CHAPTER 10

1. CHAPTER 10: DISORDERS WITH DISSOCIATIVE
AND SOMATIC SYMPTOMS
DESCRIBING AND CLASSIFYING ABNORMAL BEHAVIOR.

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Introduction
 Dissociation is a mental conditions where there is a loss of integration of mental
functions.
 Somatising is the tendency to experience physical symptoms in the face of
psychological distress.
 DSM-5 proposes to refine alignment, terminology, and diagnostic criteria.
 Factitious disorders where symptoms are intentionally produced
 Overlap of categories between disorders characterised by dissociation and somatoform
disorders
 Limitations of existing DSM and ICD approaches.
 Chapter covers related culture-specific conditions; range of other conditions with
dissociative or somatic symptoms; factitious disorders and Malingering.

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What is dissociation?
 a person's thoughts, identity, consciousness, and awareness
become separated or disconnected from one another.
 Common phenomenon in human experience, NB when faced with major
threat.
 Feel detached from ourselves, experience world as unreal or have
little or no recall of a trauma.
 Normal dissociation can also occur when person is bored, engaged
in monotonous activities, when meditating, tired or sleepy.

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What causes dissociation?
 serves as a coping mechanism or defense
mechanism in response to overwhelming or traumatic
experiences.
 Dissociation has three distinct features
 Depersonalisation
 Derealisation
 Amnesia
 Recent insights into neural mechanisms support this.

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Dissociative disorders and their
comparative nosology
 DSM-5 proposes some changes to dissociative disorder category for nomenclature, criteria and
categorisation.
 derealisation is proposed to be incorporated with Depersonalisation/ Derealisation Disorder.
 Dissociative Fugue is subsumed under Dissociative Amnesia.
 Dissociative Identity Disorder incorporates Dissociative Trance and Possession Disoder.
 DSM-5 Work Groups concerned with Conversion Disorder have not finalised its classificatory
location.
 ICD-10 differs on dissociative conditions by considering conversion as a dissociative condition.
 Diagnosis of dissociative disorders using the ICD-10 approach requires the fulfillment of the
general criteria for dissociative disorders as well as those for the specific disorders.
 Depersonalisation/Derealisation Disorder is not listed as a Dissociative (Conversion) Disorder but
instead under Other Neurotic Disorder.

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Dissociative disorders and their
comparative nosology
 ICD-10 takes a different approach:
 absence of Conversion Disorder (considered a Dissociative Disorder)
 Body Dysmorphic Disorder (subsumed under Hypochondriacal Disorder)
 Conceptually related conditions are also included:
 Acute Stress Disorder
 Posttraumatic Stress Disorder
 Borderline Personality Disorder
 Panic Attacks

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Somatoform disorders and their
comparative nosology
• Refers to tendency to experience bodily (somatic) distress in the face of psychological
stress.
 Lack of robust evidence for causal link between stress and somatising.
 Onset, exacerbation, and maintenance of symptoms correlate with stress.
 DSM-5 proposes multiple revisions to somatoform and related disorders, including:
 Renamed category: ‘Somatic Symptom Disorders’ (disorders with experience of
physical symptoms).Concern for associated psychological distress and reduced
quality of life.
 Factitious disorders and Malingering to be included under Somatic Symptom
Disorders.

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Dissociative amnesia
 Amnesia common to almost all dissociative disorders and is prominent in Dissociative
Amnesia, Dissociative Fugue, and Dissociative Identity Disorder.
 When amnesia is main symptom make diagnosis of Dissociative Amnesia.
 DSM-5 proposes that Dissociative Amnesia subsumes Dissociative Fugue.
 Not the result of failure to encode, store or retrieve information possible to recover lost
memories and deficits usually reversible.
 Involves a discrete period; not vagueness
 Involves events of a stressful or traumatic nature; may experience amnesia for many
events.
 Memory function normal in other respects.
 Where associated with minor head trauma, this is too slight to have psychological effects
on memory function matching what is observed.
 Uncommonly, travel away from familiar surroundings can occur; may assume new
identity.

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Epidemiology
 Most common of the dissociative disorders (but limited
epidemiological data).
 Age of Onset: develop at any age, but it often emerges in late
childhood, adolescence, or early adulthood.
vary depending on the individual's life experiences.
 More common in women and in younger adults.
 Incidence rises during war, social unrest and seems to
correlate with disasters.
 Incidence increases with severe trauma.

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Diagnosis, clinical features, and course
 Most cases have onset following an emotionally stressful event.
 Onset is usually abrupt.
 Most patients are aware of the memory loss (some appear upset about it,
others indifferent).
 Extent and depth of amnesia may vary.
 Other cognitive functions are unaffected; patients usually alert before and
after the onset of amnesia.
 Anxiety and depression commonly co-occur with the amnesia and stressful
event.
 End of an amnesic episode usually abrupt and complete.

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Differential diagnosis
 Different from cognitive deficits of Dementia and Delirium.
 Post-concussion amnesia involves both retrograde and
anterograde elements.
 Epilepsy commonly interrupts recall; may be abrupt
memory impairment.
 Sleepwalking (somnambulism) may resemble dissociative
state (but occurs during sleep & usually at night).
 Acute and Posttraumatic Stress Disorders characterised
by dissociative symptoms and memory disturbances.
 Factitious disorders and Malingering must be considered if
presentation is atypical.

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Dissociative identity disorder
 Highly controversial disorder; validity as a clinical or pathological entity
is doubted.
 Chronic dissociative disorder characterised by the existence of two of
more distinct identities or personalities.
 Typically follows childhood sexual or physical abuse.
 Considered the most serious of the dissociative disorders.
 Research suggests neuro-scientific validity for Dissociative Identity
Disorder.
DSM-5 proposes inclusion of possession and trance phenomena into the
diagnostic criteria for Dissociative Identity Disorder

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Epidemiology
Estimates of incidence and prevalence of
Dissociative Identity Disorder range widely.
Overwhelming majority of cases are female.
Onset mainly in adolescence mean age is
thirty
Inherited basis to the condition.
.

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Aetiology and pathogenesis
 Similar pathogenic mechanism as other dissociative
conditions.
 Nearly 100% of cases involve traumatic event
during childhood – usually physical or sexual abuse.
 Poor attachment and lack of support increase risk.

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Diagnosis, clinical presentation, and course
 Transitions between personalities can occur gradually, but more frequently occur
rapidly and quite dramatically.
 Whilst possessing one personality, the patient is amnesic of the others.
 Classically, each alter has a well-developed set of attributes.
 Patients may appear coy or seductive, look depressed or anxious, but MSE usually
normal.
 Rare for switch between alters to occur during a clinical encounter.
 Sometimes patients report hallucinations; may also be conversion symptoms.
 In children, condition more trance-like; two forms during adolescence.
 Can emerge as early as 3 years; poorer prognosis.
 Co-morbid conditions: Mood, anxiety, and substance use disorders; Borderline
Personality Disorder.
 Prognosis typically guarded and recovery incomplete.

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Differential diagnosis
 Dissociative Amnesia (but no alternate identities) and Fugue (new
identity usually superficially developed); also, Dissociative Identity
Disorder is chronic.
 Schizophrenia and other psychotic disorders (affective
incongruence and silliness; presence of delusions and formal
thought disorder).
 Bipolar conditions and Borderline Personality Disorder (but absence
of distinct personalities).
 Complex Partial Epilepsy (but atypical presentations and an obvious
external motivation in Malingering).

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Depersonalisation disorder/derealisation disorder
 Persistent or recurrent alteration in the perception of self, resulting in the suspension
of a person’s sense of their own, personal reality.
 Includes feelings of estrangement from the self, being like a machine, dead, in a
dream, or being detached from the body.
 Patients maintain intact reality testing and experience depersonalisation with full
awareness of its abnormality.
 Symptoms usually transient; often occur with anxiety states (e.g. in panic attacks).
 Derealisation is different; involves perception that the external world is not real.
 Depersonalisation + derealisation = alienation.
ICD-10 considers Depersonalisation/Derealisation Disorder under Other Neurotic
Disorders

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Epidemiology
 Depersonalisation is common even in healthy individuals.
 The sexes are equally affected.
 Particularly common during adolescence.
 Pathological depersonalisation rare.
 Onset usually between 15 and 30; can occur as young as 10.
 Prevalence of depersonalisation higher in psychiatric population (NB
in Posttraumatic Stress Disorder, Major Depressive Disorder, Panic
Disorder, Schizophrenia, and substance-use disorders).

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Aetiology and pathogenesis
 General pathological mechanism involved in
depersonalisation is dissociative detachment.
 Detachment subjective experience of altered state
of consciousness; characterised by alienation of
the self or the external world.
Arises during periods of stress; represents
adaptive response (anxiety thereby managed
brain freed to devote processing capacity to
averting threat).

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Diagnosis, clinical features, and course
 Patients with depersonalization remain aware of external world.
 Quality of experience is changed alienation (body parts feel ‘foreign’ – experienced as changing shape or size).
 May be a sense of removal of conscious self from one’s own body (e.g. autoscopy).
 Reduplication patients have experience of being duplicated and present in two different places at once.
 Reduplication also experienced in active psychosis, dementia, delirium, seizures, migraine and focal lesions
involving the parietal cortex.
 May be accompanying derealisation.
 Often, anxiety and/or panic go with depersonalisation.
 During episode, patient may appear preoccupied and dysphoric,
 Reality-testing remains intact.
 Fear of the experience may patient may avoid precipitants.
 Often, sudden first appearance of symptoms, accompanied by intense anxiety and hyperventilation.
 Tends to be a chronic condition with constant symptom intensity (periods of remission).
 May occur during periods of psychosocial stress OR relaxation, boredom & use of medicinal substances.

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Differential diagnosis
 Major Depressive Episodes, Schizophrenia and other
psychotic experiences (but history and MSE).
 Psychoactive substances.
 Serious physical pathology like cerebral neoplasm or central
nervous system infection.
 Epilepsy is main physical (non-psychiatric cause) of
depersonalisation (but abrupt onset and signs).
 Migraine may depersonalisation (but severe, classically one-
sided and throbbing headache, photosensitivity, heightened
sensitivity to sound, nausea, and vomiting).

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Related conditions across different cultures
 Latin America - Ataque de nervios (dramatic display of negative emotions and somatic symptoms after psychosocial stressor).
 China – Yi-ping (hysteria) typically affects women with histories of interpersonal conflict, illness, or following death of a loved one.
 Malay men – Amok (trance-like state; man runs or takes flight for hours); running amok is seen as a way to seek revenge/restitution for perceived
insult to man’s dignity.
 Malaysian peninsula and Indonesian archipelago – Latah (exaggerated startle responses); Myriachit is an identical condition found in the Arctic
regions of Siberia.
 New England and Canada – Jumper Disease of Maine (like Latah; fierce startle response: violent jumping and twisting; echolalia and echopraxia –
speaking in tongues).
 Arctic Inuit - Pibloktoq (another running syndrome; prodromal listlessness, fatigue, dysphoria, and mental ‘confusion’ followed by ‘seizure’ of
disruptive behaviour when person strips off clothing and embarks on a spell of frenzied running and rolling in the snow).
 Universal neural mechanism but characteristics depend on the prevailing cultural context.
 Among Africans and East Asians (communalist cultures), dissociation manifests with possession of patient by external agency (demon, deity, or
another person).
 In the West, particularly North America (individualist cultures), dissociation manifests as Dissociative Identity Disorder (competing versions of the
self)

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Amafufunyana
 In SA black population, occurrence of demon possession and the role of shamans or mediums well known.
 Amafufunyana found among Xhosa-, Zulu- and Tswana-speaking peoples; means ‘evil spirits’.
 Amafufunyana and Ukuthwasa overlap with Schizophrenia; Dissociative Trance Disorder with Possession.
 Cause = ancestral anger, bewitchment, failure to observe a traditional ritual, evil spirits, etc.
 Also, variety of witch-familiars (e.g. river snake, impundulu, and tokoloshe).
 Xhosa beliefs – caused by ‘nerves’, relationship problems, drug or alcohol abuse, and the Lord’s Will.
 Multifactorial causes (spiritual, social, interpersonal, etc.).
 Earliest sign is social withdrawal; then listlessness, poor appetite, grunting, falling down, and overt aggression
 May be vocalisations (evil spirits speaking through the person); foreign language or sound like different person.
 Communication disturbances - incoherence and neologisms; formal thought disorder
 Acute phase - person may thrash around wildly and walk on all fours; may be movements like convulsions.
 After-effects include an inability to recall events during the affliction; feeling dazed and tired.

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Ukuthwasa
 Ukuthwasa concerns a calling from ancestors for a person to undergo diviner (thwasa) training.
 Usually follows on misfortune befalling a person.
 Clinical manifestations of Ukuthwasa are varied, with anxiety, labile moods, loss of appetite, ‘confused’ feelings, and
auditory and visual hallucinations
 Also somatic complaints; person can become restless and wander from home.
 Personal hygiene is neglected and social isolation sets in.
 Sexual desire may be heightened or lost.
 Antisocial behaviour, violence, and aggression.
 Dreams NB; water = near-universal theme; also, forests and animals.
 Symptoms only remit once call for training is accepted.
 If not heeded, ‘madness’ and death may follow.
The bewildering variety of symptoms associated with Ukuthwasa allows for its placement within several diagnostic
categories

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Somatisation disorder
 Like Conversion Disorder, Somatisation Disorder
has been known for millennia; considered a form of
hysteria.
 Also known as Briquet’s Syndrome.
 1950s – renewed interest in Feighner’s
comprehensive list (59) of diagnostic criteria.
 But, these are complex and unwieldy not
commonly used in practice.
DSM-5 has proposed much simplified criteria

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Epidemiology
 Common in primary health care and general medical
practice (± 10% of patients).
 Also, probably under diagnosed.
 Affects females with an incidence five-fold that for males.
 Cultural factors.
 Mainly affects people of low socio-economic standing
and limited education.
 By definition, onset before age 30 (most commonly in
adolescence).

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Aetiology and pathogenesis
 Psychoanalytic theories - symptoms are substitutes for repressed
unacceptable impulses.
 As a social communication, produces secondary gain (avoid work and
gain sympathy and support).
 Significant psychosocial trauma (NB in childhood).
 Frontal and non-dominant parietal lobes involved.
 Decreased blood flow in brain; also, reduced metabolism and size of sub-
cortical structures.
 Demonstrated neuropsychological abnormalities (e.g. distractibility).
 Role of cytokines?
 At least partly genetic; 29% concordance in monozygotic twins.

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Diagnosis, clinical presentation, and course
 Defining feature = occurrence of multiple bodily symptoms from multiple organ systems; include
pseudo-neurological symptoms.
 Also, cognitive distortions and anxiety about symptoms, and dysphoria.
 Early psychosocial adversity (mostly in childhood); time of onset related to trauma.
 DSM-5 takes leaner approach; proposes collapse of Somatisation Disorder, Hypochondriasis,
Undifferentiated Somatoform Disorder and Pain Disorder into single new construct called
Complex Somatic Symptom Disorder.
 Although somatising is common in general medical and primary care settings, diagnosis avoided
due to cumbersome diagnostic criteria
 Hoped that simpler category will increase recognition and treatment for many patients with
substantial disease burden.
 Complaints presented in an exaggerated manner; with colourful descriptions.

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 Give vague accounts of multiple bodily complaints; historical description of symptoms often faulty.
 Interpersonal conflict, chronic distress, anxiety, and depression not uncommon.
 Self-harm and threats of suicide also not unusual.
 Female patients may be seductive or demure.
 Tend to be self-absorbed, external locus of control, seek praise, behave dependently, and manipulate
interpersonal situations.
 Nature and occurrence rates of symptoms vary across different cultures.
 Chronic, disabling condition; symptoms worsen with periods of heightened psychosocial stress.
 Symptoms come in spurts (last 6-9 months); rare to be symptom free for more than a year.
 Common co-morbid psychiatric conditions are Major Depressive Disorder, personality disorders, substance-
related disorders, Generalised Anxiety Disorder and phobias.
Most serious complications of Somatisation Disorder are iatrogenic

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Differential diagnosis
 General medical and neurological illness, NB conditions with non-
specific, transient, and fluctuating clinical manifestations (e.g.
Multiple Sclerosis and Myasthenia Gravis).
 Also, Porphyria, hyperthyroidism.
 Also, Porphyria, hyperthyroidism, hyperparathyroidism, and
haemochromatosis.
 Acquired Immune Deficiency Syndrome (AIDS).
 Psychiatric differentials include Hypochondriasis, Conversion
Disorder, and Pain Disorder.
 Also, Schizophrenia, Major Depressive Disorder and Panic Attacks.

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Hypochondriasis
 Morbid preoccupation with a disease conviction which
involves the fear of contracting, or the belief of having, a
serious disease.
 Ancient Greece – Hypochondriasis referred to
unexplained conditions in the anatomical
hypochondrium.
 Validity as a separate condition long questioned.
 Hypochondriacal symptoms often occur in (or co-morbid
with) depressive and anxiety disorders.
 Better seen as a symptom dimension?

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Epidemiology
 In general medical population, the six-month prevalence
ranges between 4% and 6% .
 Very little info about prevalence in Africa.
 Sexes are equally affected.
 Age of onset is typically in the twenties (can be at any age).
 Social class, education, and marital status appear not to
affect its expression.

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Aetiology and pathogenesis
 Psychoanalytic theory:
 disturbed object relations
 displacement of repressed hostilities to the body
 interplay between masochism, guilt, conflicted
dependency, and need for suffering and receiving
love.
 Defences against low self-esteem, inadequacy, and
conditioned reinforcement of the sick role have also
been considered causative
 Most likely a variant expression of other mental
conditions (NB anxiety disorders and depression).
 These conditions establish a hyper-vigilant state.
 Neural substrate of fear implicated.

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Diagnosis, clinical presentation, and course
 Some differences in DSM and ICD criteria.
 These patients highly heterogenous:
 25% of Hypochondriasis patients display ‘classical’ illness anxiety (fear
of having serious medical condition, but no somatic symptoms).
 75% show mix of illness anxiety and somatic symptoms.
 DSM-5 proposes reclassifying these groups into two separate disorders.
 Hypochondriacal concerns fluctuate and typically intensify under increased
psychosocial stress.
 Episodic course (episodes last months to years).
 Good prognosis includes high socio-economic status, absence of significant
personality pathology, etc.

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Differential diagnosis
 General medical conditions with ill-defined, transient, and fluctuating
phenomena (e.g. Multiple Sclerosis, Systemic Lupus Erythematosus,
etc.)
 Somatisation Disorder (but patient’s focus is on identified symptoms,
not disease entities).
 Conversion Disorder (but preponderance of female patients; sudden
and dramatic onset of pseudo-neurological symptoms).
 Pain Disorder (but focus on pain symptom and pain behaviour).
 Body Dysmorphic Disorder (but preoccupation with an anatomical
abnormality, not illness anxiety).
 Psychotic disorders – if concerns are of delusional intensity.
Co-existing anxiety and depressive disorders

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Malingering
 Illness-endorsing behaviours involving intentional and untruthful presentation of phenomena suggestive of
illness or impairment.
 Any symptom, or combination of physical or psychological symptoms, can be presented.
 In Malingering, deceit involves falsely claiming illness to avert threat or receive unfair advantage (e.g. obtain
disability grant).
 In Malingering, motivation is external and the malingerer is aware of it.
 In both Malingering and factitious disorders, the deception is volitional and occurs with full awareness.
 Success of deceit rests on two pillars:
 familiarity with the subject of deceit
 style of communication that avoids raising suspicion
 Deceitful communication succeeds if it appears natural and targets an unsuspecting audience.
 Suspicion more often raised by nature of the communication than by factual errors about the illness.
 Recognising presence of deceit rests on keen observation and familiarity with human nature.
 In both factitious disorders and Malingering, untruthfulness of a claim exists on a continuum.

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Factitious disorder
 Deceive in reporting of symptoms; misrepresent medical
and personal histories.
 DSM-5:
 proposes to relocate factitious disorders to Somatic
Symptom Disorder category
 draws attention to objective identification of deceit
 Factitious Disorder by Proxy is where caregiver
intentionally produces or feigns signs and symptoms in a
person entrusted to their care, usually a child.

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Aetiology, pathogenesis, epidemiology
 Aetiology unknown.
 Men more often affected than women.
 History of childhood abuse, poor attachment, etc.
 Frequent contact with medical system seen as source of
care and nurturance and escape from harsh familial
environment.
 This reinforces the illness-endorsing behaviour.
 But, patients provoke repeated rejection repeated cycle.
 Patients often have first-hand experience with relative with
mental disorder and/or above-average medical or
psychological knowledge.

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Diagnosis, clinical presentation, and course
 Challenge doctor-patient relationship:
 deceive and break trust
 retaliation tempting but NB to avoid confrontation
 Popularly known as Munchhausen Syndrome.
 Present with pathological lying; patient appears to believe own stories.
 Present with bewildering array of signs and symptoms; adept at manipulating
laboratory tests.
 Submit themselves to repeated dangerous diagnostic procedures.
 Co-morbid conditions (e.g. Borderline PD; depression).
 Chronic course; high morbidity.
Patients with factitious disorders are distressed and dysfunctional

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Differential diagnosis
 Differential diagnosis involves any conceivable
condition.
 Psychiatric differentials include Somatisation
Disorder, Hypochondriasis, and Pain Disorder,
Borderline, Antisocial, and Histrionic Personality
Disorder, Schizophrenia, and Malingering.
 Ganser’s Syndrome (similarities in response style).

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Malingering
 Malingering is not a mental disorder.
 Cunnien (1997): Malingering is:
 conscious and deliberate behaviour
 that constitutes a form of pretence, fabrication, or feigning
 in the presence of an objectively identifiable goal
 Can coexist with true illness.
 Neither symptom nor illness, but behaviour.
 Malingering by Proxy involves reporting untruthful symptoms in another and is motivated by an
identifiable external incentive (e.g. securing a child support grant).
 Extended Malingering involves co-opting others to endorse the index malingerer’s deceitful claims.
 Dysfunctional Malingering Syndrome involves continuation of Malingering despite lack of success.

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Conclusion
 Dissociative and somatoform disorders appear
very complex.
 Unsettled classification and often difficult
diagnostic criteria.
 Management is frequently difficult strained
therapist-patient relationship not uncommon.
 No unitary biopsychosocial explanatory model.