Theories and Models of Somatoform

disorders and Dissociative disorders

Chair Person: Ms Priya
Presenter: Ms Anitha
Somatoform disorders are characterized by the
presentation of physical symptoms with no medical
explanations .The symptoms are severe enough to
interfere with the patients ability to function in social
or occupational activities.
 Somatoform Disorder
Classification based on ICD 10 and DSM 5
ICD -10 classification
CLINICAL CASE
SOMATISATION DISORDER
Somatization disorder is characterized by the following clinical
Features:
Multiple somatic symptoms in absence of any physical
disorder.
The symptoms are recurrent and chronic (at least 2 year
duration is needed for diagnosis).
CLINICAL CASE
HYPOCHONDRIASIS
( HYPOCHONDRIACAL DISORDER)

Hypochondriasis is defined as a persistent preoccupation

with a fear (or belief) of having one (or more) serious
disease(s), based on persons own interpretation of normal
body function or a minor physical abnormality.
CLINICAL CASE
 CONVERSION DISORDER
A disoder in which the individual experiences
one or more neurological symptoms that cannot
be explained by any medical or neurological
disorder.
PERSISTENT SOMATOFORM PAIN
DISORDER

A disorder in which the presence of pain is the patients main

complaint.
CLINICAL CASE
 Factitious Disorder:
Falsification of physical or psychological
symptoms, or induction of injury or disease;
associated with deception
Presentation to others as ill, impaired, or
injured
Deceptive behavior is evident even in the
absence of obvious external rewards, such as
monetary compensation or reduced work
 Before jumping into the theories
Explanation of these disorders must address these
questions
1. Are physical symptoms a manifestation of underlying
psychological conflicts and stress?
2. Are physical symptoms generated in an involuntary
fashion?
3. What is the role of life stress and childhood abuse in
the development of SSD?
4. How do sufferers acquire the biased thinking and
dysfunctional beliefs about the health that help to
maintain many of the symptoms of these disorders?
 Theories and Models
Psychodynamic interpretation
Consciousness and Behavior
Risk factors for Somatic symptom disorders
Learning approaches
Cognitive factors
Sociocultural approaches
Biological factors
 Psychodynamic interpretation
Freuds famous writings on Hysteria
Inner conflicts, repressed emotions and life stress could
be manifested in somatic symptoms.
Conflict resolution-distressing memories, inner
conflicts, anxiety and unacceptable thoughts are
repressed in consciousness but outwardly expressed as
somatic symptoms.
Eg.Freud believed that somatic symptoms found in
conversion disorder is associated with distressing
memories of childhood seduction.
Abuse / fantasy phallic stage reawakened during
puberty leading to somatic symptoms.
 La belle indifference- Conversion disorder-helping to
repress the memories and relieve anxiety

Theorists - Underlying sexual conflict as a contributing

factor for Somatic symptom disorder(SSD) and Illness
anxiety disorder(IAS). Freud believed that repressed
sexual energy was often turned inward on the self,
transforming into physical symptoms. Leads to pain or
indicators of illness.
In Psychodynamic theorists - regressing to the state of
sick child to seek attention and relief from
responsibilities.

Contradicting evidence of Psychodynamic view-

presence of anxiety.
 Consciousness and behaviour
Significant feature of SSD and CD, is that the
sufferer is able to generate the physical deficits/
symptoms in an involuntary fashion.
Case studies- Theodor (1973) and Grosz(1966)
Peripheral vision and hysterical blindness-below
chance level
Oakley(1999)- Physical states of Hypnosis and
symptoms of Conversion disorder. Sensory
information is blocked from conscious awareness.
 Risk factors for SSD
History of abuse, trauma or significant period of
stress.
Eg-history of childhood abuse increases
vulnerability to conversion disorder(Bowma, 1996).
Negative life events before onset of the disorder-
globus pharynges
Exposure to acute stressors like relationship
difficulties, exposure to dead bodies following
military combat also contributes to SSD & IAD.
 Questions to be raised????
Not all SSD and IAD had high levels of
abuse/trauma.
Stress level compared to other
psychopathological conditions.
High level of childhood trauma and neg life
events found in other psychopathlogical
conditions.

Familial risk factors for SSD

 Learning approach
Numerous theorist suggested that SSD may
develop because many of the aspects of these
disorders are learnt through specific types of
experiences.
Eg- modelling a ill parent or significant person
Expressing symptoms of physical illness may
be reinforced by the parents.
Adopting a Sick role- Advantages &
disadvantages-help them cope as adult.
 Cognitive perspective
Interpretation biases- cognitive biases in
which an individual interprets ambiguous
sensation as threatening and evidence for
potential negative outcomes.
 Cognitive model of IAD

Physical symptoms

Negative automatic thoughts

Emotion

Behaviour change, Thinking change, Mood change
Symptoms
 Recent study-Memory bias- individuals with
many psychopathologies may have a bias
towards remembering and retrieving illness
relevant materials.
 Reasoning bias- reject evidence disagree with
their belief about illness
Rogue representation (Brown, 2004)- In SSD,
representations that provide inappropriate
templates by which information about body
shape and health are selected and interpreted.
1. History of physical illness
2. History of emotional states tht have strong
physical manifestation(anxiety-palpitations,
nausea,dizziness)
3. Exposure to physical illness in others.
 Socio cultural
Sick role in the society-
1. Exempted from normal social roles
2. Sick person seen as not responsible for the illness
Some cultures it is acceptable to show Psychological
distress through illness-eg. Latin countries and
American Hispanic women
More common among rural areas, less educated and
low socio economic status- Psychological distress is
unacceptable.
Contagious hysteria- Amish community in U.S-motor
deficit-inability to hold their head-recent conflict
within the community.
Biological model
 Medical condition contributing to disorder?
Run in families?
 Genetic component- Torgersen(1986) MZ
higher concordance rate than DZ.
Adoption studies- 859 women, Biological
father-higher levels of alcoholism or violent
crimes.
Link between antisocial behavior and SSD.
Conversion disorder and paralysis & blindness
Brain waves of the individual with con. This suggest
sensory information is reaching the app area of the
brain but are not registered in consciousness.
PET scan study-left leg paralyzed-increased
activation of right orbitofrontal and anterior
cingulate cortices but absence of activity in right
primary cortex when attempt to move. Same
patient hypnosis found similar process.
 Dissociation
Is a defense against trauma that helps persons
remove themselves from trauma as it occurs &
delays the working through of the trauma
Patients have lost sense of having one
consciousness
 ICD-10 CLASSIFIES DISSOCIATIVE DISORDERS UNDER F44
F44.0 DISSOCIATIVE AMNESIA
F44.1 DISSOCIATIVE FUGUE
F44.2 DISSOCIATIVE STUPOR
F44.3 TRANCE AND POSSESSION DISORDERS
F44.4 DISSOCIATIVE MOTOR DISORDERS
F44.5 DISSOCIATIVE CONVULSIONS
F44.6 DISSOCIATIVE ANAESTHESIA AND SENSORY LOSS
F44.7 MIXED DISSOCIATIVE [CONVERSION] DISORDERS
F44.8 OTHER DISSOCIATIVE [CONVERSION] DISORDERS
.80 GANSER'S SYNDROME
.81 MULTIPLE PERSONALITY DISORDER
.82 TRANSIENT DISSOCIATIVE [CONVERSION] DISORDERS OCCURRING IN CHILDHOOD
AND ADOLESCENCE
.88 OTHER SPECIFIED DISSOCIATIVE [CONVERSION] DISORDERS
F44.9 DISSOCIATIVE [CONVERSION] DISORDER, UNSPECIFIED
 DSM 5
Dissociative identity disorder (DID)
Dissociative amnesia including Dissociative
Fugue
Other Specified Dissociative Disorder
Unspecified Dissociative Disorder
 The patient is a 28-year old male final year medical student from
the South-Eastern region of Nigeria in sub-Saharan Africa. He was
declared missing for 10 days prior to presentation because his
whereabouts was unknown. He was later seen in a city in South-
Western Nigeria, a distance of about 634km from South-Eastern
Nigeria where he lived and schooled. Two days later, he discovered
he was with his younger sibling in South-Western Nigeria. The
patient had no knowledge of how he made the journey that takes
approximately 8 hours by road. He equally could not remember
where he slept the night he left his room, how he raised money for
the journey or the buses and routes he took. The patient denied all
memory of events for the 2 days from when he left his room at the
university to the time he suddenly realized he was at his brothers
house, 634km away. The brother, however, reported that the
patient appeared unkempt, looked exhausted but was fully
conscious and alert on arrival at his house without any assistance.
 Mary was born in 1960 and, from a young age,
was physically abused. As a teenager, she
suffered many mental problems and
overdosed several times.
It wasn't until her 20s that other personalities
began to appear. "Julie" was a very destructive
personality that ran Mary's van into a bunch
of parked cars. Sarah," another personality,
was involved in a pedophile ring.
 Tony told his story of being an only child whose doting mother died
when he was only 10. His father, a Vet freshly returned from the
Vietnam War, had raised him with the help of Tonys aunt. Hed
always been anxious and a loner. In school, hed done mediocre
work. After a year of college he dropped out and married a
girlfriend from high school. Then, his problem started.
One day I was walking around the city, minding my own business,
when suddenly I found myself looking down at myself from
somewhere near the awning of a store. It was unreal and the
weirdest thing in the world! he exclaimed, his hands shaking.
Since then, and that was 20 years ago, Ive had one experience like
that after another and never completely felt like I was back in my
body. I constantly feel spaced out.
 Theories and Models
Psychodynamic theories
Role of fantasy and Dissociative experiences
Cognitive approaches
Biological explanations
Role playing and therapeutic construction
 Psychodynamic theories

Dissociation symptoms are caused by repression.

Repression helps to unconsciously suppress
painful memories and help in preventing stressful
thoughts entering consciousness.
Repression hence helps to control conflict,
anxiety and depression.
In case of Dissociative amnesia traumatic/
stressful event is suppressed until the individual
has the strength to cope with it.
Tendency to repress develops during childhood
when strict moral codes are instilled by parents
 DID- sufferer develops alter egos in order to avoid
distressing world they were brought up in. Eg-
extramarital affairs-Movies
Evidence that individuals with diss. Disorders do
experience less conflict and anxiety compared to
other forms of psychopathology however
difficulties in objectively measuring the concepts
and mechanisms
Role of fantasy and Dissociative
experiences
Diss disorder may develop more readily in
individuals who have early dissociative or
depersonalization experiences.
Study on prison inmates with DID-12/14 were
found to have childhood diss experiences.
Imaginary companions during childhood-
10/12 had a companion. To escape the stress
they alter these personalities.
 Cognitive approaches
Theorists believe that diss disorders represent a disruption of all or part of the sufferer's memory
process.

Reconstructive memory- individuals autobiographical memory is stored as a series of discrete

elements associated with that experience.

Source monitoring ability- the ability to recall the relevant elements of an autobiographical
experience from memory.- newspaper or rumour.

In Diss amnesia may result from deficits in both reconstructive memory and source monitoring
abilities.

Reality monitoring- a form of source monitoring required to distinguish mental contents arising
from experiences from those arising from imagination.

A deficit in reality monitoring may also lead them to doubt that they have actually had a particular
experience. And both of these process contribute to diss amnesia.
 Biological explanations
Memory loss tends to be selective and many cases it is
transitory.
Role of hippocampus- integrates elements of an
autobiographical memory to recognize the past personal
experiences.
Individual with diss disorder have problems with
recollecting certain experiences (childhood abuse) may be
cause by abnormalities in hippocampus.
 Charney et al (1996), argued neurotransmitters
released during stress can modulate memory
functions-hippocampus-this release may interfere
with laying down of memory traces for high
stress incidents such as childhood abuse.
Extended stress may also cause long term, semi
permanent alterations in the release of these
neurotransmitters, causing long term amnesic
effects for experiences related to the trauma.
fMRI-prefrontal cortex-inhibiting activity in
hippocampus-Diss amnesia-memory repression.
Role playing and therapeutic
construction

DID- role playing by the sufferer in order to evoke

sympathy and to escape responsibility for their
actions.
Role playing being reinforced by significant others.
Emergence of new personalities in therapeutic
process.
Thank you