Somatoform,

Dissociative
& Personality
Chapter 16

Disorders
 Still missing essays from:
- Addison
- David
- Franczesca
- Joanna
- Andersan
- Pourochista
- Erinn
- Gavin
- Charlotte
Shape of the Day Learning Intentions

- Notes - I will understand the

- Video clip different
- Notes Somatoform,
- Video clip dissociative &
- Group Activity personality
disorders
- I will understand the
different personality
disorders
Somatoform Disorders & Dissociative
Disorders
Somatoform disorders
pathological concern of individuals with the
appearance or functioning of their bodies when
there is no identifiable medical condition
causing the physical complaints. Ex. They say
they feel pain but theres no physical visibility
to explain the pain.

Dissociative disorders
individuals feel detached from themselves or
their surroundings, and reality, experience, and
identity may disintegrate
The symptoms of dissociative disorders range
from amnesia to alternate identities Historically,
both somatoform and dissociative disorders used
to be categorized as hysterical neurosis
 Somatoform Disorders
Occur when a person manifests a psychological problem through a
physiological symptom.
Two types
Illness Anxiety Disorder (Hypochondriasis)
Has frequent physical complaints for which medical
doctors are unable to locate the cause. They often
believe that minor issues (e.g. headache, upset
stomach) are indicative are more severe illnesses.
Conversion Disorder
Report the existence of severe physical problems
(e.g. blindness, paralysis) with no biological reason.
 Conversion Disorder
Physical malfunctioning without any physical or organic
pathology
Malfunctioning often involves sensory-motor areas
Retain most normal functions, but without awareness of
this ability
Statistics
Rare condition, with a chronic sporadic course
Seen primarily in females, with onset usually in
adolescence
Freudian psychodynamic view is still popular (anxiety converted
into physical symptoms)
Detachment from the trauma and negative reinforcement seem
critical
Treatment
Core strategy is attending to the trauma
Dissociative Disorders
These disorders involve a disruption in the conscious
process.
An example - Psychogenic Amnesia where the
patient cannot remember things with no
physiological basis for the disruption in memory.
People with psychogenic amnesia can find
themselves in an unfamiliar environment creating a
Dissociative Fugue (characterized by reversible
amnesia for personal identity, including the
memories, personality, and other identifying
characteristics of individuality).
 Dissociative Amnesia
Inabilityto recall personal information, usually
of a stressful or traumatic nature 2 types in
dissociative disorder:
Selective amnesia is when a person can recall
only small parts of events that took place in a
defined period of time. For example: A veteran
of a war may recall some details, such as taking
prisoners, but not others, such as seeing a good
friend get hit.
Generalized amnesia is when a persons
amnesia encompasses his or her entire life.
These individuals are usually found by the police
or taken by others to a hospital emergency room.
 Dissociative Fugue
Sudden, unexpected travel away from
home, along with an inability to recall
ones past (new identity)
Occur in adulthood and usually end
abruptly
Treatment
Dissociative amnesia and fugue
Get better on their own
Coping mechanisms to prevent future
episodes
Most common Dissociative
Disorder is Dissociative Identity
Disorder
Used to be known as
Multiple Personality
Disorder.
A person has several
rather than one integrated
personality.
People with DID commonly
have a history of
childhood abuse or
trauma.
 Dissociative Identity Disorder
Person with this disorder may be prim & proper one moment and loud
and flirtatious the next
Each personality has its own voice and mannerisms, and the original oje
typically denies any awareness of the other(s)
Memories of one personalitys experience sometimes dont transfer to
another personality
Skeptics argue:
Suspicious that studies on DID began among practitioners of hypnosis
and that symptoms are most dramatic after beginning therapy
Therapists go fishing for multiple personalities: have you ever felt like
another part of you does things you cant control? Does this part of you
have a name? Can I talk to the angry part of you?. Once patients permit
a therapist to talk, by name, to the part of you that says those angry
things, they have begun acting out the fantasy.
If DID is bc of trauma why did the children of Holocaust not develop DID?
 Dissociative Identity Disorder
The personalities or fragments are dissociated
Switch (transition form one personality to another,
includes physical changes)
individuals with DID attempt to hide symptoms
Very high comorbidity (the simultaneous presence of two
chronic diseases or conditions in a patient. Ex. Depression &
anxiety)
Prevalence about 3%
Auditory hallucinations (coming from inside their heads)
97% severe child abuse - Extreme subtype of PTSD
Onset approximately 9 years
Suggestible people may use dissociation as defense against severe trauma
Real and false memories
Treatment DID
Reintegration of identities
Confrontation of early trauma
Hypnosis personalities are more susceptible to listen to therapist who is hypnotizing
Meet the Mother with 20
Personalities | The Oprah
Winfrey Show | Oprah
Winfrey Network
https://www.youtube.com/watch?v=n2atzoaA2NI
PERSONALITY
DISORDERS
Definitions

Personality = the enduring patterns of thinking,

feeling and reacting that define a person
Personality Disorder = an enduring pattern of
inner experience and behaviour that deviates
markedly from the expectations of the
individuals culture APA,2000
Personality Disorders are a construct (clinical)
used to understand, describe and communicate
about the complex phenomena that result when
the personality system is not functioning
optimally
When diagnosing

Pattern must be inflexible and pervasive across a

broad range of personal and social situations

Must be a source of clinically significant distress

or impairment in social, occupational or other
important areas of functioning

Must be stable and of long duration, with an onset

that can be traced back to at least adolescence of
early adulthood
Prevalence

Varies according to gender, social factors and

type
Approx. 10-14% overall
Most prevalent = Obsessive Compulsive,
Dependent, Schizotypal
Least prevalent = Narcissistic, Schizoid
Most visible = Borderline, Antisocial
Assumption of stability over time, but some
more than others (e.g. schizotypal > borderline)
Major Personality
Disorders
Cluster A: odd/eccentric ways of thinking and
behaving
Paranoid: pervasive distrust and suspicion
of others
Schizoid: Social detachment/indifference
and limited emotional experience &
expression
Schizotypal: cognitive and perceptual
distortions; eccentric behaviour; discomfort
with close relationships
Cluster A: odd/eccentric ways of thinking and behaving
Schizoid: Social detachment/indifference and limited
emotional experience & expression
Schizoid Personality Disorder
Pattern of detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings,
beginning by early adulthood and present in a variety of
contexts
A. Four or more of the following:
1. Neither desires nor enjoys close relationships, including being
part of a family
2. Almost always chooses solitary activities
3. Has little, if any, interest in having sexual experiences with
another person
4. Takes pleasure in few, if any, activities
5. Lacks close friends or confidants other than first-degree
relatives
6. Appears indifferent to the praise or criticism of others
7. Shows emotional coldness, detachment, or flattened affect
 Cluster A: odd/eccentric ways of thinking and behaving
Paranoid: pervasive distrust and suspicion of others

Paranoid Personality Disorder

Pervasive distrust and suspiciousness of others such that their
motives are interpreted as malevolent
A. Four or more of the following:
1. Suspects, without sufficient basis, that others are exploiting,
harming, or deceiving him or her
2. Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates
3. Is reluctant to confide in others because of unwarranted fear that
the information will be used maliciously against him or her
4. Reads hidden demeaning or threatening meanings into benign
remarks or events
5. Persistently bears grudges
6. Perceives attacks on his or her character or reputation that are not
apparent to others and is quick to react angrily or to counterattack
7. Has recurrent suspicions, without justification, regarding fidelity of
spouse or sexual partner
Cluster A: odd/eccentric ways of thinking and behaving.
Schizotypal: cognitive and perceptual distortions; eccentric
behaviour; discomfort with close relationships
Schizotypal Personality Disorder
Pattern of social and interpersonal deficits marked by acute
discomfort with, and reduced capacity for, close relationships as
well as by cognitive or perceptual distortions and eccentricities of
behavior
A. Five or more of the following:
1. Ideas of reference
2. Odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms
3. Unusual perceptual experiences including bodily illusions
4. Odd thinking or speech (vague, metaphorical, etc.)
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behavior or appearance that is odd, eccentric, or peculiar
8. Lack of close friends or confidants other than first degree relatives
9. Excessive social anxiety that does not diminish with familiarity
and tends to be associated with paranoid fears rather than
negative judgments about self
Major Personality
Disorders
Cluster B: dramatic/emotional/erratic
Antisocial: disregard for and violation of (the rights
of) others
Borderline: instability of interpersonal
relationships, self-image, emotions, and control over
impulses
Histrionic: excessive emotionality and attention-
seeking
Narcissistic: grandiosity; inflated sense of self-
importance; need for attention; lack of empathy
Examples in film

Borderline: Fatal Attraction

Narcissistic: The Talented Mr. Ripley,
Capote
Paranoid: Conspiracy Theory
Antisocial: Wall Street
Histrionic: Being Julia
 Histrionic Personality Disorder

Pervasive pattern of excessive emotionality and attention seeking,

beginning by early adulthood and present in a variety of contexts
A. Five or more of the following:
1. Is uncomfortable in situations in which he or she is not the center of
attention
2. Interaction with others is often characterized by inappropriate
sexually seductive or provocative behavior
3. Displays rapidly shifting and shallow expression of emotions
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking
in detail
6. Shows self-dramatization, theatrically, and exaggerated expression
of emotion
7. Considers relationships to be more intimate than they actually are
 Narcissistic Personality Disorder
Pervasive pattern of grandiosity (grand/ambitious), need for admiration,
and lack of empathy
A. Five or more of the following:
1. Has a grandiose sense of self-importance
2. Is preoccupied with fantasies of unlimited success, power, brilliance,
beauty, or ideal love
3. Believes that he or she is special and unique and can only be
understood by, or should associate with, other special or high-status
people
4. Requires excessive admiration
5. Has a sense of entitlement (i.e. unreasonable expectations of favorable
treatment or others complying to their expectations)
6. Takes advantage of others
7. Lacks empathy: is unwilling to recognize or identify with the feelings
and needs of others
8. Is often envious of others or believes that others are envious of him/her
9. Shows arrogant behaviors or attitudes
 Cluster B: dramatic/emotional/erratic
Antisocial Personality disorder

Pervasive pattern of disregard for and violation of the rights of others

A. Three or more of the following recurring since age 15
1. Failure to conform to social norms with respect to lawful behaviors as
indicated by repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning
others for personal profit or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, as indicated by repeated physical fights or
assaults
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations
7. Lack of remorse, as indicated by being indifferent to or rationalizing having
hurt, mistreated, or stolen from another
B. At least 18 years old
C. Evidence of Conduct Disorder with onset before age 15
NOTE: Requires symptoms of Conduct Disorder before age 15 (a range of
antisocial types of behavior displayed in childhood or adolescence)..
Only disorder that requires symptoms of another disorder to be present
Antisocial Personality
Disorder
More studied than any other personality disorder
Origins usually traced back to earlier periods in
development (Conduct Disorder), although can not be
diagnosed until late adolescence (DSM criteria)
Has the distinction between ASPD and criminality been
blurred? Not all psychopaths are criminals, and not all
serious offenders are psychopaths.
Psychopathy includes shallow, deceitful, unreliable
and incapable of learning from emotional experience
and seemingly lacking in basic emotions: shame, guilt,
anxiety, remorse (conscience).
Increasing age can bring a change (lessening) in overt
antisocial behaviours: less obvious impulsivity,
recklessness, social deviance. Some argue that the
behaviours merely go underground.
ASPD - Causes

Biological Factors: seems to be a genetic

loading, esp. father-son, but outcome strongly
determined by environment
Temperament and family environment
interaction: parenting (punitive, inconsistent,
low warmth), peers, school

Behavioural and social reinforcers: learned

behaviour resistant to change, modelling, peer
support
ASPD - Born bad?

Psychological factors: inability to anticipate

punishment, lack of anxiety regarding
punishment/negative consequences. Does moral
judgement cause anxiety or vica versa?

Consequent participation in risk-taking, self-promoting

behaviour with reduced ability to interpret (or pay
attention to) nonverbal cues esp. fear, distress, anger,
anxiety. Deficit or decision?

Some people born bad? (GSR, emotional

responsiveness, empathy studies)
ASPD - Treatment

Seldom seek treatment

Oftencoerced into treatment by the legal
system, however, participation does not
always equate with success
Difficulty building a therapeutic relationship
Very high recurrance of behaviour
Limited success with behavioural techniques
 Borderline Personality Disorder
Pervasion pattern of instability of interpersonal relationships,
self-image, and affects, and marked impulsivity
A. Five or more of the following:
1. Frantic efforts to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization
and devaluation
3. Identity disturbance: markedly and persistently unstable self-
image or sense of self
4. Impulsivity in at least two areas that are potentially self-
damaging
5. Recurrent suicidal behavior or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient (short-term), stress-related paranoid ideation or
severe dissociative symptoms
Borderline Personality Di
sorder
Often present due to other complaints (e.g.
somatic, self-harm, anxiety, depression,
abuse history). Large degree of comorbidity
Initially conceptualised as the borderline
between neurosis and schizophrenia but
this no longer the case
Very poor sense of/integration of self leads
to uncertainty about personal values,
identity, worth and choices = erratic,
impulsive and self-damaging behaviour
BPD - more
cognitive/behavioural features
Fear abandonment and crave relationships but
are incapable of maintaining these due to
unrealistic expectations and lack of self-cohesion
Subject to chronic feelings of depression,
worthlessness, emptiness leading to self-harm
and self-deprecating behaviour (e.g. sexual
activity, substance abuse, eating)
May demonstrate dissociation during intense
distress
Splitting tend to see people and events as
either all good or all bad, and can shift rapidly
between these.
BPD - Causes
Biological/genetic:
seems to run in families
and may be associated with genes that
contribute to anxiety, frontal lobe
dysfunction
ObjectRelations: the internalisation of early
caregiving relationships (e.g. inconsistency
= insecurity & ego confusion leads to ego
defence such as splitting)
Diathesis-stress:
vulnerability thresholds
overwhelmed e.g. by abuse & trauma
BPD - Treatment

Perceived as very difficult clients

Therapeutic relationship is key but
threatening to person with BPD therefore
attrition is high, and therapy is made
very challenging
Psychoanalysis uses the transference
relationship to interpret and integrate
Crash Course Personality
Disorders
https://www.youtube.com/watch?v=4E1JiDFxFG
k
Group Activity
Yourgroup is going to
examine 3 cases & decide on
a disorder diagnosis
I will give you some
information and offer some
possibilities, alongside some
more notes that contain more
details
Case 1

Ms Ellie is referred to you by her primary care MD because

she is concerned she has an anxiety disorder. When the pt
comes into your office she is looking down and when she
shakes your hand it is very sweaty. When asked about how
her relationships were in junior high she stated terrible. I
never fit in and didnt do much with other kids because I was
afraid they would judge me.
With this information
what are you thinking
about?
Social phobia?
Avoidant personality disorder?
What do you need to know to
Generalized anxiety disorder? figure out which one if any it is?
Schizoid personality disorder? Does this person have
relationships with others?
You elicit the following
information
She has never had an intimate
relationship although she would like to
have one and has one friend that she
has known since childhood. She is
intensely afraid of of being ridiculed so
works as a transcriptionist from her
home and sits in the back row when she
goes to church. She describes herself as
not as good as other people and
doesnt like to do new things. She
avoids new relationships unless she is
sure they are going to like me.
Her diagnosis

Given the long standing pervasive nature of her

symptoms her diagnosis is most consistent with
Avoidant Personality Disorder. Social phobia
tends to be very situational and GAD
(generalized anxiety disorder) is less pervasive.
Case 2

Jason is a 45 year old male who comes to see you to

establish primary care clinic. He tells you he has to be very
careful about what he eats because certain foods I can
feel work against my system..I feel them as they are
integrated into my body. He also notes he tries to be
careful about what he says because words have
power..they can change the way of things.
With this information
what is your differential
diagnosis?
Schizophrenia?
Delusional disorder?
Mood disorder with psychotic
features?
Schizotypal personality
disorder?
You elicit the following:

He is fairly close to his family but doesnt really

have any other people in his life. He denied
auditory, visual or tactile hallucinations, has no
thought broadcasting or thought insertion and is
able to provide organized answers although you
notice he speaks in a vague way and his affect is
constricted. His appearance is striking because
he is wearing all yellow including his shoes, belt,
hat and earring which he states is because
yellow is the color that recharges me.
 His diagnosis is most consistent with a Schizotypal personality
disorder. He does not have schizophrenia because of lack of
disorganization and lack of true psychotic Sx. He does have
magical thinking but it is not crossing into psychosis. Other
history to obtain would be whether he has a declining course
over time which you often see with schizophrenia.
Case 3

You are picking up your daughter from daycare

and one of the other parents engages you in
conversation. He states I see you got here 5
minutes after the cut off time toare they
going to charge you extra too? You know I
think this daycare is always trying to stick it to
us. I get this same thing at work. I think they
purposely make the clock in times and pick up
times inconvenient so they can dock you here
and there. Its like a conspiracy I swear!
With this information what
is your differential
diagnosis?
Irritated but normal parent?

Persecutory delusional disorder?

Schizophrenia?
Paranoid personality disorder?
You elicit the following:

He goes on to tell you that its been the same

story his whole life. He has been passed over
for promotions at work, he cant trust his friends
any further than he can throw them and he
thinks his wife is cheating on him too. With your
excellent clinical skills you also find out he
doesnt actually believe there is a plot and
doesnt have any psychotic sx.
 Hisdiagnosis is most consistent
with a Paranoid personality
disorder. He has a pervasive
distrust and suspiciousness of
others but it is not to the point of
a delusion and he is not psychotic.
Final thoughts

Itis thought you do not

cure personality disorders
however treatment can
increase the effectiveness of
the patient to function