CHAPTER 5: SOMATIC SYMPTOM, DISSOCIATIVE, AND FACTITIOUS DISORDERS
• 85-95% of the general population has at least one physical symptom every 2 to 4 weeks, and some people have
unexplained symptoms as often as every 5 to 7 days.
• Common physical complaints include chest pain, abdominal pain, dizziness, headache, chest pain, and fatigue,
yet an organic cause is only identified 10-15% of the time.
• How does one determine when physical symptoms result from psych distress rather than organic illness?
- The answer is complex and requires consideration of three interrelated factors:
1. When are physical symptoms medically unexplained? Answer: When physical examination and diagnostic
testing cannot determine any bio or physical cause.
2. When is worry or distress about physical symptoms excessive? Answer: When it results in functional
impairment or leads to medically unnecessary procedures.
3. When is physical distress considered to be caused primarily by psychological factors? Answer: Complex –
The interplay of physical symptoms, environmental stress, and emotional distress can create different
types of psych impairments known as somatic symptom and related disorders, and dissociative disorders.
SOMATIC SYMPTOM AND RELATED DISORDERS
5.1 Understand how normal physical sensations can create abnormal concerns about somatic functioning.
Somatic symptom and related disorders
• Characterised by excessive thoughts, feelings, or behaviour related to somatic symptoms.
• Physical pain is experienced but cannot be fully explained by an established medical condition.
• The individual disorders do not share an underlying emotion or common etiology; people with this category of
disorder experience thoughts, feelings, or behaviours in relation to the physical symptoms that seem out of
proportion to the symptoms themselves.
• The specific disorders include somatic symptom disorder, illness anxiety disorder, conversion disorder, and
Somatic Symptom Disorder
• In 1859, French physician Pierre Briquet wrote an influential paper describing psychiatric patients with many
somatic complaints that seemed to lack a physical cause.
• These patients were also likely to be depressed, and he noted that stressful life event could be particularly
important in the onset and maintenance of their distress. This constellation of symptoms was once called hysteria
or Briquet’s syndrome, but these terms are no longer used because they carry negative connotations.
• Known as somatic symptom disorder, the condition is defined as the presence of one or more somatic symptoms
plus abnormal/excessive thoughts, feelings, and behaviours regarding the symptoms. (NB: the thoughts, feelings,
and behaviours must be considered excessive or disproportionate to the symptoms.
• These physical complaints result in excessive health concerns and persistently high anxiety about one’s health.
Although any one symptom does not need to be consistently present, the presence of a symptomatic state is
• Common complaints include pain and gastrointestinal distress; back pain, chest pain, and headaches.
• Much less common but more dramatic are the pseudo-neurological symptoms such as pseudo-seizures, which
are sudden changes in behaviour that mimic epileptic seizures but have no organic basis
Conversion Disorder (Functional Neurological Symptom Disorder)
• Consists of symptoms of altered motor or sensory dysfunction; symptoms can be quite dramatic, such as sudden
paralysis or blindness. They are not intentionally produced and cannot be fully explained by the presence of any
• Before assigning this diagnosis, a careful medical evaluation is necessary because about 10-15% of people
originally diagnosed with this condition will later be found to have a diagnosable medical condition. • However, there is no way to determine which symptoms indicate a true neurological disorder; therapists must
strike a balance between excluding possible medical conditions and over-diagnosing and thereby reinforcing the
• Symptoms consist of various types; the most common group includes motor symptoms or deficits, such as
impaired coordination or balance, paralysis or weakness, tremor, gait abnormality, and abnormal limb posturing.
Within this group, muscle weakness, particularly in the leg, is most frequent.
• An unusual symptom, globus, which may include aphonia, sensations of choking, difficulty swallowing, shortness
of breath, or feelings of suffocation.
- In many cases, globus lasts only for a short period of time; however, if left untreated, it can lead to
abnormal eating patterns or food avoidance.
• Sensory deficits, a less common symptom group, include loss of touch or pain sensations, double vision or
blindness, deafness, and hallucinations.
• Also rare is behaviours such as psychogenic or non-seizures and convulsions.
• Symptoms of conversion disorder do not follow known neurological patterns of the human body, a factor that
is important in differentiating between a psychological and a physical disorder.
- E.g. a patient may complain of loss of sensitivity in the hand and wrist, a condition called glove
anesthesia – physical anatomy cannot explain the symptom pattern; the lack of medical reasons
for this phenomenon suggests that the symptoms could have a psych basis.
• The classic description of conversion disorder includes a symptom called la belle indifference (beautiful
indifference) defined as substantial emotional indifference to the presence of these dramatic physical symptoms.
Even when unable to walk or move their arms, some people appear undisturbed by their paralysis; they deny
emotional distress from their unusual symptoms and behave as if nothing is wrong. However, some with this
disorder are distressed by their symptoms, thus la belle difference is not a necessary symptom is not a necessary
symptom of the disorder.
• Freud and psychodynamic theorists believe that psychological distress is converted in physical symptoms, hence
the name, conversion disorder.
Illness Anxiety Disorder
• When fears or concerns persist despite medical reassurance, the problem may be Illness Anxiety Disorder.
• Those with the disorder have a high level of worry about health and easily become alarmed about the possibility of
having an illness; they are preoccupied with the possibility of having or developing and illness and often elicit
negative reactions from physicians because they cannot be reassured that they are well, and their behaviours are
similar to rituals found in OCD.
• Some constantly seek reassurance from physicians and monitor their own physical status; others with it avoid
situations associated with their fear, such as refusing to go to a hospital for fear of catching an illness.
• In the past, people with this disorder were said to have “hypochondriasis”, and sometimes the person was called
a “hypochondriac”. However, because of the presence of these phobia-like behaviours, the disorder has been
renamed illness anxiety disorder.
• Not all worries about illness warrant diagnosis of this disorder; some suffer from transient hypochondriasis, which
may result from contracting an actual acute illness or an actual life-threatening illness, or even from caring from
someone with a medical condition.
• Most often comorbid disorders accompany Illness Anxiety Disorder such as major depressive/anxiety disorders.
The disorder only exists on its own in 23% of people with hypochondriasis.
5.2 Differentiate somatic symptom, dissociative, and factitious disorders from malingering behaviour.
• Factitious disorders differ from other somatic symptom disorders in one very important way: physical or
psycho signs or symptoms of illness are intentionally produced in what appears to be a desire to assume a
sick role. - Unlike malingering, in which a person intentionally produces physical symptoms to avoid military
service, criminal prosecutions, or work to obtain financial compensation or drugs, symptom
production in this disorder is not associated with any external incentives.
- People are aware that they are producing the symptoms and making themselves ill but appear to
be unaware of why they do it; they may produce primarily physical symptoms, primarily psycho
symptoms, or both.
• First described in 1951 and then named Munchausen Syndrome (after a German nobleman known for telling
• Two types of factitious disorders:
1. Factitious Disorder Imposed on Self
- People engage in deceptive practices to produce signs of illness. Behaviours include faking elevate
body temperature, putting blood in urine to simulate kidney/urinary tract infections, or taking blood-
thinning meds to produce symptoms of haemophilia.
- They deliberately and convincingly fake chest pain or abdominal pain. They will go through numerous
invasive and dangerous diagnostic and therapeutic procedures.
- To convince physicians that they are physically ill, they manipulate lab results to substantiate their
illness claims. Although they seek and often beg for medical intervention, they never reveal the fact
that they are creating their own physical distress.
- They often go to emergency rooms during evenings an weekends when they are more likely to be
evaluated by junior clinical staff; sometimes they invent false demographic information, including
aliases and false information about their past.
- Although most with this disorder fabricate physical symptoms, some may fabricate psychological
symptoms. Common psycho symptoms include grief and depression over the recent death or a relative
(usually alive or dead for a long time). Some fake other psycho disorders, including multiple personality
disorder, substance dependence, dissociative and conversion disorders, memory loss, and PTSD.
2. Factitious Disorder Imposed on Another
- When one person induces illness symptoms on another.
- In most cases, a mother produces physical symptoms in the child. After inducing the symptoms, the
mother brings the child to the hospital and gives permission, or sometimes insists that the child
undergo invasive and dangerous diagnostic procedures.
- Child-victims ages range from infancy to teenage years. They can have many different symptoms,
including apnea (the child stops breathing), anorexia/feeding problems, diarrhea, seizures, cyanosis
(turning blue from lack of oxygen), behaviour problems, asthma, allergy, fever, and pain.
- Child-victims average 3.25 medical problems, ranging as high as 19 illnesses in a single child.
- When proved factitious, it is considered to be a form of child abuse, and the parent can be prosecuted.
- Occasionally, this disorder also occurs in nursing homes, where the health care personnel inflict these
physical symptoms on adult residents.
A NOTE ABOUT SOMATIC DISORDERS AND THE DSM-5
Because the DSM-5 is so new, there has not been an opportunity for researchers to collect data on many aspects of
these conditions. Therefore, we do not yet know how to answer, for this particular group of disorders, the important
questions that we ask throughout this book, including questions about epidemiology, functional impairment,
developmental issues, etiology, or treatment. Somatoform disorders will be used to refer to this entire diagnostic group
using data that were collected under the old diagnostic labels.
• This group of disorders produce significant functional impairment. Approx 10-15% of adults in the US report work
disability as a result of chronic back pain. • Among those with conversion disorder, only 33% maintained full-time employment. Similarly, those with
somatoform disorders worked fewer days per month than those with no disorder.
• These disorders also increase the likelihood of physical disability, occupational impairment, and overutilization of
• These disorders have a complex and chronic course. Remission rates are likewise controversial. Early studies
report that less than 10% of people recover, recently 30-50% recover a year later.
• Conversion disorder may be a more acute condition with 33-90% of patients remitted or significantly improved 2-5
year later. Of course, the most chronic cases are associated with increased functional impairment.
• Although many physical complaints lack an organic basis, they still have an enormous impact on our medical
system. Patients with medically unexplained physical symptoms constitute 15-30% of all primary care physician
appointments and sometimes several different physicians evaluate the same patient complaint.
• People with physical symptoms often “doctor-shop” to find a physician who will provide a medical explanation, and
in many cases, they receive different diagnoses from different medical specialists.
• Some remain unwilling to accept a psycho diagnosis; this leads to physician frustration, patient demoralization,
and a continuing search for physical explanation.
• Over a 1 year period, those with somatoform disorders average significantly more primary care visits. More
emergency room visits, and more hospital admissions as well as higher inpatient and outpatient care costs than
the general pop.
• Determining a physical basis for these symptoms is quite costly; in all, treatment for somatoform disorders
accounts for approximately 20% of all medical care expenses in the US. Mental health care was the only form of
health care that was no significantly higher in people with these disorders.
• People with factitious disorders often have numerous hospitalisations and can develop medical conditions as a
result of their self-administered injuries. E.g. scar tissue from numerous operations or self-injections. Sometimes
peregrination occurs, in which the patient seeks treatment at different hospitals and sometimes travels from state
to state or even country to country with false names.
• They are considered to be chronic and it would appear that this disorder would affect social and occupational
• Among child victims of factitious disorder imposed on another, 6-22% dies as a result of the medical illness
inflicted upon them, as do 25% of their siblings. The most common cause of death is suffocation or apnea.
Ethics and Responsibility
• Since factitious imposed on another may result in serious injury or death, psychologists have a responsibility to act
in the best interest of the child. A report to the state child protection agency is the first step. The investigation
requires collaboration among child protection officials, medical personnel, and psychological professionals.
• The child must be evaluated by a medical specialist to ensure that there is no medical reason for the child’s
• Sometimes a child is hospitalised in order to observe symptom patterns, as they often disappear when parents
can no longer have unfettered access to their children. In other instances, video observation is used to determine
whether parents are causing the physical symptoms to appear.
• Whereas medical pros and child protection personnel may be most involved in determining whether the child has
a legitimate medical disorder or is a victim of factitious disorder imposed on another, mental health personnel are
the pros who attempt to treat the offending parent.
• 14-20% of the general pop reports worrisome physical symptoms that have no organic basis. However few
actually meet the strict diagnostic criteria for these disorders.
• There are no known epidemiological data on the prevalence of factitious disorders in the general pop.
Sex, Race, and Ethnicity • Because these disorders are rare, we have very limited data on their interplay with variables such as sex, race,
• More women endorse the presence of somatoform disorders more frequently than men.
• They appear to occur equally across racial and ethnic groups.
• Women in one sample were younger and more likely to have had health care training or health care jobs.
• Those with the most severe forms of the disorder, including symptoms of peregrination and the adoption of
aliases, are more likely to be male.
• Among those with factitious disorder imposed on another, 77-98% are women, typically the child’s bio mother,
although fathers and foster mothers are also occasional perpetrators.
• No data available for race/ethnicity.
• Outside the US, medical systems are more likely to use a sociocultural rather than a psycho explanation;
physicians discuss patients’ physical distress in terms of family and community problems. When a sociocultural
explanation is offered, people are more likely to acknowledge that stress, social conditions, and emotions can
affect their physical status.
• Diagnostic criteria are the same in children and adolescents as in adults, but the data that do exist indicate that
somatoform disorders are rare before adulthood.
• In adults, voluntary motor dysfunction was most common followed by sensory dysfunction and pseudo-seizures.
• Factitious disorder imposed on self is most common among adults, but it does exist among children and
adolescents as well.
• Children most commonly produce symptoms such as fever (heating the thermometer to fake a fever), diabetic
insulin insufficiency (deliberately manipulating their insulin levels), bruises, and infections.
5.3 Identify the contributions of biological, psychological, and environmental factors to somatic symptom and related
How these disorders develop is poorly understood. Bio factors seem to play a role, particularly when distorted
perceptual processes exist; yet few controlled trials have examined bio causes. Currently, the evidence lies in the
realm of psychosocial factors.
• Psychodynamic – these disorders result from intrapsychic conflict, personality, and defence mechanisms. Modern
researches do not invoke psychodynamic constructs, but empirical data do support the hypotheses that children
and adults who complained of physical aches and pains had more negative emotions. More importantly, they were
also more likely to have poor self-awareness of the presence of these emotions and were less able to regulate
(change) their emotional state; perhaps if they were no able to recognize the impact of stress on their physical
functioning, they were became worried that their somatic symptoms had a medical cause.
• Behavioural principles of modelling and reinforcement may also contribute to the development of illness
behaviour. Mothers with somatoform disorder paid more attention to their children when they played with a
medical kit than when they played with a tea set or ate a snack. This increased attention may lead to an increase
in medical concerns, medical tests, or medical procedures on their children. Similarly, the more often girls were
reinforced for expressing complaints about menstrual illness, the more often they had menstrual symptoms and
disability days as adults. Also, childhood reinforcement of cold illness behaviour significantly predicted cold
symptoms and disability days for adults.
• Other environmental factors also are associated with physical symptoms, distress, and somatoform disorders.
Among adults, stress was temporarily associated with 72% of these disorders. In contrast, a history of sexual
abuse was present in 28% of the cases. Among children, family separation/loss was associated with the onset of
the disorder in 34% of the cases. Family conflict/violence was associated in 20% of the cases, and sexual assault
correlated in only 4%.
• Despite much speculation about the etiology of factitious disorders, few empirical data exist. • Among psychological theories, psychodynamic models explain factitious disorder as 1) an attempt to gain mastery
or control that was formerly elusive, 2) a form of masochism (where pleasure results from physical or
psychological pain inflicted by oneself or another), 3) the result of a deprived childhood, in which a child did not
receive attention or care, or 4) an attempt to master trauma that was experiences as a result of physical or sexual
abuse, with the physician unknowingly assuming the symbolic role of the abuser.
• From a behavioural perspective, the disorder is maintained beca