Chapter 8: Somatoform and Dissociative Disorders
One day Sam called his therapist and said "Hello Dr. Smith? I think I'm in London, England.
How did I get here?" Sam had suddenly found himself in a strange city and the last thing he
could remember was watching TV in his living room in Toronto. He'd found his therapist's
business card in his wallet and called.
It had begun with short losses of time. He would 'find himself' in an exam room writing an
exam, or suddenly he was at the dinner table, with his family, with no memory of the
preceding hours. Soon he was losing entire days. At the time of the phone call, he had
completely 'forgotten' that he had moved to London England three months earlier.
Fortunately, he had given his therapist in Toronto the name of his psychiatrist in London,
and soon he was re-connected with his family.
If you've ever had a general anesthetic you might have some inkling of what a person with
a dissociative disorder experiences. Or, if you've ever been so absorbed in a book or
movie that you forget about your surroundings and the passage of time, this is a similar
feeling. It's not a problem, of course, if you are able to 'snap out of it.' It becomes
maladaptive (a signal of psychological disorder) when the person is unable to reintegrate
into a coherent self in the appropriate context.
Some people have described dissociation as waking up from a feeling that is not at all like
sleeping. Suddenly you are just 'there.' One client suddenly 'awoke' to find himself covered
in blood and holding a massive cleaver, which startled him until he remembered he was a
meat-cutter. It is deeply disturbing to most who suffer from this, since they never know when
it will happen.
Of all the disorders currently recognized by mental health practitioners, the dissociative
disorders are the most puzzling, difficult and elusive. When contrasted with the otherwise
normal functioning of the suffering individual, it is even more troubling. Many people who
experience dissociative disorders, hide their disorder for years, privately believing they are
going insane. Probably lots of people never seek help at all.
People with dissociative disorders might be functioning perfectly well and then suddenly be
'triggered' by a particular sound, sight, smell, comment (from an earlier traumatic
experience) and they are suddenly 'removed psychologically' from the 'trauma.' It is an
incredible protective mechanism, which 'saves' the individual from unbearable pain when
they are young or vulnerable. (A great majority of people with DID were physically or
sexually abused as children.) It is only over time, when danger is no longer a problem, that
it proves maladaptive.
DID provides rather compelling evidence for the ability of the mind to escape excruciating
events. There are incredible stories about those who experience DID (Google it if you wish).
So incredible that there still exists a great deal of controversy around multiple personalities
and repressed memory.
Now we move on to another, somewhat related disorder - somatoform
disorders. Soma means body and so somatoform disorders are those in which people
complain of 'bodily' issues (which have no organic basis). This has a long history in human
development. In ancient Greece, a type of somatoform disorder would be what Plato called
'hysteria' - emotional excitability, convulsions, numbness attributed to a wandering womb
that was angry because of inactivity. (He was a great thinker, but considerably misconstrued
women and their bodies.)
Sometimes doctors have patients who complain of significant, problematic discomfort (upset
stomach, chronic pain, seizures, sexual dysfunction etc.), for which no organic cause can
be found. Then they turn to psychological origins, which has been substantiated by the fact
that when the psychological factors are addressed, the symptoms sometimes disappear. This is not at all to suggest that the symptoms were not 'real.' Just that the root issue was
psychological rather than biological.
There are cases where the patient intentionally pretends to be sick (to achieve some
objective like insurance money) and this is called malingering. Another variation is factitious
disorder, in which the individual deliberately 'fakes' an illness (like taking excessive laxatives
or medication to be 'sick') simply because they are eager to assume the role of a sick
person. I recently watched one of those medical TV shows that showcased a character
with Munchause syndrome, a type of factitious disorder. She had injected herself with
bacteria because she wanted to be a patient in the hospital, since that was when her family
best attended to her. People with hypochondriasis are those who are fearfully preoccupied
with getting a particular disease, and are convinced they have it, though they do not.
Getting to the root of physical complaints is an arduous task since pain is subjective, private
and impossible to assess with total accuracy. As well, the relationship between
psychological resolution and physical resolution is complex, not completely understood and
always worth considering. Sometimes the 'real' cause (or interaction of causes) is not
discovered until after many years.
Textbook pages 284-312
• Somatoform disorders: A group of conditions that involve physical symptoms and
complaints suggesting the presence of a medical condition but without any evidence of physical
pathology to account for them. The people with these symptoms normally focus on one aspect of
their health or appearance to the extent that they find it hard to function. Due to this, they frequent
physicians very often.
• Dissociative disorders: A group of conditions involving disruptions in a person’s normally
integrated functions of consciousness, memory, identity or perception. The people with these
conditions also may be unable to recall who they are or where they may have come from, or may
have two or more distinct identities or personality states that alternately take control of the person’s
• Dissociation: the human’s mind capacity to engage in complex mental activity in channels
split off from or independent of conscious awareness.
• The affected patients have no control over their symptoms and are not intentionally faking
symptoms or attempting to deceive others. They generally believe that there is something seriously
wrong with their bodies.
• Somatization is common in all cultural groups and societies that have been studied.
Differences among groups may reflect cultural styles of expressing distress, which are influenced
not only by cultural beliefs and practices, but also by the nature of the culture’s healthcare system.
• Hypochondriasis: People with this condition are preoccupied either with fears of
contracting a serious disease or with the idea that they actually have such a disease even though
they do not. Their preoccupations are based on the misinterpretation of one or more bodily
changes, sensations, or symptoms of minor ailments (e.g., being convinced that a slight cough is a
sign of lung cancer or worrying that a blemish is a sign of skin cancer.)
• Most commonly seen somatoform disorder and occurs equally often in males and females.
It can start at any age, although early adulthood is the most common age of onset. If left untreated
after development, it tends to become chronic although the severity may wax and wane over time.
Individuals with this also suffer from mood disorders, panic disorder, and/or other somatoform
• Individuals are often anxious and highly preoccupied with bodily functions (e.g. heart beats
or bowel movements) or with physical abnormalities (e.g., a small sore or an occasional cough) or with vague and ambiguous physical sensations (such as “tired heart” or “aching veins”). They
attribute these symptoms to a suspected disease and often have intrusive thoughts about it.
• These individuals do not fake symptoms to achieve a specific goal. Their relationships with
their doctors may be hostile and filled with conflict.
Criteria for Hypochondriasis
A. Preoccupation with fears of contracting, or the idea that one has, a serious disease, based
on misinterpretation of bodily symptoms.
B. Preoccupation persists despite appropriate medical evaluation and reassurance.
C. Preoccupation causes clinically significant distress or impairment.
D. Duration of at least 6 months.
Theoretical Perspectives on Causal Factors
• It is believed that people’s past experiences with illnesses (in both themselves and others,
as observed in the mass media) lead to the development of a set of dysfunctional assumptions
about symptoms and diseases that may predispose a person to developing hypochondriasis.
These dysfunctional assumptions could include things like “Bodily changes are usually a sign of
serious disease, because every symptom has to have an identifiable cause” or “If you don’t go to
the doctor as soon as you notice anything unusual, then it will be too late”.
• These individuals have an attentional bias for illness-related information. They also
perceive their symptoms to be more dangerous than they really are and look for confirming
evidence to prove their theory. They also tend to discount evidence that may prove they are
healthy and believe that being fully healthy means they will be symptom free.
• They also believe they have a lower probability of being able to cope with the illness and
believe they are unable to tolerate physical effort or exercise.
• Hypochondriacs also tend to report much childhood sickness and missing of school. They
also tend to have an excessive amount of illness in their families while growing up, which may lead
to strong memories of being sick or in pain, and perhaps also of having observed some of the
secondary benefits that sick people sometimes reap.
Treatment of Hypochondriasis
• Cognitive-behavioural treatment appears to be very effective for the treatment of this
illness. The cognitive components of this focus on assessing the patient’s beliefs about illness and
modifying misinterpretations of bodily sensations. The behavioural techniques include having
patients induce innocuous symptoms by intentionally focusing on parts of their body so that they
can learn that selective perception of bodily sensations plays a major role in their symptoms.
Sometimes they are also directed to engage in response prevention by not checking their body as
they usually do and by stopping their constant seeking of reassurance.
• There is also some evidence that antidepressant medication may be effective in treating
this illness, but it is not as effective as cognitive behavioural therapy.
Criteria for Somatization Disorder
A. History of many physical complaints starting before age 30 that occur over several years
and result in treatment being sought, or significant impairment in functioning.
B. Each of the following criteria must have been met at some point:
1) Four pain symptoms in different sites
2) Two gastrointestinal symptoms other than pain
3) One sexual symptom (other than pain)
4) One pseudoneurological symptom (not limited to pain)
C. Either (1) or (2): (1) After appropriate investigation, each of the symptoms under Criteria B cannot be fully
explained by a medical condition.
(2) When there is a related general medical condition, the physical complaints are in excess of
what would be expected.
D. Symptoms not intentionally produced or feigned.
• Many similarities between hypochondriasis and somatization disorder, but only people with
hypochondriasis tend to be convinced they have an organic disease. In hypochondriasis, the
person normally has only one or few symptoms but in somatization disorder, by definition, there
are multiple symptoms.
Demographics, Comorbidity, and Course of Illness
• Somatization disorder usually begins in adolescence and it believed to be 3-10 times more
common in women than men. It also tends to occur more in lower socioeconomic classes. It also
very commonly occurs with several other disorders including major depression, panic disorder,
phobic disorders, and generalized anxiety disorder. Although it has generally been considered to
be a relatively chronic condition with a poor prognosis, some recent studies have found that a
significant number of patients remit spontaneously.
Causal Factors in Somatization Disorder
• There is evidence that it runs in families and that there is a familial linkage between
antisocial disorder in men and somatization disorder in women. It is possible that the two disorders
may be linked through a common trait of impulsivity, but the nature of this relationship is not yet
• Other contributory causal factors may include an interaction of personality (ex. people high
in neuroticism with a specific family background that socially reinforces complaining about
illnesses), cognitive and learning variables.
• Patients with somatization disorder had elevated levels of cortisol (a stress hormone) and
did not show normal habituation to psychological stressors. Thus the physiological arousal caused
by psychological stressors remains elevated.
Treatment of Somatization Disorder
• Considered extremely difficult to treat but recent research has indicated that cognitive-
behavioural therapy may be helpful when combined with appropriate medical management. Here,
effective treatment involves identifying one physician who will integrate the patient’s care by seeing
the patient at regular visits and by providing physical exams focused on new complaints. At the
same time, however, the physician avoids unnecessary diagnostic testing and minimal use of
medications or other therapies. The cognitive behavioural therapy included in the treatment
focuses on promoting appropriate behaviour such as better coping and personal adjustment, and
discouraging inappropriate behaviour.
• Antidepressants can also sometimes be useful.
• Pain disorder: Characterized by the experience of persistent and severe pain in one or
more areas of the body.
• There are two coded subtypes of this disorder: (1) pain disorder associated with
psychological factors, (2) pain disorder associated with both psychological factors and a general
medical condition. Both cases can either be acute (duration of less than 6 months) or chronic
(duration of over 6 months).
Criteria for Pain Disorder
A. Pain in one or more sites as primary focus of clinical representation
B. Pain causes significant distress or impairment in functioning.
C. Psychological factors judged to have an important role in the pain.
D. Symptom or deficit is not intentionally produced or feigned. • Diagnosed more frequently in women than men and is very comorbid with anxiety mood
disorders, which may occur first or may arise later as a consequence of the pain disorder.
• These people are often unable to work or to perform some other usual daily activities.
Their inactivity may lead to depression and a loss of physical strength and endurance.
• The behaviour component of the pain can increase when exposed to attention, sympathy
or avoidance of unwanted activities. Some individuals repeatedly seek out new doctors in the hope
of getting medical confirmation of their pain or to obtain medications to relieve their suffering.
Treatment of Pain Disorder
• Pain disorder is easier to treat than somatization disorder
• Cognitive behavioural techniques can be used to treat both physical and ‘psychogenic’
pain syndromes. Treatment programs using these techniques include relaxation training, support
and validation that the pain is real, scheduling of daily activities, cognitive restructuring, and
reinforcement of “no-pain” behaviours. Patients tend to show improvement in their attitudes but do
not seem to be fully recovered from their pain.
• Antidepressant medications have been found to reduce pain intensity in a manner
independent of the effects the medications may have on mood.
Criteria for Conversion Disorder
A. One or more symptoms affecting voluntary motor or sensory function that suggest a
neurological or other medical condition.
B. Psychological factors judged to be associated with the symptoms because they were
preceded by conflicts or other stressors.
C. Symptom or deficit cannot be fully explained by a general medical condition.
D. Symptom or deficit causes distress or impairment in functioning.
• The person must not be intentionally faking or producing the symptoms
• People with conversion disorder are no more likely to experience la belle indifference (a
concept suggested by Freud stating that the people showed a lack of concern to their illness)
• Conversion disorder was grouped with somatization disorder as well as hysterical
personality under the term hysteria and Freud believed that all disorders under this term indicated
that they had repressed sexual energy. In Freud’s view, the anxiety threatens to become
conscious, so it is unconsciously converted into a bodily disturbance, thereby allowing the person
from having to deal with the conflict.
Precipitating Circumstances, Escape, and Secondary Gains
• The physical symptoms are usually seen as serving the rather obvious function of
providing a plausible excuse, enabling an individual to escape or avoid an intolerably stressful
situation without having to take responsibility for doing so.
• The primary gain for conversion symptoms is continued escape or avoidance of a
stressful situation. Because this is unconscious, the symptoms disappear as soon as the stressful
situation has been removed or resolved.
• The secondary gain is used to refer to any “external” compensation that would tend to
reinforce the maintenance of disability
Decreasing Prevalence and Demographic Characteristics
Used to be very common in civilian and (especially) military life
The amount of cases seen recently has significantly decreased because of the fact that
it apparently loses its defensive function if it can be readily shown to lack an organic basis. It is now most likely to occur with people in lower socioeconomic circles who are
Conversion disorder is more common in women than in men. It can develop at any age
but most commonly occurs between early adolescence and early adulthood.
It generally has a rapid onset after a significant stressor and often resolves within two
weeks if the stressor is moved, although it commonly recurs. It can have a chronic
course as well.
It also frequently occurs along with other disorders.
Range of Conversion Disorder Symptoms
There are 4 categories of symptoms: (1) sensory, (2) motor, (3) seizures, (4) mixed
presentation from the first 3 categories
Sensory Symptoms or Deficits
Can involve almost any sensory modality and can be diagnosed because symptoms in
the affected area are inconsistent with how known anatomical sensory pathways
Sensory symptoms or deficits are most often in the visual system, in the auditory
system, or in the sensitivity to feeling (most common of this is the glove anesthesia
where the person cannot feel anything in the area where gloves are normally worn).
With conversion blindness, the person can navigate around a room without bumping into
objects. With conversion deafness, the person can respond to his or her name.
In general, the evidence supports the idea that the sensory input is registered but that it
is somehow screened from explicit conscious recognition.
Motor Symptoms or Deficits
Can be anything from conversion paralysis (normally restricted to a single limb),to only
being able to whisper, difficulty swallowing or the sensation of a lump in the throat Seizures
Resemble epileptic seizures but can be fairly well differentiated via modern medical
technology (ex. do not show any abnormalities on EEG scans as patient with true
epileptic seizures do.)
Important Issues in Diagnosing Conversion Disorder
Accurate diagnosis can be extremely difficult because the symptoms can simulate many
medical conditions. Therefore the person must receive a thorough medical and
Due to the increase in sophistication of medical tests, misdiagnoses have significantly
decreased since the 1990s.
The other criteria used to help distinguish between conversion disorders and true
organic disorders include:
o The frequent failure of the dysfunction to conform clearly to the symptoms of
the particular disease or disorder simulated
o The nature of the dysfunction (ex. conversion blindness and how these
patients do not bump into objects)
o Under hypnosis or narcosis, the symptoms can usually be removed, shifted
or reintroduced at the suggestion of the therapist.
Distinguishing Conversion From Malingering and From Factitious Disorder
The malingering person is intentionally producing or grossly exaggerating physical
symptoms and is motivated by external incentives.
Individuals with conversion disorders are not consciously producing their symptoms, feel
themselves to be the “victims of their symptoms,” and are very willing to discuss them,
often in excruciating detail. When inconsistencies in their behaviours are pointed out,
they are usually unperturbed. By contrast, persons who are feigning symptoms are
inclined to be defensive, evasive and suspicious when asked about them; they are usually reluctant to be examined and slow to talk about their symptoms. If
inconsistencies in their behaviour are pointed out, they become more defensive.
Criteria for Factitious Disorder
A. Intentional production or feigning of physical or psychological signs or symptoms.
B. Motivation for the behaviour is to assume the sick role.
C. There are no external incentives for the behaviour.
Treatment of Conversion Disorder
Very limited knowledge on how to treat the disorder
Motor conversion symptoms have been successfully treated with a behavioural approach in
which specific exercises are prescribed in order to increase movement or walking, and then
reinforcements are provided when patients show improvements. Any reinforcements of
abnormal motor behaviours are removed in order to eliminate any sources of secondary gain.
Hypnosis combined with other therapies or hypnosis alone can be useful.