A case study illustrating the interplay between psychological and somatic dissociation.

Abstract

The concept of Dissociation was originally conceived as having a psychological and a somatic component. Nevertheless, recent versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) have isolated both elements. In the DSM the psychological manifestation of dissociation is diagnosed as a Dissociative Disorder and the somatic domain is diagnosed as a Somatoform Disorder. However, recent empirical and clinical evidence have been highlighting and corroborating a high degree of comorbidity between such disorders and a constant interplay between somatic and psychological dissociation. In the following case study, the clinical constellation of the patient nicely illustrates that her dissociative defenses began as a Conversion Disorder and how, after a mishandling of the case by a clinician, her dissociation symptoms were instantly transformed in a typical Dissociative Amnesia Disorder. Cases like this convincingly illustrate how the dissociative defenses not only subsume the mental but also extend to the bodily domain.

Keywords: Psychopathology; conversion disorder; dissociative disorder; psychogenic amnesia.

Estudio de Caso Ilustrativo de la Interrelación entre la Disociación Psicológica y la Somática

Compendio

El concepto de Disociación originalmente incluía componentes psicológicos y somáticos. Sin embargo, versiones recientes del Manual de Diagnóstico y Estadísticas de los Trastornos Mentales (DSM-IV) han deslindado ambos elementos. En el DSM las manifestaciones psicológicas de la disociación se identifican como manifestaciones de un Trastorno Disociativo; mientras que el aspecto somático se identifica como parte de los Trastornos Somatoformes. Sin embargo, en estudios clínicos recientes se ha resaltado el hecho de que hay una comorbilidad extrema entre ambos trastornos y que se puede corroborar el hecho de que hay una interdependencia entre las manifestaciones psicológicas y somáticas de la disociación. En el siguiente estudio de caso, la constelación clínica de la paciente ilustra de una manera lúcida cómo sus defensas disociativas comenzaron con la manifestación de un Trastorno Conversivo y, tras un mal manejo clínico, sus síntomas disociativos de inmediato se transformaron en un Trastorno de Amnesia Disociativa. Casos como estos muestran convincentemente cómo las defensas disociativas no sólo incluyen el aspecto psicológico, sino que también se extienden al dominio corporal.

Palabras clave: Psicopatología; trastorno conversivo; trastorno disociativo; amnesia psicógena.

When in the 19th century Pierre Janet (1859-1947) formulated his ideas about the specific components of dissociation, he clearly included the presence of both psychological and somatoform dissociative phenomena (van der Hart & Friedman, 1989). Such symptoms as anesthesia, analgesia, and loss of control over motor responses were eloquent examples of what today some researchers call "somatoform dissociation" (Nijenhuis, 2000; Nijenhuis, Spinhoven, van Dyck, van der Hart & Vanderlinden, 1996, 1998; Sar, Kundakci, Kiziltan, Bakin, & Bozkurt, 2000). Nevertheless, the members of the Task Force of the DSM-III (American Psychiatric Association, 1980) decided to separate the motor/ somatic component of dissociation and to categorize it with the Somatoform Disorders. Subsequent editions of the DSM-III-R (American Psychiatric Association, 1987) and the DSM-IV (American Psychiatric Association, 1994) have retained that division. This decision has been amply rejected or questioned (Cardeña & Spiegel, 1996; Kihlstrom, 1994; Nemiah, 1991; Nijenhuis et al., 1998; Ross, 1999) on various grounds.

First, there is extensive documentation that dissociative patients report a wide array of somatic and conversion reactions (Boon & Draijer, 1991; Martínez-Taboas, 1991; Ross, Fast, Anderson, Auty & Todd, 1990; Saxe, et al., 1994). For example, Saxe et al. (1994) compared somatization in dissociative and nondissociative patients. They found that 64% of the first group met the criteria for a Somatization Disorder, whereas none of the comparison patients met criteria for a Somatoform Disorder. For his part, Pribor, Yutzy, Dean and Wetzel (1993) found that women with high dissociation scores also reported many somatic symptoms, specially if there was a history of abuse. In this context, the research by Nijenhuis, et al. (1996, 1998) is highly relevant. Using the Somatoform Dissociation Questionnaire, which evaluates the severity of somatoform dissociative phenomena, the authors have documented that dissociative disorder patients can be clinically differentiated from patients without a dissociative disorder. The sensitivity of the scale is 94% and the specificity is …