Trastornos Somatoformes y Disociativos PDF

student learning outcomes*
Engage in innovative and integrative thinking and • Describe problems operationally to study them
problem solving: empirically [APA SLO 2.3a] (see textbook pages 187–189,
193, 195–196, 199–201, 204–205)
Describe applications that employ discipline-based • Correctly identify antecedents and consequences of
problem solving: behavior and mental processes [APA SLO 1.3b] (see
textbook pages 189–191, 197–198) Describe examples
of relevant and practical applications of psychological
principles to everyday life [APA SLO 1.3a] (see textbook
pages 185, 189–191)
*
Portions of this chapter cover learning outcomes suggested by the American Psychological Association
(2013) in their guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is
identified above by APA Goal and APA Suggested Learning Outcome (SLO).
D
o you know somebody who’s a hypochondriac? Most of us the term hysteria—which dates back to the Greek physician Hip-
do. Maybe it’s you! The popular image of this condition, pocrates, and the Egyptians before him—suggests that the cause of
now called more accurately “illness anxiety disorder” in the these disorders, which were thought to occur primarily in wom-
fifth edition of the Diagnostic and Statistical Manual of Mental en, can be traced to a “wandering uterus.” But the term hysterical
Disorders (DSM-5) (American Psychiatric Association, 2013) is of came to refer more generally to physical symptoms without known
someone who exaggerates the slightest physical symptom. Many organic cause or to dramatic or “histrionic” behavior thought to be
people continually run to the doctor even though there is noth- characteristic of women. Sigmund Freud (1894–1962) suggested
ing really wrong with them. This is usually a harmless tendency that in a condition called conversion hysteria, unexplained physical
that may even be worth some good-natured jokes. But for a few symptoms indicated the conversion of unconscious emotional con-
individuals, the preoccupation with their health or appearance flicts into a more acceptable form. The historical term conversion
becomes so great that it dominates their lives. Their problems fall remains with us (without the theoretical implications); however,
under the general heading of somatic symptom disorders. Soma the prejudicial and stigmatizing term hysterical is no longer used.
means body, and the problems preoccupying these people seem, The term neurosis, as defined in psychoanalytic theory, sug-
initially, to be physical disorders. What the somatic symptom dis- gested a specific cause for certain disorders. Specifically, neurotic
orders have in common is that there is an excessive or maladaptive disorders resulted from underlying unconscious conflicts, anxiety
response to physical symptoms or to associated health concerns. that resulted from those conflicts, and the implementation of ego
These disorders are sometimes grouped under the shorthand label defense mechanisms. Neurosis was eliminated from the diagnos-
of “medically unexplained physical symptoms” (Dimsdale et al., tic system in 1980 because it was too vague, applying to almost
2013; Woolfolk & Allen, 2011), but in some cases the medical all nonpsychotic disorders, and because it implied a specific but
cause of the presenting physical symptoms is known but the emo- unproven cause for these disorders.
tional distress or level of impairment in response to this symptom Somatic symptom disorders and dissociative disorders are not
is clearly excessive and may even make the condition worse. well understood, but they have intrigued psychopathologists and
Have you ever felt “detached” from yourself or your surround- the public for centuries. A fuller understanding provides a rich
ings? (“This isn’t really me,” or “That doesn’t really look like my hand,” perspective on the extent to which normal, everyday traits found
or “There’s something unreal about this place.”) During these experi- in all of us can evolve into distorted, strange, and incapacitating
ences, some people feel as if they are dreaming. These mild sensations disorders.
that most people experience occasionally are slight alterations, or
detachments, in consciousness or identity called dissociation or dis-
sociative experiences, but they are perfectly normal. For a few people, Somatic Symptom and Related Disorders
these experiences are so intense and extreme that they lose their iden- DSM-5 lists five basic somatic symptom and related disorders:
tity entirely and assume a new one, or they lose their memory or sense somatic symptom disorder, illness anxiety disorder, psychological
of reality and are unable to function. We discuss several types of dis- factors affecting medical condition, conversion disorder, and fac-
sociative disorders in the second half of this chapter. titious disorder. In each, individuals are pathologically concerned
Somatic symptom and dissociative disorders are strongly linked with the functioning of their bodies. The first three disorders cov-
historically, and evidence indicates they share common features ered in this section—somatic symptom disorder, illness anxiety
(Kihlstrom, Glisky, & Anguilo, 1994; Prelior, Yutzy, Dean, & Wetzel, disorder, and psychological factors affecting medical condition—
1993). They used to be categorized under one general heading, overlap considerably since each focuses on a specific somatic symp-
“hysterical neurosis.” You may remember (from Chapter 1) that tom, or set of symptoms, about which the patient is so excessively
S o m at i c S y m p t o m a n d R e l at e d D i s o r d e rs 185
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anxious or distressed that it interferes with his or her functioning, Linda easily met and exceeded all DSM-5 diagnostic crite-
or the anxiety or distress is focused on just the possibility of devel- ria for somatic symptom disorder. Linda was severely impaired
oping an illness as in illness anxiety disorder. and had suffered in the past from symptoms of paralysis (which
we refer to as a conversion symptom; see page 190). People with
somatic symptom disorder do not always feel the urgency to take
Somatic Symptom Disorder action but continually feel weak and ill, and they avoid exercising,
In 1859, Pierre Briquet, a French physician, described patients thinking it will make them worse (Rief, Hiller, & Margraf, 1998).
who came to see him with seemingly endless lists of somatic Linda’s entire life revolved around her symptoms. She once told
complaints for which he could find no medical basis (American her therapist that her symptoms were her identity: Without them,
Psychiatric Association, 1980). Despite his negative findings, she would not know who she was. By this she meant that she would
patients returned shortly with either the same complaints or new not know how to relate to people except in the context of discuss-
lists containing slight variations. For many years, this disorder was ing her symptoms much as other people might talk about their
called Briquet’s syndrome, but now would be considered somatic day at the office or their kids’ accomplishments at school. Her few
symptom disorder. Consider the case of Linda. friends who were not health-care professionals had the patience
to relate to her sympathetically, through the veil of her symptoms,
and she thought of them as friends because they “understood” her
Linda... Full-Time Patient suffering. Linda’s case is an extreme example of adopting the “sick
role” described earlier.
L inda, an intelligent woman in her 30s, came to our clinic Another common example of a somatic symptom disorder
looking distressed and pained. As she sat down, she noted would be the experience of severe pain in which psychological
that coming into the office was difficult for her because factors play a major role in maintaining or exacerbating the pain
she had trouble breathing and considerable swelling in the whether there is a clear physical reason for the pain or not. Con-
joints of her legs and arms. She was also in some pain from sider the case of the medical student.
chronic urinary tract infections and might have to leave at
any moment to go to the restroom, but she was extremely
happy she had kept the appointment. At least she was seeing
someone who could help alleviate her considerable suffering. The Medical Student... Temporary Pain
She said she knew we would have to go through a detailed
initial interview, but she had something that might save
time. At this point, she pulled out several sheets of paper
and handed them over. One section, some five pages long,
D uring her first clinical rotation, a 25-year-old third-
year medical student in excellent health was seen at her
student health service for intermittent abdominal pain of
described her contacts with the health-care system for major several weeks’ duration. The student claimed no past history
difficulties only. Times, dates, potential diagnoses, and days of similar pain. Physical examination revealed no physical
hospitalized were noted. The second section, one-and-a-half problems, but she told the physician that she had recently
single-spaced pages, consisted of a list of all medications she separated from her husband. The student was referred to the
had taken for various complaints. health service psychiatrist. No other psychiatric problems
Linda felt she had any one of a number of chronic infec- were found. She was taught relaxation techniques and given
tions that nobody could properly diagnose. She had begun supportive therapy to help her cope with her current stress-
to have these problems in her teenage years. She often dis- ful situation. The student’s pain subsequently disappeared,
cussed her symptoms and fears with doctors and clergy. and she successfully completed medical school. •
Drawn to hospitals and medical clinics, she had entered
nursing school after high school. During hospital training,
however, she noticed her physical condition deteriorating
rapidly: She seemed to pick up the diseases she was learning Once again, the important factor in this condition is not
about. A series of stressful emotional events resulted in her whether the physical symptom, in this case pain, has a clear
leaving nursing school. medical cause or not, but rather that psychological or behav-
After developing unexplained paralysis in her legs, Linda ioral factors, particularly anxiety and distress, are compounding
was admitted to a psychiatric hospital, and after a year she the severity and impairment associated with the physical symp-
regained her ability to walk. On discharge she obtained dis- toms. The new emphasis in DSM-5 on the psychological symp-
ability status, which freed her from having to work full time, toms in these disorders is useful to clinicians since it highlights
and she volunteered at the local hospital. With her chronic the psychological experiences of anxiety and distress focused on
but fluctuating incapacitation, on some days she could go in the somatic symptoms as the most important target for treat-
and on some days she could not. She was currently seeing a ment (Tomenson et al., 2012; Voigt et al., 2012). But an impor-
family practitioner and six specialists, who monitored vari- tant feature of these physical symptoms, such as pain, is that
ous aspects of her physical condition. She was also seeing it is real and it hurts whether there are clear physical reasons
two ministers for pastoral counseling. • for pain or not (Dersh, Polatin, & Gatchel, 2002; Asmundson &
Carleton, 2009).
186 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S
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Table 6.1
DSM
when he was drunk. Her mother and stepfather refused to
Diagnostic Criteria for Somatic Symptom Disorder
listen to her or believe her complaints. But she believed that
5 A. One or more somatic symptoms that are distressing and/or
result in significant disruption of daily life.
marriage would solve everything; she was finally someone
special. Unfortunately, it didn’t work out that way. She soon
B. Excessive thoughts, feelings, and behaviors related to the discovered her husband was continuing an affair with an old
somatic symptoms or associated health concerns as manifested girlfriend.
by at least one of the following: Three years after her wedding, Gail came to our clinic
1. Disproportionate and persistent thoughts about the serious- complaining of anxiety and stress. She was working part-
ness of one’s symptoms. time as a waitress and found her job extremely stressful.
2. High level of health-related anxiety. Although to the best of her knowledge her husband had
3. Excessive time and energy devoted to these symptoms or stopped seeing his former girlfriend, she had trouble getting
health concerns. the affair out of her mind.
C. Although any one symptom may not be continuously present, Although Gail complained initially of anxiety and stress,
the state of being symptomatic is persistent (typically more it soon became clear that her major concerns were about her
than 6 months). health. Any time she experienced minor physical symptoms
Specify if: such as breathlessness or a headache, she was afraid she
With predominant pain (previously pain disorder): This specifier is for had a serious illness. A headache indicated a brain tumor.
individuals whose somatic complaints predominantly involve pain. Breathlessness was an impending heart attack. Other sensa-
Specify current severity: tions were quickly elaborated into the possibility of AIDS or
Mild: Only one of the symptoms in Criterion B is fulfilled. cancer. Gail was afraid to go to sleep at night for fear that she
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. would stop breathing. She avoided exercise, drinking, and
Severe: Two or more of the symptoms specified in Criterion B are even laughing because the resulting sensations upset her.
fulfilled, plus there are multiple somatic complaints (or one very Public restrooms and, on occasion, public telephones were
severe somatic symptom). feared as sources of infection.
The major trigger of uncontrollable anxiety and fear was
From American Psychiatric Association. (2013). Diagnostic and statistical manual of
the news in the newspaper and on television. Each time an
mental disorders (5th ed.). Washington, DC.
article or show appeared on the “disease of the month,” Gail
found herself irresistibly drawn into it, intently noting symp-
Illness Anxiety Disorder toms that were part of the disease. For days afterward she
was vigilant, looking for the symptoms in herself and others
Illness anxiety disorder was formerly known as “hypochondria- and often noticing some physical sensations that she would
sis,” which is still the term widely used among the public. In illness interpret as the beginnings of the disease. She even watched
anxiety disorder as we know it today, physical symptoms are either her dog closely to see whether he was coming down with
not experienced at the present time or are very mild, but severe the dreaded disease. Only with great effort could she dismiss
anxiety is focused on the possibility of having or developing a seri- these thoughts after several days. Real illness in a friend or
ous disease. If one or more physical symptoms are relatively severe relative would incapacitate her for days at a time.
and are associated with anxiety and distress, the diagnosis would Gail’s fears developed during the first year of her mar-
be somatic symptom disorder. Using DSM-5 criteria, only about riage, around the time she learned of her husband’s affair.
20% of patients who used to meet the diagnostic criteria for DSM IV At first, she spent a great deal of time and more money than
hypochondriasis now meet criteria for illness anxiety disorder, in they could afford going to doctors. Over the years, she heard
part because they do not complain about having any somatic symp- the same thing during each visit: “There’s nothing wrong
toms at all despite experiencing serious anxiety about contracting with you; you’re perfectly healthy.” Finally, she stopped
an illness (Rief & Martin, 2014). This justified the creation of the ill- going, as she became convinced her concerns were excessive,
ness anxiety disorder category to cover that 20% segment who does but her fears did not go away and she was chronically
not report symptoms. Once again, in illness anxiety disorder the miserable. •
concern is primarily with the idea of being sick instead of the physi-
cal symptom itself. And the threat seems so real that reassurance
from physicians does not seem to help. Consider the case of Gail.
Clinical Description
Gail... Invisibly Ill Do you notice any differences between Linda, who presented with
somatic symptom disorder, and Gail, who presented with illness
anxiety disorder? There is certainly a lot of overlap (Creed & Barsky,
G ail was married at 21 and looked forward to a new life. As
one of many children in a lower-middle-class household,
she felt weak and somewhat neglected and suffered from low
2004; Leibbrand, Hiller, & Fichter, 2000), but Gail was somewhat
less concerned with any specific physical symptom and more wor-
self-esteem. An older stepbrother berated and belittled her ried about the idea that she was either ill or developing an illness.
Gail’s problems are fairly typical of illness anxiety disorder.
I l l n e ss A n x i e t y D i s o r d e r 187
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Research indicates that illness anxiety disorder and somatic
symptom disorder share many features with the anxiety and mood
disorders, particularly panic disorder (Craske et al., 1996; Creed
& Barsky, 2004), including similar age of onset, personality char-
acteristics, and patterns of familial aggregation (running in fami-
lies). Indeed, anxiety and mood disorders are often comorbid with
somatic symptom disorders; that is, if individuals with somatic
symptom disorders have additional diagnoses, these most likely
are anxiety or mood disorders (Creed & Barsky, 2004; Rief, Hiller,
& Margraf, 1998; Simon, Gureje, & Fullerton, 2001; Wollburg,
Voigt, Braukhaus, Herzog, & Lowe, 2013).
As noted above, illness anxiety disorder is characterized
SPL/Science Source
by anxiety or fear that one has a serious disease. Therefore, the
essential problem is anxiety, but its expression is different from
that of the other anxiety disorders. In illness anxiety disorder, the
individual is preoccupied with bodily symptoms, misinterpreting
In illness anxiety disorder, normal experiences and sensations are
them as indicative of illness or disease. Almost any physical sensa-
often transformed into life-threatening illnesses.
tion may become the basis for concern. Some may focus on nor-
mal bodily functions such as heart rate or perspiration, others on
minor physical abnormalities such as a cough. Some individuals them, but most learn rather quickly to stop going to doctors and
complain of vague symptoms, such as aches or fatigue. Because a emergency rooms, where they are told repeatedly that nothing is
key feature of this disorder is preoccupation with physical symp- physically wrong with them. Finally, the anxieties of individuals
toms, individuals with these disorders almost always go initially with panic disorder tend to focus on the specific set of 10 or 15
to family physicians. They come to the attention of mental health sympathetic nervous system symptoms associated with a panic
professionals only after family physicians have ruled out realistic attack. Concerns range much wider in somatic symptom disor-
medical conditions as a cause of the patient’s symptoms. ders. Nevertheless, there are probably more similarities than dif-
Another important feature of this disorder is that reassurances ferences between these groups.
from numerous doctors that all is well and the individual is healthy
have, at best, only a short-term effect. It isn’t long before patients
like Gail or Linda are back in the office of another doctor on the Statistics
assumption that the previous doctors have missed something. We can only estimate prevalence of somatic symptom disor
This is because many of these individuals mistakenly believe they ders in the general population, mostly from studies of similar
have a disease, a difficult-to-shake belief sometimes referred to as DSM-IV disorders that were defined a bit differently than the cur-
“disease conviction” (Haenen, de Jong, Schmidt, Stevens, & Visser, rent DSM-5 disorders. For example, the prevalence of DSM-IV
2000). Therefore, along with anxiety focused on the possibility of hypochondriasis, which would encompass illness anxiety disor-
disease or illness, disease conviction is a core feature of the disorder and part of somatic symptom disorder, has been estimated
der (Fergus & Valentiner, 2010; Woolfolk & Allen, 2011). to be from 1% to 5% (American Psychiatric Association, 2000).
If you have just read Chapter 5, you may think that patients In primary care settings, the median prevalence rate for hypo-
with panic disorder resemble patients with both disorders, par- chondriasis is 6.7% but as high as 16.6% for distressing somatic
ticularly patients with illness anxiety disorder. Patients with panic symptoms, which should closely approximate the prevalence of
disorder also misinterpret physical symptoms as the beginning of somatic symptom disorder and illness anxiety disorder combined
the next panic attack, which they believe may kill them. Craske in these settings (Creed & Barsky, 2004). Severe illness anxiety
and colleagues (1996) and Hiller, Leibbrand, Rief, and Fichter has a late age of onset, possibly because more physical health
(2005) suggested several differences between panic disorder and problems occur with aging (El-Gabalawy, Mackenzie, Thibodeau,
the somatic symptom disorders. Although all disorders include Asmundson, & Sareen, 2013).
characteristic concern with physical symptoms, patients with Linda’s disorder developed during adolescence. A number of
panic disorder typically fear immediate symptom-related catas- studies have demonstrated that individuals with what would now
trophes that may occur during the few minutes they are having be somatic symptom disorder tend to be women, unmarried, and
a panic attack, and these concerns lessen between attacks. Indi- from lower socioeconomic groups (see, for example, Creed &
viduals with somatic symptom disorders, on the other hand, focus Barsky, 2004; Lieb et al., 2002). In addition to a variety of somatic
on a long-term process of illness and disease (for example, cancer complaints, individuals may have psychological complaints, usu-
or AIDS). Patients with these disorders also continue to seek the ally anxiety or mood disorders (Simms, Prisciandaro, Krueger, &
opinions of additional doctors in an attempt to rule out (or per- Goldberg, 2012; Rief et al., 1998). Patients with these disorders
haps confirm) disease and are more likely to demand unnecessary who happened to be in psychiatric clinics reported seemingly
medical treatments. Despite numerous assurances that they are endless psychological complaints, including psychotic symptoms,
healthy, they remain unconvinced and unreassured. In contrast, in addition to their physical complaints (Lenze, Miller, Munir,
panic patients continue to believe their panic attacks might kill Pornoppadol, & North, 1999). Suicidal attempts that appear to
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be manipulative gestures rather than true death efforts are fre- of burning in the hands and feet in Pakistani or Indian patients
quent (Chioqueta & Stiles, 2004). Obviously, individuals with (Kirmayer & Weiss, 1993).
somatic symptom disorders overuse and misuse the health-care For a long time, researchers thought that expressing psychologi-
system, with medical bills as much as 9 times more than the aver- cal distress as somatic complaints was particularly common in non-
age patient (Barsky, Orav, & Bates, 2005; Hiller, Fichter, & Rief, Western or developing countries. But on closer inspection this does
2003; Woolfolk & Allen, 2011). In one study, 19% of people with not seem to be the case, and the impression may have resulted from
this disorder were on disability (Allen, Woolfolk, Escobar, Gara, the ways in which early studies were conducted (see, for example,
& Hamer, 2006). Although symptoms may come and go, somatic Cheung, 1995). Thus, “somatizing” psychological distress is fairly
symptom disorders and the accompanying sick role behavior are common, and fairly uniform, throughout the world (Gureje, 2004).
chronic, often continuing into old age. It is particularly important to examine for medical causes of somatic
As with anxiety disorders, culture-specific syndromes seem complaints in developing countries, where parasitic and other infec-
to fit comfortably with somatic symptom disorders (Kirmayer & tious diseases and physical conditions associated with poor nutrition
Sartorius, 2007). Among these is the disorder of koro, in which are common and not always easy to diagnose. Table 6.1 presents data
there is the belief, accompanied by severe anxiety and sometimes from a large World Health Organization study on individuals pre-
panic, that the genitals are retracting into the abdomen. Most vic- senting to primary care settings with medically unexplained physi-
tims of this disorder are Chinese males, although it is also reported cal symptoms (no longer a required criterion in DSM-5) that either
in females; there are few reports of the problem in Western cul- would or would not be sufficient to meet criteria for somatic symp-
tures. Why does koro occur in Chinese cultures? Rubin (1982) tom disorders. Notice that the rates are relatively uniform around the
points to the central importance of sexual functioning among world, as is the sex ratio (Gureje, Simon, Ustun, & Goldberg, 1997).
Chinese males. He notes that typical sufferers are guilty about When the problem is severe enough to meet criteria for disorder, the
excessive masturbation, unsatisfactory intercourse, or promiscuity. sex ratio is approximately 2:1 female to male.
These kinds of events may predispose men to focus their attention
on their sexual organs, which could exacerbate anxiety and emo-
tional arousal, much as it does in the anxiety disorders. Causes
Another culture-specific disorder, prevalent in India, is an Investigators with otherwise differing points of view agree on psy-
anxious concern about losing semen, something that obviously chopathological processes ongoing in somatic symptom disorders.
occurs during sexual activity. The disorder, called dhat, is associ- Faulty interpretation of physical signs and sensations as evidence
ated with a vague mix of physical symptoms, including dizziness, of physical illness is central, so almost everyone agrees that these
weakness, and fatigue. These low-grade depressive or anxious disorders are basically disorders of cognition or perception with
symptoms are simply attributed to a physical factor, semen loss
(Ranjith & Mohan, 2004). Other specific culture-bound somatic
symptoms associated with emotional factors would include hot TABLE 6.2
DSM
sensations in the head or a sensation of something crawling in the Diagnostic Criteria for Illness Anxiety Disorder
head, specific to African patients (Ebigno, 1986), and a sensation
5 A. Preoccupation with fears of having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in
intensity. If another medical condition is present or there is a high
risk for developing a medical condition (e.g., strong family history is
present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual
is easily alarmed about personal health status.
D. The individual performs excessive health-related behaviors (e.g.,
repeatedly checks his or her body for signs of illness) or exhibits
maladaptive avoidance (e.g., avoids doctors’ appointments and
hospitals).
E. Illness preoccupation has been present for at least 6 months,
but the specific illness that is feared may change over that
period of time.
F. The illness-related preoccupation is not better explained by
another mental disorder, such as somatic symptom disorder,
generalized anxiety disorder, or obsessive-compulsive disorder.
Specify whether:
Fuse/Jupiter Images
Care-seeking type: Medical care, including physician visits or undergo-

ing tests and procedures, is frequently used.
Care-avoidant type: Medical care is rarely used
In somatic symptom disorder, primary relationships are often with From American Psychiatric Association. (2013). Diagnostic and statistical manual of
medical caregivers; one’s symptoms are one’s identity. mental disorders (5th ed.). Washington, DC.
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Table 6.1 Frequency of Two Forms of Somatization in a Cross-Cultural Study (N = 5,438)*
ICD-10 Somatization Disorder (%) Somatic Symptom Index (%)
Center Men Women Overall Prevalene Men Women Overall Prevalence
Ankara, Turkey 1.3 2.2 1.9 22.3 26.7 25.2
Athens, Greece 0.4 1.8 1.3 7.7 13.5 11.5
Bangalore, India 1.3 2.4 1.8 19.1 20.0 19.6
Berlin, Germany 0.3 2.0 1.3 24.9 25.9 25.5
Groningen, the Netherlands 0.8 4.1 2.8 14.7 19.9 17.8
Ibadan, Nigeria 0.5 0.3 0.4 14.4 5.0 7.6
Mainz, Germany 1.0 4.4 3.0 24.9 17.3 20.6
Manchester, United Kingdom 0 0.5 0.4 21.4 20.0 20.5
Nagasaki, Japan 0 0.2 0.1 13.3 7.9 10.5
Paris, France 0.6 3.1 1.7 18.6 28.2 23.1
Rio de Janeiro, Brazil 1.5 11.2 8.5 35.6 30.6 32.0
Santiago, Chile 33.8 11.2 17.7 45.7 33.3 36.8
Seattle, Washington, United 0.7 2.2 1.7 10.0 9.8 9.8

States
Shanghai, China 0.3 2.2 1.5 17.5 18.7 18.3
Verona, Italy 0 0.2 0.1 9.7 8.5 8.9
Total 1.9 3.3 2.8 19.8 19.7 19.7
Note: Criteria from The International Classification of Diseases (10th ed.) were used in this study.
*
Weighted to the first-stage (intake) sample.
Source: Adapted from Gureje, O., Simon, G. E., Ustun, T. B., & Goldberg, D. P. (1997). Somatization
in cross-cultural perspective: A World Health Organization study in primary care. American Journal of
Psychiatry, 154, 989–995.
strong emotional contributions (Adler, Côté, Barlow, & Hillhouse, They also tend to interpret ambiguous stimuli as threatening (Haenen
1994; olde Hartman et al., 2009; Taylor & Asmundson, 2004, 2009; et al., 2000). Thus, they quickly become aware (and frightened) of any
Witthöft & Hiller, 2010). sign of possible illness or disease. A minor headache, for example,
Individuals with somatic symptom disorders experience physi- might be interpreted as a sure sign of a brain tumor. Smeets, de Jong,
cal sensations common to all of us, but they quickly focus their and Mayer (2000) demonstrated that individuals with these disorders,
attention on these sensations. Remember that the very act of focus- compared with “normals,” take a “better safe than sorry” approach to
ing on yourself increases arousal and makes the physical sensations dealing with even minor physical symptoms by getting them checked
seem more intense than they are (see Chapter 5). If you also tend to out as soon as possible. More fundamentally, they have a restrictive
misinterpret these as symptoms of illness, your anxiety will increase concept of health as being symptom-free (Rief et al., 1998).
further. Increased anxiety produces additional physical symptoms, What causes individuals to develop this pattern of somatic sen-
which creates a vicious cycle (see E Figure 6.1, which was developed sitivity and distorted beliefs? Although it is not certain, the cause is
to apply to DSM-IV hypochondriasis, but in fact applies to DSM-5 unlikely to be found in isolated biological or psychological factors.
somatic symptom disorder and illness anxiety disorder) (Salkovskis, For some patients, the fundamental causes of these disorders are
Warwick, & Deale, 2003; Warwick & Salkovskis, 1990; Witthöft & similar to those implicated in the anxiety disorders (Barlow, 2002;
Hiller, 2010). Barlow et al., 2014). For example, evidence shows that somatic
Using procedures from cognitive science such as the Stroop test symptom disorders run in families (Bell, 1994; Guze, Cloninger,
(see Chapter 2), a number of investigators (Hitchcock & Mathews, Martin, & Clayton, 1986; Katon, 1993), and that there is a mod-
1992; Pauli & Alpers, 2002) have confirmed that participants with est genetic contribution (Taylor, Thordarson, Jang, & Asmundson,
these disorders show enhanced perceptual sensitivity to illness cues. 2006). But this contribution may be nonspecific, such as a tendency
50443_ch06_ptg01_hr_184-215.indd 190 28/09/16 5:35 PM

Apprehension
Checking
Increased
Increased focus behavior and
physiological
on body reassurance
arousal
seeking
Trigger
(information, event, Perceived threat
illness, image)
Preoccupation with perceived
alteration/abnormality of bodily
sensations/state
Misinterpretation of
body sensations and/or signs
as indicating severe illness
EEFigure 6.1
Integrative model of causes of hypochondriasis. (Based on Warwick, H. M., & Salkovskis, P. M. [1990]. Hypochondriasis. Behavior Research
Therapy, 28, 105–117.)
to overrespond to stress, and thus may be indistinguishable from Treatment

the nonspecific genetic contribution to anxiety disorders. Hyper- It used to be common clinical practice to uncover unconscious con-
responsivity might combine with a tendency to view negative life flicts through psychodynamic psychotherapy. However, the results on
events as unpredictable and uncontrollable and, therefore, to be the effectiveness of this kind of treatment have seldom been reported.
guarded against at all times (Noyes et al., 2004; Barlow et al., 2014). Scientifically controlled studies have shown some support for
As we noted in Chapter 5, these factors would constitute biological cognitive behavioral treatments for health anxiety (e.g., Bouman,
and psychological vulnerabilities to anxiety. 2014; Taylor & Asmundon, 2009) and also somatic symptom disor
Why does this anxiety focus on physical sensations and der (e.g., Kleinstäuber, Witthöft, & Hiller, 2011; Sharma, & Manjula,
illness? We know that children with these concerns often report 2013; Witthoft & Hiller 2010; Woolfolk & Allen, 2011). Surprisingly,
the same kinds of symptoms that other family members may clinical reports indicate that reassurance and education can be effective
have reported at one time (Kirmayer, Looper, & Taillefer, 2003). It in some cases with health anxiety (Haenen et al., 2000; Kellner,
is therefore quite possible, as in panic disorder, that some indi- 1992)—”surprisingly” because, by definition, patients with these disor-
viduals who develop somatic symptom disorder or illness anxiety ders are not supposed to benefit from reassurance about their health.
disorder have learned from family members to focus their anxiety Reassurance is usually given only briefly, however, by family doctors
on specific physical conditions and illness. who have little time to provide the ongoing support and reassurance
Three other factors may contribute to this etiological process. that might be necessary. Mental health professionals may well be able
First, these disorders seem to develop in the context of a stressful to offer reassurance in a more effective and sensitive manner, devote
life event, as do many disorders, including anxiety disorders. Such sufficient time to all concerns the patient may have, and attend to the
events often involve death or illness (Noyes et al., 2004; Sandin, “meaning” of the symptoms (for example, their relation to the patient’s
Chorot, Santed, & Valiente, 2004). (Gail’s traumatic first year of life stress). Fava, Grandi, Rafanelli, Fabbri, and Cazzaro (2000) test-
marriage seemed to coincide with the beginning of her disorder.) ed this idea by assigning 20 patients who met diagnostic criteria for
Second, people who develop these disorders tend to have had a DSM-IV hypochondriasis to two groups. One received “explanatory
disproportionate incidence of disease in their family when they therapy” in which the clinician went over the source and origins of
were children. Thus, even if they did not develop somatic symp- their symptoms in some detail. These patients were assessed imme-
tom disorders until adulthood, they carry strong memories of diately after the therapy and again at a 6-month follow-up. The other
illness that could easily become the focus of anxiety. Third, an group was a wait-list control group that did not receive the explana-
important social and interpersonal influence may be involved tory therapy until after 6 months of waiting. All patients received usual
(Noyes et al., 2003; Barlow et al., 2014). Some people who come medical care from their physicians. In both groups, taking the time to
from families where illness is a major issue seem to have learned explain in some detail the nature of the patient’s disorder in an educa-
that an ill person often gets a lot of attention. The “benefits” of tional framework was associated with a significant reduction in fears
being sick might contribute to the development of the disorder and beliefs about somatic symptoms and a decrease in health-care
in some people. A “sick person” who receives increased attention usage, and these gains were maintained at the follow-up. For the wait-
for being ill and is able to avoid work or other responsibilities is list group, treatment gains did not occur until the patients received
described as adopting a “sick role.” explanatory therapy, suggesting this treatment is effective. This is
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a small study and follow-ups occurred for only 6 months, but the hypochondriasis to receive cognitive therapy alone, exposure
results are promising (although explanatory therapy most likely therapy without explicit cognitive interventions, or a waitlist
only benefits those with more mild forms of the disorders) (Taylor, control group. Compared to the control group, both treatments
Asmundson, & Coons, 2005). Participation in support groups may resulted in large-sized effects for improving symptoms of hypo-
also give these people the reassurance they need. chondriasis. Although the study found a significant reduction
Evaluations of more robust treatments are now available in depressive symptoms and bodily complaints for both treat-
(for a review, see Bouman, 2014). For example, in one strong ments in comparison with the waitlist, anxiety symptoms were
study, Barsky and Ahern (2005) randomized 187 patients only significantly reduced by the exposure treatment. The expo-
with DSM-IV hypochondriasis to receive either six sessions of sure procedures consisted of repeatedly confronting the patient
cognitive-behavioral treatment (CBT) from trained therapists or to stimuli that are relevant for health anxieties (e.g., documen-
treatment as usual from primary care physicians. CBT focused taries about diseases) without using any avoidance and safety
on identifying and challenging illness-related misinterpreta- behaviors (e.g., reassurance by doctors, checking the abdomen
tions of physical sensations and on showing patients how to for cancer). A few other reports suggest that drugs may help
create “symptoms” by focusing attention on certain body areas. some people with somatic symptom disorders (Fallon et al.,
Bringing on their own symptoms persuaded many patients that 2003; Kjernisted, Enns, & Lander, 2002; Kroenke, 2007; Taylor
such events were under their control. Patients were also coached et al., 2005). Not surprisingly, these same types of drugs (anti-
to seek less reassurance regarding their concerns. Results can be depressants) are useful for anxiety and depression. In one study,
seen in E Figure 6.2 as scores on the Whiteley Index of hypo- CBT and the drug paroxetine (Paxil), a selective-serotonin
chondriacal symptoms. CBT was more effective after treatment reuptake inhibitor (SSRI), were both effective, but only CBT
and at each follow-up point for both symptoms of hypochondri- was significantly different from a placebo condition. Specifi-
asis and overall changes in functioning and quality of life. But cally, 45% in the CBT group, 30% in the Paxil group, and 14%
results were still “modest,” and many eligible patients refused in the placebo group responded to treatment among all patients
to enter treatment because they were convinced their prob- who entered the study (Greeven et al., 2007).
lems were medical rather than psychological. In another strong In our clinic, we concentrate on initially providing reassur-
study, Allen et al. (2006) found that 40% of patients with more ance, reducing stress, and, in particular, reducing the frequency of
severe somatic symptom disorder treated with CBT (versus 7% help-seeking behaviors. One of the most common patterns is the
of a group receiving standard medical care) evidenced clinical person’s tendency to visit numerous medical specialists to address
improvement and these gains lasted at least a year. Escobar et al. the symptom of the week. There is an extensive medical and physi-
(2007) reported similar results. Interestingly, one recent trial cal workup with every visit to a new physician (or to one who has
suggests that cognitive interventions do not seem to be necessary not been seen for a while), at an extraordinary cost to the health-
for treating hypochondriasis (Weck, Neng, Richtberg, Jakob, care system (Barsky et al., 2005; Witthöft & Hiller, 2010). In treat-
& Stangier, 2015). This study randomly assigned patients with ment, to limit these visits, a gatekeeper physician is assigned to
each patient to screen all physical complaints. Subsequent visits
to specialists must be specifically authorized by this gatekeeper. In
the context of a positive therapeutic relationship, most patients are
4 amenable to this arrangement.
Group means on Whiteley index
Additional therapeutic attention is directed at reducing the

supportive consequences of relating to significant others on the
3 basis of physical symptoms alone. More appropriate methods of
interacting with others are encouraged, along with additional
procedures to promote healthy social and personal adjustment
2 without relying on being “sick.” In this context, CBT may then be
the most helpful (Allen et al., 2006; Mai, 2004; Woolfolk & Allen,
2011). Because Linda, like many patients with this disorder, was
receiving disability payments from the state, additional goals
1
Baseline 6 month 12 month involved encouraging at least part-time employment, with the
followup followup ultimate goal of discontinuing disability.
Treatment 3.58 2.82 2.65 Now family doctors are being trained in how better to manage
group mean these patients using some of these principles (Garcia-Campayo,
Control
Claraco, Sanz-Carrillo, Arevalo, & Monton, 2002), but results are
3.51 3.21 3.02 mixed (Woolfolk & Allen, 2011).
group mean
EEFigure 6.2 Psychological Factors Affecting

Reduction in symptoms of hypochondriasis after six sessions of CBT Medical Condition
or medical care as usual. (Adapted from Barsky, A. J., & Ahern, D. K.
[2005]. Cognitive behavior therapy for hypochondriasis: A randomized A related somatic symptom disorder is called psychological
controlled trial. JAMA, 291, 1464–1470.) factors affecting medical condition. The essential feature
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of this disorder is the presence of a diagnosed medical con-
Eloise... Unlearning Walking
dition such as asthma, diabetes, or severe pain clearly caused
by a known medical condition such as cancer that is adversely
affected (increased in frequency or severity) by one or more
psychological or behavioral factors. These behavioral or
E loise sat on a chair with her legs under her, refusing to
put her feet on the floor. Her mother sat close by, ready to
assist her if she needed to move or get up. Her mother had
psychological factors would have a direct influence on the
made the appointment and, with the help of a friend, had
course or perhaps the treatment of the medical condition. One
all but carried Eloise into the office. Eloise was a 20 year old
example would be anxiety severe enough to clearly worsen
of borderline intelligence who was friendly and personable
an asthmatic condition. Another example would be a patient
during the initial interview and who readily answered all
with diabetes who is in denial about the need to regularly
questions with a big smile. She obviously enjoyed the social
check insulin levels and intervene when necessary. In this case
interaction.
the pattern would have to be consistent in the neglect of
Eloise’s difficulty walking developed over 5 years. Her
appropriate monitoring and intervention, but the neglect is
right leg had given way and she began falling. Gradually, the
clearly a behavioral or psychological factor that is adversely
condition worsened to the point that 6 months before her
affecting the medical condition. This diagnosis would need
admission to the hospital Eloise could move around only by
to be distinguished from the development of stress or anxiety
crawling on the floor.
in response to having a severe medical condition that would
Physical examinations revealed no physical problems.
more appropriately be diagnosed as an adjustment disorder
Eloise presented with a classic case of conversion disorder.
(see Chapter 5). In Chapter 9, we discuss health psychology
Although she was not paralyzed, her specific symptoms
and the contribution of psychological factors to physical dis-
included weakness in her legs and difficulty keeping her
orders including cardiovascular disease, cancer, AIDS, and
balance, with the result that she fell often. This particular
chronic pain.
type of conversion symptom is called astasia-abasia. Eloise
lived with her mother, who ran a gift shop in the front of
Conversion Disorder (Functional her house in a small rural town. Eloise had been schooled
Neurological Symptom Disorder) through special education programs until she was about 15;
after this, no further programs were available. When Eloise
The term conversion has been used off and on since the Middle began staying home, her walking began to deteriorate. •
Ages (Mace, 1992) but was popularized by Freud, who believed
the anxiety resulting from unconscious conflicts somehow was
“converted” into physical symptoms to find expression. This
allowed the individual to discharge some anxiety without actu- In addition to blindness, paralysis, and aphonia, conversion
ally experiencing it. As in phobic disorders, the anxiety resulting symptoms may include total mutism and the loss of the sense of
from unconscious conflicts might be “displaced” onto another touch. Some people have seizures, which may be psychological
object. In DSM-5, “functional neurological symptom disorder” is in origin, because no significant electroencephalogram (EEG)
a subtitle to conversion disorder because the term is more often changes can be documented. These “seizures” are usually called
used by neurologists who see the majority of patients receiving psychogenic non-epileptic seizures. Another relatively com-
a conversion disorder diagnosis, and because the term is more mon symptom is globus hystericus, the sensation of a lump in the
acceptable to patients. “Functional” refers to a symptom without throat that makes it difficult to swallow, eat, or sometimes talk
an organic cause (Stone, LaFrance, Levenson, & Sharpe, 2010). It (Finkenbine & Miele, 2004).
is likely that the old term “conversion” will be dropped in future
editions of the DSM.
Closely Related Disorders
Distinguishing among conversion reactions, medically explained
Clinical Description symptoms, and outright malingering (faking) is sometimes dif-
Conversion disorders generally have to do with physical mal- ficult. Several factors can help, but one symptom, widely regarded
functioning, such as paralysis, blindness, or difficulty speaking as a diagnostic sign, has proved not to be useful.
(aphonia), without any physical or organic pathology to account It was long thought that patients with conversion reactions had
for the malfunction. Most conversion symptoms suggest that the same quality of indifference to the symptoms thought to be
some kind of neurological disease is affecting sensory–motor sys- present in some people with severe somatic symptom disorder. This
tems, although conversion symptoms can mimic the full range of attitude, referred to as la belle indifférence, was considered a hall-
physical malfunctioning. mark of conversion reactions, but, unfortunately, this turns out not
Conversion disorders provide some of the most intriguing, to be the case. Stone, Smyth, Carson, Warlow, and Sharpe (2006)
sometimes astounding, examples of psychopathology. What found a blasé attitude toward illness is sometimes displayed by peo-
could possibly account for somebody going blind when all visual ple with actual physical disorders, and some people with conver-
processes are normal or experiencing paralysis of the arms or sion symptoms do become quite distressed. Specifically, only 21% of
legs when there is no neurological damage? Consider the case 356 patients with conversion symptoms displayed la belle indif-
of Eloise. férence compared with 29% of 157 patients with organic disease.
C o n v e rs i o n D i s o r d e r ( F u n c t i o n a l N e u r o l o g i c a l S y m p t o m D i s o r d e r ) 193
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DSM
Table 6.3 study, neuroscientists attempted to find out (Voon et al., 2010).
These investigators assessed eight patients who presented
Diagnostic Criteria for Conversion Disorder with motor tremors without any neurological basis (conversion
(Functional Neurological Symptom Disorder)
5 A. One or more symptoms of altered voluntary motor or sensory
tremors). In a clever experiment, they used functional magnetic
resonance imaging (fMRI) to compare brain activity during
the conversion tremor, but also during a voluntary “mimicked”
function.
tremor in which patients were instructed to produce the tremor
B. Clinical findings provide evidence of incompatibility between the
on purpose. The investigators found that the conversion tremor,
symptom and recognized neurological or medical conditions.
as compared with the voluntary tremor, was associated with low-
C. The symptom or deficit is not better explained by another
er activity in the right inferior parietal cortex. Interestingly, this
medical or mental disorder.
is an area of the brain that functions to compare internal predic-
D. The symptom or deficit causes clinically significant distress or
tions with actual events. In other words, if an individual wants to
impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation. move her arm and then she decides to go ahead and move it, this
area of the brain determines if the desired action has occurred.
From American Psychiatric Association. (2013). Diagnostic and statistical manual of Because we think about making a movement before we do it,
mental disorders (5th ed.). Washington, DC. the brain concludes (correctly in most cases) that we caused the
movement to occur. But if this area of the brain is not function-
ing properly, then the brain might conclude that the movement
is involuntary.
Other factors may be more helpful in making this distinction. Of course, it is not clear whether this brain activity is a cause
Conversion symptoms often seem to be precipitated by marked or a result of conversion symptoms, but these sophisticated brain-
stress. Often this stress takes the form of a physical injury. In one imaging technologies may eventually bring us closer to under-
large survey, 324 out of 869 patients (37%) reported prior physi- standing at least one part of the puzzle of conversion symptoms
cal injury (Stone, Carson, Aditya, et al., 2009). But the occur- in some people.
rence of some identifiable stressor has not been a reliable sign of It can also be difficult to distinguish between individuals
conversion disorder, since many other disorders are associated who are truly experiencing conversion symptoms in a seemingly
with stressful events and stressful events often occur in the lives involuntary way and malingerers who are good at faking symp-
of people without any disorders. For this reason, the diagnostic toms. Once malingerers are exposed, their motivation is clear:
criterion that conversion disorder is associated with preceding They are either trying to get out of something, such as work or
stress does not appear in DSM-5. Although people with conver- legal difficulties, or they are attempting to gain something, such
sion symptoms can usually function normally, they seem truly as a financial settlement. Malingerers are fully aware of what they
unaware either of this ability or of sensory input. For example, are doing and are clearly attempting to manipulate others to gain
individuals with the conversion symptom of blindness can usu- a desired end.
ally avoid objects in their visual field, but they will tell you they More puzzling is a set of conditions called factitious disor-
can’t see the objects. Similarly, individuals with conversion symp- ders, which fall somewhere between malingering and conver-
toms of paralysis of the legs might suddenly get up and run in an sion disorders. The symptoms are under voluntary control, as
emergency and then be astounded they were able to do this. It with malingering, but there is no obvious reason for voluntarily
is possible that at least some people who experience miraculous producing the symptoms except, possibly, to assume the sick
cures during religious ceremonies may have been suffering from role and receive increased attention. Tragically, this disorder
conversion reactions. These factors may help in distinguishing may extend to other members of the family. An adult, almost
between conversion and organically based physical disorders, but always a mother, may purposely make her child sick, evidently
clinicians sometimes make mistakes, although it is not common for the attention and pity given to her as the mother of a sick
with modern diagnostic techniques. For example, Moene and child. When an individual deliberately makes someone else sick,
colleagues (2000) carefully reassessed 85 patients diagnosed with the condition is called factitious disorder imposed on another. It
conversion disorder and found 10 (11.8%) had developed some was also known previously as Munchausen syndrome by proxy.
evidence of a neurological disorder approximately 2.5 years after In any case, it is really an atypical form of child abuse (Check,
the first exam. Stone and colleagues (2005), summarizing a num- 1998). Table 6.2 presents differences between typical child abuse
ber of studies, estimate the rate of misdiagnosis of conversion and factitious disorder imposed on another (Munchausen syn-
disorders that are really physical problems is approximately 4%, drome by proxy).
having improved considerably from earlier decades. In any case, The offending parent may resort to extreme tactics to create the
ruling out medical causes for the symptoms is crucial to making a appearance of illness in the child. For example, one mother stirred
diagnosis of conversion and, given advances in medical screening her child’s urine specimen with a vaginal tampon obtained during
procedures, this is the principal diagnostic criterion in DSM-5 menstruation. Another mother mixed feces into her child’s vomit
(APA, 2013; Stone et al., 2010). (Check, 1998). Because the mother typically establishes a positive
Some conversion symptoms involve movements such as relationship with a medical staff, the true nature of the illness is
tremors that are perceived as involuntary. But what makes a most often unsuspected and the staff members perceive the par-
movement either voluntary or involuntary? In one well-done ent as remarkably caring, cooperative, and involved in providing
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Table 6.2 Child Abuse Associated with Munchausen Syndrome by Proxy Versus Typical Child Abuse
Typical Child Abuse Atypical Child Abuse (Munchausen Syndrome by Proxy)
Physical presentation of Results from direct physical contact with the child; Misrepresentation of an acute or accidental medical or surgical
the child signs often detected on physical examination illness not usually obvious on physical examination
Obtaining the diagnosis The perpetrator does not invite the discovery of the The perpetrator usually presents the manifestations of the
manifestation of the abuse abuse to the health-care system
Victims Children are either the objects of frustration and Children serve as the vector in gaining the attention the mother
anger or are receiving undue or inappropriate desires; anger is not the primary causal factor
punishment
Awareness of abuse Usually present Not usually present
Source: Reprinted, with permission, from Check, J. R. (1998). Munchausen syndrome by proxy: An atypi-
cal form of child abuse. Journal of Practical Psychiatry and Behavioral Health, 4(6), p. 341, Table 6.2.
© 1998 Lippincott, Williams & Wilkins.
for her child’s well-being. Therefore, the mother is often successful Unconscious Mental Processes
at eluding suspicion. Helpful procedures to assess the possibility Unconscious cognitive processes seem to play a role in much of
of factitious disorder imposed on another include a trial separa- psychopathology (although not necessarily as Freud envisioned
tion of the mother and the child or video surveillance of the child it), but nowhere is this phenomenon more readily and dramati-
while in the hospital. An important study has appeared validat- cally apparent than when we attempt to distinguish between con-
ing the utility of surveillance in hospital rooms of children with version disorders and related conditions. To take a closer look at
suspected factitious disorder imposed on another. In this study, the “unconscious” mental process in these conditions, we review
41 patients presenting with chronic, difficult-to-diagnose physi- briefly the case of Anna O. (see Chapter 2).
cal problems were monitored by video during their hospital stay. As you may remember, when Anna O. was 21 years old, she
In 23 of these cases, the diagnoses turned out to be factitious dis- was nursing her dying father. This was a difficult time for her. She
order imposed on another, where the parent was responsible for reported that after many days by the sick bed, her mind wandered.
the child’s symptoms, and in more than half of these 23 cases, Suddenly she found herself imagining (dreaming?) that a black
video surveillance was the method used to establish the diagno- snake was moving across the bed, about to bite her father. She
sis. In the other patients, laboratory tests or “catching” the mother tried to grab the snake, but her right arm had gone to sleep and
in the act of inducing illness in her child confirmed the diagnosis. she could not move it. Looking at her arm and hand, she imagined
In one case, a child was suffering from recurring Escherichia coli, or that her fingers had turned into little poisonous snakes. Horrified,
E. coli, infections, and cameras caught the mother injecting all she could do was pray, and the only prayer that came to mind
her own urine into the child’s intravenous line (Hall, Eubanks, was in English (Anna O.’s native language was German). After this,
Meyyazhagan, Kenney, & Cochran Johnson, 2000). she experienced paralysis in her right arm whenever she remem-
bered this hallucination. The paralysis gradually extended to the
right side of her body and, on occasion, to other parts of her body.
Table 6.4
DSM
She also experienced a number of other conversion symptoms

Diagnostic Criteria for Factitious Disorders such as deafness and, intriguingly, an inability to speak German,
although she remained fluent in English. In Josef Breuer’s treat-
5 A. Falsification of physical or psychological signs or symptoms,
or induction of injury or disease, associated with identified
ment of Anna O., she relived her traumatic experiences in her
imagination. Under hypnosis, she was able to recreate the memory
deception. of her horrific hallucination. As she recalled and processed the
B. The individual presents himself or herself to others as ill, impaired images, her paralysis left her and she regained her ability to speak
or injured. German. Breuer called the therapeutic reexperiencing of emotion-
C. The deceptive behavior is evident even in the absence of obvious ally traumatic events catharsis (purging, or releasing). Catharsis
external rewards. has proved to be an effective intervention with many emotional
D. The behavior is not better accounted for by another mental disorders, as we noted in Chapter 5.
disorder such as delusional belief system or acute psychosis. Were Anna O.’s symptoms really “unconscious,” or did she
Specify if: realize at some level that she could move her arm and the rest of
Single episode her body if she wanted to and it simply served her purpose not
Recurrent episodes: Two or more events of falsification of illness and/
to? This question has long bedeviled psychopathologists. Now
or induction of injury.
information (reviewed in Chapter 2) on unconscious cognitive
From American Psychiatric Association. (2013). Diagnostic and statistical manual of processes becomes important. We are all capable of receiving and
mental disorders (5th ed.). Washington, DC. processing information in a number of sensory channels (such as
50443_ch06_ptg01_hr_184-215.indd 195 28/09/16 5:35 PM

vision and hearing) without being aware of it. Remember the phe- are also common (Pehlivanturk & Unal, 2002; Rowe, 2010; Stone,
nomenon of blind sight or unconscious vision? Weiskrantz (1980) Carson, Duncan, et al., 2009). Conversion disorders are relatively
and others discovered that people with small, localized damage to rare in mental health settings, but remember that people who
certain parts of their brains could identify objects in their field of seek help for this condition are more likely to consult neurolo-
vision but that they had no awareness whatsoever that they could gists or other specialists. The prevalence estimate in neurological
see. Could this happen to people without brain damage? Consider settings is high, averaging about 30% (Rowe, 2010; Stone, Carson,
the case of Celia. Duncan, et al., 2009). One study estimated that 30% of all patients
Sackeim, Nordlie, and Gur (1979) evaluated the potential dif- referred to epilepsy centers have psychogenic, nonepileptic sei-
ference between real unconscious process and faking by hypnotiz- zures (Benbadis & Allen-Hauser, 2000; Schoenberg, Marsh, &
ing two participants and giving each a suggestion of total blindness. Benbadis, 2012).
One participant was also told it was extremely important that she Like severe somatic symptom disorder, conversion disorders
appear to everyone to be blind. The second participant was not are found primarily in women (Brown & Lewis-Fernandez, 2011;
given further instructions. The first participant, evidently follow- Deveci et al., 2007) and typically develop during adolescence or
ing instructions to appear blind at all costs, performed far below slightly thereafter. Conversion reactions have also been reported
chance on a visual discrimination task similar to the upright tri- in soldiers exposed to severe combat, mainly during World War I
angle task. On almost every trial, she chose the wrong answer. and II (Mucha & Reinhardt, 1970; Perez-Sales, 1990). The conver-
The second participant, with the hypnotic suggestion of blindness sion symptoms often disappear after a time, only to return later in
but no instructions to “appear” blind at all costs, performed per- the same or similar form when a new stressor occurs. In one study,
fectly on the visual discrimination tasks—although she reported 56 patients with psychogenic non-epileptic seizures (16 males and
she could not see anything. How is this relevant to identifying 40 females), who had their disorder for an average of 8 years, were
malingering? In an earlier case, Grosz and Zimmerman (1965) followed for 18 months after initial diagnosis (Ettinger, Devinsky,
evaluated a male who seemed to have conversion symptoms of Weisbrot, Ramakrishna, & Goyal, 1999). Outcome was generally
blindness. They discovered that he performed much more poorly poor for these patients, with only about half of the patients recov-
than chance on a visual discrimination task. Subsequent informa- ering. Even among those patients whose seizures had gotten bet-
tion from other sources confirmed that he was almost certainly ter, rehospitalizations were common. Approximately 20% of this
malingering. To review these distinctions, someone who is truly group had attempted suicide, and this proportion did not differ
blind would perform at a chance level on visual discrimination between those whose seizures had gotten better during the period
tasks. People with conversion symptoms, on the other hand, can and those whose seizures had not gotten better. If the patients
see objects in their visual field and therefore would perform well believed the diagnosis of conversion disorder when it was given
on these tasks, but this experience is dissociated from their aware- to them, and otherwise perceived themselves as being in good
ness of sight. Malingerers and, perhaps, individuals with factitious health and functioning well at work and at home, they had a bet-
disorders simply do everything possible to pretend they can’t see. ter chance of recovering from their psychologically based seizures.
Fortunately, children and adolescents seem to have a better long-
term outlook than adults. In one study from Turkey, fully 85% of
Celia... Seeing Through Blindness 40 children had recovered 4 years after initial diagnoses, with those
diagnosed early having the best chance of recovery (Pehlivanturk
A 15-year-old girl named Celia suddenly was unable to see. & Unal, 2002). In view of the consistency with which this disorder
Shortly thereafter, she regained some of her sight, but her occurs in countries around the world, this outcome would prob-
vision was so severely blurred that she could not read. When ably be true in other countries as well. In the beginning of the
she was brought to a clinic for testing, psychologists arranged chapter, we noted that conversion disorder and dissociative disor-
a series of sophisticated vision tests that did not require her ders share common features. Several studies provide evidence for
to report when she could or could not see. One of the tasks this (Brown & Lewis-Fernandez 2011). In one study, 72 patients
required her to examine three triangles displayed on three with conversion disorders were compared with a control group of
separate screens and to press a button under the screen con- 96 psychiatric patients suffering from various emotional disorders
taining an upright triangle. Celia performed perfectly on this who were matched for gender and age. Dissociative symptoms,
test without being aware that she could see anything (Grosz & such as feelings of unreality, were significantly more common in
Zimmerman, 1970). Was Celia faking? Evidently not, or she the patients with conversion disorder than in the control group,
would have purposely made a mistake. • based on responses to a questionnaire (Spitzer, Spelsberg, Grabe,
Mundt, & Freyberger, 1999). This finding was basically replicated
in another report on 54 patients with conversion disorder com-
pared with 50 matched patients with mood or anxiety disorders
Statistics (Roelofs, Keijsers, Hoogduin, Naring, & Moene, 2002). In other
We have already seen that conversion disorder may occur with cultures, some conversion symptoms are common aspects of reli-
other disorders, particularly somatic symptom disorder, as in the gious or healing rituals. Seizures, paralysis, and trances are com-
case of Linda. Linda’s paralysis passed after several months and mon in some rural fundamentalist religious groups in the United
did not return, although on occasion she would report “feeling States (Griffith, English, & Mayfield, 1980), and they are often
as if ” it were returning. Comorbid anxiety and mood disorders seen as evidence of contact with God. Individuals who exhibit
50443_ch06_ptg01_hr_184-215.indd 196 28/09/16 5:35 PM

such symptoms are thus held in high esteem by their peers. These
symptoms do not meet criteria for a “disorder” unless they persist
and interfere with an individual’s functioning.
Causes
Freud described four basic processes in the development of conver-
sion disorder. First, the individual experiences a traumatic event—
in Freud’s view, an unacceptable, unconscious conflict. Second,
Mario Tama/Getty Images

because the conflict and the resulting anxiety are unacceptable, the
person represses the conflict, making it unconscious. Third, the
anxiety continues to increase and threatens to emerge into con-
sciousness, and the person “converts” it into physical symptoms,
thereby relieving the pressure of having to deal directly with the
conflict. This reduction of anxiety is considered to be the primary The seizures and trances that may be symptomatic of conversion dis-
gain or reinforcing event that maintains the conversion symptom. order are also common in some rural fundamentalist religious groups
Fourth, the individual receives greatly increased attention and sym- in the United States.
pathy from loved ones and may also be allowed to avoid a difficult
situation or task. Freud considered such attention or avoidance to
be the secondary gain, the secondarily reinforcing set of events. difficulties, such as substantial school difficulties, or the loss of a
We believe Freud was basically correct on at least three counts significant figure in their lives, and they rated their mothers as
but probably not on the fourth, although firm evidence support- overinvolved and overprotective on a rating scale. Rating mothers
ing any of these ideas is sparse and Freud’s views were far more as “overinvolved” or “overprotective” suggests that these psycho-
complex than represented here. Most often, individuals with con- logically based visual symptoms may have been strongly attended
version disorder have experienced a traumatic event that must to and reinforced (Wynick, Hobson, & Jones, 1997).
be escaped at all costs (Brown & Lewis-Fernandez, 2011; Stone, The one step in Freud’s progression of events about which
Carson, Aditya, et al., 2009). This might be combat, where death some questions remain is the issue of primary gain. The notion of
is imminent, or an impossible interpersonal situation. Because primary gain accounts for the feature of la belle indifférence (cited
simply running away is unacceptable in most cases, the socially previously), where individuals seem not the least bit distressed
acceptable alternative of getting sick is substituted; but getting sick about their symptoms. In other words, Freud thought that because
on purpose is also unacceptable, so this motivation is detached symptoms reflected an unconscious attempt to resolve a conflict,
from the person’s consciousness. Finally, because the escape the patient would not be upset by them. But formal tests of this
behavior (the conversion symptoms) is successful to an extent in feature provide little support for Freud’s claim. For example, Lader
obliterating the traumatic situation, the behavior continues until and Sartorius (1968) compared patients with conversion disor-
the underlying problem is resolved. One study confirms these der with control groups of anxious patients without conversion
hypotheses, at least partially (Wyllie, Glazer, Benbadis, Kotagal, & symptoms. The patients with conversion disorder showed equal or
Wolgamuth, 1999). In this study, 34 child and adolescent patients, greater anxiety and physiological arousal than the control group.
25 of them girls, were evaluated after receiving a diagnosis of psy- Also, Stone and colleagues (2006) in the study described earlier
chologically based pseudo-seizures (psychogenic non-epileptic on “indifference” to conversion symptoms found no difference in
seizures). Many of these children and adolescents presented with distress over symptoms among patients with conversion disorder
additional psychological disorders, including 32% with mood dis- compared with patients with organic disease.
orders and 24% with separation anxiety and school refusal. Other Social and cultural influences also contribute to conversion
anxiety disorders were present in some additional patients. disorder, which, like somatic symptom disorder, tends to occur
When the extent of psychological stress in the lives of these in less educated, lower socioeconomic groups where knowledge
children was examined, it was found that most of the patients had about disease and medical illness is not well developed (Brown &
substantial stress, including a history of sexual abuse, recent paren- Lewis-Fernandez, 2011; Kirmayer et al., 2003; Woolfolk & Allen,
tal divorce or death of a close family member, and physical abuse. 2011). For example, Binzer and colleagues (Binzer, Andersen, &
The authors concluded that major mood disorders and severe trau- Kullgren, 1997) noted that 13% of their group of 30 adult patients
matic stress, especially sexual abuse, are common among children with motor disabilities resulting from conversion disorder had
and adolescents with the conversion disorder of pseudo-seizures, as attended high school, compared with 67% in a control group of
other studies have similarly indicated (Roelofs et al., 2002). patients with motor symptoms because of a physical cause. Prior
In another study, 15 adolescents who had exhibited visual experience with real physical problems, usually among other fam-
problems in childhood that were of psychological origin were ily members, tends to influence the later choice of specific con-
compared with a control group of adolescents who had experi- version symptoms; that is, patients tend to adopt symptoms with
enced childhood visual problems because of known physical which they are familiar (see, for example, Brady & Lind, 1961).
problems. Adolescents with the conversion disorder were more Furthermore, the incidence of these disorders has decreased over
likely to have experienced some significant stress and adjustment the decades (Kirmayer et al., 2003). The most likely explanation is
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that increased knowledge of the real causes of physical problems her time in a room in the back of the house while her mother
by both patients and loved ones eliminates much of the possibility attended to business out front.
of secondary gain so important in these disorders. Following similar cognitive-behavioral programs, 65% of a
Finally, many conversion symptoms seem to be part of a larger group of 45 patients with mostly motor behavior conversions (for
constellation of psychopathology. Linda had broad-ranging somatic example, difficulty walking) responded well to treatment. Inter-
symptom disorder, as well as the severe conversion symptoms, estingly, hypnosis, which was administered to approximately half
that resulted in her hospitalization. In similar cases, individuals the patients, added little or no benefit to the CBT (Moene et al.,
may have a marked biological vulnerability to develop conversion 2002, 2003).
disorder when under stress, with biological processes like those
discussed in the context of somatic symptom disorder. Neurosci-
entists are increasingly finding a strong connectivity between the Dissociative Disorders
conversion symptom and parts of the brain regulating emotion, At the beginning of the chapter, we said that when individu-
such as the amygdala, using brain-imaging procedures (Bryant & als feel detached from themselves or their surroundings, almost
Das, 2012; Rowe, 2010; Voon et al., 2010). as if they are dreaming or living in slow motion, they are hav-
For countless other cases, however, biological contributory ing dissociative experiences. Morton Prince, the founder of the
factors seem to be less important than the overriding influence of Journal of Abnormal Psychology, noted more than 100 years ago
interpersonal factors (the actions of Eloise’s mother, for example), that many people experience something like dissociation occa-
as we will discuss in the next section. There you will see that the sionally (Prince, 1906–1907). It might be likely to happen after an
extent of Eloise’s suffering and its successful resolution point pri- extremely stressful event, such as an accident (Spiegel, 2010). It also
marily to a psychological and social etiology. is more likely to happen when you’re tired or sleep deprived from
staying up all night cramming for an exam (Giesbrecht, Smeets,
Leppink, Jelicic, & Merckelbach, 2007). If you have had an experi-
Treatment ence of dissociation, it may not have bothered you much, perhaps
Although few systematic controlled studies have evaluated the because you knew the cause (Barlow, 2002). On the other hand,
effectiveness of treatment for conversion disorders, we often treat it may have been extremely frightening. Transient experiences of
these conditions in our clinics, as do others (see, for example, dissociation will occur in about half of the general population at
Campo & Negrini, 2000; Moene, Spinhoven, Hoogduin, & van some point in their lives, and studies suggest that if a person expe-
Dyck, 2002, 2003), and our methods closely follow our thinking riences a traumatic event, between 31% and 66% will have this
on etiology. Because conversion disorder has much in common feeling at that time (Hunter, Sierra, & David, 2004; Keane, Marx,
with somatic symptom disorder, many of the treatment principles Sloan & DePrince, 2011). Because it’s hard to measure dissocia-
are similar. tion, the connection between trauma and dissociation is contro-
A principal strategy in treating conversion disorder is to versial (Giesbrecht, Lynn, Lilienfeld, & Merckelbach, 2008).
identify and attend to the traumatic or stressful life event, if it is
still present (either in real life or in memory). As in the case of
Anna O., therapeutic assistance in reexperiencing or “reliving”
the event (catharsis) is a reasonable first step. Concept Check 6.1
The therapist must also work hard to reduce any reinforcing or
supportive consequences of the conversion symptoms (secondary Diagnose the somatic symptom and related disorders
gain). For example, it was quite clear that Eloise’s mother found described here by choosing one of the following: (a) illness
it convenient if Eloise stayed in one place most of the day while anxiety disorder, (b) somatic symptom disorder, (c) conversion
her mother attended to the store in the front of the house. Eloise’s
disorder.
immobility was thus strongly reinforced by motherly attention
and concern. Any unnecessary mobility was punished. The thera- 1. Emily constantly worries about her health. She has been
pist must collaborate with both the patient and the family to elimi- to numerous doctors for her concerns about cancer and
nate such self-defeating behaviors. other serious diseases—even though she doesn’t report
Many times, removing the secondary gain is easier said current notable physical symptoms—only to be reas-
than done. Eloise was successfully treated in the clinic. Through sured of her well-being. Emily’s anxiousness is exacerbat-
intensive daily work with the staff, she was able to walk again. To
ed by each small ailment (for example, mild headaches
accomplish this, she had to practice walking every day with con-
or stomach pains) that she considers to be indications
siderable support, attention, and praise from the staff. When her
mother visited, the staff noticed that she verbalized her pleasure of a major illness. ____________
with Eloise’s progress but that her facial expressions, or affect, con- 2. D. J. arrived at Dr. Blake’s office with a folder crammed
veyed a different message. The mother lived a good distance from full of medical records, symptom documentation, and
the clinic so she could not attend sessions, but she promised to lists of prescribed treatments and drugs. Several doc-
carry out the program at home after Eloise was discharged. But she tors are monitoring him for his complaints, ranging
didn’t. A follow-up contact 6 months after Eloise was discharged from marked chest pain to difficulty swallowing.
revealed that she had relapsed and was again spending almost all
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Nijenhuis, 2009). In each case, there are alterations in our relation-
D. J. recently lost his job for using too many sick days. ship to the self, to the world, or to memory processes.
______________ Although we have much to learn about these disorders, we
3. Sixteen-year-old Chad suddenly lost the use of his briefly describe two of them—depersonalization-derealization
arms with no medical cause. The complete paralysis disorder, and dissociative amnesia—before examining the fasci-
nating condition of dissociative identity disorder. As you will see,
slowly improved to the point that he could slightly
the influence of social and cultural factors is strong in dissociative
raise them. However, Chad cannot drive, pick up
disorders. Even in severe cases, the expression of the pathology
objects, or perform most tasks necessary for day-to- does not stray far from socially and culturally sanctioned forms
day life. ____________ (Giesbrecht et al., 2008; Kihlstrom, 2005a).
Depersonalization-Derealization Disorder
Investigators at Stanford University surveyed the reactions of When feelings of unreality are so severe and frightening that they
journalists who witnessed one of the first executions in California dominate an individual’s life and prevent normal functioning,
in many decades, a traumatic experience for many (Freinkel, clinicians may diagnose the rare depersonalization-derealization
Koopman, & Spiegel, 1994). The prisoner, Robert Alton Harris, disorder. Consider the case of Bonnie.
had been found guilty of the particularly brutal murder of two
16-year-old boys. As is customary, a number of journalists were
invited to witness the execution. Because there were a number of
Bonnie... Dancing Away from Herself
stays of execution, they ended up spending all night at the prison
as Harris was repeatedly led into and back out of the gas cham-
ber before he was finally executed near daybreak. Several weeks
later, the journalists filled out acute stress reaction questionnaires.
B onnie, a dance teacher in her late 20s, was accompanied
by her husband when she first visited the clinic and
complained of “flipping out.” When asked what she meant,
Between 40% and 60% of the journalists experienced several dis-
she said, “It’s the most scary thing in the world. It often
sociative symptoms. For example, during the execution, things
happens when I’m teaching my modern dance class. I’ll be
around them seemed unreal or dreamlike and they felt time had
up in front, and I will feel focused on. Then, as I’m demon-
stopped. They also felt estranged from other people and distant
strating the steps, I just feel like it’s not really me and that I
from their own emotions; a number of them felt they were strang-
don’t really have control of my legs. Sometimes I feel like I’m
ers to themselves. The fact that the journalists were sleep deprived
standing in back of myself just watching. Also I get tunnel
from staying up all night undoubtedly contributed to these dis-
vision. It seems like I can only see in a narrow space right
sociative feelings.
in front of me and I just get totally separated from what’s
These kinds of experiences can be divided into two types. Dur-
going on around me. Then I begin to panic and perspire and
ing an episode of depersonalization, your perception alters so that
shake.” It turns out that Bonnie’s problems began after she
you temporarily lose the sense of your own reality, as if you were
smoked marijuana for the first time about 10 years before.
in a dream and you were watching yourself. During an episode
She had the same feeling then and found it scary, but with
of derealization, your sense of the reality of the external world is
the help of friends she got through it. Lately the feeling
lost. Things may seem to change shape or size; people may seem
recurred more often and more severely, particularly when
dead or mechanical. These sensations of unreality are character-
she was teaching dance class. •
istic of the dissociative disorders because, in a sense, they are a
psychological mechanism whereby one “dissociates” from reality.
Depersonalization is often part of a serious set of conditions in
which reality, experience, and even identity seem to disintegrate. You may remember from Chapter 5 that during an intense
As we go about our day-to-day lives, we ordinarily have an excel- panic attack, many people (approximately 50%) experience feel-
lent sense of who we are and a general knowledge of the identity of ings of unreality. People undergoing intense stress or experi-
other people. We are also aware of events around us, of where we encing a traumatic event may also experience these symptoms,
are, and of why we are there. Finally, except for occasional small which characterize the newly defined acute stress disorder. Feel-
lapses, our memories remain intact so that events leading up to ings of depersonalization and derealization are part of several
the current moment are clear in our minds. disorders (Giesbrecht et al., 2008; Spiegel et al., 2011; Spiegel
But what happens if we can’t remember why we are in a cer- et al., 2013). But when severe depersonalization and derealiza-
tain place or even who we are? What happens if we lose our sense tion are the primary problem, the individual meets criteria for
that our surroundings are real? Finally, what happens if we not depersonalization- derealization disorder (APA, 2013). Surveys
only forget who we are but also begin thinking we are somebody suggest that this disorder exists in approximately 0.8% to 2.8%
else—somebody who has a different personality, different mem- of the population (Johnson, Cohen, Kasen, & Brook, 2006;
ories, and even different physical reactions, such as allergies we Spiegel et al., 2011). Simeon, Knutelska, Nelson, & Guralnik
never had? These are examples of disintegrated experience (Dell (2003) described 117 cases approximately equally split between
& O’Neil, 2009; Spiegel, 2010; Spiegel et al., 2013; van der Hart & men and women; Table 6.3 presents data from a study using
D e p e rs o n a l i z at i o n - D e r e a l i z at i o n D i s o r d e r 199
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DSM
Table 6.5 2003; Johnson et al., 2006). Among the 117 patients described,
73% suffered from additional mood disorders and 64% from
Diagnostic Criteria for Depersonalization- anxiety disorders at some point in their lives.
Derealization Disorder
5 Two studies (Guralnik, Giesbrecht, Knutelska, Sirroff, &
Simeon, 2007; Guralnik, Schmeidler, & Simeon, 2000) compared
A. The presence of persistent or recurrent experiences of deper-
patients who had what we now call depersonalization-derealization
sonalization, derealization, or both:
disorder with matched normal-comparison participants on a
Depersonalization: Experiences of unreality, detachment, or
comprehensive neuropsychological test battery that assessed cog-
being an outside observer with respect to one’s thoughts,
nitive function. Although both groups were of equal intelligence,
feelings, sensations, body or actions (e.g., perceptual alterations,
distorted sense of time, unreal or absent self, emotional and/or the participants with depersonalization disorder showed a dis-
physical numbing). tinct cognitive profile, reflecting some specific cognitive deficits
Derealization: Experiences of unreality or detachment with on measures of attention, processing of information, short-term
respect to surroundings (e.g., individuals or objects are experi- memory, and spatial reasoning. Basically, these patients were easily
enced as unreal, dreamlike, foggy, lifeless, or visually distorted). distracted and were slow to perceive and process new information.
B. During the depersonalization or derealization experience, real- It is not clear how these cognitive and perceptual deficits develop,
ity testing remains intact. but they seem to correspond with reports of “tunnel vision” (per-
C. The symptoms cause clinically significant distress or impair- ceptual distortions) and “mind emptiness” (difficulty absorbing
ment in social, occupational, or other important areas of new information) that characterize these patients.
functioning. Specific aspects of brain functioning are also associated
D. The disturbance is not attributable to the physiological effects with depersonalization (see, for example, Sierra & Berrios,
of a substance (e.g., a drug of abuse, medication) or another 1998; Simeon, 2009; Simeon et al., 2000). Sierra and colleagues
medical condition (e.g., seizures). (2002) compared skin conductance responding, a psychophysi-
E. The disturbance is not better explained by another mental ological measure of emotional responding (see Chapter 3), among
disorder, such as schizophrenia or panic disorder. 15 patients with depersonalization disorder, 11 patients with anxiety
disorders, and 15 control participants without any disorder. Patients
From American Psychiatric Association. (2013). Diagnostic and statistical manual of with depersonalization disorder showed greatly reduced emotional
mental disorders (5th ed.). Washington, DC.
responding compared with other groups, reflecting a tendency to
selectively inhibit emotional expression. Brain-imaging studies now
confirm deficits in perception (Simeon, 2009; Simeon et al., 2000)
Dissociative Experiences Scale Item Scores in 117
Participants with Depersonalization- Derealization and emotion regulation (Phillips et al., 2001). Other studies note
Table 6.3 Disorder (Arranged in Descending Frequency) dysregulation in the hypothalamic–pituitary–adrenocortical (HPA)
axis among these patients, compared with normal controls (Simeon,
Abbreviated Description Mean SD
Guralnik, Knutelska, Hollander, & Schmeidler, 2001; Spiegel et al.,
Surroundings seem unreal 67.4 29.6 2013), suggesting, again, deficits in emotional responding. Psycho-
Looking at the world through a fog 60.0 37.3 logical treatments have not been systematically studied. One evalua-
Body does not belong to one 50.6 34.7 tion of the drug Prozac did not show any treatment effect compared
Did not hear part of conversation 43.6 29.3 with placebo (Simeon, Guralnik, Schneider, & Knutelska, 2004).
Finding familiar place strange and unfamiliar 35.3 33.0
Staring off into space; unaware of time 32.7 31.8
Can’t remember if just did something or 31.6 28.8
Dissociative Amnesia
thought it Perhaps the easiest to understand of the severe dissociative dis-
Do usually difficult things with ease/spontaneity 31.2 31.2 orders is one called dissociative amnesia, which includes several
Act so differently/feel like two different people 28.7 32.5 patterns. People who are unable to remember anything, includ-
Talk out loud to oneself when alone 28.4 32.2 ing who they are, are said to suffer from generalized amnesia.
SD – 5 standard deviation.
Generalized amnesia may be lifelong or may extend from a period
in the more recent past, such as 6 months or a year previously.
Adapted from Simeon, D., Knutelska, M., Nelson, D., & Guralnik, O.
(2003). Feeling unreal: A depersonalization disorder update of 119 cases.
Consider the case study described here.
Journal of Clinical Psychiatry, 185, 31–36. © Physicians Post Graduate
Press, Inc.
The Woman Who Lost Her Memory
S
DSM-IV criteria for this disorder (which are very similar to everal years ago, a woman in her early 50s brought her
DSM-5 criteria) that summarizes the 10 most commonly expe- daughter to one of our clinics because of the girl’s refusal
rienced symptoms in these patients. Mean age of onset was to attend school and other severely disruptive behavior. The
16 years, and the course tended to be chronic. All patients were father, who refused to come to the session, was quarrelsome,
substantially impaired. Anxiety, mood, and personality disorders a heavy drinker, and, on occasion, abusive. The girl’s brother,
are also commonly found in these individuals (Simeon et al.,
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Table 6.6
DSM
now in his mid-20s, lived at home and was a burden on the
family. Several times a week a major battle erupted, complete Diagnostic Criteria for Dissociative Amnesia
with shouting, pushing, and shoving, as each member of the
family blamed the others for all their problems. The mother, 5 A. An inability to recall important autobiographical information,
usually of a traumatic or stressful nature, that is inconsistent
a strong woman, was clearly the peacemaker responsible for
with ordinary forgetting. Note: Dissociative amnesia most often
holding the family together. Approximately every 6 months, consists of localized or selective amnesia for a specific event or
usually after a family battle, the mother lost her memory and events; or generalized amnesia for identity and life history.
the family had her admitted to the hospital. After a few days B. The symptoms cause clinically significant distress or impair-
away from the turmoil, the mother regained her memory ment in social, occupational, or other important areas of
and went home, only to repeat the cycle in the coming functioning.
months. Although we did not treat this family (they lived C. The disturbance is not attributable to the physiological effects of
too far away), the situation resolved itself when the children a substance (e.g., alcohol or other drug of abuse, a medication)
moved away and the stress decreased. • or a neurological or other medical condition (e.g., partial com-
plex seizures, transient global amnesia, sequelae of a closed head
injury/traumatic brain injury, or other neurological condition).
D. The disturbance is not better explained by dissociative identity
Far more common than general amnesia is localized or disorder, posttraumatic stress disorder, acute stress disorder,
selective amnesia, a failure to recall specific events, usually somatic symptom disorder, or major or mild neurocognitive
disorder.
traumatic, that occur during a specific period. Dissociative
Specify if:
amnesia is common during war (Cardeña & Gleaves, 2003;
With dissociative fugue: Apparently purposeful travel or bewildered
Spiegel et al., 2013). An interesting case of a woman whose wandering that is associated with amnesia for identity or for other
father deserted her when she was young and who then was important autobiographical information.
forced to have an abortion at the age of 14 is described by Sackeim
and Devanand (1991). Years later, she came for treatment for From American Psychiatric Association. (2013). Diagnostic and statistical manual of
frequent headaches. In therapy she reported early events (for mental disorders (5th ed.). Washington, DC.
example, the abortion) rather matter-of-factly, but under hyp-
nosis she would relive, with intense emotion, the early abortion
and remember that subsequently she was raped by the abor-
tionist. She also had images of her father attending a funeral for Jeffrey... A Troubled Trip
her aunt, one of the few times she ever saw him. Upon awaken-
A
ing from the hypnotic state, she had no memory of emotion- n amnesia sufferer who had been searching for his iden-
ally reexperiencing these events, and she wondered why she tity for more than a month was back in Washington state
had been crying. In this case, the woman did not have amnesia with his fiancée on Tuesday, but he still doesn’t remember his
for the events themselves but rather for her intense emotional past life or what happened, his mother said.
reactions to the events. Absence of the subjective experience of Jeffrey Alan Ingram, 40, was diagnosed in Denver with
emotion that is often present in depersonalization-derealization dissociative fugue, a type of amnesia.
disorder and confirmed by brain-imaging studies (Phillips He has had similar bouts of amnesia in the past, likely
et al., 2001) becomes prominent here. In most cases of dissocia- triggered by stress, once disappearing for 9 months. When
tive amnesia, the forgetting is selective for traumatic events or he went missing this time, on September 6, he had been on
memories rather than generalized. his way to Canada to visit a friend who was dying of cancer,
Cognitive disorders such as dementia (discussed in Chapter 15) said his fiancée, Penny Hansen.
can also be characterized by severe forgetting or amnesia. But there “I think that the stress, the sadness, the grief of facing a
are several differences between cognitive disorders and dissociative best friend dying was enough, and leaving me was enough to
amnesia, as outlined in Table 6.4. send him into an amnesia state,” Hansen told KCNC-TV.
A subtype of dissociative amnesia is referred to as dissocia- When Ingram found himself in Denver on September 10,
tive fugue (Ross, 2009) with fugue literally meaning “flight” he didn’t know who he was. He said he walked around for
(fugitive is from the same root). In these curious cases, mem- about 6 hours asking people for help, then ended up at a
ory loss revolves around a specific incident—an unexpected hospital, where police spokeswoman Virginia Quinones said
trip (or trips). Mostly, individuals just take off and later Ingram was diagnosed with a type of amnesia known as dis-
find themselves in a new place, unable to remember why or sociative fugue.
how they got there. Usually they have left behind an intoler- Searched for his identity. Ingram’s identity came to light
able situation. During these trips, a person sometimes assumes last weekend after he appeared on several news shows asking
a new identity or at least becomes confused about the old the public for help: “If anybody recognizes me, knows who I
identity. Consider the case of Jeffrey Ingram, a 40-year-old am, please let somebody know.”
male from Washington state, who found himself unexpectedly (Continued next page)
in Denver.
D i ss o c i at i v e A m n e s i a 201
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“Penny’s brother called her right away and told her ‘Did “They’re taking it one step at a time,” Meehan said.
you watch this newscast?’ and ‘I think that’s Jeff that they’re “He said that while her face wasn’t familiar to him,
showing on television,’” said Marilyn Meehan, a spokes- her heart was familiar to him,” she said. “He can’t
woman for Hansen. remember his home, but he said their home felt like
Hansen had filed a missing person report after Ingram home to him.” •
failed to show up at her mother’s home in Bellingham,
Washington, on his way to Canada, but officials searching for © 2006 The Associated Press. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.
him had turned up nothing.
On Monday night, two Denver police detectives accom-
panied Ingram on a flight to Seattle, where he was reunited
with his fiancée.
His mother, Doreen Tompkins of Slave Lake, Alberta, was Dissociative amnesia seldom appears before adolescence and
in tears as she talked about the struggle her son and the fam- usually occurs in adulthood. It is rare for dissociative amnesia
ily still face. to appear for the first time after an individual reaches the age of
“It’s going to be very difficult again, but you know what, I 50 (Sackeim & Devanand, 1991). Once dissociative disorders do
can do it,” she told CTV news of Edmonton, Alberta. “I did appear, however, they may continue well into old age. Estimates
it before, I can do it again. I’ll do it as many times as I have of prevalence range anywhere from 1.8% to 7.3%, suggesting that
to just so I can have my son.” dissociative amnesia is the most prevalent of all the dissociative
Memory never fully regained. Ingram had experienced disorders (Spiegel et al., 2011).
an episode of amnesia in 1995 when he disappeared during a Fugue states usually end rather abruptly, and the individual
trip to a grocery store. Nine months later, he was found in a returns home, recalling most, if not all, of what happened. In this
Seattle hospital, according to Thurston County, Washington, disorder, the disintegrated experience is more than memory loss,
officials. His mother said he never fully regained his involving at least some disintegration of identity, if not the com-
memory. plete adoption of a new one.
Meehan, who works with Hansen at the state Utilities and An apparently distinct dissociative state not found in West-
Transportation Commission, said the couple would not give ern cultures is called amok (as in “running amok”). Most peo-
interviews because they want to concentrate on Ingram’s ple with this disorder are males. Amok has attracted attention
effort to regain his memory. because individuals in this trancelike state often brutally assault
and sometimes kill people or animals. If the person is not killed
Table 6.4 Differences between DA and Amnesia in Cognitive Disorders

Differences DA* Cognitive Disorders
Due to known medical disorder or physical cause No Yes
Onset related to psychological trauma/extreme stress Yes No
Exacerbated by stress Yes Yes/No; anxiety can worsen memory performance in

cognitive disorders
Memory deficits primarily in autobiographical recall Yes No, but may have circumscribed retrograde memory loss
and/or general impairment in autobiographical recall that
worsens with illness progression
Reversible with hypnosis Yes No
Improvement with sedative-hypnotics (e.g., pharmacologically facili- Yes or no change No or may make worse
tated interviews)
Varying extent and nature of the intrusion of the dissociated mental Yes No
elements to consciousness
Ability to learn new information is intact. Ability to manipulate facts Yes No

and neutral information is generally normal (e.g., finances, current
events, etc.)
Disorientation to personal identity generally only occurs in late No Yes

phase of illness
*
DA, dissociative amnesia.
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are almost never seen in Western cultures, they are among the
most common forms of dissociative states elsewhere. When the
state is undesirable and considered pathological by members of
the culture, particularly if the trance involves a perception of being
possessed by an evil spirit or another person (described next), the
individual would be diagnosed with an “other specified dissocia-
tive disorder (dissociative trance)” (APA, 2013).
AP Images/The Denver Post, Karl Gehring
Dissociative Identity Disorder

People with dissociative identity disorder (DID) may adopt
as many as 100 new identities, all simultaneously coexisting,
although the average number is closer to 15. In some cases, the
identities are complete, each with its own behavior, tone of voice,
and physical gestures. But in many cases, only a few characteristics
Jeffrey Alan Ingram found himself in Denver not knowing who he was are distinct, because the identities are only partially independent,
or why he was there after having gone missing a month earlier from so it is not true that there are “multiple” complete personalities.
Washington state. Therefore, the name of the disorder was changed in the last edi-
tion of the DSM, DSM-IV, from multiple personality disorder to
DID. Consider the case of Jonah, originally reported by Ludwig,
himself, he probably will not remember the episode. Running Brandsma, Wilbur, Bendfeldt, and Jameson (1972).
amok is only one of a number of “running” syndromes in which
an individual enters a trancelike state and suddenly, imbued
with a mysterious source of energy, runs or flees for a long time. Clinical Description
Except for amok, the prevalence of running disorders is some- During Jonah’s hospitalization, the staff was able to observe his
what greater in women, as with most dissociative disorders. behavior directly, both when he had headaches and during other
Among native peoples of the Arctic, running disorder is termed periods that he did not remember. He claimed other names at
pivloktoq. Among the Navajo tribe, it is called frenzy witchcraft. these times, acted differently, and generally seemed to be another
Despite their different culturally determined expression, run- person entirely. The staff distinguished three separate identities,
ning disorders seem to resemble dissociative fugue, with the or alters, in addition to Jonah. (Alters is the shorthand term for
possible exception of amok. the different identities or personalities in DID.) The first alter was
Dissociative disorders differ in important ways across cul- named Sammy. Sammy seemed rational, calm, and in control.
tures. In many areas of the world, dissociative phenomena may The second alter, King Young, seemed to be in charge of all sexual
occur as a trance or possession. The usual sorts of dissociative activity and was particularly interested in having as many hetero-
symptoms, such as sudden changes in personality, are attributed sexual interactions as possible. The third alter was the violent and
to possession by a spirit important in the particular culture. Often dangerous Usoffa Abdulla. Characteristically, Jonah knew nothing
this spirit demands and receives gifts or favors from the family and of the three alters. Sammy was most aware of the other person-
friends of the victim. Like other dissociative states, trance or pos- alities. King Young and Usoffa Abdulla knew a little bit about the
session seems to be most common in women and is often associ- others but only indirectly.
ated with stress or trauma, which, as in dissociative amnesia and
fugue states, is current rather than in the past.
Trance and possession are a common part of some traditional
religious and cultural practices and are not considered abnormal Jonah... Bewildering Blackouts
in that context. Dissociative trances commonly occur in India,
J
Nigeria (where they are called vinvusa), Thailand (phii pob), and onah, 27 years old and black, suffered from severe head-
other Asian and African countries (Mezzich et al., 1992; Saxena & aches that were unbearably painful and lasted for increas-
Prasad, 1989; van Duijil, Cardeña, & de Jong, 2005). In the United ingly longer periods. Furthermore, he couldn’t remember
States, culturally accepted dissociation commonly occurs during things that happened while he had a headache, except that
African American prayer meetings (Griffith et al., 1980), Native sometimes a great deal of time passed. Finally, after a par-
American rituals (Jilek, 1982), and Puerto Rican spiritist sessions ticularly bad night, when he could stand it no longer, he
(Comas-Diaz, 1981). Among Bahamians and African Americans arranged for admission to the local hospital. What prompted
from the South, trance syndromes are often referred to colloqui- Jonah to come to the hospital, however, was that other peo-
ally as “falling out.” The personality profiles of 58 cases of dissocia- ple told him what he did during his severe headaches. For
tive trance disorder in Singapore, derived from objective testing, example, he was told that the night before he had a violent
revealed that these individuals tended to be nervous, excitable, fight with another man and attempted to stab him. He fled
and emotionally unstable relative to “normals” in Singapore (Continued next page)
(Ng, Yap, Su, Lim, & Ong, 2002). Although trance and possession
D i ss o c i at i v e I d e n t i t y D i s o r d e r 203
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Table 6.7
DSM
the scene and was shot at during a high-speed chase by the
police. His wife told him that during a previous headache Diagnostic Criteria for Dissociative Identity
he chased her and his 3-year-old daughter out of the house, Disorder
threatening them with a butcher knife. During his head- 5
aches, and while he was violent, he called himself “Usoffa A. Disruption of identity characterized by two or more distinct
Abdulla, son of Omega.” Once he attempted to drown a man personality states, which may be described in some cultures as
in a river. The man survived, and Jonah escaped by swim- an experience of possession. The disruption of marked discon-
tinuity in sense of self and sense of agency, accompanied by
ming a quarter of a mile upstream. He woke up the next
related alterations in affect, behavior, consciousness, memory,
morning in his own bed, soaking wet, with no memory of perception, cognition, and/or sensory-motor functioning.
the incident. • These signs and symptoms may be observed by others or
reported by the individual.
B. Recurrent gaps in the recall of everyday events, important
personal information, and/or traumatic events that are incon-
In the hospital, psychologists determined that Sammy first sistent with ordinary forgetting.
appeared when Jonah was about 6, immediately after Jonah saw C. The symptoms cause clinically significant distress or impair-
his mother stab his father. Jonah’s mother sometimes dressed him ment in social, occupational, or other important areas of
as a girl in private. On one of these occasions, shortly after Sammy functioning.
emerged, King Young appeared. When Jonah was 9 or 10, he was D. The disturbance is not a normal part of a broadly accepted cul-
brutally attacked by a group of white youths. At this point, Usoffa tural or religious practice. Note: In children, the symptoms are
Abdulla emerged, announcing that his sole reason for existence not attributable to imaginary playmates or other fantasy play.
was to protect Jonah. E. The symptoms are not attributable to the physiological effects
DSM-5 criteria for DID include amnesia, as in dissociative of a substance (e.g., blackouts or chaotic behavior during alco-
amnesia. In DID, however, identity has also fragmented. How hol intoxication) or another medical condition (e.g., complex
many personalities live inside one body is relatively unimportant, partial seizures).
whether there are 3, 4, or even 100 of them. Again, the defining From American Psychiatric Association. (2013). Diagnostic and statistical manual of
feature of this disorder is that certain aspects of the person’s iden- mental disorders (5th ed.). Washington, DC.
tity are dissociated (Spiegel et al., 2013).
(Bliss, 1984; Giesbrecht et al., 2008; Kihlstrom, 2005a). It is pos-

Characteristics sible that alters are created in response to leading questions from
The person who becomes the patient and asks for treatment is therapists, either during psychotherapy or while the person is in
usually a “host” identity. Host personalities usually attempt to a hypnotic state.
hold various fragments of identity together but end up being
overwhelmed. The first personality to seek treatment is seldom
the original personality of the person. Usually, the host person- Kenneth... The Hillside Strangler
ality develops later (Putnam, 1992). Many patients have at least
D
one impulsive alter who handles sexuality and generates income, uring the late 1970s, Kenneth Bianchi brutally raped and
sometimes by acting as a prostitute. In other cases, all alters may murdered 10 young women in the Los Angeles area and
abstain from sex. Cross-gendered alters are not uncommon. For left their bodies naked and in full view on the sides of vari-
example, a small agile woman might have a strong powerful male ous hills. Despite overwhelming evidence that Bianchi was
alter who serves as a protector. the “Hillside Strangler,” he continued to assert his innocence,
The transition from one personality to another is called prompting some professionals to think he might have DID.
a switch. Usually, the switch is instantaneous (although in His lawyer brought in a clinical psychologist, who hypno-
movies and on television it is often drawn out for dramatic tized him and asked whether there were another part of Ken
effect). Physical transformations may occur during switches. with whom he could speak. Guess what? Somebody called
Posture, facial expressions, patterns of facial wrinkling, and even “Steve” answered and said he had done all the killing. Steve
physical disabilities may emerge. In one study, changes in hand- also said that Ken knew nothing about the murders. With
edness occurred in 37% of the cases (Putnam, Guroff, Silberman, this evidence, the lawyer entered a plea of not guilty by rea-
Barban, & Post, 1986). son of insanity.
The prosecution called on the late Martin Orne, a distin-
Can DID Be Faked? guished clinical psychologist and psychiatrist who was one
of the world’s leading experts on hypnosis and dissociative
Are the fragmented identities “real,” or is the person faking them disorders (Orne, Dinges, & Orne, 1984). Orne used proce-
to avoid responsibility or stress? As with conversion disorders, it is dures similar to those we described in the context of conver-
difficult to answer this question, for several reasons (Kluft, 1999). sion blindness to determine whether Bianchi was simulating
First, evidence indicates that individuals with DID are suggestible
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the fascination of the public after popular books, movies, and TV
DID or had a true psychological disorder. For example, Orne series appeared on this topic. Chris Costner Sizemore was the real-
suggested during an in-depth interview with Bianchi that life subject of a popular book and movie The Three Faces of Eve.
a true multiple personality disorder included at least three Ms. Sizemore, who used the pseudonym Evelyn Lancaster in her
personalities. Bianchi soon produced a third personality. By book, was played by Joanne Woodward, who later received the
interviewing Bianchi’s friends and relatives, Orne established Academy Award for Best Actress for her role in the movie. Wood-
that there was no independent corroboration of different ward later also played the psychiatrist who treated another patient
personalities before Bianchi’s arrest. Psychological tests also with DID in the 1976 TV miniseries, Sybil. The patient in Sybil
failed to show significant differences among the personali- was played by Sally Fields who won an Emmy Award for her role
ties; true fragmented identities often score differently on in the film. Although these two cases of DID became very popular,
personality tests. Several textbooks on psychopathology critics soon questioned the patients’ reports and accuracy of the
were found in Bianchi’s room; therefore, he presumably had diagnosis. On the other hand, in the case of Ms. Sizemore, some
studied the subject. Orne concluded that Bianchi responded objective tests suggest that many people with fragmented identi-
like someone simulating hypnosis, not someone deeply hyp- ties are not consciously and voluntarily simulating (Kluft, 1991,
notized. On the basis of Orne’s testimony, Bianchi was found 1999). Condon, Ogston, and Pacoe (1969) examined Ms. Sizemore
guilty and sentenced to life in prison. • and determined that one of the personalities (Eve Black) showed a
transient microstrabismus (difference in joined lateral eye move-
ments) that was not observed in the other personalities. These opti-
cal differences have been confirmed by S. D. Miller (1989), who
Some investigators have studied the ability of individuals to demonstrated that DID patients had 4.5 times the average num-
fake dissociative experiences. Spanos, Weeks, and Bertrand (1985) ber of changes in optical functioning in their alter identities than
demonstrated in an experiment that a college student could simu- control patients who simulated alter personalities. Miller concludes
late an alter if it was suggested that faking was plausible, as in the that optical changes, including measures of visual acuity, mani-
interview with Bianchi. All the students in the group were told to fest refraction, and eye muscle balance, would be difficult to fake.
play the role of an accused murderer claiming his innocence. The Ludwig and colleagues (1972) found that Jonah’s various identities
participants received exactly the same interview as Orne admin- had different physiological responses to emotionally laden words,
istered to Bianchi, word for word. More than 80% simulated an including electrodermal activity, a measure of otherwise impercep-
alternate personality to avoid conviction. Groups given vaguer tible sweat gland activity, and EEG brain waves. Using functional
instructions, and no direct suggestion an alternate personality magnetic resonance imaging (fMRI) procedures, changes in brain
might exist, were much less likely to use one in their defense. function were observed in one patient while switching from one
Objective assessment of memory, particularly implicit (uncon- personality to another. Specifically, this patient showed changes in
scious) memory, reveals that the memory processes in patients hippocampal and medial temporal activity after the switch (Tsai,
with DID do not differ from “normals” when the methodologies Condie, Wu, & Chang, 1999). A number of subsequent studies con-
of cognitive science are used (Allen & Movius, 2000; Huntjens firm that various alters have unique psychophysiological profiles
et al., 2002; Huntjens, Postma, Peters, Woertman, & van der Hart, (Cardeña & Gleaves, 2003; Putnam, 1997). Kluft (1999) suggests a
2003). Huntjens and colleagues (2006) showed that patients with number of additional clinical strategies to distinguish malingerers
DID acted more like simulators concerning other identities, about
which they profess no memory (interidentity amnesia), suggest-
ing the possibility of faking. This is in contrast to reports from
interviews with patients with DID that suggest that memories are
different from one alter to the next. Furthermore, Kong, Allen,
and Glisky (2008) found that, much as with normal participants,
patients with DID who memorized words as one identity, could
remember the words just as well after switching to another iden-
tity, contrary to their self-report of interidentity amnesia.
20th Century Fox/Kobal Collection/Art Resource

These findings on faking and the effect of hypnosis led Spanos
(1996) to suggest that the symptoms of DID could mostly be
accounted for by therapists who inadvertently suggested the
existence of alters to suggestible individuals, a model known as
the “sociocognitive model” because the possibility of identity
fragments and early trauma is socially reinforced by a therapist
(Kihlstrom, 2005a; Lilienfeld et al., 1999). A survey of American
psychiatrists showed little consensus on the scientific validity of
DID, with only one-third in the sample believing that the diagnosis
should have been included without reservation in the DSM (Pope, The 1957 film The Three Faces of Eve dramatized the case of Chris
Oliva, Hudson, Bodkin, & Gruber, 1999). (We return to this point Sizemore, whose experiences with dissociative identity disorder drew
of view when we discuss false memories.) The diagnosis captured this controversial diagnosis into the public eye.
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from patients with DID, including the observations that malinger- Statistics
ers are usually eager to demonstrate their symptoms and do so in a Jonah had 4 identities and Anna O. only 2, but the average num-
fluid fashion. Patients with DID, on the other hand, are more likely ber of alter personalities is reported by clinicians as closer to
to attempt to hide symptoms. 15 (Ross, 1997; Sackeim & Devanand, 1991). Of people with
DID, the ratio of females to males is as high as 9:1, although
Anna O... Revealed these data are based on accumulated case studies rather than
survey research (Maldonado, Butler, & Spiegel, 1998). The onset
W e return one more time to the famous case that prompted is almost always in childhood, often as young as 4 years of age,
early insights into the unconscious and contributed to although it is usually approximately 7 years after the appearance
the development of psychoanalysis. Earlier we described of symptoms before the disorder is identified (Maldonado et al.,
Anna O.’s conversion symptoms of paralysis in her right 1998; Putnam et al., 1986). Once established, the disorder tends
arm, anesthesia of her right side, and the loss of the ability to last a lifetime in the absence of treatment. The form DID
to speak her native German (although she retained perfect takes does not seem to vary substantially over the person’s lifes-
command of English). As Anna confronted her traumatic pan, although some evidence indicates the frequency of switch-
memories of watching her father die while she nursed him, ing decreases with age (Sackeim & Devanand, 1991). Different
she increasingly recovered her physical abilities. personalities may emerge in response to new life situations, as
Anna O.’s real name was Bertha Pappenheim, and she was was the case with Jonah.
an extraordinary woman. What many people don’t realize is There are not good epidemiological studies on the prevalence
that she was never completely cured by Breuer, who finally of the disorder in the population at large, although investigators
gave up on her in 1882. During the next decade, she was now think it is more common than previously estimated (Kluft,
institutionalized several times with severe recurrences of her 1991; Ross, 1997). For example, semistructured interviews of
conversion symptoms before beginning a slow recovery. She large numbers of severely disturbed inpatients found prevalence
went on to become a pioneering social worker and staunch rates of DID of between 3% and 6% in North America (Ross,
crusader against the sexual abuse of women (Putnam, 1992). 1997; Ross, Anderson, Fleisher, & Norton, 1991; Saxe et al.,
She devoted her life to freeing women who were trapped in 1993) and approximately 2% in Holland (Friedl & Draijer, 2000).
prostitution and slavery throughout Europe, Russia, and the In the best survey to date in a nonclinical (community) setting, a
Near East. Risking her own life, she entered brothels to lib- prevalence of 1.5% was found during the previous year (Johnson
erate women from their captors. She wrote a play, Women’s et al., 2006).
Rights, about sadistic men and the ongoing abuse of women. A large percentage of DID patients have simultaneous psy-
She founded a league of Jewish women in 1904 and a home chological disorders that may include anxiety, substance abuse,
for unwed mothers in 1907. In recognition of her extraor- depression, and personality disorders (Giesbrecht et al., 2008;
dinary contributions as one of the first militant feminists, a Johnson et al., 2006; Kluft, 1999; Ross et al., 1990). In one sample
commemorative stamp was later issued in her honor by the of more than 100 patients, more than seven additional diagnoses
West German government (Sulloway, 1979). were noted on the average (Ellason & Ross, 1997). Another study
Pappenheim’s friends remarked that she seemed to lead a of 42 patients documented a pattern of severe comorbid personal-
“double life.” On the one hand, she was a radical feminist and ity disorders, including severe borderline features (Dell, 1998). In
reformer. On the other hand, she belonged to the cultural some cases, this high rate of comorbidity may reflect that certain
elite in Vienna at the end of the 19th century. It is clear from disorders, such as borderline personality disorder, share many
Breuer’s notes that there were “two Anna O.’s” and that she features with DID—for example, self-destructive, sometimes
suffered from DID. One personality was somewhat depressed suicidal behavior, and emotional instability. Some investigators
and anxious but otherwise relatively normal. But in an instant, believe that most of DID symptoms can be best accounted for
she would turn dark and foreboding. Breuer was convinced by characteristics of borderline personality disorder (Lilienfeld &
that during these times “Anna” was someone else, someone Lynn, 2003). Because auditory hallucinations are common, DID
who hallucinated and was verbally abusive. And it was the is often misdiagnosed as a psychotic disorder. But the voices in
second Anna O. who experienced conversion symptoms. The DID are reported by patients as coming from inside their heads,
second Anna O. spoke only English or garbled mixtures of not outside as in psychotic disorders. Because patients with DID
four or five languages. The first Anna O. spoke fluent French are usually aware the voices are hallucinations, they don’t report
and Italian, as well as her native German. Characteristically, them and try to suppress them. These voices often encourage
one personality had no memory of what happened when doing something against the person’s will, so some individuals,
the other was “out.” Almost anything might cause an instant particularly in other cultures, appear to be possessed by demons
switch in personalities—for example, the sight of an orange, (Putnam, 1997). Although systematic studies are lacking, DID
which was Anna O.’s primary source of nourishment when seems to occur in a variety of cultures throughout the world,
she nursed her dying father. Putnam (1992, p. 36) reports that particularly in terms of experiencing possession, which is one
when Pappenheim died of cancer in 1936, “It is said that she manifestation of DID (Boon & Draijer, 1993; Coons, Bowman,
left two wills, each written in a different hand.” • Kluft, & Milstein, 1991; Ross, 1997). Coons and colleagues (1991)
found reports of DID in 21 different countries.
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Causes the present rather than the past, as in the case of the overwrought
It is informative to examine current evidence on causes for all dis- mother who suffered from dissociative amnesia. Many patients
sociative disorders, as we do later, but our emphasis here is on the are escaping from legal difficulties or severe stress at home or on
etiology of DID. Life circumstances that encourage the develop- the job (Sackeim & Devanand, 1991). But sophisticated statisti-
ment of DID seem quite clear in at least one respect. Almost every cal analyses indicate that “normal” dissociative reactions differ
patient presenting with this disorder reports to their mental health substantially from the pathological experiences we’ve described
professional being horribly, often unspeakably, abused as a child. (Waller, Putnam, & Carlson, 1996; Waller & Ross, 1997) and that
Imagine you are a child in a situation like this. What can you at least some people do not develop severe pathological dissocia-
do? You’re too young to run away. You’re too young to call the tive experiences, no matter how extreme the stress. These findings
authorities. Although the pain may be unbearable, you have no are consistent with our diathesis–stress model in that only with
way of knowing it is unusual or wrong. But you can do one thing. the appropriate vulnerabilities (the diathesis) will someone react
You can escape into a fantasy world; you can be somebody else. If to stress with pathological dissociation.
the escape blunts the physical and emotional pain just for a min- You may have noticed that DID seems similar in its etiology
ute or makes the next hour bearable, chances are you’ll escape to posttraumatic stress disorder (PTSD). Both conditions fea-
again. Your mind learns there is no limit to the identities that ture strong emotional reactions to experiencing a severe trauma
can be created as needed. Fifteen? Twenty-five? A hundred? Such (Butler et al., 1996). But remember that not everyone goes on
numbers have been recorded in some cases. You do whatever to experience PTSD after severe trauma. Only people who are
it takes to get through life. Most surveys report a high rate of biologically and psychologically vulnerable to anxiety are at risk
childhood trauma in cases of DID (Gleaves, 1996; Ross, 1997). for developing PTSD in response to moderate levels of trauma.
Putnam and colleagues (1986) examined 100 cases and found As the severity of the trauma increases, however, a greater per-
that 97% of the patients had experienced significant trauma, centage of people develop PTSD as a consequence, some with the
usually sexual or physical abuse. Sixty-eight percent reported dissociative subtype of PTSD (see Chapter 5). Still, some people
incest. Ross and colleagues (1990) reported that, of 97 cases, 95% do not become victims of the disorder even after the most severe
reported physical or sexual abuse. Some children reported being traumas, suggesting that individual psychological and biological
buried alive. Some were tortured with matches, steam irons, factors interact with the trauma to produce PTSD.
razor blades, or glass. Investigators have corroborated the exis- One perspective suggests that DID is an extreme subtype of
tence of at least some early sexual abuse in 12 patients with DID, PTSD, with a much greater emphasis on the process of dissociation
whose backgrounds were extensively investigated by examining than on symptoms of anxiety, although both are present in each
early records, interviewing relatives and acquaintances, and so disorder (Butler et al., 1996). Some evidence also shows that the
on (Lewis, Yeager, Swica, Pincus, & Lewis, 1997), although Kluft “developmental window” of vulnerability to the abuse that leads to
(1996, 1999) notes that some reports by patients are not true but DID closes at approximately 9 years of age (Putnam, 1997). After
have been confabulated (made up). that, DID is unlikely to develop, although severe PTSD might. If
Not all the trauma is caused by abuse. Putnam (1992) describes true, this is a particularly good example of the role of development
a young girl in a war zone who saw both her parents blown to bits in the etiology of psychopathology.
in a minefield. In a heart-wrenching response, she tried to piece We also must remember that we know relatively little about
the bodies back together, bit by bit. DID. Our conclusions are based on retrospective case studies or
Such observations have led to wide-ranging agreement that correlations rather than on the prospective examination of people
DID is rooted in a natural tendency to escape or “dissociate” from who may have undergone the severe trauma that seems to lead
the unremitting negative affect associated with severe abuse (Kluft, to DID (Kihlstrom, 2005a; Kihlstrom, Glisky, & Anguilo, 1994).
1984, 1991). A lack of social support during or after the abuse also Therefore, it is hard to say what psychological or biological factors
seems implicated. A study of 428 adolescent twins demonstrated might contribute, but there are hints concerning individual differ-
that a surprisingly major portion of the cause of dissociative ences that might play a role.
experience could be attributed to a chaotic, nonsupportive family
environment. Individual experience and personality factors also
contributed to dissociative experiences (Waller & Ross, 1997). Suggestibility
The behavior and emotions that make up dissociative disor- Suggestibility is a personality trait distributed normally across the
ders seem related to otherwise normal tendencies present in all population, much like weight and height. Some people are more
of us to some extent. It is quite common for otherwise normal suggestible than others; some are relatively immune to suggest-
individuals to escape in some way from emotional or physical pain ibility; and the majority fall in the midrange.
(Butler, Duran, Jasiukaitis, Koopman, & Spiegel, 1996; Spiegel Did you ever have an imaginary childhood playmate? Many
et al., 2013). Noyes and Kletti (1977) surveyed more than 100 survi- people did, and it is one sign of the ability to lead a rich fantasy life,
vors of various life-threatening situations and found that most had which can be helpful and adaptive. But it also seems to correlate
experienced some type of dissociation, such as feelings of unreal- with being suggestible or easily hypnotized (some people equate the
ity, a blunting of emotional and physical pain, and even separation terms suggestibility and hypnotizability). A hypnotic trance is also
from their bodies. Dissociative amnesia and fugue states are clearly similar to dissociation (Butler et al., 1996; Spiegel et al., 2013). Peo-
reactions to severe life stress. But the life stress or trauma is in ple in a trance tend to be focused on one aspect of their world, and
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they become vulnerable to suggestions by the hypnotist. There is lobe epileptic seizure especially can be associated with dissociative
also the phenomenon of self-hypnosis, in which individuals can dis- symptoms (Bob, 2003). Patients with dissociative experiences who
sociate from most of the world around them and “suggest” to them- have seizure disorders are clearly different from those who do not
selves that, for example, they won’t feel pain in one of their hands. (Ross, 1997). The seizure patients develop dissociative symptoms
According to the autohypnotic model, people who are suggest- in adulthood that are not associated with trauma, in clear con-
ible may be able to use dissociation as a defense against extreme trast to DID patients without seizure disorders. This is an area for
trauma (Putnam, 1991). As many as 50% of DID patients clearly future study (Hara et al., 2015).
remember imaginary playmates in childhood (Ross et al., 1990); Head injury and resulting brain damage may induce amnesia
whether they were created before or after the trauma is not entire- or other types of dissociative experience. But these conditions are
ly clear. According to this view, when the trauma becomes unbear- usually easily diagnosed because they are generalized and irrevers-
able, the person’s very identity splits into multiple dissociated ible and are associated with an identifiable head trauma (Butler
identities. Children’s ability to distinguish clearly between reality et al., 1996). Finally, strong evidence exists that sleep deprivation
and fantasy as they grow older may be what closes the develop- produces dissociative symptoms such as marked hallucinatory
mental window for developing DID at approximately age 9. People activity (Giesbrecht et al., 2007; van der Kloet, Giesbrecht, Lynn,
who are less suggestible may develop a severe posttraumatic stress Merckelbach, & de Zutter, 2012). In fact, the symptoms of individu-
reaction but not a dissociative reaction. Once again, these expla- als with DID seem to worsen when they feel tired. Simeon and Abu-
nations are all speculative because there are no controlled studies gal (2006) report that patients with DID “often liken it to bad jet lag
of this phenomenon (Giesbrecht et al., 2008; Kihlstrom, 2005b). and feel much worse when they travel across time zones” (p. 210).
Biological Contributions Real Memories and False

As in PTSD, where the evidence is more solid, there is almost Again, retrospective case studies suggest that individuals pre-
certainly a biological vulnerability to DID, but it is difficult to senting with dissociation, and particularly DID, may have expe-
pinpoint. For example, in the large twin study mentioned earlier rienced severe trauma, such as sexual abuse, early in their lives
(Waller & Ross, 1997), none of the variance or identifiable causal but that they have dissociated themselves from this experience
factors was attributable to heredity: All of it was environmental. and “repressed” the memory. But some clinical scientists suggest
As with anxiety disorders, more basic heritable traits, such as that many such memories are simply the result of strong sugges-
tension and responsiveness to stress, may increase vulnerability. tions by careless therapists who assume people with this condi-
On the other hand, much as in PTSD, there is some evidence tion have been abused. One of the most controversial issues in the
of smaller hippocampal and amygdala volume in patients with field of abnormal psychology today concerns the extent to which
DID compared with “normals” (Vermetten, Schmahl, Lindner, memories of early trauma, particularly sexual abuse, are accu-
Loewenstein, & Bremner, 2006). rate or not. This issue is not specific to any one particular mental
Interesting observations may provide some hints about brain disorder. Rather, whenever clinical decisions are based on a per-
activity during dissociation. Individuals with certain neurological son’s memory, it is important to consider the fact that memories
disorders, particularly seizure disorders, experience many disso- are not always very accurate or even true, even if they feel true.
ciative symptoms (Bowman & Coons, 2000; Bob, 2003; Cardeña, Sometimes, we can’t remember important things that did hap-
Lewis-Fernandez, Bear, Pakianathan, & Spiegel, 1996). Temporal pen and other times, we seem to remember things that actually
never happened. But this controversy often arises in the context
of studying traumatic memories, particularly as identified in DID,
so we discuss the research, both pros and cons, bearing on this
important topic, because the stakes in this controversy are enor-
mous, with considerable opportunity for harm to innocent people
on each side of the controversy.
On the one hand, if early sexual abuse did occur but is not
remembered because of dissociative amnesia, it is crucially impor-
tant to reexperience aspects of the trauma under the direction of
a skilled therapist to relieve current suffering. Without therapy,
the patient is likely to suffer from PTSD or a dissociative disor-
der indefinitely. It is also important that perpetrators are held
accountable for their actions because abuse of this type is a crime
BSIP/UIG via Getty Images
and prevention is an important goal.

On the other hand, if memories of early trauma are inadver-
tently created in response to suggestions by a careless therapist but
seem real to the patient, false accusations against loved ones could
lead to irreversible family breakup and, perhaps, unjust prison
A person in a hypnotic trance is suggestible and may become sentences for those falsely accused as perpetrators. In recent years,
absorbed in a particular experience. allegedly inaccurate accusations based on false memories have
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led to substantial lawsuits against therapists, resulting in awards In another set of studies (Ceci, 2003), preschool children were
of millions of dollars in damages. As with most issues that reach asked to think about actual events that they had experienced, such
this level of contention and disagreement, it is clear that the final as an accident, and about fictitious events, such as having to go to
answer will not involve an all-or-none resolution. There is irrefut- the hospital to get their fingers removed from a mousetrap. Each
able evidence that false memories can be created by reasonably week for 10 consecutive weeks, an interviewer asked each child
well-understood psychological processes (Bernstein & Loftus, to choose one of the scenes and to “think very hard and tell me
2009; Ceci, 2003; Frenda, Nichols, & Loftus, 2011; Geraerts if this ever happened to you.” The child thus experienced think-
et al., 2009; Lilienfeld et al., 1999; Loftus & Davis, 2006; McNally, ing hard and visualizing both real and fictitious scenes over an
2003, 2012a; Shaw & Porter, 2015; Toth, Harris, Goodman, & extended period. After 10 weeks, the children were examined by
Cicchetti, 2011; Wilson, Mickes, Stolarz-Fantino, Evrard, & a new interviewer who had not participated in the experiment.
Fantino, 2015). Some authors content that early traumatic expe- Ceci and his colleagues conducted several experiments using
riences can cause selective dissociative amnesia, with substantial this paradigm (Ceci, 1995, 2003). In one study, 58% of the pre-
implications for psychological functioning (Dahlenberg et al., school children described the fictitious event as if it had happened.
2012; Gleaves, Smith, Butler, & Spiegel, 2004; Kluft, 1999; Spiegel Another 25% of the children described the fictitious events as real
et al., 2013). In contrast, others question the assumption that peo- a majority of the time. Furthermore, the children’s narratives were
ple can encode traumatic experiences without being able to recall detailed, coherent, and embellished in ways that were not suggest-
them (e.g., Lynn et al., 2014). ed originally. More telling was that in one study, 27% of the chil-
Evidence supporting the existence of distorted or illusory dren, when told their memory was false, claimed that they really
memories comes from experiments like one by the distinguished did remember the event.
cognitive psychologist Elizabeth Loftus and her colleagues Clancy and colleagues, in a fascinating experiment, studied
(Loftus, 2003; Loftus & Davis, 2006). Loftus, Coan, and Pickrell the process of false memory creation in a group who reported
(1996) successfully convinced a number of individuals that they having recovered memories of traumatic events unlikely to have
had been lost for an extended period when they were approxi- occurred: abduction by space aliens. Among three groups—those
mately 5 years old, which was not true. A trusted companion reporting recovered memories of alien abduction, those who
was recruited to “plant” the memory. In one case, a 14-year- believe they were abducted but have no memories of it (repressed
old boy was told by his older brother that he had been lost in memories), and people who have no such beliefs or memories—
a nearby shopping mall when he was 5 years old, rescued by an some interesting differences emerged (Clancy, McNally, Schacter,
older man, and reunited with his mother and brother. Several Lenzenweger, & Pitman, 2002; McNally 2012). Those reporting
days after receiving this suggestion, the boy reported remember- recovered and repressed memories of abduction also evidenced
ing the event and even that he felt frightened when he was lost. more false recall and recognition on some cognitive tasks in the
As time went by, the boy remembered more and more details of laboratory and scored higher on measures of suggestibility and
the event, beyond those described in the “plant,” including an depression than control participants. These studies collectively
exact description of the older man. When he was finally told the indicate that memories are malleable and easily distorted, particu-
incident never happened, the boy was surprised, and he contin- larly in some individuals with certain personality traits and char-
ued to describe details of the event as if they were true. More acteristics such as vivid imaginal capabilities (absorption), and an
recently, Bernstein & Loftus (2009) reviewed a series of experi- openness to unusual ideas (McNally, 2012a).
ments demonstrating that, for example, creating a false memory But there is also plenty of evidence that therapists need to be
of becoming ill after eating egg salad led to eating less egg salad sensitive to signs of trauma that may not be fully remembered
and reporting a distaste for egg salad up to 4 months later dur- in patients presenting with symptoms of dissociative disorder or
ing a test in which the participants didn’t know they were being PTSD. Even if patients are unable to report or remember early
tested for food preferences. trauma, it can sometimes be confirmed through corroborating
Young children are quite unreliable in reporting accurate evidence (Coons, 1994). In one study, Williams (1994) interviewed
details of events (Bruck, Ceci, Francouer, & Renick, 1995), par- 129 women with documented histories, such as hospital records,
ticularly emotional events (Howe, 2007; Toth et al., 2011). In one of having been sexually abused as children. Thirty-eight percent
study (Bruck et al., 1995), 35 3-year-old girls were given a genital did not recall the incidents that had been reported to authorities
exam as part of their routine medical checkup; another 35 girls at least 17 years earlier, even with extensive probing of their abuse
were not (the control group). Shortly after the exam, with her histories. This lack of recall was more extensive if the victim had
mother present, each girl was asked to describe where the doc- been young and knew the abuser. But Goodman and colleagues
tor had touched her. She was then presented with an anatomically (2003) interviewed 175 individuals with documented child sexual
correct doll and asked again to point out where the doctor had abuse histories and found that most participants (81%) remem-
touched her. The findings indicated that the children were inac- bered and reported the abuse. Older age when the abuse ended
curate in reporting what happened. Approximately 60% of those and emotional support following initial disclosure of the abuses
who were touched in the genital region refused to indicate this, were associated with higher rates of disclosures. McNally and
whether the dolls were used or not. On the other hand, of the chil- Geraerts (2009) also present evidence suggesting that some peo-
dren in the control group, approximately 60% indicated genital ple, after many years, simply forget these early experiences and
insertions or other intrusive acts by the doctor, even though noth- recall them after encountering some reminders outside of therapy.
ing of the sort had occurred. In this group, then, it’s not necessary to invoke the concepts of
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repression, trauma, or false memory. It is simple forgetting. In attempts to reintegrate identities through long-term psychother-
summary, among those individuals reporting memories of sexual apy (Brand et al., 2009; Ellason & Ross, 1997; Kluft, 2009). Nev-
abuse, some may have experienced it and remembered it all along, ertheless, the prognosis for most people remains guarded. Coons
some people may have false memories, some may have recovered (1986) found that only 5 of 20 patients achieved a full integration
memories in therapy of “repressed” sexual abuse, and some may of their identities. Ellason and Ross (1997) reported that 12 of 54
have simply forgotten the incident, but remember later. (22.2%) patients had achieved integration 2 years after presenting
How will this controversy be resolved? Because false memo- for treatment, which in most cases had been continuous. These
ries can be created through strong repeated suggestions by an results could be attributed to other factors than therapy because
authority figure, therapists must be fully aware of the conditions no experimental comparison was present (Powell & Howell, 1998).
under which this is likely to occur, particularly when dealing with The strategies that therapists use today in treating DID are based
young children. This requires extensive knowledge of the work- on accumulated clinical wisdom, as well as on procedures that have
ings of memory and other aspects of psychological functioning been successful with PTSD (Gold & Seibel, 2009; Keane et al., 2011;
and illustrates, again, the dangers of dealing with inexperienced or Maldonado et al., 1998; see Chapter 5). The fundamental goal is to
inadequately trained psychotherapists. Elaborate tales of satanic identify cues or triggers that provoke memories of trauma, dissoci-
abuse of children under the care of elderly women in day care cen- ation, or both, and to neutralize them. More important, the patient
ters are most likely cases of memories implanted by aggressive and must confront and relive the early trauma and gain control over the
careless therapists or law enforcement officials (Lilienfeld et al., horrible events, at least as they recur in the patient’s mind (Kluft,
1999; Loftus & Davis, 2006; McNally, 2003). In some cases, elderly 2009; Ross, 1997). To instill this sense of control, the therapist must
caregivers have been sentenced to life in prison. skillfully, and slowly, help the patient visualize and relive aspects of
On the other hand, many people with dissociative disorder the trauma until it is simply a terrible memory instead of a current
and PTSD have suffered documented extreme abuse and trauma, event. Because the memory is unconscious, aspects of the experi-
which could then become dissociated from awareness. It may ence are often not known to either the patient or the therapist until
be that future research will find that the severity of dissociative they emerge during treatment. Hypnosis is often used to access
amnesia is directly related to the severity of the trauma in vul- unconscious memories and bring various alters into awareness.
nerable individuals with certain specific coping styles (Toth et al., Because the process of dissociation may be similar to the process
2011), and this type of severe dissociative reaction is also likely of hypnosis, the latter may be a particularly efficient way to access
to be proved as qualitatively different from “normal” dissocia- traumatic memories (Maldonado et al., 1998). (There is as yet no
tive experiences we all have occasionally, such as feeling unreal evidence that hypnosis is a necessary part of treatment.) DID seems
or not here for a moment or two (see, for example, Kluft, 1999; to run a chronic course and seldom improves spontaneously, which
Waller et al., 1996). Advocates on both sides of this issue agree confirms that current treatments, primitive as they are, have some
that clinical science must proceed as quickly as possible to specify effectiveness.
the processes under which the implantation of false memories is It is possible that reemerging memories of trauma may trigger
likely and to define the presenting features that indicate a real but further dissociation. The therapist must be on guard against this
dissociated traumatic experience (Frenda et al., 2011; Goodman, happening. Trust is important to any therapeutic relationship, but
Quas, & Ogle, 2010; Kihlstrom, 1997, 2005a; Lilienfeld et al., 1999; it is essential in the treatment of DID. Occasionally, medication is
Pope, 1996, 1997). Until then, mental health professionals must combined with therapy, but there is little indication that it helps
be extremely careful not to prolong unnecessary suffering among much. What little clinical evidence there is indicates that antide-
both victims of actual abuse and victims falsely accused as abusers pressant drugs might be appropriate in some cases (Kluft, 1996;
(e.g., Lynn et al., 2014). Putnam & Loewenstein, 1993).
Treatment
Individuals who experience dissociative amnesia or a fugue state Concept Check 6.2
usually get better on their own and remember what they have for-
gotten. The episodes are so clearly related to current life stress that Diagnose the dissociative disorders described here by choosing
prevention of future episodes usually involves therapeutic reso- one of the following: (a) dissociative fugue, (b) depersonalization-
lution of the distressing situations and increasing the strength of derealization disorder, (c) generalized amnesia, (d) dissociative
personal coping mechanisms. When necessary, therapy focuses on identity disorder, and (e) localized amnesia.
recalling what happened during the amnesic or fugue states, often
with the help of friends or family who know what happened, so 1. Ann was found wandering the streets, unable to recall
that patients can confront the information and integrate it into any important personal information. After searching her
their conscious experience. purse and finding an address, doctors were able to con-
For DID, however, the process is not so easy. With the per- tact her mother. They learned that Ann had just been in
son’s very identity shattered into many elements, reintegrating the a terrible accident and was the only survivor. Ann could
personality might seem hopeless. Fortunately, this is not always not remember her mother or any details of the accident.
the case. Although no controlled research has been reported on She was distressed. _____________
the effects of treatment, there are some documented successes of
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2. Karl was brought to a clinic by his mother. She was con- her. This always caused her to panic and perspire.
cerned because at times his behavior was strange. His _______________
speech and his way of relating to people and situations 4. Henry is 64 and recently arrived in town. He does not
would change dramatically, almost as if he were a differ- know where he is from or how he got here. His driver’s
ent person. What bothered her and Karl most was that license proves his name, but he is unconvinced it is his.
he could not recall anything he did during these periods. He is in good health and not taking any medication.
______________ ______________
3. Terry complained about feeling out of control. She 5. Rosita cannot remember what happened last week-
said she felt sometimes as if she were floating under end. On Monday she was admitted to a hospital,
the ceiling and just watching things happen to her. suffering from cuts, bruises, and contusions. It
She also experienced tunnel vision and felt unin- also appeared that she had been sexually assaulted.
volved in the things that went on in the room around ______________
DSM Controversies: Radical Changes in Classification
A s noted in the beginning of this chapter,

somatic symptom and related disorders
and dissociative disorders are among the
These cognitive distortions may include
excessive anxiety about health or physical
symptoms, a tendency to think the worst or
among possible treatments (Noyes et al.,
2008; Voigt et al., 2010; Voigt et al., 2012;
Wollburg et al., 2013).
oldest recognized mental disorders. And yet, “catastrophize” about these symptoms, and Another advantage of this approach
recent evidence indicates that we have much very strong beliefs that physical symptoms is that there is less burden on physicians
to learn about the nature of these disorders might be more serious than health-care to make very tricky determinations on
and that neither grouping of disorders may professionals have recognized. Also, people whether the symptoms have physical causes
comprise a uniform category that reflects presenting with these disorders often make as was the case in DSM-IV. Rather, the
shared characteristics for purposes of classifi- health concerns a very central part of their combination of chronic physical symptoms
cation (Mayou et al., 2005). For example, the lives; in other words, they adopt the “sick accompanied by the psychological factors
grouping of somatic symptom disorders was role.” For this reason, DSM-5 has changed of misattributing the meaning of the
based until recently on the assumption that very substantially the definitions of these symptoms and excessive concern is sufficient
“somatization” is a common process in which disorders to focus on two major factors: the to make the diagnosis. This new category
a mental disorder manifests itself in the form severity and number of physical symptoms, also includes psychological factors affecting
of physical symptoms. The specific disorders, as well as the severity of anxiety focused on medical condition (see Chapter 9) and the
then, simply reflect the different ways in the symptoms and the degree of behavior factitious disorders because all involve the
which symptoms can be expressed physi- change as a consequence of the symptoms. presentation of physical symptoms and/
cally. But major questions arose concerning In illness anxiety disorder, physical or concern about medical illness. Needless
the classification of these disorders (Noyes, symptoms need not even be present beyond to say, the very radical nature of change in
Stuart, & Watson, 2008; Voigt et al., 2010; just mild complaints and the focus is solely this major category of disorders is proving
Voigt et al., 2012). on severe anxiety over the prospect that to be very controversial, primarily because
Specifically, and as noted at one is ill or will become ill. Preliminary so little data exist on the validity of these
the beginning of the chapter, the explorations of the validity and utility of this new categories or even the reliability with
somatic symptom disorders all share strategy indicate that this new dimensional which they can be diagnosed. But they
presentations of somatic symptoms approach, reflecting both physical and appear to be an improvement, and clinical
accompanied by cognitive distortions psychological symptom severity, may be investigators are already busy attempting to
in the form of misattributions of or very helpful to clinicians in predicting the confirm or disconfirm the utility of this new
excessive preoccupation with symptoms. course of the disorder as well as selecting approach.
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Summary
Somatic Symptom and Related Disorders support to interventions meant to reduce stress and remove any
p pIndividuals with somatic symptom and related disorders are patho- secondary gain for the behavior. Recently, specifically tailored
logically concerned with the functioning of their bodies and bring cognitive-behavioral therapy has proved successful with these
these concerns to the attention of health professionals, who usually conditions.
find no identifiable medical basis for the physical complaints.
Dissociative Disorders
p pThere are several types of somatic symptom disorders. Somatic
p pDissociative disorders are characterized by alterations in percep-
symptom disorder is characterized by a focus on one or more
tions: a sense of detachment from one’s own self, from the world,
physical symptoms accompanied by marked distress focused on
or from memories.
the symptom that is disproportionate to the nature or severity of
the physical symptoms. This condition may dominate the indi- p pDissociative disorders include depersonalization-derealization
vidual’s life and interpersonal relationships. Illness anxiety disor- disorder, in which the individual’s sense of personal reality is
der is a condition in which individuals believe they are seriously temporarily lost (depersonalization), as is the reality of the exter-
ill and become anxious over this possibility, even though they nal world (derealization). In dissociative amnesia, the individual
are not experiencing any notable physical symptoms at the time. may be unable to remember important personal information.
In conversion disorder, there is physical malfunctioning, such as In generalized amnesia, the individual is unable to remember
paralysis, without any apparent physical problems. Distinguishing anything; more commonly, the individual is unable to recall
among conversion reactions, real physical disorders, and outright specific events that occur during a specific period (localized or
malingering, or faking, is sometimes difficult. Even more puzzling selective amnesia). In dissociative fugue, a subtype of dissociative
can be factitious disorder, in which the person’s symptoms are amnesia, memory loss is combined with an unexpected trip (or
feigned and under voluntary control, as with malingering, but for trips). In the extreme, new identities, or alters, may be formed, as
no apparent reason. in dissociative identity disorder (DID). The causes of dissociative
disorders are not well understood but often seem related to the
p pThe causes of somatic symptom disorder are not well understood.
tendency to escape psychologically from stress or memories of
Patients with this disorder are often preoccupied with physical
traumatic events.
symptoms that significantly distress or interfere with their lives. In
the case of illness anxiety disorder (formerly known as hypochon- p pTreatment of dissociative disorders involves helping the patient
driasis), the person experiences significant anxiety about having reexperience the traumatic events in a controlled therapeutic
or developing a serious medical disease. The latter diagnosis is manner to develop better coping skills. In the case of DID, therapy
similar to an anxiety disorder. Treatment of somatic symptom is often long term. Particularly essential with this disorder is a
disorders ranges from basic techniques of reassurance and social sense of trust between therapist and patient.
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student learning outcomes*

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186 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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188 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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Care-seeking type: Medical care, including physician visits or undergo-

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Ankara, Turkey 1.3 2.2 1.9 22.3 26.7 25.2

Athens, Greece 0.4 1.8 1.3 7.7 13.5 11.5

Bangalore, India 1.3 2.4 1.8 19.1 20.0 19.6

Berlin, Germany 0.3 2.0 1.3 24.9 25.9 25.5

Groningen, the Netherlands 0.8 4.1 2.8 14.7 19.9 17.8

Ibadan, Nigeria 0.5 0.3 0.4 14.4 5.0 7.6

Mainz, Germany 1.0 4.4 3.0 24.9 17.3 20.6

Manchester, United Kingdom 0 0.5 0.4 21.4 20.0 20.5

Nagasaki, Japan 0 0.2 0.1 13.3 7.9 10.5

Paris, France 0.6 3.1 1.7 18.6 28.2 23.1

Rio de Janeiro, Brazil 1.5 11.2 8.5 35.6 30.6 32.0

Santiago, Chile 33.8 11.2 17.7 45.7 33.3 36.8

Seattle, Washington, United 0.7 2.2 1.7 10.0 9.8 9.8

Shanghai, China 0.3 2.2 1.5 17.5 18.7 18.3

Verona, Italy 0 0.2 0.1 9.7 8.5 8.9

Total 1.9 3.3 2.8 19.8 19.7 19.7

190 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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to overrespond to stress, and thus may be indistinguishable from Treatment

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Additional therapeutic attention is directed at reducing the

EEFigure 6.2 Psychological Factors Affecting

192 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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194 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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Awareness of abuse Usually present Not usually present

She also experienced a number of other conversion symptoms

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196 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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Mario Tama/Getty Images

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198 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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The Woman Who Lost Her Memory

200 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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Table 6.4 Differences between DA and Amnesia in Cognitive Disorders

Onset related to psychological trauma/extreme stress Yes No

Exacerbated by stress Yes Yes/No; anxiety can worsen memory performance in

Reversible with hypnosis Yes No

Ability to learn new information is intact. Ability to manipulate facts Yes No

Disorientation to personal identity generally only occurs in late No Yes

202 C H A P T E R 6 S OMATIC S YMPTOM AND R ELATED DI S O R DE R S AND DI S S OCIATI V E DI S O R DE R S

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Dissociative Identity Disorder