Day 4 Disorders RV

Somatoform,
Dissociative
& Personality
Disorders
CHAPTER 16
Somatoform Disorders &

Dissociative Disorders
Somatoform disorders
pathological concern of individuals with the appearance or

functioning of their bodies when there is no identifiable
medical condition causing the physical complaints
Dissociative disorders
individuals feel detached from themselves or their

surroundings, and reality, experience, and identity may
disintegrate
Historically,
both somatoform and

dissociative disorders used to be
categorized as hysterical neurosis
Somatoform Disorders
Occur when a person manifests a psychological problem through a

physiological symptom.
Two types
Illness Anxiety Disorder (Hypochondriasis)

Has
frequent physical complaints for which medical

doctors are unable to locate the cause. They often
believe that minor issues (e.g. headache, upset
stomach) are indicative are more severe illnesses.
Conversion Disorder
Report
the existence of severe physical problems

(e.g. blindness, paralysis) with no biological reason.
Dissociative Disorders
These disorders involve a disruption in the conscious

process.
An example - Psychogenic Amnesia where the

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

Disorder is Dissociative Identity
Disorder
Used to be known as Multiple

Personality Disorder.
A person has several rather than

one integrated personality.
People with DID commonly have a

history of childhood abuse or
trauma.
PERSONALITY
DISORDERS
Definitions
Personality = the enduring patterns of thinking,

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

broad range of personal and social situations
Must be a source of clinically significant distress

or impairment in social, occupational or other
important areas of functioning
Must be stable and of long duration, with an onset

that can be traced back to at least adolescence of
early adulthood
One way to look at it
Dimensional Classification: personality disorders are normal

traits amplified to the extreme
recall
Five-Factor Model of
Personality: neuroticism,
extraversion, openness to
experience, agreeableness and
conscientiousness
Very
Low
Very
Introverted
Very
Low
Very
Low
Very
Low
Neuroticism
Extraversion
Very
High
Very
Extraverted
Openness
Very
High
Agreeableness
Very
High
Conscientiousness
Very
High
One way to look at it

Pathological personality traits (one or more)
Derived from the well documented 5-factor
Model of Personality (FFM) and Personality
Psychopathology Five (PSY-5).
i. Negative affectivity (vs. emotional stability)
ii. Detachment (vs. extraversion)
iii. Antagonism (vs. agreeableness)
iv. Disinhibition (vs. conscientiousness)
v. Psychoticism (vs. lucidity)
Aetiology
Aetiology Models:
Biopsychosocial Model: holistic and inclusive
Diathesis-Stress Model: individual levels of tolerance
Psychodynamic theory: driven by the unconscious
Aetiology Factors:
Genetic Predisposition
Attachment Experience
Traumatic events
Family factors and dysfunction
Sociocultural and political forces
Prevalence
Varies according to gender, social factors and
type
Approx. 10-14% overall
Most prevalent = Obsessive Compulsive,
Dependent, Schizotypal
Least prevalent = Narcissistic, Schizoid
Most visible = Borderline, Antisocial
Assumption of stability over time, but some
more than others (e.g. schizotypal > borderline)
Major Personality
Disorders
Cluster A: odd/eccentric ways of thinking and

behaving
Paranoid: pervasive distrust and suspicion of others
Schizoid: Social detachment/indifference and

limited emotional experience & expression
Schizotypal: cognitive and perceptual distortions;

eccentric behaviour; discomfort with close
relationships
Major Personality
Disorders
Cluster B: dramatic/emotional/erratic
Antisocial: disregard for and violation of (the rights

of) others
Borderline: instability of interpersonal

relationships, self-image, emotions, and control over
impulses
Histrionic: excessive emotionality and attentionseeking
Narcissistic: grandiosity; inflated sense of selfimportance; need for attention; lack of empathy
Major Personality
Disorders
Cluster C: anxious or fearful
Avoidant: social withdrawal; feelings of

inadequacy, hypersensitive to criticism
Dependent: excessive need to be taken care of;

clinging and submissive
Obsessive-compulsive: preoccupation with

orderliness, perfection and control at the expense of
flexibility
Examples in film
Borderline: Fatal Attraction
Narcissistic: The Talented Mr. Ripley,

Capote
Paranoid: Conspiracy Theory
Antisocial: Wall Street
Histrionic: Being Julia
Antisocial Personality
Disorder
More studied than any other personality disorder

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

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

interaction: parenting (punitive, inconsistent,
low warmth), peers, school
Behavioural and social reinforcers: learned

behaviour resistant to change, modelling, peer
support
ASPD - Born bad?
Psychological factors: inability to anticipate

punishment, lack of anxiety regarding
punishment/negative consequences. Does moral
judgement cause anxiety or vica versa?
Consequent participation in risk-taking, self-promoting

behaviour with reduced ability to interpret (or pay
attention to) nonverbal cues esp. fear, distress, anger,
anxiety. Deficit or decision?
Some people born bad? (GSR, emotional

responsiveness, empathy studies)
ASPD - Treatment
Seldom
seek treatment
Often
coerced into treatment by the legal

system, however, participation does not
always equate with success
Difficulty
Very
building a therapeutic relationship
high recurrance of behaviour
Limited
success with behavioural techniques
Borderline Personality Di
sorder
Often
present due to other complaints (e.g.

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

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

and may be associated with genes that
contribute to anxiety, frontal lobe
dysfunction
Object
Relations: the internalisation of early

caregiving relationships (e.g. inconsistency
= insecurity & ego confusion leads to ego
defence such as splitting)
Diathesis-stress:
vulnerability thresholds
overwhelmed e.g. by abuse & trauma
BPD - Treatment
Perceived
as very difficult clients
Therapeutic
relationship is key but

threatening to person with BPD therefore
attrition is high, and therapy is made
very challenging
Psychoanalysis
uses the transference

relationship to interpret and integrate
Case 1
Ms Ellie is referred to you by her primary care MD because

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

what Dx are you thinking
about?
Social phobia?
Avoidant personality disorder?
Generalized anxiety disorder?
Schizoid personality disorder?
What do you need to know to

figure out which one if any it is?
Is this circumscribed or more

global? does this person have
relationships with others?
You elicit the following

information
She has never had an intimate

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

symptoms her diagnosis is most consistent with
Avoidant Personality Disorder. Social phobia
tends to be very situational and GAD
(generalized anxiety disorder) is less pervasive.
Case 2
Jason is a 45 year old male who comes to see you to

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

what is your differential
diagnosis?
Schizophrenia?
Delusional disorder?
Mood disorder with psychotic

features?
Schizotypal personality
disorder?
You elicit the following:
He is fairly close to his family but doesnt really

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

disorder. He does not have schizophrenia because of lack of
disorganization and lack of true psychotic Sx. He does have
magical thinking but it is not crossing into psychosis. Other
history to obtain would be whether he has a declining course
over time which you often see with schizophrenia.
Case 3
You are picking up your daughter from daycare

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

is your differential
diagnosis?
Irritated but normal parent?
Persecutory delusional
disorder?
Schizophrenia?
Paranoid personality disorder?
You elicit the following:
He goes on to tell you that its been the same

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

personality disorder. He has a pervasive distrust
and suspiciousness of others but it is not to the
point of a delusion and he is not psychotic.
Final thoughts
It is thought you do not cure personality

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

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Somatoform,

Somatoform Disorders &

pathological concern of individuals with the appearance or

individuals feel detached from themselves or their

both somatoform and

Occur when a person manifests a psychological problem through a

Illness Anxiety Disorder (Hypochondriasis)

frequent physical complaints for which medical

the existence of severe physical problems

These disorders involve a disruption in the conscious

An example - Psychogenic Amnesia where the

Most common Dissociative

Used to be known as Multiple

A person has several rather than

People with DID commonly have a

Personality = the enduring patterns of thinking,

Pattern must be inflexible and pervasive across a

Must be a source of clinically significant distress

Must be stable and of long duration, with an onset

One way to look at it

Dimensional Classification: personality disorders are normal

One way to look at it

Biopsychosocial Model: holistic and inclusive

Diathesis-Stress Model: individual levels of tolerance

Psychodynamic theory: driven by the unconscious

Family factors and dysfunction

Sociocultural and political forces

Cluster A: odd/eccentric ways of thinking and

Paranoid: pervasive distrust and suspicion of others

Schizoid: Social detachment/indifference and

Schizotypal: cognitive and perceptual distortions;

Antisocial: disregard for and violation of (the rights

Borderline: instability of interpersonal

Histrionic: excessive emotionality and attentionseeking

Cluster C: anxious or fearful

Avoidant: social withdrawal; feelings of

Dependent: excessive need to be taken care of;

Obsessive-compulsive: preoccupation with

Borderline: Fatal Attraction

Narcissistic: The Talented Mr. Ripley,

Paranoid: Conspiracy Theory

Antisocial: Wall Street

Histrionic: Being Julia

More studied than any other personality disorder

Biological Factors: seems to be a genetic

Temperament and family environment

Behavioural and social reinforcers: learned

ASPD - Born bad?

Psychological factors: inability to anticipate

Consequent participation in risk-taking, self-promoting

Some people born bad? (GSR, emotional

coerced into treatment by the legal

building a therapeutic relationship

high recurrance of behaviour

success with behavioural techniques

present due to other complaints (e.g.

Fear abandonment and crave relationships but

seems to run in families

Relations: the internalisation of early