abnormal PSYCHOLOGY Fourth Canadian Edition Chapter 7 Somatoform and Dissociative Disorders Prepared by: Tracy Vaillancourt, Ph.D. Modified by: Réjeanne Dupuis, M.A.

Definitions Somatoform disorders— individual complains of bodily symptoms that suggest a physical defect or dysfunction but for which no physiological basis can be found; Psychological problems take a physical form Dissociative disorders— individual experiences disruptions of consciousness, memory, and identity Onset of both classes of disorders assumed to be related to stressful experience Two classes sometimes co-occur

Summary: Table 7.1 Disorder Description Pain disorder Psychological factors play a significant role in the onset and maintenance of pain. Body dysmorphic disorder Preoccupation with imagined or exaggerated defects in physical appearance. Hypochondriasis Preoccupation with fears of having a serious illness. Conversion Disorder Sensory or motor symptoms without any physiological cause. Somatization Recurrent, multiple physical complaints that have no biological basis.

Pain Disorder Person experiences pain that causes significant distress and impairment Psychological factors are viewed as playing an important role in the onset, maintenance, and severity of the pain In women diagnosed with pain disorder (compared to healthy women), fMRI showed significant grey-matter decreases in prefrontal, cingulated, and insular cortex, regions of the brain, which are critically involved in the modulation of subjective pain

Body Dysmorphic Disorder Person is preoccupied with an imagined or exaggerated defect in appearance, frequently in the face Examples: facial wrinkles, excess facial hair, or the shape or size of the nose. Women tend to focus on the skin, hips, breasts, and legs Men tend to focus on height, penis size, and body hair Occurs mostly among women Typically begins in late adolescence Comorbid with depression, social phobia, eating disorders, thoughts of suicide, substance use, and personality disorders

Hypochondriasis Individuals are preoccupied with persistent fears of having a serious disease, despite medical reassurance to the contrary Typically begins in early adulthood and has a chronic course. Comorbid with mood or anxiety disorders Prevalence rate is 5% of the general population The term ‘hypochondriasis’ has become pejorative and tends to be called ‘health anxiety disorder’

Hypochondriasis (cont.) Theory Hypochondriacs overreact to and misinterpret ordinary physical sensations and minor abnormalities and see these as evidence for their beliefs Contemporary researchers focus on ‘health anxiety’ and not hypochondriasis

Health Anxiety Health anxiety has been defined as “health-related fears and beliefs, based on interpretations, or perhaps more often, misinterpretations, of bodily signs and symptoms as being indicative of serious illness” (Asmundson, Taylor, Sevgur, & Cox, 2001, p. 4) Often measured with the Illness Anxiety Scale (IAS), which contains 4 factors Health Anxiety could be present in both hypochondriasis and an illness phobia Hypochondriasis = fear of having an illness Illness phobia = fear of contracting an illness

Salkovskis and Warwick (2001) Health Anxiety Model A critical precipitating incident A previous experience of illness and related medical factors The presence of inflexible or negative cognitive assumptions The severity of anxiety

Conversion Disorder Physically healthy people experience sensory or motor symptoms suggesting an illness related to neurological damage of some sort, although the body organs and nervous system are found to be fine. Examples: Sudden loss of vision Paralysis of arms or legs Seizures and coordination disturbances Sensation of prickling, tingling, or creeping on the skin Insensitivity to pain Anesthesias (loss or impairment of sensations) Aphonia (loss of the voice and all but whispered speech) Anosmia (loss or impairment of the sense of smell) Tends to appear suddenly in stressful situations

Hysteria Term originally used to describe what are now known as conversion disorders

Malingering and Factitious Disorder Conversion disorder is difficult to distinguish from malingering Faking an incapacity in order to avoid a responsibility Conversion reactions or malingering? La belle indifférence can help differentiate the two Characterized by a relative lack of concern or a blasé attitude toward the symptoms Found with conversion disorder

Somatization Disorder Recurrent, multiple somatic complaints, with no apparent physical cause, for which medical attention is sought Prevalence is less than 1% Symptoms are more pervasive than in hypochondriasis and usually cause impairment Considerable overlap with conversion disorder Comorbid with anxiety and mood disorders, substance abuse, & several personality disorders Specific symptoms may vary across cultures

Etiology of Somatoform Disorders Somatization Disorder More sensitive to physical sensations, over-attend to them, or interpret them catastrophically May have a memory bias for information that connotes physical threat Unrealistic anxiety about bodily systems Patients with somatization disorder have high levels of cortisol

Theories of Conversion Disorders Psychoanalytic Theory Freud: Unresolved Electra Complex Psychodynamic: 2-stage defensive reaction Behavioural Theory and Cognitive Factors Similar to malingering in that the person adopts the symptom to secure some end Social and Cultural Factors  in the incidence of conversion disorder over the last century Conversion disorder is  among people with lower socio-economic status and from rural areas

Theories (cont.) Biological Factors in Conversion Disorder Evidence is weak May be some relationship between brain structure and conversion disorder Conversion symptoms are more likely to occur on the left side than on the right side of the body Biopsychosocial Model Takes into account triggering, perpetuating, and risk factors

Therapies for Somatoform Disorders Little controlled research on treatment because somatoform disorders are rarer than other disorders Although they so tend to seek more medical treatment than people with other disorders Comorbid with anxiety and depression See treatment sections for these disorders Cognitive-behavioural approaches

Dissociative Disorders

Dissociative Amnesia Person unable to recall important personal information, usually after some stressful episode. Information not permanently lost, but cannot be retrieved during the episode of amnesia Most often memory loss involves all events during a limited period of time Total amnesia Patient does not recognize relatives and friends, but retains the ability to talk, read, and reason Retains talents and previously acquired knowledge Amnesic episode may last several hours or as long as several years. Usually disappears as suddenly as onset

Dissociative Fugue Memory loss more extensive in dissociative fugue than in dissociative amnesia. Person becomes totally amnesic and suddenly leaves home and work and assumes a new identity. Fugues typically occur after a person has experienced some severe stress

Depersonalization Disorder Person’s perception or experience of the self is disconcertingly and disruptively altered Unusual sensory experiences Impression that they are outside their bodies May feel mechanical Typically triggered by stress Usually begins in adolescence and has a chronic course Comorbid with personality disorders, anxiety disorders, and depression Note. Inclusion in DSM-IV-TR is controversial because unlike other dissociative disorders it does not involves disturbance of memory

Dissociative Identity Disorder (DID) Diagnosis requires that a person have at least two separate ego states (called alters) that exist independently of each other and that come forth and are in control at different times Usually one primary personality and two to four alters at time of diagnosis Treatment sought by the primary alter Gaps in memory occur in all cases Existence of alters must be long-lasting and cause considerable disruption in one’s life Often accompanied by headaches, substance abuse, phobias, hallucinations, suicide attempts, sexual dysfunction, and self-abusive behaviour and other dissociative symptoms such as amnesia and depersonalization

DID (cont.) Presumably begins in childhood, but rarely diagnosed until adulthood More common in women than in men Comorbid with depression, borderline personality disorder, and somatization disorder In one study 90% had a history of suicidal tendencies, depression, recurring headaches, and sexual abuse Another study is suspecting poor attachment due to exposure of frightening or chaotic behaviour from caregiver Diagnosis of DID is a very controversial

Etiology of DID Etiology of DID Psychoanalytic & behavioural perspectives: Dissociation as an avoidance response that protects the person from stressful events and memories of these events 2 major theories Result of severe physical or sexual abuse Enactment of learned social roles Therapies Psychoanalytic treatment See treatment for PTSD

Treatments of Dissociative Disorders Psychoanalytic Treatment Goal: to lift repression of traumatic events Treatments for PTSD applied to dissociative disorders Treatment of DID Hypnosis used for ‘age regression’ Goal: integration of the several personalities

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