Chapter 7: Somatic Symptom Disorders and Dissociative Disorders CYU

📖 Review Answers

1. Should somatoform disorders be removed from DSM?

Argument for removal (DSM-5 change):
- DSM-IV focused too much on “medically unexplained symptoms” → reinforced outdated mind–body dualism.
- Led to stigma (patients being told “it’s all in your head”).
DSM-5 approach:
- Renamed as Somatic Symptom and Related Disorders.
- Focuses on distress, health anxiety, and excessive thoughts/behaviours about symptoms, regardless of medical explanation.

2. Body Dysmorphic Disorder (BDD) in DSM-5

No longer under “somatoform.”
Reclassified as an OCD-related disorder in DSM-5 because of obsessive preoccupation and compulsive behaviours (checking, grooming, etc.).

3. Illness Anxiety Disorder & Hypochondriasis

Hypochondriasis (old term, DSM-IV): preoccupation with fears of having serious illness.
DSM-5 split:
- Illness Anxiety Disorder = high health anxiety, no significant somatic symptoms.
- Somatic Symptom Disorder = when bodily symptoms are present with excessive distress.

4. Illness Anxiety Disorder (definition)

Core features:
- Preoccupation with having/acquiring serious illness.
- Minimal or no somatic symptoms.
- High levels of anxiety about health + excessive checking or avoidance.
- Lasts 6+ months.

5. Conversion Disorder

DSM-5 term = Functional Neurological Symptom Disorder.
Features:
- Sensory or motor symptoms (e.g., paralysis, blindness, seizures) without medical cause.
- Patients often show la belle indifférence = lack of concern about symptoms.

Psychoanalytic Theory:

Conversion disorder is caused when a person experiences an event that creates great emotional arousal, but the effect is not expressed and the memory of the event is cut off from conscious experience

Freud’s Theory:

Freud hypothesized that conversion disorder in women is rooted in an unresolved Electra complex.

6. Role of repression, secondary gain, reinforcement (conversion disorder)

Repression (psychoanalytic): symptoms express repressed conflict/trauma.
Secondary gain (behavioural): symptoms bring benefits (attention, avoiding responsibilities).
Reinforcement: avoidance of stress + attention from others maintains symptoms.

7. Neurological/anatomical aspects of conversion disorder

Symptoms mimic real neurological disorders but don’t follow neuroanatomical rules (e.g., blindness without retinal/optic damage).
fMRI: reduced activation in right inferior frontal cortex; altered connectivity between amygdala and motor areas.

8. Why it’s hard to distinguish from real illness/malingering

Symptoms often appear very real.
True illness → follows consistent neuro pathways; conversion doesn’t.
Malingering → conscious faking for external gain; conversion is unconscious.
La belle indifférence helps differentiate conversion from malingering.

9. Somatization Disorder (DSM-IV)

Dropped in DSM-5.
Old definition = recurrent, multiple physical complaints without medical cause.
Very low prevalence (<1%), which is why it was removed.
Now diagnosed as Somatic Symptom Disorder.

10. Experimental psych evidence on unconscious

Research shows automatic/unconscious processes (like priming, implicit memory).
Differs from Freud’s “Unconscious entity” → modern view = information processing without awareness, not a hidden psychic structure.

11. Behavioural theories of somatic disorders

Symptoms maintained by reinforcement:
- Attention, care, avoiding responsibility.
- Modelling from family/peers.
Cognitive factors: catastrophic misinterpretations of bodily sensations.

12. Behavioural therapies

CBT most effective:
- Challenge catastrophic thoughts.
- Reduce checking/avoidance.
- Encourage healthier coping behaviours.
Also: stress management, relaxation.

13. Psychodynamic therapies

Aim to uncover and process unconscious conflicts/trauma.
Focus on repression, unresolved childhood issues.
Similar to PTSD therapy (trauma-focused).

14. Dissociative Disorders (DSM-5)

Amnesia: inability to recall important personal info (usually trauma-related).
Fugue: subtype of amnesia → sudden travel + new identity.
Depersonalization/Derealization: altered sense of self/reality (“robotic,” out-of-body).
Dissociative Identity Disorder (DID): 2+ distinct identities (alters) with amnesia

	- Sudden memory loss of important personal info after trauma/stress. Not ordinary forgetting.
Depersonalization/Derealization Disorder	- Persistent/recurrent feeling unreal, detached, estranged from self/environment. - Feels like “outside body” or world is dreamlike.
Dissociative Identity Disorder (DID)	- Presence of 2+ distinct alters with own memories/behaviours. Formerly “multiple personality disorder.” Trauma model of dissociation = DID beings in childhood as a result of severe physical or sexual abuse
Other Specified Dissociative Disorder	- Clinically significant symptoms but don’t meet criteria for specific dissociative disorders. Includes: mixed symptoms, coercive persuasion, acute stress-related dissociation, trance states.

15. Psychoanalytic theory of dissociation

Dissociation = defense mechanism to avoid overwhelming trauma.
Symptoms protect against re-experiencing painful memories.

16. Goal of psychoanalytic therapy (dissociative disorders)

Lift repression → integrate traumatic memories.
For DID: integrate alters into one cohesive identity.
Techniques: hypnosis, age regression, trauma processing.

DEFINITIONS

📊 High-Yield Key Terms – Somatic Symptom & Dissociative Disorders

Term	High-Yield Definition / Key Points
Anaesthesias	Loss or impairment of sensation (e.g., numbness) without medical cause → subtype of conversion disorder.
Conversion Disorder	Neurological-like symptoms (paralysis, blindness, seizures) without medical basis. Different from malingering (not under voluntary control). Often linked to stress/trauma.
Depersonalization/Derealization Disorder	Feeling unreal, estranged from self/world (e.g., watching self from outside body, body feels strange). Disrupts functioning.
Derealization	Altered perception of surroundings → world feels unreal, dream-like. Can occur in panic, schizophrenia, or fatigue.
Dissociative Amnesia	Sudden inability to recall important personal info (not ordinary forgetting). Often trauma-related.
Dissociative Disorders	Disruptions in memory, identity, or consciousness. Includes: amnesia, fugue, DID, depersonalization/derealization.
Dissociative Fugue	Sudden travel away + total amnesia + adoption of new identity. Rare.
Dissociative Identity Disorder (DID)	2+ distinct identities (“alters”) alternate control; gaps in memory. Formerly “multiple personality disorder.”
Factitious Disorder	Symptoms intentionally produced to assume “sick role.” Includes by proxy (e.g., parent makes child sick). Different from malingering (external incentives).
Hypochondriasis	Old DSM-IV term: preoccupation with having serious illness despite reassurance. Similar to Illness Anxiety Disorder.
Hysteria	Historical term (ancient Greeks) for unexplained paralysis, anaesthesia, analgesia. Old name for conversion disorder.
Illness Anxiety Disorder	DSM-5 term replacing hypochondriasis: obsessive worry about illness despite lack of medical evidence.
La Belle Indifférence	Paradoxical lack of concern about disabling symptoms (seen in conversion disorder).
Malingering	Faking illness for clear external gain (money, avoiding duty). Voluntary and conscious → unlike conversion disorder.
Pain Disorder	Severe, prolonged pain without medical basis. Often stress-related; may provide avoidance or attention. (Now folded into Somatic Symptom Disorder in DSM-5).
Somatic Symptom Disorders	DSM-5 category replacing old somatoform disorders. Core = distressing somatic symptoms + excessive thoughts/behaviours about them.
Somatization Disorder	Old DSM-IV term: multiple unexplained physical complaints, dramatic and chronic. Removed in DSM-5 (now part of Somatic Symptom Disorder).

PEOPLE + NAMES + CULTURAL THINGS

📊 High-Yield Cram Table – Somatic & Dissociative Disorders

Topic	Must-Know High-Yield Points
Malingering vs. Conversion Disorder	- Malingering = faking symptoms for external gain (money, avoiding duty). Voluntary, conscious. - Conversion Disorder = symptoms (e.g., paralysis, blindness) not under voluntary control, no clear external gain. - La belle indifférence: blasé attitude toward symptoms → sometimes seen in conversion disorder (but only ~⅓).
Factitious Disorder	- Person intentionally produces symptoms (physical/psychological). - Not for external incentives → motivation is to assume the “sick role.” - By proxy (Munchausen by proxy): parent makes child ill. Example: mother causing repeated illness in child → courts cases in Canada/US.
Case Illustration	- Risk: mislabeling someone as malingering if tools can detect feigning but not motive/volition. - Example: man misdiagnosed as malingering → later found to have frontal-temporal dementia.




Canadian Data – Everyday Dissociation	- Winnipeg study (Ross et al.): 3.3% had pathological dissociation (≈10 million North Americans). - Common everyday: daydreaming, zoning out, ignoring pain. - Pathological = depersonalization/derealization, blanking out, identity confusion.
Dissociation in Students	- High dissociation group = more maltreatment, psychopathology, poorer university adjustment. - Philippines study: ~19 students diagnosed (DID, amnesia, other dissociative disorders). Shows some students do meet criteria.
Nicholas Spanos – Socio-Cognitive Perspective	- Critic of DID as a natural disorder. Suggested role-playing + therapist cues explain many cases. - Example: Hillside Strangler (Ken Bianchi) pretended alter “Steve” existed under hypnosis. - Lab studies: 81% of students could role-play an alter under hypnosis. - Argument: DID may be socially constructed, not purely trauma-based.
Repressed Memories Debate	- Hotly contested: some survivors recall CSA years later in therapy. - Williams (1995): 38% of verified CSA victims couldn’t recall abuse decades later → supports forgetting. - Goodman et al. (2003): only 19% didn’t recall → forgetting less common. - Loftus: false memories can be created by therapist suggestion, hypnosis, or imagination. - DePrince & Freyd (2004): high dissociators show impaired recall for trauma words → supports dissociation link. - McNally et al. (2005): no evidence for special “forgetting ability” in recovered memory groups.
Legal Issues	- Canada (2007 Supreme Court): banned post-hypnotic evidence (e.g., hypnosis-recovered CSA memories). - Courts must balance risk of false memories vs. silencing real survivors.
Key Exam Distinctions	- Malingering = voluntary, external gain. - Factitious Disorder = voluntary, no external gain, “sick role.” - Conversion Disorder = involuntary, no external gain. - DID = trauma vs. socio-cognitive debate. - Repressed Memories = controversial; some forgetting shown, but false memory risk high.