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PSY 301
INTRODUCTION to PSYCHOPATHOLOGY
Dr. İlkiz Altınoğlu Dikmeer
Fall 2014
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PowerPoint  Lecture Notes Presentation
Chapter 8
Dissociative Disorders and Somatoform Disorders
(ch 6 in 11th edition)
Abnormal Psychology, Twelfth Edition
by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.
Chapter Outline
• Chapter 8: Dissociative Disorders and Somatic
Symptom Disorders
I. Dissociative Disorders
II. Somatic Symptom Disorders
Anxiety is the predominant cause of the symptoms although
not always observable. Due to the unobservable nature of
anxiety these two disorders became seperate diagnostic
categories.
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Dissociative Disorders
• All the Dissoc. Dis.s are presumed to be caused by a
common mechanism: dissociation.
• Dissociation  Some aspect of cognition or
experience becomes inaccessible to consciousness
– Mild Dissociative experiences are common, Dissoc. Dis.s
result from extremely high levels of dissociation.
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• Sudden disruption in the continuity of:
– Consciousness (lacks to perform the usual role of
integration of cognitions, emotions, motivations and
other aspects of experience in our awareness)
– Emotions
– Motivation
– Memory
– Identity
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Avoidance Response
• that protects the person from consciously
experiencing stressful events (acc. to both
psychodynamic and behavioral theorists).
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Dissociation and Memory
• How does memory work under stress?
– Psychodynamic
• Traumatic events are repressed. Memories are forgotten because they
are so aversive.
– Cognitive
• Extreme stress usually enhances rather than impairs memory  memory for
emotionally relevant stimuli is enhanced by stress, while memory for neutral
stimuli is impaired
– Interference memory formation
• Not accessible to awareness later
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Table 8.1: Diagnoses of
Dissociative Disorders
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Dissociative Amnesia
• Inability to recall important personal information
– Usually about a traumatic experience
– Not ordinary forgetting
– Not due to physical injury
– May last hours or years
• Usually remits spontaneously w/ complete recovery
and small chance of recurrence.
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Dissociative Amnesia:
Dissociative Fugue Subtype
• First documented case of dissoc fugue  in 1887 in France
• Amnesia and flight and new identity
– Latin fugere, “to flee”
• Sudden, unexpected travel with inability to recall
one’s past
– Assume new identity
• May involve new name, job, personality characteristics
– More often of brief duration
– Remits spontaneously
• After recovery, able to remember the details of life except for
the period of fugue.
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Proposed DSM-5 Criteria for Dissociative
Amnesia
• Inability to remember important personal information,
usually of a traumatic or stressful nature, that is too
extensive to be ordinary forgetfulness
• The amnesia is not explained by substances, or by other
medical or psychological conditions
• Specify dissociative fugue subtype if:
– the amnesia includes inability to recall one’s past, confusion
about identity, or assumption of a new identity, and
– sudden, unexpected travel away from home or work
– Note: Changes from DSM-IV-TR are italicized
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Memory Deficits and Dissociation
• Memory deficits in explicit but not implicit memory
• Explicit memory
– Involves conscious recall of experiences
• e.g., senior prom, mom’s birthday party
• Implicit memory
– Underlies behaviors based on experiences that cannot be
consciously recalled
• e.g., playing tennis, writing a check
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Memory Deficits and Dissociation
• Distinguishing other causes of memory loss from
dissociation:
– Dementia
• Memory fails slowly over time
• Is not linked to stress
• Accompanied by other cognitive deficits
– Inability to learn new information
– Memory loss after a brain injury
– Substance abuse
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Depersonalization/Derealization Disorder
• Perception of self is altered
– Triggered by stress or traumatic event
– No disturbance in memory
– No psychosis or loss of memory
– Often comorbid with anxiety, depression
– Typical onset in adolescence
– Chronic course
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Depersonalization/Derealization Disorder
• Depersonalization
– Lose sense of self
– Unusual sensory experiences
• Limbs feel deformed or enlarged
• Voice sounds different or distant
– Feelings of detachment or disconnection
• Watching self from outside
– Floating above one’s body
• Derealization
– World has become unreal
•
•
•
•
World appears strange, peculiar, foreign, dream-like
Objects appear at times strangely diminished in size, at times flat
Incapable of experiencing emotions
Feeling as if they were dead, lifeless, mere automatons (robot-like)
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Proposed DSM-5 Criteria for
Depersonalization/Derealization Disorder
 Depersonalization: Persistent or recurrent experiences of
detachment from one’s mental processes or body, as though one is
in a dream, despite intact reality testing, or
 Derealization: persistent or recurrent experiences of unreality of
surroundings
 Symptoms are not explained by substances, another dissociative
disorder, another psychological disorder, or by a medical condition
• Note: Changes from DSM-IV-TR are italicized
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Dissociative Identity Disorder (DID)
• Two or more distinct and fully developed personalities (alters)
– Each has unique modes of being, thinking, feeling, acting, memories, and
relationships
– Primary alter may be unaware of existence of other alters
• Most severe of dissociative disorders
– Recovery may be less complete
• Typical onset in childhood
– Rarely diagnosed until adulthood
• More common in women than men
• Often comorbid with:
– PTSD, major depression, somatic symptoms + amnesia, depers.
• Has no relation to schizophrenia
– No thought disorders or behavioral disorganization
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Proposed DSM-5 Criteria Dissociative Identity Disorder
(DID)
• A. Disruption of identity characterized by two or more distinct
personality states (alters) or an experience of possession, as
evidenced by discontinuities in sense of self, cognition, behavior,
affect, perceptions, and/or memories. This disruption may be
observed by others or reported by the patient
• B. At least two of the alters recurrently take control of behavior
• C. Inability of at least one of the alters to recall important personal
information
• D. Symptoms are not part of a broadly accepted cultural or religious
practice, and are not due to drugs or a medical condition
– Note: The DSM-IV-TR criterion A is less detailed. It specifies the presence of two or
more identities or personality states (each with its own relatively enduring pattern
of perceiving, relating to, and thinking about the environment and self)
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Dissociative Identity Disorder (DID)
• Epidemiology
– No identified reports of DID or dissociative amnesia before
1800 (Pope et al., 2006)
– Major increases in rates since 1970s (1.3% in Canada in 1991,
0.4% in Sivas, TR in 1999)
• DSM-III (1980)
– Diagnostic criteria more explicit
• Appearance of DID in popular culture
– Sybil
– The Three Faces of Eve
– Book and movie received much attention
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Etiology of Dissociative Identity Disorder (DID): Two
Major Theories
• Almost all DID patients report severe child abuse
• Both theories suggest severe physical or sexual abuse during
childhood:
• Posttraumatic Model
– DID results from severe psychological and/or sexual abuse in
childhood
• Sociocognitive Model
– DID results from learning to enact social roles.
• Occurs in response to prompting by therapists or media
• No conscious deception
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Etiology of Dissociative Identity Disorder (DID): Two
Major Theories
• Evidence raised in theory debate
– DID can be role-played
• Hypnotized students prompted to reveal alters did so (Spanos, Weekes, &
Bertrand, 1985)
– DID patients show only partial implicit memory deficits
• Alters “share” memories (Huntjen et al., 2003)
– DID diagnosis differs by clinician
• A few clinicians diagnose the majority of DID cases
– For many, symptoms emerge after therapy begins
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Treatment of Dissociative Identity Disorder (DID)
• Most treatments involve:
– Empathic and supportive therapist
– Integration of alters into one fully functioning individual
– Improvement of coping skills
• Psychodynamic approach adds:
– Overcome repression
– Use of hypnosis
– Age regression
– Can actually worsen symptoms
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Somatic Symptom Disorders (DSM-5)
Somatoform Disorders (DSM-IV-TR)
• Excessive concerns about physical symptoms or health
– ‘Soma’ means body
• In DSM-IV-TR physical symptoms have no known physical
cause
– Nearly impossible to know actual cause
– DSM-5 removes requirement that symptoms not be medically caused
• Three major somatic symptom disorders:
– Complex somatic symptom disorder
– Illness anxiety disorder
– Functional neurological syndrome
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Figure 8.3: DSM-IV-TR and Proposed DSM-5 Somatic
Symptom Disorders
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Table 6.2 (edition 11)
Summary of Somatoform Disorders
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25
Table 8.2: Diagnoses of Somatic Symptom and
Related Disorders
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Pain Disorder (DSM-IV-TR)
• DSM-IV-TR Criteria
– Pain that is severe enough to warrant clinical attention
– Psychological factors are thought to be important to the
onset, severity, or maintenance of pain
– The pain is not intentionally produced or faked
– The pain is not explained by another psychological
condition
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27
Somatization Disorder (DSM-IV-TR)
• First noted by Pierre Briquet in 1859
– Known as Briquet’s syndrome
• Multiple, recurrent somatic complaints with no
apparent physical cause
– Must have multiple symptoms which cause impairment
– Seeks treatment, usually from multiple physicians
• Hospitalization, medications, surgery common
– Exaggerated presentation of symptoms and complaints
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Somatization Disorder
• Lifetime prevalence less than 0.5%
– More frequent in women
• Especially Hispanic and African American
– Higher prevalence rates in South America and Puerto Rico
• Cultural differences
– Symptom presentation
• Burning pains in hands more common in Asia and Africa
– Culture may also influence how people seek treatment
• Psychological distress presented in physical terms
• Typical onset early adulthood
• Often accompanied by behavioral and interpersonal problems
– e.g., marital discord, poor work history
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Somatization Disorder
• DSM-IV-TR Criteria
– History of seeking treatment for many physical complaints
beginning before the age of 30 and lasting for several years
– At least four pain symptoms, as well as at least two
gastrointestinal symptoms, one sexual symptom, and one
pseudoneurological symptom (e.g., unexplained paralysis)
– Symptoms are not due to a medical condition or are
excessive given the person’s medical condition
– Symptoms do not appear to be faked
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Complex Somatic Symptom Disorder
(DSM-5)
• DSM-IV-TR separates the diagnoses of Pain Disorder (in
which the primary symptom involved pain) and
Somatization Disorder (which involves multiple somatic
symptoms from various body systems)
• DSM-5 merges these two diagnoses into Complex Somatic
Symptom Disorder
• DSM-5 places more emphasis on distress and behavior
accompanying somatic symptoms, rather than the number
or range of somatic symptoms
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Proposed DSM-5 Criteria for
Complex Somatic Symptom Disorder
• At least one somatic symptom that is distressing or disrupts daily
life
• Excessive thoughts, feelings, and behaviors related to somatic
symptom(s) or health concerns, as indicated by at least two of the
following: health-related anxiety, disproportionate concerns about
the medical seriousness of symptoms, and excessive time and
energy devoted to health concerns
• Duration of at least 6 months
• Specify: predominant somatic complaints, predominant health
anxiety, or predominant pain
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Figure 8.3: DSM-IV-TR and Proposed DSM-5 Somatic
Symptom Disorders
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reserved.
Hypochondriasis (DSM-IV-TR)
• Preoccupation with fears of having a serious disease
• This headache must mean I have a brain tumor!
– Despite medical reassurance, fears persist for at least 6
months
• Critical of medical professionals
– Incompetent and uncaring
• Typical onset early adulthood
– Tends to be chronic
• Often comorbid with mood and anxiety disorders
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Hypochondriasis
• DSM-IV-TR Criteria
– Preoccupation with fears about having a serious
disease
– The preoccupation continues despite medical
reassurance
– Not explained by a delusional disorder or body
dysmorphic disorder
– Symptoms last at least 6 months
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Illness Anxiety Disorder (DSM-5)
• Illness anxiety disorder is a new diagnosis in the
DSM-5, but it has some parallels with the DSM-IV-TR
diagnosis of hypochondriasis.
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Proposed DSM-5 Criteria for
Illness Anxiety Disorder
• Preoccupation with and high level of anxiety about having
or acquiring a serious disease
• Excessive behaviors (e.g., checking for signs of illness,
seeking reassurance) or maladaptive avoidance (e.g.,
avoiding medical care or ill relatives)
• No more than mild somatic symptoms are present
• Not explained by other psychological disorders
• Preoccupation lasts at least 6 months
– Note: Criteria that differ from the DSM-IV-TR diagnosis of
hypochondriasis are italicized. The DSM-IV-TR criteria for
hypochondriasis specify that the preoccupation must continue
despite medical reassurance.
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Figure 8.3: DSM-IV-TR and Proposed DSM-5 Somatic
Symptom Disorders
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Conversion Disorder (DSM-IV-TR)
• Sensory or motor function impaired but no known
neurological cause
–
–
–
–
Vision impairment or tunnel vision
Partial or complete paralysis of arms or legs
Seizures or coordination problems
Anesthesia
• Loss of sensation
– Aphonia
• Whispered speech
– Anosmia
• Loss of smell
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Conversion Disorder
• DSM-IV-TR Criteria
– One or more symptoms affecting motor or sensory
functioning and suggesting a neurological or medical
condition
– Symptoms are related to conflict or stress
– Symptoms are not intentionally produced and cannot be
explained by a medical condition
– Symptoms cause significant distress or functional
impairment or warrant medical evaluation
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Conversion Disorder
• Hippocrates
– Believed disorder only occurred in women
– Attributed it to a wandering uterus
• Originally known as Hysteria
– Greek word for uterus
• Freud
– Coined term conversion
– Anxiety and conflict converted into physical symptoms
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Conversion Disorder
• Onset typically adolescence or early adulthood
– Often follows life stress
• Prevalence less than 1%
– More common in women than men
• Often comorbid with:
– Major depressive disorder
– Substance abuse
– Personality disorders
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Functional Neurological Disorder (DSM-5)
• Conversion Disorder in DSM-IV-TR
• Sensory or motor function impaired but no known
neurological cause
– Vision impairment or tunnel vision
– Partial or complete paralysis of arms or legs
– Seizures or coordination problems
– Aphonia
• Whispered speech
– Anosmia
• Loss of smell
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Proposed DSM-5 Criteria for
Functional Neurological Disorder
• One or more neurologic symptoms affecting voluntary motor
function, sensory function, cognition, or seizure-like episodes
• The physical signs or diagnostic findings are internally inconsistent
or incongruent with recognized neurological disorder
• Symptoms cannot be explained by a medical condition
• Symptoms cause significant distress or functional impairment or
warrant medical evaluation
– Note: DSM-IV-TR criteria for Conversion Disorder specify that
symptoms are related to conflict or stress and are not intentionally
produced
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Etiology of Somatic Symptoms Disorders: Neurological
Factors
• No support for genetic influence
– Concordance rates in MZ twin pairs do not differ from DZ
twin pairs
• Why are some people more aware and distressed by
bodily sensation?
– Anterior insula and anterior cingulate hyperactive
– Somatic symptoms influenced by emotions and stress
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Etiology of Somatic Symptoms Disorders: Cognitive
Behavioral Factors
• Two important cognitive variables:
– Attention to bodily sensations
• Automatic focus on physical health cues
– Attributions (interpretation) of those sensations
• Overreact with overly negative interpretations
• Two important consequences:
– Sick role limits healthy life alternatives
– Help-seeking behaviors reinforced by attention or
sympathy
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Figure 8.5: Mechanisms
Involved in Somatic
Symptom Disorders
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Etiology of Functional Neurological Disorders:
Psychodynamic Perspective
• Unconscious psychological factor cause
• Blindsight
– Not consciously aware of visual input
– Failure to be explicitly aware of sensory information
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Etiology of Somatic Symptoms Disorders: Social and
Cultural Factors
• Decrease in incidence of conversion disorders since
last half of 19th century
– Higher incidence may have been due to more repressed
sexual attitudes or low tolerance for anxiety symptoms
• More prevalent
– In rural areas
– In individuals of lower SES
– In non-Western cultures
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Treatment of Somatic Symptoms Disorders
• Few controlled treatment outcome studies
• Cognitive Behavioral Treatment
– Identify and change triggering emotions
– Change cognitions about symptoms
– Replace sick role behaviors with more appropriate social
interactions
• Antidepressants
– Tofranil
• Effective even at low dosages that do not alleviate depressive symptoms
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