Somatoform and Dissociative Disorders

Somatic symptom disorder (SSD formerly known as "somatization disorder" or "somatoform

disorder") is a form of mental illness that causes one or more bodily symptoms, including pain. The
symptoms may or may not be traceable to a physical cause including general medical conditions, other
mental illnesses, or substance abuse. But regardless, they cause excessive and disproportionate levels
of distress.
The somatoform disorders are a group of psychiatric disorders in which patients present with a
myriad of clinically significant but unexplained physical symptoms. They include somatization
disorder, undifferentiated somatoform disorder, hypochondriasis, conversion disorder, pain
disorder, body dysmorphic disorder, and somatoform disorder not otherwise specified.
The unexplained symptoms of somatoform disorders often lead to:
 general health anxiety
 frequent or recurrent and excessive preoccupation with unexplained physical symptoms
 inaccurate or exaggerated beliefs about somatic symptoms
 difficult encounters with the health care system
 disproportionate disability; displays of strong, often
 negative emotions toward the physician or office staff
 unrealistic expectations and,
 occasionally, resistance to or noncompliance with diagnostic or treatment efforts.
These behaviors may result in more frequent office visits, unnecessary laboratory or imaging tests,
or costly and potentially dangerous invasive procedures.

Psychosomatic disorders
Psychosomatic means mind (psyche) and body (soma). A psychosomatic disorder is a disease
which involves both mind and body.
The term psychosomatic disorder is mainly used to mean:” a psychical disease that is thought to
be caused, or made worse, by mental health factors.”
Psychosomatic disorder, also called psycho-physiologic disorder, condition in which
psychological stresses adversely affect psychological (somatic) functioning to the point of distress.
It is a condition of dysfunction or structural damage in bodily organs through inappropriate
activation of the involuntary nervous system and the gland of internal secretion. Thus, the
psychosomatic symptom emerges as a physiological concomitant of an emotional state.
Same people also use the term psychosomatic disorder when mental factors cause psychical
symptoms, but where there is no psychical disease. For example, a chest pain may be caused due
to stress, and no psychical disease can be found. psychical symptoms that caused by mental factors
are called ‘somatization and somatoform disorders.’
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Classnotes by Samikshya Sharma Poudel
Somatoform disorders are the major forms of psychosomatic illness:
 The psychical symptms of somatoform disorders are real. However, they have
psychological roots rather than psychical causes
 The symptoms aften resembles symptoms of medical illnesses. As, such people suffering
from somatoform disorders may undergo extensive testing and medical evaluations to
determine the cause of their symptoms.
 People who suffer from somatoform disorders will generally not recognize the role these
emotions play in their psysical symptoms.
 However, they are not intentionally producing these psysical symptoms or making up their
psychical problems. Their psychical symptoms are real, but are caused by psychological
factors.
 Women are more likely than men to have a somatoform disorders.
 Symptoms usually begin before age 30 and persist for several years.
 The severity of the symptoms may vary from year to year, but there are rarely times when
symptoms are not present. Examples of somatoform symptoms include digestive problems,
headaches, pain, fatigue, menstural problems, and sexual difficulties.

Types of somatoform disorders:

These are the main types of somatoform disorders:

 Somatization Disorder - Continual complaints of physical symptoms when no physical

condition exists to cause the symptoms.
 Conversion Disorder - This usually occurs after a traumatic event, and causes
impairment of movement or senses that is only psychological in nature.
 Pain Disorder - Chronic pain in one or more areas of the body that has no identifiable
cause.
 Hypochondriasis - A belief that physical symptoms (either real or imagined) are signs
of a serious illness, even when medical tests show otherwise.
 Body Dysmorphic Disorder - A constant obsession with a physical flaw - real or
imagined - that can cause side effects.

Treatment:

Treatment is focused on managing symptoms and improving the quality of life.

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  The health care provider must show empathy and sensitivity to the client’s psychical
symptoms.
 A strong trusting relationship is key to getting help with SSD.
 Counseling for family and friends may also be useful.
 Involve the client in visual imaging and relaxation therapies to reduce psychological
pain.

Conversion disorder:

Conversion disorder is defined as a psychiatric condition in which emotional distress or

unconscious conflicts are expressed through physical symptoms. Thus, an emotional conflicts
is converted into psychical problem.

Conversion disorder, also known as functional neurological symptom disorder, occurs when
a person experiences neurological symptoms (symptoms of the nervous system) not
attributable to any medical condition. The symptoms are real and not imaginary, and they
can affect motor functions and senses.

Conversion disorder is known as non-verbal expression of emotional pain. When brain

cannot handle the emotional conflict, it tries to relieve the tension by psychically releasing
it.

Signs and symptoms of conversion disorder

Conversion disorder symptoms include:

 Difficulty walking
 Loss of balance
 Body tremors
 Weakness or paralysis
 Hearing difficulty
 Vision problems or blindness
 Loss of sensation
 Trouble swallowing

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  Seizures or shaking episodes
 Unresponsiveness
 Speech problems, such as inability to speak or slurred speech

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These

criteria include:

 loss of control of movement or sensory symptoms

 symptoms occurring after a traumatic or stressful event
 symptoms that do not appear to have an underlying medical or physical cause
 symptoms that interrupt a person's everyday activities

Causes:

 conversion disorder is triggered by stressful situations, an emotional conflicts and other

mental disorders.

Treatments

 treating any underlying mental health conditions, such as depression

 cognitive behavioral therapy (CBT)
 psychotherapy
 relaxation techniques, such as meditation or yoga
 physical therapy
 maintaining a healthy work and life balance
 seeking additional support from friends, family, and the community

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 Dissociative disorder
Dissociation is a subconscious defense mechanism that helps a person protect his or her
emotional self.
Dissociative disorders involve problems with memory, identity, emotion, perception,
behavior and sense of self.
Dissociative disorder is the stress related disorder characterized by disturbance in the
normally integrated functions of consciousness, identity and/ or memory. Dissociative
disorders have essential features of a disruption in the usually integrated functions of
consciousness, memory, identity or perception of the environment. Dissociative symptoms
are often seen in clients with PTSD. Dissociative disorders are relatively rare in the general
population but are much more prevalent among persons with histories of childhood
physical and sexual abuse.
The total population of people with dissociative disorders is estimated at 2%, with women
being more likely than men to be diagnosed

Symptoms
Symptoms and signs of dissociative disorders include:
 Significant memory loss of specific times, people and events
 Out-of-body experiences
 Depression, anxiety and/or thoughts of suicide
 A sense of detachment from your emotions or emotional numbness
 A lack of a sense of self-identity

There are three types of dissociative disorders defined in the Diagnostic and Statistical Manual of
Mental Disorders (DSM):

 Dissociative amnesia.
 Depersonalization disorder.
 Dissociative identity disorder

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Dissociative identity disorder:

Dissociative identity disorder (DID) also known previously as multiple personality disorder, has
often been confused and misunderstood. DID also known as multiple personality disorder or split
personality disorder is a chronic psychopathological condition which commonly manifests after
trauma or childhood abuse. It includes disruption in memory and identity of a person.
Dissociative identity disorder is a severe form of dissociation, a mental process which produces a lack
of connection in a person's thoughts, memories, feelings, actions, or sense of identity. One may feel
the presence of two or more people talking or living inside their head, and one may feel as though
they are possessed by other identities. Each identity may have a unique name, personal history and
characteristics, including obvious differences in voice, gender, mannerisms and even such physical
qualities as the need for eyeglasses.

Symptoms:

 Lapses in memory (dissociation), particularly of significant life events like birthday,

weddings or birth of a child
 Experiencing blackouts in time, resulting in finding oneself in places but not
recalling how one got there.
 Being frequently accused of lying
 Being called names that are completely unlike their own name or nickname
 Not recognizing themselves in the mirror
 Feeling unreal (derealization)
 Finding items in one’s profession but not recalling how things were acquired
 Feeling like more than one person

DSM –V criteria for dissociative identity disorder

A) Disruption of identity characterized by two or more distinct personality states, which

may be described in some cultures as an experience of possession. The disruption of
marked discontinuity in sense of self and sense of agency, accompanied by related
alterations in affect, behavior, consciousness, memory, perception, cognition, and/or
sensory-motor functioning. These signs and symptoms may be observed by others or
reported by the individual.

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 B) Recurrent gaps in the recall of everyday events, important personal information, and/or
traumatic events that are inconsistent with ordinary forgetting.

C) The symptoms cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D) The disturbance is not a normal part of a broadly accepted cultural or religious practice.
Note: In children, the symptoms are not better explained by imaginary playmates or
other fantasy play.

E) The symptoms are not attributable to the physiological effects of a substance (e.g.,
blackouts or chaotic behavior during alcohol intoxication) or another medical condition
(e.g., complex partial seizures).

Causes:

The causes of dissociative identity disorder appear to be complex. About 90% of the cases
of DID involve some history of abuse. Some causes are:

 Emotional, physical, or sexual abuse

 Accidents
 Natural disasters
 War
 Loss
 Trauma in early childhood

Treatment:
Dissociative identity disorder is primarily treated with psychopathology of various types.
According to the Cleveland Clinic, the following are DID therapy types:

 Psychotherapy: often thought of as “talk therapy”. This encourages communication of

conflicts and insights into problems
 Cognitive therapy: involves changing dysfunctional thought patterns

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  Family therapy: helps to educate the family about the disorder, recognize its presence as
well as work through issues that have developed in the family because of dissociative
identity disorder.
 Creative therapy such as art or music therapy: allows the patient to explore thoughts,
feelings and memories in a safe and creative way.
 Medications: The use of medication, except for the treatment of acute, specific concurrent
Axis I disorders, is not recommended. Maintenance and effective use of prescriptions given
the multiple personality states is difficult to attain. If medication is prescribed, it should be
carefully monitored.

Depersonalization/derealization disorder
Depersonalization/derealization disorder is a type of dissociative disorder that consists of
persistent or recurrent feelings of being detached (dissociated) from one’s body or mental
processes, usually with a feeling of being an outside observer of one’s life (depersonalization),
or of being detached from one's surroundings (derealization). The disorder is often triggered by
severe stress.

Depersonalization/derealization disorder occurs when you persistently or repeatedly have the

feeling that you're observing yourself from outside your body or you have a sense that things
around you aren't real, or both.

People with depersonalization/derealization disorder often have experienced severe stress, such
as the following:

 Being emotionally abused or neglected during childhood (a particularly common cause)

 Being physically abused

 Witnessing domestic violence

 Having a severely impaired or mentally ill parent

 Having a family member or close friend die unexpectedly

Symptoms

Persistent and recurrent episodes of depersonalization or derealization or both cause distress and
problems functioning at work or school or in other important areas of your life. Symptoms usually

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begin in the mid- to late teens or early adulthood. Depersonalization-derealization disorder is rare
in children and older adults.

Episodes of depersonalization-derealization disorder may last hours, days, weeks or even months
at a time. In some people, these episodes turn into ongoing feelings of depersonalization or
derealization that may periodically get better or worse.

Depersonalization symptoms

 Feelings that you're an outside observer of your thoughts, feelings, your body or parts of
your body — for example, as if you were floating in air above yourself
 Feeling like a robot or that you're not in control of your speech or movements
 The sense that your body, legs or arms appear distorted, enlarged or shrunken, or that your
head is wrapped in cotton
 Emotional or physical numbness of your senses or responses to the world around you
 A sense that your memories lack emotion, and that they may or may not be your own
memories
Derealization symptoms

 Feelings of being alienated from or unfamiliar with your surroundings — for example, like
you're living in a movie or a dream
 Feeling emotionally disconnected from people you care about, as if you were separated by
a glass wall
 Surroundings that appear distorted, blurry, colorless, two-dimensional or artificial, or a
heightened awareness and clarity of your surroundings
 Distortions in perception of time, such as recent events feeling like distant past
 Distortions of distance and the size and shape of objects

DSM -5 criteria for depersonalization/Derealization

A. The presence of persistent or recurrent experiences of depersonalization, derealization or

both: Depersonalization: Experiences of unreality, detachment, or being an outside observer
with respect to one's thoughts, feelings, sensations, body, or actions (e.g., perceptual
alterations, distorted sense of time, unreal or absent self, emotional and/or physical
numbing). Derealization: "Experiences of unreality or detachment with respect to

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Classnotes by Samikshya Sharma Poudel
 surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy,
lifeless, or visually distorted."
B. During the depersonalization or derealization experiences, reality testing remains intact.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, medication) or other medical condition (e.g., seizures).
E. The disturbance is not better explained by another mental disorder, such as schizophrenia,
panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress
disorder, or another dissociative disorder. Read more:
http://traumadissociation.com/depersonalization

Risk factors

Factors that may increase the risk of depersonalization-derealization disorder include:

 Certain personality traits that make you want to avoid or deny difficult situations or make
it hard to adapt to difficult situations
 Severe trauma, during childhood or as an adult, such as experiencing or witnessing a
traumatic event or abuse
 Severe stress, such as major relationship, financial or work-related issues
 Depression or anxiety, especially severe or prolonged depression, or anxiety with panic
attacks
 Using recreational drugs, which can trigger episodes of depersonalization or derealization

Treatment:
 Psychotherapy: Various psychotherapies (e.g., psychodynamic psychotherapy,
cognitive-behavioral therapy) are successful for some patients:

 Cognitive techniques can help block obsessive thinking about the unreal state of being.
 Behavioral techniques can help patients engage in tasks that distract them from the
depersonalization and derealization.

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Classnotes by Samikshya Sharma Poudel
  Grounding techniques use the 5 senses (e.g., by playing loud music or placing a piece
of ice in the hand) to help patients feel more connected to themselves and the world and
feel more real in the moment.
 Psychodynamic therapy helps patients deal with negative feelings, underlying conflicts,
or experiences that make certain affects intolerable to the self and thus dissociated.
 Moment-to-moment tracking and labeling of affect and dissociation in therapy
sessions works well for some patients.

Dissociative amnesia
Dissociative amnesia is a type of dissociative disorder that involves inability to recall important
personal information that would not typically be lost with ordinary forgetting. It is usually caused
by trauma or stress.
Dissociative amnesia, formerly called psychogenic amnesia, is one of a group of conditions
called dissociative disorders. Dissociative amnesia is a condition in which a person cannot
remember important information about his or her life. This forgetting may be limited to certain
specific areas (thematic), or may include much of the person’s life history and / or identity
(general).
It is rare: it affects about 1% male and 2.6 % female in the general population.
Dissociative Amnesia is not caused by head injuries or physical damage to the brain, it is amnesia
which has a psychological cause. It can occur due to mental health conditions, including
posttraumatic stress disorder and acute stress disorder, dissociative identity disorder, somatoform
disorder, and anxiety disorders. Dissociation Amnesia can last for between a few days to a few
years, but is typically less than a week. The period of time which cannot be remembered can range
from minutes to decades.

Symptoms
The main symptom of dissociative amnesia is memory loss that is inconsistent with normal
forgetfulness. The amnesia may be
 Localized

 Selective

 Generalized

Localized amnesia involves being unable to recall a specific event or events or a specific period
of time; these gaps in memory are usually related to trauma or stress.

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 For example, patients may forget the months or years of being abused as a child or the days
spent in intense combat. The amnesia may not manifest for hours, days, or longer after the
traumatic period. Usually, the forgotten time period, which can range from minutes to decades,
is clearly demarcated. Typically, patients experience one or more episodes of memory loss.

Selective amnesia involves forgetting only some of the events during a certain period of time or
only part of a traumatic event. Patients may have both localized and selective amnesia.
In generalized amnesia, patients forget their identify and life history. E.g., who they are, where
they went, to whom they spoke, and what they did, said, thought, experienced, and felt. Some
patients can no longer access well-learned skills and lose formerly known information about the
world.
Generalized dissociative amnesia is rare; it is more common among combat veterans, people
who have been sexually assaulted, and people experiencing extreme stress or conflict. Onset is
usually sudden.

In systematized amnesia, patients forget information in a specific category, such as all

information about a particular person or about their family.

In continuous amnesia, patients forget each new event as it occurs.

DSM -5 criteria for dissociative amnesia

A. An inability to recall important autobiographic information, usually of a traumatic or
stressful nature, that is inconsistent with ordinary forgetting. Note: Dissociative Amnesia
most often consists of localized or selective amnesia for a specific event or events; or
generalized amnesia for identity and life history.
B. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance (e.g., alcohol
or other drug abuse, a medication) or a neurological or other medical condition (e.g., partial
complex seizures, transient global amnesia, sequelae of a closed head injury/traumatic
brain injury, other neurological condition).
D. The disturbance is not better explained by dissociative identity disorder, posttraumatic
stress disorder, acute stress disorder, somatic symptom disorder, or major or mild
neurocognitive disorder."

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Fugue:

Dissociative fugue is a type of amnesia that is caused by an extreme psychological trauma instead
of physical trauma, illness, or another medical condition. It’s a form of dissociative amnesia that’s
severe, and it’s considered rare.

The dissociative fugue is, essentially, the active state of amnesia wherein a person is doing things
he or she will later forget. A person in a dissociative fugue will suddenly, and uncharacteristically,
travel from the home or work with a purpose in mind but without memory of some or of all of
one's past. The definition of a dissociative fugue indicates the person is not confused or dazed, but
rather he or she seems to be running away from something from which they are not aware.

Someone with dissociative fugue won’t have any memory of their past or about themselves
personally. The type of memories that they lose are sometimes referred to as autobiographical
memories. The condition is a means of escaping a situation of extreme stress that the person can’t
cope with.

Symptoms

A dissociative fugue may last only a few hours. The person undergoing it may seem to be confused
and forgetful to others during that time, but they’ll return to normal afterward. A person with
dissociative fugue lasting longer than just a few hours may have the following symptoms:

 confusion
 sudden lack of attendance at work or avoidance of other places they frequent
 loss of autobiographical memory (about themselves, other people, events in their lives,
etc.)
 detachment from their own emotions
 severe stress at work or from relationships
 confused identity
 depression, anxiety, thoughts of suicide, and other mental health issues
 inability to recognize loved ones
 wandering or going places they usually don’t go

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Classnotes by Samikshya Sharma Poudel
Causes

Dissociative fugue is caused by a situation that gives the person extreme emotional stress. A
common cause of dissociative fugue is severe sexual trauma of some sort. Other causes may
include:

 extreme feelings of shame or embarrassment

 trauma caused by war
 trauma caused by an accident
 trauma caused by a natural disaster
 kidnapping
 torture
 long-term emotional or physical abuse in childhood

Treatment

The treatment may include the following:

 creating a safe environment

 help recovering lost memories
 help reconnecting to life prior to the trauma
 gradually discovering, dealing with, and then managing the trauma that originally caused
dissociative fugue
 developing coping mechanisms to better handle future stressful situations
 regaining normal life functions
 strengthening and improving relationships

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Classnotes by Samikshya Sharma Poudel
These goals are accomplished through several types of therapies, which may include:

 family therapy
 psychotherapy
 cognitive behavioral therapy
 meditation and relaxation techniques
 music or art therapy
 clinical hypnosis
 dialectical behavior therapy

Hypochondriasis
Hypochondriasis is defined as a persistent preoccupation with a fear (or belief)) of having one (or
more) serious disease, based on person’s own interpretation of normal body function or a minor
physical abnormality. Usually it begins between 20 and 30 years of age: can occur across the life
time. Generally, people with this disorder do not develop "somatic delusions" (ideas about health
that are completely divorced from reality). The belief and fear of serious illness which lasts for six
months, beyond and despite medical reassurance.
For example, a person may fear that the normal sounds of digestion, sweating or a mark on the
skin may be a sign of a serious disease.
Hypochondriasis is in some ways similar to obsessive-compulsive disorder. The person is
obsessively preoccupied with thoughts of illness and feels compelled to do things (feel lumps,
browse for medical information, visit the doctor) to quell the anxiety they feel.
Hypochondriasis may also be called hypochondria, hypochondriasm, or hypochondriacal neurosis,
health anxiety or illness anxiety disorder. It is the excessive and unrealistic worries about health.

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Classnotes by Samikshya Sharma Poudel
Symptoms
Some symptoms include:

 Frequent doctor visits: If one doctor declares that Sal is healthy, he goes to two more to
make sure because he truly thinks he is sick and that the initial doctor is missing something.
 Requests for tests and surgery: Even though certain tests and operations come with risks,
hypochondriacs ask for them over and over again.
 Severe anxiety about health
 Excessive self-diagnosis and research: When hypochondriacs see a news story or an article
online about a new disease, they think they have it.
 Thoughts that anything unusual with the body means a serious illness
 Lack of attendance at work or school due to anxiety over possible illnesses
 Constant attention to blood pressure, heartbeat; constant examinations of body to detect
something unusual
 Constant talk about health issues - these concerns quickly become the center of
conversations

DSM-5 for Hypochondriasis

The diagnosis of illness anxiety disorder is based on criteria from the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5), including the following:

 The patient is preoccupied with having or acquiring a serious illness.

 The patient has no or minimal somatic symptoms.

 The patient is highly anxious about health and easily alarmed about personal health
issues.

 The patient repeatedly checks health status or maladaptive avoids doctor appointments
and hospitals.

 The patient has been preoccupied with illness for ≥ 6 months, although the specific illness
feared may change during that time period.

 Symptoms are not better accounted for by depression or another mental disorder.

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Classnotes by Samikshya Sharma Poudel
Causes
 Genetic
 Beliefs: some people don’t understand the meaning of body sensations aor poor
understanding of diseases can also be one of the causes of this disorder.
 History of childhood illness: if someone had serious illness in childhood then minor
physical sensations are also frightening to him/her.
 Major life stress.
 A severe symptom believed to threaten one’s health ( e.g. chest pain, memory issues)
 History of childhood abuse or neglect

Risk factor

Risk factors for illness anxiety disorder may include:

 A time of major life stress

 Threat of a serious illness that turns out not to be serious
 History of abuse as a child
 A serious childhood illness or a parent with a serious illness
 Personality traits, such as having a tendency toward being a worrier
 Excessive health-related internet use

Treatment

Psychological counseling: Psychological counseling (psychotherapy) is the primary treatment

for hypochondria. CBT may be the most effective treatment. CBT can help:

 Identify fears and beliefs about having a serious medical disease

 Learn alternate ways to view our body sensations by working to change unhelpful thoughts
 Become more aware of how our worries affect us and our behavior.
 Change the way we respond our body sensations and symptoms
 Learn skills to cope with and tolerate anxiety and stress.
 Reduce avoidance of situations and activities due to psychical sensations.

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Classnotes by Samikshya Sharma Poudel
 Education about hypochondria: known as psycho education, this type of counseling can help
patient and family better understand what hypochondria is, why a patient has it and how to cope
with patient health fears

Medications: Antidepressants medications may be helpful in treating hypochondria. E.g.

include serotonin reuptake inhibitors (SSRIs) such fluoxetine (Prozac) may help treat the illness.

Relaxation techniques, healthy diet, exercise and yoga can also be beneficial.

Supportive psychotherapy

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