1. Chapter 7
Somatic Symptoms Disorders
And Dissociative Disorders

2. Somatic Symptom and Related Disorders
Previously called Somatoform Disorders
(DSM-IV-TR)
DSM-IV-TR definitions:
overemphasized that bodily symptoms are medically unexplained
reinforced mind-body dualism
DSM-5 definitions:
emphasize distress that accompanies or is in response to the bodily concerns
Source: page 2

3. Overview: DSM-IV-TR Somatoform Disorders
DSM-IV-TR Disorder
Description
Pain disorder*
*term no longer in DSM-5
Psychological factors play a significant role in the onset and maintenance of pain.
Body dysmorphic disorder*
*DSM-5 OCD condition
Preoccupation with imagined or exaggerated defects in physical appearance.
Hypochondriasis*
Preoccupation with fears of having a
serious illness
Conversion Disorder*
*now also called Functional Neurological Symptom Disorder (DSM-5)
Sensory or motor symptoms without any physiological cause.
Somatization*
Recurrent, multiple physical complaints that have no biological basis.

4. Pain Disorder (DSM-IV-TR)
No longer diagnosed in DSM-5
Psychological factors are viewed as playing an important role in the onset, maintenance, and severity of the pain
Most likely now diagnosed with somatic symptom disorder with predominant pain

5. Body Dysmorphic Disorder (BDD)
DSM-5 includes BDD as an OCD condition
preoccupation with an imagined or exaggerated defect in appearance, frequently in the face
Examples: facial wrinkles, excess facial hair, or the shape or size of the nose.
Women tend to focus on the skin, hips, breasts, and legs
Men tend to focus on height, penis size, and body hair

6. Hypochondriasis (DSM-IV-TR)
begins in early adulthood and has a chronic course
when bodily concerns are present, diagnosed in DSM-5 as: somatic symptom disorder
When bodily symptoms are not present but person is preoccupied with persistent fears of having a serious medical disease, then diagnosed as: illness anxiety disorder
the term “hypochondriac” is pejorative, no longer used

7. Illness (Health) Anxiety
Cognitive factors are considered central
“catastrophic” misinterpretations of bodily sensations
strong beliefs that unexplained bodily changes are always a sign of serious illness

8. Cognitive Model of Health Anxiety
Four contributing factors:
Critical precipitating incident
Previous experience of illness and related medical factors
Presence of inflexible or negative cognitive assumptions
Severity of anxiety

9. Conversion Disorder
Also termed Functional Neurological Symptom Disorder (DSM-5)
Physically healthy people experience sensory or motor symptoms suggesting a neurological illness (although the body organs and nervous system are found to be fine).
Examples:
Paralysis of arms or legs
Seizures and coordination disturbances
Sensation of prickling, tingling, or creeping on the skin
Insensitivity to pain
Anaesthesias (loss or impairment of sensations)
Sudden loss or partial loss of vision (blindness or tunnel vision)
Aphonia (loss of the voice and all but whispered speech)
Anosmia (loss or impairment of the sense of smell)
Tends to appear suddenly in stressful situations

10. Hysteria
Term originally used to describe what are now known as conversion disorders

11. Conversion Disorder or Malingering?
Difficult to distinguish
Faking an incapacity in order to avoid a responsibility is termed malingering
La belle indifférence
Can help differentiate conversion disorder from malingering
Characterized by a relative lack of concern or a blasé attitude toward the symptoms
Diagnostic of conversion disorder not malingering

12. Factitious Disorder
Intentionally produce symptoms (usually physical such as pain) or cause self-injury
In contrast to malingering, the symptoms are less obviously linked to some benefit or secondary gain

13. Somatization Disorder (DSM-IV-TR)
Dropped from DSM-5
Mainly diagnosed now as somatic symptom disorder
Recurrent, multiple somatic complaints, with no apparent physical cause, for which medical attention is sought
Prevalence is low in primary care - less than 1% (which is one reason why DSM-5 changes were made)

14. Somatization Disorder (DSM-IV-TR) (cont’d)
Symptoms are more pervasive than in hypochondriasis and usually cause impairment
Considerable overlap with conversion disorder
Comorbid with anxiety and mood disorders, substance abuse, & several personality disorders
Specific symptoms may vary across cultures

15. Theories of Conversion Disorders
Psychoanalytic Theory
Specific symptoms related to traumatic events
Freud: Unresolved Electra Complex
Behavioural Theory and Cognitive Factors
Similar to malingering in that the person adopts the symptom for some additional benefit (secondary gain)
Social and Cultural Factors
 incidence of conversion disorder in the last century
 among people with lower socio-economic status and from rural areas

16. Theories (cont.) Biological Factors in Conversion Disorder
Evidence is weak
May be some relationship between brain structure and conversion disorder
Conversion symptoms are more likely to occur on the left side than on the right side of the body
Biopsychosocial Model
triggering events (ie abuse), perpetuating factors (ie life stress), and risk factors (social class)

17. Therapies for Somatoform Disorders
Little controlled research on psychological treatments because somatoform disorders are less commonly seen in psychological practices than other conditions
tend to undergo costly medical investigations and medical treatments than other disorders
Comorbid with anxiety and depression
See treatment sections for these disorders
Cognitive-behavioural approaches

18. Dissociative Disorders – DSM-5
Characterized by disruptions of consciousness, memory, and identity
Dissociative Amnesia – memory loss following a stressful experience
Depersonalization/derealization disorder – altered experience of the self
Dissociative Identity Disorder – at least two different (alternative) ego states (alters)
Other Specified Dissociative Disorder

19. Dissociative Amnesia
Person unable to recall important personal information, usually after some stressful episode.
Information not permanently lost, but cannot be retrieved during the episode of amnesia
Most often memory loss involves all events during a limited period of time
Total amnesia
Patient does not recognize relatives and friends, but retains the ability to talk, read, and reason
Retains talents and previously acquired knowledge
Amnesic episode may last several hours or as long as several years.
Usually disappears as suddenly as onset

20. Dissociative Fugue
Previously (DSM-IV-TR) was considered a category, now it is specific form of dissociative amnesia.
Memory loss more extensive in dissociative fugue than in dissociative amnesia.
Person becomes totally amnesic and suddenly leaves home and work and assumes a new identity.
Fugues typically occur after a person has experienced some severe stress

21. Depersonalization/Derealization Disorder
Person’s perception or experience of the self is disconcertingly and disruptively altered
Unusual sensory experiences
May have ‘out of body’
May feel mechanical (as if they or others are ‘robots’)
Typically triggered by stress
Usually begins in adolescence and has a chronic course
Comorbid with personality disorders, anxiety disorders, and depression
DSM-5 changed Depersonalization criteria to include Derealization, which is a sense of detachment from situational context

22. Dissociative Identity Disorder (DID)
Diagnosis requires that a person have at least two separate ego states (called ‘alters’) that exist independently of each other
Alters emerge and are in control at different times
Usually one primary ego state and two to four alters at time of diagnosis
Treatment sought by the primary alter
Gaps in memory occur in all cases
Existence of alters must be long-lasting and cause considerable disruption in one’s life
Often accompanied by headaches, substance abuse, phobias, hallucinations, suicide attempts, sexual dysfunction, and self-abusive behaviour and other dissociative symptoms such as amnesia and depersonalization

23. DID (cont.)
Presumably begins in childhood, but rarely diagnosed until adulthood
More common in women than in men
Comorbid with depression, borderline personality disorder, and somatization disorder
In one study 90% had a history of suicidal tendencies, depression, recurring headaches, and sexual abuse
Another study is suspecting poor attachment due to exposure of frightening or chaotic behaviour from caregiver
Diagnosis of DID is a very controversial

24. DID Case example Herschel Walker – Football star

25. Etiology of Dissociative Disorders
Etiology of DID
Psychoanalytic & behavioural perspectives: Dissociation as an avoidance response that protects the person from memories of traumatic experiences
2 major theories
Result of severe physical or sexual abuse
Enactment of learned social roles

26. Treatments of Dissociative Disorders
Psychoanalytic Treatment
Goal: to lift repression of traumatic events
Treatments for PTSD trauma applied to dissociative disorders
Treatment of DID
Hypnosis used for ‘age regression’
Goal: integration of the several personalities

27. Copyright
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