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

Dissociative Disorders Sudden disruption in the continuity of: Consciousness Memory Identity Dissociation Some aspect of cognition or experience becomes inaccessible to consciousness Avoidance response Copyright 2009 John Wiley & Sons, NY

Table 6.1 Summary of Dissociative Disorders Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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. Copyright 2009 John Wiley & Sons, NY

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) Copyright 2009 John Wiley & Sons, NY

Memory Deficits and Dissociation Memory deficits in explicit but not implicit memory Explicit memory Involves conscious recall of experiences e.g., senior prom, mom’s birthday party Implicit memory Underlies behaviors based on experiences that cannot be consciously recalled e.g., playing tennis, writing a check Copyright 2009 John Wiley & Sons, NY

Memory Deficits and Dissociation 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY Dissociative Fugue Amnesia plus flight Latin fugere, “to flee” Sudden, unexpected travel with inability to recall one’s past Assume new identity May involve new name, job, personality characteristics More often of brief duration Remits spontaneously Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY Dissociative Fugue DSM-IV-TR criteria Sudden, unexpected travel away from home or work Inability to recall one’s past Confusion about identity or assumption of new identity Symptoms are not explained by another medical or psychological disorder Copyright 2009 John Wiley & Sons, NY

Depersonalization Disorder Perception of self is altered Feelings of detachment or disconnection Watching self from outside Floating above one’s body Emotional numbing Unusual sensory experiences Limbs feel deformed or enlarged Voice sounds different or distant Copyright 2009 John Wiley & Sons, NY

Depersonalization Disorder 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 Copyright 2009 John Wiley & Sons, NY

Depersonalization Disorder DSM-IV-TR criteria Persistent or recurrent experiences of detachment from one’s 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 Copyright 2009 John Wiley & Sons, NY

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 Copyright 2009 John Wiley & Sons, NY

Dissociative Identity Disorder (DID) 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 Copyright 2009 John Wiley & Sons, NY

Dissociative Identity Disorder (DID) 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 Copyright 2009 John Wiley & Sons, NY

Dissociative Identity Disorder (DID) 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 Copyright 2009 John Wiley & Sons, NY

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 Copyright 2009 John Wiley & Sons, NY

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 Copyright 2009 John Wiley & Sons, NY

Figure 6.1 Handwriting Samples from Four DID Cases Copyright 2009 John Wiley & Sons, NY

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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Table 6.2 Summary of Somatoform Disorders Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

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 ¼ have plastic surgery Disappointing results Almost ½ have suicidal thoughts Copyright 2009 John Wiley & Sons, NY

Body Dysmorphic Disorder 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 Copyright 2009 John Wiley & Sons, NY

Body Dysmorphic Disorder 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Somatization Disorder First noted by Pierre Briquet in 1859 Known as Briquet’s 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 Copyright 2009 John Wiley & Sons, NY

Somatization Disorder 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 Copyright 2009 John Wiley & Sons, NY

Somatization Disorder 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 person’s medical condition Symptoms do not appear to be faked Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY 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 Copyright 2009 John Wiley & Sons, NY

Figure 6.2 Glove Anesthesia Copyright 2009 John Wiley & Sons, NY

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 Copyright 2009 John Wiley & Sons, NY

Etiology of Conversion Disorder: Genetic Factors No support for genetic influence Concordance rates in MZ twin pairs do not differ from DZ twin pairs Copyright 2009 John Wiley & Sons, NY

Etiology of Conversion Disorder: Social and Cultural Factors Decrease in incidence of conversion disorders since last half of 19th 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 Copyright 2009 John Wiley & Sons, NY

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) Copyright 2009 John Wiley & Sons, NY

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 Copyright 2009 John Wiley & Sons, NY

Treatment of Pain Disorder Antidepressants Tofranil Effective even with low dosages that don’t alleviate depressive symptoms Components of psychotherapy for pain disorder Validation of patient’s 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 Copyright 2009 John Wiley & Sons, NY

Treatment of Body Dysmorphic Disorder Cognitive Behavioral Therapy Exposure plus response prevention Prevent individual from checking appearance Antidepressants Fluoxetine (Prozac) Clomipramine (Anafranil) Copyright 2009 John Wiley & Sons, NY

Treatment of Hypochondriasis Cognitive Behavioral Therapy Reduce excessive attention to bodily sensations Challenge negative perceptions about sensations Discourage reassurance seeking from medical professionals Copyright 2009 John Wiley & Sons, NY

Treatment of Somatization Disorder Most accepted approach: Medical professionals don’t 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 Copyright 2009 John Wiley & Sons, NY

Treatment of Conversion Disorder No controlled studies to date Psychoanalytic treatments have not demonstrated usefulness Reinforcement of high functioning behavior may help Copyright 2009 John Wiley & Sons, NY

Copyright 2009 John Wiley & Sons, NY Copyright 2009 by John Wiley & Sons, New York, NY. All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the copyright owner. Copyright 2009 John Wiley & Sons, NY