Somatoform Disorders and Dissociative Disorders: Powerpoint Lecture Notes Presentation

PowerPoint Lecture Notes Presentation
Chapter 6
Somatoform Disorders and Dissociative
Disorders
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson

Copyright 2009 John Wiley & Sons, NY 2
Dissociative Disorders
Sudden disruption in the continuity of:
Consciousness
Memory
Identity
Dissociation
Some aspect of cognition or experience
becomes inaccessible to consciousness
Avoidance response
Table 6.1 Summary of Dissociative
Disorders
Dissociative Amnesia
Inability to recall important personal
information
Usually about a traumatic experience
Not ordinary forgetting
Not due to physical injury
May last hours or years
Usually remits spontaneously
Memory returns in bits and pieces
Dissociative Amnesia
DSM-IV-TR criteria
One or more episode of inability to
remember important personal information,
usually of a traumatic event, that is too
extensive to be ordinary forgetting.
Amnesia occurs outside of other
dissociative disorders, PTSD or acute
stress disorder, or somatization disorder,
and is not explained by other medical or
psychological conditions.
Memory Deficits and Dissociation
Memory research shows the recall of trauma
is usually enhanced memory for central
events.
High levels of stress hormones could interfere with
memory formation (Andreano & Cahill, 2006)
Memory deficits in explicit but not implicit
memory
Explicit memory
Involves conscious recall of experiences
e.g., senior prom, moms birthday party
Implicit memory
Underlies behaviors based on experiences that
cannot be consciously recalled
e.g., playing tennis, writing a check
Distinguishing other causes of memory loss
from dissociation:
Degenerative brain disorders
e.g., Alzheimer's Disease
Not linked to stress
Involves gradual decline over time
Accompanied by other cognitive deficits
Inability to learn new information
Substance abuse
Linked to use of drug or alcohol
Dissociative Fugue
Amnesia plus flight
Latin fugere, to flee
Sudden, unexpected travel with inability
to recall ones past
Assume new identity
May involve new name, job, personality
characteristics
More often of brief duration
Remits spontaneously
Dissociative Fugue
DSM-IV-TR criteria
Sudden, unexpected travel away from
home or work
Inability to recall ones past
Confusion about identity or assumption of
new identity
Symptoms are not explained by another
medical or psychological disorder
Depersonalization Disorder
Perception of self is altered
Feelings of detachment or disconnection
Watching self from outside
Floating above ones body
Emotional numbing
Unusual sensory experiences
Limbs feel deformed or enlarged
Voice sounds different or distant
Triggered by stress or traumatic event
No psychosis or loss of memory
Often co-morbid with anxiety, depression,
or Personality Disorders
Typical onset in adolescence
Chronic course
DSM-IV-TR criteria
Persistent or recurrent experiences of
detachment from ones mental processes
or body, as though in a dream, despite
intact reality testing
Symptoms are not explained by another
dissociative disorder, by any other
psychological disorder, or by a medical
condition
Dissociative Identity Disorder (DID)
Two or more distinct and fully developed
personalities (alters)
Each has unique behaviors, memories, and
relationships
Memory gaps common for periods of time when
alters are in control
Other symptoms: headaches,
hallucinations, self harm, suicide
attempts
Typical onset in childhood
Rarely diagnosed until adulthood
More severe than other dissociative disorders
Recovery may be less complete
More common in women than men
Often comorbid with:
PTSD, major depression, borderline personality
disorder, substance abuse, phobias
DSM-IV-TR criteria
Presence of two or more personalities
(alters)
At least two of the alters recurrently take
control of behavior
Inability of at least one of the alters to recall
important personal information
Epidemiology

No identified reports of DID or dissociative
amnesia before 1800 (Pope et al., 2006).
Major increases in rates since 1970s
DSM-III (1980)
Diagnostic criteria more explicit
Appearance of DID in popular culture
Sybil, 1973
Book and movie received much attention
Etiology of Dissociative Identity Disorder
(DID): Two Major Theories
Posttraumatic Model
DID results from severe psychological
and/or sexual abuse in childhood
Sociocognitive Model
DID a form of role-play in suggestible
individuals
Occurs in response to prompting by therapists
or media
No conscious deception
Etiology of Dissociative Identity Disorder
(DID): Two Major Theories
Evidence raised in theory debate
DID can be role-played
Hypnotized students prompted to reveal alters did so
(Spanos, Weekes, & Bertrand, 1985)
DID patients show only partial implicit memory
deficits
Alters share memories (Huntjen et al., 2003)
DID diagnosis differs by clinician
A few clinicians diagnose the majority of DID cases
For many, symptoms emerge after therapy begins
Figure 6.1 Handwriting Samples from
Four DID Cases
Treatment of Dissociative Identity
Disorder (DID)
Most treatments involve:
Empathic and supportive therapist
Integration of alters into one fully
functioning individual
Improvement of coping skills
Psychoanalytic approach adds:
Re-experience the traumatic event
Use of hypnosis
Age regression
Somatoform Disorders
Psychological problems take a physiological
form
Soma means body
Bodily symptoms have no known physical
cause
Not intentionally produced or under voluntary
control
Individuals seek medical, not psychological,
treatment
Become distressed when no medical cause is
found
Table 6.2 Summary of Somatoform
Disorders
Pain Disorder
Person experiences severe, prolonged pain
Cannot be accounted for by organic pathology
Caused or intensified by psychological factors such
as conflict and stress
Individual unaware of psychological origins
Diagnosis often challenging
Unlike pain caused by organic pathology,
individuals have difficulty localizing and describing
pain
Pain Disorder
DSM-IV-TR Criteria
Pain that is severe enough to warrant clinical
attention
Psychological factors are thought to be
important to the onset, severity, or
maintenance of pain
The pain is not intentionally produced or faked
The pain is not explained by
another psychological condition
Body Dysmorphic Disorder
Preoccupation with and extreme distress over
imagined or exaggerated defect in appearance
e.g., My nose is hideously large
Constant examination of self in mirror or avoids
mirrors completely
Some become housebound
Refuse to attend school or work
Attempt to camouflage or hide defect
have plastic surgery
Disappointing results
Almost have suicidal thoughts
Typical onset late adolescence
Slightly more common in women than men
Prevalence less than 1%
High levels of comorbidity
Most common comorbid disorders:
Major depressive disorder
Social phobia
Obsessive-compulsive disorder
Substance abuse
Personality disorders

DSM-IV-TR Criteria
Preoccupation with an imagined defect or
markedly excessive concern over a slight
defect in appearance
Preoccupation is not explained by another
psychological disorder, like anorexia
nervosa
Hypochondriasis
Preoccupation with fears of having a serious
disease
This headache must mean I have a brain tumor!
Despite medical reassurance, fears persist for at
least 6 months
Critical of medical professionals
Incompetent and uncaring
Typical onset early adulthood
Tends to be chronic
Often comorbid with mood and anxiety
disorders

Hypochondriasis
DSM-IV-TR Criteria
Preoccupation with fears about having a
serious disease
The preoccupation continues despite
medical reassurance
Not explained by a delusional disorder or
body dysmorphic disorder
Symptoms last at least 6 months
Somatization Disorder
First noted by Pierre Briquet in 1859
Known as Briquets syndrome
Multiple, recurrent somatic complaints with no
apparent physical cause
Must have multiple symptoms which cause
impairment
Seeks treatment, usually from multiple physicians
Hospitalization, medications, surgery common
Exaggerated presentation of symptoms and
complaints
Lifetime prevalence less than 0.5%
More frequent in women
Especially Hispanic and African American
Higher prevalence rates in South America and Puerto Rico
Cultural differences
Symptom presentation
Burning pains in hands more common in Asia and Africa
Culture may also influence how people seek treatment
Psychological distress presented in physical terms
Typical onset early adulthood
Often accompanied by behavioral and interpersonal
problems
e.g., marital discord, poor work history

DSM-IV-TR Criteria
History of seeking treatment for many physical
complaints beginning before the age of 30 and
lasting for several years
At least four pain symptoms, as well as at least two
gastrointestinal symptoms, one sexual symptom,
and one pseudoneurological symptom (e.g.,
unexplained paralysis)
Symptoms are not due to a medical condition or
are excessive given the persons medical condition
Symptoms do not appear to be faked

Conversion Disorder
Sensory or motor function impaired but no
known neurological cause
Vision impairment or tunnel vision
Partial or complete paralysis of arms or legs
Seizures or coordination problems
Anesthesia
Loss of sensation
Aphonia
Whispered speech
Anosmia
Loss of smell
Conversion Disorder
DSM-IV-TR Criteria
One or more symptoms affecting motor or
sensory functioning and suggesting a
neurological or medical condition
Symptoms are related to conflict or stress
Symptoms are not intentionally produced and
cannot be explained by a medical condition
Symptoms cause significant distress or
functional impairment or warrant medical
evaluation
Conversion Disorder
Hippocrates
Believed disorder only occurred in women
Attributed it to a wandering uterus
Originally known as Hysteria
Greek word for uterus
Freud
Coined term conversion
Anxiety and conflict converted into physical
symptoms
Conversion Disorder
Onset typically adolescence or early
adulthood
Often follows life stress
Prevalence less than 1%
More common in women than men
Often comorbid with:
Major depressive disorder
Substance abuse
Personality disorders
Figure 6.2 Glove Anesthesia
Etiology of Conversion Disorder:
Psychoanalytic Perspective
Individual experiences distressing event
Unable to express emotional distress
Memory of event is pushed into the unconscious
In women, disorder linked to Electra Complex
(Freud)
Sexual arousal in adulthood triggers anxiety which
is converted to physical symptoms.
No empirical support for psychoanalytic theory
Genetic Factors
No support for genetic influence
Concordance rates in MZ twin pairs do not
differ from DZ twin pairs
Social and Cultural Factors
Decrease in incidence of conversion
disorders since last half of 19
th
century
Higher incidence may have been due to more
repressed sexual attitudes or low tolerance for
anxiety symptoms
More prevalent
In rural areas
In individuals of lower SES
In non-western cultures
Etiology of other Somatoform
Disorders
Body Dysmorphic
Disorder
BDD often co-occurs
with OCD
May have shared
neurobiological risk
factors
Cognitive Behavioral
Model (see figure)

Treatment of Somatoform Disorders
Few controlled treatment outcome
studies
Cognitive Behavioral Treatment
Identify & change triggering emotions
Change cognitions about symptoms
Replace sick role behaviors with more
appropriate social interactions
Treatment of Pain Disorder
Antidepressants
Tofranil
Effective even with low dosages that dont alleviate
depressive symptoms
Components of psychotherapy for pain
disorder
Validation of patients pain
Relaxation training
Reinforce shift of focus away from pain
Help patient develop ability to cope with stress and
gain sense of control over pain
Treatment of Body Dysmorphic
Disorder
Cognitive Behavioral Therapy
Exposure plus response prevention
Prevent individual from checking appearance
Antidepressants
Fluoxetine (Prozac)
Clomipramine (Anafranil)

Treatment of Hypochondriasis
Cognitive Behavioral Therapy
Reduce excessive attention to bodily
sensations
Challenge negative perceptions about
sensations
Discourage reassurance seeking from
medical professionals
Treatment of Somatization Disorder
Most accepted approach:
Medical professionals dont dismiss
physical complaints
Minimize use of diagnostic tests and
medication
Avoid providing attention only when patient
is complaining
Stay in contact on a regular basis
Treat underlying depression and anxiety
when present
Treatment of Conversion Disorder
No controlled studies to date
Psychoanalytic treatments have not
demonstrated usefulness
Reinforcement of high functioning
behavior may help
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