Chapter 8 Flashcards
1
Q
How many people say they have had somatic symptoms in the past week?
A
80% of people in the general population
2
Q
Somatic symptom disorder (general definition)
A
When concern about physical somatic symptoms is severe and leads to significant distress or impairment. formally known as somatoform disorders
3
Q
Dissociative disorder (general definition)
A
One feelings of being out of it becomes so persistent and recurrent that the person has profound and unusual memory deficits, such as not knowing who they are
4
Q
Neurosis
A
Somatic symptom disorders and dissociative disorders were considered to be forms of neurosis, and were included with the various anxiety disorders in the past. This was because anxiety was thought to be the underlying cause of all neuroses whether or not the anxiety was experienced overly. In the DSM three the anxiety, mood, somatic symptoms, and dissociative disorders each became separate categories, as attempts to link the disorders together on the basis of hypothesized underlying causes were abandoned and instead the focus was on grouping disorders together on the basis of overt symptomatology
5
Q
Somatic symptom disorder and dissociative disorders in the DSM-V
A
In the DSM five, somatic symptom disorders and dissociative disorders are regarded as distinct diagnostic entities
6
Q
“Soma”
A
“Body”
7
Q
Somatic symptom and related disorders
A
A new category in the DSM five. The disorders in it lie at the interface between abnormal psychology and medicine. Included in this category are conditions that involve physical symptoms combined with abnormal thoughts, feelings, and behaviours in response to those symptoms. People with somatic symptom disorder‘s experienced bodily symptoms that caused them significant psychological distress and impairment. The affected patients have no control over their symptoms. They are also not intentionally faking symptoms or attempting to deceive others.
8
Q
Somatic symptom disorder’s versus normal bodily sensations and symptoms
A
Experiencing bodily sensations or symptoms is very common. In most cases these symptoms go away spontaneously. but in about 25% of cases, if symptoms persist for a longer period, prompting people to visit their doctors. Somewhere between 20 and 50% of the physical symptoms that caused people to seek medical care or medically unexplained. A subset of patients will continue to be very worried that something is seriously wrong. These people tend to continue to seek help for their physical problems, asking for and undergoing more and more tests. They become preoccupied with some aspect of their health to the extent that they show significant impairments in functioning. Such patients are more commonly found in medical settings than mental health clinics. 20% of doctor visits are caused by complaints of this sort
9
Q
Somatic symptom disorder in the DSM four versus the DSM five
A
In the DSM for a great deal of emphasis was placed on the idea that the symptoms were medically unexplained. The patient’s complaints suggested the presence of a medical condition but no physical pathology could be found to account for them. An important change in the DSM five is that no distinction is now made between medically explained and medically unexplained symptoms. The idea is less prominent because it is recognized that medicine is fallible and that a medical explanation for symptoms cannot always be provided. Whether symptoms are deemed to have a medical cause or not could also depend on the personality of the doctor or on their predominant cultural beliefs. Nonetheless medically unexplained symptoms are still a key part of some disorders such as conversion disorder
10
Q
The four most important disorders in a somatic symptom and related disorders category of the DSM five
A
There are four important disorders in this category: somatic symptom disorder; illness anxiety disorder; conversion disorder; factitious disorder.
11
Q
Old disorders that her now included within somatic symptom disorder
A
Hypochondriasis; somatization disorder; pain disorder. These disorders have now disappeared but previously had a separate diagnosis in the DSM four. Most of the people who would in the past have been diagnosed with one of these disorders will now be diagnosed with somatic symptom disorder.
12
Q
Hypochondriasis
A
Where individuals are preoccupied either with fears of contracting a serious disease or with the idea that they have a disease even though they do not. This was a diagnosis in the DSM four, but is now included within somatic symptom disorder in the DSM five. It is estimated that around 25% of people who would have been diagnosed with hypochondriasis in DSM four will be diagnosed with illness anxiety disorder in DSM five. The remaining 75% will be diagnosed with somatic symptom disorder. When hypochondriasis is accompanied by significant physical symptoms, the diagnosis will be somatic symptom disorder. When there is hypochondriasis without any physical symptoms or with very mild ones, the diagnosis will be illness anxiety disorder
13
Q
Diagnosis of somatic symptom disorder
A
Diagnosis is a descriptive one. It contains no assumptions about cause. The name of the diagnosis is chosen to reduce some of the negative connotations associated with older diagnostic terms such as hypochondriasis, as well as ideas that disorders such as these were all in the mind. For the diagnosis to be made, individuals must be experiencing chronic somatic symptoms that are distressing to them. They must also be experiencing dysfunctional thoughts, feelings and behaviors. The physical symptoms no longer need to be medically unexplained
14
Q
The addition of the psychological component to somatic symptom disorder in the DSM five
A
For a diagnosis of somatic symptom disorder, the person must be experiencing dysfunctional thoughts, feelings and or behaviors. The addition of this psychological component is new. In the DSM for all that was required was that people be experiencing somatic symptoms that were medically unexplained. No psychological features were required
15
Q
DSM-V criteria for somatic symptom disorder
A
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life
B. Excessive thoughts, feelings or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1. Disproportionate or 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 anyone somatic symptom may not be continuously present, the state of being symptomatic is persistent, typically more than six months
16
Q
How many somatic symptoms are required for a diagnosis in the DSM-V of somatic symptom disorder?
A
Only one somatic symptom is required. This is a diagnostic change that has occurred in the DSM five. If a person has any physical problem that they find distressing, even if it only involves a single symptom and is medically explained, the diagnosis of somatic symptom disorder is possible. Many patients have many physical complaints. The new DSM five criteria will likely lead to an increase in the diagnosis of somatic symptom disorder for this reason. It has been suggested that women will be disproportionately affected because they’re more frequent users of medical services and they’re most at risk of being dismissed by their doctors as catastrophizers
17
Q
Suggested revised diagnostic criteria for somatic symptom disorder
A
There has been criticism about the DSM five somatic symptom disorder criteria, considering it loosely defined and Fadily flood. This is one professionals revised diagnostic criteria offering for this disorder:
A. One or more prominent physical symptoms
B. Excessive and maladaptive thoughts, feelings and behaviours related to the physical symptoms. All three of the following must be present: clearly disproportionate and intrusive worries about the seriousness of the symptoms; extreme anxiety about the symptoms; excessive time and energy devoted to the symptoms or health concerns
C. Excessive concerns have persisted at a clearly problematic level for at least six months
D. The excessive concerns about physical symptoms are pervasive and cause significant disruption and impairment in daily life
E. If a diagnosed medical condition is present, thoughts, feelings and behaviours are grossly an excess of what would be expected given the nature of the medical condition
F. If no medical diagnosis has been made, I throw medical work up has been performed to rule out possible causes and is repeated at suitable intervals to uncover medical conditions that may declare themselves with the passage of time
G. The physical symptom or concern is not better accounted for by another mental disorder
18
Q
Criticism of the current DSM-V criteria for somatic symptom disorder
A
The current DSM5 criteria may result in a wide range of patients being assigned to the same diagnosis. Some will have any symptoms and some will have very few. Someone will have symptoms that have a medical cause and others will not.
It’s estimated that the prevalence of somatic symptom disorder will increase, and in the general population it will be around 5 to 7%.
19
Q
Historical reasons for why it was thought people develop somatoform disorders
A
This thinking date‘s back to the psychoanalytic concept of hysteria and the work of Freud, Brewer and to Janet. It was a long thought that symptoms developed as a defence mechanism against unresolved or unacceptable unconscious conflicts. Rather than being expressed directly, psychic energy was instead of channelled into more acceptable physical problems
20
Q
Current views on why people develop somatic symptom disorder
A
Several different models exist but their core features tend to be similar. First there is a focus of attention on the body. The person is hyper vigilant and has increased awareness of bodily changes. Second the person tends to see bodily sensations as somatic symptoms meaning that physical sensations are attributed to illness. Third the person tends to worry excessively about what the symptoms mean and has catastrophize Ing cognition. Fourth because of this worry the person is very distressed and seek medical attention for their perceived physical problems
21
Q
Somatic symptom disorder can be viewed as a disorder of both ________ and _________.
A
Perception and cognition. Individuals who are especially anxious about their health and tend to believe that they are very aware of and sensitive to what is happening in their bodies. But experimental studies show that these individuals have unintentional bias for illness related information. Top down processes rather than bottom-up processes seem to account for the problems that they have. People with somatic symptom disorder‘s seems to focus excessive attention on their physical experiences, labelling physical sensations as symptoms. They perceive their symptoms as more dangerous than they are and judge a disease is more likely than it really is. Once a symptom has been misinterpreted, they look for confirming evidence and discount evidence that they’re in good health. They also perceive their probability of being able to cope with the illness is extremely low and see themselves as weak and unable to tolerate physical effort or exercise. This creates a vicious cycle where anxiety about illness results in physiological symptoms of anxiety
22
Q
Past experiences with illness and somatic symptom disorder
A
It’s believed that an individuals past experiences with illness contribute to the development of a set of dysfunctional assumptions about symptoms and diseases that may predispose a person to developing a somatic symptom disorder. These dysfunctional assumptions might include: if you don’t go to the doctor as soon as you notice anything unusual, then it will be too late. This is another example of top down cognitive processes at work
23
Q
Negative effect and somatic symptom disorder
A
Negative effect is regarded as a risk factor for developing somatic symptom disorder. But it is not sufficient. Only a subset of people who are gloomy when their personalities will also be habitual reporters of physical symptoms. Other characteristics that may be important are absorption and alexithymia. People who report many symptoms but who do not have any medical conditions tend to score high on all of these three traits
24
Q
Absorption
A
The tendency to become absorbed in one’s experiences and is often associated with being highly hypnotizable
25
Alexithymia
Refers to having difficulties identifying one’s feelings.
26
When people who report a lot of physical problems are put into a negative mood, they’re reporting a physical symptoms increases. Why?
People who have difficulty identifying their feelings and who are also highly susceptible to being absorbed in their own experiences may be especially sensitive to having certain attentional top down processes activated when they experience negative events. These alterations in the attentional system may  triggered memories or past representations of symptoms that were formed as a result of prior experiences with illness. Once these schemas become active, they may cause the person to become aware of minor physical sensations or even trigger experiences of symptoms that are as real as they would be if they resulted from a known medical cause. Because all of this happens automatically, the person has no insight into or control over the process
27
Patients with somatic symptom disorder are more likely to be…
Female and have high levels of comorbid depression and anxiety
28
Impairment with somatic symptom disorder
Patients with somatic symptom disorder often have high levels of functional impairment, and many patients are severely disabled by their physical symptoms
29
Somatic symptom disorder’s and financials
Because these patients repeatedly seek medical advice, their annual medical costs are much higher than average
30
Somatic symptom disorders and secondary reinforcements
An example of the disorder of hypochondriacus, it was found that patients reported much childhood sickness and missed a lot of school. People with hypochondriacis also tend to have an excessive amount of illness in their families will growing up, which may lead to strong memories of being sick or in pain and perhaps of having observed some of the secondary benefits that sick people sometimes get
31
Malingering
Consciously faking symptoms to achieve a specific goal such as winning a personal injury lawsuit.
32
Treatment of somatic symptom disorder
Cognitive behavioural treatments are widely used to treat these disorders. Sometimes patients treated with CBT are also directed to engage in response prevention by not checking their bodies as they usually do and by stopping their constant seeking a reassurance. In addition to CBT, a certain type of medical management may provide some further benefits. Doctors can be educated in how to better manage and treat patients with these disorders so that they are less frustrated by them.
33
CBT for somatic symptom disorder
Generally the duration of CBT is relatively brief, 6 to 16 sessions. Sessions can also be delivered in a group format. CBT approaches can also reduce levels of anxiety and depression more generally. Patients do better if they receive more sessions of treatment. Patient reported that considering alternative reasons for the presence of their bodily symptoms was the most valuable aspect of CBT
34
Medical management for somatic symptom disorder‘s
medical management may provide some further benefits. Doctors can be educated in how to better manage and treat patients with these disorders so that they are less frustrated by them. One moderately effective treatment involves identifying one physician who will integrate to the patients care by seeing the patient at regular visits and by providing physical exams focussed on new complaints. The physician avoids a necessary diagnostic testing and makes minimal use of medication‘s or other therapies. Studies have found that patients show substantial decreases in healthcare expenditures over subsequent months and sometimes an improvement in physical functioning. Approach should be combined with CBT as it does not necessarily result in lowered psychological distress
35
Cognitive behavioural techniques in the treatment of somatic symptom disorder that involves pain
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. 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. Antidepressant medication‘s and certain selective serotonin reuptake inhibitors have been shown to reduce pain intensity in a manner independent of the effects the medication‘s may have on mood
36
Illness anxiety disorder
This disorder is new to the DSM five. People have high anxiety about having or developing a serious illness. This anxiety is distressing and or disruptive, but there are very few or very mild somatic symptoms.
37
DSM five criteria for illness anxiety disorder
A. Preoccupation with having or acquiring a serious illness
B. Somatic symptoms are not present or, if present, I only mild and intensity. If another medical condition is present or there is high risk for developing a medical condition, 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 behaviours or exhibit maladaptive avoidance
E. Illness preoccupation has been present for at least six months but the specific illness that is feared me change over that period of time
F. Illness related preoccupation is not better explained by another mental disorder
38
Conversion disorder [functional neurological symptom disorder]
Within the diagnostic category of somatic symptom and related disorders. This is a recent term. Historically this disorder was one of several disorders that were grouped together under the term hysteria. Characterized by the presence of neurological symptoms in the absence of a neurological diagnosis. The patient has symptoms or deficits affecting the senses or motor behaviour that strongly suggest a medical or neurological condition. But the pattern of symptoms or deficits is not consistent with any neurological disease or medical problem. Example: partial paralysis, blindness, deafness. The diagnosis can only be made after a full medical and neurological work up has been conducted. The person is not intentionally producing or faking the symptoms but 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
39
Early observations of people with conversion disorder: “la belle indifference”
These early observations suggest the 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 was known as “la belle indifference”. It was thought to be an important diagnostic criterion for conversion disorder. But it occurs only in about 20% of patients. Lack of concern about symptoms or other implications is also not specific to conversion disorder so this phenomenon has become de emphasized in more recent additions of the DSM
40
Changing the term used to describe conversion disorder
Authors of the DSM-V wanted to change the term used to describe the disorder but in the end, the term conversion disorder was retained, although this is now followed in parentheses by “functional neurological symptom disorder”.
41
DSM five criteria for a 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 a functioning or warrants medical evaluation
42
Symptoms of conversion disorder
There are four categories of symptoms:
Sensory
Motor
Seizures
Mixed presentation of the first three categories 
43
Sensory symptoms or deficits of conversion disorder
Involve almost any sensory modality, symptoms in the affected area are inconsistent with how known anatomical sensory pathways operate. Most often in the visual system, the auditory system, or in the sensitivity to feeling. 
44
Sensory symptoms of conversion disorder: sensitivity to feeling
Especially the anesthesia’s. In the anesthesia’s, the person loses their 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, but loss of sensation usually makes no anatomical sense.
45
Sensory symptoms of conversion disorder: visual system and auditory system
With conversion blindness, the person reports that they can’t 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 their name. The evidence supports the idea that the sensory input is registered, but is somehow screened from explicit, conscious recognition: explicit perception. 
46
Motor symptoms or deficits of conversion disorder
 covers a wide range of symptoms. For example, conversion paralysis is usually confined to a single limb, such as an arm or 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. the most common speech related conversion disturbance is aphonia, where a person is able to talk only in a whisper, so they can usually cough in a normal manner. Another common motor symptom is called Globus, involving a sensation of a lump in the throat. 
47
Seizures in conversion disorder
A relatively common form of conversion symptoms. These resemble epileptic seizures, but they are not true seizures. Patients do not show any EEG abnormalities and do not show confusion and loss of memory afterwards as patients with true epileptic seizures do. Also patients with conversion seizures, often show excessive thrashing about, and rising not seem with true seizures, and they rarely injure themselves in falls, or lose bowel or bladder control as patients with true seizures frequently do.
48
Misdiagnosis of conversion disorder
Because the symptoms can simulate a variety of medical conditions, accurate diagnosis is difficult. Misdiagnoses can still occur. As medical tests have become increasingly sophisticated, the rate of misdiagnoses has declined, with estimates of misdiagnoses in the 1990s, only 4%, down from nearly 30% in the 1950s.
49
Criteria for Distinguishing between conversion disorders, and true neurological disturbances
-frequent failure of the disfunction to conform clearly to the symptoms of a particular disease or disorder simulated.
-The nature of the disfunction is highly selective.
-Under hypnosis or narcosis, asleep, like state induced by drugs, the symptoms can usually be removed, shifted, or reintroduced at the suggestion of the therapist. For example, A person abruptly awakened from a sound asleep, made suddenly be able to use a paralyzed limb.
50
Prevalence of conversion disorders
They were once a relatively common in civilian and military life.
Conversion disorders are found in approximately 5% of people referred for treatment at neurology clinics. The prevalence in the general population is unknown, but the highest estimates of being around only 0.005%. 
51
Conversion disorders and war 
In World War I conversion disorder was the most frequently diagnosed psychiatric syndrome among soldiers, and was relatively common during World War II. They typically occurred under highly stressful combat conditions, and involved men who would ordinarily be considered stable.
52
Why do conversion disorders have decreased prevalence?
The decreased prevalence seems to be closely related to growing sophistication about medical and psychological disorders: a conversion disorder apparently loses its defensive function if it can be readily known to lack a medical basis. When it does occur today, it is most likely to occur in people who are medically unsophisticated. 
53
Demographic characteristics of conversion disorders
Conversion disorder occurs 2 to 3 times more often in women and men. It most commonly occurs between early adolescence and early adulthood, but can develop at any age. It has a rapid onset after a significant stressor and often resolves within two weeks if the stressor is removed, although a commonly Rickers. It frequently occurs along with other disorders, especially major depression, anxiety disorders, and other forms of somatic symptom or dissociative conditions 
54
Conversion hysteria
Freud‘s term for conversion 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 their repressed sexual desires. In Freud‘s view, the repressed anxiety threatens to become conscious so it is unconsciously converted into a bodily disturbance there by allowing the person to avoid having to deal with the conflict. This is not done consciously, 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. Freud‘s theory is no longer excepted outside psychodynamic circles, but many of his observations about primary and secondary gain are still incorporated into contemporary views of conversion disorder. 
55
Freud’s theories on conversion disorder when cast in terms of learning theory 
When cast in terms of learning theory, the physical symptoms can be seen as providing negative reinforcement, relief, or removal of an aversive stimulus, because being incapacitated in someway, make an able to individual to escape or avoid an intolerably stressful situation, without having to take responsibility for doing so. Also, they may provide positive reinforcement in the form of care, concern and attention from others. 
56
Conversion disorder when viewed through a sociocultural lens
In some cultures, expressing intense emotions is not socially acceptable. When viewed through a sociocultural lens, a diagnosis of conversion disorder can therefore be seen as a more socially, sanctioned way of expressing distress and escaping an unpleasant situation. However, although becoming sick, or disabled is more socially acceptable, it is important to keep in mind that the person is not deliberately choosing to lose their site or become unable to walk. Instead, unconscious processes are thought to be at work. 
57
Studies attempting to show the causes of conversion disorders
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. But the greater than negative impact of the preceding life events, the greater the severity of the conversion disorder symptoms.
Another study compared levels of the neurobiological marker of stress 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 market relative to the non-disordered controls. This also provides support for the link between stress and the onset of conversion disorder.
Neural imaging studies of conversion disorder are relatively rare, but provocative findings our emerging 
58
What can neural imaging tell us about conversion disorder
In one study, three patients with sensory loss received brain scans while they vibrating stimulus. It was applied to the right and left hands or feet. When the stimulus was applied to the side that had sensation and was unaffected, the brain scans revealed the expected findings. But when tactile stimulation was applied to the affected, numb body part, there was no activation in the contralateral area of the sensory cortex. Instead of the tactile stimulus activated regions in the orbitofrontal cortex and the anterior cingulate cortex. Both of these brain regions are involved in neural networks that I thought to regulate emotion and the expression of emotion.
Similar results were found in another study, but the activation was found in the insula cortex, a part of the limbic system that is thought to mediate emotional responses. When patients were asked to imagine, mentally rotating a paralyzed limb, there was activation in the anterior cingulate cortex .
Another study found that when the numb body part is stimulated, there is decreased activation in the somatosensory cortex, but increased activation in areas, such as the anterior, cingulate cortex, insula, and other brain areas implicated in emotion processing. This is consistent with the idea that sensory areas may be inhibited by overactive emotion-based processing. Abnormal activation in limbic areas might be overriding activation in motor or sensory areas, shutting off the persons, ability to detect, stimuli or move 
59
Treatment of conversion disorder
Knowledge and how to treat conversion disorder is limited. Some hospitalized patients with motor conversion symptoms have been successfully treated with a behavioural approach in which specific exercises are prescribed in order to increase movement or walking, and then reinforcements are provided when patients show improvement. Any reinforcement of abnormal motor behaviours are removed. Studies have shown success in this treatment, and the improvements were maintained over a two-year follow up. Another study used CBT to successfully treat conversion seizures. Some studies have used Hipnosis combined with other problem-solving therapies, and there are suggestions that Hipnosis, or adding Hipnosis, to other therapeutic techniques, can be useful 
60
Factitious disorder
A person intentionally produces, psychological, or physical symptoms, or both. The persons 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.
61
Factitious disorder in the DSM
In the DSM four, factitious disorder it was in a category of its own. In DSM five, it has been moved into the category of somatic symptoms and related disorders. The reason is because in most cases of factitious disorder, the person presents with somatic symptoms, and with expressed belief that they are ill. But many regard to the inclusion of this disorder in this category has unfortunate. This is because it runs the risk of further perpetuating negative stereotypes of the other disorders in this category.
62
What is the difference between factitious disorder and malingering?
The key difference is that in factitious disorder, the person receives no tangible external rewards. The person who is malingering is intentionally producing or grossly exaggerating their physical symptoms, and is motivated by external incentives, such as avoiding work, or military service or evading criminal prosecution. 
63
DSM-V criteria for factitious disorder
A. Falsification of physical or psychological signs or symptoms, or induction of injury, or disease, associated with identified deception.
B. The individual presents themselves to others as ill, impaired or injured.
C. The deceptive behaviour is evident, even in the absence of obvious external rewards.
D. The behaviour is not better explained by another mental disorder. 
64
Factitious disorder and physiology
In factitious disorder, patients may alter their own physiology, for example, by taking drugs, in order to simulate various real illnesses. They may be at risk for serious injury or death, and may even need to be committed to an institution for their own protection. 
65
Prevalence of factitious disorder
Prevalence of factitious disorder is not well-established, but it’s probably in the region of 0.5 to 0.8% of patients in general hospital settings. It is more common in women than it is in men. Research on the disorder is lacking and there’s no theoretical model of why it develops. Some of the social gains that come from being in a patient role are thought to be involved 
66
Factitious disorder imposed on another
A variant of factitious disorder, sometimes referred to as Munchhausen syndrome by proxy. The person seeking medical help has intentionally produced a medical or psychiatric illness in another person. This person is usually someone who is under their care such as a child. For example, a mother presents her own child for treatment of a medical condition she has deliberately caused. Typically symptoms the mother might withhold food from the child, gives a child drugs, or heat up thermometers. The health of the victims is often seriously endangered by this form of child abuse. And as many as 10% of cases, the actions of the mother may lead to a child’s death.
67
How can factitious disorder imposed on another be suspected?
When the victims clinical presentation is atypical, when lab results are inconsistent with each other, or with recognized diseases, or when there are many frequent returns, or increasing the 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 about what they are doing. They also appear to be devoted to their child. If the perpetrator senses that the medical staff is suspicious, they made a properly terminate contact with the facility, only to show up at another one to begin the entire process again.
68
Factitious disorder and legal difficulties
Healthcare professionals who realize they have been duped, may be reluctant to acknowledge the fallibility for fear of legal action. And misdiagnosing the disorder when the patient is innocent, can also lead to legal difficulties for healthcare professionals.
69
What is the average length of time to confirm diagnoses of factitious disorder imposed on another?
14 months
70
What is a technique that has been used with success to diagnose factitious disorder imposed on another
Covert video surveillance of the mother and child during hospitalizations. In one study 23 of 41 suspected cases were finally determined to have fictitious disorder by proxy and in 56% of those cases video surveillance was essential to the diagnosis. 
71
Distinguishing conversion disorder from other types of somatic symptom related disorders
Individuals, with conversion 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. When inconsistencies in their behaviours are pointed out, they are usually unperturbed. Any secondary canes they experienced are byproducts of the conversion symptoms themselves, and are not involved in motivating the symptoms.
72
Distinguishing malingering and factitious disorder from other somatic symptom disorders
People who are feigning symptoms are inclined to be defensive, evasive, and suspicious when asked about them; they’re usually reluctant to be examined and slow to talk about their symptoms less the pretence to be discovered. Should inconsistencies in their behaviour to be pointed out, deliberate, deceivers, as a rule immediately become more defensive 
73
Dissociative disorders
A group of conditions involving disruptions in a persons, normally integrated functions of consciousness, memory, identity, or perception. Included are 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 individuals behavior.
74
Definition of dissociation
A disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including but not limited to memory, identity, consciousness, perception, and motor control
75
Normal, mild dissociations
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. There is nothing inherently pathological about association itself.
76
When is dissociation pathological?
Association 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
77
Implicit memory
When people remember things, they cannot, consciously recall and respond to sites or sounds as if they had perceived them, even though they cannot report that they have seen or heard them - implicit perception. Implicit perception also occurs in conversion disorders for people who say they cannot see are able to respond to some visual stimuli. 
78
Cognitive processes for people with dissociative disorders
Normally integrated and well coordinated, multichannel quality of human cognition, becomes less coordinated and integrated. The effective person may be unable to access information that is normally in the forefront of consciousness, such as their own personal identity, or details of an important period of time in the recent past. the ongoing mental activity outside of awareness appears to be subverted, sometimes for the purpose of managing, severe, psychological threat. This leads to the pathological symptoms of dissociative disorders.
79
What is the purpose of a dissociative disorder?
Dissociative disorders appear, mainly to be at ways of avoiding anxiety and stress and of managing life problems that have overwhelmed the person’s usual coping resources. The person avoids stress by pathologically dissociating, escaping from their own autobiographical, memory, or personal identity.
80
Similarities between somatic symptom disorders and dissociative disorders
They both appear to be at mainly ways of avoiding anxiety and stress and of managing life problems that have over whelmed the persons usual coping resources. Both types of disorders also enable the individual to deny personal responsibility for their unacceptable wishes or behavior.
81
Several types of pathological dissociation recognized in the DSM five
Depersonalization/derealization disorder, dissociative amnesia, dissociative identity disorder. They dissociative disorders are placed in the DSM five immediately after trauma and stressor related disorders to reflect the close relationship that exists between them.
82
Two more common kinds of dissociative symptoms
Derealization and depersonalization
83
Derealization
 one’s sense of the reality of the outside world is temporarily lost
84
Depersonalization
One’s sense of one’s own self, and one’s own reality is temporarily lost
85
Prevalence of derealization and depersonalization 
As many as 50 to 74% of people have such experiences in mild form, at least once in their lives, usually during or after periods of severe stress, sleep, deprivation, or sensory deprivation.
86
What is the difference between normal de realization and depersonalization and a disorder?
When episodes of depersonalization or derealization, become persistent, and recurrent and interfere with normal functioning.
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Symptoms and feelings that people experience in depersonalization/derealization disorder
People have persistent or recurrent experiences of feeling, detached from their own bodies and mental processes, and feeling like an outside observer. They may even feel they are floating above their physical bodies, which may suddenly feel very different. During periods of depersonalization, unlike during psychotic states, reality testing, remains intact. The related experience of the realization, in which the external world is perceived, as strange and new in various ways may also occur. Often people report feeling as though they are living in a dream or a movie.
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Difference between depersonalization and psychotic states
During depersonalization, unlike during psychotic states, reality testing, remains intact. Sometimes feelings of depersonalization can be early manifestations of the development of psychotic states.
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Emotional experiences during depersonalization
Emotional experiences are attenuated or reduced during depersonalization, both at the subjective level, and at the level of neural and autonomic activity, that normally accompanies emotional responses to threatening or unpleasant, emotional stimuli. For example, in a study, participants viewed an emotional video clip, and participants with depersonalization showed higher levels of subjective and objective memory fragmentation, then controls. Memory fragmentation is March by difficulty, forming an accurate or coherent, narrative sequence of events, which is consistent with earlier research, suggesting that time distortion is a key element of the depersonalization experience.
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DSM-V criteria for depersonalization/derealization disorder
A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:
1. Depersonalization: experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions.
2. De realization: experiences of unreality or detachment with respect to surroundings.
B. During the depersonalization or de realization experiences, reality testing, remains in tact.
C. The symptoms causing clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a tributable to the physiological effects of a substance or another medical condition.
E. The disturbance is not better explained by another mental disorder
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Derealization and depersonalization in the DSM
In DSM four, derealization and depersonalization were treated as two distinct conditions. In DSM five, they have been combined. This is because research suggests that people who have prominent derealization or prominent depersonalization, look rather similar in terms of demographic characteristics, the course and severity of their problems and their comorbid conditions.
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Occasional depersonalization/derealization symptoms in other disorders
Occasional depersonalization/de realization symptoms are also sometimes reported by people with schizophrenia, borderline personality disorder, panic disorder, acute stress disorder, and post traumatic stress disorder
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Prevalence of dissociative disorders
Dissociative disorders have not been included in the major epidemiological surveys that have been conducted to date so there is no exact prevalence data. It is estimated that the lifetime prevalence of doubt depersonalization/derealization disorder is around 1 to 2% of the population with equal numbers of males and females being affected. The main age of onset is around age 16, with only a minority of people developing it after age 25. In nearly 80% of cases the disorder has a fairly chronic course with a little fluctuation in intensity.
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Comorbid conditions for depersonalization/de realization disorders
Comorbid conditions can include mood or anxiety disorders. Avoidant, borderline, and obsessive compulsive personality disorders are also elevated and people with depersonalization and derealization experiences.
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Treatments for dissociative disorders
Professional assistance in dealing with the precipitating, stressors, and introducing anxiety may be helpful. But as of yet there are no clearly effective treatments either three medication or psychotherapy.
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Retrograde amnesia
The partial or total inability to recall or identify, previously acquired information or past experiences
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Anterograde amnesia
The partial or total inability to retain new information
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Persistent amnesia
May occur in dissociative amnesia. May also result from traumatic brain, injury or diseases of the central nervous system. If the amnesia is caused by brain pathology, it most often involves failure to retain new information and experiences. That is, the information contained in experience is not registered and does not enter memory storage.
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Dissociative amnesia
Usually limited to a failure to recall, previously stored personal information, retrograde amnesia, when that failure cannot be accounted for by ordinary, forgetting. The gaps in memory most often occur following intolerably, stressful circumstances, such as war time combat conditions, for example or catastrophic events, such as serious car, accidents or Trumatic experiences. Apparently forgotten personal information is still there, Denise the level of consciousness. It sometimes becomes a parent in interviews, conducted under hypnosis, whore narcosis, and in cases were the amnesia spontaneously clears up.
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Timeline of amnesiac episodes in dissociative amnesia
Amnesiac episodes usually last between a few days and a few years. So many people experience only one such episode, some people have multiple episodes in their lifetimes. 
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A typical dissociative, amnesiac reaction
Individuals cannot remember certain aspects of their personal life, history or important facts about their identity. Yet their basic habit patterns, such as their abilities to read, talk, etc. remain intact, and they seem normal aside from the memory deficit. The only type of memory that is affected, is episodic or autobiographical memory. The other recognized forms of memory, semantic, procedural, and short-term storage seen usually to remain intact, although there is very little research on the topic. Usually there is no difficulty in coding new information information
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Dissociative fugue
In rare cases, a person may retreat still further from real life problems by going into an amnesiac state, called a dissociative fugue, which is a defence by actual flight. A person is not only amnesiac for some or all aspects of their past, but also departs from home surroundings. This is accompanied by confusion about personal identity or even the assumption of a new identity. During the fugue such individuals are unaware of a memory loss for prior stages of their life but their memory, for what happens during the Fuchs state itself is intact. Their behaviour during the fugue state is usually quite normal and unlikely to arise suspicion that something is wrong. But behaviour during the fugue state often reflects a rather different lifestyle from the previous one. 
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Emerging from dissociative fugue state
such people may suddenly emerge from the fugue state and find themselves in a strange place with no idea how they got there. But sometimes recovery from the fugue state occurs only after repeated questioning, and reminders of who they are. As the fugue state permits, their initial amnesia, remits, but a new and complete amnesia for their fugue Period occurs.
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Dissociative fugue in the DSM
In DSM five, dissociative fugue is considered to be a subtype of dissociative amnesia rather than a separate disorder, as it was in DSM four 
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DSM-V criteria for dissociative amnesia
A. An inability to recall important auto biographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary, forgetting. Note: dissociative amnesia, most often consists of localized or selective amnesia for specific events, or generalized amnesia for identity and life history.
B. The symptoms caused clinically significant Distressed Fort impairment in social, occupational, or other important areas a functioning.
C. The disturbance is not a tributable to the physiological effects of a substance or a neurological or other medical condition.
D. The disturbance is not better explained by another psychological disorder.
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Pattern of symptoms in dissociative amnesia
The pattern is essentially similar to that in conversion symptoms, except that, instead of avoiding some unpleasant situation by becoming physically dysfunctional, a person, unconsciously, avoids thoughts about the situation, or leaves the scene. Thus people experiencing dissociative amnesia are typically faced with extremely unpleasant situation, from which they see no acceptable way to escape. Eventually, the stress becomes so intolerable that large segments of their personalities and all memory of a stressful situation or suppressed..
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Studies on dissociative, amnesia, and fugue
Little systematic research has been conducted on individuals with dissociative amnesia and fugue so any conclusions should be considered tentative pending further study of large samples with appropriate control groups. What can be gathered from a handful of case studies is that these individuals semantic knowledge seems to be generally intact. The primary deficit is there compromised episodic or autobiographical memory. Brain imaging techniques have confirmed this, as people show reduced activation in their right frontal and temporal brain areas relative to normal controls. There is evidence of significant changes in the brains of people with dissociative amnesia, with subtle loss of function in the right anterior hemisphere.
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Dissociative amnesia, and implicit memory
Several cases have suggested that implicit memory is generally intact. They study showed that a person with dissociative amnesia could not remember their family members names, but when asked to guess what names might fit them, he produced their names correctly. A patient was asked to dial numbers on the phone randomly, and without realizing what he was doing, he dialled his mothers phone number.
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Dissociative amnesia, and explicit perception
Some of the memory deficits in dissociative, amnesia and fugue, have been compared to related deficits in explicit perception that occur in conversion disorders. This is convinced many people that conversion disorder should be classified with dissociative disorders, rather than with somatic symptom disorders.
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Conversion disorder: somatic symptom disorder for dissociative disorder?
Prior to the publication of DSM three, conversion disorders were classified together, with dissociative disorders as sub types of hysteria. When the DSM focussed on overt behavioural symptoms, the decision was made to include a conversion disorder, with the other somatic symptom disorders, because its symptoms were physical ones. But this ignores important differences between conversion disorders and other somatic symptom disorders, the most important being that conversion symptoms resemble neurological problems in their clinical presentation, and they mimic true neurological symptoms, just as dissociative disorders do. It has been argued that conversion disorders involve disruptions in explicit perception and action. an argument can be made that the term conversion disorder should be dropped, and the sensory and motor types of this syndrome should be classified as forms of dissociative disorders. This way, the central feature of all dissociative disorders would be a disruption of the normally integrated functions of consciousness: memory, perception, and action.
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Dissociative identity disorder [DID]
Formerly known as multiple personality disorder. A dramatic dissociative disorder. The idea is a condition in which normally integrated aspects of memory, identity and consciousness are no longer integrated.
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DID in the DSM
In DSM four, The person manifests two or more distinct identities that alternated in some way and taking control of behavior. This was accompanied by an inability to recall important, personal information that could not be explained by ordinary forgetting.
In DSM five there was a shift in emphasis. What is now required is that there can be a disruption of identity characterized by two or more distinct personality, states as well as recurrent episodes of amnesia. This disruption in identity can either be self-reported, or observed by others. In other words, the idea can now be diagnosed without other people witnessing the different personalities. Another change in the DSM five is the inclusion of pathological possession in the diagnostic criteria. Pathological possession is a common form of the ID in Africa, Asia, and many other non-western cultures.
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Trance versus possession trance
A trance is said to occur when someone experiences a temporary marked alteration in state of consciousness or identity. It is usually associated with either narrowing of awareness of the immediate surroundings or stereotyped behaviours or movements that are experienced as beyond one’s
A possession trance is similar, except that the alteration of consciousness or identity is replaced by a new identity that is attributed to the influence of a spirit, deity, or other power. In both cases amnesia is typically present for the transit state. When for religious or spiritual reasons, these states are not considered pathologically, but when they occur in voluntarily, this is a serious problem.
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Prototypical case of D ID
There are different personalities that emerge and are a parent to an outside observer. Each identity may appear to have a different, personal history, self image, and name although there may be some identities that are only partially distinct and independent from other identities. In most cases, the one identity that is most frequently encountered and carries the persons real name is the host identity. in most cases, the host is not the original identity, and it may or may not be the best adjusted identity. The alter identities may differ in striking ways involving gender, age, headedness, handwriting, sexual orientation, prescription of eyeglasses, predominant, affect, language, spoken, and general knowledge. needs and behaviours inhibited in the primary or host identity are usually liberally displayed in one or more alter identities. Certain roles, such as a child, and someone of the opposite sex are extremely common.
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Why did the term multiple personality disorder become abandoned for DID?
The reason, for this was the growing recognition that it had a misleading connotations, suggesting multiple occupancy of space, time and peoples bodies by differing but fully organized and coherent personalities. In fact, alters are not in any meaningful sense personalities, but rather reflect a failure to integrate various aspects of a persons, identity, consciousness, and memory. The term DID better captures this, as do the revised DSM five criteria.
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Switching between alter identities in DID
Alter identity is it take control at different points in time and the switches typically occur very quickly although more gradual switches can also occur. When switch is occurring people with DID, it is often easy to observe the gaps and memories for things that have happened, but this amnesia is not always symmetrical; some identities may know more about certain alters, then do other identities. 
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Additional symptoms of DID
Depression, self injurious, behavior, frequent, suicidal ideation, and attempts, erratic behavior, headaches, hallucinations, post traumatic symptoms, and other amnesiac and few symptoms.
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Comorbid disorders with DID
Depressive disorders, PTSD, substance use disorders, and borderline personality. Disorder are the most common comorbid diagnoses. The average number of comorbid diagnoses was five, with PTSD, being the most common.
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Demographic characteristics of D ID
DID usually starts in childhood the most patients are in their teens, 20s or 30s at the time of diagnosis.
Approximately 3 to 9 times more females than males are diagnosed as having the disorder and females tend to have a larger number of alters then two males. Some believe that this pronounced gender discrepancy is due to the much greater proportion of childhood sexual abuse among females than among males But this is a highly controversial point. 
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The number of alter identities in DID
This very tremendously and has increased over time. An early review reported that 2/3 of these cases had only two personalities and most of the rest had three. More recent estimates are that about 50% now show over 10 identities with some respondents claiming as many as 100. This historical trends of increasing multiplicity suggest the operation of social factors, perhaps through the encouragement of therapists. Another recent trend is that many of the reported cases of D ID now include more than usual, and even bizarre identities done in the past, such as being an animal, and more highly Implausible backgrounds.
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DSM-V criteria for dissociative identity disorder
A. Disruption of identity, characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption and identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and or sensory motor functioning. These signs and symptoms may be observed by others, or reported by the individual.
B. Recurrent gaps in the recall of every day, events, important, personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
C. The symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The disturbance is not a normal part of a Bradley excepted, cultural or religious practice. Note: in children, the symptoms are not better explained by imaginary playmates or other fantasy play.
E. The symptoms are not a tributable to the physiological effects of a substance or another medical condition.
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D ID versus schizophrenia
The general public has long been confused by the distinction between D ID and schizophrenia. It is very important to remember that people diagnosed with schizophrenia. Do not have multiple distinct identities that alternately take control over their mind and behavior. They may have a delusion and believe they are someone else, but they do not show the changes in identity, accompanied by changes in tone of voice, vocabulary, and physical appearance that are often seen when identities switch in D ID. Also people with DID do not exhibit such characteristics of schizophrenia as disorganized behavior, hallucinations coming from outside the head, and delusions, or incoherent and loose associations.
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Interrelated controversies surrounding DID, and how it develops [4]
1. Whether DID is a real disorder, or is faked, and whether even if it is real, it can be faked.
2. About how DID develops. Specifically, is DID caused by early childhood trauma or does the development of DID involve some kind of social enactment of multiple different roles that have been inadvertently encouraged by careless clinicians.
3. Those who maintain that D ID is caused by childhood trauma site evidence that the vast majority of individuals diagnosed with DID report memories of an early history of abuse. But are these memories of early history of abuse real or false?
4. If abuse has occurred in most individuals with DID, did the abuse play a causal roll or was something else correlated with the abuse actually the cause
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Controversy one: is DID real or faked?
One obvious situation in which this issue becomes critical is when it has been used by defendants and their attorneys to try to escape punishment for crimes. But some historical cases have involved complete fabrication, orchestrated by the criminal or other unscrupulous person, seeking on for advantages, and not all prosecutors, have as clever and knowledgable and expert to be able to detect this. Nevertheless, most researchers, think that factitious and malinger and cases of DID are relatively rare 
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Controversy two: if DID is not faked, how does it develop: post traumatic theory or sociocognitive theory?
Many professionals acknowledge that in most cases DID is a real syndrome, but there is marked disagreement about how it develops, and how it is maintained. The original major theory of how DID develops is post traumatic theory. The majority of patients with DID report memories of severe or horrific childhood abuse.
An alternative theory called sociocognitive theory of DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities, mostly because clinicians have inadvertently suggested, legitimized and reinforced them, and because these different identities are geared to the individuals own personal goals.
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Post traumatic theory of DID
According to post traumatic theory, DID starts from the child’s attempt to cope with an overwhelming sense of hopelessness and powerlessness in the face of repeated traumatic abuse. Lacking other resources or roots of escape, the child made associate an escape into a fantasy, becoming someone else. This escape may occur through a process like self hypnosis, and if it helps alleviate some of the pain, it will be reinforced and occur again in the future. Sometimes the child simply imagines the abuse is happening to someone else. The child may unknowingly create different selves at different points in time, possibly laying the foundation for dissociated identities.
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Diathesis stress model for DID
Only a subset of children who undergo traumatic experiences are prone to fantasy or self hypnosis. Children who are prone to fantasy, and those who are easily hypnotizable may have a diathesis for developing DID or other dissociative disorders when severe abuse. There is nothing inherently pathological about being prone to fantasy or readily hypnotizable.
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DID & PTSD
Those who view childhood abuse is playing a critical role in the development of DIDR are beginning to see DID, as perhaps a complex, and chronic variant of PTSD, which is caused by exposure to some kind of highly traumatic event, including abuse. Anxiety symptoms are more prominent in PTSD then in DID and dissociative symptoms are more prominent in DID than in PTSD. Nevertheless, both kinds of symptoms are present in both disorders. And some investigators have estimated that a very high percentage of individuals diagnosed with DID have a comorbid diagnosis of PTSD, suggesting the likelihood of some important common causal factors. DSM five now includes PTSD with dissociative symptoms as a new sub type. 
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Sociocognitive theory of DID
according to the theory, DID develops when a highly suggestible person learns to adopt and enact the roles of multiple identities, mostly because clinicians have inadvertently suggested, legitimized and reinforced them, and because these different identities are geared to the individuals own personal goals. It’s important to understand that this perspective does not view this as being done intentionally or consciously by the person involved. Rather it occurs spontaneously with little or no awareness. the suspicion is that overzealous clinicians, through fascination with clinical phenomenon of the ID and unwise use of such techniques as hypnosis are themselves largely responsible for eliciting this disorder and highly suggestible fantasy prone people
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Related situational forces that may affect DID in the individual outside the therapists office include
Memories of one’s past behavior, observations of other people’s behavior, and media portrayals of DID
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Support for the sociocognitive theory of DID
They study demonstrated that ordinary college students can be induced by suggestion under hypnosis to exhibit some of the phenomena seen in DID.
Also, there is evidence that most DID patients do not show unambiguous signs of the disorder before they enter therapy, and evidence that the number of identities often increases with time spent in therapy.
The number of cases of DID began to rise once it became more prevalent in fiction, television, and movies. at the same time the diagnostic criteria for DID was clearly specified for the first time in the DSM three. This may have led to an increased acceptance of the diagnosis by clinicians, which may have encouraged reporting it in literature. In addition, reports of abuse in patients with DID attracted a great deal of attention to this disorder which may have increased the rate at which it was being diagnosed. Prior to 1979 only about 200 cases could be found in literature. By 1999 over 30,000 cases have been reported in North America alone. 
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Prevalence estimates of DID in the general population
Hard to come by and it’s possible that no estimates are valid but one study estimated a 1.5% prevalence.
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Criticisms of the sociocognitive theory of DID
Studies done on this theory do not actually show that this is the way the idea is actually caused in real life. As well, the participants in these experiments showed only a few of the most obvious symptoms of DID and only under laboratory conditions.
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Controversy three: are recovered memories of abuse in DID real or false?
The accuracy and trustworthiness of reports of a widespread sexual and other forms of childhood abuse in DID have become a matter of major controversy. Critics argue, that many of these reports may be the result of false memories, which are intern a product of highly leading questions and suggestive techniques applied by well-meaning, but inadequately, skilled and careless psychotherapists. it is true that in some cases innocent family members have been falsely accused by patients, but it is also true, that abuse of children occurs far too often. The real difficulty is determining when the recovered memories of abuse are real and when they are false.
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How to determine if particular recovered memories are real or not
One way to document that particular recovered memories are real might be if some reliable, physiological test could be developed to distinguish between them. Researchers are trying to determine if there are different neural correlates of real and false memories that could be used to make this determination reliably. Another easier way to document whether a recovered memory is real would be to have independent verification that the abuse occurred such as through physician or police records. Critics have shown that the criteria used for corroborating evidence is very loose and suspect as to their validity. 
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Controversy for Coghlin, if abuse has occurred, does it play a causal role in DID
It is difficult to determine if abuse played a critical causal role in the development of D ID. Because child abuse happens in family environments with many other sources of adversity and trauma. One or more of these other sources could be playing the causal role. As well people who have experienced child abuse and symptoms of DID may be more likely to seek treatment than people who did not experience abuse. therefore it may not be representative of the population of all people who suffer from DID. Also childhood abuse has been claimed by some to lead to many different forms of psycho pathology. The most we will ever be able to say, perhaps, is that childhood abuse may play a non-specific role for many disorders, with other more specific factors determining which disorder develops.
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Current perspectives: Sociocognitive model for DID versus trauma model
Studies provide somewhat more support for the sociocognitive model, then for the trauma model. But theorists on both sides are not softening their possessions and acknowledging that multiple different causal pathways are likely to be involved. Advocates for post traumatic theory, or acknowledging that some cases are fake, and that some may be inadvertently caused by unskilled therapists in the course of treatment. There’s also a growing appreciation that real and false memories occur in these patients combined with a recognition of the critical need for new methods to be developed to help determine which is which.
Advocates for sociocognitive theory have acknowledged that some people with DID may have undergone real abuse, although they believe it occurs far less often, and is less likely to play a real causal role than the trauma theorists maintain 
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Differences in behaviour of people diagnosed with DID compared to the behaviour of people who are simulating DID
Diagnosed patients show more symptoms of DID then simulators do. Compared to simulators, patients with DID show more cognitive processing problems. Deficits in performance are apparent on tasks involving recognition of previously seen material as well as on recall and reaction time tasks. Cognitive problems are seen in patients with many types of disorders so they could be a result of psychopathology in general rather than DID in particular and perhaps these cognitive problems were a pre-existing vulnerability factor
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Similarities between the behaviour of people diagnosed with DID and the behaviour of people who simulated DID
The transfer of memory across personalities: most people with DID have at least some identities that seem completely unaware of the existence and experience of certain other identities. What happens when information is presented to one identity and the person switches to another identity? It was found that the self reported amnesia across identities is incomplete. What information is given to identity one and then the person switches to identity to, identity to performs better on the memory task, then would be the case if there were complete amnesia across the two identities. this is true regardless of whether explicit or implicit memory tasks are used. The transfer of information on implicit tasks is similar for diagnosed patients, as well as for simulators.
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What happens when information is presented to one identity and the person switches to another identity?
It was found that the self reported amnesia across identities is incomplete. What information is given to identity one and then the person switches to identity to, identity to performs better on the memory task, then would be the case if there were complete amnesia across the two identities. this is true regardless of whether explicit or implicit memory tasks are used.
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Cultural factors in dissociative disorders
The prevalence of dissociative disorders are influenced by the degree to which such phenomena are excepted or tolerated, either as normal, or as legitimate mental disorders by the surrounding cultural context. Many related phenomena, such as spirit, possession and dissociative trances occur frequently in many different parts of the world where the local cultures sanction them. Such experiences are not necessarily problematic when they are volitional, transient and occur as a normal part of religious or spiritual practices. But when they are involuntary and cause distress, possession states are considered to be pathological. The inclusion of pathological possession has made the diagnosis of DID more applicable to people from a wide range of cultural backgrounds. 
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Pathological possession in DID in a cultural context
The inclusion of pathological possession acknowledges that DID can present in two different form: possession form, and a non-possession form. how disorder presents may be very much determined by cultural factors.
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Understanding how pathological possession is treated by indigenous healers
May provide new perspectives that could be valuable overall. Treatments by indigenous, healers and therapists operating within western culture have many similarities. Both emphasize, addressing different aspects of the persons, identities, allowing each to have a voice through which that identities a point of view and distress can be clarified. However, in the majority of cases, culturally, sanctioned attempts to remove or exercise the alternate identity typically lead to poor outcomes.
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Amok
A cross cultural variant on dissociative disorders. Often thought of as a rage disorder. Occurs when a dissociative episode leads to violent, aggressive or homicidal behaviour directed at other people and objects. It occurs mostly in men, and is often precipitated buy a perceived, slight or insults. The person often has ideas of persecution, anger and amnesia, often followed by a period of exhaustion and depression. It occurs in places such as Malaysia, Laos, the Philippines, Papua New Guinea, Puerto Rico, and among Navajo Indians.
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Treatment of dissociative disorders: depersonalization disorder, and dissociative amnesia
Virtually no systemic controlled research has been conducted on treatment of depersonalization disorder and dissociative amnesia. The absence of randomized controlled trial’s means that very little is known about how to treat these two disorders successfully.
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Treatment of dissociative disorders: Depersonalization/derealization disorder
Depersonalization/derealization disorder may be fairly resistant to treatment, but treatment may be useful for associated problems, such as anxiety and depressive disorders. Hypnosis may be useful so patients can learn to dissociate, and then re-associate, gaining some sense of control over their experiences. Studies on Treatments with medication’s are inconsistent. There may be promise with brain stimulation treatment.
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Brain stimulation treatment for depersonalization/derealization disorder
Recent treatment showing some promise, for the treatment of dissociative disorders involves administering rTMS (repetitive transcranial magnetic stimulation)  to the temporal parietal junction, an area of the brain, highly involved in the experience of a unified self and body. After three weeks of treatment, half of the subjects showed significant reductions in depersonalization, with nonresponders showing symptom reduction after an additional three weeks of treatment.
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Dissociative disorder treatment: dissociative amnesia
It’s important for the person to be in a safe environment and simply removing them from what they perceive as a threatening situation sometimes allows for a spontaneous recovery of memory. Hypnosis as well as drugs, such as benzodiazepines, barbiturates, sodium, pentobarbital, and sodium ammo barbital is often used to facilitate recall, ever pressed and dissociated memories. After memories are recalled, it’s important for the patient to work through the memories with the therapist, so that the experiences can be reframed in new ways. But unless the memories can be independently corroborated, they should not be taken at their face value. 
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Current therapeutic approaches for people diagnosed with DID
Most current therapeutic approaches are based on the assumption of post traumatic theory that the disorder was caused by abuse. Most therapists set integration of the previously separate alters, together, with their collective, merging into the host personality, as the ultimate goal of treatment. There is often considerable resistance to this process by patients, who consider dissociation as a protective device. If it successful integration occurs, The patient eventually develops a unified personality, but it is not uncommon for only partial integration to be achieved. It’s also important to assess whether improvement in other symptoms has occurred. Treatment is more likely to produce symptom improvement, then to achieve full and stable integration of the different alter identities. 
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Theories and techniques used in the treatment of DID
Typically the treatment for the idea is psycho, dynamic and inside oriented, focussed on uncovering, and working through the trauma and other conflicts that are thought to have led to the disorder. One of the primary techniques is hypnosis. Most patients are hypnotizable, and when hypnotized are able to recover past, unconscious and frequently traumatic memories often from childhood. These memories can be processed and the patient can become aware that the dangers are no longer there. Through the use of Hipnosis, therapists are often able to make contact with different identities and reestablish connections between distinct, seemingly separate identity states. The therapist must be strongly committed, as well as professionally competent 
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Reports in literature of treatment for DID
Most reports in literature are treatment summaries of single cases. Reports should always be considered with caution, especially given the large bias in favour of publishing positive rather than negative results. Treatment outcome data for large groups of patients with DID are seldom reported and control groups are lacking. But it is clear that DID does not spontaneously remit simply with the passage of time or if a therapist chooses to ignore DID related issues 
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In general, it has been found that for treatment of DID to be successful it must be:
Prolonged, often lasting many years, and the more severe the case, the longer that treatment is needed 
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A different perspective on recovered memories that attempts to bridge the gap between the convection that repression underlies recovered memories and the alternate convection that all recovered memories are false
This third perspective suggests that some recovered memories are genuine, but we never actually repressed. Instead some abuse victims, they simply not have thought about their abuse for a long period of time, I’ve been deliberately attempting to forget the abuse (suppression rather than repression), or may have forgotten prior instances when they did recall the abuse, resulting in the false impression that a recently surfaced memory has been repressed for years. In other words, this may be getting closer to being able to reconcile some wildly, disparate perspectives about trauma and memory that have been so contentious for so long. 
