Chapter 7: Somatoform and Dissociative Disorder
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 factors in each case.
In somatoform disorders 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 found. In dissociative
disorders, the individual experiences disruptions of consciousness, memory,
Soma means, “body.” In somatoform disorders, psychological problems take
a physical form. The physical symptoms have no known physiological
explanation and are not under voluntary control. They are thought to be
liked to psychological factors, presumably anxiety, and are assumed to be
This category has been controversial ever since the release of DSM-IV.
Indeed, a group of prominent researchers presented the radical argument
that somatoform disorders should be removed from the pending DSM-5.
They listed seven concerns.
- The terminology is often unacceptable to patients
- The distinction between disease-based symptoms versus 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.
- The disorders are incompatible with other cultures.
- There is ambiguity in the stated exclusion criteria
- The subcategories fail to achieve accepted standards of reliability.
- The disorders lack clearly defined thresholds. In February 2010, the DSM-5 Somatic Symptom Disorders Work Group notes
that the current DSM-IV terminology is confusing. The work group suggested
renaming this group of disorders “somatic symptom disorders”.
Since somatization disorder, hypochondriasis, pain disorder, and
undifferentiated somatoform disorder share certain common features-
somatic symptoms and cognitive distortions, the work group proposed that
these disorders be grouped under a common rubric named “complex somatic
symptoms disorder” (CCSD). The work group suggested that three optional
specifiers cold be applied to the diagnosis: (1) multiplicity of somatic
complaints (previously somatization disorder); (2) high health anxiety
(previously hypochondriasis), and (3) pain disorder.
In pain disorder, the person experience 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.
Clients with physically based pain tend to localize it more specifically, give
more detailed sensory descriptions, and link their pain more clearly to
situations that increase or decrease it.
Valet et al. investigated women who fulfilled the DSM-IV criteria for pain
disorder using MRI. They found significant grey-matter decreases in the
prefrontal, cingulated, and insular cortex, regions of the brain known to be
critically involved in the modulation of subjective pain.
With body dysmorphic disorder (BDD) a person is preoccupied with an
imagined or exaggerated defect in appearance, frequently in the face; for
example, facial wrinkles, excess facial hair, or the shape or size of the noses.
Women tend also to focus on the skin, hips, breasts and legs, whereas men
are more inclined to believe they are too shorty, that their penises are too
small, or that they have too much body hair.
BDD occurs mostly among women, typically begins in late adolescence, and is
frequently comorbid with depression and social phobia, eating disorders,
thoughts of suicide, and substance used and personality disorder.
Some experts believe that BDD should be subsumed as a subtype of OCD
Researchers have suggested that BDD would be better classified as a social
phobia, mood disorder, or even an eating disorder.
In hypochondriasis, individuals are preoccupied with persistent fears of
having a serious disease, despite medical reassurance to the contrary.
Whereas hypochondriasis is a fear of having an illness, an illness phobia is a
fear of contracting an illness
The Illness Attitude Scale (IAS) is used commonly to assess health anxiety.
Stewart and Watt suggested that it consists reliably of four factors: (1) worry
about illness and pain; (2) disease conviction; (3) health habits; and (40
symptom interference with lifestyle.
Cognitive factors are featured in the model of health anxiety outlined by
Salkovkis and Warwick presented in the following picture. 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 or negative cognitive assumptions; and (4) the severity of anxiety.
Health anxiety will increase multiplicatively as a function of related increase
in (1) the perceived likelihood or probability of illness and (2) the perceived
cost, awfulness, and burden of illness. Health anxiety will decrease as a
function of (1) the perceived ability to cope and (2) the perceived presence of
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.
The loss or impairment of sensations called
Aphonia, loss of voice and all but whispered speech,
and anosmia, loss or impairment of these sense of
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. Hippocrates considered it an
Affliction limited solely to women and due to the
Wandering of the uterus through the body. (The Greek word hysteria means
“womb”) Presumably, the wandering uterus symbolized the longing to
produce a child.
People with conversion symptoms frequently report a history of physical or
Glove anesthesia, 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.
Carpal tunnel syndrome can produce symptoms similar to those of glove
anesthesia. Nerves in the wrist run through a tunnel formed by the wrist
bones and members. The tunnel can become swollen and may pinch the
nerves, leading to tingling, numbness, and pain in the hand.
MALINGERING AND FACTITIOUS DISORDER
Conversion disorder is difficult to distinguish from malingering. In
malingering, an individual fakes an incapability in order to avoid a
responsibility, such as work or military duty, or achieve some goal, such as
being awarded a large insurance settlement.
One aspect of behaviour that can sometimes help distinguish the two
disorders is known as la belle indifference, characterized by a relative lack of
concern or a blasé attitude toward the symptoms. Clients with conversion
disorder sometimes demonstrate this behaviour; the also appear willing and eager to talk endlessly and dramatically about their symptoms, but often
without the concern one might expect. In contrast, malingerers are likely to
be more guarded and cautious, perhaps because they consider interviews a
challenge or threat to the success of the lie. But this distinction s not
foolproof, for only about one third of people with conversion disorders show
la belle indifference.
Case Illustration: The Difficulty of Detecting Malingering
In factitious disorder people intentionally produce physical symptoms (or
sometimes psychological ones). They may make up symptoms – for example,
reporting acute pain – or inflict injuries on themselves. In contrast to
malingering with factitious disorder the symptoms are less obviously linked
to recognizable goal; the motivation for adopting the physical or
psychological symptoms in much less clear. The individual, for some
unknown reason, wants to assume the role of client.