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Abnormal Psychology PSY404

Lesson 33

DISSOCIATIVE and SOMATOFORM DISORDERS

Individuals with a dissociative disorder experience a severe disruption or alteration of their identity,

memory, or consciousness. It is based on the unbelievable things.

Example

A housewife forgets her name her entire past life she has dissociative disorder.

Kinds of Dissociative disorders

The types of dissociative disorders discussed in this lecture are dissociative amnesia, dissociative fugue,

dissociative identity disorder and depersonalized disorder. Although dissociative disorders typically involve

disruption of identity, dissociative amnesia can involve loss of memory without loss of identity.

Diagnosis of Dissociative Disorders

· For centuries, theorists considered dissociative and somatoform disorders as alternative forms of

hysteria.

· However, the descriptive approach to classification introduced in DSM-III (1980) led to the

separation of dissociative and somatoform disorders into discrete diagnostic categories.

· The distinction is preserved in DSM-IV-TR (2000), because the symptoms of the two disorders

differ greatly.

1- The symptoms of dissociative disorders apparently involve mental processes that occur outside of

conscious awareness.

2- Extreme cases of dissociation include a split in the functioning of individual's sense of self.

3- Depersonalization is a form of dissociation wherein people feel detached from themselves or their

social or physical environment.

4- Amnesia--the partial or complete loss of recall for particular events or for a particular period of

time.

5- Brain injury or disease can cause amnesia.

6- But Psychogenic Amnesia (psychologically caused) results from traumatic stress or other emotional

distress. Psychogenic amnesia may occur alone or in conjunction with other dissociative experiences.

7- It is widely accepted that psychogenic fugue and psychogenic amnesia are usually precipitated by

trauma, thus providing another link between dissociation and traumatic stress disorders.

Some researchers and clinicians argue that DID is linked with a past trauma, particularly with child's

physical or sexual abuse. The term psychogenic was used in the names of these disorders- as in

psychogenic amnesia and psychogenic fugue - to indicate that the fugue or memory loss is not

physically caused.

1-Dissociative Amnesia

each of us, throughout our lives, has forgotten certain things- a

person's name, a friend's birthday, the need to stop at a store on the way home. Forgetfulness, however,

is not yet the same as memory loss. The person with memory loss is unable to recall important personal

information too extensive to be viewed in terms of forgetfulness. When there is actual damage to the

brain, from injury or disease, the information that isn't recalled is lost forever.

· But in dissociative (psychogenic) amnesia, the memory system is not physically damaged, yet there

is selective psychologically motivated forgetting. Often, what has been forgotten is traumatic for

the individual. It can sometimes be retrieved from memory.

· There are two main types of amnesia: selective and generalized. In cases of selective dissociative

amnesia, a person forgets some but not of what happened during a certain period of time.

· In contrast to the selective dissociative amnesia, the person who is suffering from generalized

dissociative amnesia forgets one's entire life history.

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2-Dissociative fugue

the fugue state involves physical retreat; during a fugue, the individual

suddenly and unexpectedly departs. Two important features for diagnosing dissociative

(psychogenic) fugue are listed in DSM-IV: a sudden unexpected travel away from home or work

with an inability to recall one's past, and confusion about personal identity. Marked confusion about

personal identity interferes with routine daily activities, so in an effort to adjust and relate to others, the

person assumes a new identity. Despite the new assumed identity, characteristics of the "old self" are

recognizable. Often, complicated behaviors are carried out during the fugue. A victim may drive a long

distance, find a place to live, obtain employment, and begin a new life.

3-Dissociative identity disorder (DID), also known as multiple personality disorder, is

characterized by the existence of two or more distinct personalities in a single individual.

· At least two of these personalities repeatedly take control of the person's behavior, and the

individual's inability to recall information is too extensive to be explained by ordinary forgetfulness.

· The original personality especially is likely to have amnesia for subsequent personalities, which may

or may not be aware of the "alternates."

· Examples

1-"Sybil," a girl with sixteen personalities, DID is characterized by the presence of two or more distinct

personalities of personality states within one individual patterns.

2-The Three Faces of Eve, who describe a client, whose three different personalities virtual opposites in

terms of their emotional and behavioral patterns. Eve White was the quiet, polite, hard-working, and

conservative mother of a young daughter; Eve Black was seductive, impulsive, risk-taking, and

adventure-seeking. Jane, the third personality was a confident and capable woman.

4-Depersonalization disorder is a less dramatic problem that is characterized by severe and persistent

feelings of being detached from oneself.

· Depersonalization experiences include such sensations as feeling as though you were in a dream or

were floating above your body and observing yourself as acting.

SOMATOFORM DISORDERS

Do some individuals really need a cabinet full of medicines to deal with their many ailments, or they

might benefit more from psychological counseling?

· Do we sometimes respond physically- for example, by becoming paralyzed- to psychological stress?

· When mind-body interactions are maladaptive, a somatoform disorder may result. Somatoform

disorders involve physical symptoms, in the absence of physical illness for which there is no

adequate explanation. (Soma means body, and somatoform means "bodylike." One patient with a

somatoform disorder may report being blind but according to medical tests, have normal

functioning eyes.

· Somatoform disorders are problems characterized by unusual physical symptoms that occur in the

absence of a known physical illness.

1-There is no demonstrable physical cause for the symptoms of somatoform disorders. They are

somatic (physical) in form only-- their name.

2-All somatoform disorders involve complaints about physical symptoms, but not caused by physical

impairments. There is nothing physically wrong with the patient.

3-The physical problem is very real in the mind, though not the body, of the person with a somatoform

disorder.

4-The physical symptoms can take a number of different forms substantial impairment of a somatic

system, particularly a sensory or muscular system. The patient will be unable to see, for example, or will

report a paralysis in one arm.

5-In other types of somatoform disorder, patients experience multiple physical symptoms usually

numerous, complaints about such problems as chronic pain, upset stomach, and dizziness.

6-Finally, some types of somatoform disorder are defined by a preoccupation

A- With a particular part of the body say eyes or stomach or

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B- With fears about a particular illness.

The patient may constantly worry that he or she has contracted some deadly disease, for example, and

the anxiety persists despite negative medical tests and clear reassurance by a physician.

7-People with somatoform disorders typically do not bring their problems to the attention of a mental

health professional.

Instead, they repeatedly consult their physicians about their "physical" problems. This often leads to

unnecessary medical treatment.

Kinds of Somatoform Disorders

DSM-IV-TR lists five major subcategories of somatoform disorders:

(1) Conversion disorder

(2) Somatization disorder

(3) Hypochondriasis

(4) Pain disorder

(5) Body Dysmorphic disorder

1- Conversion Disorder

· The symptoms of conversion disorder often mimic those found in neurological diseases, and they

can be dramatic.

· "Hysterical" blindness or "hysterical" paralysis are examples of conversion symptoms. Although

conversion disorders often resemble neurological impairments, they sometimes can be

distinguished from these disorders because they make no anatomic sense. The term conversion

disorder accurately conveys the central assumption of the diagnosis--the idea that psychological

conflicts are converted into physical symptoms.

· One or more symptoms or deficits affecting voluntary sensory or motor functioning that cannot be

explained by a neurological or general medical condition (after appropriate investigation) and is not

a culturally sanctioned behavior. Psychological factors (though not intentional) are judged to be

involved because symptoms are exacerbated under stress and the symptoms are useful for the

patient's avoidance of stress. The symptoms or deficits cause clinically significant distress or

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

2-Somatization disorder

· Somatization disorder is characterized by a history of multiple somatic complaints in the absence of

organic impairments.

· In order to be diagnosed with somatization disorder, the patient must complain of at least eight

physical symptoms and must involve multiple somatic systems.

· Patients with somatization disorders sometimes present their symptoms in a histrionic manner--a

vague but dramatic, self-centered, and seductive style. Patients also may exhibit la belle indifference

("beautiful indifference"), a flippant lack of concern about the physical symptoms.

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3-Hypochondriasis

· Hypochondriasis is a problem characterized by a fear or belief that one is suffering from a physical

illness.

· Hypochondriasis is much more serious than normal and fleeting worries.

· The preoccupation with fears of disease extends over long periods of time.

· In addition, in hypochondriasis, a thorough medical evaluation or examination does not alleviate

the fear of the disease.

· Based on misinterpretations of bodily reactions, the sufferer is preoccupied with fears of having a

serious disease. Though not a delusion, the fear persists despite medical evaluations. The

preoccupation causes clinical distress of at least six months duration.

4-Pain disorder

· Pain disorder is characterized by preoccupation with pain.

· Complaints seem excessive and apparently are motivated at least in part by psychological factors.

· As with hypochondriasis and somatization disorder, pain disorder can lead to the repeated,

unnecessary use of medical treatments.

5-Body dysmorphic disorder

· Body dysmorphic disorder is a somatoform disorder in which the patient is preoccupied with some

imagined defect in appearance.

· The preoccupation typically focuses on some facial feature, such as the nose or mouth, and in some

cases may lead to repeated visits to a plastic surgeon.

· Preoccupation with the body part far exceeds normal worries about physical imperfections.

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Preoccupation with and imagined defect in appearance causes clinically significant distress or

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

5-Somatoform disorders must be distinguished from malingering, pretending to have a somatoform

disorder in order to achieve some external gain, such as a disability payment.

6-A related diagnostic concern is factitious disorder, a fake condition that, unlike malingering, is

motivated primarily by a desire to assume the sick role rather than a desire for external gain.

7-A rare, repetitive pattern of factitious disorder is sometimes called Munchausen syndrome, named

after Baron Karl Friedrich Hieronymus von Munchausen, an eighteenth-century writer known for his

tendency to embellish the details of his life.

Frequency of Somatoform Disorders

Conversion disorders are rare, perhaps as infrequent as 50 cases per 100,000 population. Most other

somatoform disorders also appear to be relatively rare. For example, one study found a 0.7 percent

prevalence of body dysmorphic disorder.

Hypochondriasis is also quite rare, although less severe worrying about physical illness is quite

common. The lifetime prevalence of somatization disorder in the United States is only 0.13 percent.

With the exception of hypochondriasis, all other forms of somatoform disorder are more common

among women. This is particularly true of somatization disorder, which may be as much as10 times

more common among women than men.

In addition to gender, socioeconomic status and culture are thought to contribute to somatization

disorder. In the United States, somatization is more common among lower socioeconomic groups and

people with less than a high school education. It is four times more common among African

Americans. Somatoform disorders typically occur with other psychological problems, particularly

depression and anxiety. Finally, somatization disorder has frequently been linked with antisocial

personality disorder, a lifelong pattern of irresponsible behavior that involves habitual violations of

social rules.

The two disorders do not typically co-occur in the same individual, but they often are found in different

members of the same family. An obvious--and potentially critical --biological consideration in

somatoform disorders is the possibility of misdiagnosis. A patient may be incorrectly diagnosed as

suffering from a somatoform disorder when, in fact, he or she actually has a real physical illness that is

undetected or is perhaps unknown. Because mental health professionals cannot demonstrate

psychological causes of physical symptoms objectively and unequivocally, the identification of

somatoform disorders involves a process called diagnosis by exclusion.

The physical complaint is assumed to be a part of a somatoform disorder only when various known

physical causes are excluded or ruled out. Initially, both Freud and Janet assumed that conversion

disorders were caused by a traumatic experience. Freud later came to believe that dissociation and other

intrapsychic defenses protected individuals from their unacceptable sexual impulses, not from their

intolerable memories. In Freud's view, conversion symptoms were expressions of intolerable

unconscious psychological conflicts. In Freudian terminology, this is the primary gain of the symptom.

Freud also suggested that hysterical symptoms could produce secondary gain, for example, avoiding

work or responsibility or to gain attention and sympathy.

Social and cultural theorists offer a straightforward explanation of the physical symptoms of

somatization disorder, hypochondriasis, and pain disorder. Patients with these disorders are

experiencing some sort of underlying psychological distress. However, they describe their problems as

physical symptoms and, to some extent, experience them that way because of limited insight and/or the

lack of social tolerance of psychological complaints.

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Treatment of Somatoform Disorders

1- Cognitive behavior therapy is effective in reducing physical symptoms in somatization disorder,

hypochondriasis, and body dysmorphic disorder.

2-Recent evidence also indicates that antidepressants may be helpful in treating somatoform disorders.

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