Episode 8 - PTSD, Dissociative & Somatoform Disorders

I didn't see that up there. Okay, so today we're going to talk about Dissociative and some Matterform Disorders. We're also going to talk about PTSD a little bit. By the way, I said I have your quizzes from last time and I'll get those back to you. Let me give you some details on that. Any questions or anything else you want me to cover in more detail for this chapter, something that was confusing maybe? Yeah, well definitely people are not making them up except in the case of malingering. And Munchaus and Syndrome. But most of the people who have the other somatopharm disorders genuinely experience the symptoms, the physiological symptoms. There's just no physiological cause. Yeah, but we'll get into that when I talk about somatopharm too. Anything else? Anything that sticks out? So let's talk about, what are we going to talk about first? I think, oh there we go. We're going to talk about PTSD. The key feature of PTSD or the key factor in onset of PTSD rather is the idea that someone is exposed to some sort of a traumatic event and that exposure can include anything from witnessing some sort of horrific event to actually being injured and severely, possibly severely injured to the point of almost dying from the event. But it's also important that at the same time that that event is occurring, they also experience intense feelings of fear, helplessness and horror. Of course it's difficult to imagine that anybody going through severely traumatic events like rape or combat wouldn't feel those ways. But often times you can be exposed to these events and not have these kinds of feelings. But the more intensely you are immersed in those events, the more likely that PTSD symptoms may emerge. It's also another requirement of the diagnosis is the idea that people actually re-experience the event. And they can do that in a variety of ways, oftentimes that comes in the form of nightmares. So while they're sleeping, they'll have these very intense, very realistic nightmares about the event. And sometimes they'll just have flashback memories. And oftentimes these flashback memories are triggered by maybe some sort of sound or some sort of visual stimulus that is in some way related to the event. There should be a parenthesis after being there again. Because they also need to have these psychological and/or physiological reactions to stimuli cues, stimuli in the environment that may resemble the event or somehow cause it to be brought back into memory. You know, basically from your Psych 201 memory, the idea is that our memory is composed of nodes and each of those nodes roughly corresponds to some sort of part of a memory. And memories are composed by the associations that are formed between the nodes. This is known as the associative network model of memory. And what will happen is, let's put another node out here. What will happen is if you get a cue that triggers a particular node in memory, what happens is this thing called spreading activation, and in spreading activation all of these associative links get activated. And so you get back a whole complex set of memories just from one stimuli in the environment that acts as a cue for memory. So all you have to do is encounter a sound or a site that somehow maybe even tangentially related to the original event and these memories and experiences really, like you're actually there, they'll come back, they'll come flooding back. It also, the diagnosis also needs persistent autonomic nervous system arousal. So you're persistently kind of, you know, physiological symptoms of anxiety, you know, heart rates elevated, maybe respiration is elevated, you know, you're sort of in a constant state of stress, physiologic stress response. And the diagnosis requires that the duration be more than one month, but one month of this is pretty awful. So yeah, question, Victor. That's one of the hypotheses, and we'll talk about that when we talk about the two-factor model, yeah. So you know, it is, it is conceptually related to specific phobias in that way, yeah. So frequent comorbidity, substance use disorders very common, alcohol use, for example, in order to deal with the traumatic memories and the really traumatic experiences you have re-experiencing the event. Also high levels of anxiety disorders and depressive disorders, major depressive disorders, typically not bipolar disorders. Questions, comments, ideas? Let's take a look at a little video clip of a fellow who has combat-related PTSD. Hopefully this will play normally. Okay, for some reason this video is making my computer run really slowly. Well, the first disorder is a severe psychological and emotional reaction that resolves from exposure to profound and stressful situations. PTSD can result from exposure to situations such as assault, rape, natural disasters, and war. The symptoms must last at least a month and often last for much longer. For example, it is estimated that roughly 15% of Vietnam veterans still suffered from PTSD, 15 or more years after the war. In the following interview, Carl, a 46-year-old veteran, describes some of his combat experiences in Vietnam. Carl volunteered for the Army when he was 17 years old and served as a door-gunner in a search and destroying helicopter. You want that with little bit because he looked right straight up and showing that he's not all of a sudden his eyes come up and you make contact as you squeeze and turn and just pay off. They're trying to get their weapons up and it's already too late. I mean I'm prepared with an M60 at that range and you're probably a hundred feet above them as all shooting down to the general but it's not that hard to hit with your M60s putting up to a fair amount of ammo per second and so it just exploded. I can't say that I saw the rounds hit but I saw people dropping and falling and the guy that was standing back here he started to move away and I'm spraying the whole area and when we came back over and rolled back in to take a look we didn't get any fire so then we had rich men that either they had left or they were dead so covered and then that happened and put them all back in and we called them back and we came in and we had a five dad with their weapons and probably both in the river and the story goes so we had to pack up the rounds and a good one, a great one here and it worked and worked great when nobody used it and felt exoried and felt just fucking crazy. It worked absolutely perfect and going there. When Carl returned to the United States he felt alienated from the people around him. Few people could understand the traumas he'd experienced. His feelings of isolation, anger and pain contributed to the development of his symptoms of post-traumatic stress disorder. You're coming back from Vietnam as a single person that came back. I flew back from the group of guys, got off the airplane and went home but I wasn't with anybody in my unit. I was by myself. I went back home. There wasn't anybody else in town at the time that had been in Vietnam that I knew about. Eventually I did find out that we're some, a great deal in Portland and I was Washington but there were some, nobody asked anything, they wanted to know how many people you've killed, they wanted to know that side of it but they don't want to talk about what it's really like or what it was like for you, just want to talk about the goren stuff. What I figured out, when I came back on my second week, I had some pictures and I took a nap on my and the pictures holding the head, rubbed it down my arms and people asked me, and these pictures still look at it and they shut up and go away, saw a bunch of people in school and things like that. They're still hanging out at these vertical, wherever in Hamburg and everywhere. I just, there were kids and I wasn't a kid anymore and I'd never be able to see the world the way they did it and that's, yeah, I just, I really felt like I was really different. That's one of the biggest losses, I think, is enough for anything because you love it and you love it and you love it and you love it and you love it and you love it and you love it. I feel I'm free to have the happy and joy of life as a child, without all the horrific destruction and that's a lot of work as I think back to what I think about what all the kids have done. That's probably the hardest part about the end of afterwards, but people didn't care. In the following sequences, Karl describes many of the symptoms that are typical of people with post-traumatic stress disorder, including heightened vigilance, flashbacks, startled responses and intrusive thoughts. He also describes some of the strategies that help him to cope with his disorder. I went back to school after I started PTSD treatment and back in college and started out. I always sit in the far left classroom all by the window and I was back in the room. My mother told me that I was going to commit, and I didn't have all the wishes to make it where it was any possibility I had to end with what I am going to sit down, I knew which guy the door was locked in and I had a flashback of bowling. Now I kept bowling and I kept seeing this panty-dike corner of panty-dike. It was trees, rubber trees just beyond it. As an infantry squad came down, there was groups on the other side of the trees. They were shooting, and we're in a helicopter trying to be right fire. But we can't get an angle when we can shoot the panty-dike. It was actually real bad luck. I kept writing it, I kept seeing this. I could hear the shot, I could smell it. I can smell it, I don't know if it's not there, but it was a smooth one. When I started my angry immediately, the yelled at the kids. I got started all the way around the night and we'll sleep for the gun close to me, because the first thing I'm going to do is welcome two quicks and grab a gun. Life learns that she locks to the door and says her name. She doesn't come shake you or grab you because to wake you that way is you're going to get hit. That bothers me that I was in a meeting a couple of years ago with other professionals. A window dropped and slammed on the case behind me, and I threw a cup of coffee on the table with my peers. And I was just so angry. I had a nightmare in trucey thoughts for a number of years. A pile of bodies that follows me around, mostly skeletal. I don't like going to another board there, the skull, you see in the eyes. This is just huge, overwhelming pile of bodies. You don't know anybody who does it. My sleep starts getting off and I start sleeping less. I don't know if there's something stressful going on that I need to deal with. One thing I know about PTSD is it's a stress-related disorder. I manage to stress in my life, symptoms stay down. So I'm going to do my sleep. The next one for me is a hypervigilance. And if it gets to that point, I'm starting to look and pay more attention to things, and get anxious about things and learn. around to meet people, I know there's something special going on. I'm a third one in line for me, it's just not always fun. And so I kind of watched the symptoms also. And each person has those ones who are really personal. I think that helped them so well. Carl profoundly regrets the boss of his innocence that occurred during these years of combat. As a Native American, however, he takes a consolation in tribal beliefs about the essential role of the warrior in guaranteeing the survival of his people. Look over there, thank you. The women and the children are the most important. It's why the warrior walks at the front. I know because he's expendable on that. It's OK because you're defending and keeping that alive. Keep it going, and that's a good concept. That's the way it's supposed to be. If you don't take care of the women and children, you don't have the ability to go on. And that really helps to have something like that to look for, to look at, to be a part of. So it's OK for me to have sacrificed and do that. Because it helps keep that going. Someone has to do it. Someone has to be willing. Any comments on that? It's hard to watch, huh? There's a lot of suffering there. And it's particularly relevant because every day, we have hundreds, if not thousands, of soldiers coming back from Iraq that are at risk for developing PTSD. So-- and one of the problems with the current war is that a lot of the soldiers are being drawn from reserve units. And the reserve-- I'm sorry, not the reserve units, but the national guard units. And the national guard units don't typically have the same kinds of reintegration programs that the career military does. And reintegration programs slowly reintroduce the soldier from the role of a trained killer to the role of a civilian. Because those are very different roles, very different experiences. And it's necessary to make that adjustment. Because of a lot of what he's saying, that once you've gone through an experience like this, it's hard to relate to other people that don't have that experience, and that still have the innocence about war and our place. And Victor, do you have a question? One of the things he mentioned was he got a lot of almost negative responses. Yep. During that time, period, there was a lot of pain in the response to it being on the soldiers. Yep. Today, I think we've learned, on this big sport, we're not feeling that the soldiers came back to have a little bit more reintegration. So the question is, since American culture, generally tends to view the soldiers differently that are returning from Iraq, then American culture did with soldiers returning from Vietnam. Will the-- I'm sorry, will the Iraq veterans have a lower incidence of PTSD? I don't know what the statistics look like right now. That's just really one factor in the development of the disorder, though. And it's really going to depend-- a lot of it will depend on the other kinds of social support that those soldiers have. And we'll talk about that in a second. I know that I had that similar experience of loss of innocence and having difficulty relating to people when I was at Whitman College. And I was an undergraduate, and I got cancer. And I had to go for chemotherapy. And I remember that feeling of coming back and looking at these students, who they were making plans for the rest of their life as if nothing bad would ever happen to them. And it was this weird kind of dichotomy that I remember experiencing. I wish I could live back in that innocence again. And ultimately, I healed from that. I was able to feel that kind of innocence and optimism for the future again. But it is really difficult when you go through one of those experiences. And it's really life changing and transforming. So then the issue with PTSD becomes, what are the factors that are relevant to the risk of developing PTSD? Because not everybody who goes through an experience like this, some people are going to go through tremendously more horrific experiences than do people who get PTSD. Just because you go through one of these horrific experiences doesn't mean you're going to develop PTSD. So what are some of the factors in risk? And then what are some of the factors in resilience to avoiding the onset of PTSD? Well, first of all, one of the main risks is how intense was the stress that you went through. And that will vary oftentimes on exactly how physically affecting that the experience is. Typically, people are more at risk if they're more physically affected than people who just observe a horrific experience, right? Social support is going to be a huge factor in risk. Those people who have very good social support networks, families, friends, relationship partners who are patient and able to help the individual work through the symptoms and then find some treatment. That's a real important factor. And then the victor was asking about classically conditioned fears. And so your book talks about this idea of the two-factor theory that the PTSD, these experiences, cause classically conditioned responses, physiological and psychological responses. And it works in tandem with operant conditioning because the avoidance is reinforcing for those fears, right? I'm sorry, the avoidance is reinforced. It's a reinforcing consequence of not dealing with-- you feel better so you're not dealing with those fears rather than confronting the fears. And we talked about this with anxiety disorders that unless you go through an extinction procedure and you just engage in avoidance, you're never going to actually undo that classically conditioned fear. But it's very reinforcing to avoid it because you feel better with not having to deal with it, right? What about resilience? Well, as we said, not everybody develops PTSD. And in fact, some people report coming out of the kinds of experiences that would lead to PTSD or have led to PTSD in other people. And they come out of those experiences with some sort of growth, personal growth occurs as a product of those experiences. So this is something that my advisor in graduate school, Peter Sudfeld, is a Holocaust survivor, childhood survivor of the Holocaust. And he's worked on resilience issues. And one of the things that he calls this is post-traumatic stress reorder rather than disorder. And what he sees in some of these Holocaust survivors is not what you would expect, which is that they've gone through this horrific experience, life-threatening experience. And they've survived. So why aren't the rates of PTSD extraordinarily high among these individuals? And it's related to something that is termed soluteogenesis, the idea that coming out of these traumas, you somehow undergo some personal transformation. There's a fellow named Victor Frankel. And Victor Frankl wrote a book called Man's Search for Meaning. He was a Holocaust survivor. And in his book, he describes the experience of meaning-making that we go through when we come out of these kinds of experiences, that we have to reconstruct meaning in our lives in a lot of ways. And Sudfeld's research showed that in general, Holocaust survivors really do quite well. When you compare them with matched Jewish controls of the same age, this is research, I think, in Canada and the United States. When you compare them, they actually are doing quite well in general. They generally have very good mental health. They have good relationships with their families and in their social environments. They do very well, occupationally. So I don't want you to get the idea that if you ever do go through one of these experiences, you're going to come out of it with PTSD because that's not going to be necessarily going to be the case. Does PTSD -- now, don't forget -- hold on a second -- don't forget mental health going into the event is going to be a factor of risk, too. If you're already in some way experiencing a psychological disorder, you may be at a higher -- I think there's a higher incidence of PTSD for people that have a pre-existing psychological disorder. Oh, really? Yeah, right, that's a good question, I don't know. So what distinguishes grieving from PTSD well? Well, if we go back and look at the symptoms that -- yeah, that's a good question, I don't know. I never thought about that, yeah. Yeah, I hadn't either. I didn't know about that statistic. I didn't read it in the text. But if you did, so if you did, it might qualify -- I don't know, that's a good point. Deserve some research. Okay, so let's talk about dissociative disorders. Dissociation in general means that somehow you experience a disruption in the normal continuous flow of everyday experience. So what we call these integrated functions of memory, identity, and consciousness. Now remember, your identity is tied into a lot of different things. Your identity is tied into your social groups. Your identity is tied into your memory of who you are, who you have been. Consciousness is something that's very ambiguous and hard to define. But I think in general, if you think about dissociation, think about what happens if you have some sort of a disruption in, as I said, this normal experience of continuous flow of time and continuous flow of identity through time. What happens when your identity is disrupted in some way? And it's really hard to conceptualize this, having not gone through it. But let's see if we can help you understand this. So one form of dissociation will take the form of amnesia, so dissociative amnesia. In some cases, dissociation will take the form of depersonalization. So the feeling that you are separate from your mind, separate from your body, that you're somehow outside of this that we consider yourself, right? You're outside yourself. And then in rare cases, we will see individuals who actually have distinct personalities with their own continuous sense of identity and separate memories in some cases. So very bizarre kinds of psychological experiences. One thing to think about is the idea of conscious experience versus unconscious experience. And typically, we don't really talk that much about the unconscious now. But certainly, Freud was interested in the unconscious and how the unconscious affected us. And in some ways, Freud says dissociation is really a way for the ego to defend itself against the id, this burning, lustful, libidness desires that we have. And in order to protect itself from the id, the ego depersonalizes or dissociates from the self, I already told you about hysteria, right? Yeah, that's kind of a crazy concept. So when we think about dissociative disorders, we're going to think of them in four sort of broad categories of disorders. One of them is going to revolve around memory. Others are going to revolve more on depersonalization and the other is going to involve these distinct kinds of personalities that have their own very continuous qualities. So dissociative fugue involves, let me talk about dissociative amnesia first. Dissociative amnesia means you suddenly forget everything about your past. Typically what will happen is the person will have experienced some sort of trauma or some sort of extreme stressor prior to the amnesia. Dissociative fugue is dissociative amnesia with the additional aspect that the person suddenly leaves where they have been living, right, previously, and they travel somewhere. And sometimes what will happen is they will get somewhere else, they will essentially wake up there with no idea who they are. And they will actually begin to form a new life in this new place. Fortunately, I guess you could say, fortunately with more modern communication technologies, people are much better able to, and DNA evidence, people are much better able to find out who they are if they experience this. But dissociative fugue and dissociative amnesia are relatively, all of these disorders are relatively rare. You know, we've talked previously about the mood disorders and the anxiety disorders. And those are the two biggies. Those are the two that you're going to encounter a lot in individuals. These are relatively rare. Repersonalization disorder, again, this very disturbing experience of being outside yourself, not being a part or connected to yourself, your sort of outside your body looking in. And then what used to be known as multiple personality disorder is now more commonly referred to as dissociative identity disorder. These are the actual separation or dissociation of one unique identity from another unique identity. >> Yeah, Victor, do you have a question? >> Yeah, I'm sorry. >> It's okay. >> When I have no memory of what happened to say an hour or two, do you think I have an hour or two to after? >> Mm-hm. >> That'd be dissociative at the end of each episode. >> No. >> Most events. >> Um, be, uh, it's, uh, more likely that it has a, uh, biological cause. >> And that, that sort of thing. >> Um, less likely. >> Less likely. >> Yeah. Yeah. Um, what's, uh, what's most likely happening when you have a seizure which has a biomedical explanation is that, um, you're experiencing, um, essentially a shutdown and a, um, and almost like a reboot of your brain systems. And so your ability to, um, do that long-term memory integration is disrupted. That process that typically happens in the hippocampus. That would be my guess. But again, this is going to be diagnosed in absence of a, um, a medical disorder. >> Oh. >> Yeah. I'm sorry, um, whenever we do the diagnostics, remember, we use the multi-axial system. >> Right. >> And one of those axes, um, has to do with medical conditions. And we always rule out medical condition causes before we look for, um, psychological, uh, causes of disorders, explanations for disorders, yeah. >> And similarly, these are all going to, um, you, whenever you make a diagnosis for any of, almost any of the disorders in the DSM, one of the first things to get thrown out is a substance, is it related to a substance use disorder? And you know, if you get amnesia because you have substance, you know, alcoholism, that's not dissociative amnesia, that's amnesia because you're an alcoholic, yeah. Yeah. I've got another video clip, but let's take a little break before we, uh, do that. Um, it's getting on four o'clock, Sylvia's fading fast. So, um, I, uh, come back about, uh, 10 minutes, how'd it be fine? >> Okay, so this next clip, uh, is clip, um, that's an older clip, I think, from, I don't remember what TV show it's from, but, uh, it's about a fellow named Tony. And, uh, Tony has dissociative identity disorder, uh, which at the time of this, uh, that this clip was made, uh, was referred to as multiple personality disorder. And I think he has 57 personalities, um, but this will give you a sense of what that experience is like. >> He's multiple. It's hard. There's days where you wouldn't-- >> Thank you. >> Tony suffers from multiple personality disorder. He has at least 53 among them. Tony, the original, the imposter, the controller, D.D. who remembers everything, Richard, a cousin died of a brain tumor a decade ago. Richard talks to me, it's a different sound, uh, Tony, the imposter, basically the same as myself. D.D., like I said, he's real different. It's unbelievable. But the wrong, the wrong, the wrong, the wrong voices, not where, you know, we're all the same. >> Tony is a fairly fragmented multiple, who instead of having that sort of nicely pre-flowing consciousness, which is a series of kind of normal, natural transitions from one state into another, uh, is a person who really believes that he's sharing his body with a whole lot of people. And the problem with that is that he has no control when the other person's going to come out and take consciousness away from him. >> No matter what I did, to be myself, there's days I can't control, whether it's just take over. He's into my pieces, you know, just, too many cells to deal with, but we're still able to talk to them now. They acknowledge their names to me, which is something, you know, it's a good change in here. Never did that before. >> Do you know this woman? >> No. >> No. >> Do you want to ask for who she is? >> What? >> What do you want to ask? >> Does that mean anything to you? >> No. >> Did you know that Tony's married? >> Yeah, I know. >> This is who he's married to. >> Beautiful. A therapy session. Tony's personalities are drawn out, each is probed for its secrets. >> You don't really believe me. >> That's his life. Is that my life? >> Are you married? >> No. >> Do you have a girlfriend? >> No. >> No. A personality change can be subtle or enriching, a cough, a hand of the head, a movement of the eyes. >> You don't like? >> Huh? >> Are you doing the right? >> Thanks a lot. >> Wait. You not going to anybody? >> Yeah. Do you know all of these people? >> Why don't you let that little boy come out? That's all right. Let him come out. That's okay. Hello? Anthony? Anthony? Don't be frightened. It's okay. Do you know this lady? >> Here. >> Yeah. >> This is for the love. >> Okay. >> Okay. >> Okay. >> I know. >> Are you about five years old? >> No. >> No. >> Okay. >> I know. Are you about five years old? >> No. >> No. >> No. >> No. >> No. >> No. >> No. >> No. >> No. >> Okay. >> Is that all right? >> What that little boy would like to tell me why his hand is trembling so? >> Mm-hmm. >> What do you want? >> Richard. >> What? >> How are you doing? Those lights really are getting too big. >> Richard, do you know that little boy that was just now got every boy who's hands shaking like that? >> No. >> Are you sure? Or are you just like, do you know the story about the little boy? >> No. >> Why don't you show a head for it so bad? >> Mm-hmm. >> What's the name of that one? Are you using a ritual? >> Yeah. >> Richard? >> Sure. >> Is there anybody inside you who knows everything about everyone? It's so called memory trace? >> Probably D.D. can remember everything. There are at least three D.D.s, seven years old, fourteen, thirty-seven. Tony's illness began in childhood when most cases of multiple personality began. Most are triggered by the need to flee psychologically from real, physical, or sexual abuse. Nobody had noticed what triggered Tony's. >> No, Tony, one D.D. >> Who are you? >> I think the multiple, in a way, is the kind of paradox. Because simultaneously he has an exaggerated ability to focus. That is, he focuses out existence altogether and substitutes an alternate existence. But also is unable to focus volitionally on anything he wants to focus on at the moment. If the different selves don't intern, no means say, "Hey, we did this or we did that." I'm lost. I have no recollection of what happened. It's like we went to a wedding. And I swore to God, I wasn't at that wedding. I have no memory of being a positive coach, blanked me out the whole night. And there I am, you know, a couple of days later going around asking people, "Did you see me there?" It was I there. >> How can the brain completely suppress one so-called self and focus on another? Research into multiple personality disorder is so new. >> Would it really hit me? It was when I was on the pedestrian route. I said, "Well, I was hoping that I proved them wrong." Because I think mainly the reason why I went down it was, "Well, let me go and fool these people wrong." People ain't right? >> What we know is that the brain is all the time generating electrical signals, electrical activity. If you put an electrode on the skull on the head, you can measure spontaneous electrical activity from the brain. Now, if you stimulate that person with a flash of light or a sound or an electric shock, for example, you get at a vote electrical spike. And that's what we call a vote potential to distinguish it from spontaneous electrical activity that's going on all the time, which is known as the EEG or Electrolyphalogram. >> But the men as colleagues were searching for differences in brain activity among the personality. of multiples. They matched a group of multiples with a group of normal individuals who were asked to mimic or fake new personalities. Then they tested the evoked potentials of both groups. The multiples for three of their personalities, the controls for three personalities they had invented. Among others, they tested tummy. In Tony's case, we had three of the alternate personalities tested and we tested each of these personalities for a number of days. And what you can see is that Tony, D.D. and Richard showed differences in the mapping of those of both potentials across the brain. Fred finally came into the room and I looked at the papers and he says, "This is your brain." And he said, "Yeah, he spoke. This is D.D.'s brain. This is Tony's brain. This is Richard's brain. There is a D.D. that lives in sight. There is a Richard. There is Tony to your religion." I got so upset and I felt like everything just came out of me. I had to get out of the room. Intriguing biological differences, as seen in these evoked potentials, among alter personality states, continue to be reported by investigators. In addition, partner and colleagues have found stable differences on repeated testing of visual acuity, ocular function, heart rate, galvanic skin response, respiratory rate, and retinol cerebral blood flow. This suggests that there may, in fact, be some real bodily changes that occur when the alternate personalities are out. So that gives some interesting data. Can you hit that light there? These signs suggest that multiple personality disorder is a valid psychiatric condition that provides an important scientific window into the organization of personality and consciousness. So, what are your comments about that? Maybe I missed it, but was there any information on the control group? No. I don't know. I don't know. And I presume that they've got some updated neuroscience research that obviously isn't included here. Do I know how old this film is? I'm going to say it might be close to 15-20 years. Did you notice the hospital that the neuroscientist was from? Who noticed it? A couple. Does that ring a bell? So, yeah, it's St. Elizabeth's hospital, yeah. From an unquiet mind. So now, one of the problems with the diagnosis for dissociative identity disorder is that it is controversial, right? Remember reading in the textbook. It's very rare, extraordinarily rare. Even among rare disorders of psychological disorders, it's extremely rare. And most of the cases seem to have come from a limited number of psychiatrists. And so, it's still not entirely controversial. It's still not entirely accepted by everybody at this point. But these people have a very interesting subjective experience of being different people. And certainly, from the video, you see that there are actually some physiological changes, too. All right. Any more questions, comments on dissociative disorders where we go to somatopharm? So, somatopharm disorders. Soma body, right? Somatopharm disorders that exist as part of the body. Take form in the body. And the key feature for somatopharm disorders is that people who have a somatopharm disorder have the subjective experience or the fear of a physical illness. So, either they experience, subjectively, the symptoms of a physical illness or they have an overwhelming and incapacitating fear that they have an illness. So, and it's important that obviously you can't find a physical cause using diagnostic tests. If you can find a physical cause using a diagnostic test, it's not a somatopharm disorder. It's a medical disorder. So, when we talk about somatopharm disorders, we think-- and I'm going to talk about today-- conversion disorders, hypokondriasis. So, you've heard of hypokondriacs, right? That's somebody with hypokondriasis. Somatization disorder. These two are very similar. And I'll tell you what the difference is when we get there. Body dysmorphic disorder. A very bizarre form of a disorder which involves individuals hating, disliking a part of their body. And in some cases, removing it. And then malingering, which is considered a somatopharm disorder. But the person is actually pretending, they're not. They don't have the actual subjective experience of the symptoms. So, let's talk about conversion disorder. Conversion disorder comes from originally starts out with Freud. The psychodynamic perspective, remember, focuses on unconscious conflicts. And those unconscious conflicts will lead to neurotic behavior because they are rousing anxiety. And what Freud will say is these unconscious conflicts are converted into physical symptoms. So, one of the things that Freud did after he's a physician in Vienna. And he traveled to France to work with Sharko and Sharko and Bruner who were both hypnotists in France. And Sharko and Bruner had started treating relatively wealthy perusion women. And so, they would treat them for these conversion disorders, which typically took the form of some sort of loss of sensation, either what they called glove anesthesia where you lose sensation in your hand. Or paralysis of a limb, right? And so, what they would do is they would hypnotize these women and they would experience a remission of the conversion disorder. And it would last for a few weeks and the women would have to come back and be hypnotized again. And eventually, Freud wanted to develop a more long-lasting treatment, which would become his free association therapy. And free association therapy will eventually become the talk therapy that we use now for psychological treatment in general. So, he's extraordinarily important in the development of psychological treatments. Another form of the conversion disorder was called pseudosaisis, which essentially meant that a woman became pregnant without actually having a baby in her uterus. So, they would experience all of the symptoms of pregnancy, including distended belly, but without an actual pregnancy being present. Very bizarre kinds of somatiform disorders. What we see in conversion disorders is very often there will be, again, stress-related, some sort of trauma or stress prior to the conversion disorder. Oh, victory, yeah. So, you personally took a hand in helping that girl when she is coming to work the next day, she starts feeling like she's having a heart attack. So, it sounds more like panic attack, but yeah. I don't think conversion disorders typically involve autonomic nervous system arousal. Um, I'm not sure. Yeah. Um, okay. So, uh, hypokondriasis. Um, we may in common parlance in this culture call someone a hypokondriac, when they think, you know, they're sick, but they really aren't. Um, but in hypokondriasis, true hypokondriasis. Um, the key, uh, symptom is an intense fear of having a disease, uh, despite any kind of medical proof, um, otherwise. So, um, you know, you might think, oh, well, you know, um, I have, you know, I think I have, uh, venereal disease, because, uh, having these weird symptoms. That's a lot different than having this intense fear and having, um, gone through diagnostics to prove that you don't have the disorder. So, these individuals, regardless of having gone through, um, diagnostics, they still insist that they have this disease, that, uh, that they, they still insist on being afraid that they have it. The symptomology that these people exhibit tends to be relatively vague. Um, it doesn't, it doesn't generally tend to be focused on a specific, um, system or a specific area of the body. Uh, yeah, Laura, do you have a question? Um, yes, except, except that the onset of his, um, symptoms came before age 30. So, I'll tell you why he has, he, why I think he had somatization disorder and not hypokondriasis. Maybe I have a hundred before 30. Um, very rare that hypokondriasis will occur before about age 30. That's a good question. It's unknown, yeah. Yep. I don't know. Uh, if, yeah, it could be if those surgeries were traumatic in some way. Uh, I can imagine it might be part of the onset. Yep. Um, also anesthesia for surgery has all kinds of weird effects in the body and can do all kinds of strange things. Um, so, yeah. Um, oftentimes these people can be successfully treated with a placebo drug. So basically, um, give them a plus, uh, a sugar pill and tell them that it, um, you know, it's a treatment for their, whatever their symptomology is. And they typically will accept that and they will go away for a while. Um, you know, it's kind of funny to say that, but think of, think of yourself in the shoes of a doctor who has a patient who continually comes back to you and says, "I know we got the test last week, but I, I, I, I'm convinced that the symptoms didn't exist last week. They're really intense this week. So if you do the test again, they'll find it this time." Can you imagine how frustrating that is for a doctor? So, um, so in a lot of ways, doctors, um, need to find a way to deal with these cases, you know, they need to figure out how they're going to quote-unquote treat them so that the person feels better. And of course, the ultimate treatment is through psychological help. Yeah. No, they might, they might assign a fake name to it. Yeah, I don't know. Yeah, I'm not exactly sure how they do the placebo treatment. But, placebo's don't just work for people who have hypokondriasis. There's some good controlled studies of placebo's in Japan, which show that somewhere between 30 and 40% of people will actually experience a remission of symptoms when they're given a placebo, even though it has no active effect in the body. So, placebo's are not, you know, they're sometimes useful for treatment, even with normal individuals, yeah. The other important thing about hypokondriasis is these individuals are not delusional. They instead are completely rational, and they rationalize the fear by the fact that there must have been something wrong with the tests, that they didn't find the disease that I'm afraid that I have. So, let's do another test. The biopsy, you know, the biopsy got the wrong set of cells. We need to do the biopsy again, right? And so, this can be very, you know, it's very disturbing for the individual who has the disorder. It's also very disturbing for the individuals who are caring for that person. Contrast, or not contrast, but compare hypokondriasis with somatization disorder. For one thing, somatization disorder usually has an onset before age 30 rather than after 30. And somatization disorder requires very specific system complaints in terms of symptoms. So, they need to have, for example, pain symptoms in four different areas of the body. They need to have two symptoms of gastrointestinal problems. They need to have one pseudo neurological and then one sexual symptom. And those symptoms don't have to occur simultaneously. They can occur over the course of the disorder. So, in the case of an individual that I know, who will go unnamed on the podcast, this person started out with pseudo neurological problems in his vision. He, as a teenager, thought that there was something wrong with his vision. Of course, vision tests and diagnostics couldn't find a problem. Later on, this person experienced sexual dysfunctions. Frequently complained of problems with digestion, the color of the bowels. This person would talk about how their bowels were gray instead of brown. And also experienced pain symptoms in different parts of his body. So, the onset typically is before age 30. These symptoms come and go over the course of this person's life. And so, the history of these symptoms is long and complicated. And, of course, regardless of how many diagnostic tests you run, we can't find any physiological cause for the disorder for the symptoms. Somatization occurs more commonly in certain groups. For one thing, people in lower socioeconomic status groups, for one reason or another, it's unknown why these correlations exist. Highly religious individuals seem to have more incidence of somatization. Individuals who are what are called sexually intolerant. So, they tend to not tolerate sexual differences very well. And people who are less educated. Of course, a lot of this can be related to socioeconomic status too. And the other important thing with somatization disorder is the person will seek out diagnostics from more than one doctor. They're not going to stay with one family physician, for example. They're going to go off to a lot of different specialists to try to find a cause for the symptoms that they're subjectively experiencing. So, with the demonstrate this and someone who harms themselves with the intention of getting care from a doctor, that disorder is known as, is it in your textbook? I can't remember. Fesitius disorder, yeah, I'm sorry. Fesitius disorder, yeah. Is that right? I think so. Yeah, they may harm themselves to do that. One of the ideas behind why people engage in hypokondriosis and somatization is what are they getting out of it? out of it well. their invalid status, their status as an invalid, someone who needs to be taken care of, has certain kinds of secondary gains to it. So, you are getting the attention that you want, right? Plus, you may be getting out of some responsibility that you need to serve. So, for example, military service. Sometimes these disorders will emerge as a product of military service. And this person really doesn't want to engage in that responsibility and will somatize disorders. The costs of it are very high in terms of truancy absenteeism, and then ultimately these people will oftentimes lose their jobs because you can't keep working if you're out of work all the time going to doctors, right? Plus, the cost of going to the doctors, even if you have medical insurance, the copays, and deductibles, and things like that. Okay, here's a really weird one for you. The diagnosis of body dysmorphic disorder is somewhat controversial, and the reason it's controversial is it's not clear whether it should be included in somatization disorders, or whether it should be considered a dissociative disorder, or maybe even an obsessive compulsive disorder, an anxiety disorder. The primary delusion in body dysmorphic disorder is that some part of your body is so badly malformed or mangled or ugly that you can't stand to look at it. It is so repulsive to you that you have to find a way to get rid of it, and that may mean cutting it off, so people will sometimes have this with their hands, and they will sever their hands at the wrist. With their face, they may try to cut, for example, if they notice a minor defect in their skin, they may take a razor and try to cut it out. So very, very disturbed thinking about the body part, and it's a very obsessive kind of experience. They can't stop thinking about how ugly that body part is and how much they want to get rid of it. So they'll go through these very elaborate behaviors in a very compulsive kind of way in order to try to maybe cover it up, so they'll wear, for example, they may never wear short-sleeved shirts, even though it's boiling hot. They may never be able to wear shorts because they think their legs are ugly. They may try to obscure their face with lots of makeup. Now, what's different between an OCD and this is what, when people have an obsessive compulsive disorder, they know it's irrational. There's a delusion here, and that delusional quality is telling them that it's not irrational, that it's real. Yeah, Victor. Oh, I don't know. If there's any relationship between serial killers and body dysmorphic disorder, I haven't seen that. Fortunately, we've got some good treatments for both psychological treatments, therapies, and drug treatments. The SSRIs, for some reason, tend to work pretty well with these. Why? Probably because it helps relieve some of these obsessive and compulsive symptoms. But oftentimes, it relies on very intensive behavioral and cognitive behavioral therapy to try to correct those erroneous thoughts about the body part. You can show somebody a mirror and say, "Look, you're not ugly." They'll say, "No, I'm ugly." You can show them a picture of their identical twin and say, "Look, this is your identical twin." They'll say, "Oh, he's not ugly." But you show them their picture and they say, "Oh, I'm ugly." So, it's very delusional, very consuming. Yeah. So, okay, good question. So, what's the relationship between body dysmorphic disorder and anorexia? Because adolescents with body dysmorphic disorder oftentimes look quite similar to individuals with eating disorders, because it will often focus around how fat they are or how fat they feel. And that's one of the key symptoms of an eating disorder is body image. You have an incorrect body image of yourself. You see yourself as fat, but you're 30 pounds under weight. So, it's got that similar quality. It's not as delusional. And also, in order to be diagnosed as eating disorder separately, there are certain weight criteria and behavior criteria that are associated with it. So, it is different than eating disorders, but it has a lot of very similar characteristics and features. And, in fact, for some of the eating disorders, SSRIs are used also. So, there is some overlap, but there's specific categories for eating disorders. I'm glad you brought that up, because I was thinking about that the other night. The last thing I'll talk about is malingerers. Malingerers are basically people who fake their psychological problems and sometimes physiological problems too. And so, one of the characteristics of malingering is what's called Munchhausen syndrome, which is a situation where somebody goes to a doctor and they will try to trick the doctor into thinking they have a particular disorder. And so, they'll try to trick them into giving them treatments or whatever. There's also another disorder called Munchhausens by proxy, where people will do this with their children. They will bring their children and try and convince the doctor that the child has a disorder. And this is not as severe as the others, but it can be as disruptive in terms of functioning. And certainly, if you get a child treated for a disorder that they don't have, that's going to have negative effects. Yeah. Yeah. I don't know if that's considered Munchhausens by proxy. It might be. Although it sounds criminal rather than psychological disorder, but yeah. Would a what? Seeker. Someone that goes to a doctor specifically with the idea of trying to get pain pills. Again, this would have to be in the absence of a substance use disorder, and I would presume that would be a product of the addiction. Yeah. I'm sorry. You know, always consider in these diagnostic categories that they always exclude out physical other medical problems and substance use disorders. You have your textbook. The, I don't remember where this is from here. So, if you, if you have your textbook on page 100, they have the multi-axial system. And so, Access 3 is general medical conditions. Includes medical problems that can cause symptoms of an Access 1 or Access 2 disorder or Act as a psychological stressor. So, that's always in these somatiform disorders. It's always excluding Access 3 stuff. And so in order to be on an Access 1 diagnosis, it has to exclude Access 3 stuff. [BLANK_AUDIO] questions? I prepared that clip of video from unknown white male but I don't have time to play it but if you want to go to the video star it's probably available. And this movie is the story of Douglass Bruce. Doug Bruce was a stockbroker in New York City. He gave up being a stockbroker and went to photography school to learn photography. He essentially woke up one day on a subway in New York City and didn't know who he was, where he was, how he got there, had no memory of his past. And he wound up going to a hospital and the hospital saw him and eventually he finds out who he is because they wind up getting in touch with somebody who he knows. Well, this movie traces about two or three years of his life. It's not, it's a documentary. One of his friends was a filmmaker and as soon as he told his filmmaker about this a couple months after the incident, the filmmaker started filming him. And so it traces his journey of trying to figure out who he is and to try to get some sense of identity back. Because remember, your identity and your personality is so tied into your memory of who you are, your family history, the groups you've belonged to, the experiences you've had. And so I like this because it gives a real good example of how disturbing it is to lose your identity and to try to create a new identity. Essentially, he has to go, for example, and meet his family for the first time, his parents, his siblings, his friends from, you know, when he was in college. And it also gives a good, it's an example of not sure if it's really dissociative amnesia or dissociative fugue, probably closer to dissociative fugue. And it is unusual in that it's a very long term. I think it's been three or four years since he suffered retrograde amnesia. And last time I checked, he hadn't recovered memories. I checked a few months ago. So it's very long term. And actually, the people who knew him before, the incident said, oftentimes we'll say that he's a nicer person now than he was before. So isn't that weird? Yeah. What's that? Yeah, I guess so. All right. So I will see you. Oh, I gave you back quizzes. That's out of a possible eight points because two of the items showed low reliability. So I'll see you next week, huh?