5

92 Schizophrenic, Paranoid, and Affective Disorders

function producing an abnormal amount of body chemicals. The morpho-

logical school considers the disorder to originate from personalities
doomed to live in a fat body.
Environmental theories of affective disorders involve a number of po-
sitions. The psychoanalysts' theory is similar to their theory of schizophre-
nia in that fixation at the oral stage is believed to lay the foundation for
depressive reactions later in life. But the nature of the fixation varies in the
Anxiety, Somatoform,
two disorders. The depressive's fixation results in a sense of dependency on
others that is normal for infants but pathological for adults. This orienta- and Dissociative Disorders
tion toward dependency, coupled with the loss of an important love object
later, engenders a depressive reaction. The cognitive school holds that de-
pressives are individuals who commit logical errors which force them to
conclude that they are worthless people. The behaviorist school contends
that depression is a reaction to a loss of rewarding reinforcements. Thus
this proposition is not inconsistent with psychoanalytic theory since both
consider a loss to be etiologically essential. There is also a family-related
theory of depression. According to this view, depressives are those who had
unrealisitc expectations placed on them by their parents. Often this re-
sulted from an excessive concern with status attainment by parents who
failed to achieve their aspirations and placed the burden of the accomplish-
ment on one of their children instead.

THE MEANING OF NEUROTIC DISORDER

The mental disorders presented in this chapter have traditionally been

known as the neuroses. It was mentioned in chapter 2 that the term "neu-
rosis" no longer appears in the official nomenclatu re since the APA felt
that there was no consensus as to how to define it. Today, the term "neu-
rotic disorder" is used instead. It refers to problems "... in which the pre-
dominant disturbance is a symptom or group of symptoms that is distress-
ing to the individual and is recognized by him or her as unacceptable and
a~ien (ego-dystonic); reality testing is grossly intact; behavior does not actively
vIOlate gross social norms (although functioning may be markedly im-
paired); the disturbance is relatively enduring or recurrent without treat-
ment and is not limited to a transitory reaction to stressors; and there is no
demonstrable organic etiology or factor." , Here we will deal with the three
~c:Uor forms of neurotic disorders: anxiety, somatoform, and dissociative
disorders. Neurotic disorders are also included in affective (see chapter 4)
and psychosexual disorders (see chapter 7).
The mc:U0rsymptom of the neurotic disorders is an intense experi-
ence of anxiety, a feeling of subjective distress. Anxiety is similar to fear,

,. 'American Psychiatric Association, Diagnostir and Stat~ftiral Manual of Mental Disordp

(7h!rd Edition). (Washington, D. c.: American Psychiatric Association, 1980), pp. 9-10
94 Anxiety, Somat%rm, and Dissociative Disorders
both subjectively and in objective terms of physiological disturbance. Fear,
however, is an appropriate reaction to a real danger whereas anxiety is not
related to a real, external threat or is grossly disproportionate to any such
threat. In essence, anxiety warns of an internal danger caused by an
intrapsychic conAict. Anxiety is considered to be a normal correlate of
aging and experiencing new and untried things. Children often experience
anxiety on their first day in school as do old people contemplating impend-
ing death. Pathological anxiety, on the other hand, is a response which is
inappropriate to a given situation. For example, almost anyone would ex-
perience unpleasant feelings in the presence of a man-eating beast, but
some people with neurotic disorders would be similarly upset by a docile
dog. This self-created terror is known as pure anxiety or free-floating anxiety
when it is severe, persistent, and experienced directly without the use of a
defense mechanism. A defense mechanism is a device unconsciously em-
ployed to avoid danger, anxiety, and displeasure. If a defense mechanism
is involved, the type of defense mechanism largely determines the form of
the neurotic disorder.
A number of physiological alterations have been found to correlate
with the onset of neurotic disorders. Among these are trembling, increased
heart rate, dry mouth, nausea, gooseflesh, hot and cold sensations, dizzi-
ness and faintness, urinary urgency, fatigue, muscular tension, restlessness,
insomnia, and sexual dysfunction.
Psychological symptoms are even more varied. Most of these people
are chronically unhappy. Other common features are indecisiveness, feel-
ings of inadequacy, hostility, guilt, hypersensitivity, rigidity, shyness, exces-
sive concerns with physical health, and self-centeredness. Some have
difficulties at work which are generally related to a fear of being rejected or
humiliated. The central psychological symptom of anxiety is defensiveness.
Because of a wide array of defense mechanisms employed, these disorders
can take a variety of seemingly unrelated forms.
THE PREVALENCE OF NEUROTIC DISORDERS
Neurotic disorders are so common that many people confuse them with
eccentric behavior. Books on the topic are frequently purchased as popular
reading. Questions such as how to detect such a problem, avoid it, as well as
live with it, rival issues of international news, sports and entertainment.
Undoubtedly, these problems are very much a part of our everyday world.
Some of the psychiatric literature (psychoanalytic) suggests that sup-
pression of instinctual drives can engender anxiety. For this reason, the re-
lationship between civilization and neurotic disorder is fundamental; the
higher the level of cultural development, the more complete is the suppres-
sion of the instincts, particularly the sex drive.t Simply stated, these prob-
"This thesis, originally developed by Freud, is also the essence of other psychoanalytic
views as well. See, for example, Karen Horney, "Culture and neurosis," American Sociotogical
Review, I (1936), p. 221-230.
Anxiety, Somat%rm, and Dissociative Disorders 95
!ems may be the price people pay for cultural advancement. Hence the
neurotic disorders are reportedly not common in primitive societies which
allow for the expression of innate human needs." In primitive society a per-
son is not likely to be subjected to radically different behavior standards as
a child than as an adult. In civilized society, however, as an individual pas-
ses from one age group to another, permissible behaviors become forbid-
den and vice versa. The United States epitomizes such cultural discontinu-
ity in development. During the twentieth century, immeasurable
complexities have been added to the American cultural base. Many of these
additions have come in the form of material culture, such as advances in
science and technology. But these advancements have had covert impacts
on interpersonal relationships by introducing competition and tension to
the impersonality of urban living. This growth in cultural complexity has
been accompanied by a reported increase in the prevalence of neurotic dis-
order.'
The true prevalence of these disorders is presently beyond statistical
calculation, in part because different psychiatrists use different diagnostic
standards and also because different types of methods are used to collect
data. For these reasons, some psychiatrists avoid the issue by saying that
everyone has "neurotic potential" and will display such behavior under
stress. More conservative opinions, however, indicate that no more than 5
to 25 percent of the population suffer these symptoms. People with neu-
rotic disorders comprise about 30 to 40 percent of patients who seek med-
ical help from general hospitals or private physicians although most of
their physical complaints are psychologically imposed.' These people do
not often require hospitalization, but if they are hospitalized, they are usu-
ally found in private rather than state hospitals. This is because higher-class
patients can afford better treatment than lower-class patients who fre-
quently· receive no treatment at all unless they are severely disordered,
something which only occurs in certain types of neurotic disorders.
Culture influences the prevalence of neurotic disorder beyond the
primitive-civilized differences noted above. Using anxiety as an indicator of
these problems, Lynn reports a number of cross-cultural differences
among civilized societies.6 France, Austria, West Germany, and Italy are re-
ported as high anxiety countries while Sweden, the Netherlands, and Great
Britain score low on Lynn's anxiety measures. This lends support to the
commonly accepted stereotype of the unemotional, phlegmatic Anglo-
Saxon, the excitable French, and the volatile Italian. Lynn constructs an in-
teresting hypothesis to account for these differences by suggesting that cli-
mate has an effect on anxiety. He points out that the high anxiety countries
have warmer climates and more frequent storms, both of which have a psy-
chologically unsettling effect on people.
171. 'Robert Bastide, The Sociology of Mental Di\IJrder (New York: David McKay, 1972), p.
'L c. Kolb, Modem Clinical P,ychiatry, (Philadelphia: W. B. Saunders, 1982).
''L C. Kolb, Modern Clinicat P,ychiatry.
hR. Lynn, Personality and Nati01ud Character (Oxf()rd: Pergamon Press, 1971).
96 Anxiety, Somat%rm, and Dissociative Disorders 97
Anxiety, Somat%rm, and Dissociative Disorders

PHOBIC DISORDERS
THE ONSET OF NEUROTIC DISORDERS

Symptoms
Although the onset of some of these disorders may be abrupt, the
psychopathological process which culminates in symptoms has a long his- Phobias-irrational fears-appear more frequently as a psychiatric
tory. In fact, evidence of psychological difficulties is frequently found in complaint than as a distinct syndrome. In fact some psychiatrists feel that
the childhood histories of people with neu rotic disorders. These include all psychiatric patients have phobias. This may be true, but studies of the
feeding problems in early infancy, diffIculties in toilet-training, night- prevalence of phobias in the general population suggest that a much more
mares, temper tantrums, bed-wetting (enuresis) persisting until age eight or conservative conclusion is warranted. One study in New England estimated
beyond, and thumb sucking or nail biting persisting into adolescence.? The that phobias are found in 77 people per 1000 members of the population.'o
onset is usually precipitated by a stressful event. A number of such events Most of these were mild phobias; only 2.2 per 1000 were rated as severely
are presented in Chapter 12. Most of these involve some type of change disabling. Many people have an irrational fear when they come in contact
which the individual perceives as threatening, such as pregnancy, divorce, with something harmless, like in insect, but it does not have a serious im-
or even an outstanding personal achievement. Whether a particular event pact on their lives. The diagnosis of phobic disorder is only warranted if
produces stress depends on a number of variables including how the per- the fear is a significant source of distress.
son interprets the event as well as his coping mechanisms. Individuals pre- Although people with phobias have an intense fear of some object or
disposed toward neurotic disorders are likely to interpret everyday events situation, they consciously recognize that their fear is irrational because no
in threatening ways. These events may be viewed by most people as inher- real danger is posed. They often say that they know what it is about the
ently neutral or necessary for personal growth, but to others they have be- phobic object that arouses anxiety, yet they engage in ritualized ways to
come highly charged merely by conditioning through a series of encoun- avoid contact with it. As long as they avoid the phobic object, no anxiety is
ters or because they threaten the personality with meanings hidden in the suffered. Phobias often involve useful secondary gains. For example, a fear
unconscious. Neurotic disorders occur only rarely among children, but of trains in a traveling salesman may allow him to avoid work.
when they do, they are typically preceded by stressful events within one A phobia should not be confused with a natural aversion. Many people
month of the onset." Events commonly precipitating a childhood form in- feel uncomfortable in the presence of a vicious dog but a phobic person
clude mild physical illness, change of school, reprimand for school per- may become extremely frightened around a timid dog. A phobia is also not
formance, birth of a younger sibling, and separation or impending separa- an avoidance r-eaction, which is a conditioned response whereby certain ob-
tion of a near relative." Clearly, change-particularly change in jects or environments are avoided because of some previous unpleasant ex-
interpersonal relationships-is the central aspect of precipitating events in perience with them.
childhood problems as it is in adult disorders. Phobias provide some definite advantages over other types of anxiety
disorders. Since no anxiety is experienced when the phobic object is absent,
the escape from anxiety is organized and controlled rather than diffused to
ANXIETY DISORDERS a constant threat of catastrophe. The phobic may experience somatic symp-
toms such as faintness, nausea, hyperventilation, and tremor. But since
As the term indicates, these disorders involve conditions in which anxiety is these symptoms are localized to the phobic object, this type of neurotic can
the predominant symptom. There are three forms which are presented m.ore easily engage in everyday activities without constant harassment from
here: phobic disorders, generalized anxiety disorder, and obsessive-compulswe dis- Within.
order. Other forms include panic disorder (unpredictable anxiety attacks) and Phobias with panic attacks are another story, however. Symptoms
post-traumatic stress disorder (symptoms following a psychologically traumatic such as palpitations, chest pains, excessive sweating, dizziness, hot or cold
event). Because the psychoanalytic theory involves more detail than other 0ashes, diarrhea, and fears of going crazy or vomiting in public, may strike
views, there is more space devoted to it throughout. This should not be In the form of an overwhelming episode. Panic attacks are most common
taken to mean that the psychoanalytic view is more valid than other vieWS, among phobics who have a fear of being outside the home (agorajJhobics).
but simply that is involves more specifications. Some phobias are known to spread. If, for example, a person is terri-
bly afraid of large groups of people, this fear may gradually extend to
'Menill T. Eaton, Jr. and Margaret II. Peterson, P.lychiatry (Flushing: Medical Exami- smaller groups to the point where the person feels comfortable only when
nation Publishing Company, (ne. 1969), p. 172. alone. One "contagious" case is reported of a man who became phobic for
"W. H. Lo, "Aetiological factors in childhood neurosis," BritishJounwl IIJ P.\ychiatlY, 115
(1969), pp. 889-894. • 1115. Agras, D. Sylvester, and D. Olvieau, "The epidemiology or common rears and pho-
!lIbid., p. 892. bias," (unpublished manuscript, 1969).
 Anxiety, Somat%rm, and Dissociative Disorders 99
98 Anxiety, Somat%rm, and Dissociative Disorders
TABLE 5:1 Common Phobias
the number thirteen.11 Eventually he stayed in bed on the thirteenth day of
Phobia Fear of Phobia Fear of
each month to avoid contact with calendar and newspaper dates. Then he
began to stay in bed on the twenty-seventh day of each month when he dis- acrophobia high places nyctophobia darkness, night
covered it contained thirteen letters. Eventually he avoided people entirely agoraphobia open places pathophobia disease
for fear that they would greet him with a thirteen letter statement such as aichmophobia sharp objects pecctaophobia sinning
"Good afternoon." ailurophobia cats phonophobia speaking aloud
DSM-Ill divides phobias into three groups: agoraphobia (fear of being algophobia pain photophobia strong light
aquaphobia water pnigophobia choking
alone, outside home, in closed or open spaces or in public places from
astraphobia thunder and lightning pyrophobia fire
which escape might be difficult); sociaijJho!Jia (fear of public speaking, using
claustrophobia closed places sitophobia eating
public lavatories, eating in public, and so forth); sirnjJ/e jJhobia (fear of cynophobia dogs taphophobia being buried alive
specific objects or situations other than those included in agoraphobia and ergasiophobia writing thanatophobia fear of death
social phobia, such as a fear of closed spaces (claustrojJhobia), heights (acro- hematophobia sight of blood toxophobia being poisoned
phobia) and animals or insects). A number of phobic objects and situations lalaphobia speaking xenophobia strangers
are reported in the clinical literature. For the sake of historical interest, Ta- mysophobia dirt and germs zoophobia animals
ble 5: 1 lists some of them along with their traditional labels. Recently, there necrophobia dead bodies
has been a movement away from the use of the Greek prefix. Instead, pho-
bias are described in plain English, such as fear of heights, fear of death,
and so forth. is remarkable about this case is that the person chose college teaching as an
occupation. Vomiting continued to be the normal order of events before
Agoraphobia is the most common or all the phobias. In fact, there are
an estimated three and one hall' million people who suffer from it- each lecture. After many years of hell, the phobia eventually subsided.
One of the most famous cases of phobia occurred in a (lve-year-old
enough people to fill the fourth largest city in the United States. It usually
boy who refused to go into the streets because of a fear of being bitten by
begins in the late teens or early twenties. It is diagnosed most commonly in
housewives (some of whom become hous(J!Jolllul) but it strikes people from horses which pulled the street cars in Vienna of the early 1900s. This is the
all walks of life, including people whose jobs require them to travel long case of Little Hans which was reported by Freud.1I Freud interpreted
distances, such as truck drivers. Apparently, the truck is a safe refuge from Hans's fear of the horse as a displacement of the boy's fear of his father.
the outside world. Hans's fear of his father reportedly originated in castration threats which
are common during the phallic stage. Freud held that the horse came to
Social phobias are reportedly rare. Although the onset is considered
represent his father for a number of reasons; the father had played
to be during adolescence, it is questionable whether it does not often ap- "horsie" with Hans, the horse's bridle reminded Hans of his father's mous-
pear earlier in the form of the all-too-familiar grade school phobia. Wald-
tache, and so on. It was the analysis of this case which helped to develop the
fogel describes the school phobia as " ... a reluctance to go to school be-
cause of acute fear associated with it. Usually this dread is accompanied by psychoanalytic theory of phobic disorders. Of course, it is also quite possi-
ble that Hans had had a frightening experience with horses and therefore
somatic symptoms with the gastrointestinal tract the most commonly af-
fected ... The somatic complaints come to be used as an auxiliary device to was conditioned to avoid them. It would be interesting to know how the
case would have been interpreted had Freud been a behaviorist and not
justify staying at home and often disappear when the child is reassured that been predisposed to look for unconscious f~lctors.
he will not have to attend school. The characteristic picture is of a child
Other famous cases of phobia include Augustus Caesar, the widely
nauseated or complaining of abdominal pain at breakfast and desperately
feared dictator of the Roman Empire, who was afraid to sit in the dark.
resisting all attempts at reassurance, reasoning, or coercion to get him to
K.ing James I of England, who commissioned the modern version of the
school.12 Waldfogel also states that it can last for years. This is important
Bible, feared the sight of an unsheathed sword; his contemporary King
since school phobias may later develop into social phobias in adolescence.
The author knows of a child who experienced a full-blown school phobia. Henry III
of France was afraid of cats. Daredevil Evel Knievel reportedly
has a phobia about planes, while the late Alfred Hitchcock, the master of
During adolescence he suffered anxiety in anticipation of social events,
film terror, admitted to a fear of policemen. Additionally, the late Iloward
particularly dating. The underlying threat emanated from a fear of failure
in front of others. In childhood, vomiting was the typical beginning of a ~ughes suffered from a morbid dread of germs carried by people around
him.
school day. This was also the major somatic symptom in adolescence. What
liT. A. Ross, Till' Cmlll/l0l1 Nellro.II'.1 (Baltimore: Wm. Wood and Co., 1937), pp. 219-223.
"Sigmund Freud, "Analysis of a phobia in a five-year-old boy," in Coller/I'll Pa/Jl'f.I,
12S.Waldfogcl, "Emotional crisis in a child," in Cme Studies in Counseling and Psyclwther- volume 10 (London: Ilogarth Press, 1957) pp. 5-149.
apy, ed. A. Burton (Englewood Cliffs, N.J.: Prentice-Ilall, 1959), pp. 35-36.
100 Anxiety, Somat%rm, and Dissociative Disorders
THE BIOGENIC VIEW OF PHOBIC DISORDERS
There is very little evidence that phobias are caused by biogenic factors.
Few studies have been done to assess the rate of phobias among relatives to
ascertain the effects of genetic inOuences. The fact that phobias may run in
families is not sufficient support for a genetic pespective. There are only
infrequent suggestions in the literature that people who develop patholog-
ical fears may be constitutionally predisposed to do so. Lacey, for instance,
theorized that in such people the autonomic nervouS system is easily
aroused by environmental stress." This hypothesis remains to be tested,
however.
THE ENVIRONMENTAL VIEW OF PHOBIC DISORDERS
Behaviorist Theory
The established theories of phobic disorders are environmental.
However, there is considerable disagreement as to which environmental
theory is most valid. The debate centers around differences between the
psychoanalytic and behaviorist theories. The psychoanalysts consider pho-
bias to have unconscious symbolic signifICance while the behaviorists con-
tend that phobias arise from unpleasant experiences with the phobic object
or situation. The debate is somewhat senseless because the two positions
are really not analyzing the same psychiatric phenomenon. The psychoana-
lysts study true phobias-irrational fears of an object that have no apparent
explanation. The behaviorists, however, concentrate their research on the
origin of strong fears of objects or situations which the person has actually
encountered in some threatening way. Technically, these are not phobias
but avoidance reactions which are quite rational relative to true phobias.
This is not to say that behaviorist theory is less valid than psychoanalytic
theory because the latter has concentrated on the irrational type of fear.
On the contrary, avoidance reactions can be j.ust as debilitating as phobias.
The point is that the behaviorist-psychoanalytic debate exists largely be-
cause the two schools concentrate on different types of psychiatric fears.
According to behaviorists, the etiology of phobias does not involve
any type of intrapsychic conAict or any belief that the phobic object symbol-
izes a more deep-seated fear. This school of thought stresses simple learn-
ing by association which is considered to be the basis for selecting the pho-
bic object. The model holds that phobias develop after a noxiouS
experience with the phobic object or through the process of imitating a
phobic parent.
There have been attempts to test the behaviorist theory of phobias ex-
perimentally. Some of the early experiments were not successful in
"l I. Lacey, "Somatic response patterning and su'ess: Some revisions of activation
theory" in Psychological Stress, eds. M. H. Appley and R. Trumbull (New York: McGraw-Hill,
1967).
Anxiety, Somat%rm, and Dissociative Disorders 101
demonstrating that fear is acquired through conditioning.'" However, a
later experimental study did demonstrate the inAuence of modeling on the
development of fear.'" In this study, subjects watched others experience
pain when a buzzer sounded. Eventually, the observer expressed a negative
emotional response to the sound of the buzzer alone. Of course, it is ques-
tionable whether this experiment actually demonstrated the genesis of a
phobia based on conditioning since it did not analyze an irralional fear but
an avoidance reaction. However, since people with both types of fears seek
psychiatric help, this distinction is largely theoretical, especially in light of
the fact that behaviorists have been very successful in eliminating
debilitating fears through principles of conditioning. Thus, from a practi-
cal perspective, the etiology of these conditions may not be as important as
how to effectively treat them, although it would be very helpful to differen-
tiate between people with avoidance reactions and people with true phobias
and send them to appropriate help sources.
Psychoanalytic Theory
According to psychoanalytic theory, the emotion associated with an
unconscious conAict is displaced on to a phobic object which comes to sym-
bolize the conAict. The anxiety generated by the conAict is substituted for
by fear of a specific object. The specificity of the displaced anxiety on to a
particular object makes the anxiety more manageable; that is, if the person
avoids the object, she also avoids anxiety. Thus, threatening forces from
the unconscious are alleviated by an act of camouOage. The phobia is a
compromise between wishes that are repressed in the unconscious and the
inhibiting forces that repressed the wishes. The person actually both wants
and fears the phobic object at the same time or, more appropriately, wants
that which the object symbolizes. Psychoanalysts contend that a phobic is
not really afraid of the phobic object per se, but is afraid of the wish for
what the object symbolizes. The fear simply prevents the forbidden wish
from being fulfilled. Therefore, the mother who has a phobia that she will
harm her child unconsciously wants to do exactly that. The person who is
irrationally afraid of dirt actually desires to be dirty but finds such anal-
erotic temptations upsetting. Or people who have a phobia about knives
are actually tempted to harm themselves.
At one time, psychoanalysts believed that each type of phobia had a
distinct etiology. Now the psychoanalytic theory of phobias has become less
specific; all phobias are considered to develop in response to conOicts with
unconscious impulses. These are not necessarily just conAicts involving sex-
ual and aggressive impulses but can be any "out of control" impulses such
as drives for power or the need to maintain self-esteem. It is not always
"'See, for example, H. B. English, "Three cases of the 'conditioned fear response,' ..
journal oj Abnormal and Social Psychology, 34 (1929), pp. 221-225; E. L Thorndike, The P.\yclwl-
ogy 0/ Wants, Interests and Attitudes (New York: Appleton, Century, 1935).
II;A. Bandura and T. L Rosenthal, "Vicarious classical conditioning as a function of
arousal level," journal of Personality and Social Psychology, 3 (1966), pp. 54-62.
 102 Anxiety, Somatoform, and Dissociative Disorders
possible to specify the nature of the conflict only by knowing the phobIC
object because personal experience and cultural influences affect the
meanings of symbols. Two people with a morbid fear of cats, for instance,
may suffer different underlying conflicts. To one person the cat may sym-
bolize aggressive behavior and therefore be related to a fear of aggressive
wishes. To another person, the cat may symbolize sexuality and thus repre-
sent the person's fear of sexual desires. Both of these are believed to be
common fears among people who have zoophobias. Animals are feared be-
cause they are sexually uninhibited, unpredictably violent, and openly vio-
late a number of human taboos such as incest and cannibalism.
Although it is impossible to know the origin of the anxiety by knowing
only the phobic object, certain themes reportedly appear frequently among
people with particular phobias. Claustrophobia, for example, is commonly
interpreted by psychoanalysts as a fear of being left alone with one's own
impulses and fantasies. This phobia may originate in the experience of be-
ing locked in one's room as a child. In that situation, the child can ease the
pain of loneliness through masturbation and other forms of erotic play.
Some cases of claustrophobia occur in a confIned space with others, such as
in an elevator. Here, the etiology is considered to be different. People with
elevator phobia are not afraid of physical harm if the elevator falls but feel
threatened by being in close proximity to strangers. They view strangers as
unpredictable and try to avoid confrontations with them but in an elevator
they can not be avoided. This is particularly threatening to people who be-
come anxious in social situations.
Cases of school phobia have common characteristics according to psy-
choanalytic researchers. These children almost always become anxious
when they are separated from their mothers. Some feel this implies a hlUlt
in the mother's relationship with her husband, since a mother in a satisfy-
ing marriage is not likely to have such a symbiotic relationship with her
child.'?
Other phobias have recurring psychoanalytic themes as well. Acro-
phobia, for example, is not a fear of a physical fall but of a social fall and
the loss of self-esteem that accom panies it. Sleep phobias are interpreted
IX
as fears of unconscious wishes that may arise during sleep.'9 The fear of
sleep is therefore a fear of dreams in which repressed material emerges.
Fears of darkness are believed to be the result of witnessing the primal
scene.20 The darkness triggers memories of the conditions in which the
scene was observed. A fear of being away from home is interpreted as a
fear of one's voyeuristic impulses; the person is afraid of seeing something
which is forbidden.21 Stage fright evokes underlying exhibitionistic desires
"Leon Eisenberf{, "School phobia: Diaf{nosis, f{enesis and clinical management," in
Sourcebook in Abnormal P,,)'clwlogy, cds. Leslie Y. Rabkin and .lohn E. Carr (Boston: IloughLOn
:vtifflin, 19(7), p. 429.
"Norman Cameron, Per.lo/lalil)' Df'VI'lop"II'/l1 alld P.I}rlw/mllwlogy: A Developmental
proach (Boston: Iioughton Mifflin, 19(3), p. 2HO.
"'Otto F'enichel, The P.I)'rhofllw.!)'lir Theory of Nf'lIrf!.li.1(New York: W. W. Norton,
p. 190.
~lIlbjd.,p. 206.
"Ibid., p. 72.
Anxiety, Somatoform, and Dissociative Disorders 103
or, in some cases, the feared desire to express hostility openly to others.22
Fears of high places engender feelings of sexual arousal because of their
unconscious connection with an erection.2:1 There are other recurring psy-
choanalytic themes reported in common phobic objects, such as the associa-
tion of snakes with the penis, spiders and cats with the female genitalia, and
rats and mice with children, especially younger siblings.24 Of course, many
of these associations may just be educated speculations.
GENERALIZED ANXIETY DISORDER
Symptoms
This condition is characterized by anxious over-concern extending to
panic which may occur under any circumstances and is not restricted to
specific situations or objects. In this condition, anxiety completely domi-
nates the clinical picture. The anxiety is accompanied by a variety of so-
matic difficulties such as f~ltigue, insomnia, tremor, diarrhea, headache,
dizziness, choking sensations. nausea, appetite disturbances, heart irregu-
larities, sexual diffIculties, back pain, and a desire to urinate. As anxiety
increases, somatic discharge accelerates. Where one symptom occurs alone,
the condition is designated abortive anxiety. These people also display emo-
tional disturbances such as irritability, expectant anxiety, a sense of weak-
ness, a fear of impending death, and an inability to relax. Between periodic
attacks, the individual may be comfortable but more often there is some
degree of tension. DSM-III groups the symptoms into four categories (I)
motor lension (shakiness, muscle aches, and the like); (2) autonomic
hypemctivily (sweating, dry mouth, and so forth); (3) apprehl'1lsive expectalion
(such as anticipating that something bad will happen); (4) vigilance and
scanning, (including being "on edge" and insomnia).
Some (particularly psychoanalysts) believe the symptoms represent
the person's attempts to eliminate anxiety by directly discharging it on to
the body. In this sense, the reaction is adaptive because it aets as a safety
valve, but it is a very costly form of adaptation. To suffer frolll this problem
is to be constantly on guard against an unknown danger. Since these people
do not recognize the linkages between their psychological distress and their
bodily symptoms, they begin to doubt the soundness of their body. They
often attribute their symptoms to a true organic illness and are, for exam-
ple, very susceptible to suggestions of hidden illness made during public
health cam paigns. 2:,
Anxiety is a basic component of all neurotic disorders. iiowever, in
this form, no defense mechanisms are employed to ward it ofT. Rather, the
anxiety
below: is experienced in a "free-floating" form as illustrated in the case
Ap-
1945), 2'Merrill T. Eaton,.l1'. and Margaret II. Peterson, PI)'rhiall)'. p. 16:1.
"Ibid., p. 163.
"Ibid., p. 16:~.
'-'Norman Cameron, Pl'I:\{)1!alily Developmenl and P.,.\'rlw/Hllho/g)'. p. 252.
 Anxiety, Somat%rm, and Dissociative Disorders 105
104 Anxiety, Somat%rm, and Dissociative Disorders

Walter A., an American oil geologist, aged thirty-two, who had been living
abroad for many years, came 1'01' diagnosis because of symptoms which he
feared might mean that he was going insane. For five or six years he had been
having attacks of dizziness, blurred vision, weakness, and unsteady gait. For
three years he had been suffering [rom constant "nervous tension," irritabil-
ity, fatigue, increased sex pace with incomplete satisfaction, inability to relax,
poor sleep, and [requentnightmares. For a year his restlessness had grown so
marked that he could scarcely stand still, sit or lie still ...
Soon he began having frequent anxiety attacks. The first came on suddenly
while he was dressing to go out 1'01' the evening. Something seemed to snap in
his head, everything looked unnatural, and he felt he was fainting. He lay
down for a long time, his heart pounding, his breathing labored, and with the
recurring thought, ''['m dying, I'm dying." Other attacks came later. They
consisted 01' "queer head sensations," weakness, sweating, coarse tremor, pal-
pitation and a conviction that something terrible was happening to him."1i
THE BIOGENIC VIEW OF GENERALIZED
ANXIETY DISORDER
duce neurotic anxiety in some instances. The inference is that the frontal
lobes maintain anxiety since rendering them inactive reduces anxiety. Re-
search involving surgical alteration of the brain has rarely been attempted
since the 1950s because the dangerous side effects of such surgery often
outweigh any benefits. It is important to note, however, that even if the
frontal lobes are involved in anxiety, it is probably because they simply pro-
vide the biological vehicle for anxiety not because they actually cause the
anxiety. In support of this thesis, there is no evidence that the frontal lobes
of people with neurotic disorders are qualitatively different from those of
normal persons. All that can be said is that feelings are altered when the
lobes are severed. This would likely be the outcome if normal people were
sul~jected to the same surgery.
There is also a biochemical theory of generalized anxiety which hy-
pothesizes that this type of person lives in a body which overproduces epi-
nephrine."1 This chemical is known to cause an overactivity of the central
nervous system which in turn may cause the variety of somatic symptoms
described earlier.

THE ENVIRONMENTAL VIEW OF GENERALIZED

Several biogenic theories of this problem have been advanced, including a
ANXIETY DISORDER
genetic explanation. At least one empirical study has shown that the
intrafamilial pattern is consistent with a theory of genetic transmission.
Slater and Shields compared seventeen pairs of monozygotic twins in which Behaviorist Theory
one twin had been diagnosed as having this disorder with twenty-eight The environmental theories of this disorder hinge on a contention be-
pairs of dizygotic twins in which a co-twin was so diagnosecl.~7 Concordance tween behaviorist and psychoanalytic theories. The behaviorist theory
occurred in forty-nine percent of the monozygotic twin sets and in only holds that this kind of anxiety is developed through imitation; that is, anx-
four percent of the dizygotic twin sets. Ilowever, the study did not control ious parents raise anxious children. Thus the parents provide concrete role
for the effect of being raised by the same parents. A similar, more recent models of anxiety and the child reflects the parents' insecurity by
study found significant concordance among male monozygotics but not for internalizing their anxious behavior. Cameron, for instance, reports the
female.~K Another study of schizophrenic adoptees and their relatives un- case of a woman who reacted to life situations in exactly the same anxious
covered no relationship between schizophrenia (a condition which is fre- ways her mother did.11
quently linked to heredity) and generalized anxiety.~" The behaviorist, Wolpe, holds that the cause of generalized anxiety is
On a more specific biogenic level, some believe that the major etiolog- related to the external environment.:I~ According to Wolpe, anxiety is a con-
ical factor is an inherited unstable autonomic nervous system that is ex- ditioned response to external stimuli. Thus, the person who is fearful of
pressed in emotional overresponsiveness. Others consider this kind of anx- work and reacts with vomiting while being transported to work does so be-
iety to be related to the level of neural activity of the frontal lobes of the cause the anxiety attack is a conditioned response to the experience of be-
brain, the center of the sympathetic nervous system. This has been demon- ing transported to a threatening environment.
strated in a number of ways including the use of the surgical procedure
known as prefrontal leucotomy. The operation has been reported to re- Psychoanalytic Theory

~IiFrom Penol/alily D('velujJIIII'1/1and IJ.lyr!to/){Illwlogy by Norman Camcron. Copyright © Psychoanalysts consider the origin of generalized anxiety to be a dis-
1963 by Norman Cameron. Reprinted by pcrmission of IloughlOn Mifllin Company, p. 253. turbance in the parent-child relationship. This disturbance is most pro-
~7E. Slater and.J. Shiclds, "Gcnetic aspects of anxiety," in SIt/die.1 (1Anxiely, ed. M. H. nounced when the parent produces a child who has an excessive and dis-
Lader (Ashford, England: lleadley Brothers, 19(9).
'"Svenn Torgersen, "(;enetics of ncurosis: the elTecls of sampling variation upon the :I"Alfred M. Freedman and others, Modem S)'uuP.<i.\0/ CUIII/m,III'lI.IiveTexlbooil o/P.\)'r"illl,)'
twin concordance ratio," Bri/ish/ouf/wl oj P.lyc!tiol')', 142 (1983), pp. 126-132. (~altimore: Williams and Wilkins Co., 1985).
~"Kenneth S. Kemller, Alan M. Gruenberg and John S. Strauss, "An independent anal- '''NOl'nlan Cameron, Personality Develupmenl and P.lyclwtlwmjlY, p. 268.
ysis of the Copenhagen sample of the Danish adoption study of schizophrenia: I. the relation- "Joseph Wolpe, P.lyclwthempy by Reciprocal Inhibiliou (Stanford, California: Stanford
ship betwen anxiety disorder and schizophrenia," Arc!tivl'.1 oj General P.lyc!tiatry, 38 (1981), pp. University Press, 1958)
973-977.
 Anxiety, Somat%rm, and Dissociative Disorders 107
106 Anxiety, Somat%rm, and Dissociative Disorders
but they are aggravating rituals to the person since they must be completed
t{)fted superego. This child later becomes frightened of his own sexual or to avoid anxiety. Therefore, although obsessive-compulsives may not want
aggressive impulses due to a pathological fear of punishment. The stage is to act upon their urges and even feel a need to resist them, they have to act
set for an anxiety attack when a situation arises in which anger or sexual or suffer w~rse consequences.
demands become threateningly intense. Some psychoanalysts believe that Compulsive acts are symbolic rituals which psychoanalysts believe
this kind of anxiety can be the psychological result of masturbation which serve as a sort of self-punishment and atonement for unacceptable urges.
generates excessive guilt.'" Another psychoanalytic opinion holds that sex- Phobias frequently occur with compulsions as exemplified by the common
ual deprivation can cause generalized anxiety since coitus interruptus, frus- combination of a fear of dirt and repeated hand washing (washing mania).
trated excitation, long abstinence, and the like are considered capable of The handwashing ritual is undertaken to alleviate the fear of contamina-
producing very disturbed feelings. In each of these abnormal courses of tion (mysophobia). This phenomenon is sometimes referred to as the
sexual activity there is no discharge in orgasm and therefore no psychologi- "Pontius Pilate Complex." Mysophobia may also be alleviated by opening
cal gratification. This creates a sense of psychic helplessness which then en- doors with one's elbows or handling all articles while wearing gloves. The
genders an anxiety attack. famous millionaire, Howard Hughes, suffered from mysophobia. He in-
sisted that everything be handled by Kleenex and even made his barber use
different scissors for different parts of his head to avoid germ build-up. In
OBSESSIVE COMPULSIVE DISORDER another case a woman, every Saturday, washed the church pew she ex-
pected to occupy on Sunday!
Symptoms Obsessive thoughts vary from trivial acts, such as saying a word or
phrase over and over or counting (aritlwrnania), to more complex proce-
Obsessive compulsive traits are common in normal persons. Many
dures such as reassembling the letters in words according to private equa-
people have their favorite way of arranging their bureaus or closets or tions. One such "word game" consists of spelling a word according to the
organizing their study habits. Others employ their own sleep-inducing alphabetical ordering of its letters (alphabeticizing). In another type of obses-
gadgets as a nightly bedtime preparation. A certain degree of obsessive- sion the person spends hours brooding about an abstract topic, usually reli-
compulsive drive may add a desirable quality to the individual and is partly gious or philosophical, to the exclusion of other interests. This is known
responsible for the organization necessary to accomplish a diversity of alternatively as the thinking compulsion, the obsessive-ruminative state, and
tasks. People with obsessive compulsive disorders, however, have a patho- Gruebl'lzwang.
logical exaggeration of these traits. They are not free to lead normal lives Ritualistic compulsions, which are undertaken to dispel obsessive
because they are excessively preoccupied with such concerns as cleanliness
thoughts, may be nonspecific and appear as qualities in all of the person's
or the irresistable urge to perform daily tasks in certain ways. Some of these
behavior':'" This type of compulsive performs daily activities according to a
people suffer from obsessions which are recurring, unwanted thoughts that rigid sequence. Other compulsives have more specific drives which can be
cannot be excluded from consciousness. They are ego-dystonic, that is, they
dangerous, such as an impulse to jump ofT a high building, to leap in front
are experienced as senseless and repugnant thoughts that invade con- of an approaching subway, or to act defiantly toward authorities. Some re-
sciousness. Other persons are dominated by comtJUlsions which are
searchers have suggested the existence ofa compulsive drive toward eating
recurring needs to perform a certain act. A compulsion is, in effect, an ob- which they consider to be a factor in some cases of obesity. Sometimes com-
session put into action. Although DSM-Ill reports this disorder is equally pulsions can lead to socially undesirable acts such as compulsive promiscu-
common in males and females, there are reports that, at least among
ity, arson, and shoplifting (kletJtornania).
college students, it is found more often in men." Obsessive compulsives suffer from a deep fear of not being able to
A central symptom of this disorder is constant doubting; these people
Control their environment completely. This may be the reason for the de-
must check and recheck the front door lock, the jets on the stove, the con-
velopment of phobias in so many of these people. Like phobics, obsessive
tents of pockets, answers on an exam, or rewash their hands to guarantee compulsives fee/that they would be in perfect control of the world were it
their cleanliness. Freud aptly called this disorder a "private religion" be-
not for the phobic object. Thus, the phobic object serves to capsulize their
cause it is often characterized by elaborate ceremonies, self-denials,
fundamental fear of losing control. Examples of this fear of loss of control
pennances, and ruminative thoughts about sin. abound; many obsessive compulsives have difficulty in falling asleep be-
The symptoms of this disorder may be meaningless to an observer,
cause they are no longer in command while sleeping.:\" These people are
\'William Thomas Moore, "Somc economic functions of !{cnital masturbation durin!{
adolesccnt dcvclopmcnt," in M(~\tl/,.batiol/: From II/Flllcy to SI'II/'.'(,l'IIce, cds. Irwin M. Marcus and '"'Isaac Marks," [xposurc therapy (or phobias and obsessive-compulsivc disordcrs,"
Hospital Practice, 14 (1979), pp. 101-108.
John J. Francis (New York: 1nternational Universities Press, Ine., 1975), pp. 231-276.
"Ronnic S. Stan!{ler and Adolph M. Printz, "Psychiatric dia!{nosis in a university popu- It'Leon Salzman, TILe Ob5es.,ive Penol/ality (Ncw York: Jason Aronson, 1973), p. 62.
lation," Ameri({l.lIjollnwl of P.'yclLiatry, 137 (19HO), pp. 937-940.
108 Anxiety, Somat%rm, and Dissociative Disoraus
Anxiety, Somat%rm, and Dissociative Disorders 109

also frequently incapable of expressing affection toward others because of

a perceived danger in committing themselves to other people who are not
entirely under their control. This is not to say that they shy away from sex
as well. On the contrary, they often approach sex as a personal challenge to
their endurance. Some male obsessive compulsives, for instance, believe it
is a failure not to prolong intercourse by maintaining a limitless erection.
Saltzman reports a case of a man who tried to achieve orgasm in a woman
who had never been able to have one.17 When he failed, he blamed himself!
The obsessive compulsive disorder is one of the most severe anxiety
disorders. It offers a poor prognosis; these people usually worsen as they
grow older, and they may break down when stressful events occur, such as
an accident, disease. or any abrupt change in lifestyle. When this occurs,
depression with suicidal tendencies is a frequent outcome. These people
may also develop an addiction to alcohol or drugs if they realize they can-
not completely control their environment. The addiction represents the
discarding of all controls and a movement to the opposite extreme-the
binge.
Not all cases end in such disaster. Some, in fact, develop to the point
where the patient develops unusual skills as exemplified in the following
case:
Jonathan G., a 28 year-old professional, often occupied his consciousness
obsessive thoughts. As a child, he used to count the number of letters in
words. However, in an effort to make every word balanced, he would add
vowels to the words at preconceived points so that the letters of each word
added to a number divisable by 4.1" Sometime in adolescence this process was
altered in a more sophisticated way when he began to juxtapose the letters in
words so that they were arranged alphabetically. By young adulthood,
than was so well versed in this mental game that he could put a word in its
alphabetical ordering before the average person could spell it in its normal
form. He kept the whole thing a secret until he saw a celebrity (Dick Cavett)
attempt to "alphabeticize" on national television. This served to legitimize his
obsession and allowed Jonathan to freely express his "talent" in front of oth-
ers.
THE BIOGENIC VIEW OF OBSESSIVE
COMPULSIVE DISORDER
Obsessive compulsive disorder is a complicated problem, not simply be-
cause its origin is not entirely known, hut also hecause of the complexity of
the pathways between the origin and the sympt.oms. Very little has been
said concerning biogenic causes. In the ninet.eent.h cent.ury, there was men-
tion of a possible defect. in intellectual functions which in t.urn was consid-
ered to cause a dist.orted preoccupation with unimportant ideas. This view,
however, simply reAects the somatogenic orientation of that time and has
been discarded long ago. There are reports of the disorder occurring
among many members of the same family. One such report documents the
presence of the disorder in fourteen relatives over three generations.:!!' Al-
though it is theoretically possible that gene-controlled variables may con-
tribute to the obsessive compulsive disorder, few researchers consider it
likely. Cases of the disorder occurring among relatives are interprted as the
result of disturbed interpersonal relationships perpetuated by social conta-
gIOn.
THE ENVIRONMENTAL VIEW OF OBSESSIVE
COMPULSIVE DISEASE
Behaviorist Theory
The behaviorist school of thought considers obsessions and compul-
sions to be learned and repeated over time because they are reinforced by
their positive consequences.'''' The obsession is a conditioned stimulus to
feelings of anxiety, and a compulsive act is undertaken when the person
realizes that the act can reduce anxiety attached to the obsessive thought.
with Eventually, the act becomes a fixed pattern of behavior. Sahakian summa-
rizes the behaviorist theory in the following way:
An obsessional neurosis develops as the result of a mental conflict in which
the neurotic vainly resists an overwhelming drive-not once, but
repetitively-if not invariably, then at least with a degree of regularity. Actu-
Jona-
ally, he is undergoing a state of conditioning or which he is not aware,
amounting to
chooses not to do."the establishment of a mental habit or doing things that he
According to this position, the source of the original anxiety is rela-
tively unimportant compared to understanding the pattern by which ritual-
istic actions are developed. However, this is not true for all behaviorist re-
searchers. Some research on conditioned rituals addresses the etiological
question more directly by including traumatic events in adulthood which
can produce the disorder. Kardiner, for example, reports a case of a per-
son who could not sleep at night until he performed an elaborate ceremony
consisting of lying Aat on his stomach with his nose in the pillow.'2 He also
held his face in his hands and held his breath as long as possible. This ritual
was a reenactment of a battlefield experience during which he desperately
'1'1an Ehrcnwald, "Neurosis in the family: a study or psychiatric epidemiolo!{y," Archive.1
of General Psychially, 3 (1960), pp. 232-242.

·"Ibid., pp. 29-30. Books, 'I/U. Meycr and E. S. Chesser,

1970). Behaviar Thera/))''. in Cliniml P.I)'chiall)'. (Baltimore: Penguin
·IKObsessive.compuisives typically have ravoritc numbcrs which are even. Psychoanalysts
consider this to be a symbolic attcmpt al balancin!{ the dcmands or id and superego. See Otto "William S. Sahakian, "A social learning theory or obsessional neurosis," !.Imel Annall oj
P,ychiatry and Rdaled Disciplines, 7, (1969), pp. 70-75.
Fenichel, The Psyclwanalytic Theory o! NI'U/'Osi,l, p. 21\8.
'"A Kardiner, The Traumatic Neuroses of War (New York: f loebcr, 1941), pp. 15-20.
110 Anxiety, Somat%rm, and Dissociative Disorders
tried to protect himself from an enemy attack at night. The enemy used gas
as a weapon and the person made constant adjustments of his gas mask.
Wolpe reports the rather exotic case of a man with a strong compul-
sion to strike people. II This reportedly developed when he was in the mili-
tary service and was unjustly imprisoned. When he resisted the military po-
lice, he was sent to a psychiatrist who pronounced him well. A sense of
helpless rage increased to the point where he struck a military policeman.
The compulsion to strike people reappeared eleven years later when he
was again jailed. Then it began to recur frequently and under a variety of
conditions.
The major thrust of the behaviorist argument is that the origin of ob-
sessive compulsive behavior need not be in childhood or, if it is, it is not
necessarily connected with sexual experiences as psychoanalysts hold.
Washing mania, for instance, may yield a direct reassuring effect to people
simply because in childhood it reassured them against being criticized by
their mother for having dirty hands.
psychoanalytic Theory
Freud viewed the obsessive compulsive disorder as a defense against
guilt from the incestuous wishes of the phallic stage. He believed that this
forced a regression to a prephallic period, specifically the anal stage, as an
unconscious Aight from Oedipal threats. This position is no longer ac-
cepted in psychoanalytic circles, at least not entirely. Contemporary psy-
choanalytic theory holds that obsessive compulsive behavior originates in
fixation at the anal stage without any phallic complications. The foundation
of this theory was the recurring observation that obsessive compulsivesex-
hibit two key features of the anal-sadistic stage: ideas associated with dirt
and aggressive behavior. A preoccupation with dirt signifies anal tenden-
cies because these impulses are normally modified in the remaining stages
of development. However, in many obsessive compulsives they remain as
an ingrained part of the emotional make-up. This is considered to be the
result of unresolved conAicts during the anal stage, conAicts involving or-
der and disorder, cleanliness and soiling.
Psychoanalysts believe the problem arises from the anal-sadistic stage
rather than the anal-erotic stage because sadism, in the form of painful im-
pulses, comes closer to breaking through in the obsessive compulsive disor-
der than in any other anxiety disorder. II The ego attempts to manage the
sadistic impulses which were energized by fixation at the anal-sadistic level.
In the process, the superego becomes cruel, aggressive, and excessively de-
manding. The fixation is believed to be the result of toilet-training that was
begun too early or conducted in too demanding a way by the parents. This
causes the child to become anxious. The anxiety is controlled by rigid per-
formance standards which translate into ritualistic patterns. Children who
initiate such patterns are unable to please their parents by living up to their
'''Joseph Wolpe, Psyriwtiu'm/JY by HI'ri/Jrom/lllitibitioll, p. 92.
"J~)hn C. Nemiah, FOlllulaliolt.\ of P.lyriw/Hlliw/o{!;J, (New York: Aronson,
"'Leon Salzman, The Obsessive Pel'.\OlI.a/ity, p. 47.
Anxiety, Somat%rm, and Dissociative Disorders III
demands for sphincter control. Consequently, they are left with feelings of
doubt and uncertainty, symptoms which frequently appear among obses-
sive compulsive adults. The type of parents who are likely to bring about
anal-sadistic fixation in their children are well-known. They simply cannot
tolerate soiling by their child or any stubborn attempts by the child to main-
tain autonomy. Iii The mothers are rigid and compulsive themselves. This
may be one reason why the disorder frequently appears among members
of the same family.
There is an overt relationship between the symptoms of the obsessive
compulsive disorder and an underlying conAict stemming from the anal
stage. These persons are extremely neat, clean, and orderly. They tend to
be stingy, often in the handling of money. They frequently experience con-
stipation and diarrhea. Most importantly, they have difficulty accepting au-
thority figures who attempt to control their external behavior. This last
symptom is consistent with the theory that they have fears of not being able
to fulfill expectations placed on them by others because they were unable to
live up to their parents' toilet-training demands in early life . .J ust as the
child viewed these demands as arbitrary rules, so the adult invokes similar
rules to ward off anxiety, rules which take the form of obsessions and com-
pulsions.
Psychoanalytically, the symptoms of this disorder are considered to
represent a compromise between aggressive impulses in the unconscious
and the defense mechanisms employed by the ego against them. There are
a number of such defenses in this disorder. Isolation is involved because an
unacceptable impulse from the anal-sadistic period is separated from its
memory origin. Reaction{ormation also takes place; the ritualistic activity is
the opposite of the unacceptable impulse as exemplified by a washing ritual
in a person who wishes to be dirty. Undoing occurs as well since the ritual
functions as atonement for the unacceptable impulse. Displacement is an-
other defense mechanism involved in the obsessive compulsive disorder.
Through this process, the conAict which contains forbidden wishes is dis-
placed on to something harmless such as rechecking door locks. All of these
defenses are utilized to manage the great struggle between the contradict-
ory demands of id and superego. In some cases, these defenses break
down, and the ego becomes effectively eliminated. When this happens, the
disorder can develop into a full-blown psychosis.
Psychoanalysts believe it is the harsh superego of obsessive compul-
~ives that causes the heightened sense of self-criticalness frequently found
In these people. This can result in what Nunberg described as "those
wrecked by success."'7 If they achieve a long-cherished objective, they be-
come depressed. They cannot enjoy success because their superego
': ... only permits them to await happiness but never to enjoy its
fulfillment."1XThere are many people who have attained highly prized po-
I.",
"'Norman Cameron, Per.\ollalily DevelojJment fwd Psyriw/Hlliwiogy, p. 40Y.
17llerben Nunberg, Pl'illrijJ/es of PsyriwflIwlys;1 (New York: International Universities
Press Inc., 195.'), p. 31.').
1973), p. 110.
'"Ibid., p. 316.
 112 Anxiety, Somatoform, and Dissociative Disorders
sitions (perhaps partly due to their obsessive compulsive tendencies) but
are saddened immediately afterwards. This is not uncommon among grad-
uate students who have just completed the formal requirements for the
Ph.D. In graduate school circles, this is known as the "Post-Doctoral Syn-
drome." In its more general form, Maslow refers to it as the "Jonah Syn-
drome" and he explains it is an incapacity of obsessive compulsives to enjoy
peak experiences for an extended time because of a fear of losing control
and being shattered:'"
SOMATOFORM DISORDERS
Somatoform disorders involve physical symptoms suggesting physical ill-
ness but which are due to psychological factors. There are two forms which
are presented here: conversion disorder and hYIJochondriasis. Other forms in-
clude somatization disorder (recurrent and multiple bodily complaints of sev-
eral years' duration for which medical attention has been sought), psycho-
genic pain disorder (psychologically induced pain not caused by any other
physical or mental disorder), and atypicaL smnatojorm disorder (a residual cat-
egory covering psychologically induced physical symptoms which do not fit
any of the other four types of somatoform disorder). DSM-III reports that
somatization disorder, conversion disorder and psychogenic pain disorder
are more common in women. Hypochondriasis is equally common in nlf'n
and women.
CONVERSION DISORDER
Symptoms
Some "classical" conversion symptoms include paralysis of a body
part, anesthesia, blindness, deafness, mutism, seizures, and vomiting. In
rare instances, conversion symptoms may involve the autonomic or endo-
crine system.
There is some similarity between generalized anxiety disorder and
conversion disorder, also known as conversi011 hysteria. Both problems in-
volve a displacement of anxiety onto the body, but the conversion reactions
are more striking since the special senses or parts of the voluntary nervous
system lose their functions for extended periods of time. These disorders
are a blatant example of the way in which social factors can affect the prev-
alence of mental illness. Witness the significant decline in the number of
such cases over the last century. There are a few macrosocial reasons for
this historical change. First of all, since psychiatrists (particularly psychoan-
alysts) have traditionally regarded the underlying connict in conversion
'''Abraham H. Maslow, "Neurosis as a failure of personal growth" in Psyr!wjJal/w/ogy To-
day: EXjJerimenlalion, Theo,) and Research, ed. William S. Sahakian (Itasca, Illinois: F. E. Peacock
Publishers, Inc., (970), pp. /22-130.
Anxiety, Somatoform, and Dissociative Disorders 113
disorder as sexual, it is not surprising that its frequency has declined, since
modern society presents fewer demands to repress sexual impulses. Sec-
ondly, since the civilized population is more sophisticated concerning med-
ical matters, it has become more difficult for people to convince themselves
that their disabilities are organically caused. Of course, it is possible that the
prevalence of conversion disorder has not actually declined but become
more difficult to deteq since there may have been a shift from the predom-
inance of one type of conversion symptom to another. Today's medically
sophisticated patients may be expert simulators of pain and bodily disease
whereas the "classical" symptoms of conversion disorder are generally
found only among uneducated people from rural areas.
In this psychopathology, anxiety is expressed in the form of a physical
symptom involving a body part stimulated by sensory or motor nerves. The
primary gain is a reduction or elimination of free-noating anxiety, but the
costs are considerable. The physical symptoms often do not conform to ac-
tual neurological or anatomical conditions and frequently disappear when
the individual is asleep or away from home. Certain psychological symp-
toms are also common in cases of conversion disorder. These people
display a curious lack of concern about the conversion symptom and the
disability produced by it. This phenomenon, known as La belle indifference,
was first noted among paratroopers in World War II but not among those
members of the air force whose code did not forbid expressing fear. Some
of these people seem to enjoy their disability. While this decreases their mo-
tivation to get well, it reAects the secondary gains which are found most
prominently in this type of reaction. The most common of these gains are
attention
ity allows.from others and freedom from responsibilities which the disabil-
THE BIOGENIC VIEW OF CONVERSION DISORDER
At one time the only conceivable explanation of conversion disorder was
biogenic. Since the symptoms meant the loss of a body function, the disor-
der was believed to be the result of some lesion of the nervous system. To-
day, very few researchers believe this, particularly because the symptoms
often do not correspond to known patterns of nerve distribution. However,
there are plausible organic explanations for some cases involving conversion
symptoms. One study which followed up people diagnosed as suffering
from conversion disorder nine years previously discovered that a m,uority
had developed physical diseases or had died! Undeniably, some people di-
agnosed as having this type of problem may actually be suffering from an
organic disorder. It is unlikely, however, that conversion symptoms origi-
nate from genetic factors since studies which investigated concordance
rates among monozygotics found no significant genetic patterns. ',11
'.111. Gottesman, "Differelllial inheritance of the psychollcuroses," HlIg'l'llin QlIor/{'ri)', 9,
(1962), Science,
Menial pp. 223-227; E. Slatu,
107 (1961), "The thirty-fifth
pp. 358-381. Mauclsley lecturc: hystcri~1 :1/1," .jOIIl'lI;d oj
1I4 Anxiety, Somat%rm, and Dissociative Disorders
THE ENVIRONMENTAL VIEW OF CONVERSION DISORDER
Behaviorist Theory
Wolpe contends that conversion symptoms ongmate from features
which were present in a previous disturbing experience. He reports the
case of a female who displayed the hysterical symptom of "gooseflesh" in
her calves in response to any rectal sensation including defecation. Years
before, she had had a rectal examination while awaiting the administration
of anesthesia for abdominal surgery. Thus, Wolpe considers the sensation
in her calves to be a conditioned response to anal manipulation which origi-
nally developed under stressful conditions.'"
One predominant clinical feature of this type of person is a high de-
gree of narcissism (self-loving). This predisposes the person to engage in
dramatic and often childish self-displays. It should be noted that this may
be the simple result of social imitation as some behaviorists contend. In a
sense, these people may have been prepared for conversion reactions in
childhood by a narcissistic, attention-seeking mother who provided the
child with a role model of a person dramatically preoccupied with her
body.
Other behaviorists give a different account of conversion symptoms.
They believe that a conversion reaction is the enactment of a role which
provides rewards either by reducing stress or by providing positive gains.
Thus, conversion symptoms provide an avenue of escape from an intolera-
ble situation; one person develops writer's cramp while another suffers pa-
ralysis of a leg. The writer may not actually want to write and the person
with the paralyzed leg can now avoid meeting a threat.
Psychoanalytic Theory
One of the earliest environmental theories of conversion disorder was
voiced by Bernheim. He believed that suggestibility and hypnotizability,
while normal personality attributes, are excessive in certain persons who
unconsciously and automatically lose bodily functions.:,2 Actually,
Bernheim was not far from the psychoanalytic theories of Freud and his
later followers who argued that a conflict involving sexual impulses is at the
root of conversion symptoms. Specifically, if the person cannot comfortably
accept genital strivings of the id, they are removed from conscious
awareness. Then they are retained in the unconscious, but their energy is
displaced on to a nonsexual part of the body. In the process, that body part
becomes eroticized (in a loose sense of the word) and plays the role of a
substitute genital. This process is more likely to occur in response to a sud-
den, identifiable stress. Freud believed that this stress involved some aspect
of an unresolved Oedipus/Electra complex.
Contemporary psychoanalysts do not believe that only a sexual
conflict can produce conversion symptoms. Rather, they suggest that all
:"Joseph Wolpe, P.lyr!wthera/JY by Rec;pl'O((J/ !Ilhibitiou, p. 85.
'-"1-1.Bernheim, Sugge.ltive Tltl'ru/Jeutir.l (New York: (;. P. Putnam's
Anxiety, Somat%rm, and Dissociative Disorders lIS
types of instinctual conflicts may playa role in engendering these prob-
lems. Current psychoanalytic theories distinguish between male and fe-
males since a sexual conflict is believed to be more common in these cases in
women than in men. There is some experimental evidence to support this
idea. Jordan and Kempler, for example, found that female hysterics be-
come particularly distressed when they are approached sexually."" They be-
come highly agitated by questions about their femininity. Consistent with
this, Marmour argues that the "hysteric is distressed when sexuality brings
advances, as she is really asking to be loved as a child and not as a woman."'"
Male hysterics, on the other hand, develop conversion symptoms as a way
of escaping a social challenge or some blow to their self-esteem.:':'
Psychoanalytic theory also suggests why certain body parts are se-
lected for the conversion. The body part is that which is most suitable to
represent the focal conflicts involved. This process is a type of body lan-
guage known as somatic compliance. Sometimes the choice may be of a chron-
ically weak organ such as a lame leg which suddenly goes completey numb.
However, it is believed that often the conversion symptom is symbolically im-
portant because it allows the person to avoid something uncomfortable.
Mutism in a salesman and sexual impotence in a Don Juan exemplify a de-
sire to be something else. In addition, a paralyzed hand prevents a person
from carrying out a masturbatory drive.
Not all psychoanalysts accept Freud's belief that conversion disorder
originates from phallic fixation involving an unresolved Oedipus complex.
Many feel that conversion symptoms involve fixation at multiple stages of
development but few would place fixation at a prephallic stage. There is
little emphasis on prephallic stages because conversion symptoms involve
very specific selections of body parts and the selective process is not devel-
oped in the younger child who lacks a well-differentiated view of the world.
Thus the fixation is generally considered to be at a later, more sophisticated
leveL"';
HYPOCHONDRIASIS
Symptoms
In hypochondriasis, the predominant disturbance is a preoccupation
with the bod y and with a fear of presumed diseases of various organs. The
condition differs from conversion disorder in that there are no actual losses
or distortions of function. These persons are morbidly preoccupied with
their physical or emotional health. Their unrealistic fear or belief of having
"'Brian T. Jordan and Bernhard Kempler, "Hysterical personality: an experimental in-
vestigation of sex-role connict," Jounwl of Abnorma/ P.lyr!w/ogy, 75 (1970), pp. 172-176.
'dJ. Marmour, "Orality in the hysterical personality," .10III'lla/ of the Aml'l'imu P.lyc/waua-
lytic Association, I (1954), pp. 656-671.
"''L. C. Kolb, Modem Clinical Psychiatry.
""For an elaboration of this argument see Ruth L. Munroe, Schooll 0/ P.lyr!w(LIwlytic
Sons, 1897). Thought (New York: Holt, Rinehart and Winston, 1955), p. 284.
116 Anxiety, Somat%rm, and Dissociative Disorders Anxiety, Somatoform, and Dissociative Disorders 117

a disease persists despite medical reassurance that their is nothing organic- on to go outside, but do differ in their constant and overdramatic warnings
ally wrong with them. Some of them complain of vague illness symptoms. about such things.
Others complain of organ-centered problems which are usually abdominal,
Psychoanalytic Theory
although the chest and head are frequently involved as well. When they do
have normal body ailments, their complaints are entirely out of proportion Psychoanalysts believe hypochondriacal behavior is the result of the
to their actual physical condition as the person who thinks that a headache
stems from a brain tumor. renunciation of masturbation. Hypochondriasis is said to replace mastur-
bation because the cessation of masturbation results in a "damming up" of
Many of these people are addicted to reading medical journals or
other health-related literature. Some are "food faddists" who rush to pur- libidinal energy. The person, in turn, deals with the resultant anxiety by
displacing it on to imaginary body difficulties.
chase new foods which reportedly aid health. Their preoccupation with
their body prevents them from attending to their underlying problems.
Consequently, they do most of the talking when examined by a physician, DISSOCIATIVE DISORDERS
and give a too-detailed, technical account of their symptoms. Because they
are hypersensitive to criticism, they may shift from physician to physician
as each in turn recommends psychiatric evaluation. Dissociative disorders are characterized by a sudden, temporary alteration
in the normal functions of consciousness, identity, or motor behavior. One
Hypochondriasis offers obvious secondary gains. Because hypochon-
driacs often lack attention from others, their symptoms meet an attention- form is presented here-the multiple personality. There are four other forms
including psychogenic amnesia, a memory loss not due to an organic cause.
getting need. Their symptoms also serve to rationalize any inadequacies
and allow them to avoid undesired responsibilities. The following case The amnesia may be localized (failure to recall all events during a certain
period of time), selective (failure to recall some, but not all, of the events
exemplifies a hypochondriacal reaction to anxiety: during a circumscribed period of time), generalized (failure to recall events
of the individual's entire life), or continuous (inability to recall events from a
A 50 year old man suffered from the fear that his heart would stop beating,
that his limbs would fall off, and the like. He was unable to sleep, for he particular time to the present). Another dissociative disorder is psychogenic
awoke every few minutes in order to check whether he still had all of his fugue-a state of aimless wandering. During this state, people act on the
limbs. He suffered from real sensations which he perceived as painful ones in basis of unconscious desires by traveling long distances and even assuming
the region of the heart, the extremities, and t he nose. All of those complaints a new identity. The condition may last from a few hours to days or even
culminated in the fear that he would die of "arteriosclerosis." He had heard months. Typically the return to conscious awareness occurs spontaneously
something about arteriosclerosis as appearing at his age and now imagined with no recollection of what happened. Cases of psychogenic fugue occur
that his vessels, which he thought of as some kind of lubes, would become more frequently during wartime. When they occur in civilian life, it is usu-
obstructed so that some parts of his body would have to fall olT. He ... con- ally following a traumatic emotional crisis. A third dissociative disorder is
nected his suffering with his irregular sexual life. For years he had practiced
depersonalization disorder which involves a sense of self-estrangement or un-
coitus interrupLUs. He felt that this had harmed him; he had pains in his geni-
tals and his head ... At last, he was overcome by the fear that the semen held reality. This could include the experience of peceiving oneself from a dis-
back during inlercourse would stop up his penis ... -,; tance or the feeling that one's extremities have changed in size. Temporary
feelings of this type, such as the state of "cosmic consciousness" produced
by hallucinogenic drugs, are not included. Another type of dissociative dis-
THE ENVIRONMENTAL VIEW OF HYPOCHONDRIASIS order is atypical dissociative disorder, a residual category for trance-like states
and the like which do not meet the criteria for a specific dissociative disor-
der.
Behaviorist Theory

Little etiological research on hypochondriasis has been undertaken.

Biogenic theories are nonexistent and environmental theories are sketchy. MULTIPLE PERSONALITY
This paucity of research is probably due, at least in part, to the fact that
hypochondriacal reactions are not very common. Symptoms
Behaviorists stress the innuence of social learning in hypochondriasis.
They believe the disorder is caused by overprotective parents who display The best known of the dissociative disorders is the multiple personal-
an exaggerated concern over their child's health. They do not differ from ity. It is the most dramatic of all of the dissociative disorders, has often been
other parents in warning about silting in a draft or having enough clothes the star of stage and screen, and yet it is exceedingly rare.-·" [n fact, it is so
"'Cornelia Wilbur, "Clmical considerations in the evaluation and treatment or multiple
-"Ilerman N unberg, Prill.ci/J/e.\ II! Psydwftllft/y.li.\, pp. 183-184. By permission of pub- personality" (lecture delivered at Multiple Personality Conference, Friends Ilospital,
lisher. Philadelphia, 1978).
118 Anxiety, Somat%rm, and Dissociative Disorders
uncommon that only a few hundred cases have been reported in the litera-
ture. In 1978 it was estimated that there were approximately one hundred
cases under treatment in the United States."" It is often confused by the
public with schizophrenia (because of the split involved), yet it is quite dif-
ferent from schizophrenia.
People with this condition have two or more distinct personalities,
each of which is dominant at a particular time. Usually there is one original,
relatively mature personality (core personality), which dominates until one or
several other personalities take over (subpersonafities). The core personality
is not aware of the subordinate ones. Some classic examples are Morton
Prince's case of Sally Beauchamps"" and the Southerner whose personality
became dissociated into the well-known Three Faces oj Eve.'" There is also a
report from Belgium of a nun who may be affiicted with multiple personal-
ity as she regularly engaged in drug abuse, varied sexual activities, and
murder.62 And in Ohio, a man who raped a number of university coeds is
reported to have ten different personalities including a sadistic lesbian per-
sonality who committed the rapes!
It is important to note how distinct the personalities are from each
other. Not only do they vary psychologically but there are also different
physical traits exhibited by each. These include different measures of gal-
vanic skin response, heart rate variations, brain wave alterations, as well as
different body postures and even eye color.''' Needless to say, these impor-
tant differences in the multiple personalities can cause enormous legal
problems of responsibility if one of the personalities commits a crime. Peo-
ple treated for multiple personality tend to be female, highly intelligent,
and highly creative.
There is a report of a multiple personality involving sixteen separate
identities. This is the well-publicized case of Sybil, one of the most bizarre
cases of mental illness of all times.'" Sybil had three main personalities:
Sybil herself, a timid, saintly woman who was unable to express anger;
Peggy, an aggressive and uninhibited girl; and Victoria, a sophisticated
woman of culture. Each of the three personalities, as well as the other
thirteen that Sybil exhibited in the course of treatment, differed in speech
and body movements. Each was perceived as having distinct physical char-
acteristics as well. The list of characters even included two male identities,
Mike and Sid. Each of thp personalities exhibited particular talents denied
-'''People with multiple personalities are reportedly very bright and creative people. If
they score low on I.Q. tests, it is usually because a less intelligent alternate was dominant at the
time of testing; Cornelia Wilbur, "C1inical considerations in the evaluation and treatment of
multiple personality."
""Morton Prince, Di.I.IO(iatioll 0/11 Pa.lol/a/it)' (New York: Longmans, Green, 1908).
"'C. I I. Thigpin, H. Thigpin, and I I. M. Cleckley, The Thl"l'e Faces '1 Eve,
McGraw-Hili, 1957).
'''The nun's story," Tillie Ma{;azilll' (March 13, 1978), p. 51.
"'Cornelia Wilbur, "Clinical considerations in the evaluation and treatment
personality. "
"'For a complete account of this case see F. R. Schreiber, Sybil, (Chicago:
1973).
Anxiety, Somat%rm, and Dissociative Disorders 119
the others: Sybil was the artist, Peggy was the matnematician, Victoria wa~
the master of cultural refinement, and so on. During the period when one
particular personality was in charge, Sybil had no awareness of the others'
activities. She would return to a painting she had started and find that
someone else had completed it in a different style. She ran into persons
who insisted they knew her although she felt certain that she had never
seen them before.
Sybil's multiple personalities began to emerge when she was three and
a half years old. By that time she was well experienced with her mother, an
extremely pathological person. Sybil was born the only child of a woman
diagnosed as a paranoid schizophrenic but who refused treatment. She
raised Sybil in an environment that words can not adequately describe. To
be sure, it was a hellish nightmare. Sybil observed the sexual activities of
her parents while kept in a crib in their bedroom until she was 9 years old.
Most importantly, Sybil was used by her mother as an outlet for her own
deranged needs. Among other things, Sybil was ritualistically strapped to
the kitchen table each morning while her mother inserted a variety of ob-
jects into her vagina: a buttonhook, a bottle, the handle of a knife, and a
Oashlight, to name a few. Sybil was often given enemas and forced to retain
the contents until her mother completed a tune on the piano to which Sybil
was strapped. If she soiled herself, she was punished in a violent and vi-
cious manner. Sybil's mother broke her bones, burned her body, locked
her in a trunk, and hung her upside down. She would also take Sybil for
walks and defecate on neighbors' lawns. Sybil's father was extremely re-
moved from the mother-daughter scene and passively accepted his wife's
explanation that Sybil suffered her injuries by accident.
According to Cornelia Wilbur, Sybil's psychoanalyst, the division of
Sybil's personality into a number of selves served to protect her against the
horrors of her childhood. The new personalities were not affected by
Sybil's traumatic experiences because they denied that Sybil's mother was
their mother also. Actually, Sybil's dissociation may have been a very crea-
tive way to avoid schizophrenia. Nowhere in the psychiatric literature is
there a case report of such an elaborate multiple personality. At the same
time, it seems impossible to find a comparable example of such a mon-
strously deranged mother.
THE BIOGENIC VIEW OF MULTIPLE PERSONALITY
The origin of dissociative disorders is a real mystery. Very little research
has been done on possible biogenic causes. One loosely constructed
(New York:
biogenic p,-oposition suggests that these disorders may be a pathological
exercise of the normal functions of the central nervous system. The dis-
of multiple torted functions include the screening of incoming information and the
control of behavioral responses to them. Presently, this can not be consid-
Regnery, ered as mOl-ethan an interesting hypothesis. It can only be supported when
more data are gathered concerning the physiology of awareness.
120 Anxiety, Somatoform, and Dissociative Disorders Anxiety, Somatoform, and Dissociative Disorders 121

THE ENVIRONMENTAL VIEW OF MULTIPLE PERSONALITY

unacceptable sexual wishes from the phallic stage increase in strength in
adulthood when the ordinary form of repression fails to work any longer.
Behaviorist Theory This is the traditional explanation. Others feel that the fixation is at the
Behaviorists have developed some novel etiological theories of disso- primitive, oral stage in which denial and ego-splitting are common. These
ciative disorders. They have considered the causes of amnesia, for exam- techniques are utilized in the inhmtile years before the individual develops
the more mature ability to repress threatening material.
ple, and have concluded that amnesia is a simple case of "deficient registra-
tion of impressions."'" That is, a person's attention is so monopolized by Although the nature of the fixation point remains controversial in
unpleasant feelings of anxiety that there is not enough attention left to reg- psychoanalytic circles, it is important to point out some of the possible un-
ister what is occurring. From this perspective, amnesia is not pathological conscious functions of dissociative disorders like the multiple personality.
forgetting but the failure to record an event when it first occurs. Since the disorder can be a denial of responsibility or a repression of stress-
The behaviorist theory of dissociative disorders in general is that they ful experiences, the dissociation is sometimes a separation from superego
are avoidance reactions which protect the person from severe stress. This functions. One of Freud's cases exemplifies this; he treated a patient who
theory seems particularly relevant to the multiple personality since most of tried to rip her clothes off with her right hand while simultaneously trying
these cases involve an unbearable amount of stress. In fact, one expert re- to keep them on with her Ie ft.'''' According to Freud, she was identifying
ports that all dissociative personalities were battered children.';'; with a man raping a victim and the helpless victim at the same time! This
Another common background feature among dissociative personali- caes demonstrates the use of dissociation, in the form of multiple
ties is that they were given forbidden secrets by their parents and forced to identification, to live out urges unacceptable to the superego through seri-
ally acting out various roles.
preserve them.';7 This experience is compatible with a conditioning process
whereby the personalities remain hidden from each other and have their
own secret motivation. Although it is not unusual for children to have "im- CONCLUSIONS
aginary companions", these people have companions at later ages than is
considered normal (after age six).
It is appropriate here to consider a central etiological issue regarding the
Psychoanalytic Theory neurotic disorders discussed in this chapter; namely, "What governs their
form?" To be sure, different people react to anxiety in specific ways. Some
Psychoanalytic theory holds that stressful Iife events create such over-
reduce anxiety by direct discharges on to the body (generalized anxiety dis-
whelming anxiety that a dissociative disorder is employed as an adaptive
method of resolution. The dissociative response acts to defend the ego order). Some lose a special sense or body function (conversion disorder).
Others undergo alterations in consciousness or identity (dissociative disor-
against material which is perceived as dangerous by either the conscious or ders). Phobics have an intense fear of an object or situation. Obsessive com-
the unconscious. The result may appear to be crippling, but it does avoid a
pulsives engage in ritualistic behavior. Hypochondriacs experience a felt
true disaster in the form of a psychotic break with reality. Dissociative re- reduction in physical health and strength.
sponses bring emotional tension within manageable limits. According to The specific syndrome is not a "choice" made by a person with
Cameron, "The process is a pathological form of the common demand of unmanageable anxiety. According to psychoanalytic theory, it is the conse-
many a normal harassed person who exclaims tensely, 'One thing at a time, quence of the composition of the personality which was formed from
please!' "68 Rather than displaying emotional conOicts as in conversion dis interpersonal experiences during childhood. From this perspective, the de-
order, the dissociative person tries to escape them through the use of the
fense mechanisms utilized represent ways of alleviating unconscious
defense mechanism of isolation. This separates threatening, painful mate-
conflicts originating from a traumatic period of earlier life. Thus, for in-
rial from the rest of the conscious.
stance, reaction formation may playa role in the mind of the obsessive
Psychoanalysts are generally agreed on the role of the unconscious compulsve who retains unacceptable desires to soil in defiance of earlier
and the adaptive role of isolation in the etiology of dissociative disorders as toilet-training experiences that infringed on pleasure impulses. In conver-
a group. There is some disagreement, however, regarding the stage of psy-
sion disorder, sexual conflicts are believed to be managed by displacing
chosexual development which fosters these disorders. Some believe that
them on tohere.
discussed a substitute body organ, and so on for the rest of the problems

""Joseph Wolpe, Psychotherapy by Reciprocal Inhibition, p. 94. The behaviorist theory of neurotic disorder emphasizes consCIous
"'Cornelia Wilbur, "Clinical considerations in the evaluation and treatment of multiple
personalit y."
"'Ibid. ';"Sigmund Freud, "Hysterical fancies and their relation to bisexuality," in Collected Pa-
pers of pp.
1924), Sigmund
51-58.Floeue!, volume 2 (London: Institute of Psychoanalysis and I fogarth Press,
''"Norman Cameron, Personatity Devetopment and P.\yclwpatlwtogy, p. 341.
 6
122 Anxiety, Somata/arm, and Dissociative Disorders

forces in the person's social circle that prompted particular behavior. Thus,
parents who are suggestible and reward the child for showing off predis-
pose the child toward hysterical symptoms. Those who parents made a big
fuss over health-related matters were being guided toward hypochondria-
sis at the same time, and so on. In both the behaviorist and psychoanalytic
theories of neurotic disorders, there is a crucial role played by social fac-
tors. The major difference between the theories is the significance each ac- Personality Disorders
cords to hidden, unconscious origins since these are only vital issues in psy-
choanalytic theory.

AN OVERVIEW

DSM-lII defines personality traits as " ... enduring patterns of perceiving,

relating to, and thinking about the environment and oneself ... exhibited
in a wide range of important social and personal contexts. It is only when
personality traits are inflexible and maladaptive and cause either significant
impairment in social or occupational functioning or subjective distress that
they constitute personality disorders.'" Personality disorders are a wide-
spread category of mental illness. They seldom result in hospitalization for
two reasons; first, relatively speaking, they are not as disabling as most of
the disorders discussed previously; second, one of the most common disor-
peoplethewho
ders, antisocial
are notpersonality
likely todisorder, is frequently found among criminals,
seek help.
The personality disorders are grouped into three "clusters" with
shared characteristics. The first cluster includes paranoid, schizoid, and
schizotypal personality disorders. People with these disorders often appear
"odd" or eccentric. The second cluster includes histrionic, narcissistic, antiso-
cial, and borderline personality disorders. Individuals with these disorders of-
ten appear overly dramatic, emotional, or erratic. The third cluster in-

'American Psychiatric Association, Diagnostir and Stati.l/iml Manllal oj Men/al Di.lIJrden

(Third Edition) (Washington, D. C.: American Psychiatric Association, 1980), p. 305.