Somatoform,

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

 Illness Anxiety Disorder (Hypochondriasis)

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

 These disorders involve a disruption in the conscious

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

 Personality = the enduring patterns of thinking,

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

 Personality Disorders are a construct (clinical) used

to understand, describe and communicate about
the complex phenomena that result when the
personality system is not functioning optimally
 When diagnosing…
 Pattern must be inflexible and pervasive across a broad range of
personal and social situations
 Cognition, Emotional responses, interpersonal functioning, or
impulse control

 Must be a source of clinically significant distress or impairment in

social, occupational or other important areas of functioning

 Must be stable and of long duration, with an onset that can be

traced back to at least adolescence or early adulthood
One way to look at it…

 Dimensional Classification: personality disorders are normal traits

amplified to the extreme

recall Five-Factor Model of

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

Very
Extraversion Very
Introverted Extraverted

Openness
Very Very
Low High

Agreeableness
Very Very
Low High

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

Pathological personality traits (one or more)

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

i. Negative affectivity (vs. emotional stability)

ii. Detachment (vs. extraversion)
iii. Antagonism (vs. agreeableness)
iv. Disinhibition (vs. conscientiousness)
v. Psychoticism (vs. lucidity)
Aetiology
(Cause or set of Causes)
 Aetiology Models:
 Biopsychosocial Model: holistic and inclusive
 Diathesis-Stress Model: individual levels of tolerance
 Psychodynamic theory: driven by the unconscious

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

 Varies according to gender, social factors and

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

 Cluster A: odd/eccentric ways of

thinking and behaving
 Paranoid: pervasive distrust and suspicion
of others
 Schizoid: Social detachment/indifference
and limited emotional experience &
expression
 Schizotypal: cognitive and perceptual
distortions; eccentric behaviour; discomfort
with close relationships
 Paranoid Personality
Disorder
 Pervasive distrust and suspiciousness of others such that their
motives are interpreted as malevolent
A. Four or more of the following:
1. Suspects, without sufficient basis, that others are exploiting, harming,
or deceiving him or her
2. Is preoccupied with unjustified doubts about the loyalty or
trustworthiness of friends or associates
3. Is reluctant to confide in others because of unwarranted fear that
the information will be used maliciously against him or her
4. Reads hidden demeaning or threatening meanings into benign
remarks or events
5. Persistently bears grudges
6. Perceives attacks on his or her character or reputation that are not
apparent to others and is quick to react angrily or to counterattack
7. Has recurrent suspicions, without justification, regarding fidelity of
spouse or sexual partner
 Schizoid Personality
Disorder
 Pattern of detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings,
beginning by early adulthood and present in a variety of
contexts
A. Four or more of the following:
1. Neither desires nor enjoys close relationships, including being part
of a family
2. Almost always chooses solitary activities
3. Has little, if any, interest in having sexual experiences with another
person
4. Takes pleasure in few, if any, activities
5. Lacks close friends or confidants other than first-degree relatives
6. Appears indifferent to the praise or criticism of others
7. Shows emotional coldness, detachment, or flattened affect
 Schizotypal Personality
Disorder
 Pattern of social and interpersonal deficits marked by acute
discomfort with, and reduced capacity for, close relationships as
well as by cognitive or perceptual distortions and eccentricities of
behavior
A. Five or more of the following:
1. Ideas of reference
2. Odd beliefs or magical thinking that influences behavior and is
inconsistent with subcultural norms
3. Unusual perceptual experiences including bodily illusions
4. Odd thinking or speech (vague, metaphorical, etc.)
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behavior or appearance that is odd, eccentric, or peculiar
8. Lack of close friends or confidants other than first degree relatives
9. Excessive social anxiety that does not diminish with familiarity and
tends to be associated with paranoid fears rather than negative
judgments about self
Major Personality Disorders

 Cluster B:
dramatic/emotional/erratic
 Antisocial: disregard for and violation of
(the rights of) others
 Borderline: instability of interpersonal
relationships, self-image, emotions, and
control over impulses
 Histrionic: excessive emotionality and
attention-seeking
 Narcissistic: grandiosity; inflated sense of
self-importance; need for attention; lack of
empathy
 Antisocial Personality
Disorder
 Pervasive pattern of disregard for and violation of the
rights of others
 A. Three or more of the following recurring since age
15
1. Failure to conform to social norms with respect to lawful behaviors as
indicated by repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning
others for personal profit or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, as indicated by repeated physical fights or
assaults
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations
7. Lack of remorse, as indicated by being indifferent to or rationalizing having
hurt, mistreated, or stolen from another
Antisocial Personality
Disorder
B. At least 18 years old
C. Evidence of Conduct Disorder with onset before
age 15
D. Not exclusively during the course of Schizophrenia
or a Manic Episode
 NOTE:Requires symptoms of Conduct Disorder
before age 15 (Childhood Disorder)
 Only disorder that requires symptoms of another
disorder to be present
 Borderline Personality
Disorde
 Pervasion pattern of instability of interpersonal relationships, self-image,
and affects, and marked impulsivity
A. Five or more of the following:
1. Frantic efforts to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation
3. Identity disturbance: markedly and persistently unstable self-image or sense
of self
4. Impulsivity in at least two areas that are potentially self-damaging
5. Recurrent suicidal behavior or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms
 Histrionic Personality
Disorder
 Pervasive pattern of excessive emotionality and attention seeking,
beginning by early adulthood and present in a variety of contexts
A. Five or more of the following:
1. Is uncomfortable in situations in which he or she is not the center of attention
2. Interaction with others is often characterized by inappropriate sexually
seduction or provocative behavior
3. Displays rapidly shifting and shallow expression of emotions
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self-dramatization, theatrically, and exaggerated expression of
emotion
7. Is suggestible
8. Considers relationships to be more intimate than they actually are
 Narcissistic Personality
Disorder
 Pervasive pattern of grandiosity, need for admiration, and lack of
empathy
A. Five or more of the following:
1. Has a grandiose sense of self-importance
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or
ideal love
3. Believes that he or she is “special” and unique and can only be understood by,
or should associate with, other special or high-status people
4. Requires excessive admiration
5. Has a sense of entitlement (i.e. unreasonable expectations of favorable
treatment or others complying to their expectations)
6. Takes advantage of others
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs
of others
8. Is often envious of others or believes that others are envious of him/her
9. Shows arrogant, haughty behaviors or attitudes
Major Personality Disorders

 Cluster C: anxious or fearful

 Avoidant: social withdrawal; feelings
of inadequacy, hypersensitive to
criticism
 Dependent: excessive need to be
taken care of; clinging and
submissive
 Obsessive-compulsive:
preoccupation with orderliness,
perfection and control at the
expense of flexibility
 Avoidant Personality
Disorder
 Pervasive pattern of social inhibition, feelings of inadequacy, and
hypersensitivity to negative evaluation
A. Four or more of the following:
1. Avoids occupational activities that involve significant interpersonal
contact, because of fears of criticism, disapproval, or rejection
2. Is unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because of the fear of
being shamed or ridiculed
4. Is preoccupied with being criticized or rejected in social situations
5. Is inhibited in new interpersonal situations because of feelings of
inadequacy
6. Views self as socially inept, personally unappealing, or inferior to others
7. Is unusually reluctant to take personal risks or to engage in any new
activities because they may prove embarrassing
 Dependent Personality
Disorder
 Pervasive and excessive need to be taken care of that leads to
submissive and clinging behavior and fears of separation
A. Five or more of the following:
1. Has difficulty making everyday decisions without an excessive
amount of advice and reassurance from others
2. Needs others to assume responsibility for most major areas of his or her
life
3. Has difficulty expressing disagreement with others because of fear of
loss of support or approval
4. Has difficulty initiating projects or doing things on his or her own
(because of a lack of self-confidence rather than a lack of
motivation or energy)
5. Goes to excessive lengths to obtain nurturance and support from
others, to the point of volunteering to do things that are unpleasant
6. Feels uncomfortable or helpless when alone because of
exaggerated fears of being unable to care for himself or herself
7. Urgently seeks another relationship as a source of care and support
when a close relationship ends
8. Is unrealistically preoccupied with fears of being left to take care of
himself or herself
 Obsessive-Compulsive
Personality Disorder
 Pervasive pattern of preoccupation with orderliness, perfectionism,
and mental and interpersonal control, at the expense of flexibility,
openness, and efficiency
A. Four or more of the following
1. Is preoccupied with details, rules, lists, order, organization, or
schedules to the extent that the major point of the activity is lost
2. Shows perfectionism that interferes with task completion
3. Is excessively devoted to work and productivity to the exclusion of
leisure activities and friendships
4. Is overconscientious, scupulous, and inflexible about matters of
morality, ethics, or values
5. Is unable to discard worn-out or worthless objects even when they
have no sentimental value
6. Is reluctant to delegate tasks or to work with others unless they submit
to exactly his or her way of doing things
7. Adopts a miserly spending style toward both self and others, money is
viewed as something to be hoarded for future catastrophes
8. Shows rigidity and stubornness
Examples in film

 Borderline: Anakin Skywalker (Star wars: Episode

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

 Biological Factors: seems to be a genetic loading,

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

 Temperament and family environment interaction:

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

 Behavioural and social reinforcers: learned

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

 Psychological factors: inability to anticipate punishment,

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

 Consequent participation in risk-taking, self-promoting

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

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

responsiveness, empathy studies)
ASPD - Treatment

 Seldom seek treatment

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

 Perceived as very difficult clients

 Therapeutic relationship is key but
threatening to person with BPD therefore
attrition is high, and therapy is made very
challenging
 Psychoanalysis uses the transference
relationship to interpret and integrate
Case 1

 Ms Ellie is referred to you by her primary care

MD because she is concerned she has an
anxiety disorder. When the pt comes into
your office she is looking down and when she
shakes your hand it is very sweaty. When
asked about how her relationships were in
junior high she stated “Terrible. I never fit in
and didn’t do much with other kids because I
was afraid they would judge me”.
With this information what
Dx are you thinking
about?
 Social phobia?  What do you need to
 Avoidant personality know to figure out which
disorder? one if any it is?

 Generalized anxiety  Is this circumscribed or

disorder? more global? does this
person have
 Schizoid personality relationships with others?
disorder?
You elicit the following
information
 She has never had an intimate relationship
although she would like to have one and
has one friend that she has known since
childhood. She is intensely afraid of being
ridiculed so works as a transcriptionist from
her home and sits in the back row when she
goes to church. She describes herself as “not
as good as other people” and doesn’t like
to do new things”. She avoids new
relationships unless she “is sure they are
going to like me”.
Case 2

 Jason is a 45 year old male who comes to

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

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

have any other people in his life. He denied
auditory, visual or tactile hallucinations, has no
thought broadcasting or thought insertion and is
able to provide organized answers although you
notice he speaks in a vague way and his affect is
constricted. His appearance is striking because he
is wearing all yellow including his shoes, belt, hat
and earring which he states “is because yellow is
the color that recharges me”.
Case 3

 You are picking up your daughter from daycare

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

 He goes on to tell you that its been the

same story his whole life. He has been
passed over for promotions at work, he
can’t trust his friends any further than he
can throw them and he thinks his wife is
cheating on him too. With your excellent
clinical skills you also find out he doesn’t
actually believe there is a plot and
doesn’t have any psychotic sx.
Final thoughts…

 It is thought you do not “cure”

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