Chapter 6: Somatic Symptom & Dissociative Disorders

Somatic Symptom & Related Disorders

• Core theme : excessive, maladaptive responses to bodily symptoms or health concerns.
• DSM-5 categories :
  • Somatic Symptom Disorder (SSD)
  • Illness Anxiety Disorder (IAD)
  • Psychological Factors Affecting Medical Condition (PFAMC)
  • Conversion Disorder / Functional Neurological Symptom Disorder (CD/FNSD)
  • Factitious Disorder (incl. imposed on self & imposed on another)
• Historical roots :
  • Labelled “hysterical neurosis”; linked to Greek myth of wandering uterus & Freud’s "conversion" of unconscious conflict.
  • Term “hysteria” & “neurosis” dropped; conversion retained mechanically (no psycho‐analytic implication).
• Student Learning Outcomes (APA SLO excerpts) :
  • Operationally define problems & study empirically (SLO 2.3a).
  • Identify antecedents / consequences of behaviour (SLO 1.3b).
  • Apply psychological principles to everyday life & innovative problem solving (SLO 1.3a).

General Epidemiology & Culture

• Prevalence across disorders combined in primary-care ≈ 6.7\%–16.6\%.
• Higher in women, unmarried, low SES; chronic into old age.
• Culture-bound variants : koro (genital retraction, China), dhat (semen loss, India), “burning hands/feet” (S-Asia), hot head sensations (Africa).
• Sex ratio ~ 2:1 female : male in severe somatic presentations worldwide.

Somatic Symptom Disorder (SSD)

• DSM-5 key points :
  • ≥1 distressing somatic symptom lasting >6 months.
  • Excessive thoughts/feelings/behaviours (disproportionate beliefs, high anxiety, excessive time/energy).
  • Severity specifiers : mild (1 B sx) / moderate (≥2 B sx) / severe (≥2 + multiple complaints or 1 very severe).
  • "Predominant pain" specifier (formerly pain disorder).
• Clinical pattern :
  • Life organised around illness (case Linda: symptom list as identity, avoidance of exercise, paralysis episode).
  • "Sick role" reinforced by sympathy, disability benefits.
• Aetiology (integrative model):
  1. Trigger (information/event).
  2. Perceived health threat → apprehension.
  3. Misinterpretation of normal sensations.
  4. ↑ focus on body → arousal → checking/reassurance seeking (vicious cycle).
  • Biological: modest familial aggregation; nonspecific genetic liability to negative affect & hyper-arousal.
  • Psychological: early exposure to illness in family, learned focus on bodily cues, past trauma.
  • Social: secondary gain (attention, avoidance of duties).
• Treatment :
  • Psycho-education & empathetic reassurance ("explanatory therapy").
  • Cognitive-Behavioural Therapy (CBT): identify misinterpretations, decrease checking, graded exposure to activity.
  • Gatekeeper physician limits unnecessary medical utilisation.
  • Antidepressants (SSRIs) sometimes adjunct: e.g. paroxetine vs CBT (45% vs 30% response; placebo 14%).

Illness Anxiety Disorder (IAD)

• Essentials :
  • Preoccupation with having/acquiring serious illness; somatic symptoms absent or mild.
  • High health anxiety, excessive behaviours (doctor shopping or avoidance).
  • Duration >6 months; care-seeking vs care-avoidant types.
• Case Gail :
  • Triggered after husband’s affair; catastrophic interpretation of benign sensations (headache ⇒ tumour, breathlessness ⇒ MI), compulsive media scanning for diseases.
• Comparison with Panic Disorder :
  • Panic: fear of immediate catastrophe during attacks, symptoms limited to SNS sensations.
  • IAD: long-term disease conviction, wide symptom focus, habitual physician visits.
• Stats :
  • Only ≈20\% of DSM-IV “hypochondriasis” meet DSM-5 IAD (others now SSD).
  • Late onset common (aging ↑ health problems).
• Treatment evidence :
  • 6-session CBT vs usual care: lower Whiteley Index scores at 6 & 12 months; ↓ health-care use.
  • Exposure therapy to disease cues effective; reassurance helpful if extended & contextualised.

Psychological Factors Affecting Medical Condition (PFAMC)

• Medical illness (e.g., asthma, diabetes) exacerbated by behavioural or psychological factors (e.g., anxiety-provoked bronchospasm, insulin denial).
• Must distinguish from stress response to illness (Adjustment Disorder).

Conversion Disorder / Functional Neurological Symptom Disorder (CD/FNSD)

• Definition : ≥1 symptoms of altered voluntary motor or sensory function; clinical evidence of incompatibility with recognised neuro conditions.
• Typical manifestations :
  • Paralysis, blindness, aphonia, seizures (psychogenic non-epileptic), globus hystericus, astasia-abasia.
• Cases :
  • Eloise: progressive gait weakness linked to secondary gain (mother’s over-protection).
  • Celia: functional blindness yet performs above chance on visual tasks (demonstrates “blind sight”).
• Related phenomena :
  • La belle indifférence unreliable marker.
  • Differentiate from malingering (intentional gain) & Factitious Disorder (intentional, no obvious gain).
  • Factitious imposed on another (Munchausen by proxy): form of child abuse; surveillance often needed.
• Aetiology (Freudian framework, partially supported):
  1. Traumatic/conflict event.
  2. Repression of conflict.
  3. Conversion to somatic symptom (primary gain: anxiety reduction).
  4. Secondary gain: attention, avoidance of conflict.
  • fMRI: ↓ right inferior parietal activity during involuntary tremor vs voluntary mimic (sense of agency).
  • High comorbidity with dissociation; amygdala-motor cortex connectivity altered.
• Epidemiology :
  • Prevalence in neuro clinics ≈30\%; onset adolescence; more in females; psychogenic seizures ≈30\% of epilepsy referrals.
  • Better prognosis in children (85% recovery at 4 yrs) than adults.
• Treatment :
  • Process trauma with catharsis; reduce secondary gains; graded PT; CBT (65% response); hypnosis adjunctive; family involvement; encourage work/role resumption.

Factitious Disorders

• Criteria : deliberate falsification or induction of symptoms without external reward; single or recurrent episodes.
• Munchausen by proxy :
  • Parent (usually mother) induces illness in child; atypical child-abuse pattern (e.g., contaminating IV line with urine); video monitoring diagnostic.

Dissociative Disorders – Overview

• Core feature : disruption in consciousness, memory, identity, or perception; detachment (depersonalization) or distortion of reality (derealization).
• Prevalence of transient experiences : up to 50\% population occasionally; pathological when persistent/distressing.
• Shared links with trauma & historical “hysteria”.

Depersonalization-Derealization Disorder

• Criteria : persistent/recurrent depersonalization, derealization, or both; reality testing intact; clinically significant distress; not due to substances/neuro condition.
• Case Bonnie : tunnel vision, out-of-body feelings in dance class; onset after marijuana.
• Epidemiology : 0.8–2.8\% lifetime; male ≈ female; chronic.
• Neuro-cognitive findings :
  • Attention & short-term memory deficits; “mind emptiness”.
  • ↓ skin conductance to emotional words; fMRI shows perceptual & emotion-regulation abnormalities; HPA axis dysregulation.
• Treatment : scant; CBT for panic-like misinterpretations; limited drug efficacy (fluoxetine ≅ placebo).

Dissociative Amnesia

• Subtypes :
  • Generalized: global memory loss incl. identity.
  • Localized/Selective: failure to recall traumatic events within specific period (most common).
  • Dissociative Fugue: amnesia + purposeful/bewildered travel & possible new identity.
• Cases :
  • Woman with repeated amnestic episodes after family conflicts; fugue resolves in hospital.
  • Jeff Ingram: travelled from WA to Denver, unaware of identity; previous fugue.
• Prevalence : 1.8–7.3\%; onset adulthood <50 yrs.
• Differential vs neurological amnesia (see Table 6.4): DA linked to psychological trauma, reversible, intact new learning.
• Treatment : usually self-limited; therapy to recover memories & cope with stress; hypnosis or benzodiazepine-facilitated interviews sometimes.

Dissociative Trance & Culture-Specific States

• Possession/trance with identity change common in Asia, Africa, Afro-Caribbean rituals (vinvusa, phii pob, “falling out”). Pathological when unwanted/distressing.

Dissociative Identity Disorder (DID)

• Criteria : ≥2 distinct personality states (alters) + recurrent amnesia for everyday events; not due to culture/substances.
• Phenomenology :
  • Average \approx15 alters; female : male ≤ 9:1; childhood onset (<9 yrs developmental window).
  • Host vs alters; rapid “switches” with posture, voice, handwriting, handedness changes (37% cases).
  • Comorbidities: ≥7 other diagnoses on average (anxiety, depression, BPD, substance use).
• Illustrative cases :
  • Jonah (4 alters: Sammy – rational; King Young – sexual; Usoffa Abdulla – violent protector).
  • Anna O. likely early DID manifestation.
• Assessment of authenticity :
  • Physiological differentiation: distinct electrodermal responses, micro-strabismus, fMRI hippocampal activity across alters.
  • Malingering indicators: eagerness to display symptoms, fluid switching, consistent performance below chance (e.g., Kenneth Bianchi “Hillside Strangler”).
  • Sociocognitive model: iatrogenic production via therapist suggestion; high suggestibility & absorption.
• Epidemiology :
  • Inpatient prevalence 3–6\% (N America), community 1.5\%.
• Aetiology :
  • Severe, chronic childhood abuse/neglect in ≈97\% cases; escaperole via autohypnosis.
  • Absence of social support; high suggestibility/imaginary playmates; sleep deprivation exacerbates.
  • Biological: smaller hippocampus/amygdala; temporal-lobe epileptiform activity.
• False-Memory Controversy :
  • Laboratory implantation of memories (Loftus “lost in mall”, Ceci mousetrap, Clancy alien abduction).
  • Need clinician caution to avoid suggestive procedures; documented abuse still verifiable in many DID cases.
• Treatment :
  • Phase-oriented long-term psychotherapy: safety, trauma processing, identity integration.
  • Techniques: hypnosis to access memories, CBT for current coping, reinforcement of unified functioning.
  • Integration success ~22\% after 2 yrs intensive therapy; lifelong vulnerability.

Overarching Themes & Clinical Pearls

• Somatic & dissociative disorders reflect maladaptive mind–body interactions: bodily focus vs identity fragmentation.
• Both groups often arise from stress/trauma + cognitive distortion + reinforcement.
• Assessment priorities :
  1. Rule out bona-fide medical/neurological pathology.
  2. Evaluate trauma history, cognitive style, secondary gain.
  3. Screen for comorbid mood, anxiety, PTSD.
• Treatment principles :
  • Build therapeutic alliance & provide clear explanations.
  • Limit iatrogenic harm (excess tests, suggestive interviewing).
  • Employ CBT, exposure, trauma-focused therapy; involve gatekeeper physician.
  • Address family/system factors maintaining symptoms.

Key Numerical / Formula Highlights

• SSD/IAD chronicity criterion : >6\text{ months}.
• SSD severity specifier thresholds : mild (1), moderate (\ge2), severe (\ge2 + \text{multiple or 1 severe symptom}).
• IAD care-seeking vs care-avoidant behaviour continuum.
• Functional neuroimaging in CD : ↓ right inferior parietal cortex → disrupted sense of agency (volition ≠ action).
• DID developmental window closes ~9\text{ years}; prevalence community 1.5\%.

Clinical takeaway : Whether the patient’s distress anchors in the body or fragments the self, recognise the underlying anxiety & trauma, target maladaptive beliefs/behaviours, and coordinate care to restore adaptive functioning.