Chapter Six
Somatic Symptom and
Dissociative Disorders
Somatic Symptom Disorders
• Disorders that involve physical symptoms or
anxiety over illness
– Somatic symptom disorder (SSD)
– Illness anxiety disorder
– Conversion disorder (functional neurological
symptoms disorder)
– Factitious disorder
Somatic Symptom Disorders (cont’d.)
Somatic Symptom Disorder
• Pattern of reporting distressing physical
symptoms combined with extreme concern
about health or fears of undiagnosed medical
conditions
– Symptoms must be present for at least six months
– Symptoms not under voluntary or conscious
control
– Psychological in nature but often accompanied by
medical conditions
Somatic Symptom Disorder (cont’d.)
• SSD with predominantly somatic complaints:
– Chronic complaints of specific bodily symptoms
that have no physical basis
• SSD with pain features:
– Severe or lingering pain that appears to have no
physical basis
Illness Anxiety Disorder
• Previously called hypochondriasis
• Persistent health anxiety and concern that one
has an undetected physical illness with no or
minimal somatic symptoms
• Symptoms must be present for at least six
months
Illness Anxiety Disorder (cont’d.)
• Individuals with illness anxiety concerns:
– Catastrophize
– Overgeneralize
– Display all-or-none thinking
– Show selective attention
• Cognitively based disorder
Illness Anxiety Disorder (cont’d.)
Conversion Disorder
• Also known as functional neurological
symptom disorder
• Sensory or motor impairment suggestive of a
neurological disorder, but with no underlying
medical cause
• Symptoms are not consciously being faked
– Individual is not malingering, but rather believes
there is a genuine problem
Conversion Disorder (cont’d.)
• Most common symptoms:
– Psychogenic movement
• Originating from psychological cause
• Disturbances of stance and walking
– Sensory symptoms
• Blindness, loss of voice, motor tics, and dizziness
– Psychogenic seizures
• Some symptoms are easily diagnosed, while
others require extensive neurological and
physical examination
Factitious Disorders
• Factitious disorder:
– Symptoms of illness are deliberately induced,
simulated, or exaggerated, with no apparent
external incentive
– Differs from malingering:
• Faking a disorder to achieve some goal, such as an
insurance settlement
• In factitious disorder, the individual is usually unaware
of the motivation for the behavior
Factitious Disorders (cont’d.)
• Factitious disorder imposed on another:
– Pattern of falsification or production of physical or
psychological symptoms in another individual
– Relatively new diagnostic category and as a result,
little information is available on prevalence, age of
onset, or familial pattern
– Diagnosis of this condition is difficult
Etiology of Somatic Symptom Disorders
Figure 6-2 Multipath Model for Somatic Symptom Disorders The dimensions interact
with one another and combine in different ways to result in a specific somatic symptom
disorder.
Etiology of Somatic Symptom Disorders
(cont’d.)
• Biological dimensions:
– Modest contribution of genetic factors
– Biological predisposition hardwired into central
nervous system can result in:
• Hypervigilance or exaggerated focus on bodily
sensation
• Increased sensitivity to mild bodily changes
• Tendency to react to somatic sensations with alarm
– Repetitive activation of nervous system can lead
to increased sensitivity of pain nerves
Etiology of Somatic Symptom Disorders
(cont’d.)
• Psychological dimension:
– Role of reinforcement, modeling, catastrophic
cognitions, or combination of these
– Cognitive factors:
• Somatic disorders may develop in predisposed
individuals
• Unrealistically interpret and overestimate
dangerousness of bodily symptoms
Etiology of Somatic Symptom Disorders
(cont’d.)
• Social dimension:
– Societal restrictions on women
– Rejection or abuse from family members and
feeling unloved
– History of sexual abuse or rape
– Parental modeling
• Sociocultural dimension:
– Societal restrictions on women
– Cultural factors, including lower educational
levels, ethnicity, and immigrant status
Treatment of Somatic Symptom
Disorders
• Biological:
– Antidepressant medications such as SSRIs are
used to treat somatic symptoms disorder ad
illness anxiety disorder
– Increased physical activity is recommended for
conversion disorder
Treatment of Somatic Symptom
Disorders (cont’d.)
• Psychological:
– Focus is understanding client’s view regarding
problem
– Demonstrate empathy
– View disorders within social context
– Cognitive-behavioral approaches
• Correct cognitive distortions
• Interoceptive exposure
Dissociative Disorders
• Involves some sort of dissociation, or
separation, of a part of a person’s
consciousness, memory, or identity
– Dissociative amnesia
– Depersonalization/derealization disorder
– Dissociative identity disorder
• Relatively rare
• No objective assessment:
– Possibility of feigning
Dissociative Amnesia
• Sudden partial or total loss of important
personal information or recall of events due to
psychological factors or stressors
– May occur following a traumatic event or stressful
circumstances
– May also involve a fugue state
Dissociative Amnesia (cont’d.)
• Localized amnesia:
– Lack of memory for a specific event or events
– Individuals may have selective amnesia or
systematized amnesia
• May occur after a repressed memory comes to light
• Dissociative fugue:
– Episode of complete loss of memory of one’s life
and identity , unexpected travel to new location,
or assumption of new identity
• Recovery is often abrupt and complete
Depersonalization/Derealization
Disorder
• Characterized by feelings of unreality
concerning the self and the environment
• Depersonalization is the most common
dissociative disorder
• Diagnosis given only when feelings of
unreality and detachment cause major
impairment in social or occupational
functioning
Dissociative Identity Disorder (DID)
• Formerly called multiple personality disorder
• Two or more relatively independent
personality states appear to exist in one
person, including experiences of possession
• Diagnostic controversy
Etiology of Dissociative Disorders
Figure 6-4 Multipath Model of Dissociative Identity Disorder The dimensions interact
with one another and combine in different ways to result in dissociative identity disorder.
Etiology of Dissociative Disorders
(cont’d.)
• Diagnosis depends on self-report, making it
difficult to differentiate between genuine and
faked cases
• Two most influential models, post-traumatic
and sociocognitive, are not sufficient to
explain why only some develop disorders
– Must look at vulnerabilities in biological,
psychological, social, and sociocultural dimensions
Etiology of Dissociative Disorders
(cont’d.)
• Biological dimension:
– Atypical brain functioning
• Inhibited activity in hippocampus and hypometabolism
in area of prefrontal cortex
• Variations in brain activity when comparing different
personalities
• Difficult to interpret patterns of brain activity
– Permanent structural changes in brain due to
trauma may play a role
• Reduction in amygdalar and hippocampal volumes
Etiology of Dissociative Disorders
(cont’d.)
• Psychological dimension:
– Psychodynamic theory
• Repression blocks unpleasant or traumatic events from
consciousness
• Protects individuals from painful memories or conflicts
• DID results from severe childhood abuse
Etiology of Dissociative Disorders
(cont’d.)
• Psychological dimension: (cont’d.)
– Four factors necessary for development of DID
according to posttraumatic model (PTM)
•
•
•
•
Exposure to overwhelming childhood stress
Capacity to dissociate
Encapsulating or walling off the experience
Developing different memory systems
– DID results from these factors if supportive
environment is unavailable or if personality is not
resilient
Etiology of Dissociative Disorders
(cont’d.)
Figure 6-5 The Post-Traumatic Model of Dissociative Identity Disorder Note the
importance of each of the factors in the development of dissociative identity disorder.
Source: Adapted from Kluft (1987); Loewenstein (1994).
Etiology of Dissociative Disorders
(cont’d.)
• Social and sociocultural dimension:
– Sociocognitive model (SCM):
• Displays of role enactments that have been created,
legitimized, and maintained by social reinforcement
• Patients learn about phenomenon and its
characteristics from mass media, cues provided by
therapist, personal experiences, and observation
• Iatrogenic disorder: unintentionally produced by
therapists actions and treatment strategies
• High levels of hypnotizability and suggestibility
Treatment of Dissociative Disorders
• Variety of treatments, including:
– Supportive counseling
– Hypnosis
– Personality reconstruction
– Currently no specific medication for dissociative
disorders, but used to treat accompanying anxiety
or depression
Treatment of Dissociative Disorders
(cont’d.)
• Dissociative amnesia and fugue:
– Symptoms usually spontaneously end, but often
associated with depression and/or stress
– Treating dissociative disorders indirectly by
alleviating depression and stress
• Antidepressants or cognitive-behavioral therapy for
depression
• Stress-management techniques for stress
Treatment of Dissociative Disorders
(cont’d.)
• Depersonalization/derealization disorder:
– Also subject to spontaneous remission, but at a
much slower rate
– Treatment focuses on alleviating feelings of
depression, anxiety, or fear of going insane
• Antidepressants and antianxiety medications
Treatment of Dissociative Disorders
(cont’d.)
• Dissociative identity disorder:
– Major goal is use of trauma-based therapy to
develop healthier ways of dealing with stressors
– Hierarchical treatment approach involves:
• Working on safety issues, stabilization, and symptom
reduction
• Reducing cognitive distortions
• Identifying and working through traumatic memories
• Stabilizing and learning to deal with stressors
• Developing healthy relationships and practicing selfcare
Treatment of Dissociative Disorders
(cont’d.)
• Dissociative identity disorder (cont’d.):
– Treatment is not always successful
– Greatest reduction in symptoms when individuals
are able to integrate personalities
Treatment of Dissociative Disorders
(cont’d.)
ABC Video: Robert Oxnam (Dissociative Identity Disorder)