PowerPoint  Lecture Notes Presentation
Chapter 6
Somatoform Disorders and Dissociative
Disorders
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Dissociative Disorders

Sudden disruption in the continuity of:
» Consciousness
» Memory
» Identity

Dissociation
» Some aspect of cognition or experience
becomes inaccessible to consciousness
– Avoidance response
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Table 6.1 Summary of Dissociative
Disorders
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Dissociative Amnesia

Inability to recall important personal
information
» Usually about a traumatic experience
» Not ordinary forgetting
» Not due to physical injury
» May last hours or years

Usually remits spontaneously
» Memory returns in bits and pieces
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Dissociative Amnesia

DSM-IV-TR criteria
» One or more episode of inability to
remember important personal information,
usually of a traumatic event, that is too
extensive to be ordinary forgetting.
» Amnesia occurs outside of other
dissociative disorders, PTSD or acute
stress disorder, or somatization disorder,
and is not explained by other medical or
psychological conditions.
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Memory Deficits and Dissociation

Memory research shows the recall of trauma
is usually enhanced memory for central
events.
» High levels of stress hormones could interfere with
memory formation (Andreano & Cahill, 2006)
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Memory Deficits and Dissociation


Memory deficits in explicit but not implicit
memory
Explicit memory
» Involves conscious recall of experiences
– e.g., senior prom, mom’s birthday party

Implicit memory
» Underlies behaviors based on experiences that
cannot be consciously recalled
– e.g., playing tennis, writing a check
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Memory Deficits and Dissociation

Distinguishing other causes of memory loss
from dissociation:
» Degenerative brain disorders
–
–
–
–
e.g., Alzheimer's Disease
Not linked to stress
Involves gradual decline over time
Accompanied by other cognitive deficits

Inability to learn new information
» Substance abuse
– Linked to use of drug or alcohol
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Dissociative Fugue

Amnesia plus flight
» Latin fugere, “to flee”

Sudden, unexpected travel with inability
to recall one’s past
» Assume new identity
– May involve new name, job, personality
characteristics
» More often of brief duration
» Remits spontaneously
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Dissociative Fugue

DSM-IV-TR criteria
» Sudden, unexpected travel away from
home or work
» Inability to recall one’s past
» Confusion about identity or assumption of
new identity
» Symptoms are not explained by another
medical or psychological disorder
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Depersonalization Disorder

Perception of self is altered
» Feelings of detachment or disconnection
– Watching self from outside

Floating above one’s body
– Emotional numbing
» Unusual sensory experiences
– Limbs feel deformed or enlarged
– Voice sounds different or distant
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Depersonalization Disorder
» Triggered by stress or traumatic event
» No psychosis or loss of memory
» Often co-morbid with anxiety, depression,
or Personality Disorders
» Typical onset in adolescence
» Chronic course
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Depersonalization Disorder

DSM-IV-TR criteria
» Persistent or recurrent experiences of
detachment from one’s mental processes
or body, as though in a dream, despite
intact reality testing
» Symptoms are not explained by another
dissociative disorder, by any other
psychological disorder, or by a medical
condition
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Dissociative Identity Disorder (DID)

Two or more distinct and fully developed
personalities (alters)
» Each has unique behaviors, memories, and
relationships
» Memory gaps common for periods of time when
alters are in control

Other symptoms: headaches,
hallucinations, self harm, suicide
attempts
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Dissociative Identity Disorder (DID)

Typical onset in childhood
» Rarely diagnosed until adulthood

More severe than other dissociative disorders
» Recovery may be less complete


More common in women than men
Often comorbid with:
» PTSD, major depression, borderline personality
disorder, substance abuse, phobias
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Dissociative Identity Disorder (DID)

DSM-IV-TR criteria
» Presence of two or more personalities
(alters)
» At least two of the alters recurrently take
control of behavior
» Inability of at least one of the alters to recall
important personal information
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Dissociative Identity Disorder (DID)

Epidemiology
» No identified reports of DID or dissociative
amnesia before 1800 (Pope et al., 2006).
» Major increases in rates since 1970s

DSM-III (1980)
» Diagnostic criteria more explicit

Appearance of DID in popular culture
» Sybil, 1973
» Book and movie received much attention
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Etiology of Dissociative Identity Disorder
(DID): Two Major Theories

Posttraumatic Model
» DID results from severe psychological
and/or sexual abuse in childhood

Sociocognitive Model
» DID a form of role-play in suggestible
individuals
– Occurs in response to prompting by therapists
or media
– No conscious deception
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Etiology of Dissociative Identity Disorder
(DID): Two Major Theories

Evidence raised in theory debate
» DID can be role-played
– Hypnotized students prompted to reveal alters did so
(Spanos, Weekes, & Bertrand, 1985)
» DID patients show only partial implicit memory
deficits
– Alters “share” memories (Huntjen et al., 2003)
» DID diagnosis differs by clinician
– A few clinicians diagnose the majority of DID cases
» For many, symptoms emerge after therapy begins
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Figure 6.1 Handwriting Samples from
Four DID Cases
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Treatment of Dissociative Identity
Disorder (DID)

Most treatments involve:
» Empathic and supportive therapist
» Integration of alters into one fully
functioning individual
» Improvement of coping skills

Psychoanalytic approach adds:
» Re-experience the traumatic event
– Use of hypnosis

Age regression
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Somatoform Disorders

Psychological problems take a physiological
form
» ‘Soma’ means body



Bodily symptoms have no known physical
cause
Not intentionally produced or under voluntary
control
Individuals seek medical, not psychological,
treatment
» Become distressed when no medical cause is
found
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Table 6.2 Summary of Somatoform
Disorders
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Pain Disorder

Person experiences severe, prolonged pain
» Cannot be accounted for by organic pathology
» Caused or intensified by psychological factors such
as conflict and stress


Individual unaware of psychological origins
Diagnosis often challenging
» Unlike pain caused by organic pathology,
individuals have difficulty localizing and describing
pain
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Pain Disorder

DSM-IV-TR Criteria
» Pain that is severe enough to warrant clinical
attention
» Psychological factors are thought to be
important to the onset, severity, or
maintenance of pain
» The pain is not intentionally produced or faked
» The pain is not explained by
» another psychological condition
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Body Dysmorphic Disorder
» Preoccupation with and extreme distress over
imagined or exaggerated defect in appearance
– e.g., “My nose is hideously large”
» Constant examination of self in mirror or avoids
mirrors completely
» Some become housebound
– Refuse to attend school or work
» Attempt to camouflage or hide defect
– ¼ have plastic surgery

Disappointing results
» Almost ½ have suicidal thoughts
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Body Dysmorphic Disorder




Typical onset late adolescence
Slightly more common in women than men
Prevalence less than 1%
High levels of comorbidity
» Most common comorbid disorders:
–
–
–
–
–
Major depressive disorder
Social phobia
Obsessive-compulsive disorder
Substance abuse
Personality disorders
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Body Dysmorphic Disorder

DSM-IV-TR Criteria
» Preoccupation with an imagined defect or
markedly excessive concern over a slight
defect in appearance
» Preoccupation is not explained by another
psychological disorder, like anorexia
nervosa
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Hypochondriasis

Preoccupation with fears of having a serious
disease
– This headache must mean I have a brain tumor!
» Despite medical reassurance, fears persist for at
least 6 months

Critical of medical professionals
» Incompetent and uncaring

Typical onset early adulthood
» Tends to be chronic

Often comorbid with mood and anxiety
disorders
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Hypochondriasis

DSM-IV-TR Criteria
» Preoccupation with fears about having a
serious disease
» The preoccupation continues despite
medical reassurance
» Not explained by a delusional disorder or
body dysmorphic disorder
» Symptoms last at least 6 months
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Somatization Disorder

First noted by Pierre Briquet in 1859
» Known as Briquet’s syndrome

Multiple, recurrent somatic complaints with no
apparent physical cause
» Must have multiple symptoms which cause
impairment
» Seeks treatment, usually from multiple physicians
– Hospitalization, medications, surgery common
» Exaggerated presentation of symptoms and
complaints
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Somatization Disorder

Lifetime prevalence less than 0.5%
» More frequent in women
– Especially Hispanic and African American
» Higher prevalence rates in South America and Puerto Rico

Cultural differences
» Symptom presentation
– Burning pains in hands more common in Asia and Africa
» Culture may also influence how people seek treatment
– Psychological distress presented in physical terms


Typical onset early adulthood
Often accompanied by behavioral and interpersonal
problems
» e.g., marital discord, poor work history
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Somatization Disorder

DSM-IV-TR Criteria
» History of seeking treatment for many physical
complaints beginning before the age of 30 and
lasting for several years
» At least four pain symptoms, as well as at least two
gastrointestinal symptoms, one sexual symptom,
and one pseudoneurological symptom (e.g.,
unexplained paralysis)
» Symptoms are not due to a medical condition or
are excessive given the person’s medical condition
» Symptoms do not appear to be faked
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Conversion Disorder

Sensory or motor function impaired but no
known neurological cause
»
»
»
»
Vision impairment or tunnel vision
Partial or complete paralysis of arms or legs
Seizures or coordination problems
Anesthesia
– Loss of sensation
» Aphonia
– Whispered speech
» Anosmia
– Loss of smell
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Conversion Disorder

DSM-IV-TR Criteria
» One or more symptoms affecting motor or
sensory functioning and suggesting a
neurological or medical condition
» Symptoms are related to conflict or stress
» Symptoms are not intentionally produced and
cannot be explained by a medical condition
» Symptoms cause significant distress or
functional impairment or warrant medical
evaluation
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Conversion Disorder

Hippocrates
» Believed disorder only occurred in women
» Attributed it to a wandering uterus
– Originally known as Hysteria


Greek word for uterus
Freud
» Coined term conversion
» Anxiety and conflict converted into physical
symptoms
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Conversion Disorder

Onset typically adolescence or early
adulthood
» Often follows life stress

Prevalence less than 1%
» More common in women than men

Often comorbid with:
» Major depressive disorder
» Substance abuse
» Personality disorders
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Figure 6.2 Glove Anesthesia
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Etiology of Conversion Disorder:
Psychoanalytic Perspective

Individual experiences distressing event
» Unable to express emotional distress
» Memory of event is pushed into the unconscious

In women, disorder linked to Electra Complex
(Freud)
» Sexual arousal in adulthood triggers anxiety which
is converted to physical symptoms.

No empirical support for psychoanalytic theory
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Etiology of Conversion Disorder:
Genetic Factors

No support for genetic influence
» Concordance rates in MZ twin pairs do not
differ from DZ twin pairs
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Etiology of Conversion Disorder:
Social and Cultural Factors

Decrease in incidence of conversion
disorders since last half of 19th century
» Higher incidence may have been due to more
repressed sexual attitudes or low tolerance for
anxiety symptoms

More prevalent
» In rural areas
» In individuals of lower SES
» In non-western cultures
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Etiology of other Somatoform
Disorders

Body Dysmorphic
Disorder
» BDD often co-occurs
with OCD
– May have shared
neurobiological risk
factors

Cognitive Behavioral
Model (see figure)
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Treatment of Somatoform Disorders
Few controlled treatment outcome
studies
 Cognitive Behavioral Treatment

» Identify & change triggering emotions
» Change cognitions about symptoms
» Replace sick role behaviors with more
appropriate social interactions
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Treatment of Pain Disorder

Antidepressants
» Tofranil
– Effective even with low dosages that don’t alleviate
depressive symptoms

Components of psychotherapy for pain
disorder
»
»
»
»
Validation of patient’s pain
Relaxation training
Reinforce shift of focus away from pain
Help patient develop ability to cope with stress and
gain sense of control over pain
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Treatment of Body Dysmorphic
Disorder

Cognitive Behavioral Therapy
» Exposure plus response prevention
– Prevent individual from checking appearance

Antidepressants
» Fluoxetine (Prozac)
» Clomipramine (Anafranil)
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Treatment of Hypochondriasis

Cognitive Behavioral Therapy
» Reduce excessive attention to bodily
sensations
» Challenge negative perceptions about
sensations
» Discourage reassurance seeking from
medical professionals
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Treatment of Somatization Disorder

Most accepted approach:
» Medical professionals don’t dismiss
physical complaints
» Minimize use of diagnostic tests and
medication
» Avoid providing attention only when patient
is complaining
– Stay in contact on a regular basis
» Treat underlying depression and anxiety
when present
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Treatment of Conversion Disorder
No controlled studies to date
 Psychoanalytic treatments have not
demonstrated usefulness
 Reinforcement of high functioning
behavior may help

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COPYRIGHT
Copyright 2009 by John Wiley & Sons, New
York, NY. All rights reserved. No part of the
material protected by this copyright may be
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permission of the copyright owner.
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