Somatoform,

Dissociative &
Personality
Disorders
CHAPTER 16
 Somatoform Disorders &
Dissociative Disorders
 Somatoform disorders
 pathological concern of individuals with the
appearance or functioning of their bodies when
there is no identifiable medical condition causing
the physical complaints
 Dissociative disorders
 individuals feel detached from themselves or
their surroundings, and reality, experience, and
identity may disintegrate
 Historically, both somatoform and
dissociative disorders used to be
categorized as hysterical neurosis
Somatoform Disorders
 Occur when a person manifests a psychological problem through a
physiological symptom.
 Two types……

 Illness Anxiety Disorder (Hypochondriasis)

 Hasfrequent physical complaints for which medical
doctors are unable to locate the cause. They often
believe that minor issues (e.g. headache, upset
stomach) are indicative are more severe illnesses.
 Conversion Disorder
 Reportthe existence of severe physical problems (e.g.
blindness, paralysis) with no biological reason.
Dissociative Disorders

 These disorders involve a disruption in the

conscious process.
 An example - Psychogenic Amnesia –
where the patient cannot remember
things (retrograde amnesia) with no
physiological basis for the disruption in
memory. People with psychogenic
amnesia can find themselves in an
unfamiliar environment creating a
Dissociative Fugue
Most common Dissociative
Disorder is Dissociative Identity
Disorder
 Used to be known as
Multiple Personality
Disorder.
 A person has several rather
than one integrated
personality.
 People with DID commonly
have a history of childhood
abuse or trauma.
PERSONALITY
DISORDERS
Definitions

 Personality = the enduring patterns of thinking,

feeling and reacting that define a person
 Personality Disorder = “an enduring pattern of inner
experience and behaviour that deviates markedly
from the expectations of the individual’s culture”
APA,2000

 Personality Disorders are a construct (clinical) used

to understand, describe and communicate about
the complex phenomena that result when the
personality system is not functioning optimally
When diagnosing…

 Pattern must be inflexible and pervasive

across a broad range of personal and social
situations

 Must be a source of clinically significant

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

 Must be stable and of long duration, with an

onset that can be traced back to at least
adolescence of early adulthood
One way to look at it…

 Dimensional Classification: personality

disorders are normal traits amplified to the
extreme

Recall Five-Factor Model of

Personality: neuroticism,
extraversion, openness to
experience, agreeableness and
conscientiousness
 Very
Neuroticism Very
Low High

Very
Extraversion Very
Introverted Extraverted

Openness
Very Very
Low High

Agreeableness
Very Very
Low High

Very
Conscientiousness
Low Very
High
One way to look at it…

Pathological personality traits (one or more)

Derived from the well documented 5-factor
Model of Personality (FFM) and Personality
Psychopathology Five (PSY-5).

i. Negative affectivity (vs. emotional stability)

ii. Detachment (vs. extraversion)
iii. Antagonism (vs. agreeableness)
iv. Disinhibition (vs. conscientiousness)
v. Psychoticism (vs. lucidity)
Aetiology

 Aetiology Models:
 Biopsychosocial Model: holistic and inclusive
 Diathesis-Stress Model: individual levels of tolerance
 Psychodynamic theory: driven by the unconscious

 Aetiology Factors:
 Genetic Predisposition
 Attachment Experience
 Traumatic events
 Family factors and dysfunction
 Sociocultural and political forces
Prevalence

 Varies according to gender, social factors and

type
 Approx. 10-14% overall
 Most prevalent = Obsessive Compulsive,
Dependent, Schizotypal
 Least prevalent = Narcissistic, Schizoid
 Most visible = Borderline, Antisocial
 Assumption of stability over time, but some
more than others (e.g. schizotypal > borderline)
Major Personality Disorders

 Cluster A: odd/eccentric ways of thinking and

behaving
 Paranoid: pervasive distrust and suspicion
of others
 Schizoid: Social detachment/indifference
and limited emotional experience &
expression
 Schizotypal: cognitive and perceptual
distortions; eccentric behaviour; discomfort
with close relationships
Major Personality Disorders

 Cluster B: dramatic/emotional/erratic
 Antisocial: disregard for and violation of
(the rights of) others
 Borderline: instability of interpersonal
relationships, self-image, emotions, and
control over impulses
 Histrionic: excessive emotionality and
attention-seeking
 Narcissistic: grandiosity; inflated sense of
self-importance; need for attention; lack of
empathy
Major Personality Disorders

 Cluster C: anxious or fearful

 Avoidant:
social withdrawal; feelings of
inadequacy, hypersensitive to criticism
 Dependent: excessive need to be taken
care of; clinging and submissive
 Obsessive-compulsive: preoccupation with
orderliness, perfection and control at the
expense of flexibility
Examples in film

 Borderline: Fatal Attraction

 Narcissistic: The Talented Mr. Ripley,
Capote
 Paranoid: Conspiracy Theory
 Antisocial: Wall Street
 Histrionic: Being Julia
Antisocial Personality
Disorder
 More studied than any other personality disorder
 Origins usually traced back to earlier periods in
development (Conduct Disorder), although can not be
diagnosed until late adolescence (DSM criteria)
 Has the distinction between ASPD and criminality been
blurred? Not all psychopaths are criminals, and not all
serious offenders are psychopaths.
 Psychopathy includes ”shallow, deceitful, unreliable and
incapable of learning from emotional experience” and
seemingly lacking in basic emotions: shame, guilt,
anxiety, remorse (conscience).
 Increasing age can bring a change (lessening) in overt
antisocial behaviours: less obvious impulsivity,
recklessness, social deviance. Some argue that the
behaviours merely go ”underground”.
ASPD - Causes

 Biological Factors: seems to be a genetic loading,

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

 Temperament and family environment interaction:

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

 Behavioural and social reinforcers: learned

behaviour resistant to change, modelling, peer
support
ASPD - Born bad?

 Psychological factors: inability to anticipate punishment,

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

 Consequent participation in risk-taking, self-promoting

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

 Some people ”born bad”? (GSR, emotional

responsiveness, empathy studies)
ASPD - Treatment

 Seldom seek treatment

 Often coerced into treatment by the legal
system, however, participation does not
always equate with success
 Difficulty building a therapeutic relationship
 Very high recurrance of behaviour
 Limited success with behavioural
techniques
Borderline Personality
Disorder
 Often present due to other complaints (e.g.
somatic, self-harm, anxiety, depression,
abuse history). Large degree of
comorbidity
 Initially conceptualised as the ”borderline”
between neurosis and schizophrenia but
this no longer the case
 Very poor sense of/integration of self leads
to uncertainty about personal values,
identity, worth and choices = erratic,
impulsive and self-damaging behaviour
BPD - more
cognitive/behavioural features
 Fear abandonment and crave relationships but are
incapable of maintaining these due to unrealistic
expectations and lack of self-cohesion
 Subject to chronic feelings of depression,
worthlessness, ’emptiness’ leading to self-harm and
self-deprecating behaviour (e.g. sexual activity,
substance abuse, eating)
 May demonstrate dissociation during intense
distress
 ”Splitting” – tend to see people and events as
either all good or all bad, and can shift rapidly
between these.
BPD - Causes
 Biological/genetic: seems to run in families
and may be associated with genes that
contribute to anxiety, frontal lobe dysfunction
 Object Relations: the internalisation of early
caregiving relationships (e.g. inconsistency =
insecurity & ego confusion leads to ego
defence such as splitting)
 Diathesis-stress: vulnerability thresholds
overwhelmed e.g. by abuse & trauma
BPD - Treatment

 Perceived as very difficult clients

 Therapeutic relationship is key but
threatening to person with BPD therefore
attrition is high, and therapy is made very
challenging
 Psychoanalysis uses the transference
relationship to interpret and integrate
Final thoughts…

 It is thought you do not “cure” personality

disorders however treatment can increase the
effectiveness of the patient to function
Case 3

 You are picking up your daughter from daycare

and one of the other parents engages you in
conversation. He states “I see you got here 5
minutes after the cut off time to…are they going
to charge you extra too? You know I think this
daycare is always trying to stick it to us. I get this
same thing at work. I think they purposely make
the clock in times and pick up times inconvenient
so they can dock you here and there. Its like a
conspiracy I swear!”
With this information what is
your differential diagnosis?
 Irritated but normal parent?
 Persecutory delusional disorder?
 Schizophrenia?
 Paranoid personality disorder?
You elicit the following:

 He goes on to tell you that its been the same

story his whole life. He has been passed over for
promotions at work, he can’t trust his friends any
further than he can throw them and he thinks his
wife is cheating on him too. With your excellent
clinical skills you also find out he doesn’t actually
believe there is a plot and doesn’t have any
psychotic sx.
 His diagnosis is most consistent with a Paranoid
personality disorder. He has a pervasive distrust
and suspiciousness of others but it is not to the
point of a delusion and he is not psychotic.
Case 1

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

concerned she has an anxiety disorder. When the pt comes into
your office she is looking down and when she shakes your hand it
is very sweaty. When asked about how her relationships were in
junior high she stated “terrible. I never fit in and didn’t do much
with other kids because I was afraid they would judge me”.
With this information what
Dx are you thinking
about?
 Social phobia?  What do you need to know to
figure out which one if any it is?
 Avoidant personality disorder?
 Is this circumscribed or more
 Generalized anxiety disorder?
global? does this person have
 Schizoid personality disorder? relationships with others?
You elicit the following
information
 She has never had an intimate
relationship although she would like to
have one and has one friend that she has
known since childhood. She is intensely
afraid of of being ridiculed so works as a
transcriptionist from her home and sits in
the back row when she goes to church.
She describes herself as “not as good as
other people” and doesn’t like to do new
things”. She avoids new relationships
unless she “is sure they are going to like
me”.
Her diagnosis

 Given the long standing pervasive nature of her

symptoms her diagnosis is most consistent with
Avoidant Personality Disorder. Social phobia tends
to be very situational and GAD (generalized
anxiety disorder) is less pervasive.
Case 2

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

primary care clinic. He tells you he has to be very careful
about what he eats because “certain foods I can feel work
against my system..I feel them as they are integrated into my
body”. He also notes he tries to be careful about what he says
“because words have power..they can change the way of
things”.
With this information what
is your differential
diagnosis?
 Schizophrenia?
 Delusional disorder?
 Mood disorder with psychotic
features?
 Schizotypal personality disorder?
You elicit the following:

 He is fairly close to his family but doesn’t really

have any other people in his life. He denied
auditory, visual or tactile hallucinations, has no
thought broadcasting or thought insertion and is
able to provide organized answers although you
notice he speaks in a vague way and his affect is
constricted. His appearance is striking because he
is wearing all yellow including his shoes, belt, hat
and earring which he states “is because yellow is
the color that recharges me”.
 His diagnosis is most consistent with a Schizotypal personality
disorder. He does not have schizophrenia because of lack of
disorganization and lack of true psychotic Sx. He does have
magical thinking but it is not crossing into psychosis. Other history
to obtain would be whether he has a declining course over time
which you often see with schizophrenia.