Chapter 6 – Dissociative and Somatoform Disorders
Dissociative disorders as a group include a wide range of different
symptoms that involve severe disruptions in consciousness, memory and
o One of the most severe types of dissociative disorders is known as
“dissociative identity disorder”. This is when the individual has 2 or
more distinct identities that alternate control of the person’s
Somatoform disorders as a group include conditions whereby individuals
complain about a physical defect or dysfunction for which no physiological
basis can be found.
An example of this is “hypochondria” in which people have long standing
beliefs that they have a serious illness despite medical reassurance that they
Many doctors believe that both these types of disorders result from
maladaptive ways of coping with extreme stress.
Although there are many thoughts and theories on the causes and symptoms
of these disorders, our knowledge is still quite limited.
Although dissociative and somatoform disorders are classified in separate
categories now, they share common features historically. They used to be
classified together in the anxiety disorders under neuroses since it was
assumed anxiety was the underlying feature.
Classification of disorders later shifted in emphasis from etiology to
Dissociative disorders along with some somatoform disorders were once
seen as expression of hysteria (Greek term meaning – a symptom or pattern
characterized by emotional excitability and physical symptoms with no
evident organic cause)
Plato believed these symptoms were caused in women when their womb
remained inactive for too long. Described the womb like an animal that
desired to reproduce and when this didn’t happen it became angry and
wandered around the body.
Christianity blamed hysteria with supernatural explanations. Thought it was
a result of demonic possession and that exorcism was only treatment.
Pierre Janet was first to systematically study the concept of dissociation,
which we saw as a pathological breakdown of the normal integration of
mental processes occurring as a result of traumatic experiences.
Josef Breuer and Sigmund Freud thought that trauma, usually of a sexual
nature, was a predisposing factor for hysteria and established a relationship
between dissociation and hypnotic-like states. Freud began to doubt retrospective reports of his patients traumatic sexual
experiences and decided their memories of trauma were only fantasized. He
believed the dissociation and other intrapsychic defenses developed to
protect the individual from unacceptable sexual impulses, not from real
He suggested too that “conversion” of anxiety to more acceptable physical
symptoms relieved the pressure of having to deal directly with the conflict.
This avoidance of conflict was named “primary gain” and was viewed as the
primary reinforcement maintaining the somatoform symptoms.
“Secondary gains” of the symptoms were the fact that hysterical symptoms
could allow patients to avoid responsibility and gain both attention and
Interest in dissociative processes drops and rises in level of interest
Lately in the 1970’s-90’s there was a lot of interest brought on by cases of
multiple personality being brought into public eye, new research in hypnosis
etc. Recently interest in dissociative disorders has waned once again.
Characterized by serious maladaptive disruptions or alterations of identity,
memory, and consciousness that are experienced as being beyond one’s
The defining symptom is dissociation, which is the lack of normal
integration of thoughts, feelings and experiences in consciousness and
Simple things such as knowing who we are, our names, where we live etc are
all bizarrely disturbed and remain un-integrated for people with these
It is possible to have very mild cases of dissociative disorders. These would
be for instance when you daydream or get lost in thought and forget about
your surroundings or the passing of time. As long as you can snap out of it
then there is no reason for concern.
The problem is when people are unable to control these drifts of
consciousness or they affect ability to function in daily life.
Research by Waller, Putnam, and Carlson indicated that dissociative
disorders fall into 2 groups:
o The first group involves mild, non-pathological forms of dissociation,
such as things that are normally distributed across the general
population on a continuum of sorts.
o Second group involves more serious, pathological types of
experiences, such as amnesia, identity alteration, depersonalization,
that do not occur normally across the population.
Psychological trauma and emotional distress are causal factors
Four main types of dissociative disorders that will be discussed in this
chapter are: dissociative amnesia, dissociative fugue, depersonalization
disorder, and dissociative identity disorder. To determine the prevalence in the general population doctors constructed
structured clinical interviews with a representative sample of adults. 9.1%
could be diagnosed with dissociative disorder. There was no difference
between men and women, but it was slightly more common in younger vs
Primary symptom is the inability to recall significant personal information in
the absence of organic impairment.
Typically occurs following a traumatic event
Individuals typically have no memory of the traumatic event and may not be
able to recall own name, occupation or other facts about themselves even
though they might be able to retain general knowledge of world events.
Sometimes after being in a safe environment for a few days the person’s
amnesia stops, other times it can be more chronic or recurrent.
5 patterns of memory loss characteristic of dissociative amnesia are:
1. Localized amnesia – person fails to recall information from a very
specific time period
2. Selective Amnesia – only parts of the trauma are forgotten, while
others are remembered.
3. Generalized Amnesia – person forgets all personal information from
4. Continuous Amnesia – individual forgets information from specific
date until the present
5. Systematized Amnesia – individual only forgets certain categories of
information such as certain people or places.
The first two are the most common types
False memory syndrome a proposed syndrome where people are
influenced by their therapists to remember events that never occurred.
An extremely rare and unusual condition where the individual travels
suddenly and unexpectedly and later discovers that they are in a new place;
unable to remember why or how they got there.
Usually only last a few days or weeks, but sometimes individual disappears
for long amounts of time.
They tend to take on a new identity and occupation
Confusion will only happen if they are questioned about their personal
history, other than that they tend to function reasonably well.
When they recover from this state, the report having no memory of what
Incidences seem to occur for many more people after times of high stress,
such as war or a natural disaster.
Depersonalization Disorder Depersonalization is an experience in which individuals feel a sense of
unreality and detachment from themselves.
Feelings like this are relatively common among population (about half the
general population reports such symptoms…especially when under stress)
A diagnosis is only made when symptoms are persistent and cause clinically
significant impairment or distress.
Depersonalization Disorder is experiencing recurrent episodes of
depersonalization, describing the experiences as if they are living in a dream
Describe it commonly as feeling like a robot that can respond to the
environment but with no feeling of connection.
Often combined with episodes of derealization – an experience of
detachment, unreality, and altered relationship to the outside world
Depersonalization disorder is only diagnosed when severe
depersonalization and derealization are the primary problem
Typically begins in adolescence and is chronic
Highly related to trauma, specifically emotional abuse
Brain abnormalities in perceptual pathways may play a role in the
mechanisms for these deficits
Dissociative Identity Disorder (DID)
Formerly known as multiple personality disorder
It’s diagnosed when the patient presents with two or more distinct
personality states that regularly take control of the patient’s behaviour.
The individuals inability to recall information is too extensive to be explained
by normal forgetting
Typically in DID one of the personalities is identified as the “host” whereas
other personalities are identified as “alters”
Each personality is distinct and presents with different memories, personal
histories, and mannerisms
Personalities can identify themselves as male, female, child, adult, or animals
Host personality may or may not be aware of the presence of one or more of
the alters and may report strange occurrences such as strangers claiming to
Average number of personalities an individual has is 13-16
Process of changing from one personality to another is simply referred to as
switching. Often occurring in response to a stressful situation
Change in the personalities may lead to change of tone of voice, demeanor, or
posture of the individual
Average age of diagnosis is 29-35 years
Self-destructive behaviour is common, over 75% have suicide attempts and
90% report recurrent suicidal thoughts
Etiology Two competing explanatory models have been proposed: the trauma model
and the socio-cognitive model.
Trauma Model is a diathesis-stress formulation, has a long history and
continues to be widely accepted. According to this dissociative disorder are a
result of severe childhood trauma accompanied by personality traits that
predispose the individual to employ dissociation as a defense mechanism or
The defense mechanism is no longer adaptive when it is maintained as a
habitual way of coping throughout adulthood.
People who are low in dissociative tendencies may develop anxious,
intrusive thoughts rather than a dissociative reaction.
Might be a genetic heritability component to these personality traits makes
some people more vulnerable.
Attachment theory can also help explain why some are more vulnerable
Sensitive responding by the parent to an infant’s needs results in a child who
demonstrates secure attachment, developing the skills