SOMATOFORM AND DISSOCIATIVE DISORDERS - 1
I. Somatoform Disorders
A. Preoccupied with health or body appearance.
No identifiable medical condition causing the physical complaints.
B. Hypochondriasis refers to physical complaints without a clear cause, and
particularly severe anxiety focused on the possibility of having a serious
1. Hypochondriasis shares many features with panic disorder and
other anxiety disorders, and rates of comorbidity with such
disorders (and mood disorders) are high.
2. The essential problem in hypochondriasis is anxiety, but usually
present to physician because of physical complaints.
3. Another important feature of hypochondriasis is that reassurance
from numerous doctors that the person is healthy has, at best,
only a short-term positive effect. Often such persons will return to
the same or other doctors on the assumption that the doctor
missed something initially in ruling out medical reasons for the
symptoms. This disease conviction has become a core diagnostic
feature of hypochondriasis.
a. hypochondriasis vs illness phobia
b. hypochondriasis - more likely to misinterpret physical
symptoms, display higher rates of checking behaviors, have
higher levels of trait anxiety, and have a later age of onset
than those with illness phobia.
4. Little is known about the prevalence of hypochondriasis in the
Approximately 3% of medical patients may meet criteria for
Sex ratio is 50:50
May emerge at any time, with peak periods in adolescence, middle
age (40s and 50s) and after age 60.
Focus of symptoms varies from culture to culture. SOMATOFORM AND DISSOCIATIVE DISORDERS - 2
Hypochondriasis is believed to be caused by distorted cognitive or
perceptual and emotional factors. For example, persons with
hypochondriasis tend to interpret ambiguous stimuli such as minor
pain as threatening. These cognitive distortions and increased self-
focusing tend to create anxiety and subsequently more physical
symptoms in the person, which exacerbates the symptoms.
Persons with hypochondriasis also have a restricted concept of
health as being totally symptom free.
a. Other etiological factors may include genetic vulnerabilities,
overreaction to stress, a tendency to view negative life
events as unpredictable and uncontrollable, and modeling of
illness behaviors by others.
b. In addition, persons with hypochondriasis may develop the
disorder in the context of a stressful life event, experience a
disproportionate incidence of familial disease during
childhood, and/or receive substantial attention for illness-
6. Little is known about treating hypochondriasis. Recent studies
suggest that cognitive-behavioral treatments, incorporating
identifying and challenging illness-related misinterpretations of
physical symptoms, showing patients how to voluntarily produce
the symptoms, coaching patients to rely less on reassurance, and
stress management, seem to be helpful. Little evidence exists to
support traditional psychodynamic treatment for hypochondriasis.
More recent approaches attempt to offer more substantial and
sensitive reassurance than is typical in a physician’s office and with
some encouraging results.
C. Somatization disorder (known as Briquet's syndrome until 1980),
involves an extended history of physical complaints before age 30 and
substantial impairment in social or occupational functioning. The textbook
presents the case of Linda to illustrate somatization disorder.
1. Persons with somatization disorder are concerned about the
symptoms themselves, not what they might mean. Moreover, they
show little urgency to respond to, or take action about, their
symptoms, despite feeling continually weak and ill. In somatization
disorder, the symptoms become a major part of the person’s
identity. The DSM-IV requires that the person report 8 symptoms
to meet diagnostic criteria, whereas the diagnosis
undifferentiated somatoform disorder is reserved for persons
who report fewer than 8 symptoms. SOMATOFORM AND DISSOCIATIVE DISORDERS - 3
2. Somatization disorder is rare, and prevalence rates range from
4.4% (in a large city) to 20% of a large sample of primary care
Typical age of onset is adolescence.
Often unmarried women of lower socioeconomic status.
3. Somatization disorder shares features with hypochondriasis,
including a history of family illness or injury during childhood.
Data are mixed regarding genetic contributions, although
somatization disorder is strongly linked in family studies to
antisocial personality disorder (ASPD).
a. Some evidence suggests that somatization disorder and
ASPD (as well as substance abuse and attention deficit
hyperactivity disorder) share a neurobiologically-based
People with these disorders may possess a weak
behavioral inhibition system (BIS) that does not control
the behavioral activation system (BAS). The BAS is a
brain system that underlies impulsivity, thrill-seeking
behavior, and excitability, whereas the BIS is involved in
sensitivity to threat or danger and avoidance of situations or
cues suggesting that threat or danger is imminent.
Many behaviors and traits associated with somatization
disorder also seem to reflect short-term gain (i.e., active
BAS) and insensitivity for long-term problems (i.e., weak
b. Another possibility (not mentioned in book) childhood
trauma – physical and/or sexual abuse.
c. The major difference between somatization disorder and
ASPD, however, may involve level of dependency.
Whereas males tend to display aggression and ASPD,
females tend to display dependency and little aggression.
Therefore, gender socialization may direct a specific
biological vulnerability. SOMATOFORM AND DISSOCIATIVE DISORDERS - 4
4. Treatment of somatization disorder is exceedingly difficult, and
no treatment exists with demonstrated effectiveness. Treatment of
somatization disorder typically involves
attempts to reduce the person’s tendency to visit numerous
medical specialists according to the "symptom of the week."
Use of a gatekeeper physician, one assigned to screen all
physical complaints and decide on whether further evaluation is
warranted, can be helpful.
Additional attention is directed at reducing the supportive
consequences of relating to significant others on the basis of
D. Conversion disorders refer to physical malfunctioning without any
physical or organic pathology to account for the malfunction, especially in
sensory-motor areas. Examples include paralysis, aphonia (i.e., difficulty
speaking), mutism, analgesia, seizures, blindness, loss of sense of touch,
globus hystericus (i.e., sensation of lump in throat), and astasia-abasia
(i.e., weakness in legs and loss of balance). Most conversion symptoms
suggest some kind of neurological disease, but can mimic the full range of
physical functioning. Conversion disorder is illustrated in the textbook with
the case of Eloise.
1. Freud popularized the term "conversion," believing that anxiety
from unconscious conflicts is somehow converted into physical
symptoms to find expression (i.e., anxiety is displaced onto a more
acceptable object, in this case physical problems). SOMATOFORM AND DISSOCIATIVE DISORDERS - 5
2. Several differences exist among those with
actual physical disorder,
malingering (i.e., deliberately faking symptoms),
factitious disorder (i.e., symptoms are feigned and under
voluntary control, but without any obvious reason for doing so
aside from assuming the sick role and to gain attention)
factitious disorder by proxy (i.e., caregiver making others sick;
sometimes referred to as Munchausen’s syndrome by proxy).
a. First, as with somatization disorder, conversion disorder is
often (but not always) marked by la belle indifference, or
a general apathy toward one's symptoms.
b. Second, conversion symptoms are usually precipitated by
some stressful event.
c. Third, those with conversion disorder often function
normally but display little insight into this ability. Still, an
awareness of sensory and motor information is disturbed.
(“Blind” people who can maneuver out of the way of
obstacles, but aren’t aware that they can see them. Those
who are faking will score below chance on tests of vision.)
d. In general, those with conversion disorder are dissociated
from sensory-motor awareness, whereas those who
malinger or have a factitious disorder attempt to fake this
effect (e.g., by faking blindness) and often look worse than
blind persons who perform at chance levels on visual
3. Unconscious processes are salient features of conversion disorders.
It is known that persons with small localized damage to certain
parts of their brains can identify objects in their field of vision, but
without awareness that they could, in fact, see. The textbook
presents the case of Celia to illustrate this concept. SOMATOFORM AND DISSOCIATIVE DISORDERS - 6
4. Conversion disorders are rare, and prevalence estimates in
neurological settings range from 1 to 30%, whereas in epilepsy
setting the range is between 10 and 20% of cases.
Seen primarily in women and typically develop during adolescence
or shortly thereafter.
More often in less educated, lower socioeconomic status groups
where knowledge about disease and medical illness is not well
Conversion reactions are not uncommon in soldiers exposed to
Symptoms often disappear, but return later in the same or similar
form when a new stressor occurs.
5. The Freudian psychodynamic view postulates four basic
processes in the development of conversion disorder:
a. Experience of a traumatic event, or unacceptable
b. The person represses the unacceptable conflict and resulting
anxiety, thereby making it unconscious.
c. Anxiety continues to fester and increase and threatens to
emerge into consciousness. The person converts the conflict
into physical symptoms, and thereby relieves the pressure
of having to deal directly with the conflict. The reduction in
anxiety is the primary gain or reinforcing event that
maintains the conversion symptom. Primary gain accounts
for the la belle indifference as the conversion resolution of
the conflict would not be upsetting to the patient.
d. Individual receives greatly increased attention and
sympathy from loved ones. Freud considered
attention/avoidance to represent secondary gain.
6. Little data exists to support Freud’s account; though the role of
trauma does have support. A modification of Freud’s approach
stipulates that, following the traumatic event, patients develop
symptoms purposefully but detach this motivation from
consciousness. The behaviors are subsequently maintained by
negative reinforcement. (Movie—Tommy)
7. Treatment of conversion disorder is similar to treatment for
somatization disorder. A core strategy is to identify and attend to
the trauma or stressful life event and to remove sources of
secondary gain. The therapist may also work to reduce reinforcing
or supportive consequences of the conversion symptoms (i.e.,
secondary gain). SOMATOFORM AND DISSOCIATIVE DISORDERS - 7
E. Pain disorder refers to a disorder where there may have been initial
clear reasons for pain, but where psychological factors play a large role in
the persistence of pain. It is difficult to judge cases where the causes were
primarily physical vs. psychological. An important feature of pain disorder
is that the pain is real and it hurts. The textbook presents the cases of a
medical student and a woman with cancer to illustrate pain disorder.
F. Persons with body dysmorphic disorder (BDD) (or imagined ugliness)
display a preoccupation with some imagined defect in appearance despite
reasonably normal appearance. That is, the focus is on physical
appearance. Reaction to perceived distortions in facial features is
common. These persons are fixated on mirrors, engage in suicidal
behavior, display ideas of reference (i.e., thinking that events in the world
are somehow related to them and their imagined defect) and avoidance,
and experience severe disruption in daily functioning. The condition was
previously known as dysmorphophobia (i.e., fear of ugliness). The
textbook illustrates BDD with the case of Jim.
1. The predominant focus of attention in adolescence is skin and hair.
The disorder is largely influenced by cultural standards of beauty.
Examples include skin condition, facial width, slope of nose, and
lip, neck, and foot size.
2. Many persons with BDD become fixated on mirrors and frequently
check their appearance. Others show a phobic fear and avoidance
of mirrors. Suicidal ideation, attempts, and suicide completion are
frequent consequences of BDD.
3. Best estimates of the prevalence of BDD are that is it more
common that previously thought and that it tends to run a lifelong,
chronic course if left untreated. BDD is seen equally in males and
females, few marry, and age of onset ranges from early
adolescence through the 20s, peaking at age 18 or 19. BDD is not
seen frequently in mental health settings as BDD sufferers
frequently seek out plastic surgeons.
4. Little is known about the causes or treatment of BDD,
including whether BDD runs in families, biological and predisposing
vulnerabilities. Obsessive-compulsive disorder tends to co-occur
with BDD and both disorders share similar features (e.g., intrusive
thoughts, checking). There are two and only two treatments for
BDD with any evidence of effectiveness.
a. SSRIs, such as clomipramine (Anafranil) and fluvoxamine
(Luvox) provide relief for some people; both drugs also
work for OCD.
b. Cognitive-behavior therapy, specifically exposure and
response prevention, has been successful with BDD and of
course OCD. SOMATOFORM AND DISSOCIATIVE DISORDERS - 8
5. BDD is big business for plastic surgeons. As many as 25% of
persons requesting plastic surgery meet criteria for BDD. Persons
with BDD do not benefit from plastic surgery, and preoccupation
with imagined ugliness may actually increase following plastic
II. Dissociative Disorders
A. Dissociative disorders characterize alterations or detachments in
consciousness or identity involving either dissociation or
depersonalization. Dissociative disorders include depersonalization
disorder, dissociative amnesia, dissociative fugue, dissociative trance
disorder, and dissociative identity disorder. Each involves extreme
manifestations of normal variants of depersonalization and derealization
1. Depersonalization involves distortion in perception such that a
sense of reality is lost. Symptoms of unreality are characteristic of
dissociative disorders because depersonalization is a psychological
mechanism whereby one dissociates from reality.
2. Derealization involves losing a sense of the external world (e.g.,
things may seem to change shape or size; people may appear dead
3. Feelings of depersonalization and derealization are also part of
other disorders, including panic and acute stress disorder.
B. Depersonalization disorder is a very rare condition involving severe
and frightening feelings of unreality and detachment such that they
dominate an individual’s life and interfere with normal functioning. The
textbook illustrates depersonalization disorder with the case of Bonnie.
1. Primary problem involves depersonalization and derealization.
2. Limited data suggest that 50% of persons suffering from
depersonalization disorder also have another mood or anxiety
disorder; mean onset is approximately 16.1 years of age, and the
disorder tends to be chronic.
3. Depersonalization is related to a distinct cognitive profile,
reflecting cognitive deficits in attention, short-term memory, and
spatial reasoning. Such persons are easily distracted. Such deficits
correspond with reports of tunnel vision (i.e., perceptual
distortions) and mind emptiness (i.e., difficulty absorbing new
information). SOMATOFORM AND DISSOCIATIVE DISORDERS - 9
C. Dissociative amnesia represents several forms of psychogenic memory
loss and is most often found in females. The textbook illustrates
dissociative amnesia with the case of "The Woman Who Lost Her
1. Those with generalized amnesia are unable to recall anything,
including their identity. Generalized amnesia may be lifelong or
may extend from a period in the more recent past.
2. More common is localized or selective amnesia, or a failure to
recall specific (usually traumatic) events during a specific period of
time. In most cases of amnesia, the forgetting is very selective for
traumatic events or memories rather than being generalized.
D. Dissociative fugue is related to dissociative amnesia. Persons with
dissociative fugue just take off, and later find themselves in a new place,
unable to remember why or how they got there, including an inability to
recall their past. Often a new identity is assumed. Dissociative amnesia
and fugue usually begin in adulthood, with rapid onset and dissipation,
and most are female. Dissociative fugue is illustrated in the textbook with
the case of the misbehaving sheriff.
1. A related non-Western variation of dissociative fugue is called
amok (as in running amok). This disorder is most often seen in
males and involves a trancelike state where the person often
brutally assaults or sometimes kills persons or animals. Such
persons usually do not remember the episode.
E. Dissociative trance disorder represents a condition that differs in
important ways across cultures. In this condition, the symptoms resemble
those of other dissociative disorders, with the exception that dissociative
symptoms and sudden changes in personality are attributed to possession
of a spirit known to a particular culture. This disorder is more common in
women and is often associated with some life stressor. Dissociative traces
commonly occur in India, Nigeria, Thailand, and other Asian and African
countries. This condition is considered abnormal only if the