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 Common Features  Lots of Physical Complaints Lots of Physical Complaints  Appear to be Medical Conditions Appear to be Medical Conditions  No Identifiable Medical Cause No Identifiable Medical Cause  Pathological Concern About Pathological Concern About – Physical Appearance Physical Appearance – Functioning of Their Bodies Functioning of Their Bodies  Common Features Common Features  Lots of Physical Complaints Lots of Physical Complaints  Appear to be Medical Conditions Appear to be Medical Conditions  No Identifiable Medical Cause No Identifiable Medical Cause  Pathological Concern About Pathological Concern About – Physical Appearance Physical Appearance – Functioning of Their Bodies Functioning of Their Bodies

 Clinical Description Clinical Description  Ancient Roots Ancient Roots  Physical Complaints Physical Complaints  No Known Medical Cause No Known Medical Cause  Severe Anxiety / Fear About Severe Anxiety / Fear About Possibly Having a Serious Disease  Reassurance Doesn’t Help Reassurance Doesn’t Help  Clinical Description Clinical Description  Ancient Roots Ancient Roots  Physical Complaints Physical Complaints  No Known Medical Cause No Known Medical Cause  Severe Anxiety / Fear About Severe Anxiety / Fear About Possibly Having a Serious Disease  Reassurance Doesn’t Help Reassurance Doesn’t Help

 Clinical Description Clinical Description  Essential Problem is Anxiety Essential Problem is Anxiety  Preoccupied With Bodily Symptoms Preoccupied With Bodily Symptoms  Misinterpretation of Symptoms Misinterpretation of Symptoms  Strong Disease Conviction Strong Disease Conviction  Many Medical Visits and Tests Many Medical Visits and Tests  Clinical Description Clinical Description  Essential Problem is Anxiety Essential Problem is Anxiety  Preoccupied With Bodily Symptoms Preoccupied With Bodily Symptoms  Misinterpretation of Symptoms Misinterpretation of Symptoms  Strong Disease Conviction Strong Disease Conviction  Many Medical Visits and Tests Many Medical Visits and Tests

Why not Classify Such Persons With an Illness Phobia? Why not Classify Such Persons With an Illness Phobia?

 Facts and Statistics Facts and Statistics  1% to 14% Medical Patients 1% to 14% Medical Patients  Equal Rates (Males vs. Females) Equal Rates (Males vs. Females)  May Occur Any Time May Occur Any Time  Strong Disease Conviction Strong Disease Conviction  Many Medical Visits and Tests Many Medical Visits and Tests  Facts and Statistics Facts and Statistics  1% to 14% Medical Patients 1% to 14% Medical Patients  Equal Rates (Males vs. Females) Equal Rates (Males vs. Females)  May Occur Any Time May Occur Any Time  Strong Disease Conviction Strong Disease Conviction  Many Medical Visits and Tests Many Medical Visits and Tests

 Causes Causes  Disorder of Cognition / Perception Disorder of Cognition / Perception  More Disease in Family More Disease in Family  More Illness Concern in Family More Illness Concern in Family  More Attention for Sick Behavior More Attention for Sick Behavior  Causes Causes  Disorder of Cognition / Perception Disorder of Cognition / Perception  More Disease in Family More Disease in Family  More Illness Concern in Family More Illness Concern in Family  More Attention for Sick Behavior More Attention for Sick Behavior

 Psychological Treatment Psychological Treatment  Modify Illness Perceptions Modify Illness Perceptions  Evoke Bodily Sensations Evoke Bodily Sensations  Provide “Appropriate” Reassurance Provide “Appropriate” Reassurance  More Research is Needed! More Research is Needed!  Psychological Treatment Psychological Treatment  Modify Illness Perceptions Modify Illness Perceptions  Evoke Bodily Sensations Evoke Bodily Sensations  Provide “Appropriate” Reassurance Provide “Appropriate” Reassurance  More Research is Needed! More Research is Needed!

 Clinical Description Clinical Description  Preoccupation With Appearance Preoccupation With Appearance – Imagined Defect Imagined Defect  “Imagined” Ugliness “Imagined” Ugliness  Mirrors (Fixation or Avoidance) Mirrors (Fixation or Avoidance)  Ideas of Reference Ideas of Reference  Suicidal Ideation and Tendencies Suicidal Ideation and Tendencies  Clinical Description Clinical Description  Preoccupation With Appearance Preoccupation With Appearance – Imagined Defect Imagined Defect  “Imagined” Ugliness “Imagined” Ugliness  Mirrors (Fixation or Avoidance) Mirrors (Fixation or Avoidance)  Ideas of Reference Ideas of Reference  Suicidal Ideation and Tendencies Suicidal Ideation and Tendencies

 Common Locations of Defects Common Locations of Defects  Hair Hair  Nose Nose  Skin Skin  Eyes Eyes  Head / Face Head / Face  Lips Lips  Common Locations of Defects Common Locations of Defects  Hair Hair  Nose Nose  Skin Skin  Eyes Eyes  Head / Face Head / Face  Lips Lips

 Facts and Statistics Facts and Statistics  College Students College Students – 70% Report Some Dissatisfaction 70% Report Some Dissatisfaction – 28% Meet Diagnostic Criteria 28% Meet Diagnostic Criteria  Many Consult Plastic Surgeons Many Consult Plastic Surgeons  Males = Females Males = Females  Onset Late Adolescence Onset Late Adolescence  Facts and Statistics Facts and Statistics  College Students College Students – 70% Report Some Dissatisfaction 70% Report Some Dissatisfaction – 28% Meet Diagnostic Criteria 28% Meet Diagnostic Criteria  Many Consult Plastic Surgeons Many Consult Plastic Surgeons  Males = Females Males = Females  Onset Late Adolescence Onset Late Adolescence

 The Plastic Surgery Solution? The Plastic Surgery Solution?  Quite Popular but Expensive Quite Popular but Expensive  Most are Disappointed With Results Most are Disappointed With Results  The Plastic Surgery Solution? The Plastic Surgery Solution?  Quite Popular but Expensive Quite Popular but Expensive  Most are Disappointed With Results Most are Disappointed With Results BEFORE AFTER

 Causes and Treatment Causes and Treatment  Little is Known Little is Known  Co-Occurs With OCD Co-Occurs With OCD – Intrusive Thoughts and Checking Compulsions About Appearance Intrusive Thoughts and Checking Compulsions About Appearance  Exposure + Response Prevention Exposure + Response Prevention  Causes and Treatment Causes and Treatment  Little is Known Little is Known  Co-Occurs With OCD Co-Occurs With OCD – Intrusive Thoughts and Checking Compulsions About Appearance Intrusive Thoughts and Checking Compulsions About Appearance  Exposure + Response Prevention 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 Facts and Statistics  Relatively Rare (< 1% prevalence) Relatively Rare (< 1% prevalence)  Females > Males Females > Males  Onset Around Adolescence Onset Around Adolescence  Facts and Statistics Facts and Statistics  Relatively Rare (< 1% prevalence) Relatively Rare (< 1% prevalence)  Females > Males Females > Males  Onset Around Adolescence 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 males; chronic condition Ch 7.3

 Causes Causes  Family Link Family Link  Link to Antisocial Personality Link to Antisocial Personality – Weak Behavioral Inhibition Weak Behavioral Inhibition – Strong Behavioral Activation Strong Behavioral Activation – Short Term Gain (attention & sympathy) Short Term Gain (attention & sympathy)  Causes Causes  Family Link Family Link  Link to Antisocial Personality Link to Antisocial Personality – Weak Behavioral Inhibition Weak Behavioral Inhibition – Strong Behavioral Activation Strong Behavioral Activation – Short Term Gain (attention & sympathy) Short Term Gain (attention & sympathy)

 Clinical Description Clinical Description  Pain is Real Pain is Real  Pain May Have Organic Cause Pain May Have Organic Cause  Psychological Factors Maintain Pain Psychological Factors Maintain Pain  Can be Debilitating Can be Debilitating  Clinical Description Clinical Description  Pain is Real Pain is Real  Pain May Have Organic Cause Pain May Have Organic Cause  Psychological Factors Maintain Pain Psychological Factors Maintain Pain  Can be Debilitating 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

 Depersonalization – Altered Perception of Self  Depersonalization – Altered Perception of Self  Derealization – Altered Perception of World  Derealization – Altered Perception of World  Dissociative Phenomena  Common Experience  Altered consciousness, memory  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.

Normal Dissociation Normal Dissociation Amnesia Fugue Partial DID Partial DID Complex DID Complex DID Poly-Fragmented DID Poly-Fragmented 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  Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder

 Primary Features – Depersonalization – Derealization  Primary Features – Depersonalization – Derealization  Impairs Functioning  Causes Significant Distress  Runs a Chronic Course  Impairs Functioning  Causes Significant Distress  Runs a Chronic Course  Clinical Description

 Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder  Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder

 Clinical Description  Localized or Selective – Failure to Recall Specific Events  Localized or Selective – Failure to Recall Specific Events  Several Patterns  Generalized – Unable to Remember Anything  Several Patterns  Generalized – Unable to Remember Anything

 Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder  Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder

 Clinical Description  Go to Another Location – Unaware “How They Arrived”  Go to Another Location – Unaware “How They Arrived”  Memory Loss – Specific Incident  Memory Loss – Specific Incident  May Assume New Identity  Fugue Usually Ends Abruptly

 Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder  Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder

 Clinical Description  Differ Across Cultures – Sudden Changes in Personality – Possession by Spirits  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  Depersonalization Disorder  Dissociative Amnesia  Dissociative Fugue  Dissociative Trance Disorder  Dissociative Identity Disorder

 Clinical Description  Formally – Multiple Personality Disorder  Formally – Multiple Personality Disorder  Person’s Identity is Dissociated  May Adopt 100 Identities – “Alters” – The Nature of Alters  May Adopt 100 Identities – “Alters” – The Nature of Alters

 Central Features  Host Identity – One Who Asks for Treatment – Attempt to Hold Alters Together  Host Identity – One Who Asks for Treatment – Attempt to Hold Alters Together  A Switch – Abrupt Change in Personalities – Usually Instantaneous  A Switch – Abrupt Change in Personalities – Usually Instantaneous

 Facts and Statistics  Average Number of Alters? – 15  Average Number of Alters? – 15  Females > Males (9:1)  Onset in Childhood – Linked to Extreme Abuse  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  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”  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?  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)  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 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  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