Somatic and Dissociative Disorders Notes

Somatic Symptom Disorders

Overview

  • Somatic Symptom Disorders involve physical symptoms suggesting a medical condition without evidence of physical pathology.

  • Previous terms like Hypochondriasis and Somatization Disorder are now part of DSM-5 criteria for Somatic Symptom Disorder.

Characteristics of Somatic Symptom Disorders (DSM-5)

  • Three Main Features:

    • Disproportionate thoughts about the seriousness of symptoms.

    • High level of anxiety regarding health.

    • Excessive time/energy spent on symptoms or health concerns.

Historical Terms in DSM-IV

  • Hypochondriasis:

    • Preoccupation with fears of serious disease or misinterpretation of bodily symptoms.

    • Cognitive-behavioral therapy (CBT) and SSRIs effective in treatment.

    • Prevalence: 2-7%, often chronic, usually occurs in early adulthood.

  • Somatization Disorder:

    • Symptoms include multiple physical complaints in various categories.

    • Typically needs to start before the age of 30, in the absence of a medical explanation.

    • Notable gender differences: 3-10 times more common in women.

    • Co-occurs with other mental disorders (depression, anxiety).

  • Pain Disorder:

    • Severe pain present in one or more body areas, with psychological factors considered significant.

    • Not feigned; commonly diagnosed in women.

  • Illness Anxiety Disorder:

    • High anxiety about potential illness; minimal to no somatic symptoms present.

    • 25% of individuals with hypochondriasis meet criteria.

Conversion Disorder (DSM-5)

  • Symptoms affecting sensory or motor functions without physical basis (i.e., blindness, paralysis).

  • Often occurs after significant stress and can resolve quickly if the stressor is removed.

  • Notably more common among women and in rural populations.

  • Pseudo seizures: Seizures without neurological abnormalities.

Treatment Approaches

  • Somatic Symptom Disorders:

    • Collaboration with a single physician to manage care.

    • Combination of medical treatment and CBT to promote healthy coping strategies.

    • Addressing secondary gain is crucial (avoidance of responsibilities).

  • Conversion Disorder:

    • Behavioral and cognitive-behavioral therapies targeted at managing symptoms and improving function.

Malingering and Factitious Disorders

  • Malingering: Intentional fabrication of symptoms for external incentives (e.g., financial gain).

  • Factitious Disorder: Motivation by the “sick role”, where the individual seeks the attention that comes with being ill.

Dissociative Disorders

Overview of Dissociative Disorders

  • Involve disruptions in consciousness, memory, identity, and perception.

  • Types include Depersonalization/Derealization Disorder, Dissociative Amnesia, and dissociative identity disorder.

Depersonalization/Derealization Disorder

  • Experiences include feeling detached from oneself (depersonalization) or surroundings (derealization).

  • Reality testing remains intact; sufferers often report living in a dream.

  • Onset typically around age 23; chronic in 80% of cases.

Dissociative Amnesia

  • Characterized by inability to remember autobiographical information, often due to trauma or stress.

  • Can include Dissociative Fugue, where individuals travel and cannot recall identity.

  • Treatment often leads to spontaneous recovery of memories.

Dissociative Identity Disorder (DID)

  • Involves two or more distinct identities or personality states.

  • Often initiated in childhood; prevalence is 3 to 9 times higher in women.

  • Controversies surrounding if DID is real or faked, connections to childhood abuse but multifactorial considerations.

Treatment of Dissociative Disorders

  • Emphasizes integration of identities, often using psychodynamic and insight-oriented approaches.

  • Limited knowledge on effective treatments overall.

Theories of DID Development

  • Post-Traumatic Model: 95% of cases report severe abuse, viewing DID as an escape from trauma.

  • Socio-Cognitive Theory: Suggests suggestibility in therapy leads to the adoption of multiple identities.


  1. Difference from Physical Conditions: Somatic Symptom Disorders present physical symptoms without any identifiable medical pathology, while physical conditions have clear biological or physiological causes.

  2. Hypochondriasis (DSM-IV): Characterized by persistent fears of having a serious illness or misinterpretation of bodily symptoms; it is now included in Somatic Symptom Disorders in DSM-5.

  3. Treatment of Hypochondriasis: Effective treatment often includes Cognitive-Behavioral Therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs).

  4. Somatization Disorder (DSM-IV): This disorder involves multiple physical complaints across various categories without a medical explanation, usually starting before age 30.

  5. Treatment Importance: Addressing secondary gain—where symptoms may be used to avoid responsibilities or gain attention—is crucial in treating Somatization Disorder.

  6. Overlap with Hypochondriasis: Approximately 25% of individuals with hypochondriasis meet the criteria for Illness Anxiety Disorder.

  7. Symptoms of Conversion Disorder: Symptoms may include sensory or motor dysfunction (e.g., blindness, paralysis) without any physical cause, often occurring after significant stress and can resolve upon removal of the stressor.

  8. Pseudo seizures: These are seizure-like episodes without neurological abnormalities. Distinction from seizures is made through the absence of epileptic activity on EEG and often identifiable psychological stressors triggering the episodes.


  1. Primary Gain: Refers to the direct benefit that the patient gains from having the symptoms, such as avoidance of stressful situations or responsibilities.

  2. Secondary Gain: Relates to the external advantages that an individual may achieve due to their symptoms, such as attention, sympathy, or financial benefits.

  3. Munchausen Syndrome: A type of factitious disorder where an individual deliberately produces or feigns symptoms of illness to gain attention and sympathy from others.

  4. Major Dissociative Amnesia: A significant inability to remember personal information, often linked to trauma or stress, affecting one’s identity.

  5. Dissociative Fugue: A subtype of dissociative amnesia involving sudden, unexpected travel away from home, accompanied by inability to recall one’s identity or past.

  6. Dissociative Identity Disorder (DID): A disorder characterized by the presence of two or more distinct identities or personality states, each with its own sense of self and history.

  7. Treatment Goal for Dissociative Identity Disorder: The primary goal is to integrate the separate identities into one primary identity, often using psychodynamic and insight-oriented therapy.

  8. Theories Explaining Dissociative Identity Disorder:

    • Post-Traumatic Model: Suggests that DID develops as a response to severe trauma, often as a coping mechanism to escape from the abuse.

    • Socio-Cognitive Theory: Proposes that DID may be encouraged by suggestibility during therapy, which leads to the adoption of multiple identities.