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Chapter 5 Dissociative and Somatoform Disorders

Chapter Overview:

The dissociative and somatoform disorders were historically linked with anxiety
disorders as forms of neuroses. Anxiety is expressed directly in different forms in
the anxiety disorders, but its role in the dissociative and somatoform disorders is
inferred.

Dissociative Disorders

Dissociative disorders involve changes or disturbances in identity, memory, or

consciousness that affect the ability to maintain an integrated sense of self
Dissociative disorders include dissociative identity disorder, dissociative
amnesia, dissociative fugue, and depersonalization disorder.

In dissociative identity disorder, two or more distinct personalities, each

possessing well-defined traits and memories, exist within the person and
repeatedly take control of the person’s behaviour. Dissociative amnesia involves
loss of memory for personal information. There are five types of dissociative
amnesia: localized, selective, generalized, continuous, and systematized. In
dissociative fugue, the person travels suddenly away from home or place of
work, shows a loss of memory for his other personal past, and experiences
identity confusion or takes on a new identity. Depersonalization disorders involve
persistent or recurrent episodes of depersonalization that are of sufficient
severity to cause significant distress or impairment in functioning.

Theoretical Perspectives/Treatment

Psychodynamic theorists view dissociative experiences as a form of

psychological defense by which the ego defends itself against troubling
memories and unacceptable impulses by blotting them out of consciousness.
There is increasing documentation of a link between dissociative disorders and
early childhood trauma, which lends support to the view that dissociation may
serve to protect the self from troubling memories.

To learning and cognitive theorists, dissociative experiences involve ways of

learning not to think about certain troubling behaviours or thoughts that might
lead to feelings of guilt or shame. Relief from anxiety negatively reinforces this
pattern of dissociation. Social-learning theorists and cognitive theorists suggest
that multiple personality may represent a form of role-playing behaviour. Some
dissociative states, like dissociative amnesia and fugue, may be transient and
terminate abruptly. Psychodynamic approaches help the individual uncover and
cope with dissociated painful experiences from childhood. Within the diathesis-
stress model, dissociative identity disorder may be explained in terms of a
diathesis consisting of psychological traits such as a rich inner fantasy life and

Copyright © 2013 Pearson Canada Inc.

65
high levels of hypnotizability interacting with traumatic stress in the form of
severe childhood abuse.

Biological approaches focus on the use of drugs to treat the anxiety and
depression often associated with the disorder, but drugs have not been able to
bring about reintegration of the personality. Learning perspectives focus on the
use of behavioural methods of reinforcement of the most well-adjusted
personality.

Somatoform Disorders

In somatoform disorders, there are physical complaints that cannot be accounted

for by organic causes. Thus the symptoms are theorized to reflect psychological
rather than organic factors. Three types of somatoform disorders are considered:
conversion disorder, hypochondriasis, and somatization disorder.

In conversion disorder, symptoms or deficits in voluntary motor or sensory

functions occur which suggest an underlying physical disorder but no apparent
medical basis for the condition can be found. Hypochondriasis is a preoccupation
with the fear of having, or the belief that one has, serious medical illness, but no
medical basis for the complaints can be found and fears of illness persist despite
medical reassurances. Formerly known as Briquet’s syndrome, somatization
disorder involves multiple and recurrent complaints of physical symptoms that
have persisted for many years and began prior to the age of 30, but most
typically during adolescence.

Theoretical Perspectives

The psychodynamic view holds that conversion disorders represent the

conversion into physical symptoms of the leftover emotion or energy that is cut
off from unacceptable or threatening impulses that the ego has prevented from
reaching awareness. The symptom is functional, allowing the person to achieve
both primary and secondary gains.

Learning theorists focus on the reinforcements that are associated with

conversion disorders, such as the reinforcing effects of adopting a “sick role.’ A
learning theory view likens hypochondriasis to obsessive-compulsive behaviour.
Cognitive factors in hypochondriasis include self-handicapping strategies and
cognitive distortions.

Munchausen syndrome is a form of factitious disorder involving the conscious

fabrication of medical complaints for no apparent cause other than to gain
admission to a hospital. Malingering, by contrast, involves the fabrication of
physical or psychological symptoms for obvious external gain.

Copyright © 2013 Pearson Canada Inc.

66
Treatment

Psychoanalysis seeks to uncover and bring to the level of awareness the

unconscious conflicts, originating in childhood, that are believed to be at the root
of the problem. Once the conflict is uncovered and worked through, the hysterical
symptom should disappear because it is no longer needed as a partial solution to
the underlying conflict. Behavioural approaches focus on removing sources of
reinforcement that may be maintaining the abnormal behaviour pattern.
Behaviour therapists may also work more directly to help people with somatoform
disorders learn to handle stressful or anxiety-arousing situations more effectively.

Chapter Outline:

Dissociative and Somatoform Disorders 185

Dissociative Disorders 187

Dissociative Identity Disorder 187
Dissociative Amnesia 191
Dissociative Fugue 192
Depersonalization Disorder 193
Theoretical Perspectives 194
Treatment of Dissociative Disorders 197
REVIEW IT Dissociative Disorders 199

Somatoform Disorders 199

Conversion Disorder 201
Hypochondriasis 202
Somatization Disorder 204
Other Somatoform Disorders 204
Theoretical Perspectives 205
Treatment of Somatoform Disorders 208
REVIEW IT Somatoform Disorders 209

CONCEPT MAP 211

Students Should Be Able to:

1. Distinguish the dissociative and somatoform disorders from the anxiety

disorders in terms of the theorized role of anxiety and discuss historical changes
in the classification of these diagnostic classes.

2. Describe the major features of the dissociative identity disorder, dissociative

amnesia, dissociative fugue and depersonalization disorder.

3. Explain why inclusion of depersonalization disorder as a dissociative disorder

generates controversy.
Copyright © 2013 Pearson Canada Inc.
67
4. Discuss problems in differentiating dissociative disorders from malingering.

5. Recount various theoretical perspectives on the dissociative disorders.

6. Describe various methods for treating dissociative disorders.

7. Describe the features of conversion disorder, hypochondriasis, and

somatization disorder.

8. Discuss theoretical perspectives on somatoform disorders,

9. Distinguish somatoform disorders from malingering.

10. Describe the features of Munchausen syndrome and theoretical accounts of

its origins.

Lecture and Discussion Suggestions:

1. Differentiating dissociative identity disorder and schizophrenia. People

easily confuse these two disorders, yet they are very different disorders. The
term schizophrenia comes from two Greek words meaning “to split” “the mind.”
However, Bleuler, who proposed the term schizophrenia was not referring to a
splitting of the person into different personalities, as occurs in dissociative identity
disorder. Instead, the split in schizophrenia occurs at the core of the person,
loosening the connections between the various psychic functions. Thus, in the
mind of the person with schizophrenia, ideas, perceptions, emotions, and
behaviour don’t operate as an integral whole; rather he or she may think and act
inappropriately in a given situation. Consequently, schizophrenia is a psychotic
disorder that usually requires periods of hospitalization and medication as well as
a prolonged time for recovery. People who have recovered from an acute
episode of schizophrenia often remain loners or underemployed in the
workplace. In contrast, many people with dissociative identity disorder may go
unrecognized or be alternatively diagnosed for years after the initial evaluation.
Some of them lead accomplished lives. Well functioning people with multiple
personalities may elude diagnosis because clinicians are not likely to probe for
evidence among those who function so well. Also, such people may have
developed elaborate strategies for concealing their alternate personalities, aided
by the stabilizing influences of their careers.

An analogy I have used in my classes to help students visualize the differences

between the two disorders is that dissociative identity disorder is somewhat like
taking a large mirror and neatly cutting it into several small mirrors. They are
smaller but they are still clearly mirrors. Schizophrenia, however, is like taking
that same large minor and shattering it with repeated hammer blows. What you
have left is a collection of glass fragments, none of them comprising a

Copyright © 2013 Pearson Canada Inc.

68
recognizable mirror. While this analogy is not perfect, students typically find it
helpful.

2. Child sexual abuse and the dissociative and somatoform disorders.

Freud first identified childhood experiences of sexual abuse as a significant factor
in the psychoneuroses, though he eventually dismissed them as fantasies.
Today, however, there is increasing documentation of childhood sexual abuse in
the lives of those who develop dissociative identity and somatization disorder.
For instance, it has been estimated that as many as 1 out of 4 or 5 girls and I out
of 9 or 10 boys are sexually abused before they reach 18. Certainly, only a few of
these children who suffer such childhood traumas develop multiple personalities.
Yet, recent recognition that this disorder is not as rare as once thought suggests
that we not overlook the link between child sexual abuse and dissociative identity
disorder. Similarly, one study of women with somatization disorder, compared to
those who suffered from a mood disorder, showed significant differences.
Although women in both groups reported similar childhood sexual experiences,
such as masturbating and kissing games, women with somatization disorder
were more likely to report experiences of childhood sexual abuse. More than 1
out of 2 women with somatization disorder had been sexually abused, compared
to only 1 out of 6 of those with a mood disorder (Morrison, American Journal of
Psychiatry, 1989, 146, pp. 239-241).

3. Hypochondriasis. Estimates of anywhere from 1/4 to 3/4 of the patients who

consult physicians resemble those with hypochondriasis or some other
somatoform disorder. A disproportionate number of these people are from the
lower socioeconomic groups, who complain more about physical symptoms than
psychological discomforts. Also, people coping with bereavement over the loss of
loved ones are especially prone to symptoms that mimic signs of physical
illnesses. Even though older people are susceptible to genuine age-related
changes in their health, their complaints often reflect the changing health status
of older people. Because people with hypochondriasis are often offended at the
suggestion that their beliefs or fears may be unwarranted, they frequently
become “doctor shoppers” and complain that they are not getting proper care,
thereby alienating themselves from doctors. Furthermore, they frequently refuse
referral for psychotherapy, and are not often seen in mental health facilities. In
some instances, past experience with a true organic disease, either in one’s self
or family member, predisposes one to this illness. At the same time, because
many complaints may be manifestations of early stages of neurological or
endocrine disorders, the most important differential diagnosis is the lack of a true
organic disease. However, according to the DSM-IV, even the presence of a
genuine physical illness doesn’t preclude the coexistence of hypochondriasis.

4. Differential development of dissociative disorders. Ask students why some

people who are sexually abused as children develop dissociative identity disorder
while most don’t. Individuals who develop dissociative disorders are much more
susceptible to self-hypnosis and hypnotic suggestion than the average person.
But why is this disorder more common among females than males?

Copyright © 2013 Pearson Canada Inc.

69
5. Multiple personalities. Pose the question “Don’t all of us have multiple
personalities to some extent?” Some people question whether multiple
personality disorders represent more than an extreme form of the multiple selves
found in all of us. That is, our self-concept includes hundreds of self-perceptions
of varying degrees of clarity and intensity, which represents various self-images,
needs, interests, and social roles integrated within our personality in varying
degrees. Expression of these various selves may account for much of the
inconsistency in our behaviour on occasions.

6. Malingering. Ask students how they can tell when someone is faking a
dissociative disorder or an illness. According to the DSM-IV, the essential feature
of malingering (pretending) is intentional production of false or grossly
exaggerated physical or psychological symptoms, motivated largely by external
incentives such as avoidance of work or military duty, or obtaining financial
compensation or drugs. Also, the presenting symptoms are less likely to be
symbolically related to underlying emotional conflicts, as they are in dissociative
and somatoform disorders, nor relieved by hypnosis or suggestion.

7. Out of Body Experiences. Two of the most well publicized types of

dissociation are the so-called “out of body” experiences and “near death
experiences.” You might ask students to relate any knowledge they have of these
experiences and then explore how various theoretical viewpoints might
scientifically explain them. You might also point out that while most scientists
remain skeptical about people actually leaving their bodies, many readily admit
that the people claiming to have had the experiences appear to be truthful in their
belief that the experience was real. What scientific evidence is there to support or
refute claims that one’s soul has left one’s body? What alternative explanations
are there and what scientific evidence is there to support them? This topic makes
for an interesting discussion as it is an area that many students are keenly
curious about.

8. Depersonalization experiences. The text describes some of the forms

depersonalization can take. Some of these forms occur from time to time in
otherwise normal individuals. Because your students might read this section and
wonder “Do I have depersonalization disorder?” it is useful to point out how
common such episodes are. Ross, Joshi, and Currie (1990) found that these
were especially reported by people age 25-44. For instance, 28% of those 25-34
and about 27% of those 35-44 indicated they had experienced depersonalization.
Rates were from 8-10% for most other age groups. It is also important to remind
students that DSM-IV considers depersonalization disorder only when it is
persistent and results in significant impairment of functioning.

Ross, C. A., Joshi, S., & Currie, R. (1990). Dissociative experiences in the
general population. American Journal of Psychiatry, 147, 1547-1552.

9. Repressed memories? The topics of dissociative identity disorder and

amnesia discussed in this chapter lead well into one of the major controversies of

Copyright © 2013 Pearson Canada Inc.

70
the day—repressed memory therapy. The roots of this issue go back at least to
Sigmund Freud, who originally felt that many of the problems reported to him by
female patients were due to childhood experiences of incest. These women were
telling Freud, often while under hypnosis, that they had begun to remember these
acts. Freud believed this for awhile, but gradually became convinced most of
these incestual experiences were fantasized. This was a widely held opinion until
about 1980, when it became clear that incestuous child abuse was much more
common than thought. Then, as writer Martin Gardner tells it, “in the latter 1980’s
a bizarre therapeutic fad began to emerge in the United States. Hundreds of
poorly trained therapists, calling themselves “traumatists” began to practice the
very techniques Freud discarded.”

What began was a wave of incidents in which patients, generally women 25-45
years old, began to recall childhood sexual traumas that had allegedly lain buried
in the unconscious, often for decades. In 1990 the first conviction based on
repressed memories was banded down to a man for murdering a young girl in
1969. Observers of the trial felt that the conviction was obtained almost entirely
on the basis of his daughter’s memories that had lain buried until a sudden
awakening of them. Gardner summarizes the thoughts of psychologists and
others who are quite concerned about what they feel is false memory syndrome.
These critics allege that well-meaning and sincere therapists begin treating
patients with the assumption that a sexual or other trauma had occurred early in
the patients’ early life, and then these therapists use leading questions to slowly
implant memories of events that never really happened.

There are, of course, therapists who argue that such repressed memories are
real. Many psychologists, however, doubt that the kind of repression that is
claimed in these cases is possible. This is an interesting topic to discuss with
students. Ask students to collect examples and also to search for empirical
evidence to support repressed memories.

Gardner, M. (1993). The False Memory Syndrome. Skeptical inquirer, Summer.

10. Women and somatization. Women in general use health services more
than men, even after use related to pregnancy and childbirth is accounted for.
Most somatization disorder patients are women. Discuss with the class what they
think explains these facts. It may be that traditional sex roles have made it more
acceptable for women to admit problems and seek treatment, while for men,
being sick violates the strong, sometimes “macho” image assigned to their
gender. If so, why are there at least as many males as females with
hypochondriasis? This topic can provoke a lively class discussion.

11. Reporting bodily symptoms. Ask students whether they feel that they tend
to over-report bodily aches and pains as symptoms of illness, often seeking out
medical assistance, or tend to underreport them, shrugging them off and going
about business as usual. Then have them relate their tendencies to the following
finding. According to Paul Costal and Robert McGraw (American Psychologist,

Copyright © 2013 Pearson Canada Inc.

71
40, 1985, 19-28), each of us differs in the tendency to label our bodily aches and
pains as a symptom of illness. People who habitually complain of unfounded
ailments exhibit a cluster of personality traits labeled neuroticism. Those high in
neuroticism tend to be anxious, overly self-conscious, hostile, depressed,
impulsive, and usually have low self-esteem. In contrast, people who underreport
their bodily aches and pains exhibit another cluster of traits labeled extroversion
and tend to be warm and outgoing and sufficiently involved in life that they don’t
have time to complain of their ailments.

After you have presented these descriptions, ask students which tendency is
dominant in their particular personality and the degree to which it is manifested in
underreporting or overreporting bodily aches and pains.

12. Alien Abductions? Shows such as The X-Files and best-selling books such
as Whitley Streiber’s Communion have popularized the alien abduction
phenomenon to the point where it would be difficult today to get an
“uncontaminated” sample of subjects to experimentally study the phenomenon.
Do students know of anyone who has claimed to have experienced this? What
do they think is causing these experiences and why the recent upsurge in
reported cases? Real aliens? Placebo effect? Mass hysteria? Sleep-induced
hallucinations? Or perhaps some type of stress-induced dissociative experience?
This should make for an interesting discussion.

Student Activities:

1. The Dissociative Experiences Scale. Ask students to look over the

Dissociative Experiences Scale presented in this chapter and to share their
responses. One way to use the scale is to have students go down the list,
marking the frequency with which each item occurs, such as “often,”
“occasionally,” or “rarely.” Then determine which types of dissociative
experiences occur most often or most rarely. Or you might simply go down the
list getting a show of hands for each item. Either way, ask students how they feel
when they become aware of such discrepancies in their experience. Do most of
them accept such occasional lapses in consciousness as normal?

2. Hypnosis. Have someone skilled in hypnosis conduct a class demonstration to

determine how susceptible to hypnosis your students are. You might point out
that individuals with multiple personality disorder are quite susceptible to self-
hypnosis and are especially likely to dissociate in coping with trauma. However,
hypnotic suggestibility has many constructive uses, such as enhancing
relaxation, creativity, weight loss programs, and smoking cessation.

3. Right-left hemisphere differences. Researchers have found that conversion

symptoms are more likely to occur on the left side of the body than the right
(leading to the hypothesis that they relate to the functioning of the right

Copyright © 2013 Pearson Canada Inc.

72
hemisphere and emotional arousal), may be used in a discussion of right and left
hemisphere differences. A simple demonstration of the differential functioning of
the hemispheres can be done by having students briefly interview one or two
people outside of class. The question asked should be a problem which most
college students could accomplish with concentration. For instance: “How many
letters are there in the word Washington?” or “Multiply 12 by 13.” The
interviewer’s task is to record the direction of the subject’s eye movements when
he or she pauses to think about the question. It has been reported that when
people concentrate on a reasoning problem, their eyes tend to shift up and to the
right.

4. Multiple personality in film. Two of the most famous film examples of multiple
personality (now called dissociative identity disorder in the DSM-IV) are Three
Faces of Eve and Sybil. These are generally too long to show in class, but it is
possible to have students rent the videos of these films and have a get-together
where they can view one or the other. They can report to class on the behaviour
of Eve and Sybil, and how it corresponds to the text discussion.

Potential Online Discussion questions:

1. Dissociative identity disorder is a genuine mental disorder and not “role

playing” as some suggest.
2. Dissociative identity disorder is simply “role playing” and not a genuine
mental disorder, as some suggest.
3. The historical changes in the classification of dissociative and somatoform
disorders are an indication that these disorders are determined mostly by
the culture in which they occur.

Online Resources:

Sidran Institute
www.sidran.org
The Sidran Institute’s website contains information on dissociative disorders,
including links to books and educational materials.

Imaginary Crimes
http://members.shaw.ca/imaginarycrimes/repressedmemory.htm
Information and links on repressed memory.

Recovered Memories
http://psych.athabascau.ca/html/aupr/psyclaw.shtml#Recovered_Memories
Contains useful links on recovered memories.

False Memory Syndrome Foundation

www.fmsfonline.org

Copyright © 2013 Pearson Canada Inc.

73
Further useful information on repressed and recovered memories and
dissociative disorders.

Psychology Works for Intense Illness Concern (Hypochondriasis)

www.cpa.ca/cpasite/userfiles/Documents/factsheets/hypo.pdf
Fact sheet and links on hypochondriasis from the Canadian Psychological
Association.

Video Resources:

Prentice Hall Videos

ABC News/PH-Library #1: Secret No More (Prime Time Live, 7/22/92, 27:52),
Suppressed memories of child abuse are reawakened for adults who were
abused by a local priest as children.

Other Videos

Case Study of a Multiple Personality, 30 min. (Penn State). Cleckley’s “classic”

case study of the three personalities of “Eve,” including an interview with the
patient herself.

Child Abuse, 19 min. colour (Films for the Humanities and Sciences). Describes
the common characteristics of offenders and the effects of abuse on children.

Childhood Sexual Abuse, 26 min. colour (Films for the Humanities and
Sciences). Shows how adult women learn to work out the problems caused by
sexually abusive fathers. Experts explain how the pattern of abuse spreads and
is kept secret.

Hypochondriasis and Health Care: A Tug of War, 38 min. colour (Workshop

Films). Lecture and simulated interviews with people with hypochondriasis and
ways of dealing with it.

Copyright © 2013 Pearson Canada Inc.

74
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