Disorders Focusing on Somatic and Dissociative
Symptoms


Stress and anxiety also contribute to several
other kinds of disorders, particularly disorders
that focus on somatic and dissociative
symptoms
Disorders focusing on somatic symptoms are
problems that appear to be medical but are
actually caused by psychosocial factors

Unlike psychophysiological disorders, in which
psychosocial factors interact with genuine physical
ailments, somatoform disorders are psychological
disorders masquerading as physical problems
Disorders Focusing on Somatic and Dissociative
Symptoms
These disorders include:
Factitious
disorder
Conversion
disorder
Somatic
symptom
disorder
Illness
anxiety
disorder
Body
dysmorphic
disorder
Disorders Focusing on Somatic and Dissociative
Symptoms
Disorders focusing on dissociative symptoms include
Dissociative amnesia
Dissociative
Identity disorder
Depersonalization-derealization disorder
Disorders Focusing on Somatic and Dissociative
Symptoms

These groups of disorders have much in
common:
Both may occur in response to severe stress
 Both have traditionally been viewed as forms of escape
from stress
 A number of individuals suffer from both types of
disorders
 Theorists and clinicians often explain and treat the two
groups of disorders in similar ways

What Are Disorders focusing on Somatic
Symptoms?

People with these disorders suffer actual changes
in their physical functioning
These disorders are often hard to distinguish from
genuine medical problems
 It is always possible that a diagnosis is a mistake and
that the patient's problem has an undetected organic
cause

Facticious Disorder


A disorder in which an
individual feigns or
induces physical
symptoms, typically for
the purpose of assuming
the role of a sick person
Popularly known as
Munchausen Syndrome
Facticious Disorder


The precise causes of factitious disorder are not
understood, although clinical reports have pointed
to factors such as depression, unsupportive
parental relationships during childhood, and an
extreme need for social support
Clinicians have been unable to develop
dependably effective treatments for this disorder
Conversion Disorder

A psychosocial conflict or need is converted into
dramatic physical symptoms that affect voluntary
or sensory functioning




Symptoms often seem neurological, such as paralysis,
blindness, or loss of feeling
Most conversion disorders begin between late
childhood and young adulthood
They are diagnosed in women twice as often as
in men
They usually appear suddenly, at times of stress,
and are thought to be rare
Conversion Disorder


Conversion disorders
are often similar to
“genuine” medical
ailments, physicians
sometimes rely on
oddities in the
patient’s medical
picture to help
distinguish the two
Symptoms may be at
odds with the way the
nervous system is
known to work
Somatic Symptom Disorder



People with somatic symptom disorder become
excessively distressed, concerned, and anxious
about bodily symptoms that they are
experiencing, and their lives are greatly disrupted
by the symptoms
The symptoms are longer-lasting but less
dramatic than those found in conversion disorder
In some cases, the symptoms have no known
cause
Somatization Pattern

People with somatization disorder have many
long-lasting physical ailments that have little or no
organic basis



Also known as Briquet’s syndrome
To receive a diagnosis, a patient must have a
range of ailments, including several pain
symptoms, gastrointestinal symptoms, a sexual
symptom, and a neurological symptom
Patients usually go from doctor to doctor in
search of relief
Predominant Pain Pattern

Pain disorder associated with psychological
factors
Patients may receive this diagnosis when psychosocial
factors play a central role in the onset, severity, or
continuation of pain
 Although the precise prevalence has not been
determined, it appears to be fairly common



The disorder often develops after an accident or illness that has
caused genuine pain
The disorder may begin at any age, and more women
than men seem to experience it
What Causes Conversion and Somatic Symptom
Disorders?


Previously called hysterical disorders
Widely considered unique and in need of special
explanation

No explanation has received much research support,
and the disorders are still poorly understood
What Causes Conversion and Somatic Symptom
Disorders?
The psychodynamic view
• Freud believed that these disorders represented a
conversion of underlying emotional conflicts into physical
symptoms
• Because most of his patients were women, Freud centered
his explanation on the psychosexual development of girls
and focused on the phallic stage (ages 3 to 5)
• During this stage, girls develop a pattern of sexual desires
for their fathers (the Electra complex) and recognize that
they must compete with their mothers for his attention
• Because of the mother's more powerful position, girls
repress these sexual feelings
What Causes Conversion and Somatic Symptom
Disorders?
The psychodynamic view
• Freud believed that if parents overreact to such feelings,
the Electra complex would remain unresolved and the
child might re-experience sexual anxiety throughout her
life
• Freud concluded that some women unconsciously hide
their sexual feelings in adulthood by converting them
into physical symptoms
• Today's psychodynamic theorists take issues with
Freud's explanation of the Electra conflict
• They continue to believe that sufferers of these
disorders have unconscious conflicts carried from
childhood
What Causes Conversion and Somatic Symptom
Disorders?
The psychodynamic view
• Psychodynamic theorists propose that two
mechanisms are at work in these
disorders:
• Primary gain: symptoms keep internal
conflicts out of conscious awareness
• Secondary gain: symptoms further
enable people to avoid unpleasant
activities or receive sympathy from others
What Causes Conversion and Somatic Symptom
Disorders?
The behavioral view
• Behavioral theorists propose that the physical
symptoms of these disorders bring rewards to
sufferers
• May remove individual from an unpleasant situation
• May bring attention from other people
• In response to such rewards, people learn to display
symptoms more and more
• This focus on rewards is similar to the psychodynamic
idea of secondary gain, but behaviorists view the
gains as the primary cause of the development of the
disorder
What Causes Conversion and Somatic Symptom
Disorders?
The cognitive view
• Some cognitive theorists propose that these
disorders are a form of communication,
providing a means for people to express difficult
emotions
• Like psychodynamic theorists, cognitive
theorists hold that emotions are being
converted into physical symptoms
• This conversion is not to defend against
anxiety but to communicate extreme
feelings
What Causes Conversion and Somatic Symptom
Disorders?
The multicultural view
• Some theorists believe that Western clinicians
hold a bias that sees somatic symptoms as an
inferior way of dealing with emotions
• The transformation of personal distress into
somatic complaints is the norm is many
non-Western cultures
• As we saw in Chapter 6, reactions to life's
stressors are often influenced by one's
culture
What Causes Conversion and Somatic Symptom
Disorders?
A possible role for biology
• The impact of biological processes on these disorders
can be understood through research on placebos and
the placebo effect
• Placebos: substances with no known medicinal value
• Treatment with placebos has been shown to bring
improvement to many – possibly through the power of
suggestion but likely because expectation triggers the
release of endogenous chemicals
• Perhaps traumatic events and related concerns or
needs can also trigger our “inner pharmacies” and set
in motion the bodily symptoms of conversion and
somatic symptom disorders
How Are Conversion and Somatic Symptom
Disorders Treated?


People with conversion and somatic symptom
disorders usually seek psychotherapy only as a
last resort
Individuals with preoccupation disorders typically
receive the kinds of treatments applied to anxiety
disorders, particularly OCD:
Antidepressant medication
 Exposure and response prevention (ERP)
 Cognitive-behavioral therapies

How Are Conversion and Somatic Symptom
Disorders Treated?

Treatments for these disorders often focus on the
cause of the disorder and apply the same kind of
techniques used in cases of PTSD, particularly:
Insight – often psychodynamically oriented
 Exposure – client thinks about traumatic event(s) that
triggered the physical symptoms
 Drug therapy – especially antidepressant medication

How Are Conversion and Somatic Symptom
Disorders Treated?

Other therapists try to address the physical
symptoms of these disorders, applying
techniques such as:
Suggestion – usually an offering of emotional support
that may include hypnosis
 Reinforcement – a behavioral attempt to change reward
structures
 Confrontation – an overt attempt to force patients out of
the sick role


Researchers have not fully evaluated the effects
of these particular approaches on these disorders
Illness Anxiety Disorder

People with this disorder unrealistically interpret
bodily symptoms as signs of a serious illness


Often their symptoms are merely normal bodily
changes, such as occasional coughing, sores, or
sweating
Although some patients recognize that their
concerns are excessive, many do not
Body Dysmorphic Disorder

Body dysmorphic disorder

People with this disorder, also
known as dysmorphophobia,
become deeply concerned about
some imagined or minor defect
in their appearance


Most often they focus on wrinkles,
spots, facial hair, swelling, or
misshapen facial features (nose,
jaw, or eyebrows)
Most cases of the disorder begin
in adolescence but are often not
revealed until adulthood
Dissociative Disorders

The key to our identity – the sense of
who we are and where we fit in our environment –
is memory
Our recall of past experiences helps us to react to
present events and guides us in making decisions
about the future
 People sometimes experience a major disruption of
their memory:



They may not remember new information
They may not remember old information
Dissociative Disorders

When such changes in memory lack a clear
physical cause, they are called “dissociative”
disorders

In such disorders, one part of the person's memory
typically seems to be dissociated, or separated, from
the rest
Dissociative Disorders
Types of dissociative disorders
include:
Dissociative
amnesia
Dissociative fugue
Dissociative
identity disorder
(multiple
personality
disorder)
Depersonalizationderealization
disorder
Dissociative Amnesia

People with dissociative
amnesia are unable to recall
important information,
usually of an upsetting
nature, about their lives
The loss of memory is much
more extensive than normal
forgetting and is not caused by
physical factors
 Often an episode of amnesia is
directly triggered by a specific
upsetting event

Dissociative Amnesia

Dissociative amnesia may be:
Localized – most common type; loss of all memory of
events occurring within a limited period
 Selective – loss of memory for some, but not all, events
occurring within a period
 Generalized – loss of memory beginning with an event,
but extending back in time; may lose sense of identity;
may fail to recognize family and friends
 Continuous – forgetting continues into the future; quite
rare in cases of dissociative amnesia

Dissociative Fugue

People with dissociative fugue not only forget
their personal identities and details of their past,
but also flee to an entirely different location
For some, the fugue is brief – a matter of hours or days
– and ends suddenly
 For others, the fugue is more severe: people may travel
far from home, take a new name and establish new
relationships, and even a new line of work; some
display new personality characteristics


Fugues tend to end abruptly
Dissociative Identity Disorder (Multiple Personality
Disorder)

A person with dissociative identity disorder (DID;
formerly multiple personality disorder) develops
two or more distinct personalities
(subpersonalities) each with a unique set of
memories, behaviors, thoughts, and emotions
Dissociative Identity Disorder (Multiple Personality
Disorder)

At any given time, one of the subpersonalities
dominates the person's functioning



Usually one of these subpersonalities – called the primary, or
host, personality – appears more often than the others
The transition from one subpersonality to the next
(“switching”) is usually sudden and may be dramatic
Most cases are first diagnosed in late adolescence or
early adulthood

Symptoms generally begin in childhood after episodes of
abuse


Typical onset is before age 5
Women receive the diagnosis three times as often as
men
How Do Subpersonalities Interact?

Generally there are three kinds of relationships:
Mutually amnesic relationships – subpersonalities have
no awareness of one another
 Mutually cognizant patterns – each subpersonality is
well aware of the rest
 One-way amnesic relationships – most common
pattern; some personalities are aware of others, but the
awareness is not mutual


Those who are aware (“co-conscious subpersonalities”) are
“quiet observers”
How Do Subpersonalities Interact?

Investigators used to believe that most cases of
the disorder involved two or three
subpersonalities

Studies now suggest that the average number is much
higher – 15 for women, 8 for men

There have been cases of more than 100
How Do Subpersonalities Differ?

Subpersonalities often display dramatically different
characteristics, including:

Identifying features


Abilities and preferences



Subpersonalities may differ in features as basic as age, sex, race,
and family history
Although encyclopedic information is not usually affected by
dissociative amnesia or fugue, in DID it is often disturbed
It is not uncommon for different subpersonalities to have different
abilities, including being able to drive, speak a foreign language, or
play an instrument
Physiological responses

Researchers have discovered that subpersonalities may have
physiological differences, such as differences in autonomic nervous
system activity, blood pressure levels, and allergies
Dissociative Identity Disorder (Multiple Personality
Disorder)

How common is DID?
Traditionally, DID was believed to be rare
 The number of people diagnosed with the disorder has
been increasing
 Although the disorder is still uncommon, thousands of
cases have been documented in the U.S. and Canada
alone


Two factors may account for this increase:



A growing number of clinicians believe that the disorder does exist
and are willing to diagnose it
Diagnostic procedures have become more accurate
Despite changes, many clinicians continue to question
the legitimacy of this category
How Do Theorists Explain Dissociative Amnesia
and Dissociative Identity Disorder?

A variety of theories have been proposed to
explain dissociative disorders
Older explanations have not received much
investigation
 Newer viewpoints, which combine cognitive, behavioral,
and biological principles, have captured the interest of
clinical scientists

How Do Theorists Explain Dissociative Amnesia
and Dissociative Identity Disorder?
The psychodynamic view
• Psychodynamic theorists believe that dissociative
disorders are caused by repression, the most basic
ego defense mechanism
• People fight off anxiety by unconsciously
preventing painful memories, thoughts, or
impulses from reaching awareness
• In this view, dissociative amnesia and fugue are
single episodes of massive repression
• DID is thought to result from a lifetime of excessive
repression, motivated by very traumatic childhood
events
How Do Theorists Explain Dissociative Amnesia
and Dissociative Identity Disorder?
The psychodynamic view
• Most of the support for this model is
drawn from case histories, which report
brutal childhood experiences, yet:
• Some individuals with DID do not seem
to have these experiences of abuse
• Further, why might only a small fraction
of abused children develop this
disorder?
How Do Theorists Explain Dissociative Amnesia
and Dissociative Identity Disorder?
The behavioral view
• Behaviorists believe that dissociation grows from normal
memory processes and is a response learned through
operant conditioning:
• Momentary forgetting of trauma leads to a drop in
anxiety, which increases the likelihood of future forgetting
• Like psychodynamic theorists, behaviorists see
dissociation as escape behavior
• Also like psychodynamic theorists, behaviorists rely largely
on case histories to support their view of dissociative
disorders
• Moreover, these explanations fail to explain all aspects of
these disorders
How Do Theorists Explain Dissociative Amnesia
and Dissociative Identity Disorder?
State-dependent learning
• If people learn something when they are in a
particular state of mind, they are likely to
remember it best when they are in the same
condition
• This link between state and recall is called
state-dependent learning
• This model has been demonstrated with
substances and mood and may be linked
to arousal levels
How Do Theorists Explain Dissociative Amnesia
and Dissociative Identity Disorder?
State-dependent learning
• People who are prone to develop
dissociative disorders may have state-tomemory links that are unusually rigid and
narrow; each thought, memory, and skill
is tied exclusively to a particular state of
arousal, so that they recall a given event
only when they experience an arousal
state almost identical to the state in which
the memory was first acquired
How Do Theorists Explain Dissociative Amnesia
and Dissociative Identity Disorder?
Self-hypnosis
• Although hypnosis can help people remember
events that occurred and were forgotten years ago,
it can also help people forget facts, events, and their
personal identity
• Called “hypnotic amnesia,” this phenomenon has
been demonstrated in research studies with word
lists
• The parallels between hypnotic amnesia and
dissociative disorders are striking and have led
researchers to conclude that dissociative disorders
may be a form of self-hypnosis
How Are Dissociative Amnesia and Dissociative
Identity Disorder Treated?

People with dissociative amnesia and fugue often
recover on their own


Only sometimes do their memory problems linger and
require treatment
In contrast, people with DID usually require
treatment to regain their lost memories and
develop an integrated personality

Treatment for dissociative amnesia and fugue tends to
be more successful than treatment for DID
How Do Therapists Help People With Dissociative
Amnesia And Fugue?

The leading treatments for these disorders are
psychodynamic therapy, hypnotic therapy, and
drug therapy
Psychodynamic therapists guide patients to search their
unconscious and bring forgotten experiences into
consciousness
 In hypnotic therapy, patients are hypnotized and guided
to recall forgotten events
 Sometimes intravenous injections of barbiturates are
used to help patients regain lost memories


Often called “truth serums,” the key to the drugs' success is
their ability to calm people and free their inhibitions
How Do Therapists Help Individuals With DID?

Unlike victims of dissociative amnesia or fugue,
people with DID do not typically recover without
treatment

Treatment for this pattern, like the disorder itself, is
complex and difficult
How Do Therapists Help Individuals With DID?
Recognizing the disorder
• Once a diagnosis of DID has been made, therapists
try to bond with the primary personality and with each
of the subpersonalities
• As bonds are forged, therapists try to educate the
patients and help them recognize the nature of the
disorder
• Some use hypnosis or video as a means of
presenting other subpersonalities
• Many therapists recommend group or family therapy
How Do Therapists Help Individuals With DID?
Recovering memories
• To help patients recover missing
memories, therapists use many of the
approaches applied in other dissociative
disorders, including psychodynamic
therapy, hypnotherapy, and drug treatment
• These techniques tend to work slowly in
cases of DID
How Do Therapists Help Individuals With DID?
Integrating the subpersonalities
• The final goal of therapy is to merge the different
subpersonalities into a single, integrated identity
• Integration is a continuous process; fusion is the final
merging
• Many patients distrust this final treatment goal and
their subpersonalities see integration as a form of
death
• Once the subpersonalities are integrated, further
therapy is typically needed to maintain the complete
personality and to teach social and coping skills to
prevent later dissociations
Depersonalization-Derealization Disorder


DSM-5 categorizes depersonalizationderealization disorder as a dissociative disorder,
even though it is not characterized by the
memory difficulties found in the other dissociative
disorders
Its central symptom is persistent and recurrent
episodes of depersonalization (the sense that
one’s own mental functioning or body are unreal
or detached) and/or derealization (the sense that
one’s surroundings are unreal or detached)
Depersonalization Disorder

People with this disorder feel as though they have
become separated from their body and are
observing themselves from outside


This sense of unreality can extend to other sensory
experiences and behavior
Depersonalization experiences by themselves do
not indicate a depersonalization disorder
Transient depersonalization reactions are fairly
common
 The symptoms of a depersonalization disorder are
persistent or recurrent, cause considerable distress,
and interfere with social relationships and job
performance

Depersonalization Disorder

The disorder occurs most frequently in
adolescents and young adults, hardly ever in
people older than 40


The disorder comes on suddenly and tends to be longlasting
Few theories have been offered to explain the
disorder and little research has been conducted
on the problem