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Abnormal Psychology
Fifth Edition
Oltmanns and Emery
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Copyright © Prentice Hall 2007
Chapter Seven
Acute and Posttraumatic Stress
Disorders, Dissociative Disorders,
and Somatoform Disorders
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Chapter Outline
• Acute and Posttraumatic Stress
Disorders
• Dissociative Disorders
• Somatoform Disorders
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Overview
• Dissociation is the disruption of the
normally integrated mental processes
involved in memory, consciousness,
identity, or perception.
• The DSM-IV-TR classifies PTSD as an
anxiety disorder, however, PTSD is of
unique importance and characterized by
mixed symptoms of anxiety and
dissociation.
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Acute and Posttraumatic Stress
Disorders
• Stress is an inevitable, and in some cases a
desirable, fact of everyday life.
• Some stressors, however, are so catastrophic and
horrifying that they can cause serious
psychological harm.
• Such traumatic stress is defined in DSM-IV-TR
as an event that involves actual or threatened death
or serious injury to self or others and creates
intense feelings of fear, helplessness, or horror.
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Acute and Posttraumatic Stress
Disorders
• Acute stress disorder (ASD) occurs within 4
weeks after exposure to traumatic stress and is
characterized by dissociative symptoms, reexperiencing of the event, avoidance of reminders
of the trauma, and marked anxiety or arousal.
• Posttraumatic stress disorder (PTSD) also is
defined by symptoms of re-experiencing,
avoidance, and arousal, but in PTSD the
symptoms either are longer lasting or have a
delayed onset.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD
• People who have been confronted with a traumatic
stressor re-experience the event in a number of
different ways.
• Many people with ASD or PTSD have repeated and
intrusive flashbacks, sudden memories during which
the trauma is replayed in images or thoughts—often at
full emotional intensity.
• In rare cases, re-experiencing occurs as a dissociative
state, and the person feels and acts as if the trauma
actually were recurring in the moment.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• Marked or persistent avoidance of stimuli
associated with the trauma is another
symptom of ASD and PTSD.
• Trauma victims may attempt to avoid
thoughts or feelings related to the event, or
they may avoid people, places, or activities
that remind them of the trauma.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• In PTSD, the avoidance also may manifest
itself as a general numbing of
responsiveness.
• People suffering from PTSD often complain
that they suffer from “emotional
anesthesia”—their feelings seem dampened
or even nonexistent.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• Despite their general withdrawal from
feelings, people, and painful situations,
people with ASD and PTSD also experience
increased arousal and anxiety following the
trauma, a symptom which predicts a worse
prognosis when it is more severe.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• A number of people with PTSD or ASD
also have an exaggerated startle response,
excessive fear reactions to unexpected
stimuli, such as loud noises.
• Symptoms of anxiety and arousal are the
reason why traumatic stress disorders are
grouped with the anxiety disorders in DSMIV-TR.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• Acute stress disorder is characterized by
explicit dissociative symptoms.
• Many people become less aware of their
surroundings following a traumatic event.
• They report feeling dazed, and they may
seem “spaced out” to other people.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• Other people experience depersonalization,
feeling cut off from themselves or their
environment. People with this symptom
may report feeling like a robot or as if they
were sleepwalking.
• Derealization is characterized by a marked
sense of unreality about yourself or the
world around you.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• ASD also may be characterized by features
of dissociative amnesia, specifically the
inability to recall important aspects of the
traumatic experience.
• DSM-IV-TR lists a sense of numbing or
detachment from others as dissociative
symptoms that characterize acute stress
disorder.
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Acute and Posttraumatic Stress
Disorders
Symptoms of ASD and PTSD (continued)
• A very similar symptom is listed as an
indicator of avoidance, not dissociation, in
the diagnosis of PTSD.
• This discrepancy in diagnostic criteria
reflects some of the broader controversy
about whether ASD and PTSD should be
classified as dissociative or anxiety
disorders.
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD
• Maladaptive reactions to traumatic stress
have long been of interest to the military.
• Historically, most of the military’s concern
has focused on battle dropout, that is, men
who leave the field of action as a result of
what has been called “shell shock” or
“combat neurosis.”
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• During the Vietnam War, however, battle
dropout was less frequent than in earlier
wars, but delayed reactions to combat were
much more common.
• This change prompted much interest in
PTSD, a condition first listed in the DSM in
1980 (DSM-III).
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• The basic diagnostic criteria for PTSD—reexperiencing, avoidance, and arousal—have
remained more or less the same in revisions of the
DSM.
• However, two significant changes in the
classification of traumatic stress disorders were
made with the publication of DSM-IV in 1994:
Acute stress disorder was included as a separate
diagnostic category, and the definition of trauma
was altered.
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• The diagnostic criteria for ASD and PTSD are
essentially the same.
• The two exceptions are that ASD explicitly
includes dissociative symptoms and lasts no
longer than 4 weeks, whereas PTSD continues for
at least 1 month after a trauma or it has a delayed
onset.
• Not surprisingly, many people suffer from ASD
after experiencing trauma, and the presence of
ASD may predict future PTSD.
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DSM-IV-TR Criteria for Posttraumatic
Stress Disorder (continued)
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DSM-IV-TR Criteria for Posttraumatic
Stress Disorder (continued)
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DSM-IV-TR Criteria for Acute Stress
Disorder (continued)
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• Earlier versions of DSM defined trauma as
an event “outside the range of usual human
experience.”
• Even before September 11, however,
researchers discovered that, unfortunately,
many traumatic stressors are a common part
of human experience in the United States
today.
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• Thus DSM-IV-TR defines trauma as (1) the
experience of an event involving actual or
threatened death or serious injury to self or
others and (2) a response of intense fear,
helplessness, or horror in reaction to the
event.
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• The psychological effects of exposure to natural or
man-made disasters, like September 11 or the
Oklahoma City bombing in 1995 are of great
concern.
• September 11 also called attention to the trauma
experienced by emergency workers.
• Hardiness, a personal sense of commitment,
control, and challenge in facing stress, predicts
lower rates of PTSD.
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• Many people with PTSD also suffer from
another mental disorder.
• Notably high levels of comorbidity are
found for depression, other anxiety
disorders, and substance abuse and it may
be important to distinguish between trauma
victims who internalize (e.g., get depressed)
or externalize (e.g., become antisocial).
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• Another important concern is increased
suicide risk.
• One study found that 33 percent of rape
survivors had thoughts of suicide, and 13
percent actually made a suicide attempt.
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Acute and Posttraumatic Stress
Disorders
Diagnosis of ASD and PTSD (continued)
• Differential diagnosis between ASD and
PTSD and adjustment disorder is based on
both the nature of the stressor and the type
and severity of symptoms.
• Adjustment disorders are caused by
“normal” but painful stressors, such as
losing a job, and they involve normal (if
distressing) reactions to these events.
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Acute and Posttraumatic Stress
Disorders
Frequency of Trauma, PTSD, and ASD
• The National Comorbidity Survey found that
nearly 8 percent of people living in the United
States will experience PTSD at some point in their
lives, including about 10 percent of women and 5
percent of men.
• Research finds that women are especially likely to
develop PTSD as a result of rape, while combat
exposure is a major risk factor for PTSD among
men.
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Acute and Posttraumatic Stress
Disorders
Frequency of Trauma, PTSD, and ASD
(continued)
• PSTD also is commonly found among crime
victims.
• Still, the single most common cause of PTSD is
the sudden, unexpected death of a loved one.
• In general, trauma does not occur completely at
random.
• The development of PTSD following a trauma
also is not random.
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Acute and Posttraumatic Stress
Disorders
Frequency of Trauma, PTSD, and ASD
(continued)
• Researchers have found that people who
suffer from ASD are more likely to develop
PTSD subsequently.
• The prediction is far from perfect, however,
and two caveats bear special scrutiny.
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Acute and Posttraumatic Stress
Disorders
Frequency of Trauma, PTSD, and ASD
(continued)
• First, people with subclinical ASD, that is,
with symptoms that are not severe or
pervasive enough to meet diagnostic
criteria, nevertheless are at greater risk for
PTSD than trauma victims with relatively
few psychological symptoms.
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Acute and Posttraumatic Stress
Disorders
Frequency of Trauma, PTSD, and ASD
(continued)
• Second, the different symptoms of ASD are not
equally good in predicting future PTSD.
• The presence of three symptoms—numbing,
depersonalization, and a sense of reliving the
experience—are the best predictors of PTSD.
• Other research shows how the symptoms of PTSD
diminish gradually as time passes.
• However, PTSD can be a chronic disorder.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD
• Scientists studying social factors and the risk for
PTSD have focused primarily on (1) the nature of
the trauma and the individual’s level of exposure
to it and (2) the availability of social support
following the trauma.
• Victims of trauma are more likely to develop
PTSD when the trauma is more intense, lifethreatening, and involves greater exposure.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• As with less severe stressors, social support
after a trauma can play a crucial role in
alleviating long-term psychological
damage.
• A lack of social support is thought to have
contributed to the high prevalence of PTSD
found among Vietnam veterans.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• In an analysis of more than 4,000 twin
pairs, researchers found that MZ twins had
a higher concordance rate than DZ twins for
experiencing trauma, specifically exposure
to combat.
• Following exposure to trauma, identical
twins also had higher concordance rates for
PTSD symptoms than did fraternal twins.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• A very different line of research focuses on the
biological consequences of exposure to trauma
and how these consequences may play a role in
the maintenance of PTSD.
• People with PTSD show alterations in the
functioning and perhaps even the structure of the
amygdala and hippocampus, two biological
findings consistent, respectively, with the
experience of heightened fear reactivity and
intrusive memories.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• Other evidence finds that PTSD is associated with
increased levels of circulating norepinephrine and
general psychophysiological arousal, for example,
an increased resting heart rate.
• Together, the pattern of biological findings
suggests that the sympathetic nervous system is
aroused and the fear response is sensitized in
PTSD.
• The heightened reactivity may be due to the
failure of the stress response system to shut down.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• According to two-factor theory, classical
conditioning creates fears when the terror inherent
in trauma is paired with the cues associated with
the traumatic event.
• Operant conditioning, in turn, maintains the fears.
• Specifically, when fear-producing situations are
avoided, the avoidance is negatively reinforced by
the reduction of anxiety.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• More recent psychological perspectives
focus on individual differences in the risk
for ASD and PTSD.
• In addition to preexisting mental health
problems, research indicates that cognitive
factors such as expectancies, preparedness,
and control influence the risk for PTSD
following a trauma.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• Some theories suggest that dissociation is an
unconscious defense that helps victims cope with
trauma.
• However, research indicates that dissociation is
associated with more not less PTSD.
• Dissociation may not be adaptive, but most
theorists agree that victims of trauma must, over
time, find a balance between gradually facing their
painful emotions while not being overwhelmed by
them.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• Psychologist Edna Foa, a leading PTSD
researcher, has highlighted the importance of
emotional processing, which involves facing fear,
diminishing its intensity, and coming to some new
understanding about the trauma and its
consequences.
• Integrating the experience of trauma with broader
memories and beliefs involves the task of meaning
making—finding some broader reason or higher
value for enduring the trauma.
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Acute and Posttraumatic Stress
Disorders
Causes of PTSD and ASD (continued)
• The combined evidence suggests alternative
pathways can lead to ASD and PTSD.
• Anyone might develop ASD or PTSD given a
critical level of exposure and a trauma of
sufficient intensity.
• The development of PTSD results from a
combination of factors, including personality
characteristics that predate the trauma, exposure
during the trauma, and emotional processing and
social support afterwards.
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Acute and Posttraumatic Stress
Disorders
Prevention and Treatment of ASD and
PTSD
• The potential for preventing PTSD is so
important that the Federal Emergency
Management Agency, the government
agency that deals with natural and manmade
disasters, is required to provide special
funding to community mental health centers
during disasters.
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Acute and Posttraumatic Stress
Disorders
Prevention and Treatment of ASD and PTSD
(continued)
• Perhaps the most widely used early intervention is
critical incident stress debriefing (CISD), a
single 1- to 5-hour group meeting offered within 1
to 3 days following a disaster.
• CISD involves several phases where participants
share their experiences and reactions, and group
leaders offer education, assessment, and referral if
necessary.
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Acute and Posttraumatic Stress
Disorders
Prevention and Treatment of ASD and PTSD
(continued)
• Since World War I, interventions with soldiers who
drop out of combat have been based on the three
principles of offering (1) immediate treatment in the
(2) proximity of the battlefield with the (3)
expectation of return to the front lines upon
recovery.
• The trauma of combat and the structure of the
military make generalization of these principles to
other traumas difficult, but the goals are logical ones
to modify to fit the unique circumstances of other
traumas.
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Acute and Posttraumatic Stress
Disorders
Prevention and Treatment of ASD and
PTSD (continued)
• Few studies of the treatment of ASD have
been conducted, a circumstance that is not
surprising given that the diagnosis was
developed only recently.
• Nevertheless, some research indicates that
structured interventions with ASD can lead
to the prevention of future PTSD.
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Acute and Posttraumatic Stress
Disorders
Prevention and Treatment of ASD and PTSD (continued)
• Psychotherapists who specialize in PTSD suggest some
general principles for the psychological treatment of the
disorder.
• In the order in which they are likely to be addressed in
therapy, these include
1) establishing a trusting therapeutic relationship,
2) providing education about the process of coping with
trauma,
3) stress-management training,
4) encouraging the re-experience of the trauma, and
5) integrating the traumatic event into the individual’s
experience.
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Acute and Posttraumatic Stress
Disorders
Prevention and Treatment of ASD and PTSD
(continued)
• Mounting evidence supports the effectiveness of
various cognitive behavioral treatments.
• A recent consensus statement on the
treatment of PTSD concluded that
antidepressant medication and
psychotherapy involving therapeutic reexposure are the two “first-line” therapies
for PTSD.
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Dissociative Disorders
• Dissociative disorders are characterized by
persistent, maladaptive disruptions in the
integration of memory, consciousness, or
identity—verge on the unbelievable.
• The person with a dissociative disorder may
be unable to remember many details about
the past; he or she may wander far from
home and perhaps assume a new identity; or
two or more personalities may coexist
within the same person.
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Dissociative Disorders
Hysteria and the Unconscious
• Dissociative disorders once were viewed as
expressions of hysteria.
• In Greek, hystera means “uterus,” and the term
hysteria reflects ancient speculation that these
disorders were caused by frustrated sexual desires,
particularly the desire to have a baby.
• According to the theory, the uterus becomes
detached from its normal location and moves
about the body, causing a problem in the location
where it eventually lodges.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• Variants of this somewhat sexist view
continued throughout Western history, and
as late as the nineteenth century many
physicians erroneously believed that
hysteria occurred only among women.
• New speculation about the etiology of
hysteria emerged toward the end of the
nineteenth century.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• Jean Charcot, who used hypnosis both to
treat and to induce hysteria, was particularly
influential.
• Charcot greatly influenced the thinking of
Freud, who observed Charcot’s hypnotic
treatments early in his training.
• Charcot also had a strong influence on the
work of Freud’s contemporary and rival,
Pierre Janet.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• Janet was a French philosophy professor who
conducted psychological experiments on
dissociation and who later trained as a physician in
Charcot’s clinic.
• Both Janet and Freud were eager to explain and
treat hysteria, and the problem led both of them to
develop theories about unconscious mental
processes.
• Janet saw dissociation as an abnormal process.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• To Janet, detachment from conscious awareness
occurred only as a part of psychopathology.
• In contrast, Freud considered dissociation as a
normal process, a routine means through which
the ego defended itself against unacceptable
unconscious thoughts.
• Freud saw dissociation and repression as similar
processes, and, in fact, he often used the two terms
interchangeably.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• Thus Freud viewed dissociative and
somatoform disorders to be merely two of
many expressions of unconscious conflict.
• Janet’s work became increasingly obscure
as Freudian theory dominated the mental
health professions throughout much of the
twentieth century.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• Contemporary psychologists generally
agree that unconscious processes do exist
and that they play a role in both normal and
abnormal emotion and cognition.
• Contemporary cognitive scientists continue
to debate the importance of unconscious
mental events.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• Contemporary cognitive scientists insist that
hypotheses about unconscious mental processes
must be tested in research.
• In fact, scientists have created new research
techniques to study unconscious processes, for
example, the distinction between explicit and
implicit memory.
• Explicit memory is the conscious recollection of a
past event.
• Implicit memory is indicated by changes in
behavior apparently based on a memory of a prior
event but with no conscious remembering of the
event.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• The nature of hypnosis, in which subjects
experience loss of control over their actions in
response to suggestions from the hypnotist, is a
topic of historical importance and
contemporary debate about the unconscious
mind.
• All agree that demonstrations of the power of
hypnotic suggestion are impressive, and that
different people are more or less susceptible to
hypnosis.
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Dissociative Disorders
Hysteria and the Unconscious (continued)
• However, some experts assert that hypnosis
is the dissociative experience of an altered
state of consciousness.
• Others argue that hypnosis is merely a
social role, where the subject voluntarily
complies with suggestions due to social
expectations and demands.
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Dissociative Disorders
Symptoms of Dissociative Disorders
• Like many ordinary cognitive processes, the
extraordinary symptoms of dissociative disorders
apparently involve mental processing that occurs
outside of conscious awareness.
• Extreme cases of dissociation include a split in the
functioning of the individual’s entire sense of self.
• Depersonalization is a less dramatic form of
dissociation wherein people feel detached from
themselves or their social or physical
environment.
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Dissociative Disorders
Symptoms of Dissociative Disorders (continued)
• Another dramatic example of dissociation is
amnesia—the partial or complete loss of recall for
particular events or for a particular period of time.
• Brain injury or disease can cause amnesia, but
psychogenic (psychologically caused) amnesia
results from traumatic stress or other emotional
distress.
• Psychogenic amnesia may occur alone or in
conjunction with other dissociative experiences.
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Dissociative Disorders
Symptoms of Dissociative Disorders (continued)
• It is widely accepted that fugue and psychogenic
amnesia are usually precipitated by trauma, thus
providing another link between dissociation and
traumatic stress disorders.
• In these disorders, the trauma is clear and usually
sudden, and in most cases, psychological
functioning rapidly returns to normal.
• Much more controversial is the role that trauma
might play in dissociative identity disorder (DID).
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Dissociative Disorders
Symptoms of Dissociative Disorders (continued)
• Some researchers and clinicians argue that DID is
linked with past, not present, trauma, particularly
with chronic child physical or sexual abuse.
• Many psychological scientists are skeptical about
this assertion, however, because information about
childhood trauma is based solely on clients’
reports—reports that may be distorted by many
factors, including by a therapist’s expectations.
• A related issue is the very controversial topic of
recovered memories, dramatic recollections of
long-ago traumatic experiences supposedly
blocked from the conscious mind by dissociation.
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Dissociative Disorders
Diagnosis of Dissociative Disorders
• For centuries, theorists considered dissociative and
somatoform disorders as alternative forms of
hysteria.
• However, the descriptive approach to
classification introduced in DSM-III (1980) led to
the separation of dissociative and somatoform
disorders into discrete diagnostic categories.
• The distinction is preserved in DSM-IV-TR
(2000), because the symptoms of the two disorders
differ greatly.
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Dissociative Disorders
Diagnosis of Dissociative Disorders (continued)
• DSM-IV-TR distinguishes four major subtypes of
dissociative disorders: dissociative fugue,
dissociative amnesia, depersonalization disorder,
and dissociative identity disorder.
• Dissociative fugue is characterized by sudden and
unexpected travel away from home, an inability to
recall the past, and confusion about identity or the
assumption of a new identity.
• Dissociative amnesia involves a sudden inability
to recall extensive and important personal
information that exceeds normal forgetfulness.
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Dissociative Disorders
Diagnosis of Dissociative Disorders (continued)
• As with fugue, dissociative amnesia typically is
characterized by a sudden onset in response to
trauma or extreme stress and by an equally sudden
recovery of memory.
• The most common form of amnesia in dissociative
disorders is selective amnesia, in which patients
do not lose their memory completely but instead
are unable to remember only selected personal
events and information, often events related to a
traumatic experience.
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Dissociative Disorders
Diagnosis of Dissociative Disorders
(continued)
• Depersonalization disorder is a less
dramatic problem that is characterized by
severe and persistent feelings of being
detached from oneself.
• Depersonalization experiences include such
sensations as feeling as though you were in
a dream or were floating above your body
and observing yourself act.
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Dissociative Disorders
Diagnosis of Dissociative Disorders (continued)
• Occasional depersonalization experiences are
normal and are reported by about half the
population.
• In depersonalization disorder, however, such
experiences are persistent or recurrent, and they
cause marked personal distress.
• The onset of the disorder commonly follows a new
or disturbing event, such as drug use.
• Unlike other dissociative disorders,
depersonalization disorder involves only limited
splitting between conscious and unconscious
mental processes, and no memory loss occurs.
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Dissociative Disorders
Diagnosis of Dissociative Disorders (continued)
• Dissociative identity disorder (DID), also known
as multiple personality disorder, is characterized
by the existence of two or more distinct
personalities in a single individual.
• At least two of these personalities repeatedly take
control of the person’s behavior, and the
individual’s inability to recall information is too
extensive to be explained by ordinary
forgetfulness.
• The original personality especially is likely to
have amnesia for subsequent personalities, which
may or may not be aware of the “alternates.”
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Dissociative Disorders
Frequency of Dissociative Disorders
• The prevalence of dissociative disorders is
difficult to establish.
• The conditions generally are considered to
be extremely rare.
• Some experts even doubt the very existence
of dissociative identity disorder, arguing
that DID is created by the power of
suggestion.
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Dissociative Disorders
Frequency of Dissociative Disorders
(continued)
• Given the current status of research, we
reach some cautious conclusions.
• True dissociative disorders appear to be
rare.
• Although some cases no doubt are
misdiagnosed, a much greater problem is
the creation of the diagnosis in the minds of
clinicians and clients.
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Dissociative Disorders
Causes of Dissociative Disorders
• Little systematic research has been conducted on
the etiology of dissociative disorders; thus, theory
and outright speculation dominate.
• One exception is the widely held view that the
disorders often are precipitated by trauma.
• The onset of dissociative amnesia and fugue
usually can be traced to a specific traumatic
experience thus; there is little controversy about
this etiological link.
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Dissociative Disorders
Causes of Dissociative Disorders
(continued)
• Much more dispute surrounds the purported
association between trauma and DID.
• Many case studies suggest that multiple
personalities develop in response to trauma,
particularly the trauma of child abuse.
• In fact, some researchers have compiled
large numbers of case studies from surveys
of practitioners that support this view.
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Dissociative Disorders
Causes of Dissociative Disorders (continued)
• When interpreting these findings, however,
you should note that studies of the long-term
consequences of child physical or sexual abuse
find little evidence of dissociation or, indeed,
of other consistent forms of psychopathology.
• Case studies are based on patients’ memories
and clinicians’ evaluations and are not
objective assessments of the past.
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Dissociative Disorders
Causes of Dissociative Disorders
(continued)
• Researchers have many concerns about the
validity of such retrospective reports—
evaluations of the past from the vantage
point of the present.
• Memories may be selectively recalled,
distorted, or even created to conform to a
clinician’s expectations.
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Dissociative Disorders
Causes of Dissociative Disorders
(continued)
• Even if trauma contributes to dissociative
disorders it clearly is not a sufficient cause.
• As we saw with ASD and PTSD, the vast
majority of people who experience trauma
do not develop a dissociative disorder.
• Thus, other factors must contribute to their
development.
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Dissociative Disorders
Causes of Dissociative Disorders (continued)
• Very little evidence and not much more
speculation address the role of biological factors
in the etiology of dissociative disorders.
• One theorist has suggested a developmental
disturbance in the orbital-frontal cortex, but this
possibility has not been systemically investigated.
• A preliminary twin study found no genetic
contribution to dissociative symptoms, and
suggested instead that the shared family
environment was an important contributing cause.
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Dissociative Disorders
Causes of Dissociative Disorders
(continued)
• Still, it is known that dissociative states
or permanent dissociation can result
from biological causes.
• Examples include the dramatic
personality changes that sometimes
accompany substance abuse and the
amnesia found in cognitive disorders
associated with aging.
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Dissociative Disorders
Causes of Dissociative Disorders
(continued)
• In DSM-IV-TR, a diagnosis of dissociative
disorders is explicitly excluded if the
dissociation occurs in conjunction with
substance abuse or organic pathology.
• However, evidence that biological factors
can produce dissociative symptoms is a
reason to continue to search for biological
contributions to dissociative disorders.
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Dissociative Disorders
Causes of Dissociative Disorders (continued)
• A sociological view offers a very different
perspective on the etiology of dissociative
disorders.
• At least one theorist has suggested that
dissociative disorders are produced by
iatrogenesis, the manufacture of the dissociative
disorders by their treatment.
• However, evidence that DID can be diagnosed in
the general population in Turkey, where there is no
public awareness of the disorder, leads us to
conclude that DID is a real but rare problem.
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Dissociative Disorders
Treatment of Dissociative Disorders
• Dating from the time of Janet and Freud, perhaps
the central aspect of the treatment of dissociative
disorders has been uncovering and recounting past
traumatic events.
• It is presumed that if the trauma can be expressed
and accepted, then the need for dissociation will
disappear.
• Many clinicians use hypnosis to help patients
explore and relive traumatic events.
• However, no research supports the effectiveness of
either abreaction, the emotional reliving of a past
traumatic experience, or hypnosis as a treatment for
dissociative disorders.
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Dissociative Disorders
Treatment of Dissociative Disorders (continued)
• Whatever the approach, the goal of treatment for
DID is not to have one personality triumph over
the others.
• Rather, the objective is to reintegrate the different
personalities into a whole.
• The goal of reintegration is considered to be more
of a psychological than a pharmaceutical task.
• At this time, no systematic research has been
conducted on the effectiveness of any treatment
for dissociative disorders, let alone on the
comparison of alternative treatments.
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Somatoform Disorders
• Somatoform disorders are problems
characterized by unusual physical
symptoms that occur in the absence of a
known physical illness.
• There is no demonstrable physical cause for
the symptoms of somatoform disorders.
• They are somatic (physical) in form only—
thus their name.
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Somatoform Disorders
Symptoms of Somatoform Disorders
• All somatoform disorders involve
complaints about physical symptoms, but
somatoform disorders are not caused by
physical impairments.
• There is nothing physically wrong with the
patient, yet the symptoms are not feigned.
• The physical problem is very real in the
mind, though not the body, of the person
with a somatoform disorder.
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Somatoform Disorders
Symptoms of Somatoform Disorders
(continued)
• The physical symptoms can take a number
of different forms.
• In some dramatic cases, the symptom
involves substantial impairment of a
somatic system, particularly a sensory or
muscular system.
• The patient will be unable to see, for
example, or will report a paralysis in one
arm.
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Somatoform Disorders
Symptoms of Somatoform Disorders
(continued)
• In other types of somatoform disorder,
patients experience multiple physical
symptoms rather than a single, substantial
impairment.
• In these cases, patients usually have
numerous, constantly evolving complaints
about such problems as chronic pain, upset
stomach, and dizziness.
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Somatoform Disorders
Symptoms of Somatoform Disorders
(continued)
• Finally, some types of somatoform disorder are
defined by a preoccupation with a particular
part of the body or with fears about a particular
illness.
• The patient may constantly worry that he or
she has contracted some deadly disease, for
example, and the anxiety persists despite
negative medical tests and clear reassurance by
a physician.
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Somatoform Disorders
Symptoms of Somatoform Disorders
(continued)
• People with somatoform disorders typically
do not bring their problems to the attention
of a mental health professional.
• Instead, they repeatedly consult their
physicians about their “physical” problems.
• This often leads to unnecessary medical
treatment.
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Somatoform Disorders
Diagnosis of Somatoform Disorders
• DSM-IV-TR lists five major subcategories
of somatoform disorders: (1) conversion
disorder, (2) somatization disorder, (3)
hypochondriasis, (4) pain disorder, and (5)
body dysmorphic disorder.
• The symptoms of conversion disorder
often mimic those found in neurological
diseases, and they can be dramatic.
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Somatoform Disorders
Diagnosis of Somatoform Disorders (continued)
• “Hysterical” blindness or “hysterical” paralysis are
examples of conversion symptoms.
• Although conversion disorders often resemble
neurological impairments, they sometimes can be
distinguished from these disorders because they
make no anatomic sense.
• The term conversion disorder accurately conveys
the central assumption of the diagnosis—the idea
that psychological conflicts are converted into
physical symptoms.
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Somatoform Disorders
Diagnosis of Somatoform Disorders (continued)
• Somatization disorder is characterized by
a history of multiple somatic complaints in
the absence of organic impairments.
• In order to be diagnosed with somatization
disorder, the patient must complain of at
least eight physical symptoms and must
involve multiple somatic systems.
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Somatoform Disorders
Diagnosis of Somatoform Disorders (continued)
• Patients with somatization disorders
sometimes present their symptoms in a
histrionic manner—a vague but dramatic,
self-centered, and seductive style.
• Patients also may exhibit la belle
indifference (“beautiful indifference”), a
flippant lack of concern about the physical
symptoms.
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Somatoform Disorders
Diagnosis of Somatoform Disorders (continued)
• Hypochondriasis is a problem characterized by a
fear or belief that one is suffering from a physical
illness.
• Hypochondriasis is much more serious than
normal and fleeting worries.
• The preoccupation with fears of disease extends
over long periods of time.
• In addition, in hypochondriasis, a thorough
medical evaluation or examination does not
alleviate the fear of the disease.
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Somatoform Disorders
Diagnosis of Somatoform Disorders (continued)
• Pain disorder is characterized by preoccupation
with pain.
• Complaints seem excessive and apparently are
motivated at least in part by psychological factors.
• As with hypochondriasis and somatization
disorder, pain disorder can lead to the repeated,
unnecessary use of medical treatments.
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Somatoform Disorders
Diagnosis of Somatoform Disorders (continued)
• Body dysmorphic disorder is a somatoform
disorder in which the patient is preoccupied with
some imagined defect in appearance.
• The preoccupation typically focuses on some
facial feature, such as the nose or mouth, and in
some cases may lead to repeated visits to a plastic
surgeon.
• Preoccupation with the body part far exceeds
normal worries about physical imperfections.
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Somatoform Disorders
Diagnosis of Somatoform Disorders (continued)
• Somatoform disorders must be distinguished from
malingering, pretending to have a somatoform
disorder in order to achieve some external gain,
such as a disability payment.
• A related diagnostic concern is factitious
disorder, a feigned condition that, unlike
malingering, is motivated primarily by a desire to
assume the sick role rather than by a desire for
external gain.
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Somatoform Disorders
Diagnosis of Somatoform Disorders
(continued)
• A rare, repetitive pattern of factitious
disorder is sometimes called Munchausen
syndrome, named after Baron Karl
Friedrich Hieronymus von Munchausen, an
eighteenth-century writer known for his
tendency to embellish the details of his life.
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Somatoform Disorders
Frequency of Somatoform Disorders
• Conversion disorders are rare, perhaps as
infrequent as 50 cases per 100,000 population.
• Most other somatoform disorders also appear to be
relatively rare.
• For example, one study found a 0.7 percent
prevalence of body dysmorphic disorder.
• Hypochondriasis also is quite rare, although less
severe worrying about physical illness is quite
common.
• The lifetime prevalence of somatization disorder
in the United States is only 0.13 percent.
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Somatoform Disorders
Frequency of Somatoform Disorders
(continued)
• With the exception of hypochondriasis, all
other forms of somatoform disorder are more
common among women. This is particularly
true of somatization disorder, which may be as
much as10 times more common among women
than men.
• In addition to gender, socioeconomic status
and culture are thought to contribute to
somatization disorder.
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Somatoform Disorders
Frequency of Somatoform Disorders
(continued)
• In the United States, somatization is more
common among lower socioeconomic groups
and people with less than a high school
education.
• It is four times more common among African
Americans than among Americans of European
heritage, and considerably higher in Puerto
Rico than on the U.S. mainland.
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Somatoform Disorders
Frequency of Somatoform Disorders (continued)
• Somatoform disorders typically occur with other
psychological problems, particularly depression
and anxiety.
• Finally, somatization disorder has frequently been
linked with antisocial personality disorder, a
lifelong pattern of irresponsible behavior that
involves habitual violations of social rules.
• The two disorders do not typically co-occur in the
same individual, but they often are found in
different members of the same family.
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Somatoform Disorders
Causes of Somatoform Disorders
• An obvious—and potentially critical —
biological consideration in somatoform
disorders is the possibility of misdiagnosis.
• A patient may be incorrectly diagnosed as
suffering from a somatoform disorder when,
in fact, he or she actually has a real physical
illness that is undetected or is perhaps
unknown.
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Somatoform Disorders
Causes of Somatoform Disorders (continued)
• Because mental health professionals cannot
demonstrate psychological causes of physical
symptoms objectively and unequivocally, the
identification of somatoform disorders
involves a process called diagnosis by
exclusion.
• The physical complaint is assumed to be a part
of a somatoform disorder only when various
known physical causes are excluded or ruled
out.
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Somatoform Disorders
Causes of Somatoform Disorders
(continued)
• Initially, both Freud and Janet assumed that
conversion disorders were caused by a
traumatic experience.
• Freud later came to believe that dissociation
and other intrapsychic defenses protected
individuals from their unacceptable sexual
impulses, not from their intolerable
memories.
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Somatoform Disorders
Causes of Somatoform Disorders (continued)
• In Freud’s view, conversion symptoms were
expressions of intolerable unconscious
psychological conflicts.
• In Freudian terminology, this is the primary gain
of the symptom.
• Freud also suggested that hysterical symptoms
could produce secondary gain, for example,
avoiding work or responsibility or to gain
attention and sympathy.
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Somatoform Disorders
Causes of Somatoform Disorders
(continued)
• This view has more support than Freud’s
ideas about primary gain, although
cognitive behavior therapists call this
process reinforcement, not secondary gain.
• Recent evidence does suggest that the onset
of somatization is triggered by traumatic
stress, but not necessarily sexual abuse.
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Somatoform Disorders
Causes of Somatoform Disorders (continued)
• Social and cultural theorists offer a
straightforward explanation of the physical
symptoms of somatization disorder,
hypochondriasis, and pain disorder.
• Patients with these disorders are experiencing
some sort of underlying psychological distress.
• However, they describe their problems as physical
symptoms and, to some extent, experience them
that way because of limited insight and/or the lack
of social tolerance of psychological complaints.
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Somatoform Disorders
Treatment of Somatoform Disorders
• Accumulating evidence indicates that
cognitive behavior therapy is effective in
reducing physical symptoms in
somatization disorder, hypochondriasis, and
body dysmorphic disorder.
• Recent evidence also indicates that
antidepressants may be helpful in treating
somatoform disorders.
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