- Recommend effective treatment methods for dissociative disorders and somatic symptom disorders
Therapists may prescribe different types of treatment for patients with dissociative disorders or somatic symptom disorders based on their viewpoints on the disability and various theories or frameworks. For example, a psychotherapist with a background in psychodynamic theory who studied Freud may approach a client differently by focusing on trying to assist them with overcoming unhealthy defense mechanisms. Whereas someone who has a strong CBT background may focus on psychological techniques to apply and medication management.
Treating Dissociative Disorders
Dissociative disorders are generally treated with long-term psychotherapy. Common treatment methods include an eclectic mix of psychotherapy techniques, including cognitive-behavioral therapy (CBT), insight-oriented therapies, dialectical behavioral therapy (DBT), hypnotherapy, and eye movement desensitization and reprocessing (EMDR).
Although there are multiple approaches for treating dissociative disorders, the common element of these treatments addresses the dissociative pathology and exploring prior traumatic events. Treatment of dissociative disorders is associated with improvements in symptoms of dissociation, depression, general distress, anxiety, and PTSD, as well as decreased use of medications and improved work and social functioning (Brand et al. 2009). Duration of treatment varies depending on the particular dissociative disorder being treated, with dissociative amnesia and dissociative fugue recovering more quickly and having a better outcome as compared to dissociative identity disorder and depersonalization disorder. However, a significant proportion of patients’ improvement during initial treatment may not remain stable over time, indicating the need for additional follow-up for contingent intervention in the case of recurrent dissociative symptoms or other psychopathological states.
There is no consensus in the treatment of DID, and research on treatment effectiveness focuses mainly on clinical approaches described in case studies. General treatment guidelines suggest a phased, eclectic approach with more concrete guidance and agreement on early stages; however, no systematic, empirically supported approach exists and later stages of treatment have no consensus. Even highly experienced therapists have few patients that achieve a unified identity.
Unlike DID, the length of an event of dissociative amnesia may be a few minutes or several years. If an episode is associated with a traumatic event, the amnesia may clear up when the person is removed from the traumatic situation. Similarly, once dissociative fugue is discovered and treated, many people recover quickly.
Medications can be used for comorbid disorders and/or targeted symptom relief. Medications (such as antidepressants, anti-anxiety medications, or tranquilizers) can help control the mental health symptoms associated with the disorders; however, there are no medications that specifically treat dissociative disorders.
Treating Somatic Symptom Disorders
Treatment for functional neurological symptom disorder (conversion disorder) can include hypnosis, psychotherapy, physical therapy, occupational therapy, stress management, and transcranial magnetic stimulation (TMS). Transcranial magnetic stimulation (TMS) is a form of brain stimulation in which a changing magnetic field is used to cause an electric current at a specific area of the brain through electromagnetic induction.
In treating somatic symptoms (such as functional neurological symptom disorder (conversion disorder), factitious disorder, etc.), the provider may need to avoid colluding with the patient, but also avoid denying the reality of the symptoms. Research has shown that empowering explanations are the most beneficial for patients with medically unexplained symptoms. Psychoeducation is also very important. Patients with medically unexplained symptoms often appear to be seeking reassurance, but this assurance can be difficult to deliver effectively. It is counterproductive to tell a patient that “there is nothing wrong” when their symptoms are proof that there is. On the other hand, it is important to counter specific illness fears that the patient may hold (e.g., “My symptoms mean I’ve got cancer,” “This rash shows that I have HIV,” “If I do too much I will permanently damage my spine”) if that is not the case.
If there is evidence of anxiety or depression, this should be treated in the usual way. Doing so will often, although not always, lead to a significant improvement in the patient’s somatic symptoms. A doctor that sees a patient with medically unexplained symptoms for follow-up has an important role to play in managing that patient’s interaction with medical services. Even if the doctor does not perceive themselves to be providing active therapy, they can provide regular follow-up that is not contingent on the patient being symptomatic, thereby discouraging the need for the patient to complain of symptoms in order to elicit care. It is sometimes possible to agree beforehand that only a certain proportion of the session will be devoted to discussing symptoms, and leave it to the patient to decide the content of the second half of the interview.
Overall CBT and similar therapies have shown specific usefulness in the treatment of somatic symptom disorders. Though CBT can be adapted for use in any of these disorders, like most medical treatments, it relies on the patient being sufficiently motivated to participate. One of the first goals in CBT is for the therapist and patient to come to a shared understanding of the patient’s problems using a CBT framework. Additionally, psychopharmacology can be useful in the treatment of somatic symptom disorders, especially if there’s comorbid depression or anxiety. In this case, antidepressants may be prescribed.
In clinical practice, it is common to combine a psychotherapeutic and pharmacological approach to management. The patient may have strong feelings about treatment and these should be taken into consideration.
Treating Functional Neurological Symptom Disorder (Conversion Disorder) : A Case Study
Even when a clear psychological cause is known, some physical treatment may be helpful in combination with talking therapy, as described in this case of a 13-year old girl with hand tremors.
Watch this video to see the hand tremors in a girl and the improvement following treatment (note that there is no sound).
The functional neurological symptom disorder (conversion disorder) hand tremor shown in the video occurred in a 13-year-old girl, who was treated with both a customized wrist brace and psychological therapy using cognitive behavioral therapy.
Her severe psychogenic tremor was diagnosed as a dissociative motor disorder and was videotaped at different stages during treatment. The videos were useful in showing the girl clear evidence of her improvements. The cause was psychological: severe performance and exam anxiety at school, combined with her parents’ difficult relationship. Her hand tremor prevented writing and attending school, increasing her avoidance of school.
“Stop pretending” made things worse
The tremor was inconsistent, reducing when her concentration was on something else and would stop when she grasped something, e.g., clasping her hands together. Finding no neurological or physical cause for the tremor, a physiotherapist told her to “stop pretending,” which led to prolonged sadness and anger in the girl and an increase in the tremor. Secondary gain is sometimes referred to in functional neurological symptom disorder (conversion disorder) despite not being part of the diagnostic criteria. This means the person’s functional neurological symptom disorder (conversion disorder) causes an indirect benefit: any secondary gain from not needing to attend school was clearly canceled out by her inability to sleep or eat normally due to the tremor, plus the distress it caused her. She was also hospitalized and agreed to attend the psychiatric unit. Even in cases where secondary gain is present, this should not be used as a basis for diagnosis.
The patient had anxiety-reduction sessions and learned progressive muscle relaxation. Her customized wrist brace to help her write, and she practiced writing daily. This reduced her school anxiety and avoidance, and she began attending again. She also had private lessons in the subjects she struggled with the most. In her treatment, it was key for her to understand what triggered the tremor and prevented it from diminishing. From the girl’s perspective, she found what helped most was being more active rather than listening to music alone, physical and social activity, identifying and discussing her feelings with others, eventually mastering the relaxation methods to reduce stress, and attending physical therapy aimed at symptom reduction. The combination of treatment reduced her tremor by 80% during her time in the hospital, and two weeks after discharge it was gone.
colluding: when a therapist participates with a client, buying into what they are saying either consciously or unconsciously, and by doing so avoids an issue that needs to be addressed: for patients with DID, this may involve the therapist asking to reveal the different personalities and to ask questions out of curiosity instead of helping to address specific concerns