Chapter 7 Somatoform and Dissociative Disorders

1. Chapter 7 Somatoform and Dissociative Disorders Ch 7

2. 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.

3. 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

4. The Nature of Somatoform Disorders • Common Features • Lots of Physical Complaints • Appear to be Medical Conditions • No Identifiable Medical Cause • Pathological Concern About • Physical Appearance • Functioning of Their Bodies

5. Somatoform Disorders: Hypochondriasis • Clinical Description • Ancient Roots • Physical Complaints • No Known Medical Cause • Severe Anxiety / Fear About Possibly Having a Serious Disease • Reassurance Doesn’t Help

6. Somatoform Disorders: Hypochondriasis • Clinical Description • Essential Problem is Anxiety • Preoccupied With Bodily Symptoms • Misinterpretation of Symptoms • Strong Disease Conviction • Many Medical Visits and Tests

7. Somatoform Disorders: Hypochondriasis Why not Classify Such Persons With an Illness Phobia?

8. Somatoform Disorders: Hypochondriasis • Facts and Statistics • 1% to 14% Medical Patients • Equal Rates (Males vs. Females) • May Occur Any Time • Strong Disease Conviction • Many Medical Visits and Tests

9. Somatoform Disorders: Hypochondriasis • Causes • Disorder of Cognition / Perception • More Disease in Family • More Illness Concern in Family • More Attention for Sick Behavior

10. Somatoform Disorders: Hypochondriasis • Psychological Treatment • Modify Illness Perceptions • Evoke Bodily Sensations • Provide “Appropriate” Reassurance • More Research is Needed!

11. Somatoform Disorders: Body Dysmorphic Disorder • Clinical Description • Preoccupation With Appearance • Imagined Defect • “Imagined” Ugliness • Mirrors (Fixation or Avoidance) • Ideas of Reference • Suicidal Ideation and Tendencies

12. Somatoform Disorders: Body Dysmorphic Disorder • Common Locations of Defects • Hair • Nose • Skin • Eyes • Head / Face • Lips

13. Somatoform Disorders: Body Dysmorphic Disorder • Facts and Statistics • College Students • 70% Report Some Dissatisfaction • 28% Meet Diagnostic Criteria • Many Consult Plastic Surgeons • Males = Females • Onset Late Adolescence

14. Somatoform Disorders: Body Dysmorphic Disorder • The Plastic Surgery Solution? • Quite Popular but Expensive • Most are Disappointed With Results BEFORE AFTER

15. Somatoform Disorders: Body Dysmorphic Disorder • Causes and Treatment • Little is Known • Co-Occurs With OCD • Intrusive Thoughts and Checking Compulsions About Appearance • Exposure + Response Prevention

16. 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

17. Somatoform Disorders: Conversion Disorder • Facts and Statistics • Relatively Rare (< 1% prevalence) • Females > Males • Onset Around Adolescence

18. 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 < 0.5%; females > males; chronic condition Ch 7.3

19. Somatoform Disorders: Somatization Disorder • Causes • Family Link • Link to Antisocial Personality • Weak Behavioral Inhibition • Strong Behavioral Activation • Short Term Gain (attention & sympathy)

20. Somatoform Disorders: Pain Disorder • Clinical Description • Pain is Real • Pain May Have Organic Cause • Psychological Factors Maintain Pain • Can be Debilitating

21. 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

22. 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

23. 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

24. An Overview of Dissociative Disorders • Dissociative Phenomena • Depersonalization • Altered Perception of Self • Derealization • Altered Perception of World • Common Experience • Altered consciousness, memory

25. A Self-Test 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%

26. A Self-Test 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%

27. A Self-Test Some people find that they have no memory for some important events in their lives (e.g. a wedding or graduation). 0%100%

28. A Self-Test Some people have the experience of finding themselves dressed in clothes that they don’t remember putting on. 0% 100%

29. A Self-Test Some people sometimes have the experience of feeling that other people, objects, and the world around them are not real. 0% 100%

30. Dissociation as a Spectrum Disorder Complex DID Fugue Poly-Fragmented DID Normal Dissociation Amnesia Partial DID

31. 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

32. An Overview of Dissociative Disorders • Depersonalization Disorder • Dissociative Amnesia • Dissociative Fugue • Dissociative Trance Disorder • Dissociative Identity Disorder

33. The Nature of Depersonalization Disorder • Clinical Description • Primary Features • Depersonalization • Derealization • Impairs Functioning • Causes Significant Distress • Runs a Chronic Course

34. An Overview of Dissociative Disorders • Depersonalization Disorder • Dissociative Amnesia • Dissociative Fugue • Dissociative Trance Disorder • Dissociative Identity Disorder

35. The Nature of Dissociative Amnesia • Clinical Description • Several Patterns • Generalized • Unable to Remember Anything • Localized or Selective • Failure to Recall Specific Events

36. An Overview of Dissociative Disorders • Depersonalization Disorder • Dissociative Amnesia • Dissociative Fugue • Dissociative Trance Disorder • Dissociative Identity Disorder

37. The Nature of Dissociative Fugue • Clinical Description • Memory Loss • Specific Incident • Go to Another Location • Unaware “How They Arrived” • May Assume New Identity • Fugue Usually Ends Abruptly

38. An Overview of Dissociative Disorders • Depersonalization Disorder • Dissociative Amnesia • Dissociative Fugue • Dissociative Trance Disorder • Dissociative Identity Disorder

39. The Nature of Dissociative Trance Disorder • Clinical Description • Differ Across Cultures • Sudden Changes in Personality • Possession by Spirits • Females > Males • Often Related to Trauma

40. An Overview of Dissociative Disorders • Depersonalization Disorder • Dissociative Amnesia • Dissociative Fugue • Dissociative Trance Disorder • Dissociative Identity Disorder

41. The Nature of Dissociative Identity Disorder • Clinical Description • Formally • Multiple Personality Disorder • May Adopt 100 Identities • “Alters” • The Nature of Alters • Person’s Identity is Dissociated

42. The Nature of Dissociative Identity Disorder • Central Features • Host Identity • One Who Asks for Treatment • Attempt to Hold Alters Together • A Switch • Abrupt Change in Personalities • Usually Instantaneous

43. The Nature of Dissociative Identity Disorder • Facts and Statistics • Average Number of Alters? • 15 • Females > Males (9:1) • Onset in Childhood • Linked to Extreme Abuse • Runs a Chronic Course

44. The Nature of Dissociative Identity Disorder • Causes • 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”

45. The Nature of Dissociative Identity Disorder • Other Related Features • Suggestibility, Role Playing • Spanos et al. (1994) experiment, • Hypnotizability • Similar to Dissociation • Are these related to DID? • ?

46. The Nature of Dissociative Identity Disorder • 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) • Consequences of the Debate?

47. Treatment of Dissociative Disorders • Treatment: Psychoanalysis Relevant • 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

48. Diagnostic Considerations in Somatoformand 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