Somatic and Dissociative Disorders

Somatic Symptom and Related Disorders

General Description: Somatic symptom disorder is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning. The individual experiences excessive thoughts, feelings and behaviours relating to the physical symptoms.

These physical symptoms may or may not be associated with a diagnosed medical condition, but the person genuinely believes they are sick. The emphasis in diagnosis is on the extent to which the thoughts, feelings and behaviours related to the illness are excessive or out of proportion. A person is not diagnosed solely because a medical cause cannot be identified for a symptom.

Diagnosis: A diagnosis of somatic symptom disorder requires the person to experience one or more physical symptoms that are distressing or cause disruption in daily life. Additionally, there must be excessive thoughts, feelings or behaviours related to the physical symptoms or health concerns, with at least one of the following: ongoing thoughts that are out of proportion with the seriousness of symptoms, an ongoing high level of anxiety about health or symptoms, and excessive time and energy spent on the symptoms or health concerns.

At least one symptom is constantly present, although symptoms may vary. Individuals with this disorder typically consult a primary care physician rather than a mental health professional. They may struggle to accept that their concerns are excessive and may remain fearful even with evidence to the contrary. Somatic symptom disorder often begins by age 30.

Comparison of DSM-IV and DSM-5: The DSM-5 renamed Somatization Disorder (from DSM-IV) to Somatic Symptom Disorder and reclassified it under Somatic Symptom and Related Disorders. The DSM-IV criteria required a history of many physical complaints beginning before age 30, including specific numbers of pain, gastrointestinal, sexual, and pseudoneurological symptoms. In contrast, DSM-5 focuses on one or more somatic symptoms that are distressing or disruptive, accompanied by excessive thoughts, feelings, or behaviours related to these symptoms. The DSM-5 also dropped the criterion that symptoms could not be fully explained by a medical condition. Specifiers in DSM-5 include "with predominant pain" (previously pain disorder), "persistent" (lasting more than 6 months), and current severity (mild, moderate, severe) based on the level of distress and number of related thoughts, feelings, and behaviours.

Types of Related Disorders:

• Illness Anxiety Disorder: Previously known as hypochondriasis. Characterised by a preoccupation with having or getting an illness, with constant worry about health. Individuals may frequently check for signs of illness and take extreme precautions. Unlike somatic symptom disorder, physical symptoms are generally not experienced.

• Conversion Disorder (Functional Neurological Symptom Disorder): Symptoms affect a person’s perception, sensation or movement without any evidence of a physical cause. Examples include numbness, blindness, or trouble walking, with symptoms often appearing suddenly. Depression or anxiety disorders frequently co-occur.

• Factitious Disorder: Involves producing or faking physical or mental illness even when not actually ill. Some may worsen minor illnesses intentionally. Factitious disorder imposed on another involves creating illness in someone else, such as a child. The motivation is to occupy the "sick role" and receive care. This differs from malingering, where feigned illness is for material gain.

Aetiology of Somatic Symptom Disorders: These disorders involve a misconnection between mind and body, where the mind's capacity to cope with stress is exceeded, leading to physical symptoms affecting systems like digestive, nervous, and reproductive. Major contributing factors include:

• Defence against psychological distress

• Heightened sensitivity to physical sensations

• Catastrophic thoughts

• Discomfort or pain in the body

• Family stress

• Parental modelling

• Cultural influence

• Genetic factors

• A connection between the brain, immune system, and digestive system may also be relevant.

Dissociative Disorders

General Description: Dissociative disorders involve problems with memory, identity, emotion, perception, behaviour and sense of self. Dissociative symptoms can disrupt every area of mental functioning. Examples include feeling detached or outside one's body (depersonalisation), and loss of memory or amnesia. These disorders are frequently associated with previous experiences of trauma. Dissociation itself is a normal process, like daydreaming, where there is a disconnection between thoughts, memories, feelings, actions, or sense of self. During traumatic experiences, dissociation can help a person tolerate overwhelming difficulties.

Types of Dissociative Disorders:

• Dissociative Identity Disorder

• Dissociative Amnesia

• Depersonalization/Derealization Disorder

Dissociative Identity Disorder:

• Clinical Picture: Associated with overwhelming experiences, traumatic events, and/or abuse in childhood. Previously known as multiple personality disorder. Key symptoms include the existence of two or more distinct identities (or “personality states”), accompanied by changes in behaviour, memory, and thinking, observable by others or reported by the individual. There are also ongoing gaps in memory about everyday events, personal information, and/or past traumatic events. These symptoms cause significant distress or problems in functioning and are not a normal part of cultural or religious practices (experiences of possession in some cultures are not dissociative disorders). The person's attitude and preferences may suddenly shift and back. The shifts in identity are involuntary, unwanted, and cause distress. Individuals may feel like observers of their own speech and actions, or their bodies may feel different. A person with DID feels as if they have multiple entities within them, each with its own way of thinking and remembering. The extent of functional problems can vary.

• Aetiology: People who have experienced physical and sexual abuse in childhood are at increased risk. The vast majority of people with dissociative disorders have experienced repetitive, overwhelming trauma in childhood. About 90 percent of people with DID in the US, Canada, and Europe have been victims of childhood abuse and neglect. Suicide attempts and self-injurious behaviour are common.

Depersonalization / Derealization Disorder:

• Clinical Picture: Involves significant ongoing or recurring experiences of depersonalisation, derealization, or both. Depersonalisation is the experience of unreality or detachment from one’s mind, self, or body, feeling like an outside observer. Derealization is the experience of unreality or detachment from one’s surroundings, feeling like things and people are not real. During these experiences, the person is aware of reality and that their experience is unusual. The experience is very distressful, even if the person appears unreactive. Symptoms may begin in early childhood, with an average onset age of 16.

• Aetiology: While trauma is a common association for dissociative disorders in general, the sources do not specify a distinct aetiology for depersonalization/derealization disorder beyond it being a type of dissociative disorder.

Dissociative Amnesia:

• Clinical Picture: Involves not being able to recall information about oneself (not normal forgetting). This amnesia is usually related to a traumatic or stressful event and can be: localised (inability to remember an event or period of time), selective (inability to remember specific aspects of an event), or generalized (complete loss of identity and life history, which is rare). People may not be aware of their memory loss or have limited awareness, and may minimise its importance.

• Aetiology: Associated with having experiences of childhood trauma, particularly emotional abuse and emotional neglect.

Related Conditions: Both acute stress disorder and posttraumatic stress disorder (PTSD) may involve dissociative symptoms, such as amnesia and depersonalisation or derealization.