Somatic, Dissociative, and Factitious Disorders  

What is an example of dissociative personality disorder?

Dissociative Personality Disorder

∙ Alana is a licensed clinical therapy  

∙ Lyn is shy and has trouble saying her Ls  

∙ Connie is a little girl who really likes bugs

∙ Heather is a teenager trying really hard to be adult  ∙ Lea was designated to the abuse

∙ All of these personalities exist within the same body  ∙ This personality has splintered into many pieces due to severe  trauma

∙ This is an example of Dissociative Personality Disorder ∙ This disorder can be described as a split mirror

∙ This is often confused with schizophrenia and multiple  personality disorder

What is mutually cognizant?

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∙ Some of the personalities retain memories that others do not ∙ Some of these personalities can be so compartmentalized that the  core personality does not know it exists  

∙ This disorder effects self identity, memory, and consciousness  ∙ These types of disorders are categorized by the person’s memory  splitting off, since the person disassociates in these

∙ An example of this disorder in the media is The 3 Faces of Eve Case of DID

∙ The patient had been going to treatment for 2 years ∙ She is the head of a company, and has 2 children

∙ She’s always well dressed at the meetings

∙ She was always very timid  

What is the most prominent type of dissociative amnesia?

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∙ All the women who attended the meetings were survivors of incest ∙ Her parents died, so she went to live with her grandparents  o His grandfather constantly sexually abused her throughout  her life, starting when she was 8  

∙ She felt as though she couldn’t escape the abuse from her  grandfather  

∙ She married her neighbor, who was friends with her grandfather,  who sexually abused her as well  

∙ Many abuse survivors suffer from anger issues  

∙ The patient struggled with the section on learning how to accept her anger, and she ended up being retraumatized  

∙ This caused her personality to fragment

∙ She showed up at the next meeting dressed in all pink (very  sexually), riding on a pink Harley  

∙ The next meeting she showed up with bags and bags of food  for the group  

∙ One week she showed up wearing all denim and opened her  backpack, which was full of puppies  

∙ The fact that the patient was a parent worried the therapists ∙ The patient would lose whole days that she couldn’t remember  ∙ This happens because not all of the personalities are aware of  the switch  We also discuss several other topics like What are the 2 stages of photosynthesis?

∙ There are people in the psychological field that don’t believe in this  disorder

∙ The psychologist is obligated to tell their patient if they have a  dissociative personality disorder  

∙ Patients are taught coping mechanisms for when they do begin to  feel anxious and disassociate, to bring them back to reality

∙ From a physiological perspective, focusing on something else  can help their heart rate lower, causing their anxiety to lesson ∙ They have to be taught about what triggers their dissociative  disorder, and how to calm down and deal with those triggers ∙ It is encouraged that the same personality attends therapy  ∙ In order to be diagnosed with DID, a person must have 2 or more  distinct personalities  

∙ The personalities, or alters, have distinct emotions, behaviors, and speech patters

∙ The alters can take over whenever, but there is a core  personality (this taking over is called Switching)  

∙ This disorder is rare, but it usually is diagnosed in children after  abuse We also discuss several other topics like Who is zits?

∙ 3 times more commonly in women than men  

∙ The alters can have different types of relationships, these are… ∙ Mutually amnesiac – there is no awareness of the alters to  each other  

∙ Mutually cognizant – the alters are well aware of each other  ∙ One way amnesiac – some alters are aware of some other  alters, but they aren’t all aware of each others  Don't forget about the age old question of What do parents and clinicians notice?

∙ Coconscious Alter – they can be a quiet observer, but they may  never be seen  

∙ Sometimes alters can create an awareness of themselves through  indirect means – this can be done through auditory hallucinations,  or involuntary writing  

∙ These alters have their own vital statistics  

∙ They can have different blood pressures

∙ Different prescription needs

∙ Different physiological responses to things  Don't forget about the age old question of Explain why the government was reluctant to help out the poor.

∙ There’s a documented case of an alter having an allergy to orange  juice, one of the other alters drank orange juice and the one with  the allergy took over and had an allergic reaction  

∙ Psychodynamic – dissociative disorders are caused by extreme  repression  

∙ It is a type of defense mechanism

∙ Repression is forcing oneself to not think about or remember  something that makes them anxious  

∙ They’re not allowing painful thoughts or impulses to reach the surface

∙ In this case it would be a lifetime of extreme repression  ∙ In this case, the abused child would designate the abuse and  terrible impulses and memories that come with it to different  personalities  

∙ Behavioral – dissociative disorders can arise from someone  repeatedly not thinking about the abuse as it comes  

∙ This would cause them to feel better, they could shut out the  abuse

∙ They would become conditioned to dissociate when they  experience anxiety because when they do forget, they feel  better

∙ For treatment…  

∙ The best thing to do is let the person know they have this  disorder  

∙ The next step is to integrate the personalities, so they can  become one person again  

Case – Localized Amnesia  

∙ A young man is brought to an emergency room by a stranger who  found him wandering the street

∙ He did not remember who he was or where he was  ∙ He did not ingest alcohol, and there was no physical trauma  ∙ He stayed in the hospital for a few days, and he woke up one day  panicking and remembering who he was (Riker)  

∙ He could remember things from before the episode ∙ He asked to be discharged  

∙ He was shown to have localized amnesia, during the stay in the  hospital  

∙ It was later found that on the day of his hospitalization, Riker had  killed a pedestrian by accident – he was not to blame  o The trauma of accidentally killing someone caused him to lose a space of time, to shield himself from the anxiety and  distress

∙ This is the most prominent type of dissociative amnesia  ∙ It’s almost as if they’re in a trance  

∙ Another type of amnesia is selective amnesia  

∙ This is when only certain things are forgotten  

∙ The last type is continuous amnesia – this is when the amnesia  doesn’t end (quite rare)  

∙ These symptoms interfere with their ability to function, but it isn’t  encyclopedia  

Dissociative Fugue

∙ Reverend Borne withdrew some money from the bank  ∙ He went to go buy some land – this is the last thing he remembered  ∙ His wife worried because the church didn’t treat him well, and was  worried they would be displaced

o She pressured him into taking all of their money and buying  the land  

∙ He didn’t return that night, and a missing persons report was put  out  

∙ In another town, a man showed up paying for things only in cash  ∙ The police realized that he was the reverend that was missing  ∙ Dissociative fugue is characterized by a flight – the person forgets  

their personal information and flees to start a new life somewhere  else  

∙ Usually the person wakes up suddenly, and it never happens again  ∙ Stress triggers it, in the reverend’s case he was pressured into  buying the land when he really didn’t want to  

∙ The treatment for this, as well as the other amnesias, is the help the person cope with whatever caused the repression

Depersonalization Derealization Disorder  

∙ Objects and the passage of time can become skewed with these  disorders

∙ They’re often associated with feelings of anxiety  

∙ Unlike the somatic disorders, people with these disorders can  distinguish with reality  

o They know how they are, and their memories are intact  ∙ These episodes can come on suddenly and fade gradually  ∙ Healthy people frequently experience episodes like this, about half  

of all adults have experiences with these at some point in their life  ∙ Explanations  

∙ Psychodynamic – Repression is a defense mechanism that’s  used very often  

Somatic Disorders  

∙ Soma means related to the body (used to be called somatoform  disorders)

∙ Psychical symptoms without an identifiable cause  ∙ Somatic Symptom and related Disorders  

∙ Physical complaints  

∙ Cannot be medically explained  

∙ Underlying psychological issues/conflicts

∙ Intervene with personal life  

∙ Somatic disorders

∙ Somatic Symptom Disorder  

∙ Illness Anxiety Disorder

∙ Conversion Disorder

∙ Factitious Disorder  

∙ There’s often a lot of doctor hopping with these disorders, since  they want to know what’s wrong with them  

∙ People with these disorders sometime fake symptoms for no reason  ∙ Somatic Symptom Disorder

∙ Excessive concern about their symptoms  

o Effects thoughts, feelings, and behaviors  

∙ Focus on psychological causes

∙ Doctors shopping  

∙ Criteria  

∙ Lasts for 6 or months  

∙ Cause personal distress or interfere with daily functions  ∙ These clients are heavy users of medicine, and often switch  between doctors  

∙ Hypochondriacs are often associated with this disorder ∙ These disorders are subgroups of SSD  

∙ Illness Anxiety Disorder

∙ People with hypochondriasis who complain of minor or mild  sickness believe this is a sign for serious undiagnosed illness ∙ Anxiety associated with illness rather than distress the  symptoms cause  

∙ NOT symptoms, but FEAR of what they mean  

∙ Care avoidance – these are people who postpone or avoid  medical help because of the anxiety about their illnesses ∙ Care seeking – these are people who would go doctor  shopping

Conversion Disorder  

∙ This is also called Functional Neurological Symptom Disorder  ∙ Symptoms or deficits affect ability to control voluntary movements  or impair sensory function  

∙ Loss/impairment of psychical functions either inconsistent or  incompatible with known medical conditions or diseases ∙ Emotional distress  symptoms in motor/sensory areas  ∙ What qualifies these as psychological disorders is the fact that the  loss or impairment doesn’t match up with medical conditions  ∙ It involves the conversion of emotional distress into symptoms in the motor or sensory functions  

∙ In some cases, what appears to be a conversion disorder turns out  to be intentional faking of symptoms for outside gain  ∙ This is called malingering – the key with this is there has to be some kind of external gain  

∙ An example of this could be someone who works in a factory  claiming they went deaf due to the machinery in order to get  time off work and to get workman’s comp

∙ The physical symptoms come of very suddenly, usually  accompanied with stress or an emotionally distressing event  ∙ These can also come from traumatic experiences, as well as  abuse  

∙ This used to be called hysteria  

∙ These people can show a remarkable indifference to their symptoms – This is called La belle indifference  

Factitious Disorder  

∙ People with this disorder fake or manufacture physical or  psychological symptoms with no apparent motive  

∙ They may hurt themselves, or take medications that can cause life  threatening effects  

∙ This is not malingering, since there is no apparent motive  ∙ The patients have a psychological need that faking these illnesses  fills

∙ A feigned illness where they either fake their illness, or they’re  taking medications to make themselves sick because they have  some type of psychological need to be in the sick role.  

∙ A movie that shows an example of this is The Sixth Sense ∙ Subtypes  

o Factitious disorder on self

 Munchausen syndrome – People with this disorder may  risk very dangerous  

∙ Factitious disorder imposed on another  

Theoretical Explanations  

∙ Somatic disorders (hysteria) and Conversion disorders o Hippocrates attributed these disorders to a wandering uterus   This was degrading to women and was proven untrue,  but it was one of the first theoretical explanations  

∙ There is very little biological explanations

∙ Psychodynamic Theory Explanations

o Freud – Hysteria rooted in psyche (unconscious mind)  o Symptoms are functional – they have a purpose

o Primary Gains – the person is able to keep their internal  conflicts repressed  

 This might be someone who hates someone so  

much they want to kill them, and they repress this

urge so much that their brain creates the  

symptom of a paralyzed arm  

o Secondary Gains – these symptoms allow the people to  avoid responsibilities, and they would gain sympathy  from people around them  

∙ Learning Theory  

o Focus on role of anxiety  

 Reinforcing properties for symptoms

 Secondary role in helping individual avoid/escape  

anxiety-evoking situations  

 The reward is a release for the anxiety  

∙ Cognitive Theory Explanation  

o Blaming poor performance on failing health

o Avoid other life problems

o Hypochondriasis and panic disorder may share similar  cause involve distorted way of thinking leads to  

misinterpreting minor changes in bodily sensations  

o A misattribution of thoughts – catastrophising  

Somatic Symptom and Related Disorder Treatments  

∙ Psychoanalysis

∙ Bring unconscious to unconscious awareness

∙ Behavioral (Learning)  

∙ Remove secondary reinforcement  

∙ The client would be shown better ways of handling stress, and be taught relaxation methods  

∙ Cognitive Behavior  

∙ Restructure distorted thinking  

∙ Exposure with response prevention  

∙ Unfortunately, patients with these disorders may be reluctant to  seek out psychological treatment  

∙ They’re more likely to go to a doctor to seek medical  treatment  

∙ They will most likely deny that they have these disorders, and  claim that they really are sick

Mood Disorders

∙ Moods are normal, they come and go with everybody  Case Study  

∙ William Stryon  

∙ Suffered from depression so bad he had a well documented plan to  commit suicide  

∙ He went to his lawyer and changed his will  

∙ He wrote his suicide note, at least attempted to  

∙ He stay up late to watch a play that he had written and a song in it  had shocked him out of his depression  

∙ He thought about all of the things that had happened in his house,  and how he couldn’t abandon it  

∙ Moods are feelings that color our psychological life  ∙ It’s normal to have changing moods, from joy to depression  ∙ These changed in moods reflect the things we deal with on a daily  basis  

∙ People with mood disorders experience  

∙ Severe or prolonged moods  

∙ They impair the ability to meet responsibilities  

o Severe mania  

o Hypomania (mild to moderate mania)  

o Normal/balanced mood

o Mild to moderate depression  

o Severe depression  

∙ They may become depressed even when things are going well ∙ They may be affected by things that wouldn’t affect others ∙ Their moods have extreme highs and lows  

∙ 2 forms of mood disorders

∙ Depression – Only go down  

∙ Depressive (unipolar)

∙ Major Depressive Disorder

o At LEAST one major depressive episode (no mania)  o NEVER have mania in order for this to be diagnosed  o Involves a clinical significant change in functioning  o Have to have been in place nonstop for at least 2 weeks o It covers a range of features/areas  

 Emotion – feeling depressed, tearfulness, agitated

or irritable  

 Motivation – loss of enjoyment in pleasurable  

activities, withdrawal  

 Motor – talking more slowly, changes in sleep  

habits, changes in appetite, functioning less  

effectively

 Cognition – concentration problems, thinking  

negatively about self or other or world, feeling  

guilty or remorseful, lack of self esteem, thoughts  

of suicide or death  

o Not just a state of sadness or feeling blue  

o Anhedonia – hedon  

 Hedonist – a person who seeks pleasure

 Anhedonia means a lack of all pleasure  

 They find pleasure in nothing  

o Women are twice as likely to develop this disorder  o The most common type of diagnosable disorders  o 26% of the overall population  

o This often occurs with other psychological disorders  o Psychosis – a loss of touch with reality

 There are not many disorders that have psychosis   Depression can very rarely have psychotic  features  

o Major depressive episodes can last for months, and  even up to a year  

o Some people may only experience one episode  o People with MDD will most likely have reoccurring  episodes  

o These episodes are tired to health

o The longer the period of recovery, the lower chances of  relapse  

o Usually occurs in young adult  

o The lower the socioeconomic status, the higher the risk  o Depression occurs most often in people who are single,  rather than married  

 This happens because with a partner comes a  support system  

o 2 different types of depression  

 Endogenous – Coming from within, comes from  genetics, neurotransmitters not working,  

physiological instead of psychological

 Treated with prescriptions most likely

 Exogenous – Reactive, coming from outside the  body, loss of family or friends  

 It’s important to distinguish between these types  o Seasonal Affective Disorder

 Subcategory of major depression  

 Depression with a seasonal pattern  

 Usually lifts in the spring  

 The causes remain mostly unknown, but they’re  most likely related to the changes in light  

 May affect our mood regulating neurotransmitter,  Serotonin

 The use of bright artificial light (phototherapy) is  often used  

 Primarily endogenous

o Postpartum Depression  

 Happens within 4 weeks of delivery  

 Up to 80% of new mothers experience changes  after delivery  

 1 in 7 new mothers experiences more extreme  mood disorders, this being postpartum depression  Within the first year of childbirth

 Has to persist for months and maybe even up to a year  

 Associated with the symptoms of MDD  

 Associated with hormonal changes that come with childbirth  

 They don’t last as long as MDD  

 Women with a history of mood disorders have a  higher chance of experiencing postpartum  

depression  

 Example – Andrea Yates

 She experienced a psychotic break due to  

her postpartum depression and killed her  

four children  

 Seen more often in first time mothers  

∙ Persistent Depressive Disorder  

o Lasting at least 2 years  

o May have MDD or milder dysthymia  

o This is a chronic depression, rather than an abrupt  change in mood  

o A patient may have chronic MDD, which would call for a  dual diagnosis of MDD and PDD  

o Dysthymia – less severe than MDD, but the person may  feel down all the time  

o Relapse is more likely  

o People with dysthymia may go on the be diagnosed with MDD  

∙ Premenstrual Dysphonic Disorder  

o More significant than PMS  

o Range of psychological symptoms the week before  menses  

o Symptoms  

 Sudden sadness

 Feelings of hopelessness  

 Greater reaction to rejection or loss  

 Must be associated with emotional distress  

 Inhibits the woman’s ability to function  

o The causes are still unknown  

o Critics fear that it pathologies normal PMS

∙ Bipolar – Moods go up and down  

∙ Characterized by extreme changes in mood  

∙ Mood changes from heights of elation to the depths of  depression  

∙ Can start off with either depression or mania  

∙ Depression – Begin and end abruptly  

∙ Mania –  

∙ Mixed states – characterize both mania and depression  ∙ Moods may shift very rapidly  

∙ Some may also experience mixed states where they show  mania but now enough to meet the criteria for mania  ∙ Kay Redfield Jamison – leading psychologist on bipolar  disorder, and also suffers from bipolar disorder  

o Wrote “An Unquiet Mind” and “Touched by Fire”  ∙ Usually stars around age 20

∙ Rapid cycling is uncommon, but more common in women  ∙ Alcoholism can be associated with this disorder  ∙ Bipolar I

o At least on FULL manic episode  

 People in manic episodes exhibit a lack of  

judgment  

 May jump from one topic to another  

 Rapid talking  

 Can’t censor themselves  

 Very distractible

o Typically involves mood swings (manic – major  

depression)  

o There may be normal moods in between

o People with BPI may have never had a major depressive episode  

∙ Bipolar II

o Hypomanic episode – less than manic  

 Tricky to see, looks like heightened mood  

 Less severe than manic  

 The person may feel charged with energy

 Inflated self esteem  

 Lack of fatigue  

o At least one major depressive episode  

o HAVE NEVER HAD A FULL MANIC EPISODE  

∙ Cyclothymic Disorder  

o Cyclical pattern of mod wings for at least 2 years  

o Shows up in late adolescence and persists for year  o The severity of moods isn’t as great

o Very little normal moods in between highs and lows  o The most common of the bipolar disorders, but isn’t  diagnosed very often because it’s hard to do so  

∙ Explanations  

∙ Psychodynamic theory  

o Anger turned inwards

∙ Humanistic theory  

o Individual cannot justify existence with meaning o Cannot make authentic choices that will lead to self  fulfillment  

∙ Learning theory  

o Focuses on situational factors (loss of positive  reinforcement)

o Feels like you’re doing things but it doesn’t matter ∙ Cognitive theory  

o Based on the way people see themselves in their world  o Individual may have a negative biased or distorted way  or thinking  

o Cognitive triad  

 Self

 World

 Future  

∙ Learned Helplessness  

o Martin Seligman  

o People become depressed because they learn to view  themselves as helpless  

o They feel like they cannot change their lives for the  better  

o Attributional style  

∙ Biological Factors  

o Genetics

o Neurological functioning

o Hormones

o

Personality Disorders

For Multi Axial Dx (Diagnosing)  

∙ A 5 axial system – This system was gotten rid of in DSM-5 o Axis I – Most clinical disorders listed here with a code number  (Major Depressive Disorder 308.7)

o Axis II – Personality disorders (A.S.P.D. 270.2)

o Axis III – Medical Conditions (Heart disease, Breast cancer) o Axis IV – Psychosocial concerns (homelessness, divorce, job  loss, death of someone they love)

o Axis V – Global Assessment Functioning (GAF) a number  between 1 – 100 that rates how the person is function in the  world  

 Could be written as 60/90 meaning they’re functioning  at 60% while they had been functioning at 90%  

∙ This used to be very useful since it was a consistent basis for  diagnosis and it was a very efficient shorthand, this would take up  less than half a page while having to write up a narrative would take up a lot more time and space

∙ This was used by anyone who would have been interacting with  clients with mental disorders  

Personality Disorders

∙ Personalities are long term patterns in behavior  

∙ We react in predictable and consistent ways  

∙ These are personality traits

∙ Personalities are flexible – they can be adjusted to fit the situation,  but you’re still you  

∙ As we interact with out surroundings, we have a chance to try out  flexibility in their personality

∙ An example of this is transitioning from high school to college  – there’s a huge chance to change your personality since  college is a clean slate  

∙ Someone with a personality doesn’t have this ability  ∙ Personality disorders are defined by rigid patterns of inner  experience and outward behavior  

∙ This extends across most interactions  

∙ Continues for many year  

∙ Differs from behavioral expectations  

∙ May disrupt life  

∙ May bring pain to others  

∙ The symptoms of personality disorders are much different than  clinical disorders  

∙ In the case study, the patient still had a job, he still had  relationships, except his personality never changed in many  years  

∙ Someone who has a personality disorder doesn’t experience  the psychological pain, it’s the people around him  

∙ Personality disorders usually present themselves in adolescence or  adulthood, but they can show up in childhood  

∙ People who have personality disorders most likely don’t know  it, since they’re not experiencing the side effects from it  ∙ This is the major difference between clinical and personality  disorders  

∙ They’re hard to treat and hard to diagnose  

∙ 4 – 15% of the population have personality disorders  ∙ These people tend to not self report  

∙ It’s not uncommon for people with personality disorders to have  clinical disorders  

∙ This is co-morbidity

∙ There are 10 Axis II Disorders, and they’re categorized into 3  categories of disorders  

∙ Odd or Eccentric behavior  

∙ Dramatic Personality Disorders  

∙ Anxious Personality Disorder  

∙ These often overlap and it’s hard to distinguish between these types ∙ Psychologists often say that many patients could have multiple  personality disorders  

∙ R(ule). O(ut). – A patient may have most of the symptoms but they  don’t reach the criteria listed in the DSM, so ethically the  psychologist cannot diagnose them  

∙ Axis II P.D. NOS – If the patient doesn’t have specific enough  symptoms the doctor maybe list this, which means a personality  disorder not otherwise specified  

Odd or Eccentric Disorders  

∙ People with these disorders often display odd behaviors – these  symptoms are often seen in schizophrenia  

∙ People who have these disorders are often isolated voluntarily (this  is an important distinguishing factor)  

∙ These disorders are clustered  

∙ These people often won’t seek treatment, they see nothing wrong  with themselves  

∙ Psychodynamic explanations are most common and popular, and  most of them say there’s been maltreatment in childhood (applies  to ALL personality disorders)  

∙ Paranoid Personality Disorder  

o Deep distrust of others  

o Suspicious of the motives of others  

o Avoidance of close relationships  

o Very critical of other people  

o Questioning people’s loyalty

o Psychodynamic would say that they would have distant  and rigid fathers and very demanding mothers  

o May have genetic causes, but hasn’t been founded  o Don’t see themselves as needing help  

o If they ever did seek treatment, they wouldn’t trust the  therapist  

∙ Schizoid Personality Disorder  

o Little interest in socialization  

o Focus on self  

o Rarely shows feelings  

o Don’t have close ties with others  

o They don’t form relationships  

o Weak social skills

o The stereotypical hermits  

o Probably more men than women  

o Unable to or don’t want to give love

∙ Schizotypal Personality Disorder

o Display a range of interpersonal issues that present  themselves in extremely odd or eccentric behaviors  o Ideas of reference  

o Bodily Illusions  

o Difficulty keeping focus  

o This may be a precursor to schizophrenia  

o Very difficult to treat since it’s hard to get them to  reconnect to the world

o Seen as more of a biological disorder  

Dramatic Personality Disorders  

∙ More commonly diagnosed than others  

∙ Antisocial Personality Disorders  

o Persistent disregard and violation of others’ rights  o Close link to adult criminal behavior  

o May include runaways, cruelty to animals, and fire starting  

∙ Borderline Personality Disorder  

o Great instability and changes in mood  

o Unstable self images

o Impulsivity  

o Frequent formation of intense, conflict-ridden  

relationships that involve violations of boundaries  ∙ Histrionic Personality Disorder  

o Extremely emotional  

o Attention seeking  

o Emotionally charged  

∙ Narcissistic Personality Disorder  

o Grandiose  

o Need admiration  

o Lack empathy  

Anxious Personality Disorders  

∙ Avoidant Personality Disorder  

o Sensitivity to possibility of criticism, rejection, or  disapproval  

o Reluctant to enter into relationships  

o Feel inferior or incomplete

∙ Dependent Personality Disorder  

o Low self confidence  

o Over-dependence on others  

o Persistent need to be taken care of  

∙ Obsession-Compulsive Personality Disorders  

o Focus on orderliness, perfectionism, and control  o Loss of flexibility  

o Unreasonably high standards