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Abnormal Psychology Fifth Edition Oltmanns and Emery PowerPoint Presentations Prepared by: Cynthia K. Shinabarger Reed This multimedia product and its contents are protected under copyright law. The following are prohibited by law: any public performance or display, including transmission of any image over a network; preparation of any derivative work, including the extraction, in whole or in part, of any images; any rental, lease, or lending of the program. Copyright © Prentice Hall 2007 Chapter Seven Acute and Posttraumatic Stress Disorders, Dissociative Disorders, and Somatoform Disorders Copyright © Prentice Hall 2007 Chapter Outline • Acute and Posttraumatic Stress Disorders • Dissociative Disorders • Somatoform Disorders Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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.” Copyright © Prentice Hall 2007 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). Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 DSM-IV-TR Criteria for Posttraumatic Stress Disorder (continued) Copyright © Prentice Hall 2007 DSM-IV-TR Criteria for Posttraumatic Stress Disorder (continued) Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 DSM-IV-TR Criteria for Acute Stress Disorder (continued) Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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). Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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). Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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.” Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007 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. Copyright © Prentice Hall 2007