Chapter 8 (Somatic and Dissociation)

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Chapter 8: Somatic Symptom and Dissociative Disorders

• This chapter covers somatic symptom and dissociative disorders, examining their similarities, differences, and historical understandings.

Learning Objectives

• Describe similarities & differences between somatic symptom and dissociative disorders, and their historical interpretations.
• Identify features, causes, and treatments of primary disorders in the somatic symptom category.
• Identify features, causes, and treatments of primary disorders in the dissociative category.

Somatic Symptom and Dissociative Disorders

• Somatic symptom and related disorders:
  • Characterized by prominent somatic symptoms, preoccupation/worry about illness, and excessive help-seeking behaviors.
• Dissociative disorders:
  • Involve a loss of normal integration of identity, memory, perception, emotion, behavior, consciousness, and body/motor control.
  • Involve a dissociation or disconnection between mental awareness and normally integrated mental systems.

Historic Approaches to These Disorders

• Historical commonality—some somatic symptom and dissociative disorders were historically linked and shared features.
• A past general heading— "hysterical neurosis"—was used for disorders with physical symptoms without a clear organic basis.
• "Hysteria" (wandering uterus)—associated with both somatic and dissociative experiences in historical contexts.
• Early researchers like Freud, Breuer, Janet, Morton Prince, and William James researched these disorders.
• The distinctions made—today some researchers distinguish between somatoform and psychoform (psychological) dissociation.

DSM-5 Somatic Symptom & Related Disorders

• Historically known as "somatoform disorders."
• Body Dysmorphic Disorder—moved from OCD and related disorders category.
• Hypochondriasis and Somatization Disorder—revised/renamed.
• Pain disorder—removed as separate diagnosis
• Added factitious disorder to the category.
• Psychological factors—added to the section for factors affecting other medical conditions.
• "Soma" refers to the body—Historically, the symptoms were thought to have no physical cause. Now, the DSM-5 allows for the possibility of having a diagnosed medical condition.
• Symptoms are unintentional and not under voluntary control (except in factitious disorder cases), resulting in medical treatment being sought before psychological treatment.

DSM-5—Somatic Symptom and Related Disorders: Specific Disorders

• Somatic Symptom Disorder: Characterized by one or more somatic symptoms that are distressing and have a significant impact on daily life, accompanied by abnormal thoughts, feelings, or behaviors (e.g., persistent worry, excessive time spent on symptoms).
• Illness Anxiety Disorder: Preoccupation with having or acquiring a serious illness, despite the absence or mild intensity of somatic symptoms. High health anxiety and excessive health-related behaviors are common features. This aligns with the concept of Hypochondriasis.
• Conversion Disorder (Functional Neurological Symptom Disorder): Characterized by symptoms of altered motor or sensory function (e.g., weakness, paralysis, blindness) that are inconsistent with recognized neurological or medical conditions. Causes significant distress or impairment.
• Factitious Disorder: Falsification of physical or psychological symptoms (in oneself or another) for no externally obvious reward.

DSM-5 Dissociative Disorders

• Emphasizes disruption in consciousness, memory, identity, and other psychological functions. A disruption of normal integration leads to disconnection in functioning.

Types of Dissociative Disorders

• Depersonalization/Derealization Disorder: Persistent feelings of detachment from one's mind or body, or surroundings; These symptoms cause significant distress or impairment.
• Dissociative Amnesia: Inability to recall important personal information, often related to a traumatic experience, which cannot be explained by ordinary forgetfulness. May be localised (specific time frame), selective (some events), generalised (the entire life), or continuous.
• Dissociative Fugue: Sudden, unexpected travel or relocation with inability to recall one's past and confusion about identity. Usually part of dissociative amnesia.
• Dissociative Identity Disorder (DID): Two or more distinct identities or personality states recurrently taking control of behaviour; Inability to recall important personal information. This is sometimes referred to as multiple personality disorder.

Dissociative Experiences

• Discusses amnesia, depersonalisation, derealisation, and identity confusion or alteration, and how the experiences are connected.

Aetiology of Factitious Disorder

• Proposed motivations for factitious behavior include: the need to be the center of attention, longing to be cared for, maladaptive reactions to loss or separation, anger at physicians, experiencing pleasure from deceiving others, controlling chaos in their lives, re-enactments of the abuse and mastery.

Aetiology of Dissociative Disorders

• Posttraumatic model (severe trauma in childhood leading to a dissociative ability).
• Iatrogenic/sociocognitive/fantasy model (form of role-play in suggestible and fantasy-prone individuals.)

Treatment of Dissociative Identity Disorder (DID)

• Treatment depends on the therapist's perspective.
• Proponents of the sociocognitive model may minimize or dismiss the symptoms.
• Proponents of the posttraumatic model may focus on trauma treatment similar to PTSD, also considering the need for personal stability.
• DID treatments usually follow guidelines from the International Society for the Study of Trauma and Dissociation, which aims for safety, stabilization, symptom reduction, confronting/integrating traumatic memories, and identity reconstruction.

Other

• Any Questions—Use online forum as channel if question relevant to course.