The Somatoform and Dissociative disorders were once considered to be hysterical neuroses, and were thought to be conversion of unconscious emotional conflicts into physical symptoms.
Somatoform disorders
Somatoform disorders typically involve a preoccupation with a physical complaint in the absence of any responsible organic condition. There are a number of categories of Somatoform disorders.
Hypochondriasis
Is a condition closely related to anxiety disorders. There is a preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms, in the absence of organic pathology.
Between 4 and 9% of patients in general medical practice may have this diagnosis. It is more often associated with older individuals. Patients are concerned with illness and health, but have difficulty describing specific symptoms. Patients may not have the intense fear or anxiety associated typically associated with the conditions they believe that they have.
The disorder is thought to involve a misinterpretation of bodily symptoms, as a consequence of stress, but there appears to be a learnt or familial history. Treatment tends to involve reassurance and treatment of anxiety.
Somatisation disorder
Is similar to Hypochondriasis, but is rarer and is thought to have an earlier onset. The diagnosis is based upon the number of specific symptoms (8+) reported.
Pain disorder
Patients report pain sufficient to disrupt everyday life, but in the absence of medical pathology.
Conversion disorder
Patients report a loss of sensitivity (blindness) or control (paralysis), but without discernible organic pathology. Patients may exhibit an unconcern (“la belle indifference”) and lack of the fear and anxiety that might be expected.
Pain and Conversion disorders are thought to arise from a traumatic event (e.g. combat) that must be avoided. The primary gain for patients is that the illness is a socially acceptable altenative to the conflict. which proves successful for these patients. The secondary gain for patients is the sympathy and attention received by patients.
Treatment involves attending to the traumatic/stressful event and removing it (in real life or memory), and removing sources of secondary gain.
There is a real need to distinguish these conditions from malingering. Patients with conversi0on disorders are dramatic, naïve, and will discuss symptoms in detail. Malingerers are defensive, evasive and reluctant to be examined.
Dissociative disorders
Dissociative disorders are associated with a splitting of experience or identity.
There is a wealth of empirical evidence that not all experience is conscious experience (e.g. iconic memory), nor do we necessarily have conscious access to the reasons for our behaviour (e.g. the warm/cold effect and person perception). Such mechanisms may be subverted and misused to manage psychological threat.
There are several categories of dissociative disorder:
Depersonalisation disorder
Patients experience severe and frightening feelings of being unreal or detached that impair normal functioning. There are 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).
Dissociative amnesia
Patients are unable to remember important personal information, usually of a traumatic or stressful nature.
Dissociative fugue
Patients suddenly and unexpectedly travel away from hone or work, and are unable to recall their past and have some confusion of identity or even a new identity.
Dissociative identity disorder
Previously called Multiple Personality, patients with this disorder exhibit two or more distinct identities. There is an inability to recall important personal information that is not merely forgetfulness, and the disorder is not due to substance abuse or organic pathology.
The disorder is linked to traumatic childhood abuse, and the dissociations are seen as attempts to escape from these negative experiences. Suggestibility (hypnotisability) has been linked to the condition.. Treatment focuses upon stabilising the patient, confronting and reliving the trauma so that the patient gains control over the horrible events at least in their mind.
There is a need to distinguish such conditions from malingering. Martin Orne suggests that malingerers (e.g. Kenneth Bianchi the Hillside Strangler) tend to overplay their role, respond to demand characteristics and are more aware of logical inconsistencies in their position than bona fide Dissociative Identity Disorder patients.
Prescribed reading:
* Barlow, D.H. and Durand, V.M. Abnormal psychology: An integrative approach. 2nd ed. , Pacific Grove, CA: Brooks/Cole, Ch 6..
