Brief Lecture Notes for Unit 7
(Somatoform and Dissociative Disorders)
In the anxiety disorders, anxiety was directly and consciously experienced by the subject. It thus comprised the central, defining component of the disorder. In the somatoform and dissociative disorders, in contrast, anxiety is inferred from indirect evidence. In many of these disorders, there is no direct, conscious experience of anxiety. Rather, anxiety appears to have been transmuted into something else (a physical or mental symptom) through a process known as anxiety binding. The result is called the somatization of anxiety.
The phrase "loss or impairment of physical or mental functioning" will be used frequently in this unit. What does this mean? It means a physical symptom (paralysis, blindness) or a mental symptom (amnesia, development of multiple personality states) that cannot be explained in purely physiological, medical, organic terms. In other words, in most cases, the somatoform and dissociative disorders represent a psychological condition that mimics an organic one. But we have to be careful to make sure that we really have ruled out organic causes, not always an easy thing to do.
Also included under the general umbrella of these disorders are a range of conditions that don't strictly fall within the definition above, but which are close enough in character to be placed in this category. These include:
1. Hypochondriasis: Defined as a hyperconcern with bodily or health issues, the hypochrondriac generally experiences no specific symptoms to be reported, merely an intensive preoccupation with the notion that s/he is seriously ill. This isn't a phobia because of the paradoxical emotionality involved (see below) and because of the vague nature of the health concerns (both the opposite of what we would see in the nosophobias). Core symptoms are a morbid preoccupation with health and illness, including frequently an unshakable convinction that one is seriously ill or dying despite all medical evidence to the contrary; a "hypervigilant" stance toward the body ("searching" for symptoms and making frequent misattributions about normal physical states); and a range of nonspecific, vague bodily concerns.
2. Psychosomatic illness: These are conditions where there is a definable organic cause, but in which psychological factors are also implicated. Think of these as "stress illnesses". More about these later, below, as we discuss the nature of stress and its relation to anxiety. From a psychoanalytic perspective, the nature of the symptoms may have in part a symbolic meaning (e.g., a person prone to digestive upset when stressed may feel "pulled" between two competing demands or groups of people s/he wishes to please).
We also have to rule out conscious faking of various sorts, in which a person pretends to symptoms s/he does not have in the knowledge that s/he is being deliberately dishonest. When a person does this for some obvious reason (to obtain some primary gain such as exemption from military service or fraudulent SSI benefits), we call this behavior malingering. When there is no obvious primary gain, but the behavior can be attributed to the secondary gain of gaining attention from others, we call it a factitious disorder. And a person who makes her/himself ill for either of these purposes is usually said to be suffering from Munchhausen's syndrome... note that I'm defining that term in a slightly different fashion than your text does. (Rarely, a parent or other caregiver will make someone else -- e.g., a child -- ill for this purpose -- "Munchhausen's by proxy"... but there we are getting far from the somatoform disorders.) In all these cases, a deliberate choice to deceive (by lying about symptoms, or by creating symptoms and then lying about their origin) is involved. In contrast, in a true somatoform or dissociative disorder, the symptoms are real; the person is not deliberately choosing them, and is not consciously aware of their origin. (Whether the unconscious mind is "aware" or "choosing" is another matter -- depending on your level of agreement with psychodynamic concepts.)
Thus, these disorders pose a diagnostic nightmare, because when symptoms are presented that we can't figure out in terms of organic causation, either (a) we're not smart enough to find the organic cause, (b) the symptoms are the result of deliberate fakery, or (c) the symptoms are the result of a somatoform or dissociative disorder. To help figure out which, we often turn to secondary clues. For instance, a person with an organic illness is likely to be upset by the fact, but a person with a somatoform or dissociative disorder is often paradoxically relieved. (The psychoanalytic explanation is that the conscious experience of physical or cognitive symptoms is easier to bear than the -- now repressed -- experience of anxiety.) Note that this paradoxical emotionality is also characteristic of hypochondriasis: the patient seems to "want to be ill" and is "disappointed to be well".
A cultural reason for this may be that it is more socially acceptable to be organically (physically) ill than to be functionally (mentally) ill; secondary gains of physical illness are often positive (sympathy, exemption from unpleasant tasks, being cared for) while the secondary gains of mental illness are usually negative (rejection, ostracism, alienation, stigma). In a culture in which these patterns were reversed, the opposite of anxiety binding might occur -- the "psychologizing" of physical symptoms, rather than the somatizing of mental anxiety!
When anxiety is transmuted into a physical symptom, we call the result a conversion disorder. (This has nothing whatsoever to do with conversion in a religious sense; and it's worth noting that four decades of research consistently indicate a small, but significant and robust, positive correlation between religious faith and mental health.) What is meant is that anxiety is "converted" into a physical symptom by the disguising action of the unconscious mind, as with the person who suddenly goes blind because of some unpleasant truth about herself that she doesn't want to "see". When anxiety is transmuted into a cognitive symptom like loss of memory, this is a dissociative disorder. Common types include dissociative (or fugal) amnesia and dissociative identity disorder (formerly known as multiple personality disorder). The term somatoform disorder is sometimes (though not in your text) used to cover both categories, sometimes is used strictly for conversion disorders (and related conditions like hypochondriasis that involve physical, not cognitive, symptoms).
Based on the diathesis-stress model, people who are alexithymic (have difficulty recognizing and labeling emotional states) may, according to one theory, be more likely to somatize negative emotional states such as anxiety. This is a somewhat broader view than the traditionally psychodynamic view of these disorders, in that emotions other then anxiety may be being defended against (in classical psychoanalysis, the root emotion that is repressed always involves anxiety, though admittedly, some other emotion or motivational state may be what generated the initial anxiety). Hence, people who lack an "emotional language" (A- N- types) are statistically more at risk for developiong this kind of symptomatology if subjected to an unusual trauma. Dissociative disorders specifically occur almost exclusively in individuals who (a) have experienced excessive childhood trauma and who (b) are mentally susceptible to self-generated dissociative states (self-hypnosis) as a defensive mechanism.
Typical components of dissociative states include the following. Note that most are extreme versions of normal variants. Most of us don't have multiple personalities in a literal sense, but all of us have played roles, have had times when we were caught up in a role, or have had times when we "just weren't ourselves"; these are normal, subclinical examples of what, when taken to extremes, become the split-off consciousness of a true dissociative state:
1. Selective amnesia, or related disturbances in episodic autobiographical memory
2. Selective focus of attention ("blotting out" all but the present moment)
3. Derealization ("the world seems unreal") and depersonalization (viewing oneself as if from the perspective of an outside observer)
4. Time skew (abnormal time perceptions)
In lecture, I'll try to argue that many of us have had normal experiences that mirror these more pathological variants to some extent. This is in keeping with the basic idea of the class, that for every mental illness there is a less extreme normal variant; that there are always links between the abnormal and the normal.
Click here for supplementary Unit 7 notes.
Study Guide
1. What is meant by anxiety binding? Somatization? Alexithymia? Use these terms to differentiate between the anxiety disorders and the somatoform/dissociative disorders.
2. Be able to make specific diagnoses based on case study material, showing that you can distinguish between the different kinds of disorders covered in this unit.
3. Why is hypochondriasis considered a somatoform, not an anxiety, disorder?
4. Explain two difficulties in diagnosing somatoform and dissociative disorders. Differentiate between primary and secondary gain; between malingering, factitious disorders, and Munchhausen's syndrome.
5. What are secondary clues? What role do they play in the diagnosis of somatoform and dissociative disorders?
6. How do somatoform (conversion) and dissociative disorders differ? Give some examples of each.
7. What is the role of amnesia in the dissociative disorders? What other symptom patterns are present in dissociative states?
8. Describe some nonclinical variants of dissociative states.
On to Unit 8