Chapter 7 Somatoform and Dissociative Disorders Ch 7

Chapter 7 Somatoform and Dissociative

Disorders

Ch 7

Historical Commonality

• Somatoform and dissociative disorders are very strongly historically linked and may share common features.

• They used to be categorized under one general heading, “hysterical neurosis” .

• The term “hysteria” (from the Greek “wandering uterus”) referred to physical symtoms without organic basis (somatoform disorder) or in dissociative experiences (alterations in consciousness, memory, or identity).

• Kihlstrom’s theory (D&N, p. 189): Both disorders are disruptions in the normal controlling functions of consciousness.

Somatoform Disorders

• Psychological factors produce physical symptoms in the Somatoform Disorders: – Hypochondriasis is a preoccupation with having a disease – Body dysmorphic disorder involves a preoccupation with an

imagined physical defect– Conversion disorder involves a change in sensory/motor

function– Somatization disorder involves recurrent, multiple somatic

complaints– In pain disorder, chronic pain results in distress, in which

psychological factors play a maintaining role

Ch 7.1

Common Features Lots of Physical Complaints Appear to be Medical Conditions No Identifiable Medical Cause Pathological Concern About

– Physical Appearance– Functioning of Their Bodies

Common Features Lots of Physical Complaints Appear to be Medical Conditions No Identifiable Medical Cause Pathological Concern About

– Physical Appearance– Functioning of Their Bodies

Clinical Description Ancient Roots Physical Complaints No Known Medical Cause Severe Anxiety / Fear About

Possibly Having a Serious Disease Reassurance Doesn’t Help

Clinical Description Ancient Roots Physical Complaints No Known Medical Cause Severe Anxiety / Fear About

Possibly Having a Serious Disease Reassurance Doesn’t Help

Clinical Description Essential Problem is Anxiety Preoccupied With Bodily

Symptoms Misinterpretation of Symptoms Strong Disease Conviction Many Medical Visits and Tests

Clinical Description Essential Problem is Anxiety Preoccupied With Bodily

Symptoms Misinterpretation of Symptoms Strong Disease Conviction Many Medical Visits and Tests

Why not Classify Such Persons With an Illness Phobia?

Why not Classify Such Persons With an Illness Phobia?

Facts and Statistics 1% to 14% Medical Patients Equal Rates (Males vs. Females) May Occur Any Time Strong Disease Conviction Many Medical Visits and Tests

Facts and Statistics 1% to 14% Medical Patients Equal Rates (Males vs. Females) May Occur Any Time Strong Disease Conviction Many Medical Visits and Tests

Causes Disorder of Cognition /

Perception More Disease in Family More Illness Concern in Family More Attention for Sick Behavior

Causes Disorder of Cognition /

Perception More Disease in Family More Illness Concern in Family More Attention for Sick Behavior

Psychological Treatment Modify Illness Perceptions Evoke Bodily Sensations Provide “Appropriate”

Reassurance More Research is Needed!

Psychological Treatment Modify Illness Perceptions Evoke Bodily Sensations Provide “Appropriate”

Reassurance More Research is Needed!

Clinical Description Preoccupation With Appearance

– Imagined Defect “Imagined” Ugliness Mirrors (Fixation or Avoidance) Ideas of Reference Suicidal Ideation and Tendencies

Clinical Description Preoccupation With Appearance

– Imagined Defect “Imagined” Ugliness Mirrors (Fixation or Avoidance) Ideas of Reference Suicidal Ideation and Tendencies

Common Locations of Defects Hair Nose Skin Eyes Head / Face Lips

Common Locations of Defects Hair Nose Skin Eyes Head / Face Lips

Facts and Statistics College Students

– 70% Report Some Dissatisfaction– 28% Meet Diagnostic Criteria

Many Consult Plastic Surgeons Males = Females Onset Late Adolescence

Facts and Statistics College Students

– 70% Report Some Dissatisfaction– 28% Meet Diagnostic Criteria

Many Consult Plastic Surgeons Males = Females Onset Late Adolescence

The Plastic Surgery Solution? Quite Popular but Expensive Most are Disappointed With

Results

The Plastic Surgery Solution? Quite Popular but Expensive Most are Disappointed With

ResultsBEFOREBEFORE AFTERAFTER

Causes and Treatment Little is Known Co-Occurs With OCD

– Intrusive Thoughts and Checking Compulsions About Appearance

Exposure + Response Prevention

Causes and Treatment Little is Known Co-Occurs With OCD

– Intrusive Thoughts and Checking Compulsions About Appearance

Exposure + Response Prevention

Conversion Disorder• Conversion Disorder involves sensory or motor

symptoms– Not related to known physiology of the body

• E.g. glove anesthesia– Conversion symptoms appear suddenly– Conversion symptoms are related to marked stress– The person experiencing conversion disorder is not distressed

by sudden paralysis or blindness (“La Belle Indifference”)

– Popularized by Freud

Ch 7.2

Facts and Statistics Relatively Rare (< 1% prevalence) Females > Males Onset Around Adolescence

Facts and Statistics Relatively Rare (< 1% prevalence) Females > Males Onset Around Adolescence

Somatization Disorder• Somatization Disorder involves recurrent, multiple somatic

complaints with no known physical basis• Diagnostic criteria include:

– Four pain symptoms in different locations– Two gastrointestinal symptoms– One sexual symptom other than pain– One pseudo-neurological symptom (e.g. those of conversion

disorder)• Lifetime prevalence is < 0.5%; females > males; chronic

condition

Ch 7.3

Causes Family Link Link to Antisocial Personality

– Weak Behavioral Inhibition– Strong Behavioral Activation– Short Term Gain (attention &

sympathy)

Causes Family Link Link to Antisocial Personality

– Weak Behavioral Inhibition– Strong Behavioral Activation– Short Term Gain (attention &

sympathy)

Clinical Description Pain is Real Pain May Have Organic Cause Psychological Factors Maintain

Pain Can be Debilitating

Clinical Description Pain is Real Pain May Have Organic Cause Psychological Factors Maintain

Pain Can be Debilitating

Etiology of Somatoform Disorders

• Somatoform disorder reflects oversensitivity to physical sensations

• Conversion disorder– Psychoanalytic view focuses on unconscious complexes

and secondary gain– Behavioral view focuses on similarity to malingering– The incidence of conversion disorder has declined,

suggesting a role for social factors

Ch 7.4

Therapy for Conversion Disorders

• Conversion disorder clients seek help from physicians and resent referrals to psychotherapists– Psychoanalytic therapy is not effective for conversion

disorder– The cognitive-behavioral approach involves pointing out

selective attention to physical sensations and discouraging the client from seeking medical assistance

Ch 7.5

Dissociative Disorders

• Dissociative Disorders involve the inability to recall important personal events or identity – Depersonalization disorder involves an alteration of a

person’s self-experience– Dissociative amnesia is the inability to recall important

personal information– Dissociative fugue involves extensive memory loss– Dissociative trance disorder involves a sudden change in

personality / “possession by spirits”– Dissociative identity disorder (DID) involves the presence of

two different identities (alters)

Ch 7.6

Depersonalization– Altered Perception of Self

Depersonalization– Altered Perception of Self

Derealization– Altered Perception of World

Derealization– Altered Perception of World

Dissociative Phenomena Dissociative Phenomena

Common ExperienceAltered consciousness, memory

Common ExperienceAltered consciousness, memory

Some people have the experience of driving a car and suddenly

realizing that they don’t remember what happened during all or part of

the trip.

Some people have the experience of driving a car and suddenly

realizing that they don’t remember what happened during all or part of

the trip.

0% 100%0% 100%0% 100%0% 100%

0% 100%0% 100%0% 100%0% 100%

Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was

just said.

Some people find that sometimes they are listening to someone talk and they suddenly realize that they did not hear part or all of what was

just said.

0%0% 100%100%0%0% 100%100%

Some people find that they have no memory for some important events in

their lives (e.g. a wedding or graduation).

Some people find that they have no memory for some important events in

their lives (e.g. a wedding or graduation).

0% 100%0% 100%0% 100%0% 100%

Some people have the experience of finding themselves dressed in clothes that they don’t remember

putting on.

Some people have the experience of finding themselves dressed in clothes that they don’t remember

putting on.

0% 100%0% 100%0% 100%0% 100%

Some people sometimes have the experience of feeling that other people, objects, and the world around them are

not real.

Some people sometimes have the experience of feeling that other people, objects, and the world around them are

not real.

Nor

mal

Dis

soci

atio

nN

orm

alD

isso

ciat

ion

AmnesiaAmnesia

FugueFugue

PartialDID

PartialDID

ComplexDID

ComplexDID

Poly-F

ragmen

tedD

IDP

oly-Fragm

ented

DID

Etiology of Dissociative Disorders

• Consciousness is normally a unified experience,consisting of cognition, emotion and motivation– Stress may alter the fashion in which memories

are stored resulting in amnesia or fugue– May result from

• Severe physical/sexual abuse• Learned social role enactment

Ch 7.7

Depersonalization Disorder Dissociative Amnesia Dissociative Fugue Dissociative Trance Disorder Dissociative Identity Disorder


Primary Features– Depersonalization– Derealization

Primary Features– Depersonalization– Derealization

Impairs Functioning Causes Significant Distress Runs a Chronic Course

Impairs Functioning Causes Significant Distress Runs a Chronic Course

Clinical Description Clinical Description




Localized or Selective– Failure to Recall Specific Events

Localized or Selective– Failure to Recall Specific Events

Several Patterns Generalized

– Unable to Remember Anything

Several Patterns Generalized

– Unable to Remember Anything




Go to Another Location– Unaware “How They Arrived”

Go to Another Location– Unaware “How They Arrived”

Memory Loss – Specific Incident

Memory Loss – Specific Incident

May Assume New Identity May Assume New Identity Fugue Usually Ends Abruptly Fugue Usually Ends Abruptly



Clinical Description Clinical Description Differ Across Cultures

– Sudden Changes in Personality– Possession by Spirits

Differ Across Cultures – Sudden Changes in Personality– Possession by Spirits

Females > Males Females > Males Often Related to Trauma Often Related to Trauma



Clinical Description Clinical Description Formally

– Multiple Personality Disorder

Formally – Multiple Personality Disorder

Person’s Identity is Dissociated Person’s Identity is Dissociated

May Adopt 100 Identities – “Alters”– The Nature of Alters

May Adopt 100 Identities – “Alters”– The Nature of Alters

Central Features Central Features Host Identity

– One Who Asks for Treatment– Attempt to Hold Alters Together

Host Identity – One Who Asks for Treatment– Attempt to Hold Alters Together

A Switch – Abrupt Change in Personalities– Usually Instantaneous

A Switch – Abrupt Change in Personalities– Usually Instantaneous

Facts and Statistics Facts and Statistics Average Number of Alters?

– 15

Average Number of Alters? – 15

Females > Males (9:1) Females > Males (9:1) Onset in Childhood

– Linked to Extreme Abuse

Onset in Childhood– Linked to Extreme Abuse

Runs a Chronic Course Runs a Chronic Course

Causes Causes Unspeakable Childhood Abuse

– 97% of Cases – Escape Into Fantasy World– Become Someone Else– Do What It Takes to Survive

Unspeakable Childhood Abuse– 97% of Cases – Escape Into Fantasy World– Become Someone Else– Do What It Takes to Survive

DID as a Means of Coping?--Age 9 “developmental window”

DID as a Means of Coping?--Age 9 “developmental window”

Other Related Features Other Related Features Suggestibility, Role PlayingSpanos et al. (1994) experiment, Hypnotizability Similar to Dissociation Are these related to DID?

Suggestibility, Role PlayingSpanos et al. (1994) experiment, Hypnotizability Similar to Dissociation Are these related to DID???

Abuse: Controversial Issues Abuse: Controversial Issues False vs. Real Memories Do Therapists Plant Memories? Can False Memories be Created?

– Elizabeth Loftus (D&N, p.178)– (Williams, 1995; Elliott, 1997)

False vs. Real Memories Do Therapists Plant Memories? Can False Memories be Created?

– Elizabeth Loftus (D&N, p.178)– (Williams, 1995; Elliott, 1997)

Consequences of the Debate? Consequences of the Debate?

Treatment: Psychoanalysis Relevant Treatment: Psychoanalysis Relevant Dissociative Amnesia & Fugue

– Usually Improve on Their Own– Stress Reduction and Coping

Dissociative Amnesia & Fugue– Usually Improve on Their Own– Stress Reduction and Coping

Dissociative Identity DisoderChronic, Treatment Process Difficult– No Controlled Research– Treatments are Similar to PTSD

Dissociative Identity DisoderChronic, Treatment Process Difficult– No Controlled Research– Treatments are Similar to PTSD

Diagnostic Considerations in Somatoform

and Dissociative Disorders• Separating Real Problems from Faking

– The Problem of Malingering – Deliberately faking symptoms

• Related Conditions – Factitious disorders– Factitious disorder by proxy

• False Memories and Recovered Memory Syndrome

Documents

Chapter 7 Somatoform and Dissociative Disorders Ch 7