Somatoform andDissociative Disorders

SOMATOFORM DISORDERSHypochondriasisSomatization DisorderPain DisorderConversion DisorderBody Dysmorphic Disorder

Dissociative Amnesia and FugueDissociative Identity Disorder (DID)General Sociocultural Causal Factors in

Dissociative DisordersTreatment and Outcomes in Dissociative

Disorders

DISSOCIATIVE DISORDERSDepersonalization Disorder

UNRESOLVED ISSUES:DID and the Reality of "Recovered Memories"

SOMATOFORM__ DISORDERS

ave you ever had the experience, particularly during a time of serious stress, whenyou felt like you were walking around in a daze or like you just weren't all there?Or have you known people who constantly complained about being sure they hada serious illness even though several medical tests their doctor had performedfailed to show anything wrong? Both of these are examples of mild dissociativeand somatoform symptoms experienced at least occasionally by many people.However, when these symptoms become frequent and severe and lead to signifi-cant distress or impairment, a somatoform or dissociative disorder may be diag-nosed. Somatoform and dissociative disorders appear to involve more complex andpuzzling patterns of symptoms than those we have so far encountered. As a result,they confront the field of psychopathology with some of its most fascinating anddifficult challenges, although unfortunately we do not know much about them-inpart because many of them are quite rare.

The somatoform disorders are a group of conditions that involve physicalsymptoms and complaints suggesting the presence of a medical condition but with-out any evidence of physical pathology to account for them (APA, 2000). Despitethe range of clinical manifestations-from blindness or paralysis to hypochondria-cal complaints about stomach pains thought to be a sign of cancer-in each casethe person is preoccupied with some aspect of her or his health or appearance tothe extent that she or he shows significant impairments in functioning. These indi-viduals therefore frequently show up in the practices of primary-care physicians,who then have the difficult task of deciding how to manage their complaints, whichhave no known physical basis.

The dissociative disorders, on the other hand, are a group of conditions involv-ing disruptions in a person's normally integrated functions of consciousness, mem-ory, identity, or perception (APA, 2000). Included here are some of the moredramatic phenomena in the entire domain of psychopathology: people who cannotrecall who they are or where they may have come from, and people who have twoor more distinct identities or personality states that alternately take control of theindividual's behavior. The term dissociation refers to the human mind's capacity toengage in complex mental activity in channels split off from, or independent of,conscious awareness.

As we have seen (Chapter 6), both somatoform and dissociative disorders wereonce included with the anxiety disorders under the general rubric neuroses, whereanxiety was thought to be the underlying cause of all neuroses whether or not theanxiety was experienced overtly. But in 1980, when DSM-III abandoned attempts tolink disorders together on the basis of hypothesized underlying causes and insteadfocused on grouping disorders together on the basis of overt symptomatology, thesomatoform and dissociative disorders became separate categories from the anxi-ety disorders.

pain. Such individuals are typically preoccupied with theirstate of health and with various presumed disorders or dis-eases of bodily organs. Equally key to these disorders is thefact that the affected patients have no control over theirsymptoms. They are also not intentionally faking symp-toms or attempting to deceive others. For the most part,they genuinely and sometimes passionately believesomething is terribly wrong with their bodies. The preva-lence of somatoform disorders appears to vary consider-

Soma means "body," and somatoform disorders involvepatterns in which individuals complain of bodily symp-toms or defects that suggest the presence of medical prob-lems, but for which no organic basis can be found thatsatisfactorily explains the symptoms such as paralysis or

ably among differing cultures (e.g., Isaac et al., 1995; Jancaet al., 1995).

In our discussion, we will focus on five more or lessdistinct somatoform patterns that have been identified:(1) hypochondriasis, (2) somatization disorder, (3) paindisorder, (4) conversion disorder, and (5) body dysmor-phic disorder.

HypochondriasisAccording to DSM -IV-TR, people with hypochondriasisare preoccupied either with fears of contracting a seriousdisease or with the idea that they actually have such a dis-ease even though they do not. Their preoccupations are allbased on a misinterpretation of one or more bodily signsor symptoms (e.g., being convinced that their slight coughis a sign of lung cancer). Of course the decision that ahypochondriacal complaint is based on a misinterpreta-tion of bodily signs or symptoms can be made only after athorough medical evaluation does not find a medical con-dition that could account for the signs or symptoms.Another defining criterion for hypochondriasis is that theperson is not reassured by the results of a medical evalua-tion; that is, the fear or idea of having a disease persistsdespite medical reassurance. Indeed, these individuals aresometimes disappointed when no physical problem isfound. Finally, the condition must persist for at least 6months for the diagnosis to be made, so as to not diagnoserelatively transient health concerns.

Not surprisingly, people with hypochondriasis usuallyfirst go to a medical doctor with their physical complaints.Because they are never reassured for long, and are inclinedto suspect that their doctor has missed something, theysometimes shop for additional doctors, hoping one mightdiscover what their problem really is. Because they repeat-edly seek medical advice (e.g., Fink et al., 2004), it is notsurprising that their yearly medical costs are much higherthan those of most of the rest of the population (e.g.,Hiller, Kroymann, et al., 2004; Salkovskis & Bass, 1997).These individuals generally resist the idea that their prob-lem is a psychological one that might best be treated by apsychologist or psychiatrist.

Hypochondriasis may be the most commonly seensomatoform disorder, with a prevalence in general medicalpractice officially estimated at between 2 and 7 percent(APA, 2000). It occurs about equally often in men andwomen and can start at almost any age, although earlyadulthood is the most common age of onset. Oncehypochondriasis develops, it tends to be a chronic disorderif left untreated, although the severity may wax and waneover time. Individuals with hypochondriasis often also suf-fer from mood disorders, panic disorder, and/or othersomatoform disorders (especially somatization disorder;Creed & Barsky, 2004).

MAJOR CHARACTERISTICS Individuals with hypochon-driasis are often anxious and highly preoccupied with bod-

A. Preoccupation with fears of contracting, or the idea thatone has, a serious disease, based on misinterpretation ofbodily symptoms.

B. Preoccupation persists despite appropriate medicalevaluation and reassurance.

C. Preoccupation causes clinically significant distress orimpairment.

D. Duration of at least 6 months.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition. Text Revision(Copyright 2000). American Psychiatric Association.

ily functions (e.g., heart beats or bowel movements) orwith minor physical abnormalities (e.g., a small sore oran occasional cough) or with vague and ambiguous phys-ical sensations (such as a "tired heart" or "aching veins";APA, 2000). They attribute these symptoms to a sus-pected disease, and often have intrusive thoughts aboutit. The diagnoses they make for themselves range fromtuberculosis to cancer, exotic infections, AIDS, andnumerous other diseases.

Although people with hypochondriasis are usually ingood physical condition, they are sincere in their convic-tion that the symptoms they detect represent real illness.They are not malingering-consciously faking symptomsto achieve specific goals such as winning a personal injurylawsuit. Not surprisingly, given their tendency to doubtthe soundness of their doctor's conclusions (i.e., that theyhave no medical problem) and recommendations, thedoctor-patient relationships are often marked by conflictand hostility.

The following case captures a typical clinical picturein hypochondriasis and incidentally demonstrates that ahigh level of medical sophistication does not necessarilyrule out a person's developing this disorder.

This 38-year-old physician/radiologist initiated his firstpsychiatric consultation after his 9-year-old son acciden-tally discovered his father palpating (examining by touch)his own abdomen and said, "What do you think it is thistime, Dad?"The radiologist describes the incident and his

(continued)

accompanying anger and shame with tears in his eyes. Healso describes his recent return from a 10-day stay at afamous out-of-state medical diagnostic center to whichhe had been referred by an exasperated gastroenterolo-gist colleague who had reportedly "reached the end ofthe line" with his radiologist patient. The extensive phys-ical and laboratory examinations performed at the centerhad revealed no significant physical disease, a conclu-sion the patient reports with resentment and disappoint-ment rather than relief.

The patient's history reveals a long-standing patternof overconcern about personal health matters, beginningat age 13 and exacerbated by his medical school experi-ence. Until fairly recently, however, he had maintainedreasonable control over these concerns, in part becausehe was embarrassed to reveal them to other physicians.He is conscientious and successful in his profession andactive in community life_ His wife, like his son, hasbecome increasingly impatient with his morbid preoccu-pation about life-threatening but undetectable diseases_

In describing his current symptoms, the patientrefers to his becoming increasingly aware, over the pastseveral months, of various sounds and sensations ema-nating from his abdomen and of his sometimes being ableto feel a "firm mass" in its left lower quadrant. His tenta-tive diagnosis is carcinoma (cancer) of the colon. He testshis stool for blood weekly and palpates his abdomen for15 to 20 minutes every 2 to 3 days_He has performed sev-eral X-ray studies of himself in secrecy after hours at hisoffice. (Adapted from Spitzer et aI., 2002, pp. 88-90.)

Source: Adapted with permission from the DSM-IV-TRCasebook(Copyright 2000). American Psychiatric Publishing, Inc.

THEORETICAL PERSPECTIVES ON CAUSAL FACTORSKnowledge of causal factors in somatoform disorders,including hypochondriasis, is quite minimal compared tomany other Axis I disorders such as the mood and anxietydisorders discussed in the previous few chapters. Todaymany people think hypochondriasis is closely related tothe anxiety disorders. Indeed, many researchers today pre-fer the term health anxiety to hypochondriasis (e.g., Taylor& Asmundson, 2004). Today, cognitive-behavioral views ofhypochondriasis are perhaps most widely accepted andhave as a central tenet that it is a disorder of cognition andperception. Misinterpretations of bodily sensations arecurrently a defining feature of the syndrome, but in thecognitive-behavioral view, these misinterpretations alsoplaya causal role. It is believed that an individual's pastexperiences with illnesses (in both themselves and others,and as observed in the mass media) lead to the develop-ment of a set of dysfunctional assumptions about symp-toms and diseases that may predispose a person todeveloping hypochondriasis (Bouman, Eifert, & Lejuez,1999; Salkovskis & Bass, 1997; Salkovskis & Warwick,

Hypochondriacal individuals are preoccupied with health mattersand unrealistic fears of disease. They are convinced that they havesymptoms of physical illness, but their complaints typically do notconform to any coherent symptom pattern, and they usually havetrouble giving a precise description of their symptoms.

2001). These dysfunctional assumptions might includenotions such as, "Bodily changes are usually a sign of seri-ous disease, because every symptom has to have an identi-fiable physical cause" or "If you don't go to the doctor assoon as you notice anything unusual, then it will be toolate" (Salkovskis & Bass, 1997, p. 318).

Because of these dysfunctional assumptions, individu-als with hypochondriasis seem to focus excessive attentionon symptoms, with recent experimental evidence showingthat these individuals do in fact have an attentional bias forillness-related information (Owens, Asmundson, et aI.,2004). They also perceive their symptoms as more danger-ous than they really are, and judge a particular disease to bemore likely or dangerous than it really is. Once they havemisinterpreted a symptom, they tend to look for confirm-ing evidence and to discount evidence that they are in goodhealth; in fact, they seem to believe that being healthymeans being completely symptom-free (Rief, Hiller, &Margraf, 1998a). They also perceive their probability ofbeing able to cope with the illness as extremely low

(Salkovskis & Bass, 1997) and see themselves as weak andunable to tolerate physical effort or exercise (Rief et a1.,1998a). All this tends to create a vicious cycle in which theiranxiety about illness and symptoms results in physiologicalsymptoms of anxiety, which then provide further fuel fortheir convictions that they are ill.

If we consider the secondary reinforcements that indi-viduals with hypochondriasis obtain, we can better under-stand how such patterns of thought and behavior aremaintained in spite of the misery these individuals oftenexperience. Most of us learn as children that when we aresick, special comforts and attention are provided and, fur-thermore, that we may be excused from a number ofresponsibilities. Barsky and colleagues (1994) found thattheir hypochondriacal patients reported much childhoodsickness and missing of school. They also tend to have anexcessive amount of illness in their families while growingup, which may lead to strong memories of being sick or inpain (Pauli & Alpers, 2002), and perhaps also of havingobserved some of the secondary benefits that sick peoplesometimes reap (Cote et a1., 1996; Kellner, 1985).

Interestingly, one study retested hypochondriacalpatients again 4 to 5 years later and found that those whohad remitted at follow-up had acquired significantly more(real) major medical problems than their nonremittingcounterparts (Barsky et a1.,1998). In other words, it appearsthat hypochondriacal tendencies were reduced by theoccurrence of serious medical conditions. The authors sug-gested that having a serious medical illness "served to legit-imize the patients' complaints, sanction their assumptionof the sick role, and lessen the skepticism with which theyhad previously been regarded .... As one noted, "'Now thatI know Dr. X is paying attention to me, I can believe him ifhe says nothing serious is wrong'" (p. 744).

TREATMENT OF HYPOCHONDRIASIS At least a halfdozen studies on cognitive-behavioral treatment ofhypochondriasis have found that it can be a very effectivetreatment for hypochondriasis (e.g., Barsky & Ahern,2004; Looper & Kirmayer, 2002; Wattar et a1., 2005). Thecognitive components of this treatment approach focus onassessing the patient's beliefs about illness and modifyingmisinterpretations of bodily sensations. The behavioraltechniques include having patients induce innocuoussymptoms by intentionally focusing on parts of their bodyso that they can learn that selective perception of bodilysensations plays a major role in their symptoms. Some-times they are also directed to engage in response preven-tion by not checking their body as they usually do and bystopping their constant seeking of reassurance. The treat-ment, which is relatively brief (6-16 sessions), producedlarge changes in hypochondriacal symptoms and beliefs, aswell as in levels of anxiety and depression. There is alsosome preliminary evidence that certain antidepressantmedications (especially SSRIs) may be effective in treatinghypochondriasis as well (e.g., Fallon, 2004).

Somatization disorder is characterized by many differentcomplaints of physical ailments, over at least several yearsbeginning before age 30, that are not adequately explainedby independent findings of physical illness or injury andthat lead to medical treatment or to significant life impair-ment. Not surprisingly, therefore, somatization disorder isseen most often among patients in primary medical caresettings in cultures all over the world (Guerje et a1., 1997;Iezzi et a1., 2001). Indeed, patients with somatization dis-order are enormously costly to health care systems becausethey often have multiple unnecessary hospitalizations andsurgeries (Hiller, Fichter, & Rief, 2003).

In addition to the requirement of multiple physicalcomplaints, DSM-IV- TR (APA, 2000) lists four othersymptom criteria that must be met at some time duringthe course of the disorder before a diagnosis of somatiza-tion disorder can be made. A diagnostician need not beconvinced that these claimed illnesses actually existed in apatient's background history; the mere reporting of themis sufficient. The four other criteria that must be met are:

1. Four pain symptoms. The patient must report ahistory of pain experienced with respect to at leastfour different sites or functions-for example, head,abdomen, back, joints, or rectum, or during sexualintercourse or urination.

2. Two gastrointestinal symptoms. The patient mustreport a history of at least two symptoms, other thanpain, pertaining to the gastrointestinal system-suchas nausea, bloating, diarrhea, or vomiting when notpregnant.

3. One sexual symptom. The patient must report atleast one reproductive system symptom other thanpain-for example, sexual indifference or dysfunction,menstrual irregularity, or vomiting throughoutpregnancy.

4. One pseudoneurological symptom. The patientmust report a history of at least one symptom, notlimited to pain, suggestive of a neurologicalcondition-for example, various symptoms thatmimic sensory or motor impairments such as lossof sensation or involuntary muscle contraction ina hand.

If the symptoms of somatization disorder seem similarto you in some ways to those of hypochondriasis, that isbecause there are indeed significant similarities between thetwo conditions (and they sometimes co-occur; Mai, 2004),but there are also enough distinguishing features that theyare considered two separate disorders in DSM-IV-TR. Forexample, although both disorders are characterized by pre-occupation with physical symptoms, only people withhypochondriasis tend to be convinced that they have anorganic disease. Moreover, with hypochondriasis the

A. History of many physical complaints starting before age 30that occur over several years and result in treatment beingsought, or significant impairment in functioning.

B. Each of the following criteria must have been met at sometime during the disturbance:(1) Four pain symptoms in different sites.(2) Two gastrointestinal symptoms other than pain.(3) One sexual symptom.(4) One pseudoneurological symptom.

C. Either (1) or (2):(1) After appropriate investigation, each of the symptoms

under Criterion B cannot be fully explained by amedical condition.

(2) When there is a related general medical condition, thephysical complaints are in excess of what would beexpected.

D. Symptoms not intentionally produced or feigned.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

person usually has only one or a few primary symptoms,but in somatization disorder, by definition, there are multi-ple symptoms.

The main features of somatization disorder are illus-trated in the following case summary, which also involves asecondary diagnosis of depression.

This 38-year-old married woman, the mother of five chil-dren, reports to a mental health clinicwith the chief com-plaint of depression, meeting diagnostic criteria formajor depressive disorder .... Her marriage has been achronically unhappy one; her husband is described as analcoholic with an unstable work history, and there havebeen frequent arguments revolving around finances, hersexual indifference, and her complaints of pain duringintercourse.

The history reveals that the patient ... describesherself as nervous since childhood and as having beencontinuously sickly beginning in her youth. She experi-ences chest pain and reportedly has been told by doc-tors that she has a "nervous heart." She sees physicians

frequently for abdominal pain, having been diagnosedon one occasion as having a "spastic colon." In additionto M.D. physicians, she has consulted chiropractors andosteopaths for backaches, pains in her extremities, anda feeling of anesthesia in her fingertips. She was recentlyadmitted to a hospital following complaints of abdomi-nal and chest pain and of vomiting, during which admis-sion she received a hysterectomy. Following the surgeryshe has been troubled by spells of anxiety, fainting, vom-iting, food intolerance, and weakness and fatigue. Phys-ical examinations reveal completely negative findings.(Adapted from Spitzer et aI., 2002, pp. 404-5.)

Source: Adapted with permission from the DSM-IV-TRCasebook(Copyright 2000). American Psychiatric Publishing, Inc.

DEMOGRAPHICS, COMORBIDITY, AND COURSE OFILLNESS Somatization disorder (formerly calledBriquet's syndrome after the French physician who firstdescribed it) has not been as extensively researched as sev-eral other somatoform disorders. It usually begins in ado-lescence and is believed by many to be about three to tentimes more common among women than among men. Italso tends to occur more in lower socioeconomic classes.The lifetime prevalence has been estimated to be between0.2 and 2.0 percent in women and less than 0.2 percent inmen (APA, 2000). Somatization disorder very commonlyco-occurs with several other disorders including majordepression, panic disorder, phobic disorders, and general-ized anxiety disorder. Although it has generally been con-sidered to be a relatively chronic condition with a poorprognosis, some recent studies have begun to challengethis view with some evidence that a significant number ofpatients remit spontaneously (e.g., Creed & Barsky, 2004).

CAUSAL FACTORS IN SOMATIZATION DISORDERDespite its significant prevalence in medical settings, weremain quite uncertain about the developmental courseand specific etiology of somatization disorder. There is evi-dence that it runs in families and that there is a familiallinkage between antisocial personality disorder in men(see Chapter 11) and somatization disorder in women.That is, one possibility is that some common, underlyingpredisposition, probably with an at least partly geneticbasis, leads to antisocial behavior in men and to somatiza-tion disorder in women (Cale & Lilienfeld, 2002; Guzeet aI., 1986; Lilienfeld, 1992). Moreover, somatic symptomsand antisocial symptoms in women tend to co-occur (Cale& Lilienfeld, 2002). However, we do not yet have a clearunderstanding of this relationship. One possibility is thatthe two disorders may be linked through a common trait ofimpulsivity, but the nature of this relationship is not yetunderstood.

In addition to a possible genetic predisposition todeveloping somatization disorder, other contributory

causal factors probably include an interaction of personal-ity, cognitive, and learning variables. People high on neu-roticism who come from certain kinds of familybackgrounds may develop a tendency to misinterpret theirbodily sensations as threatening or even disabling. Thismight be especially likely in families where a child is fre-quently exposed to models complaining of pain and vicar-iously learns that complaining about physical' symptomscan lead to the garnering of sympathy and attention (socialreinforcement) and even to avoidance of responsibilities (asecondary gain; Iezzi et al., 2001). This may be especiallycommon in rather disorganized and uncohesive familieswith inconsistent parental care-more often from lowersocioeconomic classes.

It has also become clear that people with somatizationdisorder selectively attend to bodily sensations and tend tosee bodily sensations as somatic symptoms. Like patientswith hypochondriasis, they tend to catastrophize aboutminor bodily complaints and to think of themselves asphysically weak and unable to tolerate stress or physicalactivity (Rief et aI., 1998a). One possible scenario sug-gested by Rief et al. (1998a) is that a vicious cycle maydevelop. If one thinks of oneself as being weak, has low tol-erance for pain and stress, and selectively attends to bodilysensations (while assuming that being healthy equals beingwithout bodily sensations), one will avoid many dailyac..t.ivitiesthat require much exertion, including physicalactivity. }.ronically, however, lowered physical activity canlead to being- physically unfit, which can in turn increasebodily sensations ",bout which to catastrophize. Moreover,selectively attendin~' to bodily sensations may actuallyincrease the intensity ot ,the sensations, further exacerbat-ing the vicious cycle. Fina,~ly, Rief, Shaw, and Fichter(1998b) also found that patients with somatization disor-der had elevated levels of cortisol (.;! stress hormone) anddid not show normal habituation to psychological stres-sors. Thus the physiological arousal caus,~d by psychologi-cal stressors remains elevated and may fu1ther contributeto the bodily sensations that individuals suffering fromthis condition worry about.

TREATMENT OF SOMATIZATION DISORDERSomatization disorder has long been considered to beextremely difficult to treat, but some recent treatmentresearch has begun to suggest that a certain type of medicalmanagement and cognitive-behavioral treatments may bequite helpful. One moderately effective treatment involvesidentifying one physician who will integrate the patient'scare by seeing the patient at regular visits (i.e., trying toanticipate the appearance of new problems) and by pro-viding physical exams focused on new complaints (i.e.,accepting her or his symptoms as valid). At the same time,however, the physician avoids unnecessary diagnostic test-ing and makes minimal use of medications or other thera-pies (Looper & Kirmayer, 2002; Mai, 2004). Several studieshave found that patients show substantial decreases inhealth care expenditures over subsequent months and

When one physician can integrate a patient's care by providingregular office visits but minimum treatment, the physicalfunctioning of patients with somatization disorder may improve.

sometimes an improvement in physical functioning(although not in psychological distress; Rost, Kashner, &Smith, 1994; Smith, Monson, & Ray, 1986). This type ofmedical management can be even more effective whencombined with cognitive-behavioral therapy that focuseson promoting appropriate behavior such as better copingand personal adjustment, and discouraging inappropriatebehavior such as illness behavior and preoccupation withphysical symptoms (e.g., Mai, 2004). As with hypochon-driasis, the focus is on changing the way the patient thinksabout bodily sensations and reducing any secondary gainthe patients may receive from physicians and family mem-bers. There are also some promising but still preliminaryresults that antidepressants can sometimes be useful intreating somatization disorder.

The symptoms of pain disorder resemble the pain symp-toms seen in somatization disorder, but with pain disorder,the other kinds of symptoms of somatization disorder arenot present. Thus pain disorder is characterized by theexperience of persistent and severe pain in one or moreareas of the body. Although a medical condition may con-tribute to the pain, psychological factors must be judged toplay an important role. In approaching the phenomenon ofpain disorder, it is very important to remember that thepain that is experienced is very real and can hurt as much aspain with purely medical causes. It is also important to notethat pain is always, in part, a subjective experience that isprivate and cannot be objectively identified by others.

DSM-IV-TR specifies two coded subtypes: (1) paindisorder associated with psychological factors, and (2) paindisorder associated with both psychological factors and ageneral medical condition. The first subtype applies wherepsychological factors are judged to playa major role inthe onset or maintenance of the pain-that is, where any

DSM-N-TR

A. Pain in one or more sites as priniary focus of clinicalpresentation.

B. Pain causes significant distress or impairment infunctioning.

C. Psychological factors judged to have an important role inthe pain. '

D. Symptom or deficit is not intentionally produced or feigned.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, Text Revision(Copyright 2000). American Psychiatric AssoCiation.

coexisting general medical condition is considered to be ofminimal causal significance in the pain complaint. The sec-ond subtype applies where the experienced pain is consid-ered to result from both psychological factors and somemedical condition that could cause pain. In either case, thepain disorder may be acute (duration ofless than 6 months)or chronic (duration of over 6 months).

The prevalence of pain disorder in the general popula-tion is unknown. It is definitely quite common amongpatients at pain clinics. It is diagnosed more frequently inwomen than in men and is very frequently comorbid withanxiety and/or mood disorders, which may occur first ormay arise later as a consequence of the pain disorder (APA,2000). People with pain disorder are often unable to work(they sometimes go on disability) or to perform someother usual daily activities. Their resulting inactivity(including an avoidance of physical activity) and socialisolation may lead to depression and to a loss of physicalstrength and endurance. This fatigue and loss of strengthcan then exacerbate the pain in a kind of vicious cycle(Bouman, Eifert, & Lejuez, 1999; FIor, Birbaumer, & Turk,1990). In addition, the behavioral component of pain isquite malleable in the sense that it can increase when itis reinforced by attention, sympathy, or avoidance ofunwanted activities (Bouman et al., 1999). Such individu-als may also repeatedly seek out new doctors in the hope ofgetting medical confirmation of their pain or to obtainmedications to relieve their suffering.

TREATMENT OF SOMATOFORM PAIN DISORDERPerhaps because it is a less complex and multifaceted dis-order than somatization disorder, pain disorder is usuallyalso easier to treat. Indeed, cognitive-behavioral tech-niques have been widely used in the treatment of bothphysical and "psychogenic" pain syndromes. Treatmentprograms using these techniques generally include relax-ation training, support and validation that the pain is

The experience of pain is always subjective and private, maki.7:ypain impossible to assess with pinpoint accuracy. Pain 'Z.ruesnotalways exist in perfect correlation with observabl~ ','Issue damageor irritation.

real, scheduling of daily activi(,es, cognitive restructuring,and reinforcement of "no-rJain" behaviors (Simon, 2002).Patients receiving such tr:<:atments tend to show substantialreduc'tions in disabili.ty and distress although changes inthe iritensity of the:lr pain tend to be smaller in magnitude.In addition, anti~~epressant medications (especially the tri-cyclic antidepressants) have been shown to reduce painintensity in a manner independent of the effects the med-ications ma'l have on mood (Simon, 2002).

Con~ersion disorder involves a pattern in which symp-tOJ:nsor deficits affecting sensory or voluntary motor func-'dons lead one to think a patient has a medical orneurological condition. However, upon medical examina-tion, it becomes apparent that the pattern of symptoms ordeficits cannot be fully explained by any known medicalcondition. A few typical examples include partial paralysis,blindness, deafness, and pseudoseizures. In addition, psy-chological factors must be judged to play an important rolein the symptoms or deficits, because the symptoms usuallyeither start or are exacerbated by preceding emotional orinterpersonal conflicts or stressors. Finally, the personmust not be intentionally producing or faking the symp-toms, as will be discussed later (APA, 2000).

Early observations dating back to Freud suggestedthat most people with conversion disorder showed verylittle of the anxiety and fear that would be expected in aperson with a paralyzed arm or loss of sight. This seeminglack of concern (known as la belle indifference-Frenchfor "the beautiful indifference") in the way the patientdescribes what is wrong was thought for a long time to bean important diagnostic criterion for conversion disorder.However, more careful research later showed that la belleindifference actually occurs in only about 30 to 50 percentof patients with conversion disorder, so it has beendropped as a criterion from recent editions of DSM. Infact, it is now thought that most patients with conversiondisorder are actually quite anxious and concerned abouttheir symptoms (Iezzi et al., 2001).

Conversion disorder is one of the most intriguing andbaffling patterns in psychopathology, and we still havemuch to learn about it. Unfortunately, contemporaryresearch on this disorder has been very sparse. The termconversion disorder is relatively recent, and historically thisdisorder was one of several disorders that were groupedtogether under the term hysteria (the others being somati-zation disorder and hysterical personality; see Chapter 2).

Freud used the term conversion hysteria for these dis-orders (which were fairly common in his practice), becausehe believed that the symptoms were an expression ofrepressed sexual energy-that is, the unconscious conflictthat a person felt about his or her sexual desires wasrepressed. However, in Freud's view, the anxiety threatensto become conscious, so it is unconsciously converted intoa bodily disturbance, thereby allowing the person to avoidhaving to deal with the conflict. For example, a person'sguilty feelings about the desire to masturbate might besolved by developing a paralyzed hand. This is not doneconsciously, of course, and the person is not aware of theorigin or meaning of the physical symptom. Freud alsothought that the reduction in anxiety and intrapsychicconflict was the primary gain that maintained the condi-tion, but he noted that patients often had many sources ofsecondary gain as well, such as receiving sympathy andattention from loved ones.

PRECIPITATING CIRCUMSTANCES, ESCAPE, AND SEC-ONDARY GAINS Although Freud's theory that conver-sion symptoms are caused by the conversion of sexualconflicts or other psychological problems into physicalsymptoms is no longer accepted outside psychodynamiccircles, many of Freud's astute clinical observations aboutprimary and secondary gain are still incorporated intocontemporary views of conversion disorder. Although thecondition is still called a conversion disorder, the physicalsymptoms are usually seen as serving the rather obviousfunction of providing a plausible excuse, enabling anindividual to escape or avoid an intolerably stressful situ-ation without having to take responsibility for doing so.Typically, it is thought that the person first experiences atraumatic event that motivates the desire to escape the

DSM-N-TR

A. One or more symptoms affecting voluntary motor orsensory function that suggest a neurological or othermedieal condition.

B. 'psychological factors judged to be associated with thesymptoms because they were preceded by conflicts or·other stressors.' -

C. ,Symptom or deficit cannot be fully explained by a generalmedical condition.

D. Symptom or deficit causes distress or impairment infunctioning. _

Source: Adapted with permission from the Diagnostic and'Statisticai Manual of Mental Disorders, Folirth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

unpleasant situation, but literal escape may not be feasibleor socially acceptable. Moreover, although becoming sickor disabled is more socially acceptable, this is true only ifthe person's motivation to do so is unconscious.

Thus, in contemporary terms, the primary gain forconversion symptoms is continued escape or avoidance ofa stressful situation. Because this is all unconscious (that is,the person sees no relation between the symptoms and thestressful situation), the symptoms go away only if thestressful situation has been removed or resolved. Relatedly,the term secondary gain, which originally referred toadvantages that the symptom(s) bestow beyond the "pri-mary gain" of neutralizing intrapsychic conflict, has alsobeen retained. Generally, it is used to refer to any "external"circumstance, such as attention from loved ones or finan-cial compensation, that would tend to reinforce the main-tenance of disability.

DECREASING PREVALENCE AND DEMOGRAPHICCHARACTERISTICS Conversion disorders were oncerelatively common in civilian and (especially) military life.In World War I, conversion disorder was the most fre-quently diagnosed psychiatric syndrome among soldiers;it was also relatively common during World War II. Con-version disorder typically occurred under highly stressfulcombat conditions and involved men who would ordinar-ily be considered stable. Here, conversion symptoms-such as paralysis of the legs-enabled a soldier to avoid ananxiety-arousing combat situation without being labeled acoward or being subject to court-martial.

Today, however, conversion disorders constitute onlysome 1 to 3 percent of all disorders referred for mentalhealth treatment. The prevalence in the general popula-tion is unknown, but even the highest estimates have been

Conversion disorders were fairly common during World War I andWorld War 1/.The disorder typically occurred in otherwise "normal"men during stressful combat conditions. The symptoms ofconversion disorder (e.g., paralysis of the legs) enabled a soldierto avoid high-anxiety combat situations without being labeled acoward or being court-martialed.

around 0.005 percent (APA, 2000). Interestingly enough,the decreasing prevalence of conversion disorder seems tobe closely related to our growing sophistication aboutmedical and psychological disorders: A conversion disor-der apparently loses its defensive function if it can bereadily shown to lack an organic basis. When it does occurtoday, it is most likely to occur in rural people from lowersocioeconomic circles who are medically unsophisticated.For example, a highly unusual recent "outbreak" of casesof severe conversion disorder involving serious motorweakness and wasting symptoms were reported in five 9-to 13-year-old girls living in a poor rural Amish commu-nity (all within a 21-month period and all within a closedistance of one another). Each of these girls had experi-enced substantial psychosocial stressors including behav-ioral problems and dysfunctional family dynamics. Therehad also been a serious crisis in the local church, leadingto a great deal of community stress (see Cassady, Kirschke,et al., 2005). Fortunately, after the caregivers of these girlswere educated regarding the psychological nature of thesymptoms and given advice to stick with one doctor, min-imize stress, and avoid reinforcement of the "sick role;'four of the five girls showed significant improvement overthe next 3 months. In the fifth case the family refused to

acknowledge the psychological component of the illness,holding to the belief that the symptoms were caused byparasites.

Conversion disorder occurs two to ten times moreoften in women than in men. It can develop at any age butmost commonly occurs between early adolescence andearly adulthood (Maldonado & Spiegel, 2001). It generallyhas a rapid onset after a significant stressor and oftenresolves within 2 weeks if the stressor is removed, althoughit commonly recurs. In many other cases, however, it has amore chronic course. Like most other somatoform disor-ders, conversion disorder frequently occurs along withother disorders, especially major depression, anxiety disor-ders, and somatization and dissociative disorders.

RANGE OF CONVERSION DISORDER SYMPTOMSThe range of symptoms for conversion disorder is practi-cally as diverse as for physically based ailments. In describ-ing the clinical picture in conversion disorder, it is useful tothink in terms of four categories of symptoms: (1) sensory,(2) motor, (3) seizures, and (4) mixed presentation fromthe first three categories (APA, 2000).

Sensory Symptoms or Deficits Conversion disordercan involve almost any sensory modality, and it can oftenbe diagnosed as a conversion disorder because symptomsin the affected area are inconsistent with how knownanatomical sensory pathways operate. Today the sensorysymptoms or deficits are most often in the visual system(especially blindness and tunnel vision), in the auditorysystem (especially deafness), or in the sensitivity to feeling(especially the anaesthesias). In the anaesthesias, the per-son loses her or his sense of feeling in a part of the body.One of the most common is glove anaesthesia, in which theperson cannot feel anything on the hand in the area wheregloves are worn, although the loss of sensation usuallymakes no anatomical sense.

With conversion blindness, the person reports that heor she cannot see and yet can often navigate about a roomwithout bumping into furniture or other objects. Withconversion deafness, the person reports not being able tohear and yet orients appropriately upon "hearing" his orher own name. Such observations lead to obvious ques-tions: In conversion blindness (and deafness), can affectedpersons actually not see or hear, or is the sensory informa-tion received but screened from consciousness? In general,the evidence supports the idea that the sensory input isregistered but that it is somehow screened from explicitconscious recognition. This implicit perception will be dis-cussed later in Developments in Thinking 8.2 on page 299.

Motor Symptoms or Deficits Motor conversion reac-tions also cover a wide range of symptoms (e.g., Maldon-ado & Spiegel, 2001). For example, conversion paralysis isusually confined to a single limb such as an arm or a leg,and the loss of function is usually selective for certain func-

tions. For example, a person may not be able to write butmay be able to use the same muscles for scratching, or aperson may not be able to walk most of the time but maybe able to walk in an emergency such as a fire where escapeis important. The most common speech-related conver-sion disturbance is aphonia, in which a person is able totalk only in a whisper, although he or she can usuallycough in a normal manner. (In true, organic laryngealparalysis, both the cough and the voice are affected.)Another common motor symptom is difficulty swallowingor the sensation of a lump in the throat (Finkenbine &Miele, 2004).

Seizures Conversion seizures, another relatively com-mon form of conversion symptom, involve pseudo-seizures, which resemble epileptic seizures in some waysbut can usually be fairly well differentiated via modernmedical technology (Bowman & Markand, 2005). Forexample, patients with pseudoseizures do not show anyEEG abnormalities and do not show confusion and loss ofmemory afterward, as patients with true epileptic seizuresdo. Moreover, patients with conversion seizures often showexcessive thrashing about and writhing not seen with trueseizures, and they rarely injure themselves in falls or losecontrol over their bowels or bladder, as patients with trueseizures frequently do.

The following case of conversion disorder clearlyshows how "functional" a conversion disorder may be inthe overall life circumstances of a patient, despite its exact-ing a certain cost in illness or disability.

Mrs. Chatterjee, a 26-year-old patient, attends a clinic inNew Delhi, India, with complaints of "fits" for the last 4years. The "fits" are always sudden in onset and usuallylast 30 to 60 minutes. A few minutes before a fit begins,she knows that it is imminent, and she usually goes tobed. During the fits she becomes unresponsive and rigidthroughout her body, with bizarre and thrashing move-ments of the extremities. Her eyes close and her jaw isclenched, and she froths at the mouth. She frequentlycries and sometimes shouts abuses. She is never inconti-nent of urine or feces, nor does she bite her tongue. Aftera "fit" she claims to have no memory of it. These episodesrecur about once or twice a month. She functions wellbetween the episodes.

Both the patient and her family believe that her "fits"are evidence of a physical illness and are not under hercontrol. However, they recognize that the fits often occurfollowing some stressor such as arguments with familymembers or friends .... She is described by her family as

being somewhat immature but "quite social" and goodcompany. She is self-centered, she craves attention fromothers, and she often reacts with irritability and anger ifher wishes are not immediately fulfilled. On physicalexamination, Mrs. Chatterjee was found to have mild ane-mia but was otherwise healthy. A mental status examina-tion did not reveal any abnormality ... and her memorywas normal. An electroencephalogram showed no seizureactivity. (Adapted from Spitzer et aI., 2002, pp. 469-70.)

Source: Adapted with permission from the DSM-IV-TRCasebook(Copyright 2000). American Psychiatric Publishing, Inc.

IMPORTANT ISSUES IN DIAGNOSING CONVERSIONDISORDER Because the symptoms in conversion disordercan simulate a variety of medical conditions, accurate diag-nosis can be extremely difficult. It is crucial that a personwith suspected conversion symptoms receive a thoroughmediGal and neurological examination. Unfortunately, how-ever, misdiagnoses can still occur. Nevertheless, as medicaltests have become increasingly sophisticated, the rate of mis-diagnoses has declined substantially from in the past, withestimates of misdiagnoses in the 1990s ranging from about5 to 10 percent (e.g., Stone, Zeidler & Sharpe, 2002).

Several other criteria are also commonly used for dis-tinguishing between conversion disorders and true organicdisturbances:

The frequent failure of the dysfunction to conformclearly to the symptoms of the particular disease ordisorder simulated. For example, little or no wastingaway or atrophy of a "paralyzed" limb occurs in con-version paralyses,except in rare andlong-standing cases.

The selective natureof the dysfunction.As already noted, inconversion blind-ness the affectedindividual does notusually bump intopeople or objects,and "paralyzed"muscles can be usedfor some activitiesbut not others.

Virtually all the symptoms of conversiondisorder can be temporarily reduced orreproduced by hypnotic suggestion.

Under hypnosis or narcosis (a sleeplike state inducedby drugs) the symptoms can usually be removed,shifted, or reinduced at the suggestion of the thera-pist. Similarly, a person abruptly awakened from asound sleep may suddenly be able to use a "para-lyzed" limb.

DISTINGUISHING CONVERSION FROM MALINGER-ING AND FROM FACTITIOUS DISORDER Sometimes,of course, people do deliberately and consciously feigndisability or illness. For these instances, the DSM distin-guishes between malingering and factitious disorder onthe basis of the feigning person's apparent goals. Themalingering person is intentionally producing or grosslyexaggerating physical symptoms and is motivated byexternal incentives such as avoiding work or military ser-vice, obtaining financial compensation, or evading crimi-nal prosecution (APA, 2000; Maldonado & Spiegel, 2001).In factitious disorder also, the person intentionally pro-duces psychological or physical symptoms (or both), butthere are no external incentives. Instead, the person's goalis simply to obtain and maintain the personal benefits thatplaying the "sick role" (even undergoing repeated hospi-talizations) may provide, including the attention and con-cern of family and medical personnel. Frequently thesepatients surreptitiously alter their own physiology-forexample, by taking drugs-in order to simulate variousreal illnesses. Indeed, they may be at risk for serious injuryor death and may even need to be committed to an insti-tution for their own protection. (See The World AroundUs 8.1 for a particularly pathological variation on this.)In the past, severe and chronic forms of factitious disor-der with physical symptoms were called "Munchausen'ssyndrome," where the general idea was that the personhad some kind of "hospital addiction" or a "professionalpatient" syndrome.

It is sometimes possible to distinguish between a con-version (or other somatoform) disorder and malingering,or factitiously "sick" role-playing, with a fair degree of con-fidence, but in other cases it is more difficult to make thecorrect diagnosis. Persons engaged in malingering andthose who have factitious disorder are consciously perpe-trating frauds by faking the symptoms of diseases or dis-abilities, and this fact is often reflected in their demeanor.Individuals with conversion disorders are not consciously

A. Intentional production or feigning of physical orpsychological signs of symptoms.

B. Motivation for the behavior is to assume the sick role.C. There are no external incentives for the behavior (e.g.,

economic gain or avoiding legal responsibilities, as seenin Malingering).

Source: Adapted with permission from the Diagnostic andStatisticalManualof MentalDisorders,FourthEdition,TextRevision(Copyright 2000). American Psychiatric Association.

producing their symptoms, feel themselves to be the "vic-tims of their symptoms," and are very willing to discussthem, often in excruciating detail (Maldonado & Spiegel,2001, p. 109). When inconsistencies in their behaviors arepointed out, they are usually unperturbed. Any secondarygains they experience are by-products of the conversionsymptoms themselves and are not involved in motivatingthe symptoms. By contrast, persons who are feigningsymptoms are inclined to be defensive, evasive, and suspi-cious when asked about them; they are usually reluctant tobe examined and slow to talk about their symptoms, lestthe pretense be discovered. Should inconsistencies in theirbehaviors be pointed out, deliberate deceivers as a ruleimmediately become more defensive. Thus conversion dis-order and deliberate faking of illness are considered dis-tinct patterns.

TREATMENT OF CONVERSION DISORDER Ourknowledge of how best to treat conversion disorder isextremely limited, because no well-controlled studies haveyet been conducted (e.g., Bowman & Markand, 2005;Looper & Kirmayer, 2002). Some hospitalized patientswith motor conversion symptoms have been successfullytreated with a behavioral approach in which specific exer-cises are prescribed in order to increase movement orwalking, and then reinforcements are provided whenpatients show improvements (e.g., praise and gainingprivileges). Any reinforcements of abnormal motor behav-iors are removed in order to eliminate any sources of sec-ondary gain. In one small study using this kind oftreatment for ten patients, all had regained their ability tomove or walk in an average of 12 days, and for seven ofthe nine available at approximately 2-year follow-up, theimprovements had been maintained (Speed, 1996). Somestudies have used hypnosis combined with other prob-lem-solving therapies, and there are some suggestions thathypnosis, or adding hypnosis to other therapeutic tech-niques, can be useful (Looper & Kirmayer, 2002; Moeneet al., 2003).

Body Dysmorphic DisorderBody dysmorphic disorder (BDD) is officially classified inDSM-IV- TR (APA, 2000) as a somatoform disorderbecause it involves preoccupation with certain aspects ofthe body. People with BDD are obsessed with someperceived or imagined flaw or flaws in their appearance.This preoccupation is so intense that it causes clinicallysignificant distress and/or impairment in social or occupa-tional functioning. Although it is not considered necessaryfor the diagnosis, most people with BDD have compulsivechecking behaviors (such as checking their appearance inthe mirror excessively or hiding or repairing a perceivedflaw). Another very common symptom is avoidance ofusual activities because of fear that other people will seethe imaginary defect and be repulsed. In severe cases theymay become so isolated that they lock themselves up in

8.1 Factitious Disorder by Proxy(Munchausen's Syndrome by Proxy)

7n a somewhat bizarre variant of factitious disorder,called factitious disorder by proxy (orMunchausen's syndrome by proxy), the personseeking medical help or consulting a mentalhealth professional falsely reports, or even

induces, medical or psychological symptoms in another per-son who is under his or her care(usually a child). In a typicalinstance, a mother presents herown child for treatment of a med-ical condition she has deliber-ately caused, disclaiming anyknowledge of its origin. Themajority of such cases involvethe gastrointestinal, genitouri-nary, or central nervous systems,apparently because diseases ordysfunctions in these systemsare most readily simulated byexcessive administration ofwidely available drugs (emetics,laxatives, diuretics, CNS stimu-lants or depressants) or otherillness-inducing chemicals (suchas cleaning products). Of course,the health of such victims isoften seriously endangered bythis repeated abuse, and theintervention of social serviceagencies or law enforcement issometimes necessary. In as manyas 10 percent of cases, this formof child abuse may lead to achild's death (Hall, Eubanks,et aI., 2000).

This disorder may be indiocated when the victim's clinicalpresentation is atypical, when

lab results are inconsistent with each other or with recog-nized diseases, or when there are unduly frequent returnsor increasingly urgent visits to the same hospital or clinic.The perpetrators (who often have extensive medical knowl-edge) tend to be highly resistant to admitting the truth(McCann, 1999), and it has been estimated that the aver-

age length of time to confirmthe diagnosis is 14 months(Rogers, 2004). If they sensethat the medical staff is suspi-cious, they may abruptly termi-nate contact with that facility,only to show up at another oneto begin the entire processanew. Compounding the prob-lem of detection is the fact thathealth care professionals whorealize they have been dupedmay be reluctant to acknowl-edge their fallibility for fear oflegal action. Misdiagnosing thedisorder when the parent is infact innocent can also lead tolegal difficulties for the healthcare professionals (McNicholas,Slonims, & Cass, 2000). Onetechnique that has been usedwith considerable success iscovert video surveillance of themother and child during hospi-talizations. In one study, 23 of41 suspected cases were finallydetermined to have factitiousdisorder by proxy, and in 56 per-cent of those cases, video sur-veillance was essential to thediagnosis (Hall et aI., 2000).

Over a period of 20 months, Jennifer, 8, shownhere with her mother, Kathy Bush, had beentaken to the hospital more than 130 times,underwent 40 surgeries, and amassed over $3million in medical expenses. Doctors and nursestestified that Jennifer's condition alwaysworsened after her mother visited her daughterat the hospital behind closed doors. In addition,Jennifer's health had significantly improvedsince being removed from her mother's care.The jury was convinced that Kathy Bush wasresponsible for causing Jennifer's illnesses.Bush was arrested and diagnosed withMunchausen's syndrome by proxy.

their house and never go out even to work, with the aver-age employment rate estimated at only about 50 percent(Neziroglu et aI., 2004).

People with BDD may focus on almost any body part:Their skin has blemishes, their breasts are too small, theirface is too thin (or too fat) or disfigured by visible bloodvessels that others find repulsive, and so on. One largestudy found that some of the more common locations forperceived defects included skin (73 percent), hair(56 percent), nose (37 percent), eyes (20 percent), legs(18 percent), chin (11 percent), breasts/chest/nipples

(21 percent), stomach (22 percent), lips (12 percent), bodybuild (16 percent), and face size/shape (12 percent;Phillips, 2005); many sufferers have perceived defects inmore than one body part. It is very important to remem-ber that these are not the ordinary concerns that most ofus have about our appearance; they are far more extreme,leading in many cases to complete preoccupation and sig-nificant emotional pain. Some researchers estimate thatabout half the people with BDD have concerns about theirappearance that are of delusional intensity (e.g., Allen &Hollander, 2004). Yet it is important to remember that

ProblemInterference with social functioning (e.g., with friends, family, or

intimate relationships) due to BDDPeriods of avoidance of nearly all social interactions because of BDDInterference with work or academic functioning because of BDDPeriods of complete avoidance of work, school, or one's role (e.g.,

maintaining a household) because of BDDDays of work missed because of BDD*Days of school missed because of BDD*Completely housebound for at least 1 week because of BDDEver felt depressed because of BDDPsychiatrically hospitalized at least once because of BDDEver thought about suicide because of BDD*Ever attempted suicideEver attempted suicide because of BDD

% of People with BDD WhoExperienced the Problem or

Average Number of Days

99%95%90%

80%52 days49 days29%94%26%63%25%14%

Source: Adapted from The Broken Mirror: Understanding and Treating Dysmorphic Disorder by Katherine A. Phillips. © 2005 OxfordUniversity Press. Reprinted by permission.

A. Preoccupation with an imagined defect in appearance. Ifslight physical anomaly is present, person's concern ismarkedly excessive.

B. Preoccupation causes significant distress or impairment.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders. Fourth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

others do not even see the defects that the person withBDD has, or if they do, they see only a very minor defectwithin the normal range.

Another common feature of BDD is that people withthis condition frequently seek reassurance from friendsand family about their defects, but the reassurances almostnever provide more than very temporary relief. They alsofrequently seek reassurance for themselves by checkingtheir appearance in the mirror countless times in a day(although some avoid mirrors completely). They are usu-ally driven by the hope that they will look different, andsometimes they may think their perceived defect does not

People with body dysmorphic disorder often seek plastic surgeryfor what they perceive to be serious flaws in their appearance.Here the actress Goldie Hawn (as she naturally looks on the left,and as a character in First Wives Club on the right). Hawn'scharacter is unhappy with her lips, wishing them to be fuller inshape. She has plastic surgery to make them fuller, and yet is stillquite unhappy with the outcome, as is typical of individuals withbody dysmorphic disorder who undergo such surgery.

look as bad as it has at other times. However, much morecommonly they feel worse after mirror gazing (Veale &Riley, 2001). They frequently engage in excessive groomingbehavior, often trying to camouflage their perceived defect

through their hairstyle, clothing, or makeup (Sarwer, Gib-bons, & Crerand, 2004).

The following case illustrates the primary features ofthis disorder.

Chris is a shy, anxious-looking, 31-year-old carpenter whohas been hospitalized after making a suicide attempt. ...He asks to meet with the psychiatrist in a darkened room.He is wearing a baseball cap pulled down over his fore-head. Looking down at the floor, Chris says he has nofriends, has just been fired from his job, and was recentlyrejected by his girlfriend. "It's my nose ... these hugepockmarks on my nose. They're grotesque! I look like amonster. I'm as ugly as the Elephant Man! These marks onmy nose are all that I can think about. I've thought aboutthem every day for the past 15 years, and I think thateveryone can see them and that they laugh at mebecause of them. That's why I wear this hat all the time.And that's why I couldn't talk to you in a bright room ...you'd see how ugly I am."

The psychiatrist couldn't see the huge pockmarksthat Chris was referring to, even in a brightly lit room. Chrisis, in fact, a handsome man with normal-appearing facialpores. [Later Chris says,] "I've pretty much kept this preoc-cupation a secret because it's so embarrassing. I'm afraidpeople will think I'm vain. But I've told a few people aboutit, and they've tried to convince me that the pores reallyaren't visible .... This problem has ruined my life. Alii canthink about is my face. I spend hours a day looking at themarks in the mirror .... 1 started missing more and morework, and Istopped going out with my friends and my girl-friend ... staying in the house most of the time .... "

Chris ... had seen a dermatologist to request der-mabrasion, but was refused the procedure because"there was nothing there." He finally convinced anotherdermatologist to do the procedure but thought it did nothelp. Eventually he felt so desperate that he made twosuicide attempts. His most recent attempt occurred afterhe looked in the mirror and was horrified by what hesaw ... "I saw how awful I looked, and I thought, I'm notsure it's worth it to go on living if I have to look like thisand think about this all the time." (Adapted from Spitzeret aI., 2002, pp. 7-9.)

Source: Adapted with permission from the DSM-IV-TR Cosebook(Copyright 2000). American Psychiatric Publishing, Inc.

PREVALENCE, GENDER, AND AGE OF ONSET Thereare no official estimates of the prevalence ofBDD, and theymight actually be difficult to obtain because of the greatsecrecy that usually surrounds this disorder. Some leadingresearchers estimate that it is not a rare disorder, affecting

perhaps 1 to 2 percent of the general population, up to 8percent of people with depression (e.g., Allen & Hollander,2004; Phillips, 2005). The prevalence seems to be approxi-mately equal in men and women (Phillips, 2005; Phillips &Diaz, 1997). The age of onset is usually in adolescence,when many people start to become preoccupied with theirappearance. People with BDD very commonly also have adepressive diagnosis (with most estimates being over 50percent; Allen & Hollander, 2004), and, as in Chris's case, itoften leads to suicide attempts or completed suicide(Neziroglu et aI., 2004; Phillips, 2001). Rates of comorbidsocial phobia and obsessive-compulsive disorder are alsoquite substantial, although not as high as for depression(Allen & Hollander, 2004).

Sufferers of BD D like Chris commonly make their wayinto the office of a dermatologist or plastic surgeon, onerecent estimate being that over 75 percent seek nonpsychi-atric treatment (Phillips, Grant, Siniscalchi, & Albertini,2001). One recent study found that 8 percent of those seek-ing cosmetic medical treatments met criteria for BDD(Crerand, Sarwer, et aI., 2004), although other studies haveestimated this to be 20 percent (Phillips, 2005). An astutedoctor will not do the requested procedures and mayinstead make a referral to a psychologist or psychiatrist. Alltoo often, though, the patient, like Chris, does get what heor she requests-and unfortunately is almost never satis-fied with the outcome.

RELATIONSHIP TO OCD AND EATING DISORDERSMany researchers believe that BDD is closely related toobsessive-compulsive disorder and have proposed it as oneof the obsessive-compulsive spectrum disorders (e.g.,Allen & Hollander, 2004). At this point, the similarities toOCD should be fairly obvious. Like people with OCD,those with BDD have prominent obsessions, and theyengage in a variety of ritualistic-like behaviors such as reas-surance seeking, mirror checking, comparing themselvesto others, and camouflage. Moreover, they are even moreconvinced that their obsessive beliefs are accurate than arepeople with OCD (Eisen, Phillips, Coles, & Rasmussen,2003). But in addition to these similarities in symptoms,research is also increasingly suggesting an overlap incauses. For example, the same sets of brain structures areimplicated in the two disorders (Rauch et aI., 2003; Rivera& Borda, 2001), and, as we will discuss later, the same kindsof treatments that work for OCD are also the treatments ofchoice for BDD (Phillips, 2005).

Other researchers have also noted significant overlap-ping features between BDD and eating disorders (espe-cially anorexia nervosa), the most striking similarity beingthe body image distortion in both kinds of conditions.Specifically, excessive concerns and preoccupation aboutphysical appearance, dissatisfaction with one's body, and adistorted image of certain features of one's body are centralto the diagnostic criteria for each (Allen & Hollander,2004; Cororve & Gleaves, 2001). (See Chapter 9.)

WHY NOW? BDD has clearly existed for centuries, if notfor all time. Why, then, did its examination in the litera-ture begin only recently? One possible reason is that itsprevalence may actually have increased in recent years ascontemporary Western culture has become increasinglyfocused on "looks as everything;' with billions of dollarsspent each year on enhancing appearance throughmakeup, clothes, plastic surgery, etc. (Fawcett, 2004). Asecond reason BDD has been understudied is that mostpeople with this condition never seek psychological or psy-chiatric treatment. Rather, they suffer silently or go to der-matologists or plastic surgeons (Crerand, Sarwer, et al.,2004; Phillips, 1996, 2001). Reasons for this secrecy andshame include worries that others will think they aresuperficial, silly, or vain and that if they mention their per-ceived defect, others will notice it and focus more on it.Part of the reason why more people are now seeking treat-ment is that the disorder has received a good deal of mediaattention in the past decade. It has even been discussed onsome daily talk shows, where it is sometimes called "imag-inary defect disorder." As increasing attention is focused onthis disorder, the secrecy and shame often surrounding itshould decrease, and more people will seek treatment. Aleading researcher in this area is Katharine Phillips (1996,2005), who carefully described the condition in The BrokenMirror: Understanding and Treating Body DysmorphicDisorder, a book that was written (and later revised) forpeople who suffer from this disorder as well as for theirfamilies and clinicians.

A BIOPSYCHOSOCIALAPPROACH TO BDD Our under-standing of what causes BDD is still in a preliminary stage,but recent research seems to suggest that a biopsychosocialapproach offers some reasonable hypotheses. First, itseems likely that there is a partially genetically based per-sonality predisposition that people with BDD may share incommon with people who have OCD and perhaps otheranxiety disorders (such as neuroticism), although evidencefor this currently is minimal. Second, BDD seems to beoccurring, at least today, in a sociocultural context thatplaces great value on attractiveness and beauty, and peoplewho develop BDD often hold attractiveness as their pri-mary value, meaning that their self-schemas are heavilyfocused around such ideas as, "If my appearance is defec-tive, then I am worthless" (endorsed by 60 percent in onestudy; Buhlmann & Wilhelm, 2004, p. 924). One possibil-ity why this occurs is that in many cases they were rein-forced as children for their overall appearance more thanfor their behavior (Neziroglu et al., 2004). Another possi-bility is that they later were teased or criticized for theirappearance, which caused conditioning of disgust, shame,or anxiety to their own image of some part of their body.In addition, substantial empirical evidence now demon-strates that people with BDD show biased attention andinterpretation of information relating to attractiveness

(e.g., Buhlmann & Wilhelm, 2004). They selectively attendto positive or negative words such as ugly or beautiful morethan to other emotional words not related to appearance,and they tend to interpret ambiguous facial expressions ascontemptuous or angry more than do controls. Whetheror not these attentional and interpretive biases play acausal role is not yet known, but certainly having suchbiases in processing information relating to attractivenesswould, at a minimum, serve to perpetuate the disorderonce it has developed.

TREATMENT OF BODY DYSMORPHIC DISORDER Aswe have already noted, the treatments that are effective forBDD are closely related to those used in the effective treat-ment of obsessive-compulsive disorder (see Chapter 6).There is some evidence that antidepressant medicationsfrom the selective serotonin reuptake inhibitor categoryoften produce moderate improvement in patients withBDD, but many are not helped or show only a modestimprovement (Phillips, 2004, 2005). In addition, a formof cognitive-behavioral treatment emphasizing exposureand response prevention has been shown to producemarked improvement in 50 to 80 percent of treated patients(Sarwer et a1., 2004; Simon, 2002). These treatmentapproaches focus on getting the patient to identify andchange distorted perceptions of his or her body duringexposure to anxiety-provoking situations (e.g., wearingsomething that highlights rather than disguises the"defect"), and on prevention of checking responses (e.g.,mirror checking, reassurance seeking, and repeated exam-ining of the imaginary defect). The treatment gains aregenerally well maintained at follow-up (Looper & Kir-mayer, 2002; Sarwer et al., 2004).

In ReVIewI.- What are the primary characteristics of

hypochondriasis and how does thecognitive-behavioral viewpoint explaintheir occurrence?

.~ What are the symptoms of somatizationdisorder and of pain disorder?

.~ What are sources of primary and secondarygains involved in conversion disorders andhow is conversion disorder distinguishedfrom malingering and from factitiousdisorder?

.,. What are the primary symptoms of bodydysmorphic disorder and how are theyrelated to obsessive-compulsive disorder?

DISSOCIATIVEDISORDERSThe concept of dissociation, which is over a century old,refers to the human mind's capacity to mediate complexmental activity in channels split off from, or independentof, conscious awareness (Kihlstrom, 1994,2001,2005). Weall dissociate to a degree some of the time. Mild dissocia-tive symptoms occur when we daydream or lose track ofwhat is going on around us, when we drive miles beyondour destination without realizing how we got there, orwhen we miss part of a conversation we are engaged in. Asthese everyday examples of acts performed without con-scious awareness suggest, there is nothing inherentlypathological about dissociation itself.

More specifically, much of a normal individual's men-tal life involves nonconscious processes that are to a largeextent autonomous with respect to deliberate, self-awaremonitoring and direction. Such unaware processingextends to the areas of memory and perception, where itcan be demonstrated that normal persons routinely showindirect evidence of remembering things they cannot con-sciously recall (implicit memory), and respond to sights orsounds as if they had perceived them (as in conversionblindness or deafness), even though they cannot reportthat they have seen or heard them (implicit perception;Kihlstrom, 2001, 2005; Kihlstrom, Tataryn, & Hoyt, 1993).As we have seen, the general idea of unconscious mentalprocesses has been embraced by psychodynamically ori-ented clinicians for many years. But only in the past quar-ter-century has it also become a major research area in thefield of cognitive psychology (though without any of thepsychodynamic implications for why so much of our men-tal activity is unconscious).

In the dissociative disorders, however, this normallyintegrated and well-coordinated multichannel quality ofhuman cognition becomes much less coordinated andintegrated. When this happens, the affected person may beunable to access information that is normally in the fore-front of consciousness, such as his or her own personalidentity or details of an important period of time in therecent past. That is, the normally useful capacity to main-tain ongoing mental activity outside of awareness appearsto be subverted, sometimes for the purpose of managingsevere psychological threat. When that happens, weobserve the pathological dissociative symptoms that arethe cardinal characteristic of dissociative disorders. As wewill see, it is likely that some people have certain personal-ity traits that make them more susceptible than others todeveloping dissociative symptoms and disorders.

Like somatoform disorders, dissociative disordersappear mainly to be ways of avoiding anxiety and stressand of managing life problems that threaten to over-whelm the person's usual coping resources. Both types of

A. Persistent or recurrent experiences of feeling detachedfrom one's mental processes or body.

B. During this experience, reality testing remains intact.

C. Causes significant distress or impairment in functioning.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

disorders also enable the individual to deny personalresponsibility for his or her "unacceptable" wishes orbehavior. In the case of DSM-defined dissociative disor-ders, the person avoids the stress by pathologically disso-ciating-in essence by escaping from his or her ownautobiographical memory, or personal identity. TheDSM -IV-TR recognizes several types of pathologicaldissociation.

Depersonalization DisorderTwo of the more common kinds of dissociative symptomsare derealization and depersonalization, which we men-tioned in Chapters 5 and 6 because they sometimes occurduring stress disorders and panic attacks. In derealizationone's sense of the reality of the outside world is temporar-ily lost, and in depersonalization one's sense of one's ownself and one's own reality is temporarily lost. As many ashalf of us have such experi-ences in mild form at leastonce in our lives, usually dur-ing or after periods of severestress, sleep deprivation, orsensory deprivation (e.g.,Khazaal, Zimmerman, &Zullino, 2005). But whenepisodes of depersonalization(and derealization) becomepersistent and recurrent andinterfere with normal func-tioning, depersonalizationdisorder may be diagnosed.

In this disorder, peoplehave persistent or recurrent experiences of feelingdetached from (and like an outside observer of) their ownbodies and mental processes. They may even feel they are,for a time, floating above their physical bodies, which maysuddenly feel very different-as if drastically changed orunreal. During periods of depersonalization, unlike during

People with derealization symptomsexperience the world as hazy andindistinct.

psychotic states, reality testing remains intact. The relatedexperience of derealization, in which the external world isperceived as strange and new in various ways, may alsooccur. As one leader in the field described it, in both states"the feeling puzzles the experiencers: the changed condi-tion is perceived as unreal, and as discontinuous with hisor her previous ego-states. The object of the experience,self (in depersonalization) or world (in derealization), iscommonly 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 sufferers also report feel-ing as though they are living in a dream or movie (Mal-donado, Butler, & Spiegel, 2002). In keeping with suchreports, recent research has shown that emotional experi-ences are attenuated during depersonalization-both atthe subjective level and at the level of neural and auto-nomic activity that normally accompanies emotionalresponses (Phillips & Sierra, 2003).

The following case is fairly typical.

_____ 1 A Foggy Siudeni

A 20-year-old male college student sought psychiatricconsultation because he was worried that he might begoing insane. For the past 2 years he had experiencedincreasingly frequent episodes of feeling "outside" him-self. These episodes were accompanied by a sense ofdeadness in his body. Inaddition, during these periods hewas uncertain of his balance and frequently stumbledinto furniture; this was more apt to occur in public, espe-cially if he was somewhat anxious. During these episodeshe felt a lack of easy, natural control of his body, and histhoughts seemed "foggy" as well. ...

The patient's subjective sense of lack of control wasespecially troublesome, and he would fight it by shakinghis head and saying "stop" to himself.This would momen-tarily clear his mind and restore his sense of autonomy,but only temporarily, as the feelings of deadness and ofbeing outside himself would return. Gradually, over aperiod of several hours, the unpleasant experienceswould fade ... At the time the patient came for treatment,he was experiencing these symptoms about twice a week,and each incident lasted from 3 to 4 hours. On severaloccasions the episodes had occurred while he was drivinghis car and was alone; worried that he might have an acci-dent, he had stopped driving unless someone accompa-nied him. (Adapted from Spitzer et aI., 2002, pp. 270-71.)

Source: Adaptedwithpermissionfromthe DSM-/V-TR Casebook(Copyright2000). AmericanPsychiatricPublishing,Inc.

In a study of 30 cases of depersonalization disorder,Simeon et al. (1997) noted elevated levels of comorbidanxiety and mood disorders, as well as avoidant, border-line, and obsessive-compulsive personality disorders (seealso Hunter, Phillips, et aI., 2003). Another study of over200 cases found that the disorder had an average age ofonset of 23. Moreover, in nearly 80 percent of cases the dis-order has a fairly chronic course (with little or no fluctua-tion in intensity; Baker, Hunter, et aI., 2003). Another studyby Simeon et al. (2001) also revealed more self-reportedemotional abuse among those with depersonalization dis-order than in a nondissociative control group.

The lifetime prevalence of depersonalization disorderis unknown, but occasional depersonalization symptomsare not uncommon in a variety of other disorders such asschizophrenia, borderline personality disorder, panic disor-der, acute stress disorder, and PTSD (Hunter, Phillips, et aI.,2003). Although severe depersonalization symptoms canbe quite frightening and may make the victim fear immi-nent mental collapse, such fears are usually unfounded.Sometimes, however, feelings of depersonalization areearly manifestations of impending decompensation andthe development of psychotic states (Chapter 14). In eithercase, professional assistance in dealing with the precipitat-ing stressors and in reducing anxiety may be helpful.

Dissociative Amnesia and FugueRetrograde amnesia is the partial or total inability to recall oridentify previously acquired information or past experi-ences; by contrast, antero-grade amnesia is thepartial or total inability toretain new information(Kapur, 1999; McNally,2003). Persistent amnesiamay occur in severalAxis I disorders such asdissociative amnesia anddissociative fugue, and inorganic brain pathologyincluding traumatic braininjury and diseases of thecentral nervous system. Ifthe amnesia is caused bybrain pathology (diag-nosed as "Amnestic Dis-order Due to a GeneralMedical Condition"; seeChapter 15), it most ofteninvolves failure to retainnew information andexperiences (anterograde amnesia). That is, the informationcontained in experience is not registered and does not entermemory storage (Kapur, 1999).

In the movie Memento,thelead character has anterogradeamnesia, which makes himunable to form any short-termmemories. He has to writenotes to himself and refer tothem constantly in order tofunction on a daily basis.

On the other hand, dissociative amnesia (orpsychogenic amnesia) is usually limited to a failure torecall previously stored personal information, when thatfailure cannot be accounted for by ordinary forgetting(retrograde amnesia). The gaps in memory most oftenoccur following intolerably stressful circumstances-wartime combat conditions, for example, or catastrophicevents such as serious car accidents, suicide attempts, orviolent outbursts. In this disorder, apparently forgottenpersonal information is still there beneath the level ofconsciousness, as sometimes becomes apparent in inter-views conducted under hypnosis or narcosis (induced bysodium amytal, or so-called "truth serum") and in caseswhere the amnesia spontaneously clears up. Four primarytypes of psychogenic amnesia are recognized by DSM-IV-TR: localized (a person remembers nothing that hap-pened during a specific period, most commonly the firstfew hours or days following some highly traumaticevent); selective (a person forgets some but not all of whathappened during a given period); generalized (a personforgets his or her life history including his or her iden-tity); and continuous (a person remembers nothingbeyond a certain point in the past until the present). Thelatter two types occur rarely.

Usually amnesic episodes last between a few days anda few years, and although some people experience only onesuch episode, many people have multiple episodes in theirlifetimes (Maldonado et al., 2002). In typical dissociativeamnesic reactions, individuals cannot remember certainaspects of their personal life history or important factsabout their identity. Yet their basic habit patterns-such astheir abilities to read, talk, perform skilled work, and soon-remain intact, and they seem normal aside from thememory deficit (Kihlstrom, 2005; Kihlstrom & Schacter,2000). Thus only a particular type of memory is affected,the type of memory psychologists refer to as episodic (per-taining to events experienced) or autobiographical mem-ory. The other recognized forms of memory-semantic(pertaining to language and concepts), procedural (how todo things), and short-term storage-seem usually toremain intact, although there is very little research on thistopic (Kihlstrom, 2005; Kihlstrom & Schacter, 2000).

In very rare cases, a person may retreat still furtherfrom real-life problems by going into an amnesic statecalled a dissociative fugue, which, as the term implies (theFrench word fugue means "flight"), is a defense by actualflight-a person not only is amnesic for some or all aspectsof his or her past but also departs from home surround-ings. This is accompanied by confusion about personalidentity or even the assumption of a new identity(although the identities do not alternate as in dissociativeidentity disorder). During the fugue, such individuals areunaware of memory loss for prior stages of their life, buttheir memory for what happens during the fugue stateitself is intact (Kihlstrom, 2005; Kihlstrom & Schacter,

A. Primary disturbance is one or more episodes of inability torecall important personal information too extensive to beexplained by ordinary forgetfulness.

B. Symptoms cause distress or impairment in functioning.

Source:Adapted with permission from the DiagnosticandStatisticalManualofMentalDisorders,FourthEdition,TextRevision(Copyright 2000). American Psychiatric Association.

A. Primary disturbance is sudden, unexpected travel awayfrom home or work with inability to recall one's past.

B. Confusion about personal identity or assumption of a newidentity.

C. Symptoms cause distress or impairment in functioning.

Source:Adapted with permission from the DiagnosticandStatisticalManualofMentalDisorders,FourthEdition,TextRevision(Copyright 2000). American Psychiatric Association.

2000). Their behavior during the fugue state is usuallyquite normal and unlikely to arouse suspicion that some-thing is wrong. However, behavior during the fugue stateoften reflects a rather different lifestyle from the previousone (the rejection of which is sometimes fairly obvious).Days, weeks, or sometimes even years later, such peoplemay suddenly emerge from the fugue state and find them-selves in a strange place working in a new occupation, withno idea how they got there. In other cases, recovery fromthe fugue state occurs only after repeated questioning andreminders of who they are. In either case, as the fugue stateremits, their initial amnesia remits-but a new, apparentlycomplete amnesia for their fugue period occurs.

The pattern in dissociative amnesia and fugue is essen-tially similar to that in conversion symptoms, except thatinstead of avoiding some unpleasant situation by becomingphysically dysfunctional, a person unconsciously avoidsthoughts about the situation or, in the extreme, leaves thescene (Maldonado et al., 2002). Thus people experiencingdissociative amnesia and fugue are typically faced withextremely unpleasant situations from which they see noacceptable way to escape. Eventually the stress becomes so

intolerable that large segments of their personalities and allmemory of the stressful situations are suppressed.

Several of these aspects of dissociative fugue are illus-trated in the following case.

A Middle ManagerTransformed into aShort-Order Cook

Burt Tate, a 42-year-old short-order cook in a small-towndiner, was brought to the attention of local police follow-ing a heated altercation with another man at the diner. Hegave his name as Burt Tate and indicated that he hadarrived in town several weeks earlier. However, he couldproduce no official identification and could not tell theofficers where he had previously lived and worked. Burtwas asked to accompany the officers to the emergencyroom of a local hospital so that he might be examined ....

Burt's physical examination was negative for evi-dence of recent head trauma or any other medical abnor-mality.... He was oriented as to current time and place,but manifested no recall of his personal history prior tohis arrival in town. He did not seem especially concernedabout his total lack of a remembered past. ...

Meanwhile, the police ... discovered that Burtmatched the description of one Gene Saunders, a resi-dent of a city some 200 miles away who had disappeareda month earlier. The wife of Mr. Saunders ... confirmedthe real identity of Burt, who ... stated that he did not rec-ognize Mrs. Saunders.

Prior to his disappearance, Gene Saunders, a middle-level manager in a large manufacturing firm, had beenexperiencing considerable difficulties at work and athome. Anumber of stressful work problems, including fail-ure to get an expected promotion, the loss of some of hiskey staff, failure of his section to meet production goals,and increased criticism from his superior-all occurringwithin a brief time frame- had upset his normal equanim-ity. He had become morose and withdrawn at home, andhad been critical of his wife and children. Twodays beforehe had left, he had had a violent argument with his 18-year-old son, who'd declared his father a failure and hadstormed out of the house to go livewith friends. (Adaptedfrom Spitzer et aI., 2002, pp. 215-16.)

Source: Adapted with permission from the DSM-IV-TR Casebook(Copyright 2000). American Psychiatric Publishing, Inc.

MEMORY AND INTELLECTUAL DEFICITS IN DISSOCIA-TIVE AMNESIA AND FUGUE Unfortunately, very littlesystematic research has been conducted on individualswith dissociative amnesia and fugue. What is known comeslargely from intensive studies of the memory and intellec-tual functioning of isolated cases with these disorders, soany conclusions should be considered tentative pendingfurther study of larger samples with appropriate control

groups. What can be gathered from a handful of such casestudies is that these individuals' semantic knowledge(assessed via the vocabulary subtest of an IQ test) seems tobe generally intact. The primary deficit these individualsexhibit is their compromised episodic or autobiographicalmemory (Kihlstrom, 2005; Kihlstrom & Schacter, 2000).Indeed, several studies using brain-imaging techniqueshave confirmed that when people with dissociative amne-sia are presented with autobiographical memory tasks,they show reduced activation in their right frontal andtemporal brain areas relative to normals doing the samekinds of tasks (Kihlstrom, 2005; Markowitsch, 1999).

However, several cases (some nearly a century old)have suggested that implicit memory is generally intact.For example, Jones (1909, as cited in Kihlstrom & Schacter,2000) studied a patient with dense amnesia and found thatalthough .he could not remember his wife's or daughter'snames, when asked to guess what names might fit them, heproduced their names correctly. In a more recent case(Lyon, 1985, as cited in Kihlstrom & Schacter, 2000), apatient who could not retrieve any autobiographical infor-mation was asked to dial numbers on a phone randomly.Without realizing what he was doing, he dialed hismother's phone number, which then led to her identifyinghim. In one particularly fascinating recent case of dissocia-tive fugue, Glisky and colleagues (2004) described a Ger-man man who had come to work in the United Statesseveral months before he experienced a traumatic incidentin which he was robbed and shot, at which point he wan-dered along unfamiliar streets for an unknown period oftime. Finally, he stopped at a motel and asked if the policecould be called because he did not know who he was (andhad no ID because he'd been robbed) and could not recallany personal details of his life. He spoke in English (with aGerman accent) but could not speak German and did notrespond to German instructions (which he denied that hespoke). In spite of his extensive loss of autobiographicalmemory (and the German language), when given a varietyof memory tasks, he showed intact implicit memory. Espe-cially striking was his ability to learn German-Englishword pairs, which he learned much faster than did normalcontrols, suggesting implicit knowledge of German eventhough he had no conscious knowledge of it.

Some of these memory deficits in dissociative amnesiaand fugue have been compared to related deficits inexplicit perception that occur in conversion disorders. Thishas convinced a good number of current theorists thatconversion disorder should be classified with dissociativedisorders rather than with somatoform disorders, as dis-cussed in Developments in Thinking 8.2.

Dissociative Identity Disorder (DID)According to DSM -IV-TR, dissociative identity disorder(DID), formerly called multiple personality disorder(MPD), is a dramatic dissociative disorder in which a

.2 Should ConversionDisorder Be Classified asa Dissociative Disorder?

Starting with Freud and Janet, and for a largeportion of the twentieth century prior to thepublication of DSM-I" in 1980, conversion dis-orders were classified together with dissocia-tive disorders as subtypes of hysteria (e.g.,

Hysterical Neurosis, Dissociative Type rather than the Hys-terical Neurosis, Conversion Type listed in DSM-II).When itwas determined that DSM-I" would rely heavily on overtbehavioral symptoms rather than on presumed underlyingetiology (namely repressed anxiety) for classifying disor-ders, the decision was made to include conversion disorderwith the other somatoform disorders, because the symp·toms always appeared to be physical ones with no demon-strable organic basis. However, as Kihlstrom (1994, 2001,2005) and others have pointed out, this way of linking con-version disorders together with all the other somatoformdisorders, by focusing on their all having baseless physicalcomplaints, ignores several important differences betweenconversion disorders and other somatoform disorders. Themost important overall difference is that conversion symp-toms (but not those of the other somatoform disorders) arenearly always pseudo neurological in nature (blindness,paralysis, anaesthesias, deafness, seizures, etc.), mimick-ing some true neurological syndromes, just as most of thedissociative disorders do.

The disorders we currently classify as dissociative dis-orders (such as dissociative amnesia and fugue and

patient manifests two or more distinct identities that alter-nate in some way in taking control of behavior. There isalso an inability to recall important personal informationthat cannot be explained by ordinary forgetting. Eachidentity may appear to have a different personal history,self-image, and name, although there are some identitiesthat are only partially distinct and independent from otheridentities. In most cases the one identity that is most fre-quently encountered and carries the person's real name isthe host identity. In most cases the host is not the originalidentity, and it mayor may not be the best-adjusted iden-tity. The alter identities may differ in striking waysinvolving gender, age, handedness, handwriting, sexualorientation, prescription for eyeglasses, predominantaffect, foreign languages spoken, and general knowledge.For example, one alter may be carefree, fun-loving, andsexually provocative, and another alter quiet, studious,serious, and prudish. Needs and behaviors inhibited in theprimary or host identity are usually liberally displayed byone or more alter identities. Certain roles such as a childand someone of the opposite sex are extremely common.

dissociative identity disorder) involve disruptions in explicitmemory for events that have occurred, or who or what one'sidentity is, or both. However, it is clear that events occurringduring a period of amnesia or in the presence of one identityare indeed registered in the nervous system, because theyinfluence behavior indirectly even when the person cannotconsciously recollect them (i.e., implicit memory remains atleast partially intact in dissociative disorders). Similarly,Kihlstrom and others have argued that the conversion disor-ders involve disruptions in explicit perception and action.That is, people with conversion disorders have no consciousrecognition that they can see or hear or feel, or no consciousknowledge that they can walk or talk. However, patients withconversion disorder can see, hear, feel, or move whentricked into doing so or when indirect physiological orbehavioral measures are used (see Janet, 1901, 1907;Kihlstrom, 1994, 2001, 2005). Thus Kihlstrom (1994, 2001,2005) makes a compelling argument that when the next edi-tion of DSMappears, the term conversion disorder shouldbe dropped and the sensory and motor types of the syn-drome should be reclassified as forms of dissociative dis-orders. This way, the central feature of all dissociativedisorders would be a disruption of the normally integratedfunctions of consciousness (memory, perception, andaction). Such a proposal is also consistent with observationsthat dissociative symptoms and disorders are quite commonin patients with conversion disorder (e.g., Sar et aI., 2004).

Criteria for Dissociative IdentityDisorder

A. Presence of two or more distinct identities, each with itsown relatively enduring pattern of perceiving, relating to,and thinking about the environment and the self.

B. At least two of the identities recurrently take control ofthe person's behavior.

C. Inability to recall important personal information that istoo extensive to be explained by ordinary forgetfulness.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

Much of the reason for abandoning the older diagnos-tic term multiple personality disorder in favor of DID wasthe growing recognition that it conveyed misleading infor-mation, suggesting multiple occupancy of space, time, andvictims' bodies by differing, but fully organized and coher-ent, "personalities." In fact, alters are not in any meaningfulsense personalities but rather reflect a failure to integratevarious aspects of a person's identity, consciousness, andmemory (APA, 2000). The term DID betters captures thesechanges in consciousness and identity than does MPD.

Alter identities take control at different points in timeand the switches typically occur very quickly (in a matterof seconds), although more gradual switches can alsooccur (APA, 2000). When switches occur in people withDID, it is often easy to observe the gaps in memories forthings that have happened-often for things that havehappened to other identities. But this amnesia is not alwayssymmetrical; that is, some identities may know moreabout certain alters than do other identities. Sometimesone submerged identity gains control by producing hallu-cinations (such as a voice inside the head giving instruc-tions). In sum, DID is a condition in which normallyintegrated aspects of memory, identity, and consciousnessare no longer integrated.

The presence of more than one identity and signifi-cant amnesia for what alter identities have experienced arenot the only symptoms of DID. Other symptoms includedepression, self-mutilation, and frequent suicidal ideationand attempts. People with DID often show moodiness anderratic behavior, headaches, hallucinations, substanceabuse, post-traumatic symptoms, and other amnesic andfugue symptoms (APA, 2000; Maldonado et aI., 2002).

The disorder usually starts in childhood, althoughmost patients are in their twenties or thirties at the time ofdiagnosis (Ross, 1997). Approximately three to nine timesmore females than males are diagnosed as having the dis-order, and females tend to have a larger number of altersthan do males (APA, 2000). Some believe that this pro-nounced gender discrepancy is due to the much greaterproportion of childhood sexual abuse among females thanamong males (see Chapter 13), but this is a highly contro-versial point, as discussed later.

Many of these features are illustrated in the case ofMary Kendall.

Mary, a 3s-year-old divorced social worker, had ... in herright forearm and hand ... chronic pain. Medical manage-ment of this pain had proved problematic, and it wasdecided to teach her self-hypnosis as a means whereby

she might control it. She proved an excellent hypnotic sub-ject and quickly learned effective pain control techniques.

Her hypnotist/trainer, a psychiatrist, describes Mary'slife in rather unappealing terms. She is said to be compe-tent professionally but has an "arid" personal and sociallife. Although her brief marriage ended some 10 years ago,she evidences little interest in men and doesn't seem tohave any close friends. She spends most of her free timedoing volunteer work in a hospice ...

In the course of the hypnotic training, Mary's psychi-atrist discovered that she seemed to have substantialgaps in her memory. One phenomenon in particular wasvery puzzling: She reported that she could not accountfor what seemed an extraordinary depletion of the gaso-line in her car's tank. She would arrive home from workwith a nearly full tank, and by the following morning ass e began her trip to work would notice that the tank wasnow only half-full. When it was advised that she keeptrack of her odometer readings, she discovered that onmany nights on which she insisted she'd remained athome, the odometer showed significant accumulations ofup to 100 miles. The psychiatrist, by now strongly sus-pecting that Mary had a dissociative disorder, also estab-lished that there were large gaps in her memories ofchildhood. He shifted his focus to exploring the appar-ently widespread dissociative difficulties.

In the course of one of the continuing hypnotic ses-sions, the psychiatrist again asked about "lost time," andwas greeted with a response in a wholly different voicetone that said, "It's about time you knew about me." Mar-ian, an apparently well-established alter identity, went onto describe the trips she was fond of taking at night ...Marian was an extraordinarily abrupt and hostile "per-son," the epitome in these respects of everything the com-pliant and self-sacrificing Mary was not. Marian regardedMary with unmitigated contempt, and asserted that "wor-rying about anyone but yourself is a waste of time."

In due course some six other alter identitiesemerged ... There was notable competition among thealters for time spent "out," and Marian was often soprovocative as to frighten some of the more timid others,which included a six-year-old child ....

Mary's history, as gradually pieced together,included memories of physical and sexual abuse by herfather as well as others during her childhood .... Hermother was described ... as having abdicated to a largeextent the maternal role, forcing Mary from a young ageto assume these duties in the family.

Four years of subsequent psychotherapy resulted inonly modest success in achieving a true "integration" ofthese diverse trends in Mary Kendall's selfhood. (Adaptedfrom Spitzer et aI., 2002, pp.S6-S7.)

Source: Adapted with permission from the DSM-/V- TR Casebook(Copyright 2000). American Psychiatric Publishing, Inc.

Chris Sizemore was the inspiration for the book and movie ThreeFaces of Eve, which explore her multiple personality disorder (nowknown as DID). Sizemore recovered in 1975 and then worked as anadvocate for the mentally ill.

The number of alter identities in DID varies tremen-dously and has increased over time. One review of 76 clas-sic cases published in 1944 reported that two-thirds ofthese cases had only two personalities and most of the resthad three (Taylor & Martin, 1944). Yet more recent esti-mates in DSM-IV-TR are that about 50 percent now showover ten identities (APA, 2000), with some respondentsclaiming as many as a hundred. This historical trend ofincreasing multiplicity suggests the operation of social fac-tors, perhaps through the encouragement of therapists, aswe discuss below (e.g., Lilienfeld et al., 1999; Piper &Merskey, 2004a, 2004b; Spanos, 1996). Another recenttrend is that many of the reported cases of DID nowinclude more unusual and even bizarre identities than inthe past (such as being an animal) and more highlyimplausible backgrounds (for example, ritualized satanicabuse in childhood).

PREVALENCE-WHY HAS DID BEEN INCREASING?Owing to their dramatic nature, cases of DID have receiveda great deal of attention and publicity in fiction, television,and motion pictures. But in fact, until relatively recently,DID was extremely rare-or at least rarely diagnosed-inclinical practice. Prior to 1979, only about 200 cases couldbe found in the entire psychological and psychiatric litera-ture worldwide. By 1999, however, over 30,000 cases hadbeen reported in North America alone (Ross, 1999),although as we will discuss later, many researchers in thisarea believe that this is a gross overestimate of true cases(e.g., Piper & Merskey, 2004b). Although their diagnosedoccurrence in clinical settings has increased enormouslyin recent years, prevalence estimates in the general popu-lation vary tremendously, and it is possible that no suchestimates are valid, given how hard it is to make this diag-nosis reliably. (For example, recall that Mary's DID wasuncovered only in the course of hypnotic sessions for painmanagement.)

Many factors probably have contributed to the drasticincrease in the reported prevalence of DID (although in anabsolute sense it is still very rare, and most practicing psy-chotherapists never see a person with DID in their entirecareers). For example, the number of cases began to rise inthe 1970s after the publication of Flora Rhea Schreiber'sSybil (1973), which increased public awareness of the con-dition (although ironically the case was later thoroughlydiscredited; see Borch-Jacobsen, 1997; Rieber, 1999). Atabout the same time, the diagnostic criteria for DID (thenMPD) were clearly specified for the first time in 1980 withthe publication of DSM -III. This seems to have led toincreased acceptance of the diagnosis by clinicians, whichmay have encouraged reporting in the literature. Clinicianswere traditionally (and often still are today) somewhatskeptical of the astonishing behavior these patients oftendisplay-such as undergoing sudden and dramatic shiftsin personal identity before the clinicians' eyes.

Another reason why the diagnosis may be made morefrequently since 1980 is that the diagnostic criteria forschizophrenia were tightened in DSM-III (1980). A goodnumber of people who had been inappropriately diag-nosed with schizophrenia before that time probably beganto receive the appropriate diagnosis of MPD (now DID).(See The World Around Us 8.3 on p. 302.) Beginning inabout 1980, prior scattered reports of instances of child-hood abuse in the histories of adult DID patients beganbuilding into what would become a crescendo. As we willsee later, many controversies have arisen regarding how tointerpret such findings, but it is definitely true that thesereports of abuse in patients with DID drew a great deal ofattention to this disorder, which in turn may have increasedthe rate at which it was being diagnosed.

Finally, it is almost certain that some of the increase inthe prevalence of DID is artifactual and has occurredbecause some therapists looking for evidence of DID incertain patients may suggest the existence of alter identities(especially when the person is under hypnosis and verysuggestible); (e.g., Kihlstrom, 2005; Piper & Merskey,2004b). The therapist may also subtly reinforce the emer-gence of new identities by showing great interest in thesenew identities. The way in which this might occur will bediscussed in more detail later.

EXPERIMENTAL STUDIES OF DID The vast majority ofwhat is known about DID comes from patients' self-reports and clinical observations by therapists orresearchers. Indeed, only a small number of experimentalstudies of people with DID have been conducted to cor-roborate clinical observations that go back a hundredyears. Moreover, most of these studies have been con-ducted on only one or a few cases, although very recently afew larger studies have been done that include appropriatecontrol groups (e.g., Dorahy, Middleton, & Irwin, 2005;Huntjens et al., 2003). In spite of such shortcomings, most

8.3The general public has long been confused by

the distinction between DID and schizophrenia.It is not uncommon for people diagnosed withschizophrenia to be referred to as having a"split personality." We have even heard people

say such things as, "I'm a bit schizophrenic on this issue"to mean that they have more than one opinion about it!

This misuse of the term split personality reflects thepublic's general misunderstanding of schizophrenia, whichdoes not involve a "split" or "Jekyll and Hyde" personalityat all. The original confusion may have stemmed from theterm schizophrenia, which was first coined by a Swiss psy-chiatrist named Bleuler. Schizien is German for "split," andphren is the Greek root for "mind." The notion that schizo-phrenia is characterized by a split mind or personality mayhave arisen this way.

However, this is not at all what Bleuler intended theword schizophrenia to mean. Rather, Bleuler was referring

of the findings from these studies are generally consistentwith one another and reveal some very interesting featuresof DID.

The primary focus of these studies has been to deter-mine the nature of the amnesia that exists between differ-ent identities. As we have already noted, most people withDID have at least some identities that seem completelyunaware of the existence and experiences of certain alteridentities, although other identities may be only partiallyamnesic of some alters (e.g., Elzinga et al., 2003; Huntjenset al., 2003). This feature of DID has been corroborated bystudies showing that when one identity (Identity 1) isasked to learn a list of word pairs, and an alter identity(Identity 2) is later asked to recall the second word in eachpair, using the first word as a cue, there seems to be notransfer of what was learned by Identity 1 to Identity 2.This interpersonality amnesia with regard to consciousrecall of the activities and experiences of at least someother identities has generally been considered a funda-mental characteristic of DID (Kihlstrom, 2001, 2005;Kihlstrom & Schacter, 2000). Nevertheless, one interest-ing recent study of 21 DID patients has challenged theidea that this interpersonality amnesia is complete. Asexpected, the DID patients all reported complete subjec-tive amnesia of a list of words (List A) learned by Identity 1when Identity 2 was "out" and was asked if s/he had anyrecall of having learned List A. However, when Identity 2was given a recognition test of his or her knowledge of ListA, s/he actually recognized about 50 percent of the words

Schizophrenia, Split Personality,and DID: Clearing Up theConfusion

to the splitting of the normally integrated associativethreads of the mind-links between words, thoughts, emo-tions, and behavior. Splits of this kind result in thinkingthat is not goal-directed or efficient, which in turn leads tothe host of other difficulties known to be associated withschizophrenia.

It is very important to remember that people diag-nosed with schizophrenia do not have multiple distinctidentities that alternately take control over their mind andbehavior. They may have a delusion and believe they aresomeone else, but they do not show the changes in iden-tity accompanied by changes in tone of voice, vocabulary,and physical appearance that are often seen when identi-ties "switch" in DID. Furthermore, people with DID (whoare probably closer to the general public's notion of "splitpersonality") do not exhibit such characteristics of schizo-phrenia as disorganized behavior, hallucinations comingfrom outside the head, and delusions.

(Huntjens et al., 2003), suggesting partial transfer ofexplicit memory across identities in this task.

As noted earlier, there are kinds of memory other thansimply what can be brought to awareness (explicit mem-ory). As with dissociative amnesia and fugue, there is evi-dence that Identity 2 has some implicit memory of thingsthat Identity 1 learned. That is, although Identity 2 maynot be able to recall consciously the things learned by Iden-tity 1, these apparently forgotten events may influenceIdentity 2's experiences, thoughts, and behaviors uncon-sciously (Kihlstrom, 2001, 2005). This might be reflectedin a test asking Identity 2 to learn the list of words previ-ously learned by Identity 1. Even though Identity 2 couldnot consciously recall the list of words, Identity 2 wouldlearn that list more rapidly than a brand-new list of words,an outcome that suggests the operation of implicit mem-ory (e.g., Eich et al., 1997; Elzinga et al., 2003; seeKihlstrom, 2001, 2005, for reviews).

Related studies on implicit transfer of memories haveshown that emotional reactions learned by one identityoften transfer across identities, too. Thus, even thoughIdentity 2 may not be able to recall an emotional event thathappened to Identity 1, a visual or auditory reminder ofthe event (a conditioned stimulus) administered to Iden-tity 2 may elicit an emotional reaction even though Iden-tity 2 has no knowledge of why it did so (e.g., Ludwig et al.,1972; Prince, 1910; see Kihlstrom & Schacter, 2000, for areview). Moreover, a very recent study by Huntjens et al.(2005) had 22 DID patients in Identity 1 learn to reevalu-

ate a neutral word in a posItIve or negative mannerthrough a simple evaluative conditioning procedure inwhich neutral words are simply paired with positive ornegative words; the neutral words then come to take onpositive or negative connotations. When Identity 2 waslater asked to emerge, s/he also categorized the formerlyneutral word in the same positive or negative manner aslearned by Identity I, showing implicit memory for thereevaluation of the word learned by Identity 1 (althoughcomplete subjective amnesia was reported by Identity 2).Nevertheless, other sophisticated studies have made it clearthat implicit memory transfer across personalities doesnot always occur, particularly with certain kinds of implicitmemory tasks where memory performance may bestrongly influenced by the identity currently being tested(e.g., Dorahy, 2001; Eich et al., 1997; Nissen et aI., 1988).But whatever the reasons why only some implicit memorytests show evidence of transfer across identities, the resultsthat do show implicit memory transfer are very important.This is because they demonstrate that explicit amnesiaacross identities cannot occur simply because one identityis trying actively to suppress any evidence of memorytransfer; if this were possible, there would be no leakage ofimplicit memories across identities (Dorahy, 2001; Eichet aI., 1997).

An even smaller number of experimental studies haveexamined differences in brain activity when individualswith DID are tested with different identities at the fore-front of consciousness. For example, in an early classicstudy, Putnam (1984) investigated EEG activity in 11 DIDpatients during different identities, and ten control sub-jects who were simulating different personality states, inorder to determine whether there were different patternsof brain wave activity during different identities (real orsimulated), as would be found if separate individuals wereassessed. The study found that there were indeed differ-ences in brain wave activity when the patients with DIDwere in different personality states and that these differ-ences were greater than those found in the simulating sub-jects (see Kihlstrom et aI., 1993; Putnam, 1997). Tsai andcolleagues (1999) used fMRI brain-imaging techniques tostudy different identities of a woman with DID while theswitch from one identity to another was occurring. Theyfound that changes in hippocampal and medial temporallobe activity occurred during the switches. These brainareas are involved in memory, so finding activity there dur-ing switches of identity (which involve changes in patternsof memory) might be expected.

CAUSAL FACTORS AND CONTROVERSIES ABOUT DIDThere are at least four serious interrelated controversiessurrounding DID and how it develops. First, some havebeen concerned with whether DID is a real disorder or isfaked, and whether, even if it is real, it can be faked. Thesecond major controversy is about how DID develops.Specifically, is DID caused by early childhood trauma, or

does the development of DID involve some kind of socialenactment of multiple different roles that have been inad-vertently encouraged by careless clinicians? Third, thosewho maintain that DID is caused by childhood trauma citemounting evidence that the vast majority of individualsdiagnosed with DID report memories of an early history ofabuse. But are these memories of early abuse real or false?Finally, if abuse has occurred in most individuals withDID, did the abuse playa causal role, or was something elsecorrelated with abuse actually the cause?

Is DID Real or Is It Faked? The issue of possible facti-tious or malingering origins of DID has dogged the diag-nosis of DID for at least a century. One obvious situation inwhich this issue becomes critical is when it has been used bydefendants and their attorneys to try to escape punishmentfor crimes ("My other personality did it"). For example, thisdefense was used, ultimately unsuccessfully, in the famouscase of the Hillside Strangler, Kenneth Bianchi (Orne,Dinges, & Orne, 1984),but it has probably beenused successfully in othercases that we are unawareof (almost by definitionbecause the person is notsent to prison but ratherto a mental hospital inmost cases). Bianchi wasaccused of brutally rap-ing and murdering tenyoung women in the LosAngeles area. Althoughthere was a great deal ofevidence that he hadcommitted these crimes,he steadfastly denied it,and some lawyersthought perhaps he hadDID. He was subse-quently interviewed by aclinical psychologist, andunder hypnosis a secondpersonality, "Steve;' emerged who confessed to the crimes,thereby creating the basis for a plea of "not guilty by reasonof insanity" (see Chapter 18). However, Bianchi was exam-ined even more closely by a renowned psychologist and psy-chiatrist specializing in this area, the late Martin Orne. Uponcloser examination, Orne determined that Bianchi was fak-ing the condition. Orne drew this conclusion in part becausewhen he suggested to Bianchi that most people with DIDhave more than two identities, Bianchi suddenly produced athird (Orne et al., 1984). Moreover, there was no evidence ofmultiple identities existing prior to the trial. When Bianchi'sfaking the disorder was discovered, he was convicted of themurders. In other words, some cases of DID may involvecomplete fabrication orchestrated by criminal or other

Kenneth Bianchi, know as the "HillsideStrangler," brutally raped and murdered10 women in the Los Angeles area. Hopingto create a plea of "not guilty by reason ofinsanity," Bianchi fabricated a secondpersonality- "Steve" - who "emerged"while Kenneth was under hypnosis. Apsychologist and psychiatrist specializingin DID determined he was faking thediagnosis and Bianchi was subsequentlyconvicted of the murders.

unscrupulous persons seeking unfair advantages, and not allprosecutors have as clever and knowledgeable an expert wit-ness as Martin Orne to help detect this. But most researchersthink that factitious and malingering cases of DID (such asthe Bianchi case or cases in which the person has a need tobe a patient) are relatively rare.

If DID Is Not Faked, How Does It Develop: Post-Traumatic Theory or Sociocognitive Theory? Manyprofessionals acknowledge that in most cases, DID is a realsyndrome (not consciously faked), but there is marked dis-agreement about how it develops and how it is maintained.In the contemporary literature, the original major theoryof how DID develops is post-traumatic theory (Gleaves,1996; Ross, 1997, 1999). The vast majority of patients withDID (over 95 percent by some estimates) report memoriesof severe and horrific abuse as children (see Figure 8.1).According to this view, DID starts from the child's attemptto cope with an overwhelming sense of hopelessness andpowerlessness in the face of repeated traumatic abuse.Lacking other resources or routes of escape, the child maydissociate and escape into a fantasy, becoming someoneelse. This escape may occur through a process like self-hypnosis (Butler et aI., 1996), and if it helps to alleviatesome of the pain caused by the abuse, it will be reinforcedand occur again in the future. Sometimes the child simplyimagines the abuse is happening to someone else. If thechild is fantasy-prone, and this continues, the child mayunknowingly create different selves at different points intime, possibly laying the foundation for multiple dissoci-ated identities.

But only a subset of children who undergo traumaticexperiences are prone to fantasy or self-hypnosis, whichleads to the idea that a diathesis-stress model may be

appropriate here. That is, children who are prone to fan-tasy and/or those who are easily hypnotizable may have adiathesis for developing DID (or other dissociative disor-ders) when severe abuse occurs (e.g., Butler et aI., 1996;Kihlstrom, Glisky, & Angiulo, 1994). Moreover, it shouldalso be emphasized that there is nothing inherently patho-logical about being prone to fantasy or readily hypnotiz-able (Kihlstrom et al., 1994).

Increasingly, those who view childhood abuse as play-ing a critical role in the development of DID are beginningto see DID as perhaps a complex and chronic variant ofpo t-traumatic stress disorder, which by definition iscaused by exposure to some kind of highly traumaticevent(s), including abuse (e.g., Brown, 1994; Maldonadoet aI., 2002; Zelikovsky & Lynn, 1994). Anxiety symptomsare more prominent in PTSD than in DID, and dissociativesymptoms are more prominent in DID than in PTSD. Nev-ertheless, both kinds of symptoms are present in both dis-orders (Putnam, 1997).

At the other extreme from post-traumatic theory issociocognitive theory, which claims that DID developswhen a highly suggestible person learns to adopt and enactthe roles of multiple identities, mostly because clinicianshave inadvertently suggested, legitimized, and reinforcedthem, and because these different identities are geared tothe individual's own personal goals (Lilienfeld et aI., 1999;Lilienfeld & Lynn, 2003; Spanos, 1994, 1996). It is impor-tant to realize that at the present time, the sociocognitiveperspective maintains that this is not done intentionally orconsciously by the afflicted individual but, rather, occursspontaneously with little or no awareness (Lilienfeld et aI.,1999). The suspicion is that overzealous clinicians,through fascination with the clinical phenomenon of DIDand unwise use of such techniques as hypnosis, are them-

Reported Childhood Abuse in Five Separate Studies of DID Patients(Total N = 843)

D Putnam et aI., 1986 (100 cases)

Ross et aI., 1990 (236 cases)

Coons et aI., 1988 (50 cases)

D Schultz et aI., 1989 (355 cases)

DRoss et aI., 1991 (102 cases)

100

80CIlbIl 60nI-CCIlu 40•..CIlc..

20

0Physical

Type of abuse Reported childhood abuse in fiveseparate studies of DID patients(Total N = 843).

selves largely responsible for eliciting this disorder inhighly suggestible, fantasy-prone patients (e.g., Piper &Merskey, 2004a, 2004b; Spanos, 1996). Consistent with thishypothesis, Spanos, Weekes, and Bertrand (1985) demon-strated that normal college students can be induced bysuggestion under hypnosis to exhibit some of the phenom-ena seen in DID, including the adoption of a second iden-tity with a different name that shows a different profile ona personality inventory. Thus people can enact a secondidentity when situational forces encourage it. Related situ-ational forces that may affect the individual outside thetherapist's office include memories of one's past behavior(e.g., as a child), observations of other people's behavior(e.g., others being assertive and independent, or sexy andflirtatious), and media portrayals of DID (Lilienfeld et al.,1999; Piper & Merskey, 2004b; Spanos, 1994).

Sociocognitive theory is also consistent with evidencethat most DID patients did not show unambiguous signsof the disorder before they entered therapy and with evi-dence that the number of alter identities often increases(sometimes dramatically) with time in therapy (Piper &Merskey, 2004b). It is also consistent with the increasedprevalence of DID since the 1970s, when the first popularaccounts of DID reached the general public, and since1980, when therapist awareness of the condition increasedas well (Lilienfeld et al., 1999; Piper & Merskey, 2004a).

However, there are also many criticisms of sociocog-nitive theory. For example, Spanos' demonstration of role-playing in hypnotized college students is interesting, but itdoes not show that this is the way DID is actually caused inreal life. For example, someone might be able to give a con-vincing portrayal of a person with a broken leg, but thiswould not establish how legs are usually broken. Moreover,the hypnotized participants in this and other experimentsshowed only a few of the most obvious symptoms of DID(such as more than one identity) and showed them onlyunder short-lived, contrived laboratory conditions. Nosuch studies have shown that other symptoms such asdepersonalization, memory lapses for prolonged periods,or auditory hallucinations can occur under such labora-tory conditions. Thus, although some of the symptoms ofDID could be created by social enactment, there is no evi-dence that the disorder can be created this way (e.g.,Gleaves, 2.1996).

Are Recovered Memories of Abuse in DID Real orFalse? Case reports of the cruelty and torture that someDID patients suffered as children are gut-wrenching toread or hear. However, the accuracy and trustworthiness ofthese reports of widespread sexual and other forms ofchildhood abuse in DID (as well as in other disorders-seeChapters 11 and 13) have become a matter of major con-troversy in recent years. Critics argue that many of thesereports of DID patients, which generally come up in thecourse of therapy, may be the result of false memories,which are in turn a product of highly leading questionsand suggestive techniques applied by well-meaning but

inadequately skilled and careless psychotherapists(Kihlstrom, 2005; Lilienfeld et al., 1999; Yapko, 1994). Itseems quite clear to many investigators that this sort ofthing has happened, often with tragic consequences. Inno-cent family members have been falsely accused by DIDpatients, convicted, and imprisoned. But it is also true thatbrutal abuse of children occurs far too often and that it canhave very adverse effects on development, perhaps encour-aging pathological dissociation (e.g., Maldonado et al.,2002; Nash et al., 1993). In such cases, prosecution of theperpetrators of the abuse is indeed appropriate. Of course,the real difficulty here is in determining when the recov-ered memories of abuse are real and when they are false (orsome combination of the two). This bitter controversyabout the issue of false memory is more extensively con-sidered in the Unresolved Issues section at the end of thischapter.

One way to document that particular recovered mem-ories are real might be if some reliable physiological testcould be developed to distinguish between them. Thus,some researchers are currently trying to determine whetherthere are different neural correlates of real and false memo-ries that could be used to make this determination reliably.Another somewhat easier way to document whether a par-ticular recovered memory is real would be to have indepen-dent verification that the abuse had actually occurred, suchas through physician, hospital, and police records. A num-ber of studies have indeed reported that they have con-firmed the reported cases of abuse, but critics have shownthat the criteria used for corroborating evidence are almostinvariably very loose and suspect as to their validity. Forexample, Chu and colleagues (1999) simply asked theirsubjects, "Have you had anyone confirm these events?"(p. 751) but did not specify what constituted confirmationand had no way of determining if subjects were exaggerat-ing or distorting the information they provided as confirm-ing evidence (Piper & Merskey, 2004a). In another exampleof a flawed study, Lewis and colleagues (1997) studied12 convicted murderers and then confirmed through med-ical, social service, and prison records that all 12 had beenseverely abused as children. Unfortunately, this study didnot include a control group of otherwise comparable mur-derers who did not exhibit DID symptoms. Hence we can-not be certain that the childhood abuse of these subjects isnot as much (or more) associated with violence or convic-tion for murder as with the development of DID specifi-cally. Moreover, Lewis and colleagues should have carefullyassessed for the possibility that some of the murderersmight have been malingering (faking DID; Lilienfeld et al.,1999). Thus, although this study may have been one of themost impressive attempts yet to document abuse indepen-dently in people with DID, it was significantly flawed, andtherefore highly inconclusive.

If Abuse Has Occurred, Does It Playa Causal Role inDID? Let us put the last controversy about the reality ofrecovered memories of abuse aside for a moment and

assume that severe abuse has occurred in the early child-hood backgrounds of many people with DID. How can wedetermine whether this abuse has played a critical causalrole in the development of DID (e.g., Piper & Merskey,2004a)? Unfortunately, many difficulties arise in answeringthis question. For example, child abuse usually happens infamily environments plagued by many other sources ofadversity and trauma (for example, various forms of psy-chopathology and extreme neglect and poverty). One ormore of these other, correlated sources of adversity couldactually be playing the causal role (e.g., Lilienfeld et aI.,1999; Nash et aI., 1993; Tillman, Nash, & Lerner, 1994).Another difficulty for determining the role of abuse is thatpeople who have experienced child abuse as well as symp-toms of DID may be more likely to seek treatment thanpeople with symptoms of DID who did not experienceabuse. Thus the individuals in most studies about theprevalence of child abuse in DID may not be representativeof the population of all people who suffer from DID.Finally, childhood abuse has been claimed by some to leadto many different forms of psychopathology includingdepression, PTSD, eating disorders, somatoform disorders,and borderline personality disorder, to name just a few.Perhaps the most we will ever be able to say is that child-hood abuse may playa nonspecific causal role for many dis-orders, with other, more specific factors determiningwhich disorder develops (see Chapters 11 and 13).

Comments on a Few of These Controversies about DIDAs we have seen, numerous studies indicate that the sepa-rate identities harbored by DID patients are somewhatphysiologically and cognitively distinct. For example, EEGactivity of various alters may be quite different. Becausesuch differences cannot in any obvious way be simulated(e.g., Eich et aI., 1997), it seems that DID must, in at leastsome cases, involve more than simply the social enactmentof roles. Moreover, this should not be too surprising, giventhe widespread evidence of separate (dissociated) memorysubsystems and nonconscious active mental processing,which indicates that much highly organized mental activ-ity is normally carried on in the background, outside ofawareness (e.g., Kihlstrom, 2005). Moreover, some peopleseem to be especially prone to pathological variants ofthese dissociative processes (Waller, Putnam, & Carlson,1996; Waller & Ross, 1997).

We should also note that each of these controversieshas usually been stated in a dichotomous way: Is DID realor faked? What causes DID-spontaneous social enact-ment of roles or repeated childhood trauma? Are recov-ered memories of abuse real or false? If abuse occurs, doesit playa primary causal role? Unfortunately, however, suchdichotomously stated questions encourage oversimplifiedanswers. The human mind does not seem to operate inthese dichotomous ways, and we need to address the com-plex and multifaceted nature of the dissociated mentalprocesses that these often miserable and severely stressed

patients are experiencing. Fortunately, theorists on bothsides of these controversies have begun to soften their posi-tions just a bit and acknowledge that multiple differentcausal pathways are likely to be involved. For example, Ross(1997,1999), a long-time advocate for a strong version ofpost-traumatic theory, has more recently acknowledgedthat some cases are faked and that some may be inadver-tently caused by unskilled therapists in the course of treat-ment. In addition, other advocates of post-traumatictheory have recently acknowledged that both real and falsememories do occur in these patients, noting that it is criti-cal that a method for determining which is which be devel-oped (e.g., Gleaves, Smith, Butler, & Spiegel, 2004). Fromthe other side, Lilienfeld and colleagues (1999), who havebeen vocal advocates for Spanos' sociocognitive theorysince his death in 1994, have acknowledged that some peo-ple with DID may have undergone real abuse, althoughthey believe it occurs far less often, and is less likely to playa real causal role, than the trauma theorists maintain (seealso Kihlstrom, 2005).

General Sociocultural Causal Factorsin Dissociative DisordersThere seems little doubt that the prevalence of dissociativedisorders, especially their more dramatic forms such asDID, is influenced by the degree to which such phenomenaare accepted or tolerated either as normal or as legitimatemental disorders by the surrounding cultural context.Indeed, in our own society, the acceptance and tolerance ofDID as a legitimate disorder has varied tremendously overtime. Nevertheless, although its prevalence varies, DID hasnow been identified in all racial groups, socioeconomicclasses, and cultures where it has been studied. For exam-ple, outside North America it has been found in countriesranging from Nigeria and Ethiopia to Turkey, India, Aus-tralia, and the Caribbean, to name a few (Maldonado et aI.,2002).

Many seemingly related phenomena, such as spiritpossession and dissociative trances, occur very frequentlyin many different parts of the world where the local culturesanctions them (Krippner, 1994). When entered into vol-untarily, trance and possession states are not consideredpathological and should not be construed as mental disor-ders. But DSM-IV-TR has noted that some people whoenter into these states voluntarily because of culturalnorms develop distress and impairment; in such cases,they might be diagnosed with dissociative trance disorder (aprovisional diagnostic category in DSM-IV- TR). Peoplereceiving this provisional diagnosis must either experiencetrances or possession trances. A trance is said to occurwhen someone experiences a temporary marked alterationin state of consciousness or identity (but with no replace-ment by an alternative identity). It is usually associatedwith either a narrowing of awareness of the immediatesurroundings, or stereotyped behaviors or movements

that are experienced as beyond one's control. A possessiontrance is similar except that the alteration of consciousnessor identity is replaced by a new identity that is attributed tothe influence of a spirit, deity, or other power. One study of58 individuals from Singapore with this diagnosis, as wellas 58 individuals with a diagnosis of major depression,found that conflicts over religious or cultural issues, priorexposure to trance states, and being a spiritual healer orhealer's helper were most predictive of who had dissocia-tive trance disorder relative to major depression (Ng &Chan,2004).

There are also cross-cultural variants on dissociativedisorders, such asAmok, which is often thought of as a ragedisorder (see The World Around Us 3.4 in Chapter 3).Amok occurs when a dissociative episode leads to violent,aggressive, or homicidal behavior directed at other peopleand objects. It occurs mostly in men and is often precipi-tated by a perceived slight or insult. The person often hasideas of persecution, anger, and amnesia, often followed bya period of exhaustion and depression. Amok is found inMalaysia, Laos, the Philippines, Papua New Guinea, andPuerto Rico and among Navajo Indians (APA, 2000).

Treatment and Outcomes inDissociative DisordersUnfortunately, virtually no systematic controlled researchhas been conducted on treatment of dissociative amnesia,fugues, and depersonalization disorder and so very little isknown about how to treat them successfully. Numerouscase histories, sometimes presented in small sets of cases,are available, but without control groups who are assessedat the same time or who receive nonspecific treatments, it isimpossible to know the effectiveness of the varied treat-ments that have been attempted (Kihlstrom, 2005). Deper-sonalization disorder is generally thought to be resistant totreatment (e.g., Simeon et aI., 1997), although treatmentmay be useful for associated psychopathology such as anxi-ety and depressive disorders. Some think that hypnosis,including training in self-hypnosis techniques, may be use-ful, because patients with depersonalization disorder canlearn to dissociate and then "reassociate;' thereby gainingsome sense of control over their depersonalization andderealization experiences (Maldonado et aI., 2002). Singlecase studies have also supported the idea that antidepres-sant medications from the serotonin reuptake inhibitor cat-egory may have positive effects, but a recent randomizedcontrolled study showed no difference between treatmentwith Prozac versus with placebo (Simeon et aI., 2004).

In dissociative amnesia and fugue, it is important forthe person to be in a safe environment, and simply remov-ing her or him from what s/he perceives as a threateningsituation sometimes allows for spontaneous recovery ofmemory. Hypnosis, as well as drugs such as benzodi-azepines, barbiturates, sodium pentobarbital, and sodiumamobarbital, are often used to facilitate recall of repressed

and dissociated memories (Maldonado et aI., 2002). Aftermemories are recalled, it is important for the patient towork through the memories with the therapist so that theexperiences can be reframed in new ways. However, unlessthe memories can be independently corroborated, theyshould not be taken at their face value (Kihlstrom, 2005).

For DID patients, most current therapeutic approachesare based on the assumption of post-traumatic theory thatthe disorder was caused by abuse (Kihlstrom, 2005). Mosttherapists set integration of the previously separate alters,together with their collective merging into the host person-ality, as the ultimate goal of treatment. When successful inte-gration occurs, the patient eventually develops a unifiedpersonality, although it is not uncommon for only partialintegration to be achieved. But it is also very important toassess whether improvement in other symptoms of DID andassociated disorders has occurred. Indeed, it seems thattreatment is more likely to produce symptom improvement,as well as associated improvements in functioning, than toachieve full and stable integration of the different alter iden-tities (Maldonado et al., 2002).

Typically the treatment is psychodynamic and insight-oriented, focused on uncovering and working through thetrauma and other conflicts that are thought to have led tothe disorder (Kihlstrom, 2005). One of the primary tech-niques used in most treatments of DID is hypnosis (e.g.,Kluft, 1993; Maldonado et aI., 2002). Most DID patientsare hypnotizable, and hypnotized DID patients are oftenable to recover past unconscious and frequently traumaticmemories, often from childhood. Then these memoriescan be processed, and the patient can become aware thatthe dangers once present are no longer there. (There isanother danger here, however. People are more suggestibleunder hypnosis, and much of what is recalled may not beaccurate. See Kihlstrom, 2005, and the Unresolved Issuessection.) Through the use of hypnosis, therapists are oftenable to make contact with different identities and reestab-lish connections between distinct, seemingly separateidentity states. An important goal is to integrate the per-sonalities into one identity that is better able to cope withcurrent stressors. Clearly, successful negotiation of thiscritical phase of treatment requires therapeutic skills of thehighest order; that is, the therapist must be strongly com-mitted as well as professionally competent. Regrettably, notall therapists are.

Most reports in the literature are treatment sum-maries of single cases, and reports of successful casesshould always be considered with caution, especially giventhe large bias in favor of publishing positive rather thannegative results. Treatment outcome data for large groupsof DID patients have been reported in only four studies weare aware of, and none of these included a control group,although it is quite clear that DID does not spontaneouslyremit simply with the passage of time, nor if a therapistchooses to ignore DID-related issues (Kluft, 1999; Mal-donado et aI., 2002). For example, ElIason and Ross (1997)

reported on a 2-year postdischarge follow-up of DIDpatients originally treated in a specialized inpatient unit.Of the original 135 such patients, 54 were located and sys-tematically assessed. All these patients, and especially thosewho had achieved full integration, generally showedmarked improvements in various aspects of their lives.However, only 12 of 54 had achieved full integration oftheir identities. Such results are promising, but we mustwonder about the clinical status of the 81 "lost" patientswho may well have done less well. Another 10-year follow-up study reported similar results in a smaller sample of 25treated DID patients. Only 12 were located 10 years later;of these, six had achieved full integration, but two of thosehad partially relapsed (Coons & Bowman, 2001). In gen-eral it has been found that (1) for treatment to be success-ful, it must be prolonged, often lasting many years, and(2) the more severe the case, the longer that treatment isneeded (Maldonado et aI., 2002).

In ReVIew~ Describe the symptoms known as

depersonalization and derealization, andindicate which disorder is primarilycharacterized by their appearance.

~ Describe dissociative amnesia anddissociative fugue, and indicate whataspects of memory are affected.

~ What are the primary symptoms of dissocia-tive identity disorder (01D) and why is itsprevalence thought to have been increasing?

~ Review the four major controversiessurrounding DID that were discussed in thischapter.

571 s we have seen in this chapter, manycontroversies surround the nature and ori-gins of DID. None have been more bitterthan those related to the truth value of"recovered" memories of childhood abuse,

particularly sexual abuse, which post-trauma theorists assertis the major causal factor in the development of DID. Indeed,a virtual chasm has developed between the "believers"(mostly but not exclusively private practitioners who treatpeople with 01 D) and the "disbelievers" (mostly but notexclusively the more academic and science-oriented mentalhealth professionals). The disbelievers are sympathetic topeople suffering DID symptoms, but they have tended todoubt that the disorder is usually caused by childhood abuseand have challenged the validity or accuracy of recoveredmemories of abuse.

For nearly 20 years, these controversies have movedbeyond professional debate and have become major publicissues, leading to countless legal proceedings. DID patientswho recover memories of abuse (often in therapy) have oftensued their parents for having inflicted abuse. But ironically,therapists and institutions have also been sued for implant-ing memories of abuse that they later came to believe had notactually occurred. Some parents, asserting they had beenfalsely accused, formed an international support organiza-tion-the False Memory Syndrome Foundation-and have

sometimes sued therapists for damages, alleging that thetherapists induced false memories of parental abuse in theirchild. Many families have been torn apart in the fallout fromthis remarkable climate of suspicion, accusation, litigation,and unrelenting hostility.

Whether DID originates in childhood abuse and whetherrecovered memories of abuse are accurate are basically sepa-rate issues, but they have tended to become fused in thecourse of the debate. Hence those who doubt the validity ofmemories of abuse are also likely to regard the phenomenonof DID as stemming from the social enactment of rolesencouraged or induced -like the memories of abuse them-selves- by misguided therapy (e.g., see Bjorklund, 2000;Lilienfeld et aI., 1999; Lynn et aI., 2004; Piper & Merskey,2004a, 2004b). Believers, on the other hand, usually takeboth DID and the idea that abuse is its cause to be estab-lished beyond doubt (e.g., see Gleaves, 1996; Gleaves et aI.,2001; Ross, 1997, 1999).

Much of the controversy about the validity of recoveredmemories is rooted in disagreements about the nature, relia-bility, and malleability of human autobiographical memory.With some exceptions, evidence for childhood abuse as acause of DID is restricted to the "recovered memories" (mem-ories not originally accessible) of adults being treated for dis-sociative experiences. Believers argue that before treatment,such memories had been "repressed" because of their trau-

matic nature or had been available only to certain alter identi-ties that the host identity was generally not aware of. Treat-ment, according to this view of believers, dismantles therepressive defense and thus makes available to awareness anessentially accurate memory recording of the past abuse.

Disbelievers counter with several scientifically well-supported arguments. For example, scientific evidence in sup-port of the repression concept is quite weak (e.g., Kihlstrom,2005; Lilienfeld & Loftus, 1998; Piper, 1998). In many allegedcases of repression, the event may have been lost to memoryin the course of ordinary forgetting rather than repression, or itmay have occurred in the first 3 to 4 years of life, before mem-ories can be recorded for retrieval in adulthood. In many othercases, evidence for repression has been claimed in studieswhere people may simply have failed to report a rememberedevent, often because they were never asked or were reluctantto disclose such very personal information (Kihlstrom, 2005;Lilienfeld & Loftus, 1999; Pope et aI., 1998).

In addition, even if memories can be repressed, thereare very serious questions about the accuracy of recoveredmemories. Human memory of past events does not operatein a computer-like manner, retrieving with perfect accuracyan unadulterated record of information previously storedand then repressed. Rather, human memory is malleable,constructive, and very much subject to modification on thebasis of events happening after any original memory trace isestablished (Loftus & Bernstein, 2005; Schacter, Norman, &Koutstaal, 2000; Tsai, Loftus, & Polage, 2000). Directlyaddressing the abuse issue, Kirsch, Lynn, and Rhue (1993)put it this way:

A traumatic history ... consists not only of past childhoodevents but also of the person's interpretations, embell-ishments, and distortions of those events from the per-spective of recent events, accomplishments, behaviors,and relationships that constitute life in the present. ...In short, memory is not immutable or preserved like a flyin amber, nor is the mind like a vast storehouse of indeli-ble impressions, facts, and information. (p. 18)

Indeed, there is now good evidence that people aresometimes very prone to the development of false memories.For example, a number of studies have now shown that whennormal adult subjects are asked to imagine repeatedly eventsthat they are quite sure had not happened to them before age10, they later increase their estimate of the likelihood thatthese events actually had happened to them (Tsai et aI.,2000). Moreover, even in a relatively short time frame, adultsubjects sometimes come to believe they have performedsomewhat bizarre acts (e.g., kissing a magnifying glass), as

well as common acts (e.g., flipping a coin), after simply hav-ing imagined they had engaged in these acts several times2 weeks earlier (Thomas & Loftus, 2002). These and otherstudies clearly show that repeated imagining of certainevents (even somewhat bizarre events) can lead people tohave false memories of events that never happened (Loftus &Bernstein, 2005). In addition, a recent experimental study byMcNally and colleagues (2005) looked at individuals whoreported either repressed or recovered memories of child-hood sexual abuse and found some evidence that they hadgreater difficulty on at least some measures than normal con-trols in distinguishing between words that they had seen ver-sus words that they had only imagined. This suggests thatpeople with repressed or recovered memories of abuse mayhave greater difficulty distinguishing between what has actu-ally happened to them and what they have imagined hap-pened to them.

By the early 1990S, however, many poorly trained thera-pists, uninformed about how the human memory systemworks, bought into the notion that a suitably vigorous thera-peutic approach could uncover a true and accurate record ofthe traumatic childhood experiences of their clients. In addi-tion, many were convinced that certain rather common adultsymptoms and complaints (e.g., headaches, poor self-esteem, unexplained anxiety) were indicative of a history ofchildhood trauma (e.g., see Bass & Davis, 1988; Blume, 1990)and justified relentless demands that the client remember thetraumatic abuse. Persuaded by the therapist's certainty andpersistence, which were accompanied by liberal use of tech-niques such as hypnosis and age regression, techniquesknown to enhance suggestibility, many clients did eventually"remember" such incidents, confirming the therapist's"expert" opinion.

Attempting to mediate the conflict and to provide bothits members and the public with guidance on the issuesinvolved, in the mid-1990S the American Psychological Asso-ciation (APA) convened a bipartisan panel of experts on bothsides called the Working Group on the Investigation of Memo-ries of Childhood Abuse (Alpert et at., 1996). As one furthermeasure of the amount of dissent and controversy raging inthis field, the Working Group agreed on almost nothing, andeach side wrote an independent report rather than con-tributed to an integrated one as originally hoped for. Unfortu-nately, no significant progress toward consensus has beenmade since the publication of that report in 1996. Thus thepublic and many professionals who are not directly involvedremain divided and confused about what to believe aboutdissociative phenomena and their connection (if any) withactual childhood abuse.

~ Somatoform disorders are those in whichpsychological problems are manifested in physicaldisorders (or complaints of physical disorders) thatoften mimic medical conditions but for which noevidence of corresponding organic pathology canbe found.

~ In hypochondriasis, an anxious preoccupation withhaving a disease is based on a misinterpretation ofbodily signs or symptoms. Medical reassurancedoes not help.

~ Somatization disorder is characterized by manydifferent complaints of physical ailments, in foursymptom categories, over at least several years.The symptoms need not actually have existed aslong as they were complained about.

~ Pain disorder is characterized by pain severeenough to disrupt life but in the absence ofenough medical pathology to explain its presence.

~ Conversion disorder involves patterns ofsymptoms or deficits affecting sensory orvoluntary motor functions, leading one to thinkthere is a medical or neurological condition, eventhough medical examination reveals no physicalbasis for the symptoms.

~ Body dysmorphic disorder involves obsessivepreoccupation with some perceived flaw or flawsin one's appearance. Compulsive checkingbehaviors (such as mirror checking) andavoidance of social activities because of fear ofbeing rejected are also common.

alter identities (P. 299)

body dysmorphic disorder (BOD)(p.290)

conversion disorder (P. 286)

depersonalization (P. 295)

depersonalization disorder (P. 295)

derealization (P. 295)

dissociation (P. 280)

dissociative amnesia (P. 297)

~ Dissociative disorders occur when the processes thatnormally regulate awareness and the multi-channelcapacities of the mind apparently becomedisorganized, leading to various anomalies ofconsciousness and personal identity.

~ Depersonalization disorder occurs in people whoexperience persistent and recurrent episodes ofderealization (losing one's sense of reality of theoutside world) and depersonalization (losingone's sense of oneself and one's own reality).

~ Dissociative amnesia involves an inability to recallpreviously stored information that cannot beaccounted for by ordinary forgetting and seems tobe a common initial reaction to highly stressfulcircumstances. The memory loss is primarily forepisodic or autobiographical memory.

~ In dissociative fugue, a person not only goes intoan amnesic state but also leaves his or her homesurroundings and becomes confused about his orher identity, sometimes assuming a new one.

~ In dissociative identity disorder, the personmanifests at least two or more distinct identitiesthat alternate in some way in taking control ofbehavior. Alter identities may differ in manyways from the host identity. There are manycontroversies about DID, including whether it isreal or faked; how it develops; whethermemories of childhood abuse are real; and, if thememories are real, whether the abuse played acausal role.

dissociative disorders (P. 280)

dissociative fugue (P. 297)

dissociative identity disorder (DID)(p.298)

factitious disorder (P. 290)

factitious disorder by proxy(p.291)

host identity (P. 299)

hypochondriasis (P. 281)

hysteria (P. 287)

malingering (P. 290)

pain disorder (P. 285)

primary gain (P. 287)

secondary gain (P. 287)

soma (P. 280)

somatization disorder (P. 283)

somatoform disorders (P. 280)