Somatic and Dissociative Disorders Overview

Somatic and Dissociative Disorders

• Somatic and dissociative symptoms were once grouped under the general term "hysteria"
• Hysteria was linked to the "wandering uterus"
• Freud proposed "conversion hysteria," where unconscious emotions and conflicts manifest as physical symptoms.

Somatic Symptom Disorder

• One or more somatic symptoms that are distressing or impairing
• Excessive thoughts, feelings, or behaviors related to the somatic symptoms
• Persistent thoughts about the seriousness of symptoms
• Persistent high levels of anxiety about symptoms
• Excessive time and energy devoted to symptoms
• Symptoms do not have to be present continuously but must be persistent (usually more than 6 months)
• Specifiers include predominant pain, persistent (severe symptoms), (marked impairment), and long duration
• Severity can be mild, moderate, or severe.

Somatic Symptom Disorder (Prevalence)

• Typically more prevalent in females
• Older adults
• Individuals with less education
• Lower socioeconomic status (SES)
• History of abuse
• Comorbid anxiety or depression
• Additional physical or psychiatric disorders
• Social stress
• Reinforcing factors contribute to prevalence

Illness Anxiety Disorder

• Preoccupation with having or developing a serious illness
• Somatic symptoms are mild or absent
• Significant anxiety about health
• Excessive health-related behaviors (checking for signs of illness)
• Maladaptive avoidance (avoiding doctor appointments, medical care)
• Preoccupation lasts at least 6 months
• Similar rates in males and females

Illness Anxiety Disorder (Causes)

• An integrative model suggests that a trigger (information, event, illness, or image) leads to a perceived threat. This perceived threat leads to apprehension, increased focus on the body, increased physiological arousal, and checking behaviors or reassurance-seeking. Misinterpretation of bodily sensations or signs occurs as a response to the perceived threat. This further perpetuates the cycle.

Somatic Symptom and Illness Anxiety

• Risk factors include stressful life events, high rates of medical issues in family members, and social and interpersonal influences
• Treatments involve cognitive behavioral therapy and explanatory therapy

Psychological Factors Affecting Medical Conditions

• A diagnosed medical condition (e.g., asthma, diabetes) exists
• Psychological or behavioral factors have an adverse impact on the medical condition
• Examples include denial about necessary medical care, such as blood sugar checks in a patient with diabetes, which is not explained by adjustment disorder.

Conversion Disorder

• Also known as Functional Neurological Symptom Disorder
• One or more symptoms or deficits affecting voluntary motor or sensory function
• Symptoms are NOT intentionally produced
• Symptoms are incompatible with recognized neurological or medical conditions
• Specifiers include weakness or paralysis, abnormal movement, swallowing symptoms, speech symptoms, seizures, anesthesia or sensory loss, special sensory symptoms, or mixed symptoms

Conversion Disorder (Specifics)

• Conversion disorder occurs two to three times more frequently in women
• A potential cause is a traumatic event in which a threat is presented
• The desire to avoid that threat can present as becoming sick and detached from conscious awareness
• Conversion symptoms serve as an escape from the original difficulties, continuing until the underlying issues are resolved
• Secondary gain/ attention, and empathy may play a role.

Conversion Disorder (Risk Factors and Treatment)

• Risk Factors: prior medical complications, lower education level, family medical problems, stress
• Treatment: identification of trauma or stressors, and reducing reinforcement.

Factitious Disorder

• Intentional feigning or physical or psychological symptoms, or creation of injury or disease
• Types: Imposed on self, Imposed on another (by proxy)
• Absence of external incentives
• Specifiers: single or recurrent episodes

Malingering

• Intentional production of false or exaggerated physical or psychological symptoms
• Motivated by external incentives.

Comparison of Somatic Disorders, Factitious Disorder, and Malingering

• Different patterns of symptom production, motivations, and gains

Dissociative Disorders

• A disturbance or alteration in the integration of identity, memory, perception, consciousness, emotion, behavior, body representation, and motor control.
• Often occur after traumatic experiences
• Often more prevalent in women

Dissociative Disorders (Types)

• Dissociative Identity Disorder: Presence of two or more distinct personality states; Recurrent episodes of amnesia; Gaps in remote or procedural memory; When personalities are not observed, symptoms manifest as recurrent, inexplicable intrusions; Alterations in sense of self; Odd changes in perception; intermittent neurological symptoms
• Dissociative Amnesia: Inability to recall autobiographical information that is inconsistent with normal forgetting. Localized, selective, or generalized types, and include wandering or fugue states.
• Depersonalization/Derealization Disorder: Intact reality, but persistent or recurrent symptoms of depersonalization (detachment from oneself) and/or derealization (detachment from surroundings).

Dissociative Amnesia (Specific Information)

• Typically onset in adulthood, but before the age of 50
• Chronic course; Fugue states often end abruptly with recall of events
• Common dissociative disorder.
• "Amok syndrome" is a particular type, characterized by violent acts and a lack of memory during the trance-like state.

Depersonalization/Derealization Disorder (Specific Symptoms)

• Symptoms: perceptual alterations, warped sense of time or space, unreal/unstable sense of self, absent or absent self, emotional or physical numbing
• Symptoms: surrounding feeling lifeless or static, blurry or distorted vision, dreamlike or foggy feelings, watching one's life as if in a movie.

Depersonalization/Derealization Disorder (Prevalence)

• Mean age of onset is roughly 16 years
• Often symptoms are better explained by acute or other disorders
• Course tends to be chronic; High rates of comorbid disorders (anxiety, mood, or personality disorders)
• Differences in perception, emotion regulation, and dysregulation of the HPA (hypothalamic-pituitary-adrenal) axis could be involved.

Dissociative Identity Disorder (Additional Information)

• In children, not better explained by imaginary friends or play
• Recurring episodes of amnesia, evidenced by: Gaps in remote episodic memory; gaps in procedural memory
• Symptoms manifest in different personalities
• Stress can exacerbate symptoms, as can a possession-form identity (a spirit or other outside entity takes control)
• Could not be better explained by cultural or spiritual practices and occurs involuntarily; causing distress
• Average number of identities = approximately 15
• Onset is often in childhood and related to trauma. People with DID may be more suggestible.