Chapter 21 Somatoform and dissociative disorders
Introduction
The disorders discussed in this chapter are the somatoform disorders and dissociative disorders. In both groups of disorders, sufferers present complaining of physical symptoms, although no medical condition is found to exist. All these disorders as well as the anxiety disorders, phobias, compulsions and obsessions (see Ch 18) and disorders of sexual functioning were once classified as ‘neurotic reactions’ or ‘neurotic disorders’. The term neurosis is not used in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV and later editions, but is mainly of historical interest and can be found in a number of seminal texts on psychiatry. The concept of neurosis was developed in 1769 by William Cullen from Edinburgh University, who believed that madness was the result of excessive irritation of the nerves (Porter 2002) and used the term to refer to nervous system disease. Since the time of Freud its meaning has changed to refer to a non-psychotic disorder characterised mainly by anxiety. The disorders that fall under the label of neurosis are ego-dystonic—that is, the symptoms are experienced as distressing to the individual.
Somatoform disorders
The somatoform disorders (see Box 21.1) are a heterogeneous group of disorders whose distinguishing characteristic is the presence of physical symptoms in the absence of a readily apparent medical condition. In order for the patient to be diagnosed as suffering from a somatoform disorder, the symptoms cannot be fully accounted for by a physical disease or another psychiatric disorder, or the effects of drugs or medication. There is usually no evidence of injury. However, these disorders are often confused with actual physical disorders and the client suffering from them truly believes they are physically ill. The symptoms cause the afflicted person significant distress and can interfere with their normal functioning. Although no medical condition exists, hospitalisation can occur, and numerous diagnostic tests and even surgery are performed (Clarke & Smith 2001). These disorders well illustrate how ‘suffering and illness are only indirectly related to the presence or absence of disease’ (Epstein, Quill & McWhinney 1999, p 221).
Box 21.1 The somatoform disorders
Undifferentiated somatoform disorder
Somatoform disorder not otherwise specified
Source: adapted from APA, DSM-IV-TR 2000.
The symptoms that accompany the disorders are referred to as either somatisation or, more commonly now, medically unexplained symptoms (MUS). In general health settings they are referred to as functional, which means they have no organic basis. The syndromes (see Box 21.2) derived from the symptoms tend to be chronic, although the common symptoms that characterise them are highly prevalent in the population at large (see Box 21.3). In the various syndromes, the symptoms tend to accrue over time rather than clustering simultaneously (Escobar 1996).
Box 21.2 Somatic syndromes arranged by medical specialty
Source: adapted from Escobar, Hoyos-Nervi & Gara 2002 and Wessely, Nimnuan & Sharpe 1999.
The word somatoform, which means ‘having bodily form’, has both Greek and Latin roots (Escobar, Hoyos-Nervi & Gara 2002). Soma is the Greek word for ‘body’, while form derives from the Latin forma meaning ‘form’ or ‘shape’. The word is intended to convey the idea that a psychiatric disorder or psychological problem can appear in the guise of somatic symptoms. This idea that a disease can take bodily form but actually reside in the mind derives, philosophically, from Western medicine’s foundation in Cartesian dualism, which assumes a division between mind and body (Kirmayer 1996). This framework also assumes that symptoms are psychological and/or physical defects that reside within the patient, and the possibility that they may be situationally caused is not generally entertained. This division of mental disorders into either physical or emotional means that it is very common for clients with a somatoform disorder to be diagnosed with a comorbid anxiety and/or mood disorder. For example, somatisation disorder commonly coexists with anxiety disorders (34%), depression (55%), personality disorders (61%) and panic disorders (26%) (Bass & Tyrer 2000; Clarke & Smith 2001; Holloway & Zerbe 2000; Kipen & Fiedler 2002). Hypochondriasis often occurs in conjunction with panic disorder (Hardy, Warmbrodt & Chrisman 2001). Mood, anxiety and personality disorders are common in clients with body dysmorphic disorder (Veale et al 1996). Castillo (1997, p 190) argues that the diagnostic practice of distinguishing between physical and mental disorders is an outcome of a disease-centred paradigm ‘which assumes that each symptom cluster has a separate biological cause that can best be treated with separate medications’.
Unlike many of the other major psychiatric disorders, the somatoform group are not linked by shared aetiologies, family histories or other factors, but through their manifestation as an organic problem (Morrison 1995). Although the DSM-IV-TR (American Psychiatric Association (APA) 2000) classifies the somatoform disorders separately from the anxiety disorders, clients with a somatoform disorder are also, as noted above, often anxious or depressed (Clarke & Smith 2001). Clinically, therefore, the disorders can be very hard to distinguish from one another. At one time all the somatoform disorders fell under the heading of ‘hysteria’ (Kirmayer & Robbins 1991, cited in McWhinney, Epstein & Freeman 1997) (see Ch 3 for a discussion of the origins of the term hysteria). Throughout the eighteenth century hysteria was generally believed to be a malady that affected mainly women (Shorter 1994). During the second half of the nineteenth century, hysteria was one of the most commonly diagnosed mental disorders (Castillo 1997).
In the DSM-IV-TR (APA 2000), somatisation disorder is the somatoform disorder that most closely resembles nineteenth-century hysteria, and conversion disorder runs a close second. However, the modern disorders are much more somatically focused. The original conception of hysteria allowed for the presence of emotional symptoms. Not only did it encompass the common somatic symptoms of paralyses and anaesthesias, generalised aches and pains, and visual disturbances, but it was also characterised by anxiety and panic, depressive and dissociative symptoms, and perceptual disturbances such as hallucinations.
The somatoform disorders, and somatisation disorder in particular, need to be distinguished from somatisation as a process which nearly everyone engages in from time to time. This process is the topic of the next section.
The process of somatisation
Somatisation was first introduced into the lexicon of psychiatry by the German psychoanalyst Wilhelm Stekel in the early 1900s (Lipsitt 2001). He used the term to refer to symptoms similar to those of conversion disorder. Over time it has come to characterise the psychological process whereby anxiety or psychological conflict is translated into physical complaints, although no mechanism has been found. These complaints might be pain, such as a headache, or reflect a concern with bodily functions such as elimination.
Somatisation is extremely common, so common in fact as to be a part of normal experience (Singh 1998). Cross-cultural studies indicate that somatisation is the most common means of expressing anxiety (Kirmayer 1984, cited in Castillo 1997). Somatic symptoms are experienced by 80% of people in any one week (Merskey 2000). For many people, somatisation is a form of coping and is one of the characteristic responses of people who have suffered trauma (Punamaki et al 2002). Somatoform symptoms are also common in refugees who have experienced severe trauma either in their countries of origin or during or after their flight (Waitzkin & Magaña 1997). From a cross-cultural perspective also, there appears to be little reason for distinguishing among anxiety, somatoform and mood disorders (Castillo 1998). In many cultures, illness is experienced holistically and no distinction is made between mental and physical illnesses. Finally, the expression of emotions in the form of bodily symptoms can occur when it is either difficult to put the feelings into words or when there are not the words with which to express psychological and emotional states (Singh 1998).
Epidemiology
It has generally been thought that the somatoform disorders were relatively rare in the community as a whole. This belief was largely based on a US survey, the Epidemiological Catchment Area (ECA) Study, which found the lifetime prevalence of somatisation disorder to be about 0.13% (Singh 1998). However, a recent study by Baumeister & Härter (2007) suggests that at a 12-month prevalence rate of 11% in the general population, they occur frequently, and are the third-highest occurring disorders. Women outnumber men at a 5:1 ratio and the lifetime prevalence rate among women is 1–2% (Sadock & Sadock 2005). Precise figures are not available for the incidence and prevalence of any of the somatoform disorders in Australia and New Zealand, but in an Italian community sample, body dysmorphic disorder (BDD) was found to have a oneyear prevalence of 0.7% (Otto et al 2001) and a point prevalence of 0.7% in a community sample of women aged 36–44 years (Otto et al 2001). In a sample of female Turkish students, 4.8% were diagnosed with BDD (Cansever et al 2003).
The somatoform disorders are usually encountered in primary healthcare settings, rarely psychiatric ones, which may go some way to explaining why they appear to have been of little interest to mental health nurses. In primary care settings no medical explanation can be given for the symptoms of about a third of clients (Escobar et al 2002), which is not to say that all these clients have a somatoform disorder, rather that unexplained somatic symptoms are exceedingly common. Between 5% and 9% of primary care patients exhibit hypochondriacal symptoms (Hardy et al 2001).
The somatoform disorders can also assume great importance in certain clinical settings. For example, it has been estimated that as many as 50% of patients presenting with gastrointestinal symptoms have a functional disorder (Ringel & Drossman 1999). In the United Kingdom as many as 4% of people attending neurology clinics suffer from a conversion disorder (Perkin 1989, cited in Halligan et al 2000). In the United States, 12% of patients in dermatologic settings and 15% seeking cosmetic surgery were found to have BDD (Phillips et al 2001).
Most of the somatoform disorders are more common in women than men (Sadock & Sadock 2005), although hypochondriasis and BDD are roughly equally distributed between the sexes (Phillips & Castle 2001). This distribution, for somatisation disorder at least, might be an artefact of the diagnostic criteria. Kihlstrom & Kihlstrom (2001) argue that DSM-IV effectively redefined somatisation as a female disorder by requiring that there be one sexual or reproductive symptom. Somatisation disorder and conversion disorder tend to be more common among the less educated and those on low incomes (Singh 1998), although it has not always been so (Shorter 1994). In the late nineteenth century, Morel, a French psychiatrist, and in the early twentieth century, Thomas Saville, a London neurologist, found hysteria and hypochondria to be equally distributed among the rich and the poor (Shorter 1994).
Somatisation disorder and BDD usually begin in adolescence (Patterson et al 2001). Conversion disorder usually appears first in adolescence or early adulthood, but might occur at any time.
Aetiology
The causes of the somatoform disorders are unknown. However, somatisation has been recognised since the ancient Egyptians (Sadock & Sadock 2003), and BDD has been recognised for centuries. References to it can be found in Greek mythology, and European, Russian and Japanese literature (Biby 1998). Theories about their possible origins can be divided roughly into two: those that consider the disorders to originate in organic structures and processes (neurogenesis) and those that believe they originate in mental phenomena (psychogenesis) (Shorter 1994). The latter position reached its apotheosis in psychoanalytic doctrine in the first half of the twentieth century, but can be traced to the seventeenth-century physician Thomas Sydenham, who believed somatisation to be a disease of the mind (Sharpe & Carson 2001). The former position is much older, but was out of favour while psychoanalytic doc trine was dominant. The term hysteria itself, by focusing on a particular bodily function, namely the uterus, suggested a belief in its organic basis. However, Thomas Willis, a seventeenth-century neurologist, believed the symptoms derived from the head (Sharpe & Carson 2001). Briquet, a nineteenth-century French physician, was convinced that hysteria had a genetic component (Shorter 1994). He was among the first to believe that patients inherited psychosomatic illnesses. Pierre Janet (1903) also thought that the condition he termed psychasthenia was biological in origin (Shorter 1994).
Psychoanalysis
Psychodynamic theory explains somatisation as an outcome of early life experiences and as a defence against psychological conflict (see Ch 8). Emotions are expressed physically when they cannot be expressed verbally through either guilt or fear (Hardy et al 2001).
Amplification
Amplification theory proposes that in some people, normal bodily sensations are amplified or heightened. Some people simply may be hypersensitive to normal bodily stimuli and attribute pathological meaning to normal somatic sensations and functions (Hardy et al 2001). Others, however, may become susceptible to media influence, public health campaigns or simple word of mouth, so symptoms that were previously ignored or dismissed are brought into awareness and assume new meaning (Barsky & Borus 1999).
Interpersonal theory
Interpersonal theory has been used as an explanation for hypochondriasis. This theory suggests that children with hypochondriasis model their behaviour on the responses to pain and illness they have observed in another family member or other adults who are ill. From an interpersonal perspective, the antecedents of hypochondriasis are believed to be found in childhood adversity where early attachments have been marked by insecurity, which, in turn, produces persistent separation anxiety (Noyes Jr et al 2002).
Developmental theory
Developmental theory suggests that translating psychological distress into physical symptoms is a learned response. The child may not have learnt adequate verbal and cognitive skills to express their psychological distress (Kirmayer & Looper 2006). Parents may also model somatic behaviour, thus teaching it to their children.
Personality
Personality factors appear to be important in the genesis of the somatoform disorders. For example, the personality characteristics of anxiousness and fearfulness are commonly associated with these disorders (Bass & Tyrer 2000). Furthermore, high numbers of clients with anxiety disorders or major depression suffer from the somatoform disorders.
Biological theories
There is as yet no strong evidence for any biological basis for the somatoform disorders, although a number of interesting hypotheses are being pursued. Sharpe & Carson (2001) suggest that new evidence supports the idea that the functional disorders are disturbances of the nervous system.
Behavioural theory
Both respondent and operant conditioning have been used to explain the somatoform disorders (Tazaki & Landlaw 2006). In respondent conditioning, if a client experienced a traumatic event (unconditioned stimulus) which led to their experiencing negative emotions such as fear or anger and these negative emotions were accompanied by physiological changes such as tachycardia and hyperventilation (conditioned response), then the future experience of the emotions alone may lead to the physiological changes. In operant conditioning, clients with a somatoform disorder may have experienced positive consequences of their complaints of physical symptoms, such as attention and sympathy; or, through their complaints they may have avoided unpleasant consequences. Either experience could result in a conditioned response.
Familial factors
Body dysmorphic disorder has been found to be four times as prevalent in those who have first-degree relatives with the condition. For hypochondriasis, studies have indicated high rates of concordance for twins (Hardy et al 2001).
Culture
According to Shorter (1994), culture is important in shaping illness. In this theory, culture shapes illness behaviour by conferring legitimacy and, hence, respectability, to certain forms of behaviour. In Western cultures greater legitimacy is accorded somatic complaints, and both patients and doctors act to interpret symptoms as indicative of bodily, rather than psychological, processes.
Assessment
The first step in assessment is taking a comprehensive history. The point to keep in mind here is that it is the client’s concerns that are paramount, rather than the health professional’s need to diagnose. Fischhoff & Wessely (2003, pp 595–6) provide some questions that can help focus on the areas of concern to the client, rather than the health professional:
Clients with multiple somatic complaints are also likely to be severely functionally impaired (Hiller, Rief & Fichter 1997), so enquiries should be made about their activities of daily living, and their occupational and social functioning.
Somatisation disorder
Somatisation disorder is characterised predominantly by multiple physical complaints, and usually runs a chronic course (Bass & Tyrer 2000; Escobar et al 2002). People with unexplained somatic symptoms have usually sought medical treatment many times over many years (Maynard 2003). The symptoms they present with tend to be multiple and recurring. They will often present in a dramatic way, providing vivid descriptions of the effect of the symptoms on their lives, but are vague about the details of the symptoms themselves. The most common symptoms clients complain about are listed in Box 21.4.
Clients are often described as appearing anxious and/or angry. The distress clients experience should be treated as real, as should the experience of the symptoms. They are not lying or imagining their symptoms. The client should be asked what they think has caused the symptoms, how the symptoms interfere with their everyday activities and how they handle them. Examples of helpful questions the nurse could ask the client are listed in Box 21.5.
Communication is often impaired because there are sometimes gaps in the client’s history, and they are often inclined to over-dramatise, to make false generalisations about what is happening to them from limited evidence, and to oversimplify. They are also said to be very demanding of health professionals’ time and attention, because despite the numerous negative tests they will not be reassured that there is nothing physically wrong with them. They may also express feelings of helplessness in the face of perceived failures on the part of health professionals to cure them and at the same time will usually refuse to see a psychiatrist or will sim ply ignore the referral. In contrast to clients with other chronic disorders, such as rheumatoid arthritis or diabetes, Holloway & Zerbe (2000) report that clients with somatisation disorder tend to be passive with respect to finding a cure.
Most physicians (see, for example, Singh 1998 and Barsky & Borus 1999) advocate ruling out a physical cause for the client’s complaints before contemplating the possibility of a psychological cause for the symptoms. However, Epstein et al (1999) argue that such a strategy simply prioritises organic disease, and perpetuates the idea that there is a division between mental and physical phenomena.
Hypochondriasis
People with hypochondriasis are intensely preoccupied with their bodily functions and report a wide range of symptoms. Whereas the client with somatisation disorder is focused on the symptoms, the hypochondriacal client is focused on what the symptoms might signify (Singh 1998). They often misinterpret ordinary bodily functions such as gastric noises and sensations, or are intensely aware of their heartbeats and breathing and attribute them to a serious physical illness. They either fear or are convinced they have a serious illness, despite medical assurances to the contrary. While a type of somatoform disorder, hypochondriasis is also a frequent symptom in many mental illnesses. Although most people with hypochondriasis fear a physical illness, a very small number fear insanity. The symptoms experienced are not imaginary or simply ‘all in their mind’.
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