Abnormal Psychology, the science and treatment of psychological disorders by A. M. Kring, S. L. Johnson, G. C. Davison and J. M. Neale (thirteenth edition) – Chapter 8

Dissociation refers to some aspect of emotion, memory or experience being inaccessible consciously. Depersonalization/derealization involves a form of dissociation involving detachment. The person feels removed from the sense of self and surroundings. The lifetime prevalence of depersonalization/derealization disorder is about 2.5%. The lifetime prevalence of dissociative amnesia is about 7.5%. The lifetime prevalence of dissociative identity disorder is about 1%-3%.

Clinical profile depersonalization/derealization disorder:

This disorder involves no disturbances of memory. It usually begins in adolescence and is usually triggered by stress. It is very comorbid with personality disorders, depression and anxiety disorders. Depersonalization refers to experiences of detachment from one’s mental processes or body (e.g: as in a dream). Derealization refers to experiences of unreality of surroundings.

Clinical profile dissociative amnesia:

The amnesia usually disappears as suddenly as it began, with complete recovery and only a small chance of recurrence. Procedural memory remains intact during episodes of amnesia. Alcohol and medication can cause blackouts and potentially explain the amnesia. Dissociative amnesia and fugue are rare, even among people who have experienced intense trauma. People experiencing stress tend to focus on the central features of the threatening situation and stop paying attention to peripheral features. People tend to remember emotionally relevant information more than neutral information surrounding an event. It is possible that extremely high levels of stress hormones could interfere with memory formation.

Clinical profile dissociative identity disorder:

Dissociative identity disorder is much more common in women than in men. It is highly comorbid with posttraumatic stress disorder, major depressive disorder, somatic symptom disorders and personality disorders. It is often accompanied by headaches, hallucinations, suicide attempts and self-injurious behaviour.

The prevalence of DID appears to be increasing over time. This potentially occurs because of the diagnostic criteria and growing literature may have increased detection and recognition of symptoms. There are two theories explaining dissociative identity disorder:

1. Posttraumatic model
   Some people are likely to use dissociation to cope with trauma. This is the key factor for developing alters after trauma. Children who were abused are at an increased risk for dissociative identity disorder.
2. Sociocognitive model
   People who have been abused seek explanations for their symptoms and distress and alters appear in response to suggestions by therapists, exposure to media or other cultural influences. This means that DID is iatrogenic, created within treatment.

Both theories assume that early childhood trauma plays a major role in the development of the disorder.

The goal of the treatment of DID should be to convince the person that splitting into different personalities is no longer necessary to deal with traumas. Treatment could teach a person more effective ways to cope with stress. Age regression is using hypnosis and encouraging people to go back in the mind to traumatic events in childhood. This can worsen DID symptoms.

Somatic symptom and related disorders are defined by excessive concerns about physical symptoms or health. Somatic symptom-related disorders tend to co-occur with anxiety disorders, mood disorders, substance use disorders and personality disorders.

Clinical profile somatic symptom disorder:

The disorder can be diagnosed regardless of whether symptoms can be explained medically. The symptoms may begin or intensify after some conflict or stress. Clinical profile illness anxiety disorder:

This disorder often co-occurs with anxiety and mood disorders. Somatic symptom disorder is accompanied by somatic symptoms and the illness anxiety disorder is not accompanied by somatic symptoms. The somatic symptom disorder is three times as common as an anxiety disorder.

Clinical description conversion disorder:

Symptoms of the conversion disorder usually develop in adolescence or early adulthood, typically after a major life stressor. The prevalence is less than 1%. More women than men have conversion disorder. It is comorbid with other somatic disorders, dissociative disorders, substance use disorders and personality disorders.

The disorders do not seem to be heritable. Pain and uncomfortable physical sensations increase activity in the anterior insula and the anterior cingulate cortex. These regions have strong connections with the somatosensory cortex. Some people may have hyperactive brain regions that are involved in evaluating the unpleasantness of body sensations. Pain and somatic symptoms can be increased by anxiety, depression and stress hormones. The anterior cingulate cortex is important in experiences of pain.

Once a somatic symptom develops, attention to body sensation and interpretation of those sensations are important. People with excessive distress about their somatic symptoms may automatically focus on cues of physical health problems. People prone to these worries tend to interpret their physical symptoms in the worst possible way.

Psychodynamic theory suggests that the physical symptom is a response to an unconscious psychological conflict. Psychodynamic theory suggests that the conversion disorder might involve unconscious processing of perceptual stimuli and motivation to be symptomatic.

Social and cultural factors shape the symptoms of conversion disorder. Symptoms are more common among people from rural areas and people of lower socioeconomic status. Modelling and social factors shape how conversion symptoms unfold.

Clinical profile factitious disorder:

In malingering, a person intentionally fakes a symptom to avoid responsibility or to receive a reward. The main goal of the factitious disorder seems to be to adopt the patient role.

There are several treatment methods of somatic symptom and related disorders;

1. Interventions in primary care
   This is teaching primary care teams to tailor care for people with somatic symptom-related disorders. This can include informing when someone is a frequent user of health care services.
2. Cognitive behavioural treatment
   This includes several cognitive behavioural methods, such as learning people to pay less attention to their bodies. It is important to focus on what people can do and not on what people cannot do because of their somatic complaints. This treatment reduces the distress of somatic symptoms and not the actual somatic symptoms.

People that have the somatic symptom disorder with pain can receive acceptance and commitment therapy, a variant of cognitive behavioural treatment where the therapist encourages the patient to adopt a more accepting attitude toward pain, suffering and moments of depression. Antidepressants can help if pain is the dominant symptom of somatic symptom disorder.