Ch. 6 Somatic Symptoms and Dissociative Disorders

Somatization:

A tendency to communicate distress through physical symptoms and to pursue medical help for these symptoms.

Somatic Symptom Disorder:

A mental disorder in which a person experiences physical symptoms that may or may not have a discoverable physical cause, as well as distress.

These symptoms may resemble minor complaints such as general achiness or pain in different areas of the body. Complaints that are more moderate may include loss of sexual desire, nausea and vomiting, and bloating. The person is highly stressed by the symptoms.

Some people are excessively preoccupied with the consequences of various physical symptoms. These people may be less concerned with general symptoms, but they fear they have a serious illness. In addition, others have symptoms that are quite severe and include sudden blindness, deafness, or paralysis. These physical symptoms may be linked to depression and anxiety. Other people deliberately induce symptoms in themselves.

A key part of the disorder, however, is that the person has recurrent thoughts that the symptom is serious or has great anxiety about the symptom or one’s health. The persona may also devote substantial time and energy to the symptom, such as visiting doctors. The symptoms the person feels are real—-they are not ‘faked’—and the symptoms may or may not have a medical condition.

Some people with an SSD experience significant pain. People with SSD may complain of pain in areas of the body difficult to assess for pain. Including the back, neck, face, chest, pelvic area, abdomen, sciatic nerve, urinary system, and muscles. Some people initially experience pain from a physically traumatic event but continue to report pain even when fully healed. A burn victim may continue to report pain even when grafts and dressings are finished and when no medical explanation for pain exists. Other people undergo limb amputation and still report pain in that limb, a condition known as phantom pain that may have psychological and physical causes. Other common complaints include fatigue, shortness of breath, dizziness, and heart palpitations.

People with SSD may also have certain personality traits or patterns—they may be attention-seeking, seductive, manipulative, dependent, and/or hostile toward family, friends, and clinicians. They may show aspects of personality disorders marked by dramatic or unstable behavior.

Functional Somatization:

Medically unexplained symptoms not part of another mental disorder

Presenting Somatization:

Somatic symptoms usually presented as a part of another mental disorder, especially anxiety or depression.

Someone with depression may feel fatigued or have a low sex drive, but these physical symptoms are because of the depression. Overlap may occur between functional and presenting somatization. Mental conditions such as depression and stress are good predictors of whether someone with chronic physical symptoms will seek help.

DSM-5

1. One or more somatic symptoms that are distressing or result in significant disruption of daily life

2. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following.

   1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

   2. Persistently high level of anxiety about health or symptoms

   3. Excessive time and energy devoted to these symptoms.

3. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months). Specify if symptoms primarily involve pain, if symptoms have a persistent course, and if the severity is mild, moderate, or severe symptoms with multiple somatic complaints or one very severe somatic symptom.

Psychological Components:

1. Stress

2. Conflict

3. Isolation

4. Trauma

Psychosomatic:

Describes people with physical symptoms that seem “all in their head.” They complain about real physical symptoms or diseases but the complaints seem exaggerated or far-fetched.

Continuum of Somatization and Somatic Symptom Disorder:

1. Normal

   1. Emotions

      1. Optimism regarding health

   2. Cognitions

      1. No concerns about health

   3. Behaviors

      1. Attending regular, preventative checkups with a physician

2. Mild

   1. Emotions

      1. Mild physical arousal and feeling uncertainty about certain physical symptoms

   2. Cognitions

      1. Some worry about health, perhaps after reading a certain magazine article

   3. Behaviors

      1. Checking physical body a bit more or scheduling one unnecessary physician visit.

3. Moderate

   1. Emotions

      1. Moderate physical arousal and greater uncertainty about one’s health

   2. Cognitions

      1. Strong worry about aches, pains, possible disease, or appearance. Fleeting thoughts about death or dying.

   3. Behaviors

      1. Scheduling more doctor visits but generally feeling relieved after each one.

4. SSD—Less Severe

   1. Emotions

      1. Intense physical arousal misinterpreted as a sign or symptom of some terrible physical disorder

   2. Cognitions

      1. Intense worry about physical state or appearance. Intense fear that one has a serious disease. Common thoughts about death and dying.

   3. Behaviors

      1. Regular doctor shopping and requests for extensive and repetitive medical tests with little or no relief. Checking body constantly for symptoms

5. SSD-More Severe

   1. Emotions

      1. Extreme physical arousal with great trouble concentrating on anything other than physical state.

   2. Cognitions

      1. Extreme worry about physical state. Extreme fear of having a serious potential disease. Frequent thoughts about death and dying.

   3. Behaviors

      1. Avoidance of many social and work activities. Scheduling regular surgeries, attending specialized clinics, or searching for exotic diseases.

Prevalence of 0.8-4.7%

Illness Anxiety Disorder:

A somatic symptom disorder marked by excessive preoccupation with fear of having a disease.

Someone with this disorder may worry about hepatitis or AIDS based on minor changes in pulse rate, perspiration, or energy level. This disorder is related to hypochondriasis and many of those with the older diagnosis are expected to meet the criteria for illness anxiety disorder.

Thoughts about having an illness are constant and may resemble those of OCD. People with this anxiety may also have significant fears of contamination and of taking prescribed medication. They’re intensely aware of bodily functions, and many complain about their symptoms in detail (unlike those with SSD). This may be because they want to help their physician find a “diagnosis” and a “cure” even though an actual disease may not exist. Many people with this disorder fascinate themselves with medical information and have autosuggestibility.

Autosuggestibility:

Reading or hearing about an illness can lead to fear of having that disease.

DSM-5

1. Preoccupation with having or acquiring a serious illness.

2. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk of developing a medical condition, the preoccupation is clearly excessive or disproportionate.

3. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.

4. The individual performs excessive health-related behaviors or exhibits maladaptive avoidance.

5. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.

6. The illness-related preoccupation is not better explained by another mental disorder. Specify whether medical care is frequently used (care-seeking type) or medical care is rarely used (care-avoidant type).

Prevalence of 0.25-1.0%

Conversion Disorder:

An SSD marked by odd pseudoneurological symptoms that have no discoverable medical cause.

Includes sudden blindness or deafness, paralysis of one or more areas of the body, loss of feeling or ability to experience pain in a body area, feeling a large lump in the throat (Globus hystericus), and pseudoseizures.

Pseudoseizures:

Seizure-like activity such as twitching or loss of consciousness without electrical disruptions in the brain.

Symptoms related to the disorder are real—not faked—but have no medical explanation. The symptoms are also not part of a behavior or experience that is part of one’s culture. Many religious and healing rituals in different cultures involve peculiar changes such as loss of consciousness, but this is not conversion disorder.

Psychological, not physical, stressors generally trigger symptoms of conversion disorder. Including trauma, conflict, and stress. A soldier may suddenly become paralyzed in a highly stressful wartime experience. A psychodynamic theorist might say the terror of trauma is too difficult to bear, and so distress is “converted” into a sensorimotor disability that is easier to tolerate. However, these symptoms do not cause substantial distress nor significantly interfere with daily functioning. People with this disorder experience la belle indifference and are relatively unconcerned about their symptoms. A lack of concern may indicate other psychological factors are at play, perhaps including dramatic or attention-seeking behavior.

DSM-5

1. One or more symptoms of altered voluntary motor or sensory function

2. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

3. The symptom or deficit is not better explained by another medical condition or mental condition.

4. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

   1. Specify symptom type, the symptoms are acute (less than 6 months) or persistent (6 months or more), and if symptoms occur with or without a psychological stressor.

Prevalence of 0.3%

Factitious Disorder:

A mental disorder marked by the deliberate production of physical or psychological symptoms to assume the sick role.

A person with this disorder may fabricate physical complaints such as stomachaches or psychological complaints such as sadness to assume the sick role. People with this disorder may purposefully make themselves sick by taking medications or inducing fevers. This disorder is thus different from SSD and Illness anxiety in which a person does not deliberately cause his symptoms.

DSM-5:

1. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

2. The individual presents himself or herself to others as ill, impaired, or injured.

3. The deceptive behavior is evident even in the absence of obvious external rewards.

4. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

Munchausen Syndrome:

A severe factitious disorder in which a person causes symptoms and claims he has a physical or mental disorder.

This could involve mimicking seizures or injecting bacteria into oneself. This disorder may be somewhat more common among women visiting obstetricians and gynecologists, including women who deliberately induce vaginal bleeding. Some with this syndrome may experience stressful life events or depression or have aspects of BPD or antisocial personality disorder.

Munchausen Syndrome by Proxy (Factitious Disorder Imposed on Another):

When adults deliberately induce illness or pain into a child and then present the child for medical care. (e.g. Gypsy Rose story)

The parent is usually the perpetrator and often denies knowing the origin of the child’s problem. The child generally improves once separated from the parent Most child victims of this are younger than 4 years, and most perpetrators are mothers. The main motive for these terrible acts is the attention and sympathy the parent receives from others.

DSM-5:

1. The falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.

2. The individual presents another individual (victim) to others as ill, impaired, or injured.

3. The deceptive behavior is evident even in the absence of obvious external rewards.

Malingering:

Deliberate production of physical or psychological symptoms with some external motivation.

Not a formal DSM-5 diagnosis but rather an additional condition that may be a focus of clinical attention. A person may complain of back pain or claim he hears voices to avoid work or military service, obtain financial compensation or drugs, or dodge criminal prosecution. Symptom exaggeration may occur, especially in cases involving disability or workers compensation (30%), personal injury (29%), criminality (19%), and medical or psychiatric issues (8%).

Epidemiology

Many people with SSDs remain in the medical system and not the mental health system, and many have vague symptoms, so data regarding epidemiology remains sparse. Complicating matters is that several known medical conditions include vague, undefined symptoms that make it difficult to tell whether a person has a true physical disorder. Examples include fibromyalgia, chronic fatigue syndrome, lupus, and irritable bowel syndrome.

Many people display moderate somatization and not a formal SSD. Medically unexplained symptoms occur in about 40.2 to 49.0% of patients presenting to primary care doctors. Factors associated with high total somatic symptoms include less education, nonmarried status, history of child maltreatment, presence of other medical illnesses, anxiety, and depression. Somatic symptoms are also common among college students.

Stigma

People of different cultures may report various types of psychological symptoms depending on local norms and whether stigma is present. For example, those from Asian cultures tend to use somatic complaints to express depression because doing so is less stigmatizing than admitting emotional sadness. Fear of stigma may delay treatment among some people with depression and somatization. Family members, friends, and even physicians may view a person with an SSD as more of a nuisance than someone who needs psychological help.

People with unexplained medical symptoms, such as those with chronic fatigue syndrome, often face blame or dismissal from others who attribute their symptoms to emotional problems. This may affect their decision to seek treatment. People with somatization concerned about stigma will also continue to emphasize somatic and not psychological explanations for their symptoms.

Biological Risk Factors for SSDs

Genetics

SSD may have a moderate genetic basis, with a heritability of 0.44. Illness anxiety may also have a moderate genetic basis, with a reported heritability estimate of 0.54 to 0.69. SSDs often cluster among family members, particularly female relatives and between parents and children. Several aspects of SSDs have a genetic basis as well, especially anxiety, anxiety sensitivity, depression, and alexithymia.

Brain Features

Another biological risk factor for SSDs may be brain changes, especially in areas relevant to emotion, perception, and physical feeling. Key aspects of the brain thus include the amygdala and limbic system, hypothalamus, and cingulate, prefrontal, and somatosensory cortices. These areas may be overactive in some people with SSDs. Some people may perceive or “feel” bodily changes and experiences that are not actually occurring. The amygdala is associated with fearful emotional responses and physical symptoms such as increased heart rate and sweating. An overactive amygdala may explain why people with SSDs experience many physical changes and concern about the changes.

Others propose that changes in these brain areas interfere with inhibitory behavior and promote hypervigilance about symptoms, as well as increased central nervous system activity and stressful responses. Some disruption is occurring in communications between the brain and the body. Some people with SSDs may feel they must constantly check indicators such as heart rate, blood pressure, and respiration.

People with phantom limb pain appear to have changes in the brain’s motor and somatosensory cortices. The brain initially seems to have trouble adjusting to the missing limb because motor and somatosensory cortices must undergo a neuronal reorganization to account for the missing limb. Other researchers have also noted substantial somatization among people with medical illnesses such as coronary heart disease, multiple sclerosis, diabetes, chronic obstructive pulmonary disease, cancer, or arthritis.

Other biological evidence also suggests that people with SSDs have brain changes that lead to distractibility, difficulty growing accustomed to continuous stimuli such as physical sensations, and limited cognitive functioning. These brain changes may include dysfunction in the frontal lobe and right hemisphere. Changes in the right hemisphere may help explain why many somatic complaints tend to be on the left side of the body.

Neuroimaging evidence reveals possible changes in blood flow to key brain areas. Researchers have found changes in different areas of the cortex among people with conversion disorder. Decreased blood flow may occur in areas of the prefrontal cortex and other aspects of the brain related to loss of sensory and motor function as seen in conversion disorder.

Environmental Risk Factors For SSDs

Illness Behavior and Reinforcement

Illness behavior is a key concept of SSDs and refers to behaviors one does when sick. Examples include resting in bed, seeing a physician, and taking medication. Partners, family members, and friends may reinforce these behaviors by giving sympathy, attention, and comfort. This may help explain the phenomenon of la belle indifference in people with conversion disorder. We also generally accept sickness as a socially appropriate means of withdrawing from obligations, so negative reinforcement can be powerful as well. For people with SSDs, social reinforcement for constant complaints or doctor visits may help explain why these disorders persist for long periods. Such demands for attention may intersect as well with someone’s dramatic personality structure or disorder.

Another form of comfort relevant to this population is reassurance. Many of us feel reassured by medical tests and doctor reports that give us a “clean bill of health” but people with SSDs may not. Reassurance is also an effective anxiety-reducer in the short term but not the long term. People may pursue ongoing, repetitive, and lengthy medical tests and visits. Some believe children model parents’ use of reassurance-seeking as they age. Children may copy parents’ frequent complaints about physical symptoms or calls to friends for sympathy.

Secondary Gain sometimes refers to receiving social reinforcement for somatic complaints. Psychodynamics theorists view primary gain as unconscious use of physical symptoms to reduce psychological stress. People who pay close attention to minor physical symptoms reduce attention toward some internal or external stressor. Some may find it easier to concentrate on minor bodily changes than major life stressors such as marital conflict, financial troubles, or academic failure.

Cognitive Factors

Related to illness behaviors are illness beliefs or somatic attributes, or perceived causes of physical symptoms. People may believe a virus, a psychological condition such as depression, or an external problem such as working too much causes their illness or physical sensation. People with SSDs tend to adopt biological or illness explanations for their symptoms compared with people with other disorders, who adopt psychological explanations. A person coming home from a long and difficult day of work may adopt a physical explanation for their fatigue (I am sick), whereas many of us would adopt a psychological explanation (I am stressed out).

Those with SSDs also see themselves as particularly vulnerable to illness and engage more in illness behaviors. The presence of anxiety and depression, problems also related to cognitive distortions, seem closely linked to increased health anxiety and internal illness beliefs as well.

Another cognitive factor is somatosensory awareness, or a tendency to notice and amplify physical sensations. This is a condition seen in those with panic disorder and refers to people who closely attend to minor bodily changes. The changes become amplified and seem more severe than they are. Overlap does exist between Illness anxiety disorder and panic disorder.

Cultural Factors

Psychological conditions are highly stigmatizing in non-Western countries, so a greater emphasis on physical symptoms may be more acceptable. Many cultures have “cultural idioms of distress” to make various experiences seem more normal. The Vietnamese notion of phong tap, which refers to general aches and pains and distress as attributable to fatigue and cold. Attributing one’s mental distress to external factors beyond one’s control is acceptable practice. This may fit into the notion that social reinforcement in a culture is important for how people express their stress.

Evolutionary and Other Factors

Evolutionary theories of SSDs are sparse, but symptoms of conversion disorder may have developed as an adaptive way of coping with inescapable threats to life. People faced with warfare or massacre may show debilitating symptoms such as blindness as to signal to others that one is not a danger; this may help ward off harm. Displaying somatic complaints relates to social closeness and adaptive coping among people faced with the loss of a close relative. This may increase support or care from others.

Other general factors may also apply to SSDs. Including poor medical attention and care, stressful life events, and general emotional arousal. Poor medical attention and care may include insufficient feedback by a general physician to someone worried about a particular disease as well as unnecessary treatment. Stressful life events relate closely to the severity of conversion disorder symptoms. Some also point to large-scale events such as terrorism as potentially related to medically unexplained symptoms.

Causes of SSDs

Different factors likely cause SSDs, but much controversy remains about exactly how these problems originate. Some believe the best way to view SSDs is as changes in perception, control, and attention. Some people misinterpret or misperceive sensory experiences as real and dangerous symptoms of some serious medical problem. One with SSD may also view internal sensory experiences as uncontrollable, meaning the symptoms are beyond their ability to influence or treat, which makes the experiences more frightening.

The way people with SSDs misperceive internal sensations is similar to the way some people with anxiety-related disorders, especially panic disorder. Recall that somatic symptoms and anxiety-related disorders are closely linked. One possibility for this link is that physical symptoms of anxiety, such as heart palpitations or dizziness, become part of a powerful memory later used to explain minor physical discomfort. An anxious person might have chest pain and worry (wrongly) that they are having a heart attack. This person may later have slightly blurred vision and worry (wrongly) that they have a brain tumor.

People with SSDs also over-attend even to minor changes in their body. If you constantly and intensively check on your heart or respiration rate, you may notice some changes over time. These are normal, however, for people with SSDs, over-attention amplifies the intensity of their symptoms and contributes to worries about their meaning. They may come to believe they have a serious condition. Such over-attention exists in people with anxiety-related and depressive disorders. All of these processes—sensory misperception, feelings of uncontrollability, and over-attention—can then lead to illness behaviors, social reinforcement for playing the “sick role”, avoidance of daily activities, and an SSD.

Prevention of SSDs

Data is scarce regarding the prevention of SSDs, but information about the disorders in children and adolescents may be instructive. Youths with somatization are often female, and their parents are often of lower socioeconomic status and educational level. Stressful life events, traumatic experiences such as maltreatment, history of physical disease, unnecessary medical interventions, and the presence of other mental disorders such as anxiety and depression also relate to somatization in youths. Others have stated as well as some youths receive substantial attention from parents for somatic complaints, and this serves as a reinforcer.

Given this information, strategies to prevent the development of SSDs may include several components. Including educating children and parents about dangerous and non-dangerous physical symptoms, attending to serious but not uncommon bodily changes, helping youths cope with traumatic events and related mental disorders, ensuring adequate and competent health care, and practicing anxiety management. Given that SSDs may endure over time, addressing risk factors for the problems as early as possible is important.

Assessment of SSDs

Interviews

Interviews gather information about people with SSDs include structured, research-based ones such as the “Structured Clinical Interview for DSM-5,” ”Composite International Diagnostic Interview,” “Somatoform Disorders Schedule,” and “International Diagnostic Checklist.” These interviews cover diagnostic criteria for various SSDs.

Questions given to someone with a possible SSD should involve a detailed history of physical and psychological problems. SSDs can be complex and long-standing, and we know these disorders often begin in childhood and adolescence, so questions about one’s history should extend far into the past. Pertinent topics include early and recent life experiences and stressors, medications and substance use history, others’ reactions to somatic complaints, cognitive distortions, interference in daily functioning, and motivation for seeking and pursuing psychological treatment for what the client may believe is mostly a medical problem.

Questionnaires

Screening instruments also exist for possible SSDs. common ones include the “Screening for Somatoform Disorders (SOMS),” and “SOMS-7,” which cover diagnostic criteria and measure a person’s medically unexplained physical symptoms. Psychological factors are often a part of SSDs, so some questionnaires assess these constructs. The “Somatic Symptoms Experiences Questionnaire,” for example, assesses health worries, illness experience, difficulties in interaction with doctors, and impact of illness.

Other questionnaires specific to hypochondriasis include the “Whiteley Index,” “Illness Behavior Questionnaire,” “Illness Attitude Scales,” and “Somatosensory Amplification Scale (SAS).” These scales measure diagnostic symptoms, perceptions of illness, and awareness of internal sensations.

Personality Assessment

SSDs and unrealistic health concerns sometimes relate to certain personality traits or disorders. Assessment for this population may include personality inventories. The “Minnesota Multiphasic Personality Inventory—2 (MMPI-2)” includes clinical subscales for hypochondriasis, somatic complaints, and health concerns. Several MMPI-2 scales have been to used to discriminate people with malingering and somatoform patient conditions from control patients. Others have found the scales useful for assessing coping strategies, emotional dysfunction, somatic complaints, low positive emotions, and cynicism in this population.

Biological Treatment of SSDs

People with SSDs often experience comorbid anxiety and depression, so a key treatment approach has been medication to address these conditions. The most common medications for this population gas been selective serotonergic reuptake inhibitors such as escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), and paroxetine (Paxil). Use of these drugs for somatic symptoms and illness anxiety disorders helps improve anxiety and depression, as well as fear of disease, symptom occupation, and overall functioning. Antidepressant medication may help reduce the severity of pain as well. Much work remains regarding these medications with respect to dosing, treatment duration and individualized assignment, and long-term outcome.

Psychological Treatment of SSDs

Cognitive Therapy

Cognitive therapy for anxiety-related disorders involves examining inaccurate statements a person may be making and encouraging the person to challenge the thought and think more realistically. This therapy works the same for the treatment of people with SSDs. People with SSDs should first understand the connection between their thoughts and their physical symptoms. Someone who constantly worries about having a disease and who checks her body constantly for changes may amplify those changes and misperceive them as dangerous. Cognitive therapy helps a person examine evidence to challenge this thought process. A person may come to realize that minor physical sensations and changes are not dangerous because all humans have them and because the symptoms are often temporary and controllable.

A client with an SSD may also benefit from logically examining their thoughts about the consequences of physical symptoms. Biofeedback, in which a person learns to consciously control bodily functions such as heart rate, can be useful in this regard.

Various SSDs involve problematic thought processes that can be treated with cognitive therapy. People with illness anxiety disorder fear their symptoms indicate a serious disease. A cognitive therapist may help a client deal with anxiety disorder discuss evidence for and against a disease belief, asses realistic probabilities for a certain physical symptom, and understand that a 100% certainty of knowing one is not ill is never possible. A person with abdominal distress should list all possible reasons and probabilities for such distress, including cancer but also gas, indigestion, and other common but harmless conditions. Mindfulness-based cognitive therapy with meditation may be helpful as well.

Behavior Therapy

Behavior therapy for SSD helps a person reduce excess behaviors such as checking symptoms and visiting doctors. Behavior therapy aims to reduce the excess attention-seeking and reassurance-seeking behaviors that many people with SSDs engage in; these behaviors cause others to reinforce their symptoms. Contingency Management involves educating family members and friends about a person’s SSD and encouraging them to reinforce “well” behaviors such as going to work, finishing chores, and staying active. This seems especially important for treating conversion disorder, in which and emphasis is placed on removing medical and social attention for abnormal sensory-motor conditions, administering physical therapy to restore normal movement, and helping clients cope with stress and trauma.

The primary behavioral treatment components for SSDs are relaxation training, exposure, response prevention, and social skills and assertiveness training. These treatments are similar for anxiety-related disorders, especially OCD. SSDs often have an anxious component, so treatments aimed at anxiety may work well for this population. Relaxation training and exposure are often conducted together to help ease muscle tension, which aggravates physical symptoms, and reduce anxiety when a person confronts anxiety-provoking stimuli. Such stimuli usually include avoided situations such as social interactions, dating, and work. Response prevention involves limiting the number of times a person can monitor physical symptoms or engage in some other excess behavior. Many therapists use behavioral procedures with cognitive therapy to treat people with SSDs.

Cognitive plus behavioral therapy for people with SSDs is quite helpful in many cases. Exposure, response prevention, and cognitive therapy in one study produced significant improvements in illness attitudes and behaviors as well as somatoform symptoms. Success rates for people with SSDs are generally less positive, however, than for people with anxiety disorders or depression. This is because people with SSDs often show multiple symptoms over long periods. The most useful approach for this population will likely include medication and comprehensive psychological treatment within medical and mental health settings.

Long-Term Outcome for People with SSDs

Longitudinal studies indicate that many people (50-70%) with medically unexplained symptoms or SSD disorder show improvement over time. But that 10 to 30% deteriorate. People with illness anxiety disorder often have a more chronic course, with 50 to 70% maintaining their symptoms over time. Predictors of more chronic course of SSD include greater severity of symptoms such as degree of pain or illness as well as poor physical functioning. Other possible predictors include female gender, comorbid mood problems, and unrealistic fear of illness.

People do respond to treatment for these problems, although researchers have found certain characteristics related to better long-term outcomes. These characteristics include longer treatment as well as less anxiety and fewer pretreatment symptoms, comorbid conditions, cognitive distortions about bodily functioning, and hospital stays.

Dissociation:

A feeling of detachment or separation from oneself.

Dissociation refers to some separation of emotions, thoughts, memories, or other inner experiences from oneself

Separation is often mild and temporary and can include things like daydreaming, being absorbed by a film, spacing out, or highway hypnosis. In other cases, separation is moderate, meaning a person may feel temporarily outside of her body or walk through hallways as if in a fog. Or a person may feel he cannot recall all details of a certain event.

These episodes of dissociation are normal because they are temporary and do not interfere with daily life. A person may take an important test and feel dissociated for the first few minutes. They may feel as if they are watching themselves take the test and have trouble concentrating on the questions. Usually, this feeling dissipates quickly, and the ability to concentrate returns. Another person may see a terrible accident and feel as if events are progressing in dreamlike slow motion. Minor dissociation may help us temporarily handle stress by keeping it at arm’s length. The dissociation usually dissipates as we adjust to the stressful situation, calm ourselves, and do what we need to do.

Dissociative Disorder:

A class of mental disorders marked by disintegration of memory, consciousness, or identity.

In some cases, however, separation can be severe and lead to dissociative disorders. Which involve disturbance in consciousness, memory, or identity. A person may experience some form of dissociation for lengthy periods of time or in some extremely odd way. Such extreme dissociation may be reinforced over time because it works so well— in other words, the person does not have to address a particular trauma.

Continuum of Dissociation and Dissociative Disorders

1. Normal

   1. Emotions

      1. Feeling good connections with others and environment.

   2. Cognitions

      1. No concerns about forgetfulness

   3. Behavior

      1. Occasional forgetfulness but little problem with remembering with a cue

2. Mild

   1. Emotions

      1. Mild physical arousal, especially when forgetting something

   2. Cognitions

      1. Slight worry about lack of concentration on an examination or about increasing forgetfulness as one ages.

   3. Behaviors

      1. Daydreaming during class, minor “spacing out” during a boring abnormal psych lecture, mild forgetfulness.

3. Moderate

   1. Emotions

      1. Greater difficulty concentrating, feeling more alienated from others and one’s environment.

   2. Cognitions

      1. Greater worry about minor dissociation, such as sitting in a car at the supermarket and wondering how one arrived here.

   3. Behaviors

      1. Highway hypnosis, more frequent forgetfulness, or acting as if in a fog or dream.

4. Dissociative Disorder-less severe

   1. Emotions

      1. Intense difficulty concentrating and feelings of estrangement from others.

   2. Cognitions

      1. Intense worry about substantial dissociation or “gaps” in memory or little realization that something is wrong.

   3. Behaviors

      1. Infrequent episodes of depersonalization, intense forgetfulness, or missing appointments with others.

5. Dissociative Disorder-More Severe

   1. Emotions

      1. Feelings of complete alienation and separation from others or one’s environment

   2. Cognitions

      1. Potential lack of insight or thought about one’s personal identity or changed living situation

   3. Behaviors

      1. Severe and frequent episodes of dissociation, constant amnesia or fugue, presence of multiple personalities.

Dissociative Amnesia:

A dissociative disorder marked by severe memory loss for past and/or recent events.

Dissociative amnesia involves forgetting highly personal information, typically after some traumatic event. A person may have trouble remembering their name after a car accident or assault. To be defined as dissociative amnesia. The memory loss can, however, cause distress and impair one’s ability to function on a daily basis. Imagine being unable to remember who you are—this would cause enormous stress and would obviously prevent you from working.

Dissociative amnesia can come in several forms. People with dissociative amnesia may have only one severe episode of forgetfulness or several smaller or equally severe episodes. This may depend on the degree of trauma in their life. Recollection of important personal information may return suddenly for some but more gradually in others. Oddly, a person may remember personal information but remember historical events or how to drive a car. Such semantic or procedural memory can be lost in some cases, however. Dissociative Amnesia seems common among television characters, but loss of widespread personal information is actually quite rare.

Dissociative Fugue:

A dissociative problem marked by severe memory loss and sudden travel away from home or work.

Dissociative amnesia can also include dissociative fugue. Some people develop amnesia about personal events and suddenly move to another part of the country or world. People with dissociative fugue can’t recall their past, sometimes their identity, and end up living and working far away from family and friends. The person often assumes a new identity or is greatly confused about personal identity. Dissociative fugue most often occurs after a traumatic event. A man about to be publicly embarrassed in a scandal may suddenly move to another part of the country and assume a new name or job. Fugue states are characterized by dissociation, so in this case, the person did not consciously plan to move. Instead, they likely had little recollection of what happened to them in the past. Fugue states can eventually disappear and a person may resume his old life, although memories of the original trauma may still be poor.

DSM-5

1. An inability to recall important autobiographical information, usually of traumatic or stressful nature, that is inconsistent with ordinary forgetting

   1. Note: Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history.

2. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

3. The disturbance is not attributable to the physiological effects of a substance or a neurological or other medical condition.

4. The disturbance is not better explained by dissociative identity disorder, PTSD, acute stress disorder, SSD, or major or mild neurocognitive disorder.

   1. Specify if with dissociative fugue, or travel or wandering associated with amnesia for identity or other autobiographical information.

Dissociative Identity Disorder (DID):

A dissociative disorder marked by multiple personalities in a single individual.

Once know as multiple personality disorder, a person may feel as if strange events are happening around them. The person may have trouble recalling personal information and have memory gaps about childhood or recent events. To be defined as DID, the development of multiple personalities must not result from substance use or a medical condition. Identity “splitting” is often due to a traumatic event such as child maltreatment.

What is remarkable about DID is that true differences supposedly exist among the personalities. Each personality may have its own distinctive traits, memories, posture, clothing preferences, and even physical health. Keep in mind a person with DID is not pretending to be someone different, such as when an adult acts and talks like a child. Instead, true differences exist in behavior and other characteristics to make someone unique. Some researchers, however, question the existence of multiple personalities and see only differences in representations of different emotional states or sociocultural expectations. Others maintain that DID is a valid diagnosis but one should involve a clearer definition of symptoms.

Many people with DID have a host personality and subpersonalities, or alters. A host personality is one of the most people see and is likely to present most of the time. A host personality is like your general personality that changes from time to time but is not dramatically different. Subpersonalities, however, are additional distinct personalities within a person that occasionally supplant the host personality and interact with others.

The relationships between subpersonalities and the subpersonalities and the host personality can be complex. Different relationship possibilities exist for the various personalities of the person with DID, including the following:

1. Two-way Amnesiac Relationship

   1. The personalities are not aware of the existence of one another.

2. One-way Amnesiac Relationship

   1. Some personalities are aware of other personalities, but this awareness is not always reciprocated.

3. Mutually Aware Relationship

   1. The personalities are aware of all other personalities and may even communicate with one another.

   Prevalence: 1%

DSM-5:

1. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.

2. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.

3. The disturbance is not a normal part of broadly accepted cultural or religious practice.

   1. In children, the symptoms are not better explained by imaginary playmates or other fantasy play.

4. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

5. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).

Depersonalization/Derealization Disorder:

A dissociative disorder marked by chronic episodes of detachment from one’s body and feelings of derealization.

Derealization:

A sense that surrounding events are not real.

People with this disorder maintain a sense of reality but may feel they are floating above themselves, watching themselves go through the motion of an event, or feel as if they are in a movie or like a robot. Depersonalization often exists with derealization.

Depersonalization or derealization episodes can be short or long, but a person may have trouble feeling sensations of emotions. These episodes cause great distress and significantly interfere with daily functioning. The depersonalization or derealization episodes should not occur because of another mental disorder such as panic disorder, or substance use or a medical condition. However, people with panic and other anxiety-related disorders commonly report depersonalization and derealization. Brief episodes of depersonalization are common in the general population and are not a mental disorder. Symptoms of depersonalization and fugue are sometimes difficult to tease apart.

Prevalence: 1-2%

DSM-5

1. The presence of persistent or recurrent experiences of depersonalization, derealization, or both.

2. During the depersonalization or derealization experiences, reality testing remains intact.

3. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

4. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures).

5. The disturbance is not better explained by another mental disorder.

Epidemiology

Symptoms of these disorders are often hidden, and many people with dissociative disorders do not seek therapy. Many people who attend therapy for some other disorder, however, also experience symptoms of dissociation. Symptoms of dissociation are also common in PTSD, panic, and OCD. Up to 25% of people with another mental disorder have a dissociative disorder. The prevalence of pathological dissociation ranges depending on the assessment method but may be up to 10%.

The prevalence of dissociative amnesia, however, is highly debatable. Some researchers claim its a rare phenomenon, but others believe the disorder is more common than previously thought. The discrepancy derives from controversy as to whether adults can suddenly recall long-forgotten events from childhood.

Pathological dissociation may be more common in younger people and is fairly equal across men and women. Men are more likely to experience amnesia, however, and woman may be more likely to experience DID. Dissociative experiences may also be more common among certain cultural groups. Pibloktoq is an episode involving a type of dissociative fugue in which people leave home and shed their clothes in Arctic weather. Others speculate African Americans use dissociation as a coping strategy for operating as a minority group or that this group is more susceptible to dissociation.

Aspects of dissociative disorders seem highly comorbid with other mental disorders, especially those involving trauma. Up to 30% of people with PTSD, for example, report high levels of dissociative symptoms. Dissociative behavior is also quite common among homeless and runaway youths and adolescents who have experienced trauma.

Stigma

One group of researchers surveyed people with dissociative and other disorders and found that nearly 60% believed that most people would not allow someone with a mental disorder to take care of their children and that most young women would be reluctant to date a man who had a mental disorder. Most respondents also believed that potential employers would bypass applications of psychiatric patients. In addition, a majority of those surveyed believed that people in the general population saw psychiatric patients as less intelligent, trustworthy, and valued with respect to their opinions. Negative beliefs could lead to reluctance to rely on others for support or seek treatment if psychological symptoms persist or worsen.

Biological Risk Factors for Dissociative Disorders

Brain Features

A key aspect of dissociative disorders is disintegration of consciousness, memory, and identity. Brain areas responsible for integrating incoming information may be altered in some way. Key brain areas for integration include the amygdala, locus coeruleus, thalamus, hippocampus, anterior cingulate cortex, and frontal cortex. Some believe disintegration or dissociation in times of stress create and arousal threshold in these brain areas. Reaching this threshold triggers increased alertness but also inhibition of strong emotional responses such as anxiety.

We may detach ourselves from a terrible event so we an control our responses and react adaptively. A person in a car accident may feel they are floating above the crash scene but at the same time can rescue others, talk to police, and call family members. Their alertness increases, but excesses in emotion and physical arousal are temporarily blunted. This person may later appreciate the full weight of what happened and experience nightmares or flashbacks of the trauma. People with acute stress or PTSD commonly have dissociation.

Dissociative disorders, especially depersonalization/derealization and perhaps amnesia/fugue, may also be due to problems in connection between various brain areas, especially between sensory systems (eyesight, hearing) and the limbic system. A possible consequence of such disruption is that a person sees an event, especially a strongly negative event, but “detaches” themself and experiences little emotional response. Such disconnection can also lead to blunted pain experiences and a decrease in irrelevant thoughts. Evidence indicates that people undergoing depersonalization have blunted reactions to arousing stimuli. Others have found that neurochemical changes endorphin, endogenous opioid, and glutamate systems to depersonalization as well.

Memory Changes

Work in the area of memory changes and dissociative disorder remains in development, but some suggest that intense negative emotions lead to compartmentalization and difficulty retrieving information. Exposure to a negative event and intense negative emotions may instigate a segregation or “compartmentalization of one part of the mind from other areas. Compartmentalization may help explain why certain memories or personalities are not “known” by the host personality.

Compartmentalization may not be complete, however. When one personality learns new information, interference in learning another personality can occur. One personality may also retrieve information learned by another personality. This provides support for the existence of mutually aware or one-way amnesiac relationships among personalities. Transfer of information across different personalities may depend, however, on emotional and personal content of the information. Difficulty retrieving information is also common in people with DID and dissociative amnesia. People with these disorders may have trouble distinguishing true and false memories, especially of childhood. They often have deficits in short-term memory and working memory, which is the ability to hold information while completing another task Problems in these areas of memory, which may result from emotional arousal, may relate to irrelevant thoughts and dissociative experiences.

When trying to recall a phone number, a person may temporarily forget because they are thinking of other things or “spacing out.” People with dissociative disorders may have such problems on a grander scale. What causes these memory changes to begin with is unclear. One possibility is that people with DID and dissociative amnesia have reduced blood flow in the right frontotemporal cortex. Excessive stress and trauma may create these metabolic changes.

Environmental Risk Factors

Trauma

Traumatic experiences and PTSD are closely linked to dissociative disorders. Adult dissociation often follows a severe traumatic event such as child treatment. Consider a 4-year-old child experiencing severe physical maltreatment from a parent. The options available to this child are few: He is unlikely to run away, kill the parent, or commit suicide. An alternative coping strategy is to dissociate or detach from the trauma in a psychological way. Such dissociation may be mild in the form of thinking about something else or more severe in the form of developing amnesia or even a different personality.

Traumatic problems may follow dissociation in other cases. A good predictor of PTSD is dissociation during a traumatic event. Someone who dissociates during a traumatic event may not cognitively process all relevant stimuli in that situation. Such avoidance can help produce symptoms of PTSD, and exposure to reminders of the trauma is a key part of treatment for PTSD. A person who is assaulted may dissociate somewhat and even describe their attacker to the police. They may cognitively avoid other stimuli associated with the event such as the parking lot where the assault occurred. If they walk through the parking lot in the future, doing so may trigger posttraumatic stress.

Dissociation may be a way of temporarily coping with a terrible event. This is especially likely if the event involved intense fears of death, loss, or lack of control. Such fears are in addition to the terror of trauma and increase the likelihood one will experience long-term emotional distress or PTSD. Other researchers, however, refute a casual relationship between dissociation and trauma because some 3rd variable may explain the relationship. A 3rd variable such as intense family conflict could explain trauma and dissociation in an adolescent (so trauma or dissociation may not have caused each other). People with dissociative disorders also do not remember earlier traumatic events with great accuracy.

Cultural Factors

Cultural factors may also relate to dissociation because cases of DID seemed to peak before 1920 and after 1970. In addition, 82% of cases of DID occur in Western countries. Some speculate that changes in how the concept of “self” is defined from generation to generation may affect the prevalence of DID. Some people may rely on “an alternate personality” explanation to avoid personal responsibility for certain acts, event violent ones.