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Chapter 7
Somatoform and Dissociative
Disorders
Ch 7
Historical Commonality
• Somatoform and dissociative disorders are very strongly
historically linked and may share common features.
• They used to be categorized under one general heading,
“hysterical neurosis” .
• The term “hysteria” (from the Greek “wandering uterus”)
referred to physical symtoms without organic basis
(somatoform disorder) or in dissociative experiences
(alterations in consciousness, memory, or identity).
• Kihlstrom’s theory (D&N, p. 189): Both disorders are
disruptions in the normal controlling functions of
consciousness.
Somatoform Disorders
• Psychological factors produce physical symptoms in
the Somatoform Disorders:
– Hypochondriasis is a preoccupation with having a disease
– Body dysmorphic disorder involves a preoccupation with
an imagined physical defect
– Conversion disorder involves a change in sensory/motor
function
– Somatization disorder involves recurrent, multiple somatic
complaints
– In pain disorder, chronic pain results in distress, in which
psychological factors play a maintaining role
Ch 7.1

Common Features
Lots of Physical Complaints
 Appear to be Medical
Conditions
 No Identifiable Medical Cause
 Pathological Concern About
– Physical Appearance
– Functioning of Their Bodies


Clinical Description
Ancient Roots
 Physical Complaints
 No Known Medical Cause
 Severe Anxiety / Fear About
Possibly Having a Serious
Disease
 Reassurance Doesn’t Help


Clinical Description
Essential Problem is Anxiety
 Preoccupied With Bodily
Symptoms
 Misinterpretation of Symptoms
 Strong Disease Conviction
 Many Medical Visits and Tests

Why not Classify Such
Persons With an Illness
Phobia?

Facts and Statistics





1% to 14% Medical Patients
Equal Rates (Males vs. Females)
May Occur Any Time
Strong Disease Conviction
Many Medical Visits and Tests

Causes
Disorder of Cognition /
Perception
 More Disease in Family
 More Illness Concern in Family
 More Attention for Sick Behavior


Psychological Treatment
Modify Illness Perceptions
 Evoke Bodily Sensations
 Provide “Appropriate”
Reassurance
 More Research is Needed!


Clinical Description
Preoccupation With Appearance
– Imagined Defect
 “Imagined” Ugliness
 Mirrors (Fixation or Avoidance)
 Ideas of Reference
 Suicidal Ideation and
Tendencies


Common Locations of Defects






Hair
Nose
Skin
Eyes
Head / Face
Lips

Facts and Statistics
College Students
– 70% Report Some
Dissatisfaction
– 28% Meet Diagnostic Criteria
 Many Consult Plastic Surgeons
 Males = Females
 Onset Late Adolescence

 The
Plastic Surgery Solution?
Quite Popular but Expensive
 Most are Disappointed With
Results
BEFORE
AFTER


Causes and Treatment
Little is Known
 Co-Occurs With OCD
– Intrusive Thoughts and
Checking Compulsions About
Appearance
 Exposure + Response Prevention

Conversion Disorder
• Conversion Disorder involves sensory or
motor symptoms
– Not related to known physiology of the body
• E.g. glove anesthesia
– Conversion symptoms appear suddenly
– Conversion symptoms are related to marked stress
– The person experiencing conversion disorder is not
distressed by sudden paralysis or blindness (“La Belle
Indifference”)
– Popularized by Freud
Ch 7.2

Facts and Statistics
Relatively Rare (< 1% prevalence)
 Females > Males
 Onset Around Adolescence

Somatization Disorder
• Somatization Disorder involves recurrent, multiple
somatic complaints with no known physical basis
• Diagnostic criteria include:
– Four pain symptoms in different locations
– Two gastrointestinal symptoms
– One sexual symptom other than pain
– One pseudo-neurological symptom (e.g. those
of conversion disorder)
• Lifetime prevalence is < 0.5%; females > males;
chronic condition
Ch 7.3

Causes
Family Link
 Link to Antisocial Personality
– Weak Behavioral Inhibition
– Strong Behavioral Activation
– Short Term Gain (attention &
sympathy)


Clinical Description
Pain is Real
 Pain May Have Organic Cause
 Psychological Factors Maintain
Pain
 Can be Debilitating

Etiology of Somatoform
Disorders
• Somatoform disorder reflects oversensitivity to
physical sensations
• Conversion disorder
– Psychoanalytic view focuses on unconscious
complexes and secondary gain
– Behavioral view focuses on similarity to malingering
– The incidence of conversion disorder has declined,
suggesting a role for social factors
Ch 7.4
Therapy for Conversion
Disorders
• Conversion disorder clients seek help from
physicians and resent referrals to
psychotherapists
– Psychoanalytic therapy is not effective for conversion
disorder
– The cognitive-behavioral approach involves pointing out
selective attention to physical sensations and
discouraging the client from seeking medical assistance
Ch 7.5
Dissociative Disorders
• Dissociative Disorders involve the inability to recall
important personal events or identity
– Depersonalization disorder involves an alteration of a
person’s self-experience
– Dissociative amnesia is the inability to recall important
personal information
– Dissociative fugue involves extensive memory loss
– Dissociative trance disorder involves a sudden change
in personality / “possession by spirits”
– Dissociative identity disorder (DID) involves the
presence of two different identities (alters)
Ch 7.6

Dissociative Phenomena
 Depersonalization
– Altered Perception of Self
 Derealization
– Altered Perception of World
 Common Experience
Altered consciousness, memory
Some people have the experience
of driving a car and suddenly
realizing that they don’t remember
what happened during all or part of
the trip.
0%
100%
Some people find that sometimes
they are listening to someone talk
and they suddenly realize that they
did not hear part or all of what was
just said.
0%
100%
Some people find that they have no
memory for some important events in
their lives
(e.g. a wedding or graduation).
0%
100%
Some people have the experience
of finding themselves dressed in
clothes that they don’t remember
putting on.
0%
100%
Some people sometimes have the
experience of feeling that other people,
objects, and the world around them are
not real.
0%
100%
Normal
Dissociation
Amnesia
Partial
DID
Poly-Fragmented
DID
Fugue
Complex
DID
Etiology of Dissociative
Disorders
• Consciousness is normally a unified
experience,consisting of cognition, emotion
and motivation
– Stress may alter the fashion in which memories
are stored resulting in amnesia or fugue
– May result from
• Severe physical/sexual abuse
• Learned social role enactment
Ch 7.7

Depersonalization Disorder




Dissociative Amnesia
Dissociative Fugue
Dissociative Trance Disorder
Dissociative Identity Disorder

Clinical Description
 Primary Features
– Depersonalization
– Derealization
 Impairs Functioning
 Causes Significant Distress
 Runs a Chronic Course

Depersonalization Disorder

Dissociative Amnesia


Dissociative Fugue
Dissociative Trance Disorder
 Dissociative Identity Disorder

Clinical Description
 Several Patterns
 Generalized
– Unable to Remember Anything
 Localized or Selective
– Failure to Recall Specific Events

Depersonalization Disorder

Dissociative Amnesia

Dissociative Fugue


Dissociative Trance Disorder
Dissociative Identity Disorder

Clinical Description
 Memory Loss
– Specific Incident
 Go to Another Location
– Unaware “How They Arrived”
 May Assume New Identity
 Fugue Usually Ends Abruptly

Depersonalization Disorder


Dissociative Amnesia
Dissociative Fugue

Dissociative Trance Disorder

Dissociative Identity Disorder

Clinical Description
 Differ Across Cultures
– Sudden Changes in Personality
– Possession by Spirits
 Females > Males
 Often Related to Trauma

Depersonalization Disorder



Dissociative Amnesia
Dissociative Fugue
Dissociative Trance Disorder

Dissociative Identity Disorder

Clinical Description
 Formally
– Multiple Personality Disorder
 May Adopt 100 Identities
– “Alters”
– The Nature of Alters
 Person’s Identity is Dissociated

Central Features
 Host Identity
– One Who Asks for Treatment
– Attempt to Hold Alters Together
 A Switch
– Abrupt Change in Personalities
– Usually Instantaneous

Facts and Statistics
 Average Number of Alters?
– 15
 Females > Males (9:1)
 Onset in Childhood
– Linked to Extreme Abuse
 Runs a Chronic Course

Causes
 Unspeakable Childhood Abuse
– 97% of Cases
– Escape Into Fantasy World
– Become Someone Else
– Do What It Takes to Survive
 DID as a Means of Coping?
--Age 9 “developmental window”

Other Related Features
 Suggestibility, Role Playing
Spanos et al. (1994) experiment,
 Hypnotizability
 Similar to Dissociation
?
 Are these related to DID?
 Abuse:
Controversial Issues
 False vs. Real Memories
 Do Therapists Plant Memories?
 Can False Memories be Created?
– Elizabeth Loftus (D&N, p.178)
– (Williams, 1995; Elliott, 1997)
 Consequences of the Debate?
 Treatment:
Psychoanalysis Relevant
 Dissociative Amnesia & Fugue
– Usually Improve on Their Own
– Stress Reduction and Coping
 Dissociative Identity Disoder
Chronic, Treatment Process Difficult
– No Controlled Research
– Treatments are Similar to PTSD
Diagnostic Considerations in
Somatoform
and Dissociative Disorders
• Separating Real Problems from Faking
– The Problem of Malingering – Deliberately
faking symptoms
• Related Conditions – Factitious disorders
– Factitious disorder by proxy
• False Memories and Recovered Memory
Syndrome