PSYB32H3 Lecture Notes - Somatic Symptom Disorder, Carpal Tunnel Syndrome, Somatization
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CHAPTER 7 – SOMATOFORM AND DISSOCIATIVE DISORDERS:
Somatoform and dissociative disorders are related to anxiety disorders in that, in early versions of
the DSM, all these disorders were subsumed under the heading of neuroses because anxiety was
considered the predominant underlying factor in each case.
somatoform disorder: the individual complains of bodily symptoms that suggest a physical defect
or dysfunction – sometimes rather dramatic in nature – but for which no physiological basis can be
dissociative disorder: the individual experiences disruptions of consciousness, memory and
The onset of both classes of disorders is assumed by many to be related to some stressful
experience and the two classes sometimes co-occur.
Psychological problems take a physical form, no known physiological explanation and are not under
The bodily symptoms of these disorders fall typically into two groups:
(a) One group of symptoms reflects arousal in the autonomic nervous system and is
accompanied by palpable distress in the form of anxiety and depression.
(b) The second group of symptoms reflects thoughts and intentions that are not consciously
recognized. (SEE TABLE 7.1, page 194).
Argument that somatoform disorders should be removed from the pending DSM-V has seven
•The terminology of the somatoform category is often unacceptable to patients
•The distinction between symptoms that are disease-based vs, those that are psychogenic may
be more apparent than real
•There is great heterogeneity among the disorders – the only common link is physical illness that
is not attributable to an organic cause
•Somatoform disorders are incompatible with other cultures
•There is ambiguity in the stated exclusion criteria for the disorders
•The subcategories have often failed to achieve accepted standards of reliability.
•Somatoform disorders lack clearly defined thresholds in terms of the symptoms needed for a
Pain disorder: the person experiences pain that causes significant distress and impairment;
psychological factors are viewed as playing an important role in the onset, maintenance, and severity
of the pain. The patient may be unable to work and may become dependent on painkillers or
- The pain may have a temporal relation to some conflict or stress, or it may allow the individual
to avoid some unpleasant activity and to secure attention and sympathy not otherwise available.
- Accurate diagnosis is difficult because the subjective experience of pain is always a
psychologically influenced phenomenon.
Body dysmorphic disorder (BDB): a person is preoccupied with an imagined or exaggerated
defect in appearance, frequently in the face – eg; facial wrinkles, excess facial hair, or the shape or size
of the nose.
- Women tend also to focus on the skin, hips, breasts and legs, whereas men are more inclined to
believe they are too short, that their penises are too small, or that they have too much body
- Occurs mostly among women, typically begins in late adolescence, and is frequently comorbid
with depression and social phobia, eating disorder and thoughts of suicide.
- BDB is chronic. Preoccupation with imagined defects in physical appearance may not be a
disorder itself, but a symptom that can occur in several disorders.
Hypochondriasis: is a somatoform disorder in which individuals are preoccupied with persistent
fears of having a serious disease, despite medical reassurance to the contrary.
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- Patients are frequent consumers of medical services and are likely to have mood or anxiety
- Is evident in ~5% of the general population and is about as common as other psychiatric
- Not well differentiated from somatisation disorder.
- Focus is more on health anxiety rather than hypochondriasis per se.
-Health anxiety: health related fears and beliefs, based on interpretations, or perhaps more often,
misinterpretations, of bodily signs and symptoms as being indicative of serious illness.
- Whereas hypochondriacs have a fear of having an illness, an illness phobia is a fear of
contracting an illness.
- The Illness Attidutes Scale (IAS) is one self-report measure that is used commonly by
researchers to assess heath anxiety. Consists reliably of four factors:
(1) worry about illness and pain (i.e. illness fears)
(2) disease conviction (i.e. illness beliefs)
(3) health habits (i.e. safety-seeking behaviours)
(4) symptom interference with lifestyle (i.e. disruptive effects
- Health anxiety is mostly learned.
- Cognitive factors are featured in the model of health anxiety outlined by Salkovskis and
Warwick. This model has four contributing factors:
•(1) a critical precipitating incident
•(2) a previous experience of illness and related medical factors
•(3) the presence of inflexible negative cognitive assumptions (i.e. believing strongly that
unexplained bodily changes are always a sign of serious illness
•(4) the severity of anxiety. The severity of anxiety is a function of two factors that will increase
anxiety and two that will decrease it.
oHealth anxiety will increase multiplicatively as a function of related increases in (1)
perceived likelihood or probability of illness and (2) the perceived presence of rescue
factors (i.e the availability and perceived effectiveness of medical help).
In conversion disorder, physiologically normal people experience sensory or motor symptoms,
such as a sudden loss of vision or paralysis, suggesting an illness related to neurological damage of
some sort, although the body organs and nervous system are found to be fine.
- Sufferers may experience paralysis of arms or legs; seizures and coordination disturbances; a
sensation of prickling, tingling, or creeping on the skin; insensitivity to pain; or the loss or
impairment of sensations, called anaesthesias.
- Vision may be severely impaired, the person may become partially or completely blind or have
-Aphonia, loss of the voice and all but whispered speech and anosmia, loss or impairment of the
sense of smell, are other conversion disorders.
- Conversion symptoms appear suddenly in stressful situations, allowing the individual to avoid
some activity or responsibility or to receive badly wanted attention.
- Term conversion derived originally from Freud, who thought that the energy of a repressed
instinct was diverted into sensory-motor channels and blocked functioning. Thus, anxiety and
psychological conflict were believed to be converted into physical symptoms.
- Prevalence or conversion disorder is less than 1%, and more women than men are given the
- Co-morbid with other axis 1 diagnosis, such as depression and substance abuse, and with
personality disorders, notably borderline and histrionic personality disorders.
Hysteria: the term originally used to describe what are now known as conversion disorders, has a
long history, dating back to the earliest writings on abnormal behaviour.
It is important to distinguish a conversion paralysis or sensory dysfunction from similar problems
that have a neurological basis. (i.e. glove anaesthesia a rare syndrome in which the individual
experiences little or no sensation in the part of the hand that would be covered by a glove.
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