 A.
Somatic Symptom and Related
Disorders
o Somatic Symptom Disorder
o Illness Anxiety Disorder
o Conversion Disorder (Functional
Neurological Symptom Disorder)
o Factitious Disorder and Factitious
Disorder Imposed on Another
o Factitious Disorder Imposed on
Self
o Factitious Disorder Imposed on
Another
o Causal Factors
o Treatment
B. Dissociative Disorders
o Dissociative Identity Disorder
o Dissociative Amnesia
o Depersonalization/Derealization
Disorder
o Causal Factors
o Treatment of Dissociative
Disorders
 SOMATIC SYMPTOM
DISORDER
Diagnostic Criteria
A. One or more somatic symptoms that
are distressing or result in significant
disruption of daily life.
B. Excessive thoughts, feelings, or
behaviors related to the somatic symptoms
or associated health concerns as
manifested by at least one of the
following:
1. Disproportionate and persistent
thoughts about the seriousness of
one’s symptoms.
2. Persistently high level of anxiety
about health or symptoms.
3. Excessive time and energy
devoted to these symptoms or
health concerns.
C. Although any one somatic symptom
may not be continuously present, the state
of being symptomatic is persistent
(typically more than 6 months).
Specify if:
o With predominant pain
(previously pain disorder): This
specifier is for individuals whose
somatic symptoms predominantly
involve pain.
Specify if:
o Persistent: A persistent course is
characterized by severe
symptoms, marked impairment,
and long duration (more than 6
months).
Specify current severity:
o Mild: Only one of the symptoms
specified in Criterion B is
fulfilled.
o Moderate: Two or more of the
symptoms specified in Criterion
B are fulfilled.
o Severe: Two or more of the
symptoms specified in Criterion
B are fulfilled, plus there are
multiple somatic complaints (or
one very severe somatic
symptom).
 ILLNESS ANXIETY DISORDER
Diagnostic Criteria
A. Preoccupation with having or acquiring
a serious illness.
B. Somatic symptoms are not present or, if
present, are only mild in intensity. If
another medical condition is present or
there is a high risk for developing a
medical condition (e.g., strong family
history is present), the preoccupation is
clearly excessive or disproportionate.
C. There is a high level of anxiety about
health, and the individual is easily alarmed
about personal health status.
 D. The individual performs excessive
health-related behaviors (e.g., repeatedly
checks his or her body for signs of illness)
or exhibits maladaptive avoidance (e.g.,
avoids doctor appointments and hospitals).
E. Illness preoccupation has been present
for at least 6 months, but the specific
illness that is feared may change over that
period of time.
F. The illness-related preoccupation is not
better explained by another mental
disorder, such as somatic symptom
disorder, panic disorder, generalized
anxiety disorder, body dysmorphic
disorder, obsessive-compulsive disorder,
or delusional disorder, somatic type.
Specify whether:
o Care-seeking type: Medical care,
including physician visits or
undergoing tests and procedures,
is frequently used.
o Care-avoidant type: Medical
care is rarely used.
 CONVERSION DISORDER
FUNCTIONAL NEUROLOGICAL
SYMPTOM DISORDER
Diagnostic Criteria
A. One or more symptoms of altered
voluntary motor or sensory function.
B. Clinical findings provide evidence of
incompatibility between the symptom and
recognized neurological or medical
conditions.
C. The symptom or deficit is not better
explained by another medical or mental
disorder.
D. The symptom or deficit causes
clinically significant distress or
impairment in social, occupational, or
other important areas of functioning or
warrants medical evaluation.
 FACTITIOUS DISORDER
Diagnostic Criteria
Factitious Disorder Imposed on Self
A. Falsification of physical or
psychological signs or symptoms, or
induction of injury or disease, associated
with identified deception.
B. The individual presents himself or
herself to others as ill, impaired, or
injured.
C. The deceptive behavior is evident even
in the absence of obvious external
rewards.
D. The behavior is not better explained by
another mental disorder, such as
delusional disorder or another psychotic
disorder.
Factitious Disorder Imposed on Another
(Previously Factitious Disorder by
Proxy)
A. Falsification of physical or
psychological signs or symptoms, or
induction of injury or disease, in another,
associated with identified deception.
B. The individual presents another
individual (victim) to others as ill,
impaired, or injured.
C. The deceptive behavior is evident even
in the absence of obvious external
rewards.
D. The behavior is not better explained by
another mental disorder, such as
delusional disorder or another psychotic
disorder.
 Note: The perpetrator, not the victim,
receives this diagnosis.
 CAUSAL FACTORS
Biological Factors
Genetic factors only modestly contribute
to these disorders, according to twin and
family studies. Environment plays a much
greater role. However, biological
vulnerabilities, such as lower pain
thresholds, heightened sensitivity to pain,
and greater sensitivity to somatic cues, are
suspected of playing a key role in the
development of somatic symptoms and
health anxiety.
A biological predisposition, hardwired
into the central nervous system, can result
in
o hypervigilance or exaggerated
focus on bodily sensation,
o increased sensitivity to even mild
bodily changes, and
o a tendency to react to somatic
sensations with alarm
It is also possible that repetitive activation
of the sympathetic nervous system due to
chronic exposure to stressors can lead to
increased sensitivity of the nerves
associated with pain and subsequent
increases in pain sensation.
Studies have also suggested that
conversion disorder may result from
abnormal actions of inhibitory neural
systems.
o Example: Bryan and Das (2012)
compared MRI scans of a patient
with conversion disorder
(involving an inability to speak)
before and after successful
psychotherapy. Before treatment,
there was evidence of impaired
connectivity in the speech
network; this abnormality was no
longer evident after treatment
o Reference: Bryant, R. A., & Das,
P. (2012). The neural circuitry of
conversion disorder and its
recovery. Journal of Abnormal
Psychology, 121, 289–296.
In contrast, individuals with SSD with
predominant pain show increased
excitability between areas of the brain
related to emotional behaviors. Can brain
reactivity involving brain regions
associated with pain be reduced or
inhibited?
o Some studies have found that
those with chronic pain
conditions had reduced cerebral
gray matter in the prefrontal areas
of the brain and increases in gray
matter increased cognitive control
over pain, reducing the perception
of pain.
Psychological Factors
Psychodynamic Perspective
In psychodynamic theory, somatic
symptoms defend against the awareness of
unconscious emotional issues.
o Freud believed that hysterical
reactions (biological complaints
of pain, illness, or loss of physical
function) were caused by the
repression of some type of
conflict, usually sexual in nature.
To protect the individual from
intense anxiety, this conflict is
converted into a physical
symptom.
o The psychodynamic view
suggests that two mechanisms
 produce and then sustain somatic
symptoms.
o The first provides a primary gain
for the person by protecting him
or her from the anxiety associated
with the unacceptable desire or
conflict; the need for protection
gives rise to the physical
symptoms.
o This focus on the body keeps the
person from becoming aware of
the underlying conflict.
o Then a secondary gain accrues
when the person’s dependency
needs are fulfilled through
attention and sympathy.
o Example: Some patients with
conversion symptoms all relied
on family members and friends to
complete domestic tasks and were
receiving disability allowances.
Cognitive-Behavioral Perspectives
Some contend that people with SSD,
conversion disorder, and factitious
disorders assume the “sick role” because it
is reinforcing and because it allows them
to escape unpleasant circumstances or to
avoid responsibilities.
o Example: Men with supportive
wives (attentive to pain cues)
reported significantly greater pain
when their wives were present
than when their wives were
absent.
Catastrophic misinterpretations of bodily
sensations or changes in bodily functions
might be important in the etiology of SSD
and illness anxiety disorder.
o Health anxiety arises because
symptoms are interpreted as being
very serious or due to
catastrophic conditions that could
result in disability or death.
o Individuals’ preoccupation with
disease and inordinately high
anxiety levels are fueled by
intrusive imagery such as
“visualizing that the doctor tells
me that I have cancer” or “I’m
lying on my death bed with my
children and partner crying”
o According to this perspective,
catastrophic cognitions related to
somatic symptoms are more
likely to develop in individuals
who are biologically or
psychologically predisposed to
having these thoughts—people
who have somatic sensitivity, a
low pain threshold, a history of
illness, or who or have received
parental attention for somatic
symptoms. It is hypothesized that
distressing cognitions develop in
the following manner:
o External triggers (traumatic or
anxiety-evoking stressors) or
internal triggers (anxiety-
producing thoughts such as “My
father died of cancer at age 47”)
result in physiological arousal.
o The individual perceives bodily
changes associated with these
triggers such as increased heart
rate or respiration.
o Thoughts and worries about
possible disease begin in response
to these physical sensations.
o These thoughts amplify bodily
sensations, causing further
physical reactions and concern.
o Catastrophic thoughts increase in
response to the magnified bodily
sensations, creating a circular
feedback pattern.
o Consistent with this perspective,
individuals with SSD tend to
misinterpret and overestimate the
dangerousness of bodily
symptoms.
o Example: Some individuals with
SSD involving chest pain in the
absence of cardiac pathology
were highly attuned to cardiac-
related symptoms and exhibited
anxiety reactions in response to
heart palpitations and chest
discomfort. Similarly, individuals
with health anxiety interpreted
 nine common bodily sensations as
indications of disease.
Social Factors
o Some individuals with SSD report
being rejected or abused by
family members and feeling
unloved.
o Some individuals may seek out
contact with medical staff as a
source of attention or comfort
because of social isolation or an
inability to connect with family or
friends.
o The development of illness or
injury sensitivity appears to be
closely linked with parental
characteristics such as being
preoccupied with or overly
attentive to somatic complaints
expressed by their children.
o Additionally, individuals with
SSD frequently have parents or
family members with chronic
physical illnesses or high health
anxiety.
Sociocultural Factors
o Cultural factors can influence the
frequency, expression, and
interpretation of somatic
complaints. Risk factors
associated with SSD and related
disorders include lower
educational levels, ethnicity, and
immigrant status.
o Differences such as those just
described may reflect different
cultural views of the relationship
between mind and body.
o The dominant view in Western
culture is the psychosomatic
perspective—that psychological
conflicts are sometimes expressed
via physical symptoms. But many
other cultures have a social network and adaptive coping skills.
somatopsychic perspective—that
physical problems produce
psychological and emotional
symptoms. Although many of us
believe that our psychosomatic
view is the correct one, the
somatopsychic view is the
dominant perspective in most
cultures.
 TREATMENT
Biological Treatment
Antidepressant medications such as
selective serotonin reuptake inhibitors are
sometimes used to treat SSD and illness
anxiety disorder.
Psychological Treatments
Treatment for SSD and related disorders
focuses primarily on understanding the
client’s view of his or her problem.
Individuals with somatic symptom, illness
anxiety, and conversion disorders are
often frustrated, disappointed, and angry
following years of encounters with the
medical profession. They believe that
treatment strategies have been ineffective
and resent the implication that they are
“fakers” or “problem patients”.
A newer approach to treating SSD and
illness anxiety disorder involves
demonstrating empathy regarding the
physical complaints, accepting them as
genuine, and providing information about
symptoms that are often stress-related
such as hypertension and headaches.
In another approach, SSD is viewed
within a social context—somatic
complaints are seen as reflecting
unsatisfying or inadequate social
relationships. Individuals who assume a
“sick role” often control others through
bodily complaints or receive some
reinforcement, such as escape from
responsibility. Therapy is directed toward
developing and improving the individual’s
Because many patients with somatic
symptom and health anxiety disorders
appear to have cognitive distortions, such
as a conviction that they are especially
vulnerable to disease, cognitive-behavioral
 approaches focused on correcting these
misinterpretations are successful.
Because individuals with SSD often show
a fear of internal bodily sensations,
cognitive-behavioral therapists include
interoceptive exposure (exposure to bodily
sensations) during treatment. Therapists
ask clients to perform activities that
typically trigger anxiety symptoms, such
as breathing through a straw,
hyperventilating, spinning, or climbing
stairs, until feared reactions such as light-
headedness, chest discomfort, or increased
heart rate occur. The activities are
repeated until the bodily sensations no
longer elicit anxiety or fear.
Relaxation training can also effectively
reduce the sympathetic nervous system
activity found in individuals with somatic
symptoms. Mindfulness-based cognitive
therapy is another approach that can lower
anxiety. Clients learn to experience and
observe their problematic thoughts and
symptoms without judgment or emotion,
and without reacting to them. Instead of
responding with fear and anxiety, the
individual merely observes and reflects on
thoughts and physical reactions. This
process weakens the connection between
emotional arousal and the symptoms and
thoughts.
 DISSOCIATIVE IDENTITY
DISORDER
Diagnostic Criteria
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 in identity involves 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.
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).
 DISSOCIATIVE AMNESIA
Diagnostic Criteria
A. An inability to recall important
autobiographical 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 of 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.
 DEPERSONALIZATION/
DEREALIZATION DISORDER
Diagnostic Criteria
A. The presence of persistent or recurrent
experiences of depersonalization,
derealization, or both:
1. 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).
2. Derealization: Experiences of
unreality or detachment with
respect to 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
another 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.
 CAUSAL FACTORS
Biological Factors
Biological explanations for dissociative
disorders have focused on disruptions in
encoding of memories due to acute stress
and the inability to retrieve
autobiographical material because of the
release of hormones such as
glucocorticoid, which may impede the
recall of traumatic events.
In dissociative amnesia, MRI scans show
inhibited neural activity in the
hippocampus apparently associated with
memory repression, and positron emission
tomography (PET) scans show reduced
metabolism in an area of the prefrontal
cortex that is involved in the retrieval of
autobiographical memories.
Switching between personalities is
associated with activation or inhibition of
certain brain regions, particularly the
hippocampus, an area involved in
memories and hypothesized to be involved
in the generation of dissociative states and
amnesia.
However, these patterns of brain activity
are difficult to interpret because it is
unclear what causes them and what
specific role they play, if any, in
dissociative disorders.
Chronic activation of stress responses due
to childhood trauma can result in
permanent structural changes in the brain.
Reduced volume in the hippocampus and
amygdala may hamper the ability of the
brain to encode, store, and retrieve
memory; comprehend contradictory
information; and integrate emotional
memories. Such alterations may play an
etiological role in dissociative amnesia,
DID, and depersonalization.
Psychological Factors
Psychodynamic Theory
o Dissociative disorders are caused
by an individual’s use of
repression to block unpleasant or
traumatic events from
consciousness. This process
protects the individual from
painful memories or conflicts.
o In dissociative amnesia and
fugue, for example, memories of
specific events or large parts of
the individual’s personal identity
are no longer available to
conscious awareness.
o Dissociation is carried to an
extreme in DID.
o Here, the splits in mental
processes become so persistent
that independent identities are
formed, each with a unique set of
memories.
o Contemporary psychodynamic
theorists propose a post-traumatic
model of DID that focuses on the
role of severe childhood abuse,
parental neglect or abandonment,
or other early traumatic events.
According to this model, the
factors necessary for the
development of DID include:
o being exposed to overwhelming
childhood stress, such as
traumatic physical or sexual
abuse;
o genetic or biological
predispositions, psychiatric
vulnerabilities, life stressors, and
having the capacity to dissociate;
o encapsulating or walling off the
experience; and
o developing different memory
systems.
o According to the post-traumatic
model, the split in personality
develops because of traumatic
early experiences combined with
an inability to escape them. If a
supportive environment is not
available or if the personality is
not resilient, these factors can
result in DID.
o In the case of Sybil, who was
severely abused by her mother,
Dr. Wilbur—Sybil’s psychiatrist
—speculated that Sybil escaped
“an intolerable and dangerous
reality” by dividing into different
personalities.
o Consistent with this perspective,
most individuals diagnosed with
DID do report a history of
physical or sexual abuse during
childhood. In fact, individuals
with DID have the highest rate of
childhood psychological trauma
compared to people with other
psychiatric disorders.
o To develop DID, the individual
must have the capacity to
dissociate—or separate—certain
memories or mental processes in
response to traumatic events.
o The post-traumatic model
presupposes exposure to
childhood trauma.
o In most studies, information on
child abuse is based on self-
reports, is not independently
corroborated, and involves
varying definitions and degrees of
abuse.
Social and Sociocultural Factors
Sociocognitive model of DID
 o Individuals with the disorder
learn about DID and its
characteristics through the mass
media and, under certain
circumstances, begin to act out
these roles.
o Vulnerable individuals may
demonstrate these behaviors
when therapists inadvertently use
questions or techniques that
evoke dissociative types of
problem descriptions by clients.
Proponents of the sociocognitive
model cite the large increase in
DID cases after mass media
portrayals of this disorder as
support for their perspective.
o Therapists are also exposed to
mass media portrayals of DID
and may unconsciously
encourage reports of DID from
clients. This would be referred to
as an iatrogenic disorder—a
condition unintentionally
produced by a therapist through
mechanisms such as selective
attention, suggestion,
reinforcement, and expectations
that are placed on the client.
o Although iatrogenic influences
can occur in any disorder, such
effects may be more common
with dissociative disorders,
because of the high levels of
hypnotizability and suggestibility
found in individuals with these
conditions.
 TREATMENT
Treating Dissociative Amnesia and
Dissociative Fugue
It has been noted that depression is often
associated with the fugue state and that
severe stress is associated with both
dissociative amnesia and fugue. A
reasonable therapeutic approach is to treat
these dissociative disorders indirectly by
alleviating the depression and the stress
that may underlie dissociative symptoms
with antidepressants, cognitive-behavioral
therapy, and stress management
techniques.
Treating
Depersonalization/Derealization
Disorder
Various antidepressants and antianxiety
medications may be prescribed to treat
these symptoms. Because catastrophic
attributions and appraisals sometimes play
a role in the development of
depersonalization/derealization symptoms,
some therapists focus on “normalizing”
minor dissociative reactions and thoughts
in response to stressful situations.
Mindfulness techniques in which the
individual focuses on the breathing
process itself while nonjudgmentally
observing dissociative sensations can help
reduce the fear and anxiety associated
with depersonalization/derealization
symptoms.
Behavioral techniques are occasionally
used to treat
depersonalization/derealization disorder.
Treating Dissociative Identity
Disorder
Trauma-focused therapy is used to help
the individual develop healthier ways of
dealing with stressors. Trauma-focused
therapy for DID also helps the different
identities or alters become aware of one
another, consider each as legitimate parts
of the individual, and resolve their
differences. Each of the personalities is
validated for helping the main personality
cope with stressors and traumatic events.
The desired outcome is an integration or
harmony among the different alters and a
final fusion of the personality states. In
other words, the goal is for the alters to be
completely integrated, merged, and
assimilated into one personality.