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Abnormal Psychology, Twelfth Edition

by
Ann M. Kring,
Sheri L. Johnson,
Gerald C. Davison,
& John M. Neale
Copyright © 2012 John Wiley & Sons, Inc. All rights reserved.
 Chapter8: Dissociative Disorders and
Somatic Symptom Disorders

I. Dissociative Disorders
II. Somatic Symptom Disorders

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


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

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


 How does memory work under stress?
• Psychodynamic
 Traumatic events are repressed
• Cognitive
 Extreme stress usually enhances rather than impairs memory
• Interference memory formation
 Not accessible to awareness later

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


 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

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


 Amnesia and flight and new identity
• 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

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


 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
• sudden, unexpected travel away from home or work
• Note: Changes from DSM-IV-TR are italicized

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


 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

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


 Distinguishing other causes of memory loss from
dissociation:
• 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
• Substance abuse

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


 Perception of self is altered
• Triggered by stress or traumatic event
• No disturbance in memory
• No psychosis or loss of memory
• Often comorbid with anxiety, depression
• Typical onset in adolescence
• Chronic course

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


 Depersonalization
• Lose sense of self
• Unusual sensory experiences
 Limbs feel deformed or enlarged
 Voice sounds different or distant
• Feelings of detachment or disconnection
 Watching self from outside
 Floating above one’s body

 Derealization
• 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.


 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

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


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

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


 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)
© 2012 John Wiley & Sons, Inc. All rights reserved.
 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
• The Three Faces of Eve
• Book and movie received much attention

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


 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

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


 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

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


 Most treatments involve:
• Empathic and supportive therapist
• Integration of alters into one fully functioning
individual
• Improvement of coping skills

 Psychodynamic approach adds:


• Overcome repression
• Use of hypnosis
 Age regression
 Can actually worsen symptoms

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


 Excessive concerns about physical symptoms or
health
• ‘Soma’ means body
 In
DSM-IV-TR physical symptoms have no known
physical cause
• Nearly impossible to know actual cause
• DSM-5 removes requirement that symptoms not be medically
caused
 Three major somatic symptom disorders:
• Complex somatic symptom disorder
• Illness anxiety disorder
• Functional neurological syndrome

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


© 2012 John Wiley & Sons, Inc. All rights reserved.
© 2012 John Wiley & Sons, Inc. All rights reserved.
 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.


 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.
 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.
© 2012 John Wiley & Sons, Inc. All rights reserved.
 Conversion Disorder in DSM-IV-TR
 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
• Aphonia
 Whispered speech
• Anosmia
 Loss of smell

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


 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
• Famous case of Anna O.

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


 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

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


 Onset typically adolescence or early adulthood
• Often follows life stress
 Prevalence less than 1%
• More common in women than men
 Often comorbid with:
• Other Somatic symptom disorders
• Major depressive disorder
• Substance use disorders

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


 No support for genetic influence
• 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
• Somatic symptoms influenced by emotions and stress

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


 Two important cognitive variables:
• Attention to bodily sensations
 Automatic focus on physical health cues
• Attributions (interpretation) of those sensations
 Overreact with overly negative interpretations
 Two important consequences:
• Sick role limits healthy life alternatives
• Help-seeking behaviors reinforced by attention or
sympathy

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


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

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


 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

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


 Fewcontrolled treatment outcome studies
 Cognitive Behavioral Treatment
• Identify and change triggering emotions
• Change cognitions about symptoms
• Replace sick role behaviors with more appropriate
social interactions
 Antidepressants
• Tofranil
 Effective even at low dosages that do not alleviate depressive
symptoms

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


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.

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