1. Abnormal Psychology, Twelfth Edition by Ann M. Kring, Sheri L. Johnson, Gerald C. Davison, & John M. Neale & John M. Neale Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.

2.  Chapter 8: Dissociative Disorders and Somatic Symptom Disorders I. Dissociative Disorders II. Somatic Symptom Disorders © 2012 John Wiley & Sons, Inc. All rights reserved.

4.  Dissociation Some aspect of cognition or experience becomes inaccessible to consciousness Some aspect of cognition or experience becomes inaccessible to consciousness  Avoidance response  Sudden disruption in the continuity of: Consciousness Consciousness Emotions Emotions Motivation Motivation Memory Memory Identity Identity © 2012 John Wiley & Sons, Inc. All rights reserved.

5.  How does memory work under stress? Psychodynamic Psychodynamic  Traumatic events are repressed Cognitive Cognitive  Extreme stress usually enhances rather than impairs memory Interference memory formation Interference memory formation  Not accessible to awareness later © 2012 John Wiley & Sons, Inc. All rights reserved.

6.  Inability to recall important personal information Usually about a traumatic experience Usually about a traumatic experience Not ordinary forgetting Not ordinary forgetting Not due to physical injury Not due to physical injury May last hours or years May last hours or years  Usually remits spontaneously © 2012 John Wiley & Sons, Inc. All rights reserved.

7.  Amnesia and flight and new identity Latin fugere, “to flee” Latin fugere, “to flee”  Sudden, unexpected travel with inability to recall one’s past Assume new identity Assume new identity  May involve new name, job, personality characteristics More often of brief duration More often of brief duration Remits spontaneously Remits spontaneously © 2012 John Wiley & Sons, Inc. All rights reserved.

8.  Inability to remember important personal information, usually of a traumatic or stressful nature, that is too extensive to be ordinary forgetfulness  The amnesia is not explained by substances, or by other medical or psychological conditions  Specify dissociative fugue subtype if: the amnesia includes inability to recall one’s past, confusion about identity, or assumption of a new identity, and the amnesia includes inability to recall one’s past, confusion about identity, or assumption of a new identity, and sudden, unexpected travel away from home or work sudden, unexpected travel away from home or work Note: Changes from DSM-IV-TR are italicized Note: Changes from DSM-IV-TR are italicized © 2012 John Wiley & Sons, Inc. All rights reserved.

9.  Memory deficits in explicit but not implicit memory  Explicit memory Involves conscious recall of experiences 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 Underlies behaviors based on experiences that cannot be consciously recalled  e.g., playing tennis, writing a check © 2012 John Wiley & Sons, Inc. All rights reserved.

10.  Distinguishing other causes of memory loss from dissociation: Dementia Dementia  Memory fails slowly over time  Is not linked to stress  Accompanied by other cognitive deficits  Inability to learn new information Memory loss after a brain injury Memory loss after a brain injury Substance abuse Substance abuse © 2012 John Wiley & Sons, Inc. All rights reserved.

11.  Perception of self is altered Triggered by stress or traumatic event Triggered by stress or traumatic event No disturbance in memory No disturbance in memory No psychosis or loss of memory No psychosis or loss of memory Often comorbid with anxiety, depression Often comorbid with anxiety, depression Typical onset in adolescence Typical onset in adolescence Chronic course Chronic course © 2012 John Wiley & Sons, Inc. All rights reserved.

12.  Depersonalization Lose sense of self Lose sense of self Unusual sensory experiences Unusual sensory experiences  Limbs feel deformed or enlarged  Voice sounds different or distant Feelings of detachment or disconnection Feelings of detachment or disconnection  Watching self from outside  Floating above one’s body  Derealization World has become unreal World has become unreal  World appears strange, peculiar, foreign, dream-like  Objects appear at times strangely diminished in size, at times flat  Incapable of experiencing emotions  Feeling as if they were dead, lifeless, mere automatons © 2012 John Wiley & Sons, Inc. All rights reserved.

13.  Depersonalization: Persistent or recurrent experiences of detachment from one’s mental processes or body, as though one is in a dream, despite intact reality testing, or  Derealization: persistent or recurrent experiences of unreality of surroundings  Symptoms are not explained by substances, another dissociative disorder, another psychological disorder, or by a medical condition Note: Changes from DSM-IV-TR are italicized Note: Changes from DSM-IV-TR are italicized © 2012 John Wiley & Sons, Inc. All rights reserved.

14.  Two or more distinct and fully developed personalities (alters) Each has unique modes of being, thinking, feeling, acting, memories, and relationships Each has unique modes of being, thinking, feeling, acting, memories, and relationships Primary alter may be unaware of existence of other alters Primary alter may be unaware of existence of other alters  Most severe of dissociative disorders Recovery may be less complete Recovery may be less complete  Typical onset in childhood Rarely diagnosed until adulthood Rarely diagnosed until adulthood  More common in women than men  Often comorbid with: PTSD, major depression, somatic symptoms PTSD, major depression, somatic symptoms  Has no relation to schizophrenia No thought disorders or behavioral disorganization No thought disorders or behavioral disorganization © 2012 John Wiley & Sons, Inc. All rights reserved.

15.  A. Disruption of identity characterized by two or more distinct personality states (alters) or an experience of possession, as evidenced by discontinuities in sense of self, cognition, behavior, affect, perceptions, and/or memories. This disruption may be observed by others or reported by the patient  B. At least two of the alters recurrently take control of behavior  C. Inability of at least one of the alters to recall important personal information  D. Symptoms are not part of a broadly accepted cultural or religious practice, and are not due to drugs or a medical condition Note: The DSM-IV-TR criterion A is less detailed. It specifies the presence of two or more identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self) Note: The DSM-IV-TR criterion A is less detailed. It specifies the presence of two or more identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self) © 2012 John Wiley & Sons, Inc. All rights reserved.

16.  Epidemiology No identified reports of DID or dissociative amnesia before 1800 (Pope et al., 2006) No identified reports of DID or dissociative amnesia before 1800 (Pope et al., 2006) Major increases in rates since 1970s Major increases in rates since 1970s  DSM-III (1980) Diagnostic criteria more explicit Diagnostic criteria more explicit  Appearance of DID in popular culture Sybil Sybil The Three Faces of Eve The Three Faces of Eve Book and movie received much attention Book and movie received much attention © 2012 John Wiley & Sons, Inc. All rights reserved.

17.  Posttraumatic Model DID results from severe psychological and/or sexual abuse in childhood DID results from severe psychological and/or sexual abuse in childhood  Sociocognitive Model DID a form of role-play in suggestible individuals DID a form of role-play in suggestible individuals  Occurs in response to prompting by therapists or media  No conscious deception © 2012 John Wiley & Sons, Inc. All rights reserved.

18.  Evidence raised in theory debate DID can be role-played 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 DID patients show only partial implicit memory deficits  Alters “share” memories (Huntjen et al., 2003) DID diagnosis differs by clinician DID diagnosis differs by clinician  A few clinicians diagnose the majority of DID cases For many, symptoms emerge after therapy begins For many, symptoms emerge after therapy begins © 2012 John Wiley & Sons, Inc. All rights reserved.

19.  Most treatments involve: Empathic and supportive therapist Empathic and supportive therapist Integration of alters into one fully functioning individual Integration of alters into one fully functioning individual Improvement of coping skills Improvement of coping skills  Psychodynamic approach adds: Overcome repression Overcome repression Use of hypnosis Use of hypnosis  Age regression  Can actually worsen symptoms © 2012 John Wiley & Sons, Inc. All rights reserved.

20.  Excessive concerns about physical symptoms or health ‘Soma’ means body ‘Soma’ means body  In DSM-IV-TR physical symptoms have no known physical cause Nearly impossible to know actual cause Nearly impossible to know actual cause DSM-5 removes requirement that symptoms not be medically caused DSM-5 removes requirement that symptoms not be medically caused  Three major somatic symptom disorders: Complex somatic symptom disorder Complex somatic symptom disorder Illness anxiety disorder Illness anxiety disorder Functional neurological syndrome Functional neurological syndrome © 2012 John Wiley & Sons, Inc. All rights reserved.

23.  At least one somatic symptom that is distressing or disrupts daily life  Excessive thoughts, feelings, and behaviors related to somatic symptom(s) or health concerns, as indicated by at least two of the following: health-related anxiety, disproportionate concerns about the medical seriousness of symptoms, and excessive time and energy devoted to health concerns  Duration of at least 6 months  Specify: predominant somatic complaints, predominant health anxiety, or predominant pain © 2012 John Wiley & Sons, Inc. All rights reserved.

24.  DSM-IV-TR separates the diagnoses of Pain Disorder (in which the primary symptom involved pain) and Somatization Disorder (which involves multiple somatic symptoms from various body systems)  DSM-5 merges these two diagnoses into Complex Somatic Symptom Disorder  DSM-5 places more emphasis on distress and behavior accompanying somatic symptoms, rather than the number or range of somatic symptoms © 2012 John Wiley & Sons, Inc. All rights reserved.

25.  Preoccupation with and high level of anxiety about having or acquiring a serious disease  Excessive behaviors (e.g., checking for signs of illness, seeking reassurance) or maladaptive avoidance (e.g., avoiding medical care or ill relatives)  No more than mild somatic symptoms are present  Not explained by other psychological disorders  Preoccupation lasts at least 6 months Note: Illness anxiety disorder is a new diagnosis in the DSM-5, but it has some parallels with the DSM-IV-TR diagnosis of hypochondriasis. Criteria that differ from the DSM-IV-TR diagnosis of hypochondriasis are italicized. The DSM-IV-TR criteria for hypochondriasis specify that the preoccupation must continue despite medical reassurance. Note: Illness anxiety disorder is a new diagnosis in the DSM-5, but it has some parallels with the DSM-IV-TR diagnosis of hypochondriasis. Criteria that differ from the DSM-IV-TR diagnosis of hypochondriasis are italicized. The DSM-IV-TR criteria for hypochondriasis specify that the preoccupation must continue despite medical reassurance. © 2012 John Wiley & Sons, Inc. All rights reserved.

26.  Conversion Disorder in DSM-IV-TR  Sensory or motor function impaired but no known neurological cause Vision impairment or tunnel vision Vision impairment or tunnel vision Partial or complete paralysis of arms or legs Partial or complete paralysis of arms or legs Seizures or coordination problems Seizures or coordination problems Aphonia Aphonia  Whispered speech Anosmia Anosmia  Loss of smell © 2012 John Wiley & Sons, Inc. All rights reserved.

27.  Hippocrates Believed disorder only occurred in women Believed disorder only occurred in women Attributed it to a wandering uterus Attributed it to a wandering uterus  Originally known as Hysteria  Greek word for uterus  Freud Coined term conversion Coined term conversion Anxiety and conflict converted into physical symptoms Anxiety and conflict converted into physical symptoms Famous case of Anna O. Famous case of Anna O. © 2012 John Wiley & Sons, Inc. All rights reserved.

28.  One or more neurologic symptoms affecting voluntary motor function, sensory function, cognition, or seizure- like episodes  The physical signs or diagnostic findings are internally inconsistent or incongruent with recognized neurological disorder  Symptoms cannot be explained by a medical condition  Symptoms cause significant distress or functional impairment or warrant medical evaluation Note: DSM-IV-TR criteria for Conversion Disorder specify that symptoms are related to conflict or stress and are not intentionally produced Note: DSM-IV-TR criteria for Conversion Disorder specify that symptoms are related to conflict or stress and are not intentionally produced © 2012 John Wiley & Sons, Inc. All rights reserved.

29.  Onset typically adolescence or early adulthood Often follows life stress Often follows life stress  Prevalence less than 1% More common in women than men More common in women than men  Often comorbid with: Other Somatic symptom disorders Other Somatic symptom disorders Major depressive disorder Major depressive disorder Substance use disorders Substance use disorders © 2012 John Wiley & Sons, Inc. All rights reserved.

30.  No support for genetic influence Concordance rates in MZ twin pairs do not differ from DZ twin pairs Concordance rates in MZ twin pairs do not differ from DZ twin pairs  Why are some people more aware and distressed by bodily sensation? Anterior insula and anterior cingulate hyperactive Anterior insula and anterior cingulate hyperactive Somatic symptoms influenced by emotions and stress Somatic symptoms influenced by emotions and stress © 2012 John Wiley & Sons, Inc. All rights reserved.

31.  Two important cognitive variables: Attention to bodily sensations Attention to bodily sensations  Automatic focus on physical health cues Attributions (interpretation) of those sensations Attributions (interpretation) of those sensations  Overreact with overly negative interpretations  Two important consequences: Sick role limits healthy life alternatives Sick role limits healthy life alternatives Help-seeking behaviors reinforced by attention or sympathy Help-seeking behaviors reinforced by attention or sympathy © 2012 John Wiley & Sons, Inc. All rights reserved.

33.  Unconscious psychological factor cause  Blindsight Not consciously aware of visual input Not consciously aware of visual input Failure to be explicitly aware of sensory information Failure to be explicitly aware of sensory information © 2012 John Wiley & Sons, Inc. All rights reserved.

34.  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 Higher incidence may have been due to more repressed sexual attitudes or low tolerance for anxiety symptoms  More prevalent In rural areas In rural areas In individuals of lower SES In individuals of lower SES In non-Western cultures In non-Western cultures © 2012 John Wiley & Sons, Inc. All rights reserved.

35.  Few controlled treatment outcome studies  Cognitive Behavioral Treatment Identify and change triggering emotions Identify and change triggering emotions Change cognitions about symptoms Change cognitions about symptoms Replace sick role behaviors with more appropriate social interactions Replace sick role behaviors with more appropriate social interactions  Antidepressants Tofranil Tofranil  Effective even at low dosages that do not alleviate depressive symptoms © 2012 John Wiley & Sons, Inc. All rights reserved.

36. Copyright 2012 by John Wiley & Sons, Inc. 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. © 2012 John Wiley & Sons, Inc. All rights reserved.