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Dissociative Disorders and Trauma Discussion Assignment

Dissociative Disorders and Trauma Discussion AssignmentDissociative Disorders and Trauma Discussion AssignmentChapter 8Discuss the relationship of trauma to dissociative amnesia and dissociative identity disorder.Schizophrenia Chapter 13Review the changes in the diagnosis of schizophrenia that have occurred historically and the changes in the current definition due to the DSM 5 publication. How has brain research advanced the understanding of schizophrenia?8 somatic symptom and dissociative disorderslearning objectives 8·  8.1 What are somatic symptom disorders?·  8.2 What is illness anxiety disorder?·  8.3 What is conversion disorder (functional neurological symptom disorder)?·  8.4 What is the difference between a factitious disorder and malingering?·  8.5 What are the primary features of dissociative disorders?·  8.6 What is depersonalization/derealization disorder?·  8.7 What is dissociative amnesia?·  8.8 What is dissociative identity disorder?ORDER A PLAGIARISM-FREE PAPER HEREHave you ever had the experience, particularly during a time of serious stress, when you felt like you were walking around in a daze or like you just weren’t all there? Or have you known people who constantly complained about being sure they had a serious illness even though medical tests failed to show anything wrong? Both of these are examples of mild dissociative and somatic symptoms experienced at least occasionally by many people. However, when these symptoms become frequent and severe and lead to significant distress or impairment, a somatic symptom or dissociative disorder may be diagnosed. Somatic symptom disorders (formerly known as  somatoform disorders ) and dissociative disorders appear to involve more complex and puzzling patterns of symptoms than those we have so far encountered. As a result, they confront the field of psychopathology with some of its most fascinating and difficult challenges. Unfortunately, however, we do not know much about them—in part because many of them are quite rare and difficult to study.As we have seen ( Chapter 6 ), both somatic symptom and dissociative disorders were once included with the various anxiety disorders (and neurotic depression) under the general rubric neuroses, where anxiety was thought to be the underlying cause of all neuroses whether or not the anxiety was experienced overtly. But in 1980, when DSM-III abandoned attempts to link disorders together on the basis of hypothesized underlying causes (as with neurosis) and instead focused on grouping disorders together on the basis of overt symptomatology, the anxiety, mood, somatic symptom, and dissociative disorders each became separate categories. Dissociative Disorders and Trauma Discussion AssignmentSomatic Symptom and Related DisordersThe somatic symptom disorders lie at the interface between abnormal psychology and medicine. They are a group of conditions that involve physical symptoms combined with abnormal thoughts, feelings, and behaviors in response to those symptoms (APA,  2013 ).  Soma  means “body,” and somatic symptom disorders involve patterns in which individuals complain of bodily symptoms that suggest the presence of medical problems but where there is no obvious medical explanation that can satisfactorily explain the symptoms such as paralysis or pain. Despite a wide range of clinical manifestations, in each case the person is preoccupied with some aspect of her or his health to the extent that she or he shows significant impairments in functioning.In DSM-IV a great deal of emphasis was placed on the idea that the symptoms were medically unexplained. In other words, although the patient’s complaints suggested the presence of a medical condition no physical pathology could be found to account for them (Allen & Woolfolk,  2012 ; Witthöft & Hiller,  2010 ). In DSM-5 this idea is less prominent, because it is recognized that medicine is fallible and that a medical explanation for symptoms cannot always be provided. Nonetheless, medically unexplained symptoms are still a key part of some disorders (such as conversion disorder) that we will describe later.Equally key to these disorders is the fact that the affected patients have no control over their symptoms. They are also not intentionally faking symptoms or attempting to deceive others. For the most part, they genuinely believe something is terribly wrong with them. Not surprisingly, these patients are frequent visitors to their primary-care physicians.Sometimes, of course, people do deliberately and consciously feign disability or illness. Also placed in the somatic symptoms and related disorders category in DSM-5 is factitious disorder. In  factitious disorder  the person intentionally produces psychological or physical symptoms (or both). Although this may strike you as strange, the person’s goal is to obtain and maintain the benefits that playing the “sick role” (even to the extent of undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel. However, there are no tangible external rewards. In this way factitious disorder differs from malingering. In  malingering  the person is intentionally producing or grossly exaggerating physical symptoms and is motivated by external incentives such as avoiding work or military service or evading criminal prosecution (APA,  2013 ; Maldonado & Spiegel,  2001 ).Dissociative Disorders and Trauma Discussion AssignmentIn our discussion, we will focus on four disorders in the somatic symptom and related disorders category. These are (1) somatic symptom disorder; (2) illness anxiety disorder; (3) conversion disorder; and (4) factitious disorder.Somatic Symptom DisordersThis new diagnosis includes several disorders that were previously considered to be separate diagnoses in DSM-IV. The old disorders of (1) hypochondriasis, (2) somatization disorder, and (3) pain disorder have all now disappeared from DSM-5. Most of the people who would in the past have been diagnosed with any one of these disorders will now be diagnosed with a somatic symptom disorder. In each case, individuals must be experiencing chronic somatic symptoms that are distressing to them and they must also be experiencing dysfunctional thoughts, feelings, and/or behaviors. In the past, the diagnosis required evidence that the symptoms were medically unexplained. However, as we noted earlier, this is no longer required for the diagnosis (in part because it is very difficult to prove something is medically unexplainable). Instead the focus in DSM-5 is on there being at least one of the following three features: (1) disproportionate and persistent thoughts about the seriousness of one’s symptoms; (2) persistently high level of anxiety about health or symptoms; and/or (3) excessive time and energy devoted to these symptoms or health concerns (Allen & Woolfolk, 2013). Symptoms have to have persisted for at least six months.Patients with somatic symptom disorder are usually seen in medical clinics. They are more likely to be female, nonwhite, and less educated than are people with symptoms that have an obvious medical basis. Patients with somatic symptom disorder frequently engage in illness behavior that is dysfunctional, such as seeking additional medical procedures or diagnostic tests when the physician fails to find anything physically wrong with them. Whereas most of us are relieved when tests do not reveal any problems, people with somatic symptom disorder are likely to think something was missed and therefore seek help from another physician, leading to needlessly high medical bills due to unnecessary tests, hospitalizations, and even surgeries. High levels of functional impairment are common, as is comorbid psychopathology—especially depression and anxiety.Research suggests that people with somatic symptom disorders tend to have a cognitive style that leads them to be hyper-sensitive to their bodily sensations. They also experience these sensations as intense, disturbing, and highly aversive. Another characteristic of such patients is that they tend to think catastrophically about their symptoms, often overestimating the medical severity of their condition.In the following sections, we will be discussing hypochondriasis, pain disorder, and somatization disorder. It’s important to note that in DSM-5, these disorders were technically dropped and are now part of the somatic symptom disorders. However, the history of and the research on these disorders is still important to understand.HypochondriasisDSM-5 criteria for: Somatic Symptom Disorder·  A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.·  B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:Dissociative Disorders and Trauma Discussion Assignment·  1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.·  2. Persistently high level of anxiety about health or symptoms.·  3. Excessive time and energy devoted to these symptoms or health concerns.·  C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.Approximately 75 percent of people previously diagnosed with hypochondriasis will be diagnosed with somatic symptom disorder in DSM-5 (APA,  2013 ). In  hypochondriasis  the person is preoccupied either with fears of contracting a serious disease or with the idea that of having that disease even though they do not. These very distressing preoccupations are thought to all be based on a misinterpretation of one or more bodily signs or symptoms (e.g., being convinced that a slight cough is a sign of lung cancer). Of course the decision that a complaint is hypochondriacal and is based on a misinterpretation of bodily signs or symptoms can only be made after a thorough medical evaluation has failed to find a medical condition that could account for the signs or symptoms. Another typical feature of hypochondriasis is that the person cannot be reassured by the results of a medical evaluation. In other words, the fear or idea of having a disease persists despite lack of medical evidence. Indeed, these individuals are sometimes disappointed when no physical problem is found. The condition has to persist for at least 6 months for the diagnosis to be made so as to not diagnose relatively transient health concerns.Not surprisingly, people with hypochondriasis usually first see a medical doctor for their physical complaints. Because they are never reassured for long and are inclined to suspect that their doctor has missed something, they sometimes shop for additional doctors, hoping one might discover what their problem really is. Because they repeatedly seek medical advice (e.g., Bleichhardt & Hiller,  2006 ; Fink et al.,  2004 ), it is hardly surprising that their annual medical costs are much higher than average (e.g., Fink et al.,  2010 ; Hiller et al.,  2004 ). People with hypochondriasis are generally resistant to the idea that their problem is a psychological one that might be best treated by a psychologist or psychiatrist.Dissociative Disorders and Trauma Discussion AssignmentPrior to DSM-5, hypochondriasis was one of the two most commonly seen somatic symptom disorders with a prevalence in general medical practices of 2 to 7 percent (APA,  2000 ). Hypochondriasis occurs about equally often in men and women and can start at almost any age, although early adulthood is the most common age of onset. Hypochondriasis is regarded as a persistent disorder if left untreated, although its severity can fluctuate over time. Individuals with hypochondriasis often also suffer from mood disorders, panic disorder, or other types of somatic symptom disorders (Creed & Barsky,  2004 ). This is one reason why hypochondriasis is now not differentiated from other somatic symptom disorders in DSM-5.MAJOR CHARACTERISTICSIndividuals with hypochondriasis tend to be highly preoccupied with bodily functions (e.g., heart beats or bowel movements), or with minor physical abnormalities (e.g., a small sore or an occasional cough), or with vague and ambiguous physical sensations (such as a “tired heart” or “aching veins”). They attribute these symptoms to a particular disease and often have intrusive thoughts about it. The diagnoses they make for themselves include cancer, exotic infections, AIDS, and numerous other diseases.  Watchthe Video Henry: Hypochondriasis on MyPsychLabAlthough people with hypochondriasis are usually in good physical condition, they are sincere in their conviction that the symptoms they detect represent real illness. In other words, they are not malingering—consciously faking symptoms to achieve a specific goals such as winning a personal injury lawsuit. Not surprisingly, given their tendency to doubt the soundness of their doctors’ conclusions (i.e., that they have no medical problem) and recommendations, the relationships they have with their doctors are often marked by conflict and hostility.The following case captures the typical clinical picture in hypochondriasis. It also demonstrates that a high level of medical sophistication does not necessarily protect someone from developing this or a related disorder.An “Abdominal Mass” This 38-year-old physician/radiologist initiated his first psychiatric consultation after his 9-year-old son accidentally discovered his father palpating (examining by touch) his own abdomen and said, “What do you think it is this time, Dad?” The radiologist describes the incident and his accompanying anger and shame with tears in his eyes. He also describes his recent return from a 10-day stay at a famous out-of-state medical diagnostic center to which he had been referred by an exasperated gastroenterologist colleague who had reportedly “reached the end of the line” with his radiologist patient. The extensive physical and laboratory examinations performed at the center had revealed no significant physical disease, a conclusion the patient reports with resentment and disappointment rather than relief.Dissociative Disorders and Trauma Discussion AssignmentThe patient’s history reveals a long-standing pattern of overconcern about personal health matters, beginning at age 13 and exacerbated by his medical school experience. Until fairly recently, however, he had maintained reasonable control over these concerns, in part because he was embarrassed to reveal them to other physicians. He is conscientious and successful in his profession and active in community life. His wife, like his son, has become increasingly impatient with his morbid preoccupation about life-threatening but undetectable diseases.In describing his current symptoms, the patient refers to his becoming increasingly aware, over the past several months, of various sounds and sensations emanating from his abdomen and of his sometimes being able to feel a “firm mass” in its left lower quadrant. His tentative diagnosis is carcinoma (cancer) of the colon. He tests his stool for blood weekly and palpates his abdomen for 15 to 20 minutes every 2 to 3 days. He has performed several X-ray studies of himself in secrecy after hours at his office.Source: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 88–90). Washington, DC: (Copyright © 2002). American Psychiatric Association.CAUSAL FACTORSOur knowledge of causal factors involved in somatic symptom disorders, including hypochondriasis, is quite minimal. This is especially true when compared to knowledge about the mood and anxiety disorders discussed in the preceding chapters. Currently, cognitive-behavioral views of hypochondriasis are perhaps most widely accepted. These have as a central tenet that it is a disorder of cognition and perception. Misinterpretations of bodily sensations are currently a defining feature of the syndrome, but in the cognitive-behavioral view these misinterpretations also play a causal role. It is believed that an individual’s past experiences with illnesses (in both him- or herself and others, and as observed in the mass media) lead to the development of a set of dysfunctional assumptions about symptoms and diseases that may predispose a person to developing hypochondriasis (Marcus et al.,  2007 ; Salkovskis & Warwick,  2001 ). These dysfunctional assumptions might include notions such as, “Bodily changes are usually a sign of serious disease, because every symptom has to have an identifiable physical cause” or “If you don’t go to the doctor as soon as you notice anything unusual, then it will be too late” (Salkovskis & Bass,  1997 , p. 318; see also Marcus et al.,  2007 ).Dissociative Disorders and Trauma Discussion AssignmentIndividuals with hypochondriasis are preoccupied with unrealistic fears of disease. They are convinced that they have symptoms of physical illness, but their complaints typically do not conform to any coherent symptom pattern, and they usually have trouble giving a precise description of their symptoms.Because of these dysfunctional assumptions, individuals with hypochondriasis seem to focus excessive attention on symptoms, with experimental studies showing that these individuals do in fact have an attentional bias for illness-related information (Owens et al.,  2004 ; see also Jasper & Witthöft,  2011 ). Although their physical sensations probably do not differ from those in normal controls (Marcus et al.,  2007 ), they perceive their symptoms as more dangerous than they really are and judge a particular disease to be more likely or dangerous than it really is. Once they have misinterpreted a symptom, they tend to look for confirming evidence and to discount evidence that they are in good health; in fact, they seem to believe that being healthy means being completely symptom-free (Rief et al.,  1998a ). They also perceive their probability of being able to cope with the illness as extremely low (Salkovskis & Bass,  1997 ) and see themselves as weak and unable to tolerate physical effort or exercise (Rief et al.,  1998a ). All this tends to create a vicious cycle in which their anxiety about illness and symptoms results in physiological symptoms of anxiety, which then provide further fuel for their convictions that they are ill.If we also consider the secondary reinforcements that individuals with hypochondriasis obtain by virtue of their disorder, we can better understand how such patterns of thought and behavior are maintained in spite of the misery these individuals often experience. Most of us learn as children that when we are sick special comforts and attention are provided and, furthermore, that we may be excused from a number of responsibilities. Barsky and colleagues ( 1994 ) found that their patients with hypochondriasis reported much childhood sickness and missing of school. People with hypochondriasis also tend to have an excessive amount of illness in their families while growing up, which may lead to strong memories of being sick or in pain (Pauli & Alpers,  2002 ), and perhaps also of having observed some of the secondary benefits that sick people sometimes reap (Cote et al.,  1996 ; Kellner,  1985 ).Interestingly, one study retested patients with hypochondriasis 4 to 5 years later and found that those who had remitted at follow-up had acquired significantly more (real) major medical problems than their nonremitting counterparts (Barsky et al.,  1998 ). In other words, it appears that hypochondriacal tendencies were reduced by the occurrence of serious medical conditions. The authors suggested that having a serious medical illness “served to legitimize the patients’ complaints, sanction their assumption of the sick role, and lessen the skepticism with which they had previously been regarded …. As one noted, ‘Now that I know Dr. X is paying attention to me, I can believe him if he says nothing serious is wrong’” ( p. 744 ).TREATMENT OF HYPOCHONDRIASISMore than a dozen studies on cognitive-behavioral treatment of hypochondriasis have found that it can be a very effective treatment for hypochondriasis (e.g., Barsky & Ahern,  2004 ; Tyrer,  2011 ; see also Hedman et al.,  2011 , for an example of Internet-based Cognitive Behavioral Therapy). The cognitive components of this treatment approach focus on assessing the patient’s beliefs about illness and modifying misinterpretations of bodily sensations. The behavioral techniques include having patients induce innocuous symptoms by intentionally focusing on parts of their body so that they can learn that selective perception of bodily sensations plays a major role in their symptoms. Sometimes they are also directed to engage in response prevention by not checking their bodies as they usually do and by stopping their constant seeking of reassurance. The treatment is relatively brief (6 to 16 sessions) and can be delivered in a group format. In these studies such treatment produced large changes in hypochondriacal symptoms and beliefs as well as in levels of anxiety and depression.Dissociative Disorders and Trauma Discussion AssignmentSomatization DisorderThe DSM-IV diagnosis of somatization disorder is another disorder that has now been subsumed into the broader category of somatic symptom disorder in DSM-5.  Somatization disorder  is characterized by many different physical complaints. To qualify for the diagnosis, these had to begin before age 30, last for several years, and not be adequately explained by independent findings of physical illness or injury. They also had to have led to medical treatment or to significant life impairment. Not surprisingly, somatization disorder has long been seen most often among patients in primary medical care settings (Guerje et al.,  1997 ; Iezzi et al.,  2001 ). Indeed, patients with this variant of somatic symptom disorder are enormously costly to health care systems because they often have multiple unnecessary hospitalizations and surgeries (Barsky et al.,  2005 ; Hiller et al.,  2003 ).The DSM-IV-TR (APA,  2000 ) criteria required that patients report a large number of symptoms across a wide range of domains (e.g., 4 pain symptoms, two gastrointestinal symptoms, one sexual symptom and one neurological-type symptom). Thus, to qualify for a diagnosis of somatization disorder, a patient had to have experienced at least 8 out of 33 specified symptoms (Rief & Barsky,  2005 ). Over time, the rather arbitrary nature of this became increasing apparent and the formal diagnostic criteria began to be modified by many researchers and clinicians (e.g., Rief & Broadbent,  2007 ). Following suit, in DSM-5 the long and complicated symptom count is no longer required and somatization disorder is now considered to be just another variant of somatic symptom disorder.Another advantage of the recent change in DSM-5 is that it is no longer necessary for us to be concerned about whether somatization disorder and hypochondriasis are really two different and distinct disorders. There are indeed significant similarities between the two conditions. They also sometimes co-occur (Mai,  2004 ). Some years ago leading researchers in this area expressed concerns about whether somatization disorder and hypochondriasis could really be regarded as separate disorders (e.g., Creed & Barsky,  2004 ). Combining them both into a common category in DSM-5 and considering them to be variants of somatic symptom disorder is probably a wise move.The main features of somatization disorder are illustrated in the following case summary, which also involves a secondary diagnosis of depression.Dissociative Disorders and Trauma Discussion AssignmentNot-Yet-Discovered Illness This 38-year-old married woman, the mother of five children, reports to a mental health clinic with the chief complaint of depression, meeting diagnostic criteria for major depressive disorder …. Her marriage has been a chronically unhappy one; her husband is described as an alcoholic with an unstable work history, and there have been frequent arguments revolving around finances, her sexual indifference, and her complaints of pain during intercourse.The history reveals that the patient … describes herself as nervous since childhood and as having been continuously sickly beginning in her youth. She experiences chest pain and reportedly has been told by doctors that she has a “nervous heart.” She sees physicians frequently for abdominal pain, having been diagnosed on one occasion as having a “spastic colon.” In addition to M.D. physicians, she has consulted chiropractors and osteopaths for backaches, pains in her extremities, and a feeling of anesthesia in her fingertips. She was recently admitted to a hospital following complaints of abdominal and chest pain and of vomiting, during which admission she received a hysterectomy. Following the surgery she has been troubled by spells of anxiety, fainting, vomiting, food intolerance, and weakness and fatigue. Physical examinations reveal completely negative findings.DEMOGRAPHICS, COMORBIDITY, AND COURSE OF ILLNESSSomatization disorder usually begins in adolescence and is believed by many to be about three to ten times more common among women than among men. It also tends to occur more among less educated individuals and in lower socioeconomic classes. The lifetime prevalence has been estimated to be between 0.2 and 2.0 percent in women and less than 0.2 percent in men (APA,  2000 ). Somatization disorder very commonly co-occurred with several other disorders including major depression, panic disorder, phobic disorders, and generalized anxiety disorder. It has generally been considered to be a relatively chronic condition with a poor prognosis, although sometimes the disorder remits spontaneously (e.g., Creed & Barsky,  2004 ).CAUSAL FACTORS IN SOMATIZATION DISORDERDespite its prevalence in medical settings, researchers are still not certain about the developmental course and specific etiology of somatization disorder. There is evidence that somatization disorder runs in families and that there is a familial linkage between antisocial personality disorder in men (see  Chapter 10 ) and somatization disorder in women. That is, one possibility is that some common, underlying predisposition, probably at least partly genetically based, leads to antisocial behavior in men and to somatization disorder in women (Cale & Lilienfeld,  2002b ; Guze et al.,  1986 ; Lilienfeld,  1992 ). Moreover, somatic symptoms and antisocial symptoms in women tend to co-occur (Cale & Lilienfeld,  2002b ). However, we do not yet have a clear understanding of this relationship. One possibility is that the two disorders are linked through a common trait of impulsivity.Dissociative Disorders and Trauma Discussion AssignmentIt has also become clear that people with somatization disorder selectively attend to, and show perceptual amplification of, bodily sensations. They also tend to see bodily sensations as somatic symptoms (Martin et al.,  2007 ). Like patients with hypochondriasis, they tend to catastrophize about minor bodily complaints (taking them as signs of serious physical illness) and to think of themselves as physically weak and unable to tolerate stress or physical activity (Martin et al.,  2007 ; Rief et al., 1998).TREATMENT OF SOMATIZATION DISORDERSomatization disorder was long considered to be extremely difficult to treat, and general practitioners experienced a great deal of uncertainty and frustration in working with these patients. However, in the past 15 years some treatment research has begun to suggest that a certain type of medical management along with cognitive-behavioral treatments may be quite helpful and that general practitioners can be educated in how to better manage and treat somatization patients and be less frustrated by them (Rosendal et al.,  2005 ; see also Edwards & Edwards,  2010 ). One moderately effective treatment involves identifying one physician who will integrate the patient’s care by seeing the patient at regular visits (thereby trying to anticipate the appearance of new problems) and by providing physical exams focused on new complaints (thereby accepting her or his symptoms as valid). At the same time, however, the physician avoids unnecessary diagnostic testing and makes minimal use of medications or other therapies (Looper & Kirmayer,  2002 ; Mai,  2004 ). Several studies have found that these patients show substantial decreases in health care expenditures over subsequent months and sometimes an improvement in physical functioning (although not necessarily in psychological distress; e.g., Rost et al.,  1994 ). This type of medical management can be even more effective when combined with cognitive-behavioral therapy that focuses on promoting appropriate behavior, such as better coping and personal adjustment, and discouraging inappropriate behavior such as illness behavior and preoccupation with physical symptoms (e.g., Bleichhardt et al.,  2004 ; Mai,  2004 ).Pain DisorderThe third DSM-IV diagnosis subsumed into the new category of somatic symptom disorder is pain disorder.  Pain disorder  is characterized by persistent and severe pain in one or more areas of the body that is not intentionally produced or feigned. Although a medical condition may contribute to the pain, psychological factors are judged to play an important role. Indeed psychological factors play a role in all forms of pain. The pain disorder may be acute (duration of less than 6 months) or chronic (duration of over 6 months). When working with patients with pain disorder it is very important to remember that the pain that is experienced is very real and can hurt as much as pain that comes from other sources. It is also important to note that pain is always, in part, a subjective experience that is private and cannot be objectively identified by others.Dissociative Disorders and Trauma Discussion AssignmentWhen one physician integrates a patient’s care, the physical functioning of patients with somatization disorder may improve. Why should this be?The experience of pain is always subjective and private, making pain impossible to assess with pinpoint accuracy. Pain does not always exist in perfect correlation with observable tissue damage or irritation. Psychological factors influence all forms of pain.The prevalence of pain disorder in the general population is unknown. It is definitely quite common among patients at pain clinics. It is diagnosed more frequently in women than in men and is very frequently comorbid with anxiety or mood disorders, which may occur first or may arise later as a consequence of the pain disorder. People with pain disorder are often unable to work (they sometimes go on disability) or to perform some other usual daily activities. Their resulting inactivity (including an avoidance of physical activity) and social isolation may lead to depression and to a loss of physical strength and endurance. This fatigue and loss of strength can then exacerbate the pain in a kind of vicious cycle (Bouman et al.,  1999 ; Flor et al.,  1990 ). In addition, the behavioral component of pain is quite malleable in the sense that it can increase when it is reinforced by attention, sympathy, or avoidance of unwanted activities (Bouman et al.,  1999 ). Finally, there is suggestive evidence that people who have a tendency to catastrophize about the meaning and effects of pain may be the ones most likely to progress to a state of chronic pain (Seminowicz & Davis,  2006 ).Dissociative Disorders and Trauma Discussion AssignmentTREATMENT OF PAIN DISORDERPerhaps because it is a less complex and multifaceted disorder than somatization disorder, pain disorder is usually easier to treat. Indeed, cognitive-behavioral techniques have been widely used in the treatment of both physical and more psychological pain syndromes. Treatment programs generally include relaxation training, support and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and reinforcement of “no-pain” behaviors (Simon,  2002 ). Patients receiving such treatments tend to show substantial reductions in disability and distress, although changes in the intensity of their pain tend to be smaller in magnitude. In addition, antidepressant medications (especially the tricyclic antidepressants) and certain SSRIs have been shown to reduce pain intensity in a manner independent of the effects the medications may have on mood (Aragona et al.,  2005 ; Simon,  2002 ).ILLNESS ANXIETY DISORDERIllness anxiety disorder is new to DSM-5. In this newly identified disorder, people have high anxiety about having or developing a serious illness. This anxiety is distressing and/or disruptive but there are very few (mild) somatic symptoms. (see the DSM-5 criteria box below).It is estimated that around 25 percent of people who would have been diagnosed with hypochondriasis in DSM-IV will be diagnosed with illness anxiety disorder in DSM-5 (APA,  2013 ).Conversion Disorder (Functional Neurological Symptom Disorder)DSM-5 criteria for: Illness Anxiety Disorder·  A. Preoccupation with having or acquiring a serious illness.·  B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.·  C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.·  D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).·  E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.Dissociative Disorders and Trauma Discussion Assignment·  F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.Conversion disorder  is one of the most intriguing and baffling patterns in psychopathology, and we still have much to learn about it. It involves a pattern in which symptoms or deficits affecting the senses or motor behavior strongly suggest that the patient has a medical or neurological condition. However, upon a thorough medical examination, it becomes apparent that the pattern of symptoms or deficits cannot be fully explained by any known medical condition. A few typical examples include partial paralysis, blindness, deafness, and pseudoseizures. The person is not intentionally producing or faking the symptoms, Rather, psychological factors are often judged to play an important role because symptoms usually either start or are exacerbated by preceding emotional or interpersonal conflicts or stressors.Early observations dating back to Freud suggested that most people with conversion disorder showed very little of the anxiety and fear that would be expected in a person with a paralyzed arm or loss of sight. This seeming lack of concern (known as la belle indifférence—French for “the beautiful indifference”) in the way the patient describes what is wrong was thought for a long time to be an important diagnostic criterion for conversion disorder. However, more careful research later showed that la belle indifférenceactually occurs in only about 20 percent of patients with conversion disorder, so it was dropped as a criterion from recent editions of the DSM (Stone et al.,  2006 , 2011).The term conversion disorder is relatively recent. Historically this disorder was one of several disorders that were grouped together under the term  hysteria .Freud used the term conversion hysteria for these disorders (which were fairly common in his practice) because he believed that the symptoms were an expression of repressed sexual energy—that is, the unconscious conflict that a person felt about his or her repressed sexual desires. However, in Freud’s view, the repressed anxiety threatens to become conscious, so it is unconsciously converted into a bodily disturbance, thereby allowing the person to avoid having to deal with the conflict. For example, a person’s guilty feelings about the desire to masturbate might be solved by developing a paralyzed hand. This is not done consciously, of course, and the person is not aware of the origin or meaning of the physical symptom. Freud also thought that the reduction in anxiety and intrapsychic conflict was the “primary gain” that maintained the condition, but he noted that patients often had many sources of “secondary gain” as well, such as receiving sympathy and attention from loved ones. Authors of DSM-5 had many suggestions for changing the name of this disorder (e.g., to psychogenic, functional, and dissociative). In the end, a conservative approach was taken and the term conversion disorder was retained, although this is now followed in parentheses by “Functional neurological symptom disorder” (Stone et al., 2011).Dissociative Disorders and Trauma Discussion AssignmentPRECIPITATING CIRCUMSTANCES, ESCAPE, AND SECONDARY GAINSFreud’s theory that conversion symptoms are caused by the conversion of sexual conflicts or other psychological problems into physical symptoms is no longer accepted outside psychodynamic circles. However, many of Freud’s astute clinical observations about primary and secondary gain are still incorporated into contemporary views of conversion disorder. Although the condition is still called a conversion disorder, the physical symptoms are usually seen as serving the rather obvious function of providing a plausible bodily “excuse” enabling an individual to escape or avoid an intolerably stressful situation without having to take responsibility for doing so. Typically, it is thought that the person first experiences a traumatic event that motivates the desire to escape the unpleasant situation, but literal escape may not be feasible or socially acceptable. Moreover, although becoming sick or disabled is more socially acceptable, this is true only if the person’s motivation to do so is unconscious.Thus, in contemporary terms, the  primary gain  for conversion symptoms is continued escape or avoidance of a stressful situation. Because this is all unconscious (i.e., the person sees no relation between the symptoms and the stressful situation), the symptoms go away only if the stressful situation has been removed or resolved. Relatedly, the term  secondary gain , which originally referred to advantages that the symptom(s) bestow beyond the “primary gain” of neutralizing intrapsychic conflict, has also been retained. Generally, it is used to refer to any “external” circumstance, such as attention from loved ones or financial compensation, that would tend to reinforce the maintenance of disability.DSM-5 criteria for: Conversion Disorder·  A. One or more symptoms of altered voluntary motor or sensory function.·  B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.·  C. The symptom or deficit is not better explained by another medical or mental disorder.·  D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.Given the important role often attributed to stressful life events in precipitating the onset of conversion disorder, it is unfortunate that little is actually known about the exact nature and timing of these psychological stress factors (Roelofs et al.,  2005 ). However, one study compared the frequency of stressful life events in the recent past in patients with conversion disorder and depressed controls and did not find a difference in frequency between them. Moreover, the greater the negative impact of the preceding life events, the greater the severity of the conversion disorder symptoms (Roelofs et al.,  2005 ). Another study compared levels of a neurobiological marker of stress (lower levels of brain-derived neurotropic factor) in individuals with conversion disorder versus major depression versus no disorder. Both those with depression and those with conversion disorder showed reduced levels of this marker relative to the nondisordered controls (Deveci et al.,  2007 ). This also provides support for the link between stress and the onset of conversion disorder.Dissociative Disorders and Trauma Discussion AssignmentDECREASING PREVALENCE AND DEMOGRAPHIC CHARACTERISTICSConversion disorders were once relatively common in civilian and (especially) military life. In World War I, conversion disorder was the most frequently diagnosed psychiatric syndrome among soldiers; it was also relatively common during World War II. Conversion disorder typically occurred under highly stressful combat conditions and involved men who would ordinarily be considered stable. Here, conversion symptoms—such as paralysis of the legs—enabled a soldier to avoid an anxiety-arousing combat situation without being labeled a coward or being subject to court-martial.Conversion disorders are found in approximately 50 percent of people referred for treatment at neurology clinics. The prevalence in the general population is unknown, but even the highest estimates have been around only 0.005 percent (APA,  2013 ). Interestingly, this decreased prevalence seems to be closely related to our growing sophistication about medical and psychological disorders: A conversion disorder apparently loses its defensive function if it can be readily shown to lack a medical basis. When it does occur today, it is most likely to occur in rural people from lower socioeconomic circles who are medically unsophisticated. For example, a highly unusual “outbreak” of cases of severe conversion disorder involving serious motor weakness and wasting symptoms was reported in five 9- to 13-year-old girls living in a small, poor, rural Amish community. Each of these girls had experienced substantial psychosocial stressors including behavioral problems, dys-functional family dynamics, and significant community stress from a serious local church crisis (see Cassady et al.,  2005 ). Fortunately, after the caregivers of these girls were educated regarding the psychological nature of the symptoms and given advice to stick with one doctor, minimize stress, and avoid reinforcement of the “sick role,” four of the five girls showed significant improvement over the next 3 months. In the fifth case, the family refused to acknowledge the psychological component of the illness, holding to the belief that the symptoms were caused by parasites.Dissociative Disorders and Trauma Discussion AssignmentConversion disorders were fairly common during World War I and World War II. The disorder typically occurred in otherwise “normal” men during stressful combat conditions. The symptoms of conversion disorder (e.g., paralysis of the legs) enabled a soldier to avoid high-anxiety combat situations without being labeled a coward or being court-martialed.Conversion disorder occurs two to three times more often in women than in men (APA  2013 ). It can develop at any age but most commonly occurs between early adolescence and early adulthood (Maldonado & Spiegel,  2001 ). It generally has a rapid onset after a significant stressor and often resolves within 2 weeks if the stressor is removed, although it commonly recurs. In many other cases, however, it has a more chronic course. Like most other somatic symptom disorders, conversion disorder frequently occurs along with other disorders, especially major depression, anxiety disorders, and other forms of somatic symptom or dissociative conditions.RANGE OF CONVERSION DISORDER SYMPTOMSThe range of symptoms for conversion disorder is practically as diverse as it is for physically based ailments. In describing the clinical picture in conversion disorder, it is useful to think in terms of four categories of symptoms: (1) sensory, (2) motor, (3) seizures, and (4) a mixed presentation of the first three categories (APA,  2013 ).Sensory Symptoms or Deficits Conversion disorder can involve almost any sensory modality, and it can often be diagnosed as a conversion disorder because symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate. Today the sensory symptoms or deficits are most often in the visual system (especially blindness and tunnel vision), in the auditory system (especially deafness), or in the sensitivity to feeling (especially the anesthesias). In the anesthesias, the person loses her or his sense of feeling in a part of the body. One of the most common is glove anesthesia, in which the person cannot feel anything on the hand in the area where gloves are worn, although the loss of sensation usually makes no anatomical sense.With conversion blindness, the person reports that he or she cannot see and yet can often navigate about a room without bumping into furniture or other objects. With conversion deafness, the person reports not being able to hear and yet orients appropriately upon “hearing” his or her own name. Such observations lead to obvious questions: In conversion blindness (and deafness), can affected people actually not see (or hear), or is the sensory information received but screened from consciousness? In general, the evidence supports the idea that the sensory input is registered but is somehow screened from explicit conscious recognition (explicit perception).Motor Symptoms or Deficits Motor conversion reactions also cover a wide range of symptoms (e.g., Maldonado & Spiegel,  2001 ; see also Stone et al., 2010). For example, conversion paralysis is usually confined to a single limb such as an arm or a leg, and the loss of function is usually selective for certain functions. For example, a person may not be able to write but may be able to use the same muscles for scratching, or a person may not be able to walk most of the time but may be able to walk in an emergency such as a fire where escape is important. The most common speech-related conversion disturbance is aphonia, in which a person is able to talk only in a whisper although he or she can usually cough in a normal manner. (In true, organic laryngeal paralysis, both the cough and the voice are affected.) Another common motor symptom, called globus hystericus, is difficulty swallowing or the sensation of a lump in the throat (Finkenbine & Miele,  2004 ).Dissociative Disorders and Trauma Discussion AssignmentSeizures Conversion seizures, another relatively common form of conversion symptom, involve pseudoseizures, which resemble epileptic seizures in some ways but can usually be fairly well differentiated via modern medical technology (Bowman & Markand,  2005 ; Stonnington et al.,  2006 ). For example, patients with pseudoseizures do not show any EEG abnormalities and do not show confusion and loss of memory afterward, as patients with true epileptic seizures do. Moreover, patients with conversion seizures often show excessive thrashing about and writhing not seen with true seizures, and they rarely injure themselves in falls or lose control over their bowels or bladder, as patients with true seizures frequently do.The following case of conversion disorder clearly shows how “functional” a conversion disorder may be in the overall life circumstances of a patient despite its exacting a certain cost in illness or disability.A Wife with “Fits” Mrs. Chatterjee, a 26-year-old patient, attends a clinic in New Delhi, India, with complaints of “fits” for the last 4 years. The “fits” are always sudden in onset and usually last 30 to 60 minutes. A few minutes before a fit begins, she knows that it is imminent, and she usually goes to bed. During the fits she becomes unresponsive and rigid throughout her body, with bizarre and thrashing movements of the extremities. Her eyes close and her jaw is clenched, and she froths at the mouth. She frequently cries and sometimes shouts abuses. She is never incontinent of urine or feces, nor does she bite her tongue. After a “fit” she claims to have no memory of it. These episodes recur about once or twice a month. She functions well between the episodes.Both the patient and her family believe that her “fits” are evidence of a physical illness and are not under her control. However, they recognize that the fits often occur following some stressor such as arguments with family members or friends …. She is described by her family as being somewhat immature but “quite social” and good company. She is self-centered, she craves attention from others, and she often reacts with irritability and anger if her wishes are not immediately fulfilled. On physical examination, Mrs. Chatterjee was found to have mild anemia but was otherwise healthy. A mental status examination did not reveal any abnormality … and her memory was normal. An electroencephalogram showed no seizure activity.Dissociative Disorders and Trauma Discussion AssignmentSource: Adapted with permission from DSM-IV-TR Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (pp. 469–70). Washington, DC. (Copyright © 2002). American Psychiatric Association.IMPORTANT ISSUES IN DIAGNOSING CONVERSION DISORDERBecause the symptoms in conversion disorder can simulate a variety of medical conditions, accurate diagnosis can be extremely difficult. It is crucial that a person with suspected conversion symptoms receive a thorough medical and neurological examination. Unfortunately, however, misdiag-noses can still occur. Nevertheless, as medical tests (especially brain imaging) have become increasingly sophisticated, the rate of misdiagnoses has declined substantially from in the past, with estimates of misdiagnoses in the 1990s at only 4 percent down from nearly 30 percent in the 1950s (e.g., Stone et al.,  2005 ).Several other criteria are also commonly used for distinguishing between conversion disorders and true neurological disturbances:·  • The frequent failure of the dysfunction to conform clearly to the symptoms of the particular disease or disorder simulated. For example, little or no wasting away or atrophy of a “paralyzed” limb occurs in conversion paralyses, except in rare and long-standing cases. Virtually all the symptoms of conversion disorder can be temporarily reduced or reproduced by hypnotic suggestion.·  • The selective nature of the dysfunction. As already noted, in conversion blindness the affected individual does not usually bump into people or objects, and “paralyzed” muscles can be used for some activities but not others.·  • Under hypnosis or narcosis (a sleeplike state induced by drugs), the symptoms can usually be removed, shifted, or re-induced at the suggestion of the therapist. Similarly, a person abruptly awakened from a sound sleep may suddenly be able to use a “paralyzed” limb.Dissociative Disorders and Trauma Discussion AssignmentTREATMENT OF CONVERSION DISORDEROur knowledge of how best to treat conversion disorder is very limited because few well-controlled studies have yet been conducted (e.g., Bowman & Markand,  2005 ; Looper & Kirmayer,  2002 ). However, it is known that some hospitalized patients with motor conversion symptoms have been successfully treated with a behavioral approach in which specific exercises are prescribed in order to increase movement or walking, and then reinforcements (e.g., praise and gaining privileges) are provided when patients show improvements. Any reinforcements of abnormal motor behaviors are removed in order to eliminate any sources of secondary gain. In one small study using this kind of treatment for 10 patients, all had regained their ability to move or walk in an average of 12 days, and for seven of the nine patients available at approximately 2-year follow-up, the improvements had been maintained (Speed,  1996 ). At least one study has also used cognitive-behavior therapy to successfully treat psychogenic seizures (LaFrance et al.,  2009 ). Some studies have used hypnosis combined with other problem-solving therapies, and there are some suggestions that hypnosis, or adding hypnosis to other therapeutic techniques, can be useful (Looper & Kirmayer,  2002 ; Moene et al.,  2003 ).Distinguishing Somatization, Pain, and Conversion Disorders from Malingering and Factitious DisorderDSM-5 criteria for: Factitious DisorderFactitious Disorder Imposed on Self·  A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.·  B. The individual presents himself or herself to others as ill, impaired, or injured.·  C. The deceptive behavior is evident even in the absence of obvious external rewards.·  D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.Earlier we mentioned that the DSM distinguishes between malingering and factitious disorder on the basis of the feigning person’s apparent goals. Malingering is diagnosed if the person is intentionally producing or grossly exaggerating physical symptoms and is motivated by external incentives such as avoiding work or obtaining financial compensation. Factitious disorder is diagnosed if the person intentionally produces psychological or physical symptoms, the person’s goal being simply to obtain and maintain the personal benefits that playing the “sick role” (even undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel. In factitious disorder, frequently these patients surreptitiously alter their own physiology—for example, by taking drugs—in order to simulate various real illnesses. Indeed, they may be at risk for serious injury or death and may even need to be committed to an institution for their own protection. The World Around Us box above describes a particularly pathological variation on this theme. In the past, severe and chronic forms of factitious disorder with physical symptoms were called “Munchausen’s syndrome,” where the general idea was that the person had some kind of “hospital addiction” or a “professional patient” syndrome.the WORLD around us: Factitious Disorder Imposed on Another (Munchausen’s Syndrome by Proxy)In a somewhat bizarre variant of factitious disorder called factitious disorder imposed on another (or Munchausen’s syndrome by proxy), the person seeking medical help or consulting a mental health professional has intentionally produced a medical or psychiatric illness (or appearance of an illness) in another person who is under his or her care (usually a child; e.g., Pankratz,  2006 ). In a typical instance, a mother presents her own child for treatment of a medical condition she has deliberately caused, disclaiming any knowledge of its origin. Of course, the health of such victims is often seriously endangered by this repeated abuse, and the intervention of social service agencies or law enforcement is sometimes necessary. In as many as 10 percent of cases, this atypical form of child abuse may lead to a child’s death (Hall et al.,  2000 ).Dissociative Disorders and Trauma Discussion AssignmentOver a period of 20 months, Jennifer, 8, shown here with her mother, Kathy Bush, was taken to the hospital more than 130 times, underwent 40 surgeries, and amassed over $3 million in medical expenses. Doctors and nurses testified that Jennifer’s condition always worsened after her mother visited her daughter at the hospital behind closed doors. In addition, Jennifer’s health had significantly improved since being removed from her mother’s care. The jury was convinced that Kathy Bush was responsible for causing Jennifer’s illnesses. Bush was arrested and diagnosed with Munchausen’s syndrome by proxy.This disorder may be indicated when the victim’s clinical presentation is atypical, when lab results are inconsistent with each other or with recognized diseases, or when there are unduly frequent returns or increasingly urgent visits to the same hospital or clinic. The perpetrators (who often have extensive medical knowledge) tend to be highly resistant to admitting the truth (McCann,  1999 ), and it has been estimated that the average length of time to confirm the diagnosis is 14 months (Rogers,  2004 ). If the perpetrator senses that the medical staff is suspicious, he or she may abruptly terminate contact with that facility, only to show up at another one to begin the entire process anew. Compounding the problem of detection is the fact that health care professionals who realize they have been duped may be reluctant to acknowledge their fallibility for fear of legal action. Misdiagnosing the disorder when the parent is in fact innocent can also lead to legal difficulties for the health care professionals (McNicholas et al.,  2000 ; Pankratz,  2006 ). One technique that has been used with considerable success is covert video surveillance of the mother and child during hospitalizations. In one study, 23 of 41 suspected cases were finally determined to have factitious disorder by proxy, and in 56 percent of those cases video surveillance was essential to the diagnosis (Hall et al.,  2000 ).It is sometimes possible to distinguish between a conversion (or other somatic symptom) disorder and malingering, or factitiously “sick-role-playing,” with a fair degree of confidence, but in other cases it is more difficult to make the correct diagnosis. Persons engaged in malingering (for which there are no formal diagnostic criteria) and those who have factitious disorder are consciously perpetrating frauds by faking the symptoms of diseases or disabilities, and this fact is often reflected in their demeanor. In contrast, individuals with conversion disorders (as well as with other somatic symptom disorders) are not consciously producing their symptoms, feel themselves to be the “victims of their symptoms,” and are very willing to discuss them, often in excruciating detail (Maldonado & Spiegel,  2001 , p. 109). When inconsistencies in their behaviors are pointed out, they are usually unperturbed. Any secondary gains they experience are byproducts of the conversion symptoms themselves and are not involved in motivating the symptoms. On the other hand, persons who are feigning symptoms are inclined to be defensive, evasive, and suspicious when asked about them; they are usually reluctant to be examined and slow to talk about their symptoms lest the pretense be discovered. Should inconsistencies in their behaviors be pointed out, deliberate deceivers as a rule immediately become more defensive. Thus conversion disorder and deliberate faking of illness are considered distinct patterns.Dissociative Disorders and Trauma Discussion Assignmentin review·  ● What are the primary characteristics of hypochondriasis, and how does the cognitive-behavioral viewpoint explain their occurrence?·  ● What are the symptoms of somatization disorder and of pain disorder?·  ● What are sources of primary and secondary gains involved in conversion disorders, and how is conversion disorder distinguished from malingering and from factitious disorder?Dissociative DisordersDissociative disorders  are a group of conditions involving disruptions in a person’s normally integrated functions of consciousness, memory, identity, or perception (APA,  2013 ; Spiegel et al.,  2013 ). Included here are some of the more dramatic phenomena in the entire domain of psychopathology: people who cannot recall who they are or where they may have come from, and people who have two or more distinct identities or personality states that alternately take control of the individual’s behavior.The term  dissociation  refers to the human mind’s capacity to engage in complex mental activity in channels split off from, or independent of, conscious awareness (Kihlstrom,  1994 ,  2001 ,  2005 ). The concept of dissociation was first promoted over a century ago by the French neurologist Pierre Janet (1859–1947). We all dissociate to a degree some of the time. Mild dissociative symptoms occur when we daydream or lose track of what is going on around us, when we drive miles beyond our destination without realizing how we got there, or when we miss part of a conversation we are engaged in. As these everyday examples suggest, there is nothing inherently pathological about dissociation itself. Dissociation only becomes pathological when the dissociative symptoms are “perceived as disruptive, invoking a loss of needed information, as producing discontinuity of experience” or as “recurrent, jarring involuntary intrusions into executive functioning and sense of self” (Spiegel et al., 2011, p. E19).Much of the mental life of all human beings involves automatic nonconscious processes that are to a large extent autonomous with respect to deliberate, self-aware direction and monitoring. Such unaware processing extends to the areas of implicit memory and implicit perception, where it can be demonstrated that all persons routinely show indirect evidence of remembering things they cannot consciously recall ( implicit memory ) and respond to sights or sounds as if they had perceived them (as in conversion blindness or deafness) even though they cannot report that they have seen or heard them ( implicit perception ; Kihlstrom,  2001 ,  2005 ; Kihlstrom et al.,  1993 ). As we learned in  Chapter 3 , the general idea of unconscious mental processes has been embraced by psychodynamically oriented clinicians for many years. But only in the past 30 years has it also become a major research area in the field of cognitive psychology (though without any of the psychodynamic implications for why so much of our mental activity is unconscious).Dissociative Disorders and Trauma Discussion AssignmentIn people with dissociative disorders, however, this normally integrated and well-coordinated multichannel quality of human cognition becomes much less coordinated and integrated. When this happens, the affected person may be unable to access information that is normally in the forefront of consciousness, such as his or her own personal identity or details of an important period of time in the recent past. That is, the normally useful capacity of maintaining ongoing mental activity outside of awareness appears to be subverted, sometimes for the purpose of managing severe psychological threat. When that happens, we observe the pathological dissociative symptoms that are the cardinal characteristic of dissociative disorders. Like somatic symptom disorders, dissociative disorders appear mainly to be ways of avoiding anxiety and stress and of managing life problems that threaten to overwhelm the person’s usual coping resources. Both types of disorders also enable the individual to deny personal responsibility for his or her “unacceptable” wishes or behavior. In the case of DSM-defined dissociative disorders, the person avoids the stress by pathologically dissociating—in essence, by escaping from his or her own autobiographical memory or personal identity. The DSM-5 recognizes several types of pathological dissociation. These include depersonalization/derealization disorder, dissociative amnesia, dissociative fugue (a subtype of dissociative amnesia) and dissociative identity disorder. Dissociative Disorders and Trauma Discussion Assignment

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