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Somatoform,

Dissociative
& Personality
Disorders
CHAPTER 16

Somatoform Disorders &


Dissociative Disorders

Somatoform disorders

pathological concern of individuals with the appearance or


functioning of their bodies when there is no identifiable
medical condition causing the physical complaints

Dissociative disorders

individuals feel detached from themselves or their


surroundings, and reality, experience, and identity may
disintegrate

Historically,

both somatoform and


dissociative disorders used to be
categorized as hysterical neurosis

Somatoform Disorders

Occur when a person manifests a psychological problem through a


physiological symptom.

Two types

Illness Anxiety Disorder (Hypochondriasis)


Has

frequent physical complaints for which medical


doctors are unable to locate the cause. They often
believe that minor issues (e.g. headache, upset
stomach) are indicative are more severe illnesses.

Conversion Disorder
Report

the existence of severe physical problems


(e.g. blindness, paralysis) with no biological reason.

Dissociative Disorders

These disorders involve a disruption in the conscious


process.

An example - Psychogenic Amnesia where the


patient cannot remember things (retrograde
amnesia) with no physiological basis for the
disruption in memory. People with psychogenic
amnesia can find themselves in an unfamiliar
environment creating a Dissociative Fugue

Most common Dissociative


Disorder is Dissociative Identity
Disorder

Used to be known as Multiple


Personality Disorder.

A person has several rather than


one integrated personality.

People with DID commonly have a


history of childhood abuse or
trauma.

PERSONALITY
DISORDERS

Definitions

Personality = the enduring patterns of thinking,


feeling and reacting that define a person
Personality Disorder = an enduring pattern of
inner experience and behaviour that deviates
markedly from the expectations of the
individuals culture APA,2000
Personality Disorders are a construct (clinical)
used to understand, describe and communicate
about the complex phenomena that result when
the personality system is not functioning
optimally

When diagnosing

Pattern must be inflexible and pervasive across a


broad range of personal and social situations

Must be a source of clinically significant distress


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

Must be stable and of long duration, with an onset


that can be traced back to at least adolescence of
early adulthood

One way to look at it

Dimensional Classification: personality disorders are normal


traits amplified to the extreme

recall

Five-Factor Model of
Personality: neuroticism,
extraversion, openness to
experience, agreeableness and
conscientiousness

Very
Low

Very
Introverted

Very
Low

Very
Low

Very
Low

Neuroticism

Extraversion

Very
High

Very
Extraverted

Openness
Very
High

Agreeableness

Very
High

Conscientiousness
Very
High

One way to look at it


Pathological personality traits (one or more)
Derived from the well documented 5-factor
Model of Personality (FFM) and Personality
Psychopathology Five (PSY-5).
i. Negative affectivity (vs. emotional stability)
ii. Detachment (vs. extraversion)
iii. Antagonism (vs. agreeableness)
iv. Disinhibition (vs. conscientiousness)
v. Psychoticism (vs. lucidity)

Aetiology
Aetiology Models:

Biopsychosocial Model: holistic and inclusive

Diathesis-Stress Model: individual levels of tolerance

Psychodynamic theory: driven by the unconscious

Aetiology Factors:

Genetic Predisposition

Attachment Experience

Traumatic events

Family factors and dysfunction

Sociocultural and political forces

Prevalence
Varies according to gender, social factors and
type
Approx. 10-14% overall
Most prevalent = Obsessive Compulsive,
Dependent, Schizotypal
Least prevalent = Narcissistic, Schizoid
Most visible = Borderline, Antisocial
Assumption of stability over time, but some
more than others (e.g. schizotypal > borderline)

Major Personality
Disorders

Cluster A: odd/eccentric ways of thinking and


behaving

Paranoid: pervasive distrust and suspicion of others

Schizoid: Social detachment/indifference and


limited emotional experience & expression

Schizotypal: cognitive and perceptual distortions;


eccentric behaviour; discomfort with close
relationships

Major Personality
Disorders

Cluster B: dramatic/emotional/erratic

Antisocial: disregard for and violation of (the rights


of) others

Borderline: instability of interpersonal


relationships, self-image, emotions, and control over
impulses

Histrionic: excessive emotionality and attentionseeking

Narcissistic: grandiosity; inflated sense of selfimportance; need for attention; lack of empathy

Major Personality
Disorders

Cluster C: anxious or fearful

Avoidant: social withdrawal; feelings of


inadequacy, hypersensitive to criticism

Dependent: excessive need to be taken care of;


clinging and submissive

Obsessive-compulsive: preoccupation with


orderliness, perfection and control at the expense of
flexibility

Examples in film

Borderline: Fatal Attraction

Narcissistic: The Talented Mr. Ripley,


Capote

Paranoid: Conspiracy Theory

Antisocial: Wall Street

Histrionic: Being Julia

Antisocial Personality
Disorder

More studied than any other personality disorder


Origins usually traced back to earlier periods in
development (Conduct Disorder), although can not be
diagnosed until late adolescence (DSM criteria)
Has the distinction between ASPD and criminality been
blurred? Not all psychopaths are criminals, and not all
serious offenders are psychopaths.
Psychopathy includes shallow, deceitful, unreliable
and incapable of learning from emotional experience
and seemingly lacking in basic emotions: shame, guilt,
anxiety, remorse (conscience).
Increasing age can bring a change (lessening) in overt
antisocial behaviours: less obvious impulsivity,
recklessness, social deviance. Some argue that the
behaviours merely go underground.

ASPD - Causes

Biological Factors: seems to be a genetic


loading, esp. father-son, but outcome strongly
determined by environment (adoption studies)

Temperament and family environment


interaction: parenting (punitive, inconsistent,
low warmth), peers, school

Behavioural and social reinforcers: learned


behaviour resistant to change, modelling, peer
support

ASPD - Born bad?

Psychological factors: inability to anticipate


punishment, lack of anxiety regarding
punishment/negative consequences. Does moral
judgement cause anxiety or vica versa?

Consequent participation in risk-taking, self-promoting


behaviour with reduced ability to interpret (or pay
attention to) nonverbal cues esp. fear, distress, anger,
anxiety. Deficit or decision?

Some people born bad? (GSR, emotional


responsiveness, empathy studies)

ASPD - Treatment
Seldom

seek treatment

Often

coerced into treatment by the legal


system, however, participation does not
always equate with success

Difficulty
Very

building a therapeutic relationship

high recurrance of behaviour

Limited

success with behavioural techniques

Borderline Personality Di
sorder
Often

present due to other complaints (e.g.


somatic, self-harm, anxiety, depression,
abuse history). Large degree of comorbidity
Initially conceptualised as the borderline
between neurosis and schizophrenia but
this no longer the case
Very poor sense of/integration of self leads
to uncertainty about personal values,
identity, worth and choices = erratic,
impulsive and self-damaging behaviour

BPD - more
cognitive/behavioural features

Fear abandonment and crave relationships but


are incapable of maintaining these due to
unrealistic expectations and lack of self-cohesion
Subject to chronic feelings of depression,
worthlessness, emptiness leading to self-harm
and self-deprecating behaviour (e.g. sexual
activity, substance abuse, eating)
May demonstrate dissociation during intense
distress
Splitting tend to see people and events as
either all good or all bad, and can shift rapidly
between these.

BPD - Causes
Biological/genetic:

seems to run in families


and may be associated with genes that
contribute to anxiety, frontal lobe
dysfunction

Object

Relations: the internalisation of early


caregiving relationships (e.g. inconsistency
= insecurity & ego confusion leads to ego
defence such as splitting)

Diathesis-stress:

vulnerability thresholds
overwhelmed e.g. by abuse & trauma

BPD - Treatment
Perceived

as very difficult clients

Therapeutic

relationship is key but


threatening to person with BPD therefore
attrition is high, and therapy is made
very challenging

Psychoanalysis

uses the transference


relationship to interpret and integrate

Case 1

Ms Ellie is referred to you by her primary care MD because


she is concerned she has an anxiety disorder. When the pt
comes into your office she is looking down and when she
shakes your hand it is very sweaty. When asked about how
her relationships were in junior high she stated terrible. I
never fit in and didnt do much with other kids because I was
afraid they would judge me.

With this information


what Dx are you thinking
about?

Social phobia?

Avoidant personality disorder?

Generalized anxiety disorder?

Schizoid personality disorder?

What do you need to know to


figure out which one if any it is?

Is this circumscribed or more


global? does this person have
relationships with others?

You elicit the following


information

She has never had an intimate


relationship although she would like to
have one and has one friend that she
has known since childhood. She is
intensely afraid of of being ridiculed so
works as a transcriptionist from her
home and sits in the back row when she
goes to church. She describes herself as
not as good as other people and
doesnt like to do new things. She
avoids new relationships unless she is
sure they are going to like me.

Her diagnosis

Given the long standing pervasive nature of her


symptoms her diagnosis is most consistent with
Avoidant Personality Disorder. Social phobia
tends to be very situational and GAD
(generalized anxiety disorder) is less pervasive.

Case 2

Jason is a 45 year old male who comes to see you to


establish primary care clinic. He tells you he has to be very
careful about what he eats because certain foods I can
feel work against my system..I feel them as they are
integrated into my body. He also notes he tries to be
careful about what he says because words have
power..they can change the way of things.

With this information


what is your differential
diagnosis?

Schizophrenia?

Delusional disorder?

Mood disorder with psychotic


features?

Schizotypal personality
disorder?

You elicit the following:

He is fairly close to his family but doesnt really


have any other people in his life. He denied
auditory, visual or tactile hallucinations, has no
thought broadcasting or thought insertion and is
able to provide organized answers although you
notice he speaks in a vague way and his affect is
constricted. His appearance is striking because
he is wearing all yellow including his shoes, belt,
hat and earring which he states is because
yellow is the color that recharges me.

His diagnosis is most consistent with a Schizotypal personality


disorder. He does not have schizophrenia because of lack of
disorganization and lack of true psychotic Sx. He does have
magical thinking but it is not crossing into psychosis. Other
history to obtain would be whether he has a declining course
over time which you often see with schizophrenia.

Case 3

You are picking up your daughter from daycare


and one of the other parents engages you in
conversation. He states I see you got here 5
minutes after the cut off time toare they
going to charge you extra too? You know I
think this daycare is always trying to stick it to
us. I get this same thing at work. I think they
purposely make the clock in times and pick up
times inconvenient so they can dock you here
and there. Its like a conspiracy I swear!

With this information what


is your differential
diagnosis?
Irritated but normal parent?

Persecutory delusional
disorder?

Schizophrenia?

Paranoid personality disorder?

You elicit the following:

He goes on to tell you that its been the same


story his whole life. He has been passed over
for promotions at work, he cant trust his friends
any further than he can throw them and he
thinks his wife is cheating on him too. With your
excellent clinical skills you also find out he
doesnt actually believe there is a plot and
doesnt have any psychotic sx.

His diagnosis is most consistent with a Paranoid


personality disorder. He has a pervasive distrust
and suspiciousness of others but it is not to the
point of a delusion and he is not psychotic.

Final thoughts

It is thought you do not cure personality


disorders however treatment can increase the
effectiveness of the patient to function