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CHAPTER 5
SOMATIC SYMPTOM AND RELATED DISORDERS
AND DISSOCIATIVE DISORDERS
CHAPTER OVERVIEW
This chapter outlines the primary features of somatic symptom and related disorders and
dissociative disorders. With respect to the former, the symptoms, prevalence, etiology, and
treatment of somatic symptom disorder, illness anxiety disorder, and conversion disorder
(functional neurological symptom disorder) are discussed, as well as psychological factors
affecting a medical condition. For dissociative disorders, depersonalization-derealization
disorder and dissociative amnesia (including dissociative fugue states) are discussed. The chapter
also describes the relation between malingering and factitious disorders in the context of
conversion reactions and dissociative identity disorder. In addition, the major characteristics of
dissociative trance and dissociative identity disorder are described, including available treatment
approaches.
LEARNING OBJECTIVES
1.
2.
3.
4.
Identify the defining features of somatic symptom and related disorders.
Identify treatments that have been developed for somatic symptom and related
disorders.
Describe and distinguish the different types of dissociative disorders.
Describe important etiological and treatment factors for each type of dissociative
disorder.
CHAPTER OUTLINE
SOMATIC SYMPTOM AND RELATED DISORDERS
Somatic Symptom Disorder
Illness Anxiety Disorder
Psychological Factors Affecting Other Medical Conditions
Conversion Disorder (Functional Neurological Symptom Disorder)
DISSOCIATIVE DISORDERS
Depersonalization-Derealization Disorder
Dissociative Amnesia
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Dissociative Identity Disorder
DETAILED OUTLINE
Somatic Symptom and Related Disorders
What are the defining features of somatic symptom and related disorders?
 Individuals with somatic symptom and related disorders are pathologically concerned with
the appearance or functioning of their bodies and bring these concerns to the attention of
health professionals, who usually find no identifiable medical basis for the physical
complaints.
 There are several types of somatic symptom disorders. Somatic symptom disorder is
characterized by a focus on one or more physical symptoms accompanied by marked anxiety
and distress focused on the symptom that is disproportionate to the nature or severity of the
physical symptoms. This condition may dominate the individual’s life and interpersonal
relationships. Illness anxiety disorder is a condition in which individuals believe they are
seriously ill and become anxious over this possibility, even though they are not experiencing
any notable physical symptoms at the time. In conversion disorder, there is physical
malfunctioning, such as paralysis, without any apparent physical problems. Distinguishing
among conversion reactions, real physical disorders, and outright malingering, or faking, is
sometimes difficult. Even more puzzling can be factitious disorder, in which the person’s
symptoms are feigned and under voluntary control, as with malingering, but for no apparent
reason.
 DISCUSSION POINT:
What are some examples of normal physical symptoms that someone with somatic symptom
disorder might interpret catastrophically?
 DISCUSSION POINT:
How might a psychologist detect the difference between headaches due to physical factors
and those that might be conversion symptoms?
 The causes of somatic symptom disorders are not well understood but seem closely related to
anxiety disorders.
What treatments have been developed for somatic symptom and related disorders?
 Treatment of somatic symptom disorders ranges from basic techniques of reassurance and
social support to interventions meant to reduce stress and remove any secondary gain for the
behavior. Recently, specifically tailored cognitive-behavioral therapy has proved successful
with these conditions.
Dissociative Disorders
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What are the defining features and different types of dissociative disorders?
 Dissociative disorders are characterized by alterations in perceptions: a sense of detachment
from one’s own self, from the world, or from memories.
 Dissociative disorders include depersonalization-derealization disorder, in which the
individual’s sense of personal reality is temporarily lost (depersonalization), as is the reality
of the external world (derealization). In dissociative amnesia, the individual may be unable to
remember important personal information. In generalized amnesia, the individual is unable to
remember anything; more commonly, the individual is unable to recall specific events that
occur during a specific period (localized or selective amnesia). In dissociative fugue, a
subtype of dissociative amnesia, memory loss is combined with an unexpected trip (or trips).
In the extreme, new identities, or alters, may be formed, as in dissociative identity disorder
(DID).
What factors influence the etiology and treatment of dissociative disorders?
 The causes of dissociative disorders are not well understood but often seem related to the
tendency to escape psychologically from stress or memories of traumatic events.
 DISCUSSION POINT:
Why might an alter identity develop in an individual?
Ask students to generate examples of ways that an alter identity may be adaptive to the
person.
 Treatment of dissociative disorders involves helping the patient re-experience the traumatic
events in a controlled therapeutic manner to develop better coping skills. In the case of DID,
therapy is often long term. Particularly essential with this disorder is a sense of trust between
therapist and patient.
KEY TERMS
somatic symptom disorder, 171
dissociative disorder, 171
illness anxiety disorder, 173
conversion disorder, 178
malingering, 179
factitious disorder, 179
depersonalization, 183
derealization, 183
derealization-depersonalization disorder, 183
dissociative amnesia, 184
generalized amnesia, 184
localized or selective amnesia, 185
dissociative fugue, 185
dissociative trance disorder, 187
dissociative identity disorder (DID), 187
alters, 187
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IDEAS FOR INSTRUCTION
1.
Activity: When Have I Assumed the Sick Role? To expose students to characteristics
endorsed by people diagnosed with a somatic symptom disorder, including features of
malingering or factitious disorders, you could ask students if they have ever used or faked
physical symptoms to get out of having to perform important life activities (e.g., exams,
classes, work, social functions), including use of such tactics to gain attention and
sympathy from others.
2.
Activity: Understanding Somatic Symptom Disorder. You could administer the
Hypochondriasis Scale of the MMPI-2 to your students. After scoring the scale, you could
discuss results and how the test items relate to the DSM-5 diagnosis. To depict the process
of a person with somatic symptom disorder, ask your students to keep a log of their bodily
sensations for a few days. Examples may include stomach rumblings, headaches, muscle
soreness, frequent urination, stiffness, tingling sensations, skin color changes,
perspiration, and fatigue among others. Have the students bring in their record and ask
them to consider how a person with somatic symptom disorder might interpret these
normal sensations. What physical ailment could they represent? Also, discuss with them
why anxiety is so prevalent among people with this disorder. (Be sure to remind students
that the diagnosis of hypochondriasis has been renamed in DSM-5. This may stimulate a
discussion of the stigma associated with certain labels)
3.
Activity: “Normal” Dissociations. Before exploring the dissociative disorders, ask your
students to identify periods of dissociation that are normal. For example, most students
have had the experience of wanting to drive to a friend's house, but ending up at their
school or office because they are so used to driving that route. Others have had
experiences of driving on the highway only to find that they have no recollection of the
last 10 or so miles they have driven, including obvious landmarks they had passed along
the way. Alternatively, many have had the experience of dialing a phone number
intending to talk to one particular friend, only to have dialed the number of someone else
without being consciously aware of doing so. These examples illustrate that one can fail to
be conscious of what one is doing, and yet safely guide oneself through a task. Another
example occurs when studying. Again, almost every student has had the experience of
reading pages of material (perhaps in their Abnormal text!), only to snap out of their
“trance” and realize that, although their eyes were moving over the words, they were
thinking about very different things besides their textbook material. That is, they get to the
bottom of a page and have no idea how they got there. Finally, many students may have
experienced some form of trauma in which they felt cut off from feelings or numb from
shock. Highlighting these experiences helps illustrate that dissociative disorders are not as
bizarre as they first appear. Emphasizing the continuum of behavior is important here to
enhance student empathy for people with this class of disorders. We are all capable of
forms of dissociation, and people with severe dissociative disorders may be simply using a
natural process to protect themselves from the ongoing onslaught of trauma.
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4.
Activity: Invited Hypnotist or Pain Specialist. A useful class activity can be to invite a
guest lecturer with expertise in hypnotism or the treatment of pain-related disorders to
come and speak to your class.
5.
Video Activity: Abnormal Psychology, Inside/Out, Vol. 2. This video segment
presents the case of Mike, who suffered a brain injury after racing his car and cannot
learn or remember new information. After describing dissociative amnesia, play this
video segment and ask the class to determine whether Mike would meet diagnostic
criteria for a dissociative amnesia. Use this video clip to illustrate important facets of
amnesia and the critical features that would not warrant a diagnosis of dissociative
amnesia in this case.
6.
Dissociative Identity Disorder (DID). Previously referred to as multiple personality
disorder (MPD), this dissociative disorder involves a disturbance of identity in which two
or more separate and distinct personality states (or identities) control the individual’s
behavior at different times. Use
http://www.nami.org/Template.cfm?Section=By_Illness&Template=/ContentManageme
nt/ContentDisplay.cfm&ContentID=165620 to help develop a lecture and discussion of
dissociative identity disorder. Show http://www.youtube.com/watch?v=7iHJfIH20TY as
example of dissociative identity disorder.
SUPPLEMENTARY READING MATERIAL
Additional Readings:
(Please note: many of these references use outdated terminology, but may nonetheless be
instructive on the basic foundations of somatic symptom and related disorders and dissociative
disorders)
Bliss, E. L. (1980). Multiple personalities?: A report of 14 cases with implications for
schizophrenia and hysteria. Archives of General Psychiatry, 37, 1388-1397.
Chase, T. (1990). When rabbit howls. New York: Jove.
Ford, C. V. (1995). Dimensions of somatization and hypochondriasis. Special issue:
Malingering and conversion reactions. Neurological Clinics, 13, 241-253.
Kellner, R. (1986). Somatization and hypochondriasis. New York: Praeger.
Kellner, R. (1991). Psychosomatic syndromes and somatic symptoms. Washington, DC:
American Psychiatric Press.
Kluft, R. P. (1991). Multiple personality disorder. In A. Tasman & S. M. Goldfinger
(Eds.), American Psychiatric Press Review of Psychiatry, vol. 10. Washington, DC:
American Psychiatric Press.
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Loewenstein, R. J. (1991). Psychogenic amnesia and psychogenic fugue: A
comprehensive review. In A. Tasman & S. M. Goldfinger (Eds.), American Psychiatric
Press Review of Psychiatry, vol. 10. Washington, DC: American Psychiatric Press.
Lynn, S. J., & Rhue, J. W. (1994). Dissociation: Clinical and theoretical perspectives.
New York: Guilford.
Miller, M., & Bowers, K. S. (1993). Hypnotic analgesia: Dissociated experience or
dissociated control? Journal of Abnormal Psychology, 102, 29-38.
Putnam, F. W., et al. (1986). The clinical phenomenology of multiple personality
disorder: A review of 100 recent cases. Journal of Clinical Psychiatry, 47, 285-293.
Sizemore, C. C., Pittillo E. (1978). I'm Eve. The compelling story of the international
case of multiple personality. New York: Jove.
Spanos, N. P. (1996). Multiple identities and false memories: A sociological
perspective. Washington, DC: American Psychological Association.
Thigpen, C. H., & Cleckley, H. M. (1957). The three faces of Eve. New York: McGrawHill.
Waites, E. A. (1993). Trauma and survival: Post-traumatic and dissociative disorders in
women. New York: Norton.
Weintraub, M. I. (1983). Hysterical conversion reactions: A clinical guide to diagnosis
and treatment. New York: SP Medical and Scientific Books.
SUGGESTED VIDEOS
A Case Study of Multiple Personality: The Three Faces of Eve. (Insight Media). This
classic recording of a woman with three distinct personalities includes a case background, actual
interview sessions in which the psychiatrist elicits each personality, and scenes with the patient
after complete recovery. (30 min)
Agnes of God. Jane Fonda plays a court-appointed psychiatrist who must make sense out
of pregnancy and apparent infanticide in a local convent. The film illustrates stigmata as an
example of a conversion reaction.
The devils. This film, adapted from Aldous Huxley’s book, The Devils of Loundun, traces
the lives of 17th century French nuns who experienced highly erotic dissociative states attributed
to possession by the devil.
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Freud. This film illustrates several clinical manifestations of somatoform disorders (e.g.,
paralysis, false blindness, and false pregnancy).
Hanna and her sisters. Woody Allen stars as a hopeless hypochondriac who spends his
days worrying about brain tumors, cancer, and cardiovascular disease.
Primal fear. The film depicts a man who commits heinous crimes, purportedly as a result
of a dissociative disorder. The film raises questions about the problem of malingering and
differential diagnosis.
The three faces of Eve. This film portrays a woman with three personalities (i.e., Eve
White, Eve Black, and Jane).
Twelve o’clock high. This film depicts a general who develops conversion disorder (i.e.,
paralysis) in response to his role in the death of several of his subordinates. This film is based on
a true story.
ONLINE RESOURCES
American Society of Clinical Hypnosis
http://www.asch.net/
A good resource for research relevant to altered states of consciousness.
Child Abuse: Statistics, Research, and Resources
http://www.jimhopper.com/abstats/
A good resource for current research and informational links related to child abuse.
Pediatric Conversion Disorder
http://www.emedicine.com/ped/topic2780.htm
This article presents material related to conversion disorder, including the history of the
diagnosis and current data on prevalence.
International Society for the Study of Trauma and Dissociation
http://www.isst-d.org/
Offers information about diagnosis and treatment of dissociative disorders.
Mental Help Net - Dissociative Disorders
http://www.mentalhelp.net/poc/center_index.php?id=41
Offers information and connections to other websites related to dissociative disorders.
Recovered Memories of Sexual Abuse
http://www.jimhopper.com/memory/
A useful scholarly source of information and links related to recovered memories of
sexual abuse.
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The Sidran Institute
http://www.sidran.org/
The website for the Sidran Institute, which focuses on trauma and trauma-related
disorders. It provides a glossary of dissociative disorder terms, a brochure on dissociative
identity disorder, and tips for survivors as well as an article on the effects of dissociative identity
disorder on children of trauma survivors.
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WARNING SIGNS FOR
SOMATIC SYMPTOM DISORDER
 Frequent visits to the doctor
 Fixation on a disease that no doctor has diagnosed
 Rejection of a doctor’s reassurance that there is nothing seriously wrong
 Continuous doctor-shopping
 Checking your body many times a day/week for peculiarities
 Preoccupation with an illness that you see on television or in the newspaper
 Excessive concern about fear or pain
 Frequent thoughts of death
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WARNING SIGNS FOR
FACTITIOUS DISORDER IMPOSED ON ANOTHER
 Illness that persists in spite of traditionally effective treatments
 The child has been to many doctors without a clear diagnosis
 The parent (usually the mother) seems eager for the child to undergo
additional tests, treatments, or surgeries
 The parent is very reluctant to have the child out of her sight
 Another child in the same family has had an unexplained illness
 Parent has a background in healthcare
 Symptoms appear only when the parent is present
(Recall that this diagnosis does not apply exclusively to the victimization of a
child, but can involve any dependent individual)
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WARNING SIGNS
FOR DISSOCIATIVE IDENTITY DISORDER
 Two or more distinct personalities exist within one person
 Each personality has its own way of thinking about things and relating to
others
 At least two of the identities take control of the person’s behavior
 The person is unable to recall important personal information
.
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