DISSOCIATIVE DISORDERS

Dissociative Amnesia
A 29-year-old female experienced the onset of dissociative amnesia during an academic trip to China. She was found in a hotel bathroom unconscious, with no signs of structural or neurologic abnormalities or alcohol or chemical consumption. The woman was sent home but could not remember her name, address, family, or any facts about her home life. The amnesia persisted for nearly 10 months, until the feeling of blood on the woman's fingers triggered the recollection of events from the night of onset of dissociative amnesia, and, subsequently, other facts and events. The woman finally remembered having witnessed a murder that night in China. She recalled being unable to help the victim out of fear for her own safety. She came to remember other aspects of her life; however, some memories remain unretrievable. Case 2 The patient was a 19-year-old male military service member who was hospitalized on two separate occasions after he was found to have toxic salicylate levels. Both times, he presented to a primary care clinic with complaints of nausea, disequilibrium, labored breathing, diaphoresis, and hemetemesis. Laboratory evaluations revealed toxic salicylate levels, but the patient denied ingesting any medication, denied memory loss, and was without psychiatric complaint. He was admitted to the psychiatric ward, where he was noted to be polite but anxious, speaking with a stutter, appearing inhibited in the milieu, and avoiding most interpersonal contact. He continued to deny ingestion of aspirin, despite physical signs and laboratory evidence of overdose. At the time of his second hospitalization, he reported finding an empty aspirin bottle in his room. He was also more forthcoming with some of his current stressors. He shared that he had joined the military after September 11 with a sense of patriotism and the fantasy of serving with heroes. He had not anticipated the difficulty he would have separating from his family, nor the disappointment he would experience upon finding that his military peers did not meet his expectations of the idealized hero. He disclosed that he had previously witnessed an assault on his roommate by other service members, who had then made threats against his life. Poisoning was considered, but was deemed unlikely since the perpetrators were in jail pending trial. A benzodiazepine-assisted interview was conducted, but it failed to elicit memories of either ingestion. The patient underwent psychological testing to assist in diagnosis. The Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) indicated that he was experiencing a significant level of distress. The validity profile suggested over-reporting of symptoms, which was thought to be related to an inability to express his needs in a more sophisticated manner. The Structured Interview of Reported Symptoms (SIRS) suggested that there was a low probability that he was feigning symptoms, and the most prominent theme in the patient's Rotter Incomplete Sentence Blank (RISB) involved feelings of interpersonal rejection and alienation. The patient was discharged from the inpatient psychiatric ward with an Axis I diagnosis of dissociative amnesia and an Axis II diagnosis of avoidant personality disorder. He remained unable to recall details of the ingestions while hospitalized and in the months that followed, and was eventually discharged from active duty service with no further psychiatric sequelae.

Dissociative Fugue
Commonly, individuals who experience the onset of dissociative fugue are found wandering in a dazed or confused state, unable to recall their own identity or recognize their own relatives or daily surroundings. Often, they have suffered from some post-traumatic stress, as in the case of a 35-year-old businessman who disappeared more than 2 years after narrowly escaping from the World Trade Center attack in 2001, leaving behind his wife and children. The man was missing for more than 6 months when an anonymous tip helped police in Virginia identify him. Case 2 A man, who is unable to identify himself, walks into a police station, and told the police personnel that he woke up on the street and has no idea as to who he is. His family locates him two weeks later, after which he returns to normal.

Dissociative Identity Disorder

In a case of dissociative identity disorder, a woman who had been physically and sexually abused by her father throughout her childhood and adolescence exhibited at least 4 personalities as an adult. Each personality was of a different age, representing the phases of the woman's experience a fearful child, a rebellious teenager, a protective adult, and the woman's primary personality. Only one of the personalities, the protective adult, was consciously aware of the others, and during therapy sessions was realized to have been developed to protect the woman during the abusive experiences. When one of the secondary personalities took over, it often led to episodic dissociative amnesia, during which the woman acted out according to the nature of the dominating personality. During intensive therapy sessions, each personality was called upon as necessary to facilitate their integration. Case 2 Mary was a quiet 30-year-old woman who was meek and reticent and had many avoidant traits. She was talking about some of the events of her past, which included severe sexual abuse starting at the age of 20 months. She began to tell the psychiatrist about a crying voice she heard constantly:

Mary: Baby cries all the timeBabyI hear her. She is sad all the time. She cant talk, but she cries all the time. (Mary stops speaking. Her demeanor and posture were now so different the psychiatrist was startled. It really felt as though a different person was in the room.) Mary (now Edith): She is a wimp. I would never put up with any of that sh--. Ill kill him. Ill kill him. Ill kill you too and she deserves to die. Psychiatrist: Who? Baby? Mary (now Edith): Mary. Shes a wimp. Psychiatrist: What about Baby? Mary (now Edith): What are you talking about? Psychiatrist: May I speak to Mary? Mary (now Edith): She doesnt have the guts to come here.

Depersonalization Disorder
Depersonalization disorder generally leads to observable distress in the affected individual. It often occurs in individuals who are also affected by some other psychological nondissociative

disorder, as in the case of a 19-year-old college student who was suffering from sleep deprivation at the onset of depersonalization disorder. The young man experienced increased anxiety as he struggled to meet his responsibilities as a scholarship-dependent student athlete. Teammates expressed concern about his apparent distress to their coach who arranged for the young man to speak with a therapist. The young man described feeling as though he were observing the interactions of others as if it were a film. The young man's anxiety was determined to contribute to severe sleep deprivation, which triggered episodes of depersonalization. Case 2 Dr. Anders* felt frightened of Tony* from the very first time she met him. Fear was the least prevalent feeling that this well-seasoned psychiatrist experienced when dealing with patients. However, something about the tall, emaciated, 42-year-old was unsettling. He shuffled into her small, private office like a much older man would. Dr. Anders directed him to sit in the comfortable, black leather chair across from her. After slowly removing his charcoal-colored, tweed jacket that was too large for him, he sat down on the edge of the chair. He reeked of cigarettes. Dr Anders searched for and found the telltale sign of a yellow thumb and forefinger, which indicated a penchant for chain-smoking unfiltered cigarettes. "I can't take it anymore, doctor. You must help me," he pleaded. His face surrounded by long, straight, brown hair was finely sculpted like Michelangelo's David. His heavy-lidded, blue eyes looked sad. "Take your time and tell me what's wrong," she encouraged. What was it that was so disturbing about his presence, she wondered, as she felt her own heart beating rapidly as they talked? "I've been this way for over 20 years. I don't have much hope. You're the fifth psychiatrist I've seen. No one knows how to help me," he said. Stress strained his already raspy voice and made it climb up a notch higher. It was a bad sign that she was the fifth psychiatrist. His condition sounded chronic and entrenched. Tony told his story of being an only child whose doting mother died when he was only 10. His father, a Vet freshly returned from the Vietnam War, had raised him with the help of Tony's aunt. He'd always been anxious and a loner. In school, he'd done mediocre work. After a year of college he dropped out and married a girlfriend from high school. Then, his problem started. "One day I was walking around the city, minding my own business, when suddenly I found myself looking down at myself from somewhere near the awning of a store. It was unreal and the weirdest thing in the world!" he exclaimed, his hands shaking. "Since then, and that was 20 years ago, I've had one experience like that after another and never completely felt like I was back in my body. I constantly feel spaced out." Clearly, Tony was terrified of his experience. It was Tony's sense of an absence of himself that frightened Dr. Anders, not his presence, which she had assumed at first. Tony denied any drug use. He claimed he was too scared to try anything. Dr. Anders thought he looked like a junkie or pothead, but later when she took blood and urine samples, she found that he was perfectly clean and free of drugs. He had separated from his wife, who said she was tired of dealing with his constant complaints of being "spaced out." They still called each other and had phone sex once per week, since neither could stand to deal with the other in person. Tony was on SSI and lived in a poor Brooklyn neighborhood. He spent his days sitting indoors, smoking two packs of cigarettes per day and brooding about his condition. He wanted Dr. Anders to refill a prescription he had taken twice daily for over 10 years. She told him she would help by giving him an antidepressant as well. He took the two prescriptions, but

when he returned the following week, Dr. Anders learned that he hadn't filled his prescription for the antidepressant. He had just continued with the first medication, an addictive tranquilizer. Their sessions went on like this for several months. Dr. Anders would prescribe an antidepressant, or an antipsychotic, or a mood stabilizer. Tony would agree to try the new medicine since he "most certainly desired" to be helped, but inevitably he would only take the one. Tony had done exactly the same thing with his previous four psychiatrists. He explained his behavior with the claim that he was too fearful to try anything new. During psychotherapy sessions, Tony spoke about his condition and how horrible it was to feel so unreal and outside of himself. He rarely was relieved of this feeling. Medication helped only slightly. He never had any hallucinations or delusions, panic attacks or depressive episodes except relating to his condition.

SOMATOFORM DISORDERS

Body Dysmorphic Disorder

Sarah is a 23-year-old woman who believes she has had BDD for the past eight years. When she was 15-years old she began obsessing over the shape of her nose. She had plastic surgery at 18. Two other reconstructive nose surgeries followed because she was unhappy with the results. Although many men her age feel she is attractive and often express interest in her, Sarah has stopped dating, and now rarely even goes out with her girlfriends. Obsessions over her skin and her cheekbones have also surfaced, and she has also sought consultation to have those perceived "flaws" corrected with surgery. She continues to use multiple skin care products to cover minor acne scaring, and is exploring the possibility of a cheek implant to correct what she believes to be an asymmetric appearance of her cheekbones. She has had several bouts of major depression, and has admitted herself on two occasions to a psychiatric hospital because she was seriously considering committing suicide, and she suffered one overdose of her anti-depressant medications. Case 2 Jane, a 32-year-old single Hispanic female, had been obsessed since high school with her huge nose and pock-marked skin. She reported being absolutely convinced that she looked deformed and atrocious. She could not be talked out of her beliefs. Additionally, she was convinced that people on the street took special notice of her hideous nose and skin, and that they talked about her and snickered behind her back because she was so ugly. Due to these beliefs, Jane became severely depresed. She was unable to work or even leave her home. She attempted suicide twice and was hospitalized psychiatrically after both attempts. Although advised against it, Jane received two rhinoplasties for a nose that outwardly appeared normal. She also received a course of isotreninoin (Accutane). These treatments left Jane even more obsessed with her appearance and feeling more depressed because her last hopes hadnt cured her perceived ugliness. Jane underwent psychodynamic psychotherapy without any benefit. In addition, she had trials of several medications (several antipsychotics and low doses of antidepressants), which failed to improve her symptoms. Only after a trial of escitalopram (30mg/d) did Jane report improvement in her BDD symptoms. In fact, while Jane continued the medication, her improvement was sustained. After stopping the medication, however, Janes symptoms recurred.

Hypochondriasis
The following is an example of a cognitive therapy session with Lisa in which the therapist helps her generate alternate explanations for her frequent headaches: Therapist: You said you feel as though you have a headache, and you believe that this feeling indicates that you have a brain tumor. Is this correct? Lisa: Yes, I read that frequent headaches are one of the symptoms of a tumor. Therapist: Do you have any other evidence that you have a tumor? Lisa: Not really. I have seen two specialists who assured me that I am fine. I also had an MRI done recently. Therapist: Is it possible that there could be something else responsible for the way you are feeling? Lisa: I suppose there could be. Therapist: Try to generate some other possible explanations. Lisa: Well, I do get headaches from staring at a computer screen all day at work. Therapist: Okay that's one explanation. What else? Lisa: It could be stress. Therapist: When do you tend to feel stressed out? Lisa: I guess when I think about getting headaches. Therapist: What happens when you think about getting headaches? Lisa: I usually end up getting one. Therapist: Are you saying that simply focusing on your head may be responsible for producing the headache? Lisa: I guess thinking about it does make it worse. Therapist: It seems then that a tumor is not the only possible explanation for your symptom. Case 2 A middle-aged female patient whose life was dominated by a wide variety of somatic discomforts presented herself, in a desperate plight, to a psychiatrist for consultation. I am 40 years old, she said, and I have terrible pains all over my body. I feel anxious all the time and sometimes even panicky. I have had all kinds of therapy - from Freudian to pharmacological and nothing seems to work. I am depressed, I cant sleep, and my family is getting fed up with me. Doctors keep telling me that I need more treatment or that I should take more pills or that I should be seen four or five times a week, lying on a couch. They tell me that all my problems are related to sexual anxiety. But none of this helps. I am treated as though I am stupid, but I actually have studied psychology and read lots of books, but none of this helps. I do not want to just be told take these eight pills and call me in a couple of weeks. I need to see a doctor who is humane and can accept my heightened illness anxiety without dismissing me with some medication or other, especially if it does not work. I am desperate to find a doctor who understands this, but even psychiatrists dont seem to have the patience to stay with me.

Somatization Disorder
Mark has had numerous physical complaints for years. Medical tests have not found a cause, and Mark's doctor suspects that he may have somatization disorder. Case 2 Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These

operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician. Ms. J's primary care physician has followed her for many years and has made the diagnosis of somatization disorder. The treatment plan includes regular frequent visits to monitor her chronic pain complaints. Use of medication with addictive potential is restricted. Physical symptoms are monitored with limited use of invasive diagnostic procedures. Outpatient visits focus on identifying sources of stress and encouraging healthy coping mechanisms.

Conversion disorder
A young womans family brings her to the hospital and she presents with a chief complaint of spells. It seems that over the past several weeks, the patient has suffered from attacks of bilateral arm jerking, followed by bilateral leg jerking after she lowers herself to the floor. Often, her head shakes violently side to side and her eyes are seen to "roll back in her head" followed by forced eye closure. These incidents follow episodes of emotional outbursts, and the patient is fortunately able to warn others that Im about to have a seizure! After hearing this, her family grabs the patient and places her in a chair or on the ground until the spell is over, which sometimes can wax and wane for 20-30 minutes with varying intensity. These spells are not accompanied by loss of bladder or bowel continence, but often the patient bites the tip of her tongue and kicks over tables or strikes family members during an episode. This most recent spell occurred while the patient was driving her car, in which she warned of an impending seizure and pulled the car to the shoulder just before losing consciousness; her spell was much more intense than she has had in the past. She has no significant past medical history and takes no medications. She reports a past history of childhood sexual abuse from a paternal uncle several years ago. On exam, her vitals signs are normal and her neurologic evaluation is without significant findings. She is not orthostatic. Laboratory work-up, including urine toxin screen, is negative. Case 2 The present single case study evaluated the efficacy of a cognitive-behavioral intervention for the treatment of a patient diagnosed with globus hystericus, a conversion disorder characterized by a perceived lump in the throat. The patient was a non-mentally retarded 12-year-old female who refused to swallow solids because she thought that her throat muscles would involuntarily constrict and result in choking. She lost approximately .5 lbs. per week during the 6 months prior to treatment. Improvements in weight gain were demonstrated consequent to the implementation of behavior therapy, with weight gain being particularly pronounced after contingency contracting was added to therapy. Weight gain was maintained at 1, 6, and 10 months post treatment.

SAMAR STATE UNIVERSITY COLLEGE OF ARTS AND SCIENCES Catbalogan City

PROJECT IN ABNORMAL PSYCHOLOGY

Submitted By:
Pamela Bianca D. Orcuse BS Psychology 4

Submitted To:
Prof. Abigail M. Cabaguing