints.
sensations, and control of bodily movements, often
resulting from traumatic experiences, intolerable Clinical Description
problems, or disturbed relationships. -People with somatic symptom disorder do not always
feel the urgency to take action but continually feel
“Somatic symptom and dissociative disorders weak and ill, and they avoid exercising, thinking it will
used to be categorized under one general heading, make them worse.
hysterical neurosis.” -Another common example of a somatic symptom
Explanation: (Why separate Somatic Symptom disorder would be the experience of severe pain in
Disorder and Dissociative Disorders) The term neurosis, as which psychological factors play a major role in
defined in psychoanalytic theory, suggested a specific cause
maintaining or exacerbating the pain whether there is
for certain disorders. Specifically, neurotic disorders
a clear physical reason for the pain or not.
resulted from underlying unconscious conflicts, anxiety that
resulted -Once again, the important factor in this condition is
from those conflicts, and the implementation of ego not whether the physical symptom, in this case pain,
defense mechanisms. Neurosis was eliminated from the has a clear medical cause or not, but rather that
psychological or behavioral factors, particularly Severe: Two or more of the symptoms specified in
anxiety and distress, are compounding the severity Criterion B are fulfilled, plus there are multiple somatic
and impairment associated with the physical complaints (or one very severe somatic symptom).
symptoms. CASE OF GAIL…INVISIBLY ILL
Gail was married at 21 and looked forward to a new life. As
-But an important feature of these physical
one of many children in a lower-middle-class household,
symptoms, such as pain, is that it is real and it hurts
she felt weak and somewhat neglected and suffered from
whether there are clear physical reasons for pain or
low self-esteem. An older stepbrother berated and belittled
not. her when he was drunk. Her mother and stepfather refused
II. ILLNESS ANXIETY DISORDER to listen to her or believe her complaints. But she believed
Linda felt she had any one of a number of chronic infections that marriage would solve everything; she was finally
that nobody could properly diagnose. She had begun to someone special. Unfortunately, it didn’t work out that
have these problems in her teenage years. She often way. She soon
discussed her symptoms and fears with doctors and clergy. discovered her husband was continuing an affair with an
Drawn to hospitals and medical clinics, she had entered old girlfriend. Three years after her wedding, Gail came to
nursing school after high school. During hospital training, our clinic complaining of anxiety and stress. She was
however, she noticed her physical condition deteriorating working part time as a waitress and found her job
rapidly: she seemed to pick up the diseases she was extremely stressful.
learning about. A series of stressful emotional events Although to the best of her knowledge her husband had
resulted in her leaving nursing school. After developing stopped seeing his former girlfriend, she had trouble
unexplained paralysis in her legs, Linda was admitted to a getting the affair out of her mind. Although Gail complained
psychiatric hospital, and after a initially of anxiety and stress, it soon became clear that her
year she regained her ability to walk. On discharge she major concerns were about her health. Any time she
obtained disability status, which freed her from having to experienced minor physical symptoms such as
work full time, and she volunteered at the local hospital. breathlessness or a headache, she was afraid she had a
With her chronic but fluctuating incapacitation, on some serious illness. A headache indicated a brain tumor.
days she could go in and on some days she could not. She Breathlessness was an impending heart attack. Other
was currently seeing a family practitioner and six sensations were quickly elaborated into the possibility of
specialists, who monitored various aspects of her physical AIDS or cancer. Gail was afraid to go
condition. She was also seeing two ministers for pastoral
counseling. Clinical Description
-was formerly known as “hypochondriasis”
DSM 5 CRITERIA: SOMATIC SYMPTOM DISORDER -physical symptoms are either not experienced at the
A. One or more somatic symptoms that are distressing present time or are very mild, but severe anxiety is
and/or result in significant disruption of daily life. focused on the possibility of having or developing a
B. Excessive thoughts, feelings, and behaviors related to serious disease.
the somatic symptoms or associated health concerns as
-concern is primarily with the idea of being sick
manifested by at least one of the following:
instead of the physical symptom itself.
1. Disproportionate and persistent thoughts about the
Example:
seriousness of one’s symptoms.
Individuals with these disorders almost always go initially to
2. High level of health-related anxiety.
family physicians. They come to the attention of mental
3. Excessive time and energy devoted to these symptoms or
health professionals only after family physicians have ruled
health concerns.
out realistic medical conditions as a cause of the patient’s
C. Although any one symptom may not be continuously
symptoms
present, the state of being symptomatic is persistent
(typically more than 6 months).
Specify if:
With predominant pain (previously pain disorder): This
specifier is for individuals whose somatic complaints Difference and Similarities between Somatic
predominantly involve pain.
Symptom Disorder & Illness Anxiety Disorder
Specify current severity:
Mild: Only one of the symptoms in Criterion B is fulfilled. “Gail was somewhat less concerned with any specific
Moderate: Two or more of the symptoms specified in physical symptom and more worried about the idea
Criterion B are fulfilled.
that she was either ill or developing an illness, Gail’s B. Somatic symptoms are not present or, if present, are
problems are fairly typical of illness anxiety disorder.” only mild in intensity. If another medical condition is
“Somatic symptom disorder and illness anxiety present or there is a high risk for developing a medical
condition (e.g., strong family history is present), the
disorder are characterized by anxiety or fear that one
preoccupation is clearly excessive or disproportionate.
has a serious disease. Therefore, the essential
C. There is a high level of anxiety about health, and the
problem is anxiety, but its expression is different from
individual is easily alarmed about personal health status.
that of the other anxiety disorders.” D. The individual performs excessive health-related
“Another important feature of these disorders(SSD behaviors (e.g., repeatedly checks his or her body for signs
and IAD) is that reassurances from numerous doctors of illness) or exhibits maladaptive avoidance (e.g., avoids
that all is well and the individual is healthy have, at doctors’ appointments and hospitals).
best, only a short term effect. It isn’t long before E. Illness preoccupation has been present for at least
patients like Gail or Linda are back in the office of 6months, but the specific illness that is feared may change
another doctor over that period of time.
F. The illness-related preoccupation is not better
on the assumption that the previous doctors have
explained by another mental disorder, such as
missed something. This is because many of these
somatic symptom disorder, generalized anxiety
individuals have disease conviction.” disorder, or obsessive-compulsive disorder.
Disease conviction- difficult-to-shake belief Specify whether:
that they have a disease. “Therefore, along with Care-seeking type: Medical care, including physician visits
anxiety focused on the possibility of disease or illness, or undergoing tests and procedures, is frequently used.
disease Care-avoidant type: Medical care is rarely used.
conviction is a core feature of both disorders.”
to sleep at night for fear that she would stop breathing. Difference between Somatic Symptom
She avoided exercise, drinking, and even laughing because Disorders and Panic Disorder
the resulting sensations upset her. Public restrooms and, >Panic Disorder= typically fear immediate symptom-
on occasion, public telephones were feared as sources of related catastrophes that may occur during the few
infection. The major trigger of uncontrollable anxiety and minutes they are having a panic attack, and these
fear
concerns lessen between attacks.
was the news in the newspaper and on television. Each
>Somatic Symptom Disorder= focus on a long term
time an article or show appeared on the “disease of the
process of illness and disease (for example, cancer or
month,” Gail found herself irresistibly drawn into it, intently
noting symptoms that were part of the disease. For days AIDS). Patients with these disorders also continue to
afterward she was vigilant, looking for the symptoms in seek the opinions of additional doctors in an attempt
herself and others and often noticing some physical to rule out (or perhaps confirm) disease and are more
sensations that she would interpret as the beginnings of the likely to demand unnecessary medical treatments.
disease. She even watched her dog Statistics
closely to see whether he was coming down with the *As with anxiety disorders, culture-specific
dreaded disease. Only with great effort could she dismiss
syndromes seem to fit comfortably with somatic
these thoughts after several days. Real illness in a friend
symptom disorders:
or relative would incapacitate her for days at a time.
Gail’s fears developed during the first year of her
Koro-there is the belief, accompanied by severe
marriage, around the time she learned of her husband’s anxiety and sometimes panic, that the genitals are
affair. At first, she spent a great deal of time and more retracting into the abdomen.
money than they could afford going to doctors. Over the -most victims of this disorder are Chinese males,
years, she heard the same thing during each visit: “There’s although it is also reported in females.
nothing wrong with you; you’re perfectly healthy.” Finally, Dhat-an anxious concern about losing semen.
she stopped going, as she became convinced her concerns -associated with a vague mix of physical symptoms,
were excessive, but her fears did not go away and she was
including dizziness, weakness, and fatigue.
chronically miserable.
-is prevalent in India.
DSM 5 CRITERIA: ILLNESS ANXIETY DISORDER
Causes
A. Preoccupation with fears of having or acquiring a serious
illness. *Integrative Model of causes of Somatic
Symptom Disorder and Illness Anxiety Disorder:
*Three other factors may contribute to this etiological Clinical Description
process: -generally have to do with physical malfunctioning,
1. These disorders seem to develop in the context of a such as paralysis, blindness, or difficulty speaking
stressful life event (aphonia), without any physical or organic pathology
2. These disorders seem to develop in the context of a to account for the malfunction.
stressful life event -Most conversion symptoms suggest that some kind
3. An important social and interpersonal of neurological disease is affecting sensory– motor
influence may be involved “The benefits of being sick systems, although conversion symptoms can mimic
might contribute to the development of the disorder the full range of physical malfunctioning.
in some people. A sick person who receives increased -In addition to blindness, paralysis, and aphonia,
attention for being ill and is able to avoid work or conversion symptoms may include total mutism and
other responsibilities is described as adopting a sick the loss of the sense of touch.
role.” -Another relatively common symptom is globus
Treatment hystericus.
“Unfortunately, relatively little is known Aphonia-loss of the voice resulting from damage to
about treating these disorders. Although it was the vocal tract.
common clinical practice in the past to uncover Mutisim-refusal or inability to speak although the
unconscious conflicts through psychodynamic organs of speech are undamaged.
psychotherapy, results on the effectiveness of this -also called aphrasia
kind of treatment have seldom been reported.” Globus hystericus- sensation of a lump in the throat
Explanatory therapy-includes a number of that makes it difficult to swallow, eat, or sometimes
interventions intended to persuade the patient there talk.
is nothing wrong with his/her physical health. CASE OF ELOISE…UNLEARNING WALKING
Cognitive-behavioral treatment (CBT Eloise sat on a chair with her legs under her, refusing to put
Paxil (Paxil) her feet on the floor. Her mother sat close by, ready to
assist her if she needed to move or get up. Her mother had
III. PSYCHOLOGICAL FACTORS AFFECTING made the appointment and, with the help of a friend, had
MEDICAL CONDITION all but carried Eloise into the office. Eloise was a 20- year-
old of borderline intelligence who was friendly and
-essential feature of this disorder is the presence of a
personable during the initial interview and who readily
diagnosed medical condition such as asthma,
answered all questions with a big smile. She obviously
diabetes, or severe pain clearly caused by a known enjoyed the social interaction. Eloise’s difficulty walking
medical condition such as cancer that is adversely developed over 5 years. Her right leg had given way and she
affected (increased in frequency or severity) by one or began falling. Gradually, the condition worsened to the
more psychological or behavioral factors. These point that 6 months before her admission to the hospital
behavioral or psychological factors would have a Eloise could move around only by crawling on the floor.
direct influence on the course or perhaps the Physical examinations revealed no physical problems. Eloise
treatment of the medical condition. presented with a classic case of conversion disorder.
Example: Although she was not paralyzed, her specific symptoms
Anxiety severe enough to clearly worsen an asthmatic included weakness in her legs and difficulty keeping her
condition. Another example would be a patient with balance, with the result that she fell often. This particular
diabetes who is in denial about the need to regularly check type of conversion symptom is called astasia-abasia. Eloise
insulin levels and intervene when necessary lived with her mother, who ran a
DSM 5 CRITERIA: CONVERSION DISORDER
IV. CONVERSION DISORDER (FUNCTIONAL
(FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER)
NEUROLOGICAL DISORDER
A. One or more symptoms of altered voluntary motor or
Conversion- popularized by Freud, who believed the sensory function.
anxiety resulting from unconscious conflicts somehow B. Clinical findings provide evidence of incompatibility
was “converted” into physical symptoms to find between the symptom and recognized neurological or
expression. medical conditions.
Functional-refers to a symptom without an organic C. The symptom or deficit is not better explained by
cause. another medical or mental disorder.
D. The symptom or deficit causes clinically significant Factitious disorder imposed on another known
distress or impairment in social, occupational, or other previously as Munchausen syndrome by proxy.
important areas of functioning or warrants medical -when an individual deliberately makes someone else
evaluation. gift shop in the front of her house in a small
sick.
rural town. Eloise had been schooled through special
-In any case, it is really an atypical form of child abuse.
education programs until she was about 15; after this, no
Example:
further programs were available. When Eloise began
The offending parent may resort to extreme tactics to
staying home, her walking began to deteriorate
create the appearance of illness in the child, one mother
stirred her child’s urine specimen with a vaginal tampon
Closely Related Disorders
obtained during menstruation. Another mother mixed feces
“Distinguishing among conversion reactions, real
into her child’s vomit. Because the mother typically
physical disorders, and outright malingering establishes a positive relationship with a medical staff, the
(faking) is sometimes difficult. Several factors can true nature of the illness is most often unsuspected and the
help, but one symptom, widely regarded as a staff members perceive the parent as remarkably caring,
diagnostic sign, has proved not to be useful.” cooperative,
“It was long thought that patients with conversion and involved in providing for her child’s wellbeing.
reactions had the same quality of indifference to the Therefore, the mother is often successful at eluding
symptoms thought to be present in some people with suspicion
severe somatic symptom disorder.” Causes
La belle indifference-this attitude was considered a *Freud described 4 basic processes in the
hallmark of conversion reactions, but, unfortunately, development of conversion disorder:
this turns out not to be the case. 1. The individual experiences a traumatic event— in
-an abnormal lack of concern about one's afflictions or Freud’s view, an unacceptable, unconscious conflict.
disabilities, characteristic of some conversion 2. Since the conflict and the resulting anxiety are
disorders. unacceptable, the person represses the conflict,
-Conversion symptoms often seem to be precipitated making it unconscious.
by marked stress. Often this stress takes the form of a 3. The anxiety continues to increase and threatens to
physical injury. emerge into consciousness, and the person “converts”
-Although people with conversion symptoms can it into physical symptoms, thereby relieving the
usually function normally, they seem truly unaware pressure of having to deal directly.
either of this ability or of sensory input. DSM 5 CRITERIA: FACTITIOUS DISORDER
Example: A. Falsification of physical or psychological signs or
Individuals with the conversion symptom of blindness can symptoms, or induction of injury or disease, associated with
usually avoid objects in their visual field, but they will tell identified deception.
you they can’t see the objects. Similarly, individuals with B. The individual presents himself or herself to others as ill,
conversion symptoms of paralysis of the legs might impaired or injured.
suddenly get up and run in an emergency and then be C. The deceptive behavior is evident even in the absence of
astounded they were able to do this. It is possible that at obvious external rewards.
least some people who experience miraculous cures during D. The behavior is not better accounted for by another
religious ceremonies may have been suffering from mental disorder such as delusional belief system or acute
conversion reactions psychosis.
Specify if:
Single episode
V. FACTITIOUS DISORDERS
Recurrent episodes: Two or more events of falsification of
Clinical Description illness and/or induction of injury.
-fall somewhere between malingering and conversion
disorders. Primary gain-reduction of anxiety.
-the symptoms are under voluntary control, as with -reinforcing event that maintains the
malingering, but there is no obvious reason conversion symptom.
or voluntarily producing the symptoms except, 4. The individual receives greatly increased
possibly, to assume the sick role and receive increased attention and sympathy from loved ones and may
attention. also be allowed to avoid a difficult situation or
task a.Depersonalization-an episode wherein your
Secondary gain-Freud consider this perception alters so that you temporarily lose the
attention as this. sense of your own reality, as if you were in a dream
-secondarily reinforcing set of events. and you were watching yourself.
“We believe Freud was basically correct on at b.Derealization-an episode wherein your sense of
least three counts but probably not on the fourth, the reality of the external world is lost. Things may
although firm evidence supporting any of these seem to change shape or size; people may seem dead
ideas is sparse and Freud’s views were far more or mechanical.
complex than represented here.” -an experience or perception of the external world as
Treatment unreal, strange, or alien, as if it were a stage on which
-A principal strategy in treating conversion people were acting.
disorder is to identify and attend to the traumatic “These sensations of unreality are characteristic of the
or stressful life event, if it is still present (either in dissociative disorders because, in a sense, they are a
real life or in memory). As in the case of Anna O., psychological mechanism whereby one dissociates
therapeutic assistance in reexperiencing or from reality.”
“reliving” the event (catharsis) is a reasonable first I. DEPERSONALIZATION - DEREALIZATION
step. DISORDER
-The therapist must also work hard to reduce any CASE OF BONNIE…DANCING AWAY FROM HERSELF
reinforcing or supportive consequences of the Bonnie, a dance teacher in her late 20s, was accompanied
conversion symptoms (secondary gain). by her husband when she first visited the clinic and
DISSOCIATIVE DISORDERS complained of “flipping out.” When asked what she meant,
she said, “It’s the scariest thing in the world. It often
“When individuals feel detached from themselves or
happens when I’m teaching my modern dance class. I’ll be
their surroundings, almost as if they are dreaming or
up in front and I will feel focused on. Then, as I’m
living in slow motion, they are having dissociative demonstrating the steps, I just feel like it’s not really me
experiences.” and that I don’t really have control of my legs. Sometimes I
Example: feel like I’m standing in back of myself just watching. Also I
CASE: Investigators at Stanford University surveyed the get tunnel vision. It seems like I can only see in a narrow
reactions of journalists who witnessed one of the first space right in front of me and I just get totally separated
executions in California in many decades, a traumatic from what’s going on around me. Then I begin to panic and
experience for many. The prisoner, Robert Alton Harris, had perspire and shake.” It turns out that Bonnie’s problems
been found guilty of the particularly brutal murder of two began after she smoked marijuana for the first time about
16-year-old boys. As is customary, a number of journalists 10 years before. She had the same feeling then and found it
were invited to witness the execution. Because there were a scary, but with the help of friends she got through it. Lately
number of stays of execution, they ended up spending all the feeling recurred more often and more severely,
night at the prison as Harris was repeatedly led into and particularly when she was teaching dance class.
back out of the gas chamber before he was finally executed
near daybreak.
OUTCOME: Several weeks later, the journalists filled out Clinical Description
acute stress reaction questionnaires. Between 40% and 60% -feelings of unreality are so severe and
of the journalists experienced several dissociative frightening that they dominate an individual’s life
symptoms. For example, during the execution, things and prevent normal functioning.
around them seemed unreal or dreamlike and they felt time
-feelings of depersonalization and derealization
had stopped. They also felt estranged from other people
are part of several disorders. But when severe
and distant from their
own emotions; a number of them felt they were strangers
depersonalization and derealization are the
to themselves. The fact that the journalists were sleep primary problem, the individual meets criteria for
deprived from staying up all night undoubtedly contributed depersonalization-derealization disorder.
to these dissociative feelings. -marked by the presence of persistent and
*These kinds of experiences can be divided into 2 recurrent episodes of depersonalization,
types: derealization, or both.
II. DISSOCIATIVE AMNESIA
Clinical Description cycle in the coming months. Although we did not treat this
-lack of conscious access to memory, typically of family (they lived too far away), the situation resolved
itself when the children moved away and the stress
a stressful experience. The dissociative fugue
decreased.
subtype involves loss of memory for one’s entire
DSM 5 CRITERIA: DISSOCIATIVE AMNESIA
past or identity.
A. An inability to recall important autobiographical
-includes several patterns. People who are
information, usually of a traumatic or stressful
unable to remember anything, including who nature, that is inconsistent with ordinary forgetting.
they are, are said to suffer from generalized Note: Dissociative amnesia most often consists of
amnesia. localized or selective amnesia for a specific event or
-far more common than general amnesia is events; or generalized amnesia for identity and life
localized/selective amnesia. history.
DSM 5 CRITERIA: DEPERSONALIZATION- B. The symptoms cause clinically significant distress or
DEREALIZATION DISORDER impairment in social, occupational, or other important
A. The presence of persistent or recurrent experiences areas of functioning.
of depersonalization, derealization, or both: C. The disturbance is not attributable to the physiological
Depersonalization: Experiences of unreality, detachment, effects of a substance (e.g., alcohol or other drug of abuse,
or being an outside observer with respect to one’s a medication) or a neurological or other medical condition
thoughts, feelings, sensations, body (e.g., partial complex seizures, transient global amnesia,
or actions (e.g., perceptual alterations, distorted sense of sequelae of a
time, unreal or absent self, emotional and/or physical closed head injury/traumatic brain injury, or other
numbing). neurological condition).
Derealization: Experiences of unreality or detachment with D. The disturbance is not better explained by dissociative
respect to surroundings (e.g., individuals or objects are identity disorder, posttraumatic stress disorder, acute
experienced as unreal, dreamlike, foggy, lifeless, or visually stress disorder, somatic symptom disorder, or major or mild
distorted). neurocognitive disorder.
B. During the depersonalization or derealization experience, Specify if:
reality testing remains intact. With dissociative fugue: Apparently purposeful travel or
C. The symptoms cause clinically significant distress or bewildered wandering that is associated with amnesia for
impairment in social, occupational, or other important identity or for other important autobiographical
areas of functioning. information.
D. The disturbance is not attributable to the physiological -seldom appears before adolescence and usually
effects of a substance (e.g., a drug of abuse, medication) or occurs in adulthood.
another medical condition (e.g., seizures). -is the most prevalent of all the dissociative disorders.
E. The disturbance is not better explained by another Dissociative fugue – an individual suddenly
mental disorder, such as schizophrenia or panic disorder. and unexpectedly travels away from home or a
THE WOMAN WHO LOST HER MEMORY customary place of daily activities and is unable to
Several years ago, a woman in her early 50s brought recall some or all of his or her past.
her daughter to one of our clinics because of the girl’s -symptoms also include either confusion about
refusal to attend school and other severely disruptive
personal identity or assumption of a new identity.
behavior. The father, who refused to come to the session,
-no other signs of mental disorder are present, and
was quarrelsome, a heavy drinker, and, on occasion,
the fugue state can last from hours to months.
abusive. The girl’s brother, now in his mid-20s, lived at
home and was a burden on the family. Several times a -fugue states usually end rather abruptly, and the
week a major battle erupted, complete with shouting, individual returns home, recalling most, if not all, of
pushing, and shoving, as each member of the family what happened.
blamed the others for all their problems. The mother, a Localized/Selective amnesia - a failure to recall
blamed the others for all their problems. The mother, a specific events, usually traumatic, that occur during a
strong woman, was clearly the peacemaker responsible specific period.
for holding the family together. Approximately every 6 -the forgetting of particular issues, people, or events
months, usually after a family battle, the mother lost her
that is too extensive to be explained by normal
memory and the family had her admitted to the hospital.
forgetfulness and that is posited to be organized
After a few days away from the turmoil, the mother
regained her memory and went home, only to repeat the
according to emotional, rather than temporal, escaped by swimming a quarter of a mile upstream. He
parameters. woke up the next morning in his own bed, soaking wet,
“An apparently distinct dissociative state not found in with no memory of the incident.
Western cultures is called amok (as in running
amok).” Clinical Description
Amok - individuals in this trancelike state often -may adopt as many as 100 new identities, all
brutally assault and sometimes kill people or animals. simultaneously coexisting, although the average
If the person is not killed himself, he probably will not number is closer to 15.
remember the episode. -defining feature of this disorder is that certain
Running Amok - is only one of a number of “running” aspects of the person’s identity are dissociated.
syndromes in which an individual enters a trancelike -in the case of Jonah, the staff distinguished 3 alters.
state and suddenly, imbued with a mysterious source Alters - shorthand term for the different identities or
of energy, runs or flees for a long time. personalities in DID.
“The running disorder has different names in various -in some cases, the identities are complete, each with
cultures.” its own behavior, tone of voice, and physical gestures.
>Artic=Pivloktoq But in many cases, only a few characteristics are
>Navajo=Frenzy witchcraft distinct, because the identities are only partially
“Dissociative disorders differ in important ways across independent, so it is not true that there are “multiple”
cultures.” complete personalities.
>India & Nigeria=Vinvusa “Therefore, the name of the disorder was changed in
>Thailand=Phii pob the last edition of the DSM, DSM-IV, from multiple
>Bahamians & African Americans from the personality disorder to DID.”
South=“Falling out” Characteristics
Dissociative trance - when the state is undesirable “The person who becomes the patient and asks for
and considered pathological by members of the treatment is usually a “host” identity. The first
culture, particularly if the trance involves a perception personality to seek treatment is seldom the original
of being possessed by an evil spirit or another person, personality of the person. Usually, the host
the individual would be diagnosed with an “other personality develops later.”
specified dissociative disorder." Host personalities = usually attempt to hold various
fragments of identity together but end up being
III. DISSOCIATIVE IDENTITY DISORDER overwhelmed.
CASE OF JONAH…BEWILDERING BLACKOUTS “Many patients have at least one impulsive alter who
Jonah, 27 years old and black, suffered from severe handles sexuality and generates income, sometimes
headaches that were unbearably painful and lasted by acting as a prostitute. In other cases, all alters may
increasingly longer periods. Furthermore, he couldn’t abstain from sex. Cross-gendered alters are not
remember things that happened while he had a headache, uncommon.”
except that sometimes a great deal of time passed. Finally, Example:
after a particularly bad night, when he could stand it no A small agile woman might have a strong powerful male
longer, he arranged for admission to the local hospital. alter who serves as a protector
What prompted Jonah to come to the hospital, however, “The transition from one personality to another is
was that other people told him what he did during his called a switch.”
severe headaches. For example, he was told that the night
Switch - is instantaneous (although in movies and on
before he had a violent fight with another man and
television it is often drawn out for dramatic effect).
attempted to stab him. He fled the scene and was shot at
during a high-speed chase by the police. His wife told him -physical transformations may occur. Posture, facial
that during a previous headache he chased her and his 3- expressions, patterns of facial wrinkling, and even
year-old daughter out of the house, threatening them with physical disabilities may emerge.
a butcher knife. During his headaches, and while he was Statistics
violent, he called himself -average number of alter personalities is reported by
“Usoffa Abdulla, son of Omega.” Once he attempted to clinicians as closer to 15.
drown a man in a river. The man survived, and Jonah
-onset is almost always in childhood, often as young the ability to lead a rich fantasy life, which can be
as 4 years of age, although it is usually approximately helpful and adaptive. But it also seems to
7 years after the appearance of symptoms before the correlate with being suggestible or easily
disorder is identified. hypnotized (some people equate the terms
-disorder tends to last a lifetime in the absence of suggestibility and hypnotizability).”
treatment. “People in a trance tend to be focused on one aspect
-frequency of switching decreases with age. of their world, and they become vulnerable to
Causes suggestions by the hypnotist. There is also the
-almost every patient presenting with this disorder phenomenon of self-hypnosis.”
reports to their mental health professional being Self-hypnosis – individuals can dissociate from most
horribly, often unspeakably, abused as a child. Most of the world around them and “suggest” to
surveys report a high rate of childhood trauma in themselves that, for example, they won’t feel pain in
cases of DID. one of their hands.
-however, not all the trauma is caused by abuse. Autohypnotic model - people who are suggestible
-such observations have led to wide-ranging may be able to use dissociation as a defense against
agreement that DID is rooted in a natural tendency to extreme trauma.
escape or “dissociate” from the -according to this model, when the trauma becomes
unbearable, the person’s very identity splits into
DSM 5 CRITERIA: DISSOCIATIVE IDENTITY multiple dissociated identities. Children’s ability to
DISORDER distinguish clearly between reality and fantasy as they
A. Disruption of identity characterized by two or more grow older may be what closes the developmental
distinct personality states, which may be described in some window for developing DID at approximately age 9.
cultures as an experience of possession. The disruption of People who are less suggestible may develop a severe
marked discontinuity in sense of self and sense of agency, posttraumatic stress reaction but not a dissociative
accompanied by related alterations in affect, behavior, reaction.
consciousness, memory, perception, cognition, and/or
Treatment
sensorymotor functioning. These signs and symptoms may
be observed by others or reported by the individual. >Dissociative amnesia & Dissociative Fugue
B. Recurrent gaps in the recall of everyday events, -therapeutic resolution of the distressing situations
important personal information, and/or traumatic events and increasing the strength of personal
that are inconsistent with ordinary forgetting. coping mechanisms.
C. The symptoms cause clinically significant distress or -hypnosis
impairment in social, occupational, or other important -benzodiazepines
areas of functioning. >Dissociative Identity Disorder (DID)
D. The disturbance is not a normal part of a broadly
“For DID, however, the process is not so easy. With
accepted cultural or religious practice. Note: In
the person’s very identity shattered into many
children, the symptoms are not attributable to
elements, reintegrating the personality might seem
imaginary playmates or other fantasy play.
E. The symptoms are not attributable to the hopeless.”
physiological effects of a substance (e.g., blackouts or -long term psychotherapy with hypnosis
lOMoARcPSD|23754914

chaotic behavior during alcohol intoxication) or

another medical condition (e.g., complex partial
seizures). unremitting negative affect associated with
severe abuse.
-individual experience and personality factors also
contributed to dissociative experiences.
Suggestibility
-is a personality trait distributed normally across the
population, much like weight and height.
“Did you ever have an imaginary childhood
playmate? Many people did, and it is one sign of