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

2. 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

3. 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.

5. 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

6. 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

7. 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’

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Dissociative Disorders

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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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