Transcript Rieger Chapter Summaries PowerPoint 05

CHAPTER 5
SOMATOFORM AND
DISSOCIATIVE DISORDERS
5-1
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
AIMS AND OBJECTIVES

Define somatoform and dissociative disorders

Describe historical approaches

Review information regarding prevalence, age of onset, and
course

Discuss current aetiological findings

Outline treatment approaches
5-2
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Somatoform disorders involve the presentation of medically
unexplained symptoms

Dissociative disorders involve the loss of normal integration
of identity, memory, perception, or consciousness

Dissociation is the mechanism whereby one part of mental
functioning (e.g., memory, consciousness, perception, or
identity) is split off from the rest

Factitious disorders involve the deliberate feigning of
illness, usually to gain the security or care of medical attention
(e.g., Munchausen’s syndrome)
5-3
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Historical approaches

The ancient term “hysteria,” referred to nonfatal malady of
women that included different types of bodily symptoms

The most classic case of hysteria is Anna O, written by Joseph
Breurer and Sigmund Freud

Anna O was a young Viennese woman who reported multiple
somatoform symptoms, which were suggested to be associated
with the psychological trauma of her father’s illness and death
5-4
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Historical approaches

The term conversion signifies the transformation of
psychological material into somatic symptoms

The treatment of Anna O was the first described case of the
psychoanalysis, the “talking cure”

Freud theorised that hysteria was the result of consciously
unacceptable sexual fantasies from childhood
5-5
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE DISORDERS

Somatoform disorders

To be assigned a somatoform disorder diagnosis, the
symptoms must be understood to derive from psychological
factors, rather than having a medical basis

DSM-IV-TR somatoform diagnoses include:

Conversion disorder - a motor or sensory neurological disturbance
(e.g., paralysis) that onsets after a psychological stress, with no
physical disorder to explain the impairment

Pain disorder - severe pain in one or more anatomical sites, not
fully explainable by physical pathology
5-6
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE DISORDERS

Somatoform disorders

DSM-IV-TR somatoform diagnoses (cont.)



Somatisation disorder - a history of multiple physical complaints in
several different body sites, beginning before age 30 and occurring
over several years
Hypochondriasis – Preoccupation with fears of having or belief that
one has a serious disease despite appropriate medical reassurance
Body dysmorphic disorder – preoccupation with an imagined defect
in appearance, with markedly excessive concern
5-7
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Somatoform disorders

Epidemiology

Medically unexplained physical symptoms are common, not just in
those with somatoform disorders

Formal clinical somatoform disorders are rare in the general
community; much more prevalent among high utilisers of health
services

Anxiety and depression are common in people with unexplained
physical symptoms and those with somatoform disorder

Somatoform disorders are more common among women
5-8
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Aetiology

Biological factors



Research has found underactivity of hypothalamic-pituitary-adrenal
(HPA) axis in patients with unexplained symptoms, such as fatigue
Neurobiological models focus on how sensory/motor info is
processed
Gate Control Theory (Melzak & Wall, 1965) of pain:




Neural “gates” in the spinal cord can be opened or closed, determining the
amount of pain the individual experiences
More activity in the pain fibers  more gates are opened
More activity in the peripheral fibers regarding stimuli around the body 
more gates are closed
Messages from the brain can open or close the gates
5-9
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Aetiology

Trauma and personality factors

Patients with somatoform disorders more likely to have experienced
adverse events in childhood

One theory proposes that memory of early trauma is contained in
emotions, reflex actions, or bodily sensations (van der Kolk, 1994)

Negative events in childhood may also give rise to personality
characteristics that predispose the person to a somatoform disorder


People with somatoform disorders have higher rates of alexithymia, difficulty
experiencing or expressing emotions
Failing to identify and express emotional distress may lead to
increased physiological arousal
5-10
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Aetiology

Cognitive and behavioural factors

Cycle of somatosensory amplification – tendency to experience
somatic sensations as intense and distressing
5-11
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Treatment

Acute somatoform disorders

When patient presents to GP with pain and tests are normal, GP
may undertake reattribution, which consists of 3 steps:



Thorough history and physical examination
“Broadening the agenda” – explaining that pain may be caused by
psychosocial factors
Making the link between psychological factors and physical symptoms
5-12
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Treatment

Chronic somatoform disorders



Conduct thorough physical and psychiatric assessment
Identify single case manager to ensure coordinated
approach
Employ specific psychological interventions, such as:




challenging illness attributions,
self-monitoring, and
coping strategies, such as progressive muscle relaxation
Specific somatoform disorders

Hypochondriasis


Specific CBT interventions, including education, reattribution,
attention exercises
Body dysmorphic disorder

Graduated exposure, cognitive restructuring, attention training
5-13
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Dissociative disorders

Description of dissociative experiences and disorders






Amnesia – absence of memory for a period of time
Depersonalisation – change in individual’s sense of physical
self
Derealisation – change in individual’s sense of the world
Identity confusion – feelings of uncertainty regarding one’s
identity
Identity alteration – objective behaviours indicating that an
individual has assumed alternative identities at different times
DSM-IV-TR diagnoses of dissociative disorders




Depersonalisation disorder
Dissociative amnesia
Dissociative fugue – sudden unexpected travel away from
home with inability to recall one’s past and identity confusion
Dissociative identity disorder – 2 or more distinct identities
5-14
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Dissociative disorders

Epidemiology




Prevalence data for dissociative disorders not well
established
Depersonalisation is a common experience (26 - 74%), but
depersonalisation disorder is not (.8 - 2.4%)
Prevalence of dissociative amnesia is controversial, but
recent estimate of 1.8% in a community sample
Dissociative identity disorder – 1% in the community, but
much higher in clinical samples

Why increased prevalence of this disorder in the past 50 years?
• Increased recognition?
• Culture-bound syndrome?
• More prevalence studies needed
5-15
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Dissociative disorders

Aetiology




Most dissociative disorders believed to be stress-related
Depersonalisation disorder – most common immediate
precipitants are extreme stress, depression, anxiety, and
substance use
Dissociative amnesia - biological explanations focus on the effects
of stress on different brain symptoms, e.g., hippocampus and
amygdala, while psychological explanations focus motivations for
not remembering
Dissociative identity disorder – dominant theory is that it is related
to severe childhood trauma
5-16
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Dissociative disorders

Treatment



Depersonalisation disorder – no evidence for efficacy of
pharmacotherapy yet, some preliminary support for CBT
Dissociative fugue and amnesia – most cases resolve
spontaneously, some clinical case reports of use of imaginal
exposure or hypnosis
Dissociative identity disorder – treatment guidelines suggest a 3
phase approach:




Develop trusting relationship
Exposure-based techniques for traumatic memories
Bringing together separate identities
Much more empirical support is needed, particularly controlled trials
5-17
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SOMATOFORM AND DISSOCIATIVE
DISORDERS

Dissociative disorders

Current challenges and controversies

Recovered memory/false memory debate


Dissociative amnesia position: severe traumatic experiences are often
repressed
False memory position: trauma is always remembered, so-called
recovered memories are actually false memories

Evidence that participants report having had amnesia for traumas

Some participants later retract allegations of abuse and claim the
therapist implanted the memory

Other experimental evidence that false memories can be created
for non-traumatic events
5-18
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
SUMMARY

Historical Approaches to Somatoform and Dissociative
Disorders

Somatoform Disorders





DSM-IV-TR Diagnosis
Epidemiology
Aetiology
Treatment
Dissociative Disorders





DSM-IV-TR Diagnosis
Epidemiology
Aetiology
Treatment
Current Controversies and Challenges
5-19
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd