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Chapter 8
Somatic Symptom and
Dissociative Disorders

Cherednychenko Ihor/Shutterstock

Learning Objectives
8.1 List four disorders included in the DSM-5 8.6 List three DSM-5 dissociative disorders.
category of somatic symptom and related 8.7 Summarize the clinical features of
disorders. depersonalization/derealization disorder.
8.2 Explain the causes of and treatments for 8.8 Describe the clinical features of dissociative
somatic symptom disorder. amnesia.
8.3 Identify the key difference between illness 8.9 Describe the clinical features of dissociative
anxiety disorder and somatic symptom identity disorder and explain why this
disorder. disorder is so controversial.
8.4 Summarize the clinical features of 8.10 Describe the cultural factors, treatments,
conversion disorder, also noting its and outcomes in dissociative disorders.
prevalence, causes, and treatment.
8.5 Explain the difference between factitious
disorder and malingering.
257
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258 Chapter 8

Have you ever had the experience, particularly during a

time of serious stress, when you felt like you were walking I Know Something Is Wrong
around in a daze or like you just weren’t all there? What Richard is a 46-year-old software engineer who reports a long his-
about physical symptoms? Mild dissociative or somatic tory of many somatic complaints. His problems began in high school
symptoms are experienced at least occasionally by almost when he started to have headaches and pain in his chest. As time
all of us. Indeed, up to 80 percent of people in the general has progressed he has developed a broad range of symptoms all
population say that they have had somatic (physical) symp- over his body including back pain, abdominal pain and discomfort,
toms in the past week (Hiller et al., 2006). But when concern joint pain, feelings of dizziness, and a general sense of weakness
about these symptoms is severe and leads to significant dis- and fatigue. During the past 20 years, Richard has seen many doc-
tors and received numerous medical examinations. Although he
tress or impairment, a somatic symptom disorder may be
has received several descriptive diagnoses that do little more than
diagnosed. And when feelings of “being out of it” become
describe his symptoms, no medical explanation for his problems
so persistent and recurrent that the person has profound
has been found. Richard worries constantly that something is being
and unusual memory deficits (such as not knowing missed and that, on the days the tests were done, the underlying
who they are), the diagnosis of a dissociative disorder may problem was somehow unable to be detected. Richard subscribes
be warranted. to several health newsletters and frequently uses the Internet to learn
In the past both somatic symptom disorders (formerly more about the possible causes of his symptoms. He realizes his
known as somatoform disorders) and dissociative disor- current doctor is getting annoyed with his frequent visits, but he
ders were included with the various anxiety disorders continues to worry constantly about his health.
(and neurotic depression) and considered to be forms of
neurosis. This was because anxiety was thought to be the
underlying cause of all neuroses whether or not the anxi- As we have already noted, experiencing bodily sensa-
ety was experienced overtly. But in 1980, when DSM-III tions or symptoms is very common. In most cases, these
abandoned attempts to link disorders together on the basis symptoms go away spontaneously. But in about 25 percent
of hypothesized underlying causes (as with neurosis) and of cases, the symptoms persist for a longer period, prompt-
instead focused on grouping disorders together on the ing people to visit their doctors. Studies conducted
basis of overt symptomatology, the anxiety, mood, somatic throughout the world show that somewhere between 20
symptom, and dissociative disorders each became separate and 50 percent of the physical symptoms that cause people
categories. to seek medical care are medically unexplained. In other
This approach has continued to this day. In DSM-5 words, no medical cause can be found (Kroenke, 2003). For
somatic symptom disorders and dissociative disorders are many people that is the end of it. They are satisfied when
regarded as distinct diagnostic entities. Recognizing this, in told that all the tests that they have had are negative. But a
this chapter we discuss each of these conditions separately. subset of patients (like Richard) will continue to be very
Let’s start by taking a look at some of the diagnoses listed worried that something is seriously wrong—that they have
in the category of somatic symptom and related disorders. a not-yet-diagnosed disease. These people tend to continue
to seek help for their physical problems, asking for and
undergoing more and more tests. In other words, they

Somatic Symptom and become preoccupied with some aspect of their health to the

Related Disorders: An
Overview
8.1 List four disorders included in the DSM-5 category
of somatic symptom and related disorders.
The category of somatic symptom and related disorders is
new to DSM-5. The disorders in it lie at the interface
StockphotoVideo/Fotolia

between abnormal psychology and medicine. Included in

this category are conditions that involve physical symp-
toms combined with abnormal thoughts, feelings, and
behaviors in response to those symptoms (American Psy-
chiatric Association [APA], 2013). Soma means “body.”
People with somatic symptom disorders experience bodily
Some people become preoccupied with their health and continue to
symptoms that cause them significant psychological dis- seek help for their medical problems even when no specific problem
tress and impairment. Richard is a good example. can be detected.
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Somatic Symptom and Dissociative Disorders 259

extent that they show significant impairments in function- The diagnosis of somatic symptom disorder is a
ing. As you might expect, such patients are much more descriptive one. It contains no assumptions about cause.
commonly found in medical settings than in mental health The name of the diagnosis was chosen to reduce some of
clinics. It is estimated that about 20 percent of doctor visits the negative connotations associated with older diagnostic
are caused by complaints of this sort (Steinbrecher et al., terms such as hypochondriasis, as well as ideas that disor-
2011). In the United States, almost every family doctor ders such as these were “all in the mind.” As you know
reports seeing these patients frequently (Dimsdale, 2011). from Chapter 5, we are now beginning to understand just
In DSM-IV a great deal of emphasis was placed on the how closely the mind and the body affect each other.
idea that the symptoms were medically unexplained. In For the diagnosis of somatic symptom disorder to be
other words, although the patient’s complaints suggested made, individuals must be experiencing chronic somatic
the presence of a medical condition, no physical pathology symptoms that are distressing to them. They must also be
could be found to account for them (Allen & Woolfolk, experiencing dysfunctional thoughts, feelings, and/or
2012; Witthöft & Hiller, 2010). In DSM-5, an important behaviors. The addition of this psychological component is
change was introduced. No distinction is now made new. In DSM-IV all that was required was that people expe-
between medically explained and medically unexplained rience somatic symptoms that were medically unexplained.
symptoms. The idea of medically unexplained symptoms is In other words, no psychological features were required.
less prominent because it is recognized that medicine is This was a rather strange omission because a common
fallible and that a medical explanation for symptoms can- characteristic of DSM mental disorders is that there are
not always be provided. Whether symptoms are deemed to psychological features in addition to other signs and symp-
have a medical cause or not could also depend on the per- toms (Rief & Martin, 2014). Another radical change is that,
sonality of the doctor or on his or her predominant cultural as we noted earlier, the physical symptoms no longer need
beliefs (Klaus et al., 2013). Nonetheless, medically unex- to be medically unexplained. The DSM-5 criteria for
plained symptoms are still a key part of some disorders somatic symptom disorder are shown in the DSM-5 box.
(such as conversion disorder) that we will describe later.
Equally key to these disorders is the fact that the
affected patients have no control over their symptoms.
They are also not intentionally faking symptoms or DSM-5 Criteria for. . .
attempting to deceive others. For the most part, they genu- Somatic Symptom Disorder
inely believe something is terribly wrong with them. In our
A. One or more somatic symptoms that are distressing or
discussion, we focus specifically on the four most impor-
result in significant disruption of daily life.
tant disorders in the somatic symptom and related disor-
B. Excessive thoughts, feelings, or behaviors related to the
ders category. These are (1) somatic symptom disorder,
somatic symptoms or associated health concerns as man-
(2) illness anxiety disorder, (3) conversion disorder, and
ifested by at least one of the following:
(4) factitious disorder.
1. Disproportionate and persistent thoughts about the
seriousness of one’s symptoms.

Somatic Symptom Disorder 2. Persistently high level of anxiety about health or

symptoms.
8.2 Explain the causes of and treatments for somatic 3. Excessive time and energy devoted to these symptoms
symptom disorder. or health concerns.

Somatic symptom disorder is regarded as the most major C. Although any one somatic symptom may not be continuously
present, the state of being symptomatic is persistent (typically
diagnosis in its category. The new diagnosis includes sev-
more than 6 months).
eral disorders that were previously considered to be sepa-
Source: Reprinted with permission from the Diagnostic and Statistical
rate diagnoses in DSM-IV. The old disorders of (1) Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American
hypochondriasis, (2) somatization disorder, and (3) pain Psychiatric Association.

disorder are gone. Most of the people who would in the

past have been diagnosed with any one of these disorders
will now be diagnosed with somatic symptom disorder. Another diagnostic change that has occurred is that
For example, 74 percent of people previously diagnosed now, in DSM-5 only one somatic symptom is required. In
with hypochondriasis (where individuals are preoccupied other words, if a person has any physical problem that
either with fears of contracting a serious disease or with they find distressing (even if it involves only a single
the idea that they have a disease even though they do not) symptom and is medically explained), the diagnosis of
qualify for the diagnosis of somatic symptom disorder in somatic symptom disorder is possible. Of course most
DSM-5 (Bailer et al., 2016). patients, like Richard, have many physical complaints.
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260 Chapter 8

It is also the case that people can suffer a great deal, even
if they only have one symptom. But the new DSM-5 crite- Table 8.1 Suggested Revised Diagnostic Criteria
for Somatic Symptom Disorder
ria will likely lead to an increase in the diagnosis of
somatic symptom disorder for this reason. Estimates are A: One or more prominent physical symptoms.
that the prevalence of somatic symptom disorder in the B: Excessive and maladaptive thoughts, feelings, and behaviors related
general population will be around 5 to 7 percent (APA, to the physical symptoms. All three of the following must be present:
(a) clearly disproportionate and intrusive worries about the serious-
2013). However, there has been much criticism that the ness of the symptoms, (b) extreme anxiety about the symptoms,
new diagnostic criteria are far too loose and will lead to and (c) excessive time and energy devoted to the symptoms or
health concerns.
many people being mislabeled as having a mental disor-
der (Frances, 2013b). It has also been suggested that C: The excessive concerns have persisted at a clearly problematic level
for at least 6 months.
women will be disproportionately affected because they
D: The excessive concerns about physical symptoms are pervasive and
are more frequent users of medical services and because cause significant disruption and impairment in daily life.
they are most at risk of being dismissed by their doctors
E: If a diagnosed medical condition is present, the thoughts, feelings,
as “catastrophizers” (Frances & Chapman, 2013). and behaviors are grossly in excess of what would be expected,
Another concern is that people diagnosed with somatic given the nature of the medical condition.
symptom disorder might look very different from a clinical F: If no medical diagnosis has been made, a thorough medical workup
perspective (Rief & Martin, 2014). For example, Richard has been performed to rule out possible causes and is repeated at
suitable intervals to uncover medical conditions that may declare
would be diagnosed with somatic symptom disorder. And themselves with the passage of time.
so would Jane, who suffers from migraines and is very G: The physical symptom or concern is not better accounted for by
upset and anxious about the effect her headaches have on another mental disorder (e.g., anxiety, depressive, or psychotic dis-
order).
her life. Yet another person who would qualify for the
somatic symptom disorder diagnosis is Ellen. Ellen devel- SOURCE: Based on Frances, A. (2013a). DSM-5 somatic symptom disorder, Journal of
Nervous and Mental Disease, 201, 530–531.
oped breast cancer when she was 41. After surgery, radia-
tion, and chemotherapy, her breast cancer is in remission.
explained symptoms (like Ellen or Jane) be treated with the
Nonetheless, Ellen is very fearful that it might come back.
same approaches used for patients who have medically
Now age 44, Ellen has physical symptoms and headaches.
unexplained symptoms (like Richard)? Can we assume
These could be attributed to side effects of the medications
that there are similar mechanisms at work in both cases?
she has to take. But because the fear that the cancer could
For those who seek to develop new treatments, the changes
recur is always on Ellen’s mind, she too would get the
in DSM-5 present some interesting challenges.
same diagnosis as Richard who worries constantly about
his health even though he has not been diagnosed with a
specific medical problem. Causes of Somatic Symptom Disorder
It is very likely that the diagnostic criteria for somatic Why do people develop somatic symptom disorders? The
symptoms disorder will be modified over time. This is to historical roots of these disorders date back to the psycho-
be expected. As we mentioned in Chapter 1, the DSM must analytic concept of hysteria and the work of Freud, Breuer,
always be considered a work in progress. In their revision and Janet (see Chapter 2). It was long thought that symp-
efforts, the DSM-5 work group may have loosened the toms developed as a defense mechanism against unre-
diagnostic criteria too much. Indeed, Alan Frances, who solved or unacceptable unconscious conflicts. Rather than
served as the chair of the task force that developed DSM- being expressed directly, psychic energy was instead
IV, has called the DSM-5 somatic symptom disorder a channeled into more acceptable physical problems.
“loosely defined and fatally flawed” diagnosis and recom- Current views take a much more cognitive-behavioral
mended that clinicians not use it (Frances, 2013a, p. 531). approach. Of course, somatic symptom disorder is still a
Frances has even offered revised diagnostic criteria for this relatively new disorder and so has not yet been investigated
disorder. These are shown in Table 8.1. Compare them to much in its own right. Nonetheless, cognitive-behavioral
the DSM-5 criteria. In what ways are they different? Do perspectives on disorders such as hypochondriasis and
you think they provide any improvements? somatoform disorders (which are now subsumed within
As they now stand, the current DSM-5 criteria may the new diagnosis) are likely still valid and informative.
result in a wide range of patients being assigned the same Although several different models exist (Brown, 2004;
diagnosis (Rief & Martin, 2014). Some will have many Kirmayer & Taillefer, 1997; Rief & Barsky, 2005), their core
symptoms and some will have very few. Some will have features tend to be quite similar. First, there is a focus of
symptoms that have a medical cause; others will not. attention on the body. In other words, the person is hyper-
Unknown at this time is whether this broad grouping of vigilant and has an increased awareness of bodily changes.
clinical conditions will impede the successful development Second, the person tends to see bodily sensations as somatic
of new treatments. Should patients with medically symptoms, meaning that physical sensations are attributed to
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Somatic Symptom and Dissociative Disorders 261

illness. Third, the person tends to worry excessively about show that these individuals have an attentional bias for
what the symptoms mean and has catastrophizing cogni- illness-related information (Gropalis et al., 2013; see also
tions. Fourth, because of this worry, the person is very dis- Jasper & Witthöft, 2011). In other words, top-down (cogni-
tressed and seeks medical attention for his or her perceived tive) processes, rather than bottom-up processes (such as
physical problems. Figure 8.1 illustrates the basic model. differences in bodily sensations), seem to account for the
According to this formulation, somatic symptom dis- problems that they have. Although their physical sensa-
order can be viewed as disorder of both perception (notic- tions probably do not differ from those of normal controls
ing benign sensations such as one’s heart skipping a beat) (Marcus, Gurley, et al., 2007), people with somatic symp-
and cognition (“Does this mean I have a serious heart toms disorders seem to focus excessive attention on their
problem?”). Individuals who are especially anxious about physical experiences, labelling physical sensations as
their health tend to believe that they are very aware of and symptoms. They also perceive their symptoms as more
sensitive to what is happening in their bodies. But this dangerous than they really are and judge a particular dis-
does not seem to be the case. Rather, experimental studies ease to be more likely or dangerous than it really is. Once
they have misinterpreted a symptom, they tend to look for
Figure 8.1 Simplified Model of Somatic Symptom confirming evidence and to discount evidence that they are
Disorder in good health; in fact, they seem to believe that being
People with somatic symptom disorder tend to have a cognitive style healthy means being completely symptom free (Rief et al.,
that leads them to be hypersensitive to their bodily sensations. They 1998). They also perceive their probability of being able to
also experience these sensations as intense, disturbing, and highly
aversive. Another characteristic of such patients is that they tend to
cope with the illness as extremely low (Salkovskis & Bass,
think catastrophically about their symptoms, often overestimating 1997) and see themselves as physically weak and unable to
the medical severity of their condition. tolerate physical effort or exercise (Riebel et al., 2013; Woll-
burg et al., 2013). All this tends to create a vicious cycle in
which their anxiety about illness and symptoms results in
physiological symptoms of anxiety, which then provide
My stomach
hurts and
further fuel for their convictions that they are ill.
feels funny.
Attention
to bodily
sensations

Something
is wrong.
I must be
Attribution sick.
of sensations
to illness

Do I have
an ulcer?
Could this
be stomach
Worry/ cancer?
catastrophic
thinking
Darkbird/123RF

I need to
see my doctor
as soon as
possible.
Some individuals with somatic symptom disorder are preoccupied
Help seeking
with unrealistic fears of disease. They are convinced that they have
symptoms of physical illness, but their complaints typically do not
conform to any coherent symptom pattern, and they usually have
trouble giving a precise description of their symptoms.
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262 Chapter 8

It is also believed that an individual’s past experiences be female and to have high levels of comorbid depression
with illnesses (in both him- or herself and others, and also and anxiety (Creed & Barsky, 2004; Voigt et al., 2012), as
as observed in the media) contribute to the development of illustrated in the following case example.
a set of dysfunctional assumptions about symptoms and
diseases that may predispose a person to developing a
In Physical and Emotional Pain
somatic symptom disorder (Marcus, Gurley, et al., 2007;
Salkovskis & Warwick, 2001). These dysfunctional assump- Anna G., a 38-year-old married woman, the mother of five children,
tions might include notions such as “Bodily changes are reports to a mental health clinic with the chief complaint of depres-
sion, meeting diagnostic criteria for major depressive disorder. Her
usually a sign of serious disease, because every symptom
marriage has been a chronically unhappy one. Anna describes her
has to have an identifiable physical cause” or “If you don’t
husband as an alcoholic with an unstable work history, and there
go to the doctor as soon as you notice anything unusual,
have been frequent arguments revolving around finances, her sexual
then it will be too late” (Salkovskis & Bass, 1997, p. 318; see indifference, and her complaints of pain during intercourse.
also Marcus, Gurley, et al., 2007). This is another example Anna describes herself as having been nervous since childhood
of top-down cognitive processes at work. and also as having been continuously sick from an early age. She
Negative affect is regarded as a risk factor for develop- experiences chest pain and says she has been told by doctors that
ing somatic symptom disorder. However, negative affect she has a “nervous heart.” Anna sees physicians frequently for
alone is not sufficient. Many people tend to be rather abdominal pain, having been diagnosed on one occasion as having a
gloomy in their personalities, but only a subset of these “spastic colon.” In addition to physicians, Anna has consulted chiro-
people will also be habitual reporters of physical symp- practors and osteopaths for backaches, pains in her extremities, and
toms. Other characteristics that may be important are a feeling of anesthesia in her fingertips. She was recently admitted to
a hospital following complaints of abdominal and chest pain and of
absorption and alexithymia. Absorption is a tendency to
vomiting. During this admission she received a hysterectomy. Since
become absorbed in one’s experiences and is often associ-
the surgery she has been troubled by spells of anxiety, fainting, vom-
ated with being highly hypnotizable. Alexithymia, on the
iting, food intolerance, weakness, and fatigue. So far, physical exam-
other hand, refers to having difficulties identifying one’s inations have failed to reveal any explanations for her symptoms.
feelings. People who report many symptoms but who do
not have any medical conditions tend to score high on all Although somatic symptom disorders are often accom-
of these three traits (Bogaerts et al., 2015). panied by a lot of misery and suffering, they may be main-
Research is also showing that when people who report tained to some degree by secondary reinforcements. Most of
a lot of physical problems are put into a negative mood (by us learn as children that when we are sick we get special
viewing negative pictures, for example), their reporting of comforts and attention, as well as being excused from school
physical symptoms increases (Bogaerts et al., 2015; Con- or other responsibilities. In the case of the DSM-IV disorder
staninou et al., 2013). So what may be happening? People of hypochondriasis, Barsky and colleagues (1994) found
who have difficulty identifying their feelings and who are that their patients reported much childhood sickness and
also highly susceptible to being absorbed in their own missed a lot of school. People with hypochondriasis also
experiences may be especially sensitive to having certain tend to have an excessive amount of illness in their families
attentional (top-down) processes activated when they while growing up, which may lead to strong memories of
experience negative events. These alterations in the atten- being sick or in pain (Pauli & Alpers, 2002) and perhaps of
tional system may trigger memories or past representa- having observed some of the secondary benefits that sick
tions of symptoms (cognitive schemas) that were formed people sometimes get (Cote et al., 1996; Kellner, 1985).
as a result of prior experiences with illness. Once these Having said this, it is important to keep in mind that
schemas become active, they may cause the person to people with somatic symptom disorders are not malinger-
become aware of minor physical sensations or even trigger ing—consciously faking symptoms to achieve a specific
experiences of symptoms that are as “real” as they would goal such as winning a personal injury lawsuit. They expe-
be if they resulted from a known medical cause. Because all rience physical problems that cause them great concern. As
of this is thought to happen automatically, the person has described earlier, these symptoms may be caused by brain
no insight into or control over the process. processes that occur below the radar of the person’s con-
As we have already told you, patients with somatic scious awareness.
symptom disorder are usually seen in medical clinics.
Because they repeatedly seek medical advice (e.g., Bleich- Treatment of Somatic
hardt & Hiller, 2006; Fink et al., 2004), their annual medical
costs are much higher than average (e.g., Fink et al., 2010; Symptom Disorder
Hiller et al., 2004). High levels of functional impairment The cognitive-behavioral model provides a good explana-
are also common and many patients are severely disabled tion of the causes of somatic symptom disorders. It should
by their physical symptoms (van der Leeuw et al., 2015). therefore come as little surprise that cognitive-behavioral
Patients with somatic symptom disorder are more likely to treatments are widely used to treat these disorders
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Somatic Symptom and Dissociative Disorders 263

(e.g., Barsky & Ahern, 2004; Tyrer, 2011; see also Hedman
et al., 2011, for an example of Internet-based cognitive-
behavioral therapy [CBT]). In the case of Richard, the
patient you met at the beginning of this chapter, for exam-
ple, the cognitive components of this treatment approach
might focus on assessing his beliefs about illness and mod-

UpperCut Images/Alamy Stock Photo

ifying misinterpretations of his bodily sensations. Behav-
ioral techniques might include having Richard induce
innocuous symptoms by intentionally focusing on parts of
his body so that he could learn that selective perception of
his own bodily sensations could play a major role in his
symptoms. Sometimes patients treated with CBT are also
directed to engage in response prevention by not checking
their bodies as they usually do and by stopping their con-
stant seeking of reassurance. Generally, the duration of
When one physician integrates a patient’s care, the physical
CBT is relatively brief (6 to 16 sessions). Sessions can also functioning of patients with somatic symptom disorder may
be delivered in a group format (Weck et al., 2015). In addi- improve. Why should this be?
tion to helping reduce physical symptoms and anxiety
about symptoms, CBT approaches can also reduce levels of In addition, antidepressant medications (especially the
anxiety and depression more generally (Olatunji et al., tricyclic antidepressants) and certain selective serotonin
2014). Not surprisingly, patients do better if they receive reuptake inhibitors have been shown to reduce pain inten-
more sessions of treatment. In a recent study, patients also sity in a manner independent of the effects the medications
reported that considering alternative reasons for the pres- may have on mood (Aragona et al., 2005; Simon, 2002).
ence of their bodily symptoms (for example, a headache
doesn’t necessarily signal the presence of a brain tumor)
was the most valuable aspect of CBT (Weck et al., 2015). Illness Anxiety Disorder
In addition to CBT, a certain type of medical manage-
8.3 Identify the key difference between illness anxiety
ment may provide some further benefits. General practitio-
disorder and somatic symptom disorder.
ners can be educated in how to better manage and treat
patients with these disorders so that they are less frustrated Illness anxiety disorder is new to DSM-5. People with this
by them (Rosendal et al., 2005; see also Edwards & disorder have high anxiety about having or developing a
Edwards, 2010). One moderately effective treatment serious illness. This anxiety is distressing and/or disrup-
involves identifying one physician who will integrate the tive, but there are very few (or very mild) somatic symp-
patient’s care by seeing the patient at regular visits (thereby toms (see the DSM-5 criteria box).
trying to anticipate the appearance of new problems) and Around 25 percent of people who would have been
by providing physical exams focused on new complaints diagnosed with hypochondriasis in DSM-IV are diagnosed
(thereby accepting all symptoms as valid). At the same with illness anxiety disorder in DSM-5 (Bailer et al., 2016).
time, however, the physician avoids unnecessary diagnos- Although DSM-5 treats illness anxiety disorder and somatic
tic testing and makes minimal use of medications or other symptom disorder as distinct clinical diagnoses, recent
therapies (Looper & Kirmayer, 2002; Mai, 2004). Several research suggests they are very similar. For example, the
studies have found that patients show substantial decreases average age of onset of both illness anxiety disorder and
in health care expenditures over subsequent months and somatic symptom disorder is at age 20 (Newby et al., 2017).
sometimes an improvement in physical functioning
(although not necessarily in psychological distress; e.g.,
Rost et al., 1994). That is why this approach is best com-
bined with CBT (e.g., Bleichhardt et al., 2004 ; Mai, 2004).
Cognitive-behavioral techniques are also widely used
in the treatment of somatic symptom disorder that involves
pain. Treatment programs generally include relaxation
training, support and validation that the pain is real, sched-
uling of daily activities, cognitive restructuring, and rein-
forcement of “no-pain” behaviors (Simon, 2002). Patients
receiving such treatments tend to show substantial reduc-
tions in disability and distress, although changes in the
intensity of their pain tend to be smaller in magnitude.
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264 Chapter 8

this disorder was one of several disorders that were

DSM-5 Criteria for. . . grouped together under the term hysteria.
Conversion disorder is an intriguing and baffling clini-
Illness Anxiety Disorder cal condition and we still have much to learn about it. It is
A. Preoccupation with having or acquiring a serious illness. characterized by the presence of neurological symptoms in
the absence of a neurological diagnosis (see Feinstein,
B. Somatic symptoms are not present or, if present, are only
mild in intensity. If another medical condition is present or 2011). In other words, the patient has symptoms or deficits
there is a high risk for developing a medical condition (e.g., affecting either the senses or motor behavior. These would
strong family history is present), the preoccupation is clearly ordinarily strongly suggest a medical or neurological con-
excessive or disproportionate. dition. However, the pattern of symptoms or deficits is not
C. There is a high level of anxiety about health, and the consistent with any neurological disease or medical prob-
individual is easily alarmed about personal health status. lem. A few typical examples include partial paralysis,
D. The individual performs excessive health-related behaviors blindness, deafness, and episodes of limb shaking accom-
(e.g., repeatedly checks his or her body for signs of illness) panied by impairment or loss of consciousness that resem-
or exhibits maladaptive avoidance (e.g., avoids doctor ble seizures. Of course, the diagnosis can only be made
appointments and hospitals). after a full medical and neurological workup has been con-
E. Illness preoccupation has been present for at least 6 ducted. It is also important to emphasize that the person is
months, but the specific illness that is feared may change not intentionally producing or faking the symptoms.
over that period of time. Rather, psychological factors are often judged to play an
F. The illness-related preoccupation is not better explained important role because symptoms usually either start or
by another mental disorder, such as somatic symptom are exacerbated by preceding emotional or interpersonal
disorder, panic disorder, generalized anxiety disorder, body conflicts or stressors, as in the following case example.
dysmorphic disorder, obsessive-compulsive disorder, or
delusional disorder, somatic type.
Source: Reprinted with permission from the Diagnostic and Statistical Unable to See for Seven Days
Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American
Psychiatric Association. The patient, a 21-year-old university student in Ethiopia, came to
the hospital, accompanied by her mother. She said that she had not
been able to see for the past week. An ophthalmologic exam was
done, followed by a neurological examination. Both failed to reveal
There are many other similarities as well. This calls into any specific problems. The patient was cooperative during all the
question whether it is appropriate to have two distinct disor- testing, with normal concentration and attention. Apart from report-
ders, both of which reflect health anxiety (Bailer et al., 2016). ing severe visual impairment, the patient was smiling and reported
The main difference between them appears to be severity. feeling nothing unusual.
People with somatic symptom disorder have more comorbid Questioning by clinic staff revealed that, 1 month earlier, the
patient had been unable to speak for 2 weeks. Her inability to speak
conditions and visit doctors more frequently (which makes
developed during a time when she had been experiencing difficulties
sense because, unlike patients with illness anxiety disorder,
in her studies and a few hours after her mother told her that her
they have medical symptoms). Over time, it may be that
father had a life-threatening illness. With the assistance of friends,
these two disorders will be combined into a single diagnosis who helped train her to speak again, the patient recovered. A week
in a future revision of the DSM, with severity being a speci- later, while preparing for an examination, she became completely
fier that is noted to provide additional information. unable to see.
Eight months before her current presentation at the clinic, the
patient had been voiceless for another period of 6 weeks. At that

Conversion Disorder time, she had received a laryngoscopy, which revealed nothing
abnormal. The patient was treated with valium and also given some

(Functional Neurological therapy to help her manage her stress and anxiety. After 3 days of
relaxation therapy and slow-breathing training, she began to be able

Symptom Disorder) to produce a coughing sound. The following day she was able to say
a few words and the next day she became fully communicative again.
8.4 Summarize the clinical features of conversion These same stress management techniques were used this
disorder, also noting its prevalence, causes, and time to help the patient with her loss of vision. She was also offered
materials suitable for a blind person and asked to complete tactile
treatment.
tasks, making patterns with different shapes. A little later she was
Another disorder within the diagnostic category of somatic given painting materials. Although the patient said that she could not
symptom and related disorders is conversion disorder. see what she was doing, she was able to reproduce shapes and
The term conversion disorder is relatively recent. Historically wrap paper around pieces of wood to make pearls for a necklace.
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Somatic Symptom and Dissociative Disorders 265

All the while, the clinic staff were encouraging and supportive, prais- (2) motor, (3) seizures, and (4) a mixed presentation of the
ing the patient for her skills. Then, after about a week, the patient first three categories (APA, 2013).
started to see flashes of light. A short while later she began to
recognize several people. Finally, after 3 weeks, she was able to SENSORY SYMPTOMS OR DEFICITS Conversion disor-
see normally again. (Taken from Mulugeta et al., 2015.) der can involve almost any sensory modality. The diagno-
sis is often made when symptoms in the affected area are
Early observations dating back to Freud suggested that inconsistent with how known anatomical sensory path-
most people with conversion disorder showed very little of ways operate. Sensory symptoms or deficits are most com-
the anxiety and fear that would be expected in a person mon in the visual system (especially blindness and tunnel
with a paralyzed arm or loss of sight. (Wouldn’t you be vision), in the auditory system (especially deafness), or in
pretty upset if you suddenly woke up blind or unable to the sensitivity to feeling (especially the anesthesias). In the
move your arm?) This seeming lack of concern was known anesthesias, the person loses feeling in a part of the body.
as la belle indifférence—French for “the beautiful indiffer- One of the most common is glove anesthesia, where the per-
ence.” For a long time it was thought to be an important son cannot feel anything on the hand in the area where
diagnostic criterion for conversion disorder. However, la gloves are worn, although the loss of sensation usually
belle indifférence occurs only in about 20 percent of patients. makes no anatomical sense (nerves do not stop at the wrist).
Lack of concern about symptoms or their implications is With conversion blindness, the person reports being
also not specific to conversion disorder. For these reasons, unable to see. However, it is not uncommon for the person
this phenomenon has become de-emphasized in more to be able to navigate around a room without bumping
recent editions of the DSM (Stone et al., 2006, 2011). into furniture or other objects. With conversion deafness,
Authors of DSM-5 had many suggestions for changing the person reports not being able to hear and yet orients
the term used to describe the disorder (e.g., to psychogenic, appropriately upon “hearing” his or her own name. Such
functional, and dissociative). In the end, a conservative observations lead to obvious questions: In conversion
approach was taken and the term conversion disorder was blindness (and deafness), can affected people actually not
retained, although this is now followed in parentheses by see (or hear), or is the sensory information received but
“functional neurological symptom disorder” (Stone et al., screened from consciousness? In general, the evidence sup-
2011). The DSM-5 criteria for conversion disorder are ports the latter idea; sensory input is registered but is
shown in the DSM box. somehow screened from explicit conscious recognition
(explicit perception).

MOTOR SYMPTOMS OR DEFICITS Motor conversion

DSM-5 Criteria for. . . reactions also cover a wide range of symptoms (e.g.,
Conversion Disorder Maldonado & Spiegel, 2001; see also Stone et al., 2011). For
example, conversion paralysis is usually confined to a sin-
A. One or more symptoms of altered voluntary motor or sensory
gle limb such as an arm or a leg. The loss of function is also
function.
usually selective for certain functions. For example, a per-
B. Clinical findings provide evidence of incompatibility between son may not be able to write but may be able to use the
the symptom and recognized neurological or medical
same muscles for scratching. Or a person may not be able
conditions.
to walk most of the time but may be able to walk in an
C. The symptom or deficit is not better explained by another emergency such as during a fire when escape is important.
medical or mental disorder.
The most common speech-related conversion disturbance
D. The symptom or deficit causes clinically significant distress is aphonia. Here, the person is able to talk only in a whisper
or impairment in social, occupational, or other important although he or she can usually cough in a normal manner.
areas of functioning or warrants medical evaluation.
(In true, organic laryngeal paralysis, both the cough and
Source: Reprinted with permission from the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American
the voice are affected.) Another common motor symptom,
Psychiatric Association. called globus, involves the sensation of a lump in the throat
(Finkenbine & Miele, 2004).

SEIZURES An additional relatively common form of con-

Range of Conversion Disorder version symptom involves seizures. These resemble epi-
leptic seizures, although they are not true seizures
Symptoms (Bowman & Markand, 2005; Stonnington et al., 2006). For
The range of symptoms for conversion disorder is very example, patients do not show any EEG abnormalities and
diverse. In describing the clinical picture, it is useful to do not show confusion and loss of memory afterward, as
think in terms of four categories of symptoms: (1) sensory, patients with true epileptic seizures do. Moreover, patients
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266 Chapter 8

with conversion seizures often show excessive thrashing

about and writhing not seen with true seizures, and they
rarely injure themselves in falls or lose bowel or bladder
control as patients with true seizures frequently do.

Important Issues in Diagnosing

Conversion Disorder
Because the symptoms in conversion disorder can mimic a
variety of medical conditions, accurate diagnosis can be
extremely difficult. It is crucial that a person with suspected
conversion symptoms receive a thorough medical and neu-
rological examination. Unfortunately, however, misdiag-
noses can still occur. Nevertheless, as medical tests (especially
brain imaging) have become increasingly sophisticated, the
rate of misdiagnosis has declined substantially, although it
does still occur (van Meerkerk-Aanen et al., 2017).
Several other criteria are also commonly used for dis-

TopFoto/The Image Works

tinguishing between conversion disorders and true neuro-
logical disturbances:
• The frequent failure of the dysfunction to conform
clearly to the symptoms of the particular disease or dis-
order simulated. For example, little or no wasting away
or atrophy of a “paralyzed” limb occurs in conversion
Conversion disorders were fairly common during World War I and
paralyses, except in rare and long-standing cases. World War II. The disorder typically occurred in otherwise “normal”
• The nature of the dysfunction is highly selective. As men during stressful combat conditions. The symptoms of
already noted, in conversion blindness the affected conversion disorder (e.g., paralysis of the legs) enabled a soldier to
individual does not usually bump into people or avoid high-anxiety combat situations without being labeled a coward
or being court-martialed.
objects, and “paralyzed” muscles can be used for some
activities but not others.
unknown, but even the highest estimates have been around
• Under hypnosis or narcosis (a sleeplike state induced only 0.005 percent (APA, 2013). Interestingly, this decreased
by drugs), the symptoms can usually be removed, prevalence seems to be closely related to our growing
shifted, or reinduced at the suggestion of the therapist. sophistication about medical and psychological disorders:
Similarly, a person abruptly awakened from a sound A conversion disorder apparently loses its defensive func-
sleep may suddenly be able to use a “paralyzed” limb. tion if it can be readily shown to lack a medical basis. When
it does occur today, it is most likely to occur in people who
are medically unsophisticated. For example, a highly
Prevalence and Demographic unusual “outbreak” of cases of severe conversion disorder
Characteristics involving serious motor weakness and wasting symptoms
Conversion disorders were once relatively common in was reported in five 9- to 13-year-old girls living in a small,
civilian and (especially) military life. In World War I, con- poor, rural Amish community. Each of these girls had expe-
version disorder was the most frequently diagnosed psy- rienced substantial psychosocial stressors including behav-
chiatric syndrome among soldiers; it was also relatively ioral problems, dysfunctional family dynamics, and
common during World War II. Conversion disorder typi- significant community stress from a serious local church
cally occurred under highly stressful combat conditions crisis (see Cassady et al., 2005). Fortunately, after the care-
and involved men who would ordinarily be considered givers of these girls were educated regarding the psycho-
stable. Here, conversion symptoms—such as paralysis of logical nature of the symptoms and given advice to stick
the legs—enabled a soldier to avoid an anxiety-arousing with one doctor, minimize stress, and avoid reinforcement
combat situation without being labeled a coward or being of the “sick role,” four of the five girls showed significant
subject to court-martial. improvement over the next 3 months. In the fifth case, the
Conversion disorders are found in approximately family refused to acknowledge the psychological compo-
5 percent of people referred for treatment at neurology nent of the illness, holding to the belief that the symptoms
clinics. The prevalence in the general population is were caused by parasites.
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Somatic Symptom and Dissociative Disorders 267

Conversion disorder occurs two to three times more (relief or removal of an aversive stimulus) because being
often in women than in men (APA, 2013). It can develop at incapacitated in some way may enable the individual to
any age but most commonly occurs between early adoles- escape or avoid an intolerably stressful situation without
cence and early adulthood (Maldonado & Spiegel, 2001). It having to take responsibility for doing so. In addition,
generally has a rapid onset after a significant stressor and they may provide positive reinforcement in the form of
often resolves within 2 weeks if the stressor is removed, care, concern, and attention from others. It is the case that,
although it commonly recurs (Merkler et al., 2015). Like in some cultures, expressing intense emotions is not
most other somatic symptom disorders, conversion disor- socially acceptable. In such situations, a diagnosis of con-
der frequently occurs along with other disorders, espe- version disorder may be a more socially sanctioned way
cially major depression, anxiety disorders, and other forms of expressing distress and escaping an unpleasant situa-
of somatic symptom or dissociative conditions. tion. However, although becoming sick or disabled is
more socially acceptable, we must keep in mind that the
person is not deliberately choosing to lose his or her sight
Causes of Conversion Disorders or become unable to walk. Instead, unconscious processes
Conversion disorders are thought to develop as a result of are thought to be at work.
stress or internal conflicts of some kind. Freud used the Given the important role often attributed to stressful
term conversion hysteria for these disorders (which were life events in precipitating the onset of conversion disorder,
fairly common in his practice) because he believed that the it is unfortunate that little is actually known about the
symptoms were an expression of repressed sexual energy— exact nature and timing of these psychological stress fac-
that is, the unconscious conflict that a person felt about his or tors (Roelofs et al., 2005). One study compared the fre-
her repressed sexual desires. However, in Freud’s view, the quency of stressful life events in the recent past in patients
repressed anxiety threatens to become conscious, so it is with conversion disorder and depressed controls and did
unconsciously converted into a bodily disturbance, thereby not find a difference in frequency between them. However,
allowing the person to avoid having to deal with the con- the greater the negative impact of the preceding life events,
flict. This is not done consciously, of course, and the person the greater the severity of the conversion disorder symp-
is not aware of the origin or meaning of the physical symp- toms (Roelofs et al., 2005). Another study compared levels
tom. Freud also thought that the reduction in anxiety and of a neurobiological marker of stress (lower levels of brain-
intrapsychic conflict was the primary gain that maintained derived neurotropic factor) in individuals with conversion
the condition, but he noted that patients often had many disorder versus individuals with major depression or those
sources of secondary gain as well, such as receiving sym- with no disorder. Both those with depression and those
pathy and attention from loved ones. with conversion disorder showed reduced levels of this
Freud’s theory that conversion symptoms are caused marker relative to the nondisordered controls (Deveci
by the conversion of sexual conflicts or other psychologi- et al., 2007). This also provides support for the link between
cal problems into physical symptoms is no longer stress and the onset of conversion disorder.
accepted outside psychodynamic circles. However, many Neuroimaging studies of conversion disorder are still,
of Freud’s clinical observations about primary and sec- like the disorder itself, relatively rare. Many are case stud-
ondary gain are still incorporated into contemporary ies or involve only small numbers of patients. Nonetheless,
views of conversion disorder. For example, viewed although research in this area is still in its infancy, provoca-
through the lens of learning theory, the physical symp- tive findings are emerging. Some of these are described in
toms can be seen as providing negative reinforcement the Developments in Research box.

Developments in Research
What Can Neuroimaging Tell Us about Conversion Disorder?
Functioning neuroimaging approaches to the study of conversion and left hands (or feet). When the stimulus was applied to the
disorder hold the potential to provide insights into what is hap- side that had sensation and was unaffected, the brain scans
pening in the brain when people with sensory or motor deficits revealed the expected findings. In other words, there was activa-
are asked to move a paralyzed limb or receive stimulation to a tion in somatosensory areas of the brain on the opposite side to
numb body part. In one interesting study, three patients with the side being stimulated. (This is because most human motor
sensory loss (involving numbness in the hand or foot) received and sensory fibers cross the midline and so stimulation of the
brain scans while a vibrating stimulus was applied to their right right side of the body affects the left side of the brain.) However,
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268 Chapter 8

when tactile stimulation was applied to the affected (numb) body

part, there was no activation in the contralateral area of the sen-
Figure 8.2
sory cortex. Figure 8.2 provides an illustration of this. Instead, the This functional magnetic resonance image shows somatosensory
activity evoked by stimulation in a patient with sensory conversion
tactile stimulus activated regions in the orbitofrontal cortex and
disorder affecting the left hand. When the patient’s left hand was
the anterior cingulate cortex (Ghaffar et al., 2006). This is interest- stimulated, no activity was seen in the primary somatosensory
ing because both of these brain regions are involved in neural cortex (arrow). However, increased activity was seen in this area
networks that are thought to regulate emotion and the expres- of the brain when the patient’s right hand was stimulated (circle)
sion of emotion. (Source: Feinstein, A. (2011). Conversion disorder: advances in our
understanding. Canadian Medical Association Journal, 183, 915-920.
Similar results were found in another study involving two
Used with permission.)
patients with conversion paralysis in the legs (Saj et al., 2014).
When the patients were asked to slightly move their arms (or to
imagine doing so), there was activation in the motor cortex, as
expected. However, when asked to move their legs, there was
activation in the insula cortex—a part of the limbic system that is
thought to mediate emotional responses. What was also interest-
ing was that when the patients were asked to imagine mentally
rotating a paralyzed limb, there was activation in the anterior cin-
gulate cortex.
To date, the largest functional neuroimaging study of sen-
sory conversion disorder involves 10 female patients (Burke et al.,
2014). Again, the findings suggest that when the anesthetic body
part is stimulated, there is decreased activation in the somatosen-
sory cortex but increased activation in areas such as the anterior
cingulate cortex, insula, and other brain areas implicated in emo-
tion processing. All of this is consistent with the idea that sensory
areas may perhaps be inhibited by overactive emotion-based ability to detect stimuli (in the case of anesthesia) or move a limb
processing. Strange as it may seem, what may be happening in (in the case of paralysis). Although much more needs to be
patients with conversion disorders is that abnormal activation in learned, there is some possibility that neuroimaging research may
limbic areas (or areas connected to them) might be overriding actually be supporting some of Freud’s thinking about the origins
activation in motor or sensory areas, shutting off the person’s of conversion disorders!

Treatment of Conversion Disorder used cognitive-behavior therapy to successfully treat con-

version seizures (LaFrance et al., 2009). Some studies have
Our knowledge of how best to treat conversion disorder is
used hypnosis combined with other problem-solving ther-
very limited because few well-controlled studies have been
apies, and there are suggestions that hypnosis, or adding
conducted (e.g., Bowman & Markand, 2005; Looper &
hypnosis to other therapeutic techniques, can be useful
Kirmayer, 2002). However, approaches similar to those
(Looper & Kirmayer, 2002; Moene et al., 2003).
used to help the patient who suddenly became unable to
see (described in the earlier case study) are often helpful.
The Developments in Practice box provides another example
involving treatment of a patient who was mute.
Some hospitalized patients with motor conversion
symptoms have been successfully treated with a behav-
ioral approach in which specific exercises are prescribed in
order to increase movement or walking, and then rein-
forcements (e.g., praise and gaining privileges) are pro-
vided when patients show improvements. Any
reinforcements of abnormal motor behaviors are removed
Bertys30/Fotolia

in order to eliminate any sources of secondary gain. In one

small study using this kind of treatment for 10 patients, all
had regained their ability to move or walk in an average of
12 days, and for seven of the nine patients available at an
approximately 2-year follow-up, the improvements had Virtually all the symptoms of conversion disorder can be temporarily
been maintained (Speed, 1996). At least one study has also reduced or reproduced by hypnotic suggestion.
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Somatic Symptom and Dissociative Disorders 269

Developments in Practice
Treatment of a Patient Who Was Mute
Bryant and Das (2012) describe a creative treatment that was When neural activation before and after treatment was
used to help a 51-year-old Australian woman who had been mute examined, some interesting observations were made. One rather
for 4 years. Although she was unable to speak, she was, rather surprising finding was that there was a similar amount of activa-
surprisingly, able to sing. As part of the treatment the therapist tion in speech-related brain networks during the period when the
used a form of karaoke, asking the patient to imagine singing patient was mute and after recovery. Specifically, a brain area
along to her favorite songs when they were played on a CD player called the inferior frontal gyrus or IFG (which contains Broca’s
in the therapist’s office. After two sessions, the patient was not area—an area known to be associated with speech production)
only able to sing along, but she also began to speak to the thera- showed an increase in activation during both brain scans. The
pist. The following week her voice returned in contexts outside major finding from the study, however, was that, after recovery,
the therapist’s office as well. the patient had increased positive connectivity between the IFG
What makes this case even more interesting is that the and the anterior cingulate and decreased connectivity between
researchers also collected brain imaging data on the patient the IFG and the amygdala. In other words, after recovery, the
before and after treatment. In the initial brain scan, the patient was patient’s speech areas were more linked to brain regions involved
asked to keep her lips and teeth together (to avoid any movement in emotion regulation (anterior cingulate) and less linked to brain
that would make the scan unusable) and try to vocalize the letters regions associated with anxiety (amygdala). This case study pro-
of the alphabet as loudly as possible. For the second scan, con- vides the first demonstration that recovery from conversion disor-
ducted 4 weeks after her speech returned, the patient was asked der is associated with enhanced connectivity between the area of
to do the same thing. Although no sounds were detected during the brain that was implicated in the conversion disorder symp-
the initial scan, the patient made audible sounds during the toms (in this case speech production) and neural networks that
second scan. play a role in emotion regulation.

Factitious Disorder
DSM-5 Criteria for. . .
8.5 Explain the difference between factitious disorder
and malingering. Factitious Disorder
The disorders we have discussed so far all assume that the Factitious Disorder Imposed on Self
people who are experiencing symptoms are reporting their A. Falsification of physical or psychological signs or symp-
problems as accurately and as truthfully as possible. But toms, or induction of injury or disease, associated with
sometimes people do deliberately and consciously feign identified deception.
disability or illness. Also placed in the somatic symptoms B. The individual presents himself or herself to others as ill,
and related disorders category in DSM-5 is factitious impaired, or injured.
disorder. In factitious disorder the person intentionally
C. The deceptive behavior is evident even in the absence of
produces psychological or physical symptoms (or both). obvious external rewards.
Although this may strike you as strange, the person’s goal
D. The behavior is not better explained by another mental
is to obtain and maintain the benefits that playing the “sick
disorder, such as delusional disorder or another psychotic
role” (even to the extent of undergoing repeated hospital- disorder.
izations) may provide, including the attention and concern
Source: Reprinted with permission from the Diagnostic and Statistical
of family and medical personnel. The DSM-5 criteria for Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American
Psychiatric Association.
factitious disorder are shown in the DSM-5 box.
In DSM-IV, factitious disorder was in a category of its
own. In DSM-5 it has been moved into the category
To group them now with a disorder that is characterized by
of somatic symptom and related disorders. The reason for
deliberately feigning illness runs the risk of further perpet-
the move is because in most cases of factitious disorder, the
uating these negative stereotypes.
person presents with somatic symptoms and with the
expressed belief that he or she is ill. However, many regard
the inclusion of factitious disorder in the somatic symptom Identifying Factitious Disorder
and related disorders category as very unfortunate (Rief & What is the difference between factitious disorder and
Martin, 2014). These disorders have a history of being stig- malingering? The key difference is that, in factitious disor-
matized and many doctors do not take them very seriously. der, the person receives no tangible external rewards.
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270 Chapter 8

In contrast, the person who is malingering is intentionally detection is the fact that health care professionals who
producing or grossly exaggerating his or her physical realize they have been duped may be reluctant to
symptoms and is motivated by external incentives such as acknowledge their fallibility for fear of legal action. Mis-
avoiding work or military service or evading criminal diagnosing the disorder when the parent is in fact inno-
prosecution (APA, 2013; Maldonado & Spiegel, 2001). cent can also lead to legal difficulties for the health care
In factitious disorder, patients may surreptitiously alter professionals (McNicholas et al., 2000; Pankratz, 2006).
their own physiology—for example, by taking drugs—in One technique that has been used with considerable suc-
order to simulate various real illnesses. Indeed, they may cess is covert video surveillance of the mother and child
be at risk for serious injury or death and may even need to during hospitalizations. In one study, 23 of 41 suspected
be committed to an institution for their own protection. cases were finally determined to have factitious disorder
The prevalence of factitious disorder is not well estab- by proxy, and in 56 percent of those cases video surveil-
lished, although it is probably in the region of 0.5 to 0.8 lance was essential to the diagnosis (Hall et al., 2000).
percent of patients in general hospital settings (Bouman,
2015). The disorder is also thought to be more common in
women than it is in men. Systematic research on this disor-
der is lacking and there is currently no theoretical model of
why it develops. Some of the social gains that come from

Joe Larese/Pool The Journal News/AP Images

being in a patient role are thought to be involved, however.
A dangerous variant of factitious disorder is factitious
disorder imposed on another (sometimes referred to as
Munchausen’s syndrome by proxy). Here, the person seeking
medical help has intentionally produced a medical or psy-
chiatric illness (or the appearance of an illness) in another
person. This person is usually someone (such as a child)
who is under his or her care (e.g., Pankratz, 2006). In a typ-
ical instance, a mother presents her own child for treat-
ment of a medical condition she has deliberately caused.
To produce symptoms, the mother might withhold food Lacey Spears is currently serving a 20-year prison term for causing the
from the child, add blood to the child’s urine, give the death of her 5-year-old son, Garnett. According to prosecutors, ever
child drugs to make him or her throw up, or heat up ther- since her son was an infant, Spears had administered salt into his
mometers to make it seem as if the child has a fever. If the feeding tube to make him sick. She had told doctors that her son
could not keep food down and so needed to have a feeding tube
child is hospitalized, the mother might deliberately infect
inserted. Prosecutors alleged that Spears made her son sick because
an intravenous (IV) line to make the child more ill. Of she craved social media attention, even posting pictures of her dying
course, the health of the victims is often seriously endan- son on Facebook. Although she denied any mental illness, the judge in
gered by this form of child abuse and the intervention of the case said that Spears had a diagnosis of Munchausen’s by proxy.
social service agencies or law enforcement is sometimes
necessary. In as many as 10 percent of cases, the actions of
the mother may lead to a child’s death (Hall et al., 2000).
This disorder may be suspected when the victim’s
clinical presentation is atypical, when lab results are
inconsistent with each other or with recognized diseases,
SciShow Psych/BoClips

or when there are many frequent returns or increasingly

urgent visits to the same hospital or clinic. The perpetra-
tors (who often have extensive medical knowledge) tend
to be highly resistant to admitting the truth about what
they are doing (McCann, 1999). They also appear to be
devoted to their child, making it hard for health care
providers to suspect that they are the cause of the child’s Distinguishing Between Different
problems. It has been estimated that the average length
Types of Somatic Symptom and
of time to confirm the diagnosis is 14 months (Rogers,
2004). If the perpetrator senses that the medical staff is Related Disorders
suspicious, he or she may abruptly terminate contact Given that all the diagnoses we have discussed so far
with that facility, only to show up at another one to begin involve the presentation of physical symptoms, how can
the entire process anew. Compounding the problem of we distinguish between them? Persons engaged in malin-
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Somatic Symptom and Dissociative Disorders 271

gering (for which there are no formal diagnostic criteria) discontinuity of experience” or as “recurrent, jarring invol-
and those who have factitious disorder are consciously untary intrusions into executive functioning and sense of
perpetrating frauds by faking the symptoms of diseases or self”1 (Spiegel et al., 2011b, p. E19).
disabilities. This fact is often reflected in their defensive Much of our mental life involves automatic noncon-
demeanor. In contrast, individuals with conversion disor- scious processes that occur below the radar of deliberate
ders (as well as with other somatic symptom disorders) are self-awareness and monitoring. Such unaware processing
not consciously producing their symptoms. They believe extends to the areas of implicit memory and implicit per-
themselves to be the “victims of their symptoms,” and are ception; all people routinely show indirect evidence of
very willing to discuss them, often in excruciating detail remembering things they cannot consciously recall
(Maldonado & Spiegel, 2001, p. 109). When inconsistencies (implicit memory) and respond to sights or sounds as if
in their behaviors are pointed out, they are usually unper- they had perceived them even though they cannot report
turbed. Any secondary gains they experience are by- that they have seen or heard them (implicit perception;
products of the conversion symptoms themselves and are Kihlstrom, 2001, 2005; Kihlstrom et al., 1993). This type of
not involved in motivating the symptoms. On the other responding also occurs in conversion disorders where
hand, persons who are feigning symptoms are inclined to people who say that they cannot see nonetheless are able
be evasive and suspicious when asked about them; they to respond to some visual stimuli. The general idea of
are usually reluctant to be examined and slow to talk about unconscious mental processes has been embraced by psy-
their symptoms in case their pretense is discovered. If chodynamically oriented clinicians for many years. Now
inconsistencies in their behaviors are pointed out, deliber- this is a major research area in the field of cognitive psy-
ate deceivers quickly become more defensive. chology (though without any of the psychodynamic impli-
cations for why so much of our mental activity is
unconscious).
Dissociative Disorders: In people with dissociative disorders, this normally
integrated and well-coordinated multichannel quality of
An Overview human cognition becomes much less coordinated and
integrated. As a result, the affected person may be unable
8.6 List three DSM-5 dissociative disorders.
to access information that is normally in the forefront of
Dissociative disorders are a group of conditions involving consciousness, such as his or her own personal identity
disruptions in a person’s normally integrated functions of or details of an important period of time in the recent
consciousness, memory, identity, or perception (APA, 2013; past. That is, the normally useful capacity of maintaining
Spiegel et al., 2013). Included here are some dramatic clini- ongoing mental activity outside of awareness appears to
cal presentations: people who cannot recall who they are or be subverted, sometimes for the purpose of managing
where they may have come from, and people who have severe psychological threat. When that happens, we
two or more distinct identities or personality states that observe the pathological symptoms that are the cardinal
alternately take control of the individual’s behavior. characteristic of dissociative disorders. Like somatic
The concept of dissociation was first promoted over a symptom disorders, dissociative disorders appear
century ago by the French neurologist Pierre Janet (1859– mainly to be ways of avoiding anxiety and stress and of
1947). Dissociation can be defined as “a disruption of and/ managing life problems that have overwhelmed the per-
or discontinuity in the normal, subjective integration of one son’s usual coping resources. Both types of disorders
or more aspects of psychological functioning, including— also enable the individual to deny personal responsibil-
but not limited to—memory, identity, consciousness, per- ity for his or her “unacceptable” wishes or behavior. In
ception and motor control” (Spiegel et al., 2011a, the case of DSM-defined dissociative disorders, the per-
p. 826). We all dissociate to a degree some of the time. Mild son avoids the stress by pathologically dissociating—in
dissociative symptoms occur when we daydream or lose essence, by escaping from his or her own autobiographi-
track of what is going on around us, when we drive miles cal memory or personal identity. The DSM-5 recognizes
beyond our destination without realizing how we got several types of pathological dissociation. These include
there, or when we miss part of a conversation we are depersonalization/derealization disorder, dissociative
engaged in. (Figure 8.3 provides examples of items from amnesia, and dissociative identity disorder. The dissocia-
the Dissociative Experiences Scales, a self-report measure tive disorders are placed in DSM-5 immediately after
of dissociation.) As these everyday examples suggest, trauma and stressor-related disorders, to reflect the close
there is nothing inherently pathological about dissociation
itself. Dissociation only becomes pathological when the 1
Spiegel, D., Loewenstein, R. J., Lewis-Fernandez, R., Sar, V., Simeon, D.,
dissociative symptoms are “perceived as disruptive, Vermetten, E., Cardena, E., & Dell, P. F. (2011b, p. E19). Dissociative
invoking a loss of needed information, as producing disorders in DSM-5. Depression and Anxiety, 28, 824–852.
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272 Chapter 8

Figure 8.3 Dissociative Experiences Scales

This figure shows sample items from the Dissociative Experiences Scales (DES), a 28-question test often used to screen
for dissociative symptoms. The higher the DES score, the more likely it is that the individual has a dissociative disorder.
(Adapted from Serenity Programme™, www.serene.me.uk.)

Dissociative Experiences Scales (DES)

Identifier Date

This questionnaire consists of twenty-eight questions about experiences that you may have in your
daily life. We are interested in how o!en you have these experiences. It is important, however, that
your answers show how o!en these experiences happen to you when you are not under the influence
of alcohol or drugs. To answer the questions, please determine to what degree the experience described
in the question applies to you and select the number to show what percentage of the time you have
the experience. 100% means ‘always’, 0% means ‘never’ with 10% increments in between. This
assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please
speak with a qualified health professional.

Never 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Always
Some people have the experience of driving a car and suddenly realizing that they
1 don’t remember what has happened during all or part of the trip. Select a number 0%
to show what percentage of the time this happens to you

Some people find that sometimes they are listening to someone talk and they
2 suddenly realize that they did not hear all or part of what was said. Select a 0%
number to show what percentage of the time this happens to you

Some people have the experience of finding themselves in a place and having no
3 idea how they got there. Select a number to show what percentage of the time 0%
this happens to you

Some people have the experience of finding themselves dressed in clothes that
4 they don’t remember putting on. Select a number to show what percentage of 0%
the time this happens to you

relationship that exists between them. However, symp- lost. In depersonalization one’s sense of one’s own
toms of dissociation are transdiagnostic, meaning that self and one’s own reality is temporarily lost. In the 1998
they are associated with many different forms of psycho- Steven Spielberg film, Saving Private Ryan, Captain John
pathology. As we might expect, the highest levels of dis- Miller (played by Tom Hanks) experiences an episode of
sociation are reported by patients with dissociative derealization after being shot. Events around him unfold
disorders, followed by patients with post-traumatic as if occurring in a slow-motion and silent movie.
stress disorder, borderline personality disorder, and Dissociative experiences are far from rare in the general
conversion disorder (Lyssenko et al., 2017). population. As many as 50 to 74 percent of us have such
experiences in mild form at least once in our lives, usually
during or after periods of severe stress, sleep deprivation, or
Depersonalization/ sensory deprivation (e.g., Khazaal et al., 2005; Reutens et al.,
2010). But when episodes of depersonalization or derealiza-
Derealization Disorder tion become persistent and recurrent and interfere with nor-
mal functioning, depersonalization/derealization disorder
8.7 Summarize the clinical features of may be diagnosed, as in the following case example.
depersonalization/derealization disorder.
Two of the more common kinds of dissociative symptoms
are derealization and depersonalization (both of which Living in a Dream
sometimes occur during panic attacks). In derealization The patient, a 22-year-old man employed as a mail carrier in India,
one’s sense of the reality of the outside world is temporarily came to the outpatient clinic reporting feelings of unreality, heaviness
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Somatic Symptom and Dissociative Disorders 273

in his head, and a sense that his surroundings had changed. He told level of neural and autonomic activity that normally
the doctors that his problems had begun suddenly, 6 months earlier accompanies emotional responses to threatening or
when he was with his friends. According to the patient, he felt that his unpleasant emotional stimuli (Lemche et al., 2007; Phillips
friends had changed—that they were no longer his friends but more & Sierra, 2003; Stein & Simeon, 2009). After viewing an
like ghosts or devils. Scared, the patient hurried home, but when he
emotional video clip, participants with depersonalization
got home and saw his mother, he felt that she, too, had changed.
showed higher levels of subjective and objective memory
These feelings continued and it became hard for the patient to tell
fragmentation than controls (Giesbrecht et al., 2010).
the difference between the real and the unreal. Although he contin-
ued to work in his job, he no longer had any interest in social activi- Memory fragmentation is marked by difficulties forming
ties. When he went into a crowded place, he felt as if he was in a an accurate or coherent narrative sequence of events,
dream or somehow roaming in a different kind of a world. He realized which is consistent with earlier research suggesting that
that these feelings were his own and he sometimes pinched himself time distortion is a key element of the depersonalization
to feel the pain and try and get rid of the feelings of unreality. (Based experience (Simeon et al., 2008).
on Ghosh et al., 2007.)

In this disorder, people have persistent or recurrent

experiences of feeling detached from (and like an outside
observer of) their own bodies and mental processes. They
may even feel they are, for a time, floating above their
physical bodies, which may suddenly feel very different—
as if drastically changed or unreal. In contrast to what hap-
pens during psychotic states, during depersonalization,
reality testing remains intact. The related experience of
derealization, in which the external world is perceived as

Lisa O’Connor/ZUMA Press, Inc./Alamy Stock Photo

strange and new in various ways, may also occur. In both
states “the feeling puzzles the experiencers: the changed
condition is perceived as unreal, and as discontinuous with
his or her previous ego-states. The object of the experience,
self (in depersonalization) or world (in derealization), is
commonly described as isolated, lifeless, strange, and unfa-
miliar; oneself and others are perceived as ‘automatons,’
behaving mechanically, without initiative or self-control”
(Kihlstrom, 2001, p. 267). Often people, like the man in the
case study you just read, report feeling as though they are
living in a dream or movie (Maldonado et al., 2002).
In keeping with such reports, research has shown that
emotional experiences are attenuated or reduced during
depersonalization—both at the subjective level and at the Adam Duritz, Counting Crows frontman, has talked about his
experiences and struggles with depersonalization/derealization
disorder.

In DSM-IV, derealization and depersonalization were

treated as two distinct conditions. In DSM-5 they are
combined. This is because research suggests that people
who have prominent derealization or prominent deperson-
alization look rather similar in terms of demographic char-
Estherpoon/Shutterstock

acteristics, the course and severity of their problems, and

their comorbid conditions (see Lynn et al., 2015). The cur-
rent DSM-5 criteria for depersonalization/derealization
disorder are shown in the DSM box. Because transient
symptoms of depersonalization or derealization are wide-
spread in the general population, to qualify for a diagnosis,
People with derealization symptoms experience the world as hazy episodes of depersonalization or derealization must be
and indistinct. persistent or recurrent.
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274 Chapter 8

DSM-5 Criteria for. . .

Depersonalization/Derealization Disorder
A. The presence of persistent or recurrent experiences of deper- C. The symptoms cause clinically significant distress or impair-
sonalization, derealization, or both: ment in social, occupational, or other important areas of
1. Depersonalization: Experiences of unreality, detach- functioning.
ment, or being an outside observer with respect to one’s D. The disturbance is not attributable to the physiological effects
thoughts, feelings, sensations, body, or actions (e.g., of a substance (e.g., a drug of abuse, medication) or another
perceptual alterations, distorted sense of time, unreal or medical condition (e.g., seizures).
absent self, emotional and/or physical numbing). E. The disturbance is not better explained by another mental dis-
2. Derealization: Experiences of unreality or detachment order, such as schizophrenia, panic disorder, major depressive
with respect to surroundings (e.g., individuals or objects disorder, acute stress disorder, posttraumatic stress disorder,
are experienced as unreal, dreamlike, foggy, lifeless, or or another dissociative disorder.
visually distorted).
Source: Reprinted with permission from the Diagnostic and Statistical Manual
B. During the depersonalization or derealization experiences, of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric
reality testing remains intact. Association.

Dissociative disorders have not been included in the experiences; by contrast, anterograde amnesia is the partial
major epidemiological surveys that have been conducted or total inability to retain new information (Gilboa et al.,
to date, so we have no exact prevalence data. It is estimated 2006; Kapur, 1999). Persistent amnesia may occur in disso-
that the lifetime prevalence of depersonalization/dereal- ciative amnesia. It may also result from traumatic brain
ization disorder is around 1 to 2 percent of the population injury or diseases of the central nervous system. If the
with equal numbers of males and females being affected amnesia is caused by brain pathology, it most often involves
(APA, 2013; Reutens et al., 2010). Although the disorder failure to retain new information and experiences (antero-
can start in childhood, the mean age of onset is around age grade amnesia). That is, the information contained in expe-
16, with only a minority of people developing it after age rience is not registered and does not enter memory storage
25 (APA, 2013). Moreover, in nearly 80 percent of cases, the (Kapur, 1999).
disorder has a fairly chronic course with little or no fluctu- On the other hand, dissociative amnesia is usually
ation in intensity (Baker et al., 2003). Comorbid conditions limited to a failure to recall previously stored personal
can include mood or anxiety disorders. Avoidant, border- information (retrograde amnesia) when that failure cannot
line, and obsessive-compulsive personality disorders are be accounted for by ordinary forgetting (see the DSM-5
also elevated in people with depersonalization and dereal- box for the current diagnostic criteria). The gaps in mem-
ization experiences (e.g., Hunter et al., 2003; Mula et al., ory most often occur following intolerably stressful
2007; Reutens et al., 2010). circumstances—wartime combat conditions, for example,
Although severe depersonalization/derealization or catastrophic events such as serious car accidents, suicide
symptoms can be quite frightening and may make the per- attempts, or traumatic experiences (Maldonado & Spiegel,
son fear imminent mental collapse, such fears are usually 2007; Spiegel et al., 2011a). In this disorder, apparently for-
unfounded. Sometimes, however, feelings of depersonali- gotten personal information is still there beneath the level
zation can be early manifestations of the development of
psychotic states (see Chapter 13). In either case, profes-
sional assistance in dealing with the precipitating stressors
and in reducing anxiety may be helpful. Unfortunately,
however, as of yet there are no clearly effective treatments—
either through medication or psychotherapy.

Dissociative Amnesia
8.8 Describe the clinical features of dissociative amnesia.
Retrograde amnesia is the partial or total inability to recall
or identify previously acquired information or past
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Somatic Symptom and Dissociative Disorders 275

word fugue means “flight”), is a defense by actual flight.

DSM-5 Criteria for. . . The person is not only amnesic for some or all aspects of
his or her past but also departs from home surroundings.
Dissociative Amnesia This is accompanied by confusion about personal identity
A. An inability to recall important autobiographical information, or even the assumption of a new identity (although the
usually of a traumatic or stressful nature, that is inconsistent identities do not alternate as they do in dissociative iden-
with ordinary forgetting. tity disorder). During the fugue, such individuals are
Note: Dissociative amnesia most often consists of localized unaware of memory loss for prior stages of their life, but
or selective amnesia for a specific event or events; or their memory for what happens during the fugue state
generalized amnesia for identity and life history. itself is intact (Kihlstrom, 2005; Kihlstrom & Schacter, 2000).
B. The symptoms cause clinically significant distress or impair- Their behavior during the fugue state is usually quite nor-
ment in social, occupational, or other important areas of mal and unlikely to arouse suspicion that something is
functioning. wrong. However, behavior during the fugue state often
C. The disturbance is not attributable to the physiological reflects a rather different lifestyle from the previous one
effects of a substance (e.g., alcohol or other drug of abuse, (the rejection of which is sometimes fairly obvious). Days,
a medication) or a neurological or other medical condition weeks, or sometimes even years later, such people may
(e.g., partial complex seizures, transient global amnesia, suddenly emerge from the fugue state and find themselves
sequelae of a closed head injury/traumatic brain injury, in a strange place, working in a new occupation, with no
other neurological condition).
idea how they got there. In other cases, recovery from the
D. The disturbance is not better explained by dissociative fugue state occurs only after repeated questioning and
identity disorder, posttraumatic stress disorder, acute stress reminders of who they are. In either situation, as the fugue
disorder, somatic symptom disorder, or major or mild neuro-
state remits, their initial amnesia remits—but a new, appar-
cognitive disorder.
ently complete amnesia for their fugue period occurs. In
Source: Reprinted with permission from the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American DSM-5 dissociative fugue is considered to be a subtype of
Psychiatric Association. dissociative amnesia rather than a separate disorder as it
was in DSM-IV.

of consciousness. It sometimes becomes apparent in inter-

views conducted under hypnosis or narcosis (induced by
sodium amytal, or so-called truth serum) and (obviously)
in cases where the amnesia spontaneously clears up.
Amnesic episodes usually last between a few days and

CSU Archives/Everett Collection Historical/Alamy Stock Photo

a few years. Although many people experience only one
such episode, some people have multiple episodes in their
lifetimes (Maldonado & Spiegel, 2007; Staniloiu &
Markowitsch, 2010). In typical dissociative amnesic reac-
tions, individuals cannot remember certain aspects of their
personal life history or important facts about their identity.
Yet their basic habit patterns—such as their abilities to
read, talk, perform skilled work, and so on—remain intact,
and they seem normal aside from the memory deficit
(Kihlstrom, 2005; Kihlstrom & Schacter, 2000). Thus, the
only type of memory that is affected is episodic (pertaining
to events experienced) or autobiographical memory (pertain-
ing to personal events experienced). The other recognized
forms of memory—semantic (pertaining to language and
concepts), procedural (how to do things), and short-term
storage— tend to remain intact, although there is very little The celebrated English mystery writer Agatha Christie vanished
research on this topic (Kihlstrom, 2005; Kihlstrom & suddenly in December 1926. Her mother had died a few months
Schacter, 2000). Usually there is no difficulty encoding new earlier and her husband was having an affair that he made little effort
to conceal. The writer was eventually found in a health resort in
information (Maldonado & Spiegel, 2007).
Harrogate, Yorkshire, where she had checked in calling herself Teresa
In rare cases a person may retreat still further from Noel. She had told people she was a mother from Cape Town, who
real-life problems by going into an amnesic state called a was grieving the loss of her child. When her husband arrived and
dissociative fugue. This, as the name implies (the French identified her, she simply remarked, “Fancy, my brother just arrived.”
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276 Chapter 8

The pattern in dissociative amnesia is essentially deficit these individuals exhibit is their compromised epi-
similar to that in conversion symptoms, except that instead sodic or autobiographical memory. Indeed, several stud-
of avoiding some unpleasant situation by becoming physi- ies using brain imaging techniques have confirmed that
cally dysfunctional, a person unconsciously avoids when people with dissociative amnesia are presented
thoughts about the situation or, in the extreme, leaves the with autobiographical memory tasks, they show reduced
scene (Maldonado & Spiegel, 2007; Maldonado et al., 2002). activation in their right frontal and temporal brain areas
Thus, people experiencing dissociative amnesia are typi- relative to normal controls doing the same kinds of tasks
cally faced with extremely unpleasant situations from (Kihlstrom, 2005; Markowitsch, 1999). In a review of nine
which they see no acceptable way to escape. Eventually the cases of dissociative amnesia for which brain imaging
stress becomes so intolerable that large segments of their data were available, the authors concluded there was evi-
personalities and all memory of the stressful situations are dence of significant changes in the brains of these patients,
suppressed. mostly centered on subtle loss of function in the right
Several of these aspects are illustrated in the following anterior hemisphere—changes similar to those seen in the
case example of dissociative amnesia with dissociative brains of patients with organic memory loss (Staniloiu &
fugue. Markowitsch, 2010).
However, several cases (some nearly a century old)
have suggested that implicit memory is generally intact. For
How Did I Get Here?
example, Jones (1909, as cited in Kihlstrom & Schacter,
The patient is a 28-year-old medical student from Nigeria. He had 2000) studied a patient with dense amnesia and found that
been declared missing several days earlier after he disappeared from although he could not remember his wife’s or daughter’s
his room. While studying late one night, the patient says that he
names, when asked to guess what names might fit them,
suddenly saw a human skeleton sitting and reading across the table
he produced their names correctly. In a more contempo-
from him. He said that the whole room started to turn and every-
rary case (Lyon, 1985, as cited in Kihlstrom & Schacter,
thing inside it became unstable and unreal. The patient remembers
being very afraid but denies knowing anything about what happened 2000), a patient who could not retrieve any autobiographi-
after this and has no idea when he left his room. However, 2 days cal information was asked to dial numbers on a phone ran-
later, the patient was found at his younger brother’s house, almost domly. Without realizing what he was doing, he dialed his
400 miles away. The patient said he had no idea how he got there, mother’s phone number, which then led to her identifying
how he found the money for the journey, or what transportation or him. In one particularly fascinating contemporary case of
roads he took. He simply had no memory of anything that happened dissociative fugue, Glisky and colleagues (2004) describe a
before he arrived, exhausted and looking very disheveled, at his German man who had come to work in the United States.
brother’s home. Several months before he had experienced a traumatic inci-
The amnesic episode appears to have been triggered by aca- dent in which he had been robbed and shot. After the
demic and financial stressors. After other academic failures, the
trauma, he wandered along unfamiliar streets for an
patient was in serious danger of failing the final examinations that he
unknown period of time. Finally, he stopped at a motel and
was due to take in 3 months. Because of his problems in school, his
asked if the police could be called because he did not know
family was also threatening to no longer help him financially. All of
this had made the patient feel depressed and unable to cope. who he was (he had no ID because he had been robbed)
While he was at the clinic, the young medical student was and could not recall any personal details of his life. He
treated with antidepressant medication combined with psychother- spoke English (with a German accent) but could not speak
apy. He responded well. However, even after recovering enough to German and did not respond to instructions in German
take his final examinations (which he did not pass), the patient was (which he denied that he spoke). In spite of his extensive
still unable to recall what happened in the period after he left his loss of autobiographical memory (and the German lan-
room and traveled 400 miles to his brother’s house. (Based on guage), when given a variety of memory tasks, he showed
Igwe, 2013.) intact implicit memory. Especially striking was his ability
to learn German–English word pairs, which he learned
Little systematic research has been conducted on indi- much faster than did normal controls, suggesting implicit
viduals with dissociative amnesia and fugue. What is knowledge of German even though he had no conscious
known comes largely from intensive studies of the mem- knowledge of it.
ory and intellectual functioning of isolated cases with Some of the memory deficits in dissociative amnesia
these disorders, so any conclusions should be considered and fugue have been compared to related deficits in explicit
tentative pending further study of larger samples with perception that occur in conversion disorders. This has
appropriate control groups. What can be gathered from a convinced many people that conversion disorder should
handful of such case studies is that these individuals’ be classified with dissociative disorders rather than with
semantic knowledge (assessed via the vocabulary subtest somatic symptom disorders. This issue is discussed in
of an IQ test) seems to be generally intact. The primary more detail in the Thinking Critically about DSM-5 box.
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Somatic Symptom and Dissociative Disorders 277

DSM-5 Thinking Critically about DSM-5

Where Does Conversion Disorder Belong?
Starting with Freud and Janet, and for a large portion of the twen- identity are indeed registered in the nervous system because they
tieth century prior to the publication of DSM-III in 1980, conver- influence behavior indirectly even when the person cannot
sion disorders were classified together with dissociative disorders consciously recollect them (i.e., implicit memory remains at least
as subtypes of hysteria. When it was determined that DSM-III partially intact in dissociative disorders).
would rely heavily on overt behavioral symptoms rather than on Similarly, Kihlstrom and others have argued that the conver-
ideas about underlying etiology (in this case, repressed anxiety) sion disorders involve disruptions in explicit perception and action.
for classifying disorders, the decision was made to include con- That is, people with conversion disorders have no conscious rec-
version disorder with the other somatic symptom disorders. This ognition that they can see or hear or feel, or no conscious knowl-
was because its symptoms were physical ones with no demon- edge that they can walk or talk or feel. However, patients with
strable medical basis. However, as Kihlstrom (2005) and others conversion disorder can see, hear, feel, or move when tricked into
have pointed out, this ignores some very important differences doing so or when indirect physiological or behavioral measures
between conversion disorders and other somatic symptom disor- are used (see Janet, 1901, 1907; Kihlstrom, 2001, 2005). Thus,
ders. The most important overall difference is that conversion an argument can be made that, in future editions of the DSM, the
symptoms (but not those of the other somatoform disorders) term conversion disorder should be dropped and the sensory and
nearly always resemble neurological problems in their clinical pre- motor types of the syndrome should be reclassified as forms of
sentation (such as blindness, paralysis, anesthesias, deafness, dissociative disorders. This way, the central feature of all dissocia-
and seizures). In other words, they mimic true neurological tive disorders would be a disruption of the normally integrated
syndromes, just as most of the dissociative disorders do. functions of consciousness (memory, perception, and action).
The disorders we currently classify as dissociative disorders Such a proposal is also consistent with observations that disso-
(such as dissociative amnesia and dissociative identity disorder) ciative symptoms and disorders are quite common in patients
involve disruptions in explicit memory (which concerns the kind of with conversion disorder (Lyssenko et al., 2017) as well as with
events we can intentionally remember). The person may be the neuroimaging findings we described earlier. This proposal was
unable to recall events that have occurred, or there may be dis- seriously considered and heavily debated by the DSM-5 task
ruptions in knowledge of one’s identity, or both. However, events force. For now, however, conversion disorder remains in the
occurring during a period of amnesia or in the presence of one category of somatic symptom disorder and related disorders.

Mr. Brooks, Raising Cain, Dressed to Kill), as well as in the

media. In DSM-IV, it was required that the person manifest
two or more distinct identities (or personality states) that
alternated in some way in taking control of behavior. This
was accompanied by an inability to recall important per-
sonal information that could not be explained by ordinary
forgetting.
In DSM-5 there is a subtle shift of emphasis. What is
required now is a disruption of identity characterized by
two or more distinct personality states as well as recurrent
episodes of amnesia. Importantly, this disruption in iden-
tity can either be self-reported or observed by others. In
other words, DID can now be diagnosed without other
Dissociative Identity people witnessing the different personalities.
Another change in DSM-5 is the inclusion of patho-
Disorder logical possession in the diagnostic criteria for DID. A
trance is said to occur when someone experiences a tempo-
8.9 Describe the clinical features of dissociative
rary marked alteration in state of consciousness or iden-
identity disorder and explain why this disorder is
tity. It is usually associated with either a narrowing of
so controversial.
awareness of the immediate surroundings, or stereotyped
Dissociative identity disorder (DID), formerly known as behaviors or movements that are experienced as beyond
multiple personality disorder, is a dramatic dissociative disor- one’s control. A possession trance is similar except that the
der. It has long been a focus of interest in movies (Sybil, alteration of consciousness or identity is replaced by a
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278 Chapter 8

new identity that is attributed to the influence of a spirit, One thing it suggested was the presence of organized and
deity, or other power. In both cases amnesia is typically coherent “personalities.” But alters are not in any meaning-
present for the trance state. When entered into voluntarily ful sense personalities. Rather they reflect a failure to inte-
for religious or spiritual reasons, trance and possession grate various aspects of a person’s identity, consciousness,
states are not considered pathological. However, when and memory (Spiegel, 2006). The term DID better captures
they occur involuntarily, outside accepted cultural con- this, as do the DSM-5 criteria (see the DSM-5 box). Indeed
texts, and cause distress, this is a serious problem. In Spiegel (one prominent theorist in this area) has argued
DSM-5, the diagnostic criteria for DID have been modified that “the problem is not having more than one personality,
to include pathological possession. Pathological posses- it is having less than one” (Spiegel, 2006, p. 567).
sion is a common form of DID in Africa, Asia, and many Alter identities take control at different points in time.
other non-Western cultures (Spiegel et al., 2013). This Switches between them typically occur very quickly (in a
important change makes the diagnosis of DID more inclu- matter of seconds), although more gradual switches can
sive and applicable to a broader range of cultural groups. also occur. When switches occur in people with DID, it is
In the prototypical case of DID, however, there are dif- often easy to observe the gaps in memories for things that
ferent personalities that emerge and are apparent to an out- have happened—often for things that have happened to
side observer. Each identity may appear to have a different other identities. But this amnesia is not always symmetrical;
personal history, self-image, and name, although there may that is, some identities may know more about certain alters
be some identities that are only partially distinct and inde- than other identities. In sum, DID is a condition in which
pendent from other identities. In most cases the one identity normally integrated aspects of memory, identity, and con-
that is most frequently encountered and carries the person’s sciousness are no longer integrated. Additional symptoms
real name is the host identity. Also in most cases, the host is of DID include depression, self-injurious behavior, frequent
not the original identity, and it may or may not be the best- suicidal ideation and attempts, erratic behavior, headaches,
adjusted identity. The alter identities may differ in striking hallucinations, posttraumatic symptoms, and other amne-
ways involving gender, age, handedness, handwriting, sex- sic and fugue symptoms (APA, 2013; Maldonado et al.,
ual orientation, prescription for eyeglasses, predominant 2002). Depressive disorders, PTSD, substance-use disor-
affect, foreign languages spoken, and general knowledge. ders, and borderline personality disorder are the most com-
For example, one alter may be carefree, fun loving, and sex- mon comorbid diagnoses (Maldonado & Spiegel, 2007).
ually provocative, and another alter quiet, studious, seri- One recent study found that among patients with diagnoses
ous, and prudish. Needs and behaviors inhibited in the of DID, the average number of comorbid diagnoses (based
primary or host identity are usually liberally displayed by on structured diagnostic interviews) was five, with PTSD
one or more alter identities. Certain roles such as a child being the most common (Rodewald et al., 2011).
and someone of the opposite sex are extremely common. DID usually starts in childhood, although most
Much of the reason for abandoning the older diagnos- patients are in their teens, 20s, or 30s at the time of diagno-
tic term multiple personality disorder in favor of DID was the sis. Approximately three to nine times more females than
growing recognition that it had misleading connotations. males are diagnosed as having the disorder, and females

DSM-5 Criteria for. . .

Dissociative Identity Disorder
A. Disruption of identity characterized by two or more distinct D. The disturbance is not a normal part of a broadly accepted
personality states, which may be described in some cultures cultural or religious practice.
as an experience of possession. The disruption in identity Note: In children, the symptoms are not better explained by
involves marked discontinuity in sense of self and sense of imaginary playmates or other fantasy play.
agency, accompanied by related alterations in affect, behav- E. The symptoms are not attributable to the physiological effects
ior, consciousness, memory, perception, cognition, and/or of a substance (e.g., blackouts or chaotic behavior during alco-
sensory-motor functioning. These signs and symptoms may hol intoxication) or another medical condition (e.g., complex
be observed by others or reported by the individual. partial seizures).
B. Recurrent gaps in the recall of everyday events, important
Source: Reprinted with permission from the Diagnostic and Statistical
personal information, and/ or traumatic events that are incon- Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American
sistent with ordinary forgetting. Psychiatric Association.

C. The symptoms cause clinically significant distress or impairment

in social, occupational, or other important areas of functioning.
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Somatic Symptom and Dissociative Disorders 279

the encouragement of therapists, as we discuss later (e.g.,

Kihlstrom, 2005; Lilienfeld et al., 1999; Piper & Merskey,
2004a, 2004b). Another recent trend is that many of the
reported cases of DID now include more unusual and even

David Longstreath/AP Images

bizarre identities than in the past (such as being an animal)
and more highly implausible backgrounds (e.g., ritualized
satanic abuse in childhood). (See The World Around Us box
for more information.)

Causal Factors and Controversies

about DID
Chris Sizemore was the inspiration for the book and movie Three
DID has long been a controversial disorder. Even today, there
Faces of Eve, which explored her multiple personality disorder (now
known as DID). After her recovery, Sizemore worked as an advocate
is debate about the validity of DID and how it develops. In
for the mentally ill. the following sections, we discuss four key questions that are
central to understanding the sources of disagreement.
tend to have a larger number of alters than do males
1. Is DID a real disorder or is it faked? And even if it is
(Maldonado & Spiegel, 2007). Some believe that this pro-
real, can it be faked?
nounced gender discrepancy is due to the much greater
2. How does DID develop? Is it caused by early child-
proportion of childhood sexual abuse among females than
hood trauma, or does the development of DID involve
among males, but this is a highly controversial point.
some kind of socially caused enactment of multiple
The number of alter identities in DID varies tremen-
different roles—roles that have been inadvertently en-
dously and has increased over time (Maldonado & Spiegel,
couraged by careless or overly enthusiastic clinicians?
2007). One early review of 76 classic cases reported that
two-thirds of these cases had only two personalities and 3. Are the memories of early childhood abuse reported
most of the rest had three (Taylor & Martin, 1944). More by the vast majority of individuals diagnosed with
recent estimates are that about 50 percent now show over DID real or false?
10 identities with some respondents claiming as many as a 4. If abuse has occurred in most individuals with DID,
hundred. This historical trend of increasing multiplicity did the abuse play a causal role, or was something else
suggests the operation of social factors, perhaps through correlated with the abuse actually the cause?

The World Around Us

DID, Schizophrenia, and Split Personality: Clearing Up the Confusion
People are often confused by the distinction between DID and this kind result in thinking that is not goal directed or efficient,
schizophrenia. It is not uncommon for those diagnosed with which in turn leads to the host of other difficulties known to be
schizophrenia to be referred to as having a “split personality.” You associated with schizophrenia.
might also have heard people say such things as “I’m a bit schizo- It is very important to remember that people diagnosed with
phrenic on this issue” when they mean that they have more than schizophrenia do not have multiple distinct identities that alter-
one opinion about it. This misuse of the term split personality nately take control over their mind and behavior. They may have a
reflects a misunderstanding of schizophrenia, which does not delusion and believe they are someone else, but they do not show
involve a “split” or “Jekyll and Hyde” personality at all. The original the changes in identity accompanied by changes in tone of voice,
confusion may have stemmed from the term schizophrenia, which vocabulary, and physical appearance that are often seen when
was first coined by a Swiss psychiatrist named Bleuler. The word identities “switch” in DID. Furthermore, people with DID (who are
comes from the Greek root schizo meaning “to split or crack,” and probably closer to the general public’s notion of “split personality”)
phren, which is the Greek root for “mind.” The notion that schizo- do not exhibit such characteristics of schizophrenia as disorga-
phrenia is characterized by a split mind or split personality may nized behavior, hallucinations coming from outside the head, and
have arisen this way (see McNally, 2007, for a historical review of delusions, or incoherent and loose associations (e.g., Kluft, 2005).
how this confusion arose).
However, this is not at all what Bleuler intended the word Have you ever confused these terms or heard other people
schizophrenia to mean. Rather, Bleuler was referring to the split- do so? In what ways does “split personality” in the context of
ting of the normally integrated associative threads of the mind— schizophrenia differ from “split personality” in the context of
links between words, thoughts, emotions, and behavior. Splits of dissociative identity disorder?
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280 Chapter 8

IS DID A REAL DISORDER OR ARE PEOPLE FAKING? of multiple identities existing prior to the trial. When
The possibility that DID is a factitious or malingered disor- Bianchi’s faking was discovered, he was convicted of the
der has been a controversial diagnostic issue for at least a murders. Nevertheless, most researchers think that facti-
century. There are good reasons for this. The disorder could tious and malingering cases of DID (such as in the Bianchi
be used by defendants and their attorneys to try to escape case or cases in which the person has a need to be a patient)
punishment for crimes (“My other personality did it”). For are relatively rare.
example, this defense was used, ultimately unsuccessfully,
HOW DOES DID DEVELOP? If we accept that, in most
in the famous case of the Hillside Strangler, Kenneth
cases, DID is a real syndrome (not consciously faked), how
Bianchi. Bianchi was accused of brutally raping and mur-
does it develop and how is it maintained? According to
dering 10 young women in the Los Angeles area. Although
trauma theory, DID starts from early childhood traumati-
there was a great deal of evidence that he had committed
zation and reflects an attempt to cope with an overwhelm-
these crimes, he steadfastly denied it, and some lawyers
ing sense of hopelessness and powerlessness in the face of
thought perhaps he had DID. He was subsequently inter-
repeated traumatic abuse (Gleaves, 1996; Maldonado &
viewed by a clinical psychologist, and under hypnosis a
Spiegel, 2007; Ross, 1997, 1999). Lacking other resources or
second personality, “Steve,” emerged. Steve confessed to
routes of escape, the child may dissociate and escape into a
the crimes, thereby creating the basis for a plea of “not
fantasy, becoming someone else. Sometimes the child sim-
guilty by reason of insanity” (see Chapter 17). However,
ply imagines the abuse is happening to someone else. If the
Bianchi was later examined even more closely by a
child is fantasy prone, and continues to stay fantasy prone
renowned specialist, the late Martin Orne. Upon closer
over time, the child may unknowingly create different
examination, Orne determined that Bianchi was faking.
selves at different points in time, possibly laying the foun-
Orne drew this conclusion in part because when he sug-
dation for dissociated identities. Viewed in this way, DID
gested to Bianchi that most people with DID have more
can be regarded as a coping method for dealing with
than two identities, Bianchi (voila!) suddenly produced a
extreme stress. It reflects an attempt to “compartmental-
third (Orne et al., 1984). Moreover, there was no evidence
ize” traumatic experiences (Lynn et al., 2012).
In support of trauma theory, the vast majority of
patients with DID (over 95 percent by some estimates)
report memories of severe and horrific childhood abuse.
Figure 8.4 shows results from several early studies. More
recent investigations report similar findings (Dorahy et al.,
2015). But only a subset of children who undergo traumatic

Figure 8.4
Reported childhood abuse in four separate studies of patients with
DID (total n = 488).

Reported Childhood Abuse in Four

Separate Studies of Patients
with DID (Total n = 488)
Putnam et al., 1986 (100 cases) Coons et al., 1988 (50 cases)
Ross et al., 1989 (236 cases) Ross et al., 1991 (102 cases)
100
Bettmann/Getty Images

80
Percentage

60

40

Kenneth Bianchi, aka the “Hillside Strangler,” brutally raped and 20

murdered 10 women in the Los Angeles area. Hoping to plead “not
guilty by reason of insanity,” Bianchi fabricated a second 0
Sexual Physical
personality—“Steve”—who “emerged” while Kenneth was under
Type of abuse
hypnosis. A clinical specialist determined he was faking, and Bianchi
was convicted of the murders.
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Somatic Symptom and Dissociative Disorders 281

experiences are prone to fantasy or self-hypnosis. This Sociocognitive theory is consistent with evidence that
suggests that a diathesis–stress model may be more appro- most DID patients do not show unambiguous signs of the
priate here. That is, children who are prone to fantasy and disorder before they enter therapy and with evidence that
those who are easily hypnotizable may have a diathesis for the number of identities often increases (sometimes dra-
developing DID (or other dissociative disorders) when matically) with time spent in therapy (Boysen & VanBer-
severe abuse occurs (e.g., Butler et al., 1996; Kihlstrom gen, 2013; Piper & Merskey, 2004b). Also consistent with
et al., 1993). However, it is important to keep in mind that, the sociocultural perspective are changes in the prevalence
in isolation, there is nothing inherently pathological about of DID. Owing to their dramatic nature, cases of DID
being prone to fantasy or being highly hypnotizable receive a great deal of attention and publicity in fiction,
(Kihlstrom et al., 1994). television, and movies. But, for a long time, DID was pre-
The other prevailing explanation for DID is sociocog- sumed to be extremely rare in clinical practice. The number
nitive theory (Lynn et al., 2012). According to this theory, of cases began to rise in the 1970s after the publication of
DID develops when a highly suggestible person learns to Flora Rhea Schreiber’s book Sybil (1973). Ironically, the
adopt and enact the roles of multiple identities, mostly case that made people much more aware of the condition
because clinicians have inadvertently suggested, legiti- and triggered an epidemic of DID has now been thor-
mized, and reinforced them and because these different oughly discredited (see Nathan, 2011; Paris, 2012c; Rieber,
identities are geared to the individual’s own personal goals 2006). Some aspects of Sybil’s case are described below.
(Lilienfeld & Lynn, 2003; Lilienfeld et al., 1999; Spanos,
1994, Spanos, 1996). It is important to understand that the
Sybil: Did She Really Have Multiple Personality
sociocognitive perspective does not view this as being done
Disorder?
intentionally or consciously by the person involved. Rather,
it occurs spontaneously with little or no awareness (Lilien- Sybil (whose real name was Shirley Mason) was a troubled woman
from Minnesota with a history of traumatic abuse. Over the course of
feld et al., 1999). The suspicion is that overzealous clini-
therapy with Dr. Cornelia Wilbur she went on to develop 16 alter per-
cians, through fascination with the clinical phenomenon of
sonalities. However, there is no evidence that Shirley had any alters
DID and unwise use of such techniques as hypnosis, are
or even any symptoms of dissociative identity disorder prior to start-
themselves largely responsible for eliciting this disorder in ing therapy with Dr. Wilbur. There was also no evidence that Shirley
highly suggestible, fantasy-prone people (e.g., Giesbrecht was ever mistreated in childhood. Yet under Wilbur’s questioning
et al., 2008; Piper & Merskey, 2004a, 2004b; Spanos, 1996). and through Wilbur’s suggestive prompts, Shirley began to “recall”
For example, asking a question such as, “Is there another many instances of sadistic abuse from her mother. Numerous alters
part of you with whom I have not spoken?” may encourage also began to emerge. The idea that these were developed in an
some patients to respond by developing an alter identity. effort to please Wilbur is suggested by another aspect to the story.
In an early examination of the sociocognitive hypoth- When a colleague was covering Shirley’s treatment while Dr. Wilbur
esis, Spanos et al. (1985) demonstrated that otherwise ordi- was away at a professional meeting, Shirley asked the new psy-
nary college students can be induced by suggestion under chiatrist, “Well, do you want me to be Helen?”, meaning one of her
other personalities. The new psychiatrist was understandably rather
hypnosis to exhibit some of the phenomena seen in DID.
confused. When he asked Shirley what she meant, she told him,
These included the adoption of a second identity with a
“Well, when I’m with Dr. Wilbur, she wants me to be Helen” (Nathan,
different name that showed a different profile on a person-
2011, p. 131). And when Shirley later confessed to Dr. Wilbur that
ality inventory. Spanos and colleagues thus demonstrated she had been essentially lying and did not have any multiple person-
that people can enact a second identity when situational alities, Wilbur interpreted this as a sign of resistance in the therapy.
forces encourage it. The therapy continued in the same manner and Shirley soon took
Of course, just because Spanos and colleagues were back her confession.
able to demonstrate role-playing in hypnotized college
students does not mean that DID is actually caused this
way in real life. For example, someone might be able to ARE RECOVERED MEMORIES OF ABUSE IN DID REAL
give a convincing portrayal of a person with a broken leg, OR FALSE? Case reports of the cruelty and torture that
but this would not establish how legs are usually broken. some patients with DID experienced as children are heart-
Moreover, the hypnotized participants in this and other breaking to read or hear. However, the accuracy and trust-
experiments showed only a few of the most obvious symp- worthiness of these reports of widespread sexual and other
toms of DID (such as more than one identity) and showed forms of childhood abuse have been challenged. In many
them only under short-term and contrived laboratory cases, there is an absence of corroborative evidence of the
conditions. Thus, although some of the symptoms of DID abuse such as through physician, hospital, and police
could be created by social enactment, this is not the same records. A number of studies have indeed reported that
thing as demonstrating that the disorder can be created this they have confirmed the reported cases of abuse, but critics
way (e.g., Gleaves, 1996). have shown that the criteria used for corroborating
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282 Chapter 8

evidence are almost invariably very loose and suspect as to neglect, and poverty are just a few examples. So one or
their validity. For example, Chu and colleagues (1999) more of these other, correlated sources of adversity could
simply asked their subjects, “Have you had anyone con- actually be playing the causal role (e.g., Lilienfeld et al.,
firm these events?” (p. 751) but did not specify what consti- 1999; Nash et al., 1993).
tuted confirmation and had no way of determining if Another challenge is that people with symptoms of
subjects were exaggerating or distorting the information DID and histories of childhood abuse may be more likely
they provided as confirming evidence (Loftus & Davis, to seek treatment than people with symptoms of DID who
2006; Piper & Merskey, 2004a). Critics further argue that did not experience abuse. Thus, the individuals in most
many of the memories that come up during the course of studies on the prevalence of child abuse in DID may not be
therapy may be false memories—products of leading ques- representative of the population of all people with DID.
tions and suggestive techniques applied by well-meaning Finally, childhood abuse is thought to play a role in many
but inadequately skilled and careless psychotherapists different forms of psychopathology including depression,
(Lilienfeld et al., 1999; Loftus & Davis, 2006; Yapko, 1994). PTSD, eating disorders, somatic symptom disorder, and
It seems quite clear that the creation of false memories borderline personality disorder, to name just a few. So why
has indeed happened, often with tragic consequences. do we think it plays a key causal role in DID? Perhaps the
Innocent family members have been falsely accused by most we will ever be able to say is that childhood abuse
patients with DID and have sometimes been convicted and may play a nonspecific role for many disorders, with other,
imprisoned. But it is also true that brutal abuse of children more specific factors determining which disorder develops
occurs far too often and that such abuse can have very (see Chapters 10 and 12).
adverse effects on development, perhaps even leading to
pathological dissociation (e.g., Maldonado & Spiegel, 2007;
Nash et al., 1993). In such cases, prosecution of the perpe-
Current Perspectives
trators of the abuse is necessary and appropriate. Of course, With the publication of DSM-III in 1980, the diagnostic
it is not always easy to determine when the recovered criteria for DID (which was then called multiple personal-
memories of abuse are real and when they are false (or ity disorder, as noted) were clearly specified for the first
some combination of the two). This bitter controversy about time. This seems to have led to increased acceptance of the
the issue of false memory is more extensively considered in diagnosis by clinicians and perhaps encouraged reporting
the Unresolved Issues section at the end of this chapter. of it in the psychological and psychiatric literature. Also,
In an effort to address this issue, Lewis and colleagues around the same time, prior scattered reports of child-
(1997) studied 12 convicted murderers with DID and con- hood abuse in the histories of adult patients began build-
firmed, through medical, social service, and prison records, ing into what would later become a crescendo. Although
severe abuse in almost all (11/12) of them. Unfortunately, many controversies arose regarding how to interpret such
there was no comparison group of murderers who did not findings, reports of abuse in patients with DID attracted
exhibit DID symptoms. Hence, we cannot be certain that more attention to the disorder. This may also have
the childhood abuse was linked to the development of DID increased the rate at which it was diagnosed. Indeed,
specifically or simply with being violent and receiving a prior to 1979, only about 200 cases could be found in the
murder conviction. Critics also note that Lewis and col- entire psychological and psychiatric literature worldwide.
leagues should have carefully assessed for the possibility By 1999, however, over 30,000 cases had been reported in
that some of the murderers might have been malingering North America alone (Ross, 1999), although many
(i.e., faking DID; Lilienfeld et al., 1999). However, given that researchers believed that this was a gross overestimate
all of the inmates were already incarcerated and had made (e.g., Piper & Merskey, 2004b).
no efforts to use their trauma histories in their legal cases, Many factors likely contributed to the drastic increase
this is perhaps not especially likely (Brand et al., 2016). in the reported prevalence of DID that we saw after 1980.
Some of the increase almost certainly occurred because
IF ABUSE HAS OCCURRED, DOES IT PLAY A CAUSAL some therapists looked for evidence of DID in certain
ROLE IN DID? If we put the controversy about the reality patients and hinted at the existence of alter identities (espe-
of recovered memories of abuse aside and accept that cially when the person was under hypnosis and very
severe abuse did occur in the early childhoods of many suggestible; e.g., Kihlstrom, 2005; Piper & Merskey, 2004b).
people with DID, a critical question still remains. How can Therapists may also have subtly reinforced the emergence
we determine whether this abuse has played a critical of new identities by showing great interest if any emerged.
causal role in the development of DID (e.g., Piper & Mer- Nevertheless, such factors probably did not (and do not)
skey, 2004a)? Child abuse often happens in family environ- explain all cases of diagnosed DID.
ments plagued by many other sources of adversity and Current prevalence estimates suggest that the preva-
trauma. Psychopathology in family members, extreme lence of DID in community samples is between 1 and
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Somatic Symptom and Dissociative Disorders 283

There are also many similarities between simulators

and diagnosed patients with DID. Of these, perhaps the
most important concerns the transfer of memory across per-
sonalities. Inter-identity amnesia is a key feature of DID.

Rick Mackler/Zuma Press/Newscom

Most people with DID have at least some identities that
seem completely unaware of the existence and experiences
of certain other identities. This then raises the question of
what happens when information is presented to one iden-
tity and the person switches to another identity—one who is
not supposed to have any knowledge of the other identity.
Does any information transfer from one identity to another?
In their review, Boysen and Van Bergen (2014) describe the
results of all available studies to date and conclude that the
Former Georgia football star Herschel Walker has written a book, self-reported amnesia across identities is incomplete. In
Breaking Free: My Life with Dissociative Identity Disorder (2008), in other words, when information is given to Identity 1 and
which he tells about his struggle with this disorder.
then the person switches to Identity 2, Identity 2 performs
better on the memory task than would be the case if there
1.5 percent. One study of 658 people in upstate New York were complete amnesia across the two identities. This is true
indicated a 1.5 percent prevalence (Johnson et al., 2006). A regardless of whether explicit or implicit memory tasks are
similar prevalence figure of 1.1 percent was reported for a used. What is also important is that the transfer of informa-
community sample of women in Turkey (Şar et al., 2007). tion on implicit tasks (which do not require the intentional
The prevalence of DID is even higher (around 6 percent) or conscious processing of information) is similar for diag-
when groups with high exposure to trauma or cultural nosed patients as well as for simulators.
oppression are studied (Foote et al., 2006). It is also worth By way of example, Huntjens and colleagues (2005)
noting that DID has been observed in most parts of the had 22 DID patients in Identity 1 learn to reevaluate a neu-
world, even in places where there was virtually no personal tral word in a positive or negative manner through a sim-
or professional knowledge of the disorder at the time, ple evaluative conditioning procedure in which neutral
including rural Turkey (Akyuz et al., 1999; see also Maldo- words are simply paired with positive or negative words;
nado & Spiegel, 2007) and Shanghai, China (Xiao et al., 2006). the neutral words then come to take on positive or nega-
There are now around 20 studies that have compared tive connotations. When Identity 2 was later asked to
the behavior of people diagnosed with DID with the emerge, he or she also categorized the formerly neutral
behavior of people who are asked (after appropriate train- word in the same positive or negative manner as learned
ing) to simulate DID (see Boysen & VanBergen, 2014). The by Identity 1, showing implicit memory for the reevalua-
findings suggest some important similarities as well as tion of the word learned by Identity 1 (although complete
some key differences. Overall, however, they provide subjective amnesia was reported by Identity 2).
somewhat more support for the sociocognitive model than What does the lack of evidence of complete amnesia in
for the trauma model. DID mean for our understanding of the disorder? The fact
One way in which simulators and diagnosed patients that simulators and diagnosed patients are similar in this
differ is that diagnosed patients show more symptoms of regard might argue against the validity of the DID diagno-
DID than simulators do. This, of course, could be related to sis. However, we know little about how the memories of
the quality of training the simulators had. Another poten- people with DID can or should function. As Boysen and
tially more important difference is that, compared to simu- VanBergen (2014) note, in DID memory may be available
lators, patients with DID show more cognitive processing but not be subjectively accessible. Our brains naturally inte-
problems. Deficits in performance are apparent on tasks grate and incorporate new material. But there may be an
involving recognition of previously seen material, as well important difference between what our brains know and
as on recall and reaction time tasks. However, cognitive what we are aware that we know.
problems (compared to healthy controls) are seen in Controversies concerning DID are often stated in a
patients with many types of disorders (including anxiety dichotomous way: Is DID real or faked? What causes
disorders, mood disorders, and schizophrenia). So they DID—spontaneous social enactment of roles or repeated
could be a result of psychopathology in general rather than childhood trauma? Are recovered memories of abuse real
DID in particular. We also have no way of knowing or false? If abuse occurs, does it play a primary causal role?
whether these cognitive problems resulted from the DID or But framing questions in such a manner encourages over-
predated it, perhaps functioning as a pre-existing vulnera- simplified answers and creates unnecessary divisiveness
bility factor. (Vissia et al., 2016; Merckelbach et al., 2016). Yet there is
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284 Chapter 8

agreement that DID represents, at least in part, “a disorder DID has long been a highly contentious topic, there seems
of self-understanding” (Dalenberg et al., 2012, p. 568; see to be little reason for this to be the case going forward.
also Lynn et al., 2014). Theorists on both sides are also now
acknowledging that multiple different causal pathways are
likely to be involved. Advocates of trauma theory accept
that some cases are faked and that some may be inadver-
Cultural Factors,
tently caused by unskilled therapists in the course of treat-
ment. There is also a growing appreciation that both real
Treatments, and Outcomes
and false memories do occur in these patients, combined in Dissociative Disorders
with a recognition of the critical need for new methods to
be developed to help determine which is which (e.g., 8.10 Describe the cultural factors, treatments, and
Gleaves & Williams, 2005; Gleaves et al., 2004). On the other outcomes in dissociative disorders.
side, advocates of sociocognitive theory now acknowledge All disorders occur within a cultural context and DID is no
that trauma may play a causal role in dissociation. That exception. In the following sections we discuss the role of
said, they believe it occurs far less often, and is less likely to culture in DID and also describe some approaches that are
play a central, specific, and causal role, than the trauma used to treat these challenging clinical conditions.
theorists maintain (Kihlstrom, 2005; Lynn et al., 2014).
Where does this leave us now? Over time, the socio-
Cultural Factors in Dissociative
cognitive model has evolved. It is now, in essence, a diathe-
sis–stress model, as mentioned earlier. It is thought that Disorders
some people are more predisposed than others to develop There seems little doubt that the prevalence of dissociative
DID when exposed to socio-cultural influences such as disorders, especially their more dramatic forms such as DID,
media portrayals of DID, therapist cueing, and the like. A is influenced by the degree to which such phenomena are
relevant factor here is having a propensity to fantasize. It is accepted or tolerated either as normal or as legitimate men-
also thought that having a variety of sleep-related prob- tal disorders by the surrounding cultural context. Indeed, in
lems (such as waking dreams, nightmares, and unusual our own society, the acceptance and tolerance of DID as a
perceptual experiences while falling asleep or during wak- legitimate disorder have varied tremendously over time.
ing) might provide a bridge between sociocognitive mod- Many related phenomena, such as spirit possession
els and trauma models of DID because these seem to and dissociative trances, occur frequently in many differ-
increase risk for dissociative symptoms (Lynn et al., 2012). ent parts of the world where the local cultures sanction
Sleep problems might also be especially common in those them (Krippner, 1994; Spiegel et al., 2013). Such experi-
who have experienced abuse. ences are not necessarily problematic when they are voli-
And, increasingly, those who view childhood abuse as tional, transient, and occur as a normal part of religious or
playing a critical role in the development of DID are begin- spiritual practices. However, when they are involuntary
ning to see DID as perhaps a complex and chronic variant of and cause distress, possession states are considered to be
posttraumatic stress disorder, which by definition is caused pathological.
by exposure to some kind of highly traumatic event(s),
including abuse (e.g., Brown, 1994; Maldonado & Spiegel,
2007; Maldonado et al., 2002). Anxiety symptoms are more
prominent in PTSD than in DID, and dissociative symptoms
are more prominent in DID than in PTSD. Nevertheless,
both kinds of symptoms are present in both disorders (Put-
nam, 1997; Lyssenko et al., 2017). Moreover, some (but not
Jan Sochor/Alamy Stock Photo

all) investigators have estimated that a very high percentage

of individuals diagnosed with DID have a comorbid diagno-
sis of PTSD, suggesting the likelihood of some important
common causal factors (Vermetten et al., 2006; see also Rode-
wald et al., 2011). Recognizing this, DSM-5 now includes
PTSD with dissociative symptoms as a new subtype.
In conclusion, it seems as if the time is right for the dif-
ferent perspectives on DID to be reconciled. Trauma is
When they occur as part of a religious or spiritual ceremony,
clearly important. But sleep disturbances, fantasy prone- possession trances are not pathological. However, when they occur
ness, suggestive media, and problematic psychotherapeutic spontaneously and cause distress, possession states are regarded in
techniques likely also play a role. Although the etiology of DSM-5 as a cultural variant of dissociative identity disorder.
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Somatic Symptom and Dissociative Disorders 285

The features of pathological possession are very simi- dissociate and then “reassociate,” thereby gaining some
lar to DID. They include distinct changes in identity as well sense of control over their depersonalization and derealiza-
as full or partial amnesia for the event. In pathological pos- tion experiences (Maldonado & Spiegel, 2007; Maldonado
session, however, the other identity is not experienced as et al., 2002). Many types of antidepressant, antianxiety, and
another internal personality state but as an external spirit, antipsychotic drugs have also been tried and some have
power, or deity. The inclusion of pathological possession had modest effects. However, one randomized controlled
into the diagnostic criteria for DID in DSM-5 has made the study showed no difference between treatment with Prozac
diagnosis more applicable to people from a wide range of versus with placebo (Simeon et al., 2004). A recent treatment
cultural backgrounds. The inclusion of pathological pos- showing some promise for the treatment of dissociative dis-
session also acknowledges that DID can present in two dif- orders involves administering rTMS (repetitive transcranial
ferent forms: a possession form and a nonpossession form. magnetic stimulation) to the temporoparietal junction, an
In other words, how the disorder presents may be very area of the brain highly involved in the experience of a uni-
much determined by cultural factors (Spiegel et al., 2013). fied self and body (Mantovani et al., 2011). After 3 weeks of
Understanding how pathological possession is treated treatment, half of the subjects showed significant reductions
by indigenous healers may also provide new perspectives in depersonalization, with nonresponders showing symp-
that could be valuable overall. Interestingly, treatments by tom reduction after an additional 3 weeks of treatment.
indigenous healers and therapists operating within West-
ern culture have many similarities. Both, for example,
emphasize addressing different aspects of the person’s
identities, allowing each to have a voice through which
that identity’s point of view and distress can be clarified. In
contrast, however, in the majority of cases, culturally sanc-
tioned attempts to remove or exorcise the alternate identity
typically lead to poor outcomes.
There are also cross-cultural variants on dissociative
disorders, such as amok, which is often thought of as a rage
disorder. Amok occurs when a dissociative episode leads to
violent, aggressive, or homicidal behavior directed at other
people and objects. It occurs mostly in men and is often pre-
cipitated by a perceived slight or insult. The person often In dissociative amnesia, it is important for the person to
has ideas of persecution, anger, and amnesia, often followed be in a safe environment. Simply removing the person from
by a period of exhaustion and depression. Amok occurs in what he or she perceives as a threatening situation some-
places such as Malaysia, Laos, the Philippines, Papua New times allows for spontaneous recovery of memory. Hypno-
Guinea, Puerto Rico, and among Navajo Indians. sis, as well as drugs such as benzodiazepines, barbiturates,
sodium pentobarbital, and sodium amobarbital, is often
Treatment and Outcomes used to facilitate recall of repressed and dissociated memo-
ries (Maldonado & Spiegel, 2007; Maldonado et al., 2002).
in Dissociative Disorders After memories are recalled, it is important for the patient
Unfortunately, virtually no systematic, controlled research to work through the memories with the therapist so that the
has been conducted on treatment of depersonalization dis- experiences can be reframed in new ways. However, unless
order and dissociative amnesia. The absence of randomized the memories can be independently corroborated, they
controlled trials means that very little is known about how should not be taken at their face value (Kihlstrom, 2005).
to treat these two disorders successfully. Numerous case For people diagnosed with DID, most current thera-
histories, sometimes presented in small sets of cases, are peutic approaches are based on the assumption of trauma
available, but without control groups who are assessed at theory that the disorder was caused by abuse (Kihlstrom,
the same time or who receive nonspecific treatments, it is 2005). Most therapists set integration of the previously
impossible to know the effectiveness of the varied treat- separate alters, together with their collective merging into
ments that have been attempted (Kihlstrom, 2005). the host personality, as the ultimate goal of treatment (e.g.,
In general, depersonalization/derealization disorder Maldonado & Spiegel, 2007). There is often considerable
may be fairly resistant to treatment, although treatment resistance to this process by patients with DID, who con-
may be useful for associated problems such as anxiety and sider dissociation as a protective device (e.g., “I knew my
depressive disorders. Some think that hypnosis, including father could get some of me, but he couldn’t get all of me”;
training in self-hypnosis techniques, may be useful because Maldonado & Spiegel, 2007, p. 781). If successful integra-
patients with depersonalization disorder can learn to tion occurs, the patient eventually develops a unified
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286 Chapter 8

personality, although it is not uncommon for only partial committed as well as professionally competent. Regretta-
integration to be achieved. But it is also very important to bly, this is not always the case.
assess whether improvement in other symptoms of DID Most reports in the literature are treatment summaries
and associated disorders has occurred. Indeed, it seems of single cases. Reports of successful cases should always
that treatment is more likely to produce symptom improve- be considered with caution, especially given the large bias
ment, as well as associated improvements in functioning, in favor of publishing positive rather than negative results.
than to achieve full and stable integration of the different Treatment outcome data for large groups of patients with
alter identities (Maldonado & Spiegel, 2007; Maldonado DID are seldom reported and control groups are lacking.
et al., 2002). Nonetheless, it is clear that DID does not spontaneously
Typically the treatment for DID is psychodynamic and remit simply with the passage of time, or if a therapist
insight oriented, focused on uncovering and working chooses to ignore DID-related issues (Kluft, 1999; Maldo-
through the trauma and other conflicts that are thought to nado et al., 2002). For example, Ellason and Ross (1997)
have led to the disorder (Kihlstrom, 2005). One of the pri- reported on a 2-year postdischarge follow-up of patients
mary techniques used in most treatments of DID is hypno- with DID who were originally treated in a specialized
sis (e.g., Kluft, 1993; Maldonado & Spiegel, 2007; inpatient unit. Of the original 135 patients, 54 were located
Maldonado et al., 2002). Most patients with DID are hyp- and systematically assessed. All of them, especially those
notizable and when hypnotized are able to recover past who had achieved full integration, generally showed
unconscious and frequently traumatic memories, often marked improvements in various aspects of their lives.
from childhood. Then these memories can be processed, However, only 12 of the 54 had achieved full integration of
and the patient can become aware that the dangers once their identities. Such results are encouraging, although we
present are no longer there. (One problem here is that such must wonder about the clinical status of the 81 “lost”
patients are suggestible under hypnosis, so much of what patients who may likely have done less well. Another
is recalled may not be accurate; see Kihlstrom, 2005; Loftus 10-year follow-up study reported similar results in a
& Davis, 2006). Through the use of hypnosis, therapists are smaller sample of 25 patients with DID who received treat-
often able to make contact with different identities and ment. Only 12 were located 10 years later; of these, 6 had
reestablish connections between distinct, seemingly sepa- achieved full integration, but 2 of those had partially
rate identity states. An important goal is to integrate the relapsed (Coons & Bowman, 2001). In general, it has been
personalities into one identity that is better able to cope found that (1) for treatment to be successful, it must be pro-
with current stressors. Clearly, successful negotiation of longed, often lasting many years, and (2) the more severe
this critical phase of treatment requires therapeutic skills of the case, the longer that treatment is needed (Maldonado &
the highest order; that is, the therapist must be strongly Spiegel, 2007; Maldonado et al., 2002).

Unresolved Issues
DID and the Reality of “Recovered Memories”
Trauma theorists assert that the major causal factor in the devel- therapists for damages, alleging that the therapists induced false
opment of DID is childhood abuse, particularly sexual abuse. In memories of parental abuse in their children. Within such a cli-
many cases, these memories of abuse are “recovered” during mate of suspicion, accusation, litigation, and unrelenting hostility,
therapy, meaning that the person was unaware of these experi- many families have been torn apart.
ences before entering therapy. This has raised questions about Whether DID originates in childhood abuse and whether
the validity or accuracy of recovered memories of abuse and led recovered memories of abuse are accurate are basically separate
to intense and often bitter debate (see Loftus & Davis, 2006, for issues. Nonetheless, they have tended to become fused in the
a review). course of the debate. Hence, those who doubt the validity of
These controversies have also moved beyond professional memories of abuse are also likely to regard the phenomenon of
debate becoming major public issues and leading to numerous DID as stemming from the social enactment of roles encouraged
legal proceedings. For example, patients with DID who have or induced—like the memories of abuse themselves—by mis-
recovered memories of abuse have sued their parents for having guided therapy (e.g., see Bjorklund, 2000; Lilienfeld et al., 1999;
inflicted abuse on them. Ironically, therapists and institutions have Lynn et al., 2004; Piper & Merskey, 2004a, 2004b). Believers, on
also been sued for implanting memories of abuse in patients, who the other hand, have usually taken both DID and the idea that
later came to believe abuse had not actually occurred. An interna- abuse is its cause to be established beyond doubt (e.g., see
tional support organization—the False Memory Syndrome Foun- Gleaves, 1996; Gleaves et al., 2001; Ross, 1997, 1999).
dation—was created by some parents who asserted they had Much of the controversy about the validity of recovered
been falsely accused. In some instances, parents have sued memories is rooted in disagreements about the nature, reliability,
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Somatic Symptom and Dissociative Disorders 287

and malleability of human autobiographical memory. With some times during a research visit 2 weeks earlier (Thomas & Loftus,
exceptions, evidence for childhood abuse as a cause of DID is 2002). These and other studies clearly show that when we repeat-
restricted to the “recovered memories” (memories not originally edly imagine experiencing certain events (even somewhat bizarre
accessible) of adults being treated for dissociative experiences. ones) this can lead us to have false memories of events that never
Believers argue that before treatment such memories had been happened (Loftus & Bernstein, 2005; Loftus & Davis, 2006).
“repressed” because of their traumatic nature or had been avail- One fascinating study compared a group of people who had
able only to certain alter identities that the host identity was gen- continuous memories of childhood abuse with two groups who
erally not aware of. Treatment, according to this view, dismantles had recovered memories of abuse. In one of the latter groups the
the repressive defense and thus makes available to awareness an memories had been recovered during therapy; in the other group
essentially accurate memory recording of the past abuse. the memories had been recovered outside of the context of ther-
Disbelievers, on the other hand, note that scientific evidence apy. The researchers then attempted to corroborate these recov-
in support of the repression concept is quite weak (e.g., Kihl- ered memories. They found corroborative evidence for over half of
strom, 2005; Loftus & Davis, 2006; Piper, 1998). In many alleged those who had recovered memories outside of therapy. But for
cases of repression, the event may have been lost to memory in those who recovered their memories during therapy, no corrobo-
the course of ordinary forgetting rather than repression, or it may rating evidence was found (Geraerts et al., 2007).
have occurred in the first 3 to 4 years of life, before memories can Understanding the science of memory is important—
be recorded for retrieval in adulthood. In many other cases, evi- especially for clinicians. False beliefs about how memory works
dence for repression has been claimed in studies where people are likely to encourage therapeutic techniques such as age
may simply have failed to report a previously remembered event, regression or hypnosis to assist patients with recovering mem-
often because they were never asked or were reluctant to dis- ories. This can create a context for the creation of false memo-
close such very personal information (Kihlstrom, 2005; Loftus & ries. But not all recovered memories may be false. McNally and
Davis, 2006; Pope et al., 1998). Geraerts (2009) suggest that some abuse victims may simply
Even if memories can be repressed, there are very serious not have thought about their abuse for a long time and may
questions about the accuracy of recovered memories. Contrary to have been deliberately trying to forget the abuse (suppression
what many people (including many clinical professionals) believe, rather than repression), or may have forgotten prior instances
human memory does not operate like a video recorder, allowing when they did recall the abuse, resulting in the false impression
stored information to be accurately retrieved and reviewed at a that a recently surfaced memory had been repressed for years.
later time. Rather, human memory is fallible and, as Lynn and col- In other words, we may be getting closer to being able to rec-
leagues (2015) have noted, more reconstructive than reproduc- oncile some widely disparate perspectives about trauma and
tive and very much subject to modification on the basis of events memory that have been so contentious for so long.
happening after any original memory trace is established (Loftus &
Bernstein, 2005; Loftus & Davis, 2006; Schacter et al., 2000).
Indeed, research shows that in certain circumstances, peo-
ple are sometimes very prone to the development of false memo-
ries (see Wade et al., 2007, for a review). When healthy adults are
asked to imagine repeatedly events that they were initially sure had

Intelecom Learning/BoClips
not happened to them as children, they later increased their esti-
mate of how likely it was that these events had actually happened
to them (e.g., Tsai et al., 2000). Moreover, over a relatively short
time, adult research subjects sometimes came to believe they had
performed somewhat strange acts (such as kissing a magnifying
glass), as well as common acts (such as flipping a coin), after
simply having imagined they had engaged in these acts several

Summary
8.1 List four disorders included in the DSM-5 category the symptoms the person also experiences abnormal
of somatic symptom and related disorders. thoughts, feelings, and behaviors.
• Somatic symptom disorder and related disorders lie at • Included in the category of somatic symptom and
the interface of abnormal psychology and medicine. related disorders are somatic symptom disorder, ill-
These are disorders in which psychological problems ness anxiety disorder, conversion disorder, and facti-
are manifested in physical symptoms. In response to tious disorder.
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288 Chapter 8

8.2 Explain the causes of and treatments for somatic about having an illness even though they may have
symptom disorder. no symptoms.
• Somatic symptom disorder occurs in individuals who 8.4 Summarize the clinical features of conversion disorder,
have multiple somatic complaints lasting at least also noting its prevalence, causes, and treatment.
6 months. Even if the symptoms do not seem to have a
• Conversion disorder involves patterns of symptoms or
medical explanation, the person’s suffering is regarded
deficits (such as loss of vision or paralysis) that affect
as authentic.
sensory or voluntary motor functions. Although the
• The psychoanalytic perspective on somatic symptom clinical problem suggests a medical or neurological
disorder views physical symptoms as resulting from condition, medical examination reveals no physical
unresolved or unacceptable unconscious conflicts. basis for the symptoms.
Instead of being expressed directly, psychic energy is
• Approximately 20 percent of patients with conversion
channeled into physical problems, which are more
disorder show very little of the anxiety or concern that
socially acceptable.
might be expected given their symptoms. This is
• A more current perspective is cognitive-behavioral. known as la belle indifférence.
According to this formulation, people with somatic
• Conversion disorders are found in approximately 5
symptom disorder are hypervigilant, focusing a great
percent of people treated at neurology clinics. The
deal of attention on their bodies and on bodily changes.
prevalence in the general population is thought to be
They also have a tendency to label bodily sensations as
very low (no more than 0.005 percent), although the
somatic symptoms, attributing physical sensations to
exact prevalence is unknown. Conversion disorders
illness. This is combined with excessive worry about
are thought to develop in response to extreme stress
what the symptoms mean, leading to catastrophizing
that the person is unable to cope with. They are more
cognitions. Because of their worries, people become
prevalent in women, and most commonly occur
very distressed and seek medical attention for their
between early adolescence and early adulthood. The
perceived physical problems.
physical problems often resolve if the stressor is
• Cognitive-behavioral therapy is helpful for patients with removed and the person receives support and encour-
somatic symptom disorder and related disorders. Cog- agement, although recurrence is quite typical.
nitive aspects of the treatment focus on assessing beliefs
about illness and modifying misinterpretations of bodily 8.5 Explain the difference between factitious disorder
sensations. Behavioral techniques might include having and malingering.
the patient induce innocuous symptoms by intentionally • Individuals with factitious disorder intentionally pro-
focusing on parts of the body to learn the role that selec- duce medical or psychological symptoms (or both).
tive perception and hypervigilance play. Patients might They do this in the absence of external rewards in
also be directed to engage in response prevention and order to take on an illness role.
told not to check their bodies as they usually do. • Malingering involves the intentional production of
• In addition to CBT, medical management may provide symptoms or the exaggeration of symptoms. This is
some further benefits. Having one physician who inte- motivated by external factors such as a wish to claim
grates the patient’s care, sees the patient regularly, and insurance money, to avoid work or military service, or
accepts all symptoms as valid, but who also avoids unnec- to get leniency in a criminal prosecution.
essary diagnostic testing can be helpful in some cases.
8.6 List three DSM-5 dissociative disorders.
• For somatic symptom disorder that involves pain,
treatment generally includes relaxation training, sup- • Dissociative disorders occur when the processes that
port and validation that the pain is real, scheduling of normally regulate awareness and the multichannel
daily activities, cognitive restructuring, and reinforce- capacities of the mind apparently become disorga-
ment of “no-pain” behaviors. Antidepressant medica- nized, leading to various anomalies of consciousness
tions are also sometimes used. and personal identity.
• Three dissociative disorders included in DSM-5 are
8.3 Identify the key difference between illness anxiety
disorder and somatic symptom disorder. depersonalization/derealization, dissociative amne-
sia, and dissociative identity disorder.
• Illness anxiety disorder and somatic symptom disor-
8.7 Summarize the clinical features of
der are similar in many ways. However, in somatic
depersonalization/derealization disorder.
symptom disorder symptoms must be present. In
contrast, illness anxiety disorder is a diagnosis that • Depersonalization/derealization disorder occurs
can be used for individuals who are very anxious in people who experience persistent and recurrent
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Somatic Symptom and Dissociative Disorders 289

episodes of derealization (losing one’s sense of reality of alternate in some way in taking control of behavior.
the outside world) and/or depersonalization (losing Alter identities may differ in many ways from the
one’s sense of oneself and one’s own reality). Despite host identity.
this, reality testing overall remains intact and the person • DID is controversial for many reasons. Not everyone
has good awareness of what is happening to her or him. believes it is a real disorder. Some famous cases of
• The lifetime prevalence of depersonalization/dereal- DID have been faked, and the disorder has been used
ization disorder is 1 to 2 percent. Equal numbers of as a defense by people accused of serious crimes.
males and females are affected. The disorder can start Currently, there is no way of distinguishing “true”
in childhood. However, the typical age of onset is DID from simulated DID. Of course, this does not
around age 16 with only a minority of people over age mean we can conclude that genuine cases of DID do
25 developing the disorder. not exist.
• There are no established and effective treatments for • There is also controversy about how DID develops.
depersonalization/derealization disorder. The disor- According to trauma theory, DID develops as a result
der usually has a fairly chronic course with little or no of severe childhood trauma. Sociocultural theory, in
fluctuation in intensity. Comorbid conditions include contrast, maintains that the disorder gets shaped by
mood or anxiety disorders. Rates of avoidant, border- clinicians who inadvertently encourage patients to
line, and obsessive-compulsive personality disorders adopt multiple different roles. These then become rein-
are also higher in people with depersonalization and forced with increased attention.
derealization experiences.
8.10 Describe the cultural factors, treatments, and
8.8 Describe the clinical features of dissociative amnesia. outcomes in dissociative disorders.

• Dissociative amnesia involves an inability to recall pre- • By adding pathological possession to the diagnostic
viously stored information that cannot be accounted criteria for DID, DSM-5 now acknowledges the role of
for by ordinary forgetting. It is thought to be a reaction cultural factors more explicitly. It is recognized that
to extremely stressful circumstances. The memory loss culture may shape how DID presents clinically. Includ-
is primarily for episodic or autobiographical memory. ing possession and nonpossession forms of DID makes
Other aspects of memory generally remain intact. the diagnosis more culturally inclusive. Other cultur-
• In rare cases a person may retreat from real-life prob- ally influenced conditions, such as amok, also have a
lems by going into an amnesic state called a dissocia- dissociative component.
tive fugue, in which a person is not only amnesic for • The treatment for DID is typically psychodynamic
some or all aspects of his or her past but also departs and insight oriented. Hypnosis is also often used. The
from home surroundings. Dissociative fugue is a sub- focus is on uncovering and working through the
type of dissociative amnesia. trauma and other conflicts that are thought to have
led to the disorder. Little is known about how to treat
8.9 Describe the clinical features of dissociative
derealization/depersonalization disorders. In the
identity disorder and explain why this disorder
is so controversial. case of dissociative amnesia, removing the person
from what he or she perceives as a threatening situa-
• In dissociative identity disorder, the person mani- tion sometimes allows for spontaneous recovery of
fests at least two or more distinct identities that memory.

Key Terms
alter identities, p. 278 dissociative identity disorder (DID), malingering, p. 269
conversion disorder, p. 264 p. 277 primary gain, p. 267
depersonalization, p. 272 factitious disorder, p. 269 secondary gain, p. 267
depersonalization/derealization factitious disorder imposed on sociocognitive theory (of DID), p. 281
disorder, p. 272 another, p. 270 soma, p. 258
derealization, p. 272 host identity, p. 278 somatic symptom disorder, p. 258
dissociation, p. 271 hysteria, p. 264 somatoform disorders, p. 258
dissociative amnesia, p. 274 illness anxiety disorder, p. 263 trauma theory, p. 280
dissociative disorder, p. 258 implicit memory, p. 271
dissociative fugue, p. 275 implicit perception, p. 271
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Chapter 9
Eating Disorders and Obesity

David J. Green - lifestyle themes/Alamy Stock Photo

Learning Objectives
9.1 Identify the clinical aspects of eating 9.4 Define obesity and explain why it is a
disorders. worldwide problem.
9.2 Explain the risk and causal factors in eating 9.5 Describe who is most at risk for obesity.
disorders.
9.6 Explain current treatments for obesity.
9.3 Discuss how eating disorders are treated.

290