Cogito ergo sum.

I think, therefore, I am.

Rene Descartes




Lecture 5


Somatoform and Dissociative Disorders


Dale L. Johnson


            The disorders in this section all have to do with knowing: knowing about one's body and knowing about one's self, one's past, and one's relations to others. The early French psychiatrists realized that knowing was central to these disorders, but this realization was not seen as a cognitive matter until quite recently. "Knowing" in the earlier theories was about the absence of knowing because of repression and repression was believed to be the result of intrapsychic conflict.


Somatoform Disorders



            Clinical Description

            The person develops severe anxiety that is focused on the possibility of having a severe disease. The person regards this as so likely that reassurance from physicians fails to provide relief.

            See the case of Gail in your textbook.

            This has much in common with the anxiety disorders. This is partly the result of a DSM-IV redefinition of the disorder which now links it more exclusively to anxiety. The anxiety is about having the disease, not that one might get the disease.

            People with this disorder tend to misinterpret ambiguous physical signs.


Diagnostic Criteria for Hypochondriasis

A.  Preoccupation wiht fears of having, or the idea that one has, a serious illness based on the person's misinterpretation of bodily symptoms.

B.  The preoccupation persists despite appropriate medical evaluation and reassurance.

C.  The belief in Criterion A is not of delusional intensity and is not restricted to  circumscribed concern about appearance.

D.  The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

E.  The duration of the disturbance is at least 6 months.

F.  The preoccupation is not better accounted for by other disorders.


Source: DSM-IV, APA, 1994.



            Statistics and Course

            The prevalence is unknown. Estimates range from 1% to 14% of medical patients. There are no estimates for the general population.  The sex ratio is presumed to be equal.



            The person's perception of physical signs of physical signs is faulty. It is, therefore, a disorder of cognition or perception. It has been demonstrated that people with this disorder have an enhanced sensitivity to illness cues. Thus, a minor headache is seen as equalling a brain tumor. Think of how we ordinarily handle the perception of our physical well-being. If a new ache develops, we mentally review the ache, where it is, how intense, when it began, was there ever such an ache before? Quickly, we do a self-diagnosis and decide, "Aha! I ran 5 miles yesterday instead of my usual 3 and now I am feeling it." Or, we might decide it is new and is a warning sign. Perhaps we let it go for awhile and then we seek help from an expert (if we have health insurance and can afford help).

            For some reason, the person with hypochondriasis makes the same self-check and usually decides that the result is that one has some awful illness. The signs from the body all point in the direction of dire consequences.

            The predispositions are unknown, but there may have been a prior trauma or an  illness that has frightened the person. Risk factors for hypochondriasis are essentially unknown. There is some evidence that it runs in families, and thus, may be either genetic or learned. If parents place a great emphasis on physical signs as indicators of illness, the child may develop a sensitivity to these signs and a tendency to over-interpret their significance.

            It is important to keep in mind the rewards that may be found in discovering that one has an interesting illness. The reinforcement is treatment by the medical community and family. There are sick role benefits. We should not discount these behaviors and learn to provide alternative rewards.


            Until recently little has been known about treatment. There have been few controlled studies. One of these (Warwick, H. M., Clark, D. M, Cobb, A. M., & Salkovskis, P. M. (1996). A controlled trial of cognitive-behavioural treatment of hypochondriasis. British Journal of Psychiatry, 169, 189-195.) randomly assigned 32 patients to CBT or to a no-treatment, waiting list control. At 3 month follow-up, patients who had received CBT were doing significantly better on measures than patients in the control group. Two other studies using CBT have had similar positive results.

            Reassurance is effective with some patients and support groups seem to benefit others, but this work has not been tested with controlled clinical trials.

*   *   *

Somatization Disorder

            Clinical Description

                        This disorder was first termed,Briquet’s syndrome, after the man who defined the disorder in 1859. The key features are multiple somatic complaints presented in a vague, exaggerated way. The main difference from hypochoncriasis is that there is less anxiety; indeed, it is remarkably absent. The focus is on the symptoms and not what they might mean. Notice the lack of interest in knowing. The disorder has an obsessive quality. Life is organized around symptoms.



DSM-IV Criteria for Somatization Disorder

A.  A history of many physical complaints beginning before age 30 that occur over a period of several years and result in treatment being sought, or impairment in social, occupational or other important areas of functioning..

B.  Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of disturbance:

            1.  Four pain symptoms. A history of pain related to at least four different sites or functions of the body.

            2.  Two gastrointestinal symptoms. A story of at least two gastrointestinal symptoms other than pain such as nausea, diarrhea, bloating, vomiting (other tnan pregnancy),or intolerance of several different foods.

            3.  One sexual symptom; e.g., erectile dysfunction, irregular menses, excessive bleeding.

            4.  On pseudoneurological symptom; e.g., deafness, blindness, double vision.

Source: DSM-IV, APA, 1994.



            Statistics and Course

            Very rare. ECA   females    0.2%    2/1000

                                        males      0.01%  1/10,000

                                    Used DSM-III criteria.

            The disorder's severity occurs on a continuum. The number of symptoms reported ranges widely.



            One cause seems to be having been a witness to injury or traumatic event.

            Genetic. Torgerson (Archives of General Psychiatry 1986)    MZ 29%, DZ 10%

                                    Others have found a genetic component.

            It appears to be linked to such antisocial characteristics as lying, vandalism, theft, and irresponsibility. There is little anxiety and there may be a manipulative, deceitful component. Both disorders begin early in life, run a chronic course, and are associated with many social and interpersonal problems.

            What does somatization  have in common with antisocial personality disorder?  A neurobehavioral disinhibition syndrome. This behavioral Activation Syndrome is characterized by impulsivity and thrill seeking.

            The Behavioral Inhibition Syndrome (BIS) ensures responsivity to threat or danger. We feel anxious when we get certain signals. People with antisocial personality disorder are less inclined to be anxious. They are impulsive--responsive to short-term rewards.

            BIS brain circuiting involves the septal area of the brain through the hippocampus to the orbital frontal cortex. There is dysfunction in this circuitry. This also appears in attention deficit disorder.

            People with somatization disorder are different for social/cultural reasons. There is a markedly high degree of dependency. Dependence and lack of physical aggression are feminine characteristics (which is to say they may appear in men and women and are conceptually in contrast to masculinity).


            Somatization disorder is believed to be difficult to treat (as are antisocial personality disorders). There is only one (to my knowledge)  demonstrably effective treatment for this disorder. Group therapy for somatization disorder that is based on short cognitive-behavioural treatment model. (Lidbeck, J., 1997 Acta Psychiatrica Scandinavica, 96, 14-24.) When results were analyzed 6 months after treatment, the participants who had received group CBT were doing significantly better than the control group. Control group patients did not improve. Certainly, more research is called for, but this study points to a way of effective treatment.

            Warning: some people diagnosed with this disorder, and the other somatoform disorders, are subsequently found to have a real physical illness such as multiple sclerosis. Clinicians are warned to do a searching physical diagnostic examination.

*   *   *

Conversion Disorder


            Physical malfunctioning without physical pathology.

            The term “conversion” was used by Freud who theorized that anxiety arising from unconscious conflicts was converted from psychological to physical expression. The person could get rid of the anxiety without confronting it, without acknowledging that it is my anxiety, that it is my future that is threatened.

            What is the difference between conversion disorder and simple malingering or consciously trying to look bad? For one thing, in conversion there is indifference (not knowing) to the disability whereas the malingerer makes a point of proving that he or she is disabled. Malingerers have an object in mind; they want to get something out of the disability. They are fully aware of what they are doing. There was a NYPD episode in which a man faked insanity. He was tricked into revealing himself. In conversion disorder, the person cannot be tricked into revealing self.

            In factitious disorders the symptoms are faked and under full awareness, but for no apparent reason, except perhaps to assume the sick role. This may be shared by family and in this case it is a factitious disorder by proxy.



DSM-IV Criteria for Conversion Disorder

A.  One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or general medical condition.

B.  Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom is preceded by conflicts or other stressors.

C.  The symptom is not intentionally produced or feigned.

D.  the symptom cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.

E.  The symptom causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Source: DSM-IV, APA, 1994.



            Unconscious mental processes come into play in trying to understand conversion disorders. The case of Anna O. is a famous example. As Freud described the case she had a conversion reaction, but records discovered later show that she suffered from tuberculous meningitis which she contracted from her father. She had nursed her father for a long time. She may also have had a conversion disorder, but it is impossible to know in retrospect. Freud failed to acknowledge his misdiagnosis, even though he knew he had been in error.

            One thing is clear. People with this disorder are not good describers of their physical problem. This has something to do with cognitive style. There is a remarkable vagueness of the presentation. I have seen several cases, all in VA hospitals, and I recall that trying to find out about the problem was a frustrating challenge.


            Statistics and Course

            Prevalence: 1% to 30%. These estimates are absurdly wide. The disorder is almost certainly rare. The condition seems to be quite chronic.

            It seems to occur most often in women who have a low IQ, low socioeconomic status (SES), isolated environments, and fundamentalist religion . Basic to all of this is the issue of knowing. People who develop this disorder are not sophisticated. They do not read the New York Times or watch PBS.

            There is some evidence that the disorder is declining in incidence. But how can we know without data? Perhaps if it is declining it is related to the general increase in IQ of the population that has been underway for several decades. Perhaps with more public communication (radio, TV) there is growing sophistication.



            Several forms of treatment are effective in the short term. This includes hypnosis, faith healing and psychoanalysis.

            Perhaps the most effective treatment is to attend to the traumatic event and remove opportunities for secondary gain. It is also necessary to change environmental reinforcers. One might try behavioral family therapy. There are no controlled studies of treatment effectiveness.

*   *   *


Pain Disorder

            Pain experienced beyond expectations for a physical condition.

*   *   *


Body Dysmorphic Disorder

            The disorder is based on imagined ugliness. In some other somatoform disorders there is imagined illness; here the focus is on beauty or ugliness. it is related to obsessive compulsive disorder and to anorexia. There is an obsessive quality about the concern which resists conventional correction. People in general rate themselves as a little above average in beauty. They do this by focusing on certain features: "You have lovely eyes." They ignore other features such as big ears (e.g., Clark Gable).



DSM-IV Criteria for Body Dysmorphic Disorder

A.  Preoccupation with an imagined defect in appearance. If a slight physical anomally is preent, the person's concern is markedly excessive.

B.  The preoccupation causes significant distress or impairment in social, occupational or other important areas of functioning.

C.  The preoccupation is not better accouted for by other mental disorders.

Source: DSM-IV, APA, 1994.




            70% of college students are dissatisfied with some aspect of their body. But BDD goes beyond wishing to be more beautiful. See the criteria above: the concern has to be disabling.

            There are cultural definitions of beauty, such as slimness for American women and more roundedness for women in the Middle East. There is also great cross-cultural agreement. One universal seems to be that symetry of facial features is associated with beauty.

            The prevalence of BDD is unknown. There maybe a slightly greater prevalence for females, but perhaps men simply hide their concern more. Age of onset peaks at age 19.


            It was an important discovery that BDD is related to obsessive-compulsive disorder and that the two disorders co-occur in families. In OCD the obsession is often about germs; in BDDthe obsession is about ugliness. They are not so different.

            The most effective treatments are the SSRI anti-depressant medications; especially, Prozac. It may be that the other SSRIs are equally effective, but research is lacking.

            Plastic surgery provides no benefit because it is never good enough, and the obsession is still present.

            Prozac is not the only treatment. I recall at case at the Winter VA Hospital in Topeka, Kansas.  A man came to the hospital with the complaint that his penis was too small. He had gone shopping, from one VA hospital to another. His penis was measured and he was always told he did not have a problem. Finally, at Topeka, his penis was again carefully measured and found to be in the normal range, but the patient was told it was small. He was advised that given this limitation he would have to focus on his sexual technique, and then on his vocational esteem. He was given lessons on sexual technique, books to read, and homework assignments. At follow-up he was doing well.

*   *   *   *   *

Dissociative Disorders


            There are two types of feelings of unreality:  depersonalization, in which one loses a sense of one's own reality; and derealization, in which the sense of the realness of the external world is altered.

            These forms of awareness have been the subject of concern by the existential philosophers such as Heidegger and Sartre. They have analyzed how one is grounded; that is, how one functions in the ordinary world. For Heidegger, the person in the ordinary world is in care. In the dissociative disorders, this groundedness has gone wrong. It is as though they have a tenuous connection with the real world, including the social world. I recall seeing a play once, the title is forgotten, in which the hero would wander on stage with "Who am I?" spells. No one could help him.


Depersonalization Disorder



DSM-IV Criteria for Depersonalization Disorder

A.  Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of one's mental processes or body; e.g., feeling like one is in a dream.

B.  During the depersonalization experience reality testing remains intact.

C.  The depersonalization causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

D.  The depersonalization experience is not part of another disorder.

Source: DSM-IV, APA, 1994.



            Although the text mentions that the experience tends to be chronic, it also appears more fleetingly, especially in adolescents. In these one or two time forms of the depersonalization there is no impairment of functioning and most adolescents view the experiences as part of the mystery of growing up.

            Making a distinction between depersonalization disorder as distinct from the consequences of substance use is crucial for the diagnosis.

*   *   *

Dissociative Amnesia



DSM-IV Criteria for Dissociative Amnesia

A.  The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.

B.  The disturbance does not occur exclusively during the course of dissociative identity disorder, dissociative fugue, post traumatic stress disorder, or somatization disorder, and is not due to substance abuse or medication.

C.  The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Source: DSM-IV, APA, 1994.



            This disorder must be distinquished from amnesia associated with acute alcohol intoxication. Some people who abuse alcohol begin having black-outs, or amnestic periods at about age 30. These may occur more frequently as drinking proceeds.

*   *   *


Dissociative Fugue


DSM-IV Criteria for Dissociative Fugue

A.  The predominant disturbance is sudden,unexpected travel away from home or one's customary place of work, with inability to recall one's past.

B.  Confusion about personal identity or assumption of a new name (partial or complete).

C.  The symptoms cause clinically significant stress or impairment in social, occupational or other important areas of functioning.

Source: DSM-IV, APA, 1994.



            I have never encountered a case of dissociative fugue that was not characterized by heavy drinking. Even the case on P. 160 in the text (The Sherif) includes drinking.

            On p. 160 the authors of the text mention cultural variations on this disorder. They refer to frenzy witchcraft among the Navajo. They neglect to mention that I wrote the first report on that Navajo disorder. Fame is so elusive!

*   *   *


Dissociative Identity Disorder (DID)

             This disorder was once called multiple personality disorder and was popularized in several movies (e.g., Three faces of Eve). Only a short time ago, after years of almost no research on this disorder, there was a surge of research and reports appeared on what seemed like a monthly basis. Now, there are few reports again. What has happened is that for a time, researchers believed they had identified many cases of DID. The identification procedures were severely criticized and it became clear that many of the personalities presented by patients had been suggested by the clinicians. There has been a reaction and now many researchers doubt that DID even exists. Others think it is more common than believed earlier.


            Clinical Description



DSM-IV Criteria for Dissociative Identity Disorder



A.  The presence of two or more identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, or thinking about the environment and self).

B.  At least two of these identities or personality states recurrently take control of the person's behavior.

C.  Inability to recall personal information that is too extensive to be explained by ordinary forgetfulness.

D.  The disturbance is not due another disorder,

Source: DSM-IV, APA, 1994.





            The first question is what is the host identity? Who is the original person? What is this person like?  Personality? Intelligence? Experiences?

            Quite often the person with DID is described as impulsive, quickly shifting interests or goals.

            Another major question is how does the person switch from one ego to another. Is it really any different from the way an actress shifts from her home identity to the role she plays on stage or in a movie?  When we saw Helen Hunt in the movie "What women want" was this the "real" Helen Hunt, or was she playing a role? She played a role and got paid for it. Is the switching of the person with DID any different? This issue has not been resolved.

            So, is the behavior real or fake? Possibly a bit of both. It is possible to be caught up in playing a role. It becomes real.  In fact, however, I do not know the answer to this question, and I have not seen much research on the matter.

            One problem is that DID seems to occur in people who are very suggestible. A careless therapist may be assisting in the creation of multiple identities.

































            The case of Sybil  was regarded as a valid case of DID, a book was written and a movie made that was often shown in abnormal psychology classes. Then, the case was shown to be a fraud. Nevertheless, 40% of psychology teachers surveyed still regard the case as valid and continued to use the movie.

            A survey of American psychiatrists found that 67% had serious reservations abou the diagnosis. Psychiatrists in Israel were also skeptical.



            Several studies have reported on the life histories of people with DID. Almost all of the cases were women. Nearly all reported having been sexually abused by age 5 and nearly all had developed an ability to retreat into phantasy or trance states. DID does seem to be a kind of post-traumatic stress disorder. It should be noted that all of these studies were retrospective case studies. The reported abuse may not have happened, but may be part of the dramatic role presentation of the person with DID.



            The goal of treatment is to bring the diverse personalities together into one. Many different types of therapies have been tried, but there have been no controlled treatment trials with adequate samples,and there is only one follow-up. One study (Coons, 2001, Journal of Trauma and Dissociation, 2, 73-89) followed25 patients for 10 years. They had all been in treatment.  12 patients provided follow-up data. 6 had achieved full integration of their personality states, but 2 of them relapsed into DID. Teen-age patients did better than older patients. All of the patients reported improvement.  Of course, nothing is known about the 13 patients who did not report on their experiences.


True Memories and False

            The section on this topic in the textbook is important and you should read it carefully.

            Memory does not exist like the bytes on a computer hard drive. Human memory is always dynamic. We create our remembered history as we go along. We also discover our history through the recollections of others (which are no more accurate) and through such objective records as photos and home movies. I recall having a distinct recollection of being with father in some woods along the Missouri river when I was about 4 years of age. Later, while looking through a neglected family photo album, I saw a picture of me at age 4 with my father in the woods. I remembered the photo having seen it many times as a child, but I did not remember the actual event.

            Careless and unskilled therapists have created "memories" in clients who they were treating. As it has been fashionable to look for signs of child abuse in troubled adults, these therapist suggested that there was child abuse, and some of their clients then discovered that they had been abused (even though they had not). A problem is that objective evidence is nearly always lacking. This is not to say that we cannot recall events from our childhoods, traumatic and non-traumatic, but it is certain that we do not have a tape-recorder memory of the events. They are always contructed to some degree.

            Most research now shows that traumatic events are recalled. They are not repressed and hidden from conscious awareness.

            Doesn't the therapist have to help the client recover memories that are distressing? The answer is "yes" if you subscribe to a psychodynamic theory of therapy. It is "no" if your allegiance is with the cognitive-behavioral approach. In the latter, it is what is happening now that is of most importance.