Somatoform, Dissociative, and Related Disorders 1

Chapter 8:Somatoform, Dissociative,

and Related Disorders
So it is that a patient can confront his doctor with his
symptoms, and put on him the whole onus of their cure.
Mayer-Gross, Slater, and Roth, Clinical Psychiatry

Somatoform disorders are an important group of conditions characterized

by unexplained physical symptoms. Patients with these disorders behave
as though ill (e.g., report symptoms, visit doctors, take medications, claim
disability), yet are without organic disease. Consequently, they baffle and
frustrate physicians. These disorders are common; 30% of primary care
patients present with unexplained symptoms, and a substantial proportion
of these have somatoform disorders. Because they do not respond to
medical reassurance, they continue to seek care, demanding tests,
procedures, and medications that are unwarranted. Most see primary care
physicians, not psychiatrists, and resist the idea that their condition is
psychiatric.

TABLE 8-1. DSM-IV-TR somatoform disorders

Somatization disorder
Conversion disorder
Hypochondriasis
Pain disorder
With psychological factors
With both psychological factors and a general medical
condition Body dysmorphic disorder Undifferentiated
somatoform disorder Somatoform disorder not otherwise
specified

Seven somatoform disorders are listed in DSM-IV-TR (see Table 8-1), and
all share the common feature of excessive concern with bodily symptoms
that are unexplained by physical or laboratory findings.
They include somatization disorder, conversion disorder, hypochondriasis, pain
disorder, and body dysmorphic disorder. The categories undifferentiated somatoform
disorder and somatoform disorder not otherwise specified are reserved for patients who
have somatic symptoms but do not meet criteria for one of the more specific
2 INTRODUCTORY TEXTBOOK OF PSYCHIATRY

disorders. Dissociative disorders, factitious disorders, and malingering are also

discussed in this chapter.

Somatoform Disorders

Somatization Disorder
Somatization disorder begins early in life affects mostly women and is
characterized by multiple somatic symptoms that are medically
unexplained. The physical complaints involve most organ systems and
are often presented dramatically. To receive the diagnosis, patients must
have at least eight unexplained symptoms, including four pain, two
gastrointestinal, one sexual, and one pseudoneurological symptom (see
Table 8-2). For the symptoms to meet the criteria, they cannot be fully
explained by a general medical condition, and the distress or impairment
must be greater than would be expected from the history, physical
examination, or laboratory findings. In making the diagnosis, it is useful
to have old medical records available and to interview the patient on
more than one occasion. Because these patients medical histories are often
extensive and because they are not always reliable historians, clinical
assessment may take extra time.
The frequency of common symptoms in somatization disorder is
summarized in Table 8-3, and complaints from a typical patient are
presented in Table 8-4.
Although a simple count of symptoms appears arbitrary, research has
shown that this approach identifies a homogeneous group of patients
who have a predictable course and outcome. The following case from our
hospital illustrates the variety and stability of symptoms found in
somatization disorder. The case also illustrates how these patients receive
inappropriate diagnoses and unnecessary evaluations by physicians
unfamiliar with the disorder.
Somatoform, Dissociative, and Related Disorders 3
 4 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
TABLE 8-2. DSM-IV-TR diagnostic criteria for somatization^disorder
A. A history of many physical complaints beginning tjefore age 3Q3^krs that occur over a
period of^eVeral yearsju)d result in treatment being sought or significant 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 the disturbance:
(1) four pain symptoms: a history of pain related to at least four different sites or functions
(e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during
sexual intercourse, or during urination)
(2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other
than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or
intolerance of several different foods)
(3) one sexual symptom: a history of at least one sexual or reproductive symptom other than
pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses,
excessive menstrual bleeding, vomiting throughout pregnancy)
(4) one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a
neurological condition not limited to pain (conversion symptoms such as impaired
coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in
throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double
vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of
consciousness other than fainting)
C. Either (1) or (2):
(1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully
explained by a known general medical condition or the direct effects of a substance (e.g., a
drug of abuse, a medication)
(2) when there is a related general medical condition, the physical complaints or resulting
social or occupational impairment are in excess of what would be expected from the
history, physical examination, or lakosatmy findings—
D. The symptoms are not intentionally produce or feigned (as in Factitious Disorder or
Malingering).
 Somatoform, Dissociative, and Related Disorders 5

TABLE 8-3. Common symptoms in somatization disorder

Symptom % Symptom %

Nervousness 92 Sexual indifference 44

Back pain 88 Dysuria 44
Weakness 84 Aphonia 44
joint pain 84 Other bodily pains 36
Dizziness 84 Vomiting 32
Extremity pain 84 Anesthesia 32
Fatigue 84 Thoughts of suicide 28
Abdominal pain 80 Burning pains in rectum,
Nausea vagina, mouth 28
80
Lump in throat 28
Headache 80
72 Feel life is hopeless 28
Dyspnea
Weight loss 28
Trouble doing anything
because of feeling bad 72 Anorgasmia 24
Chest pain 72 Diarrhea 20

Abdominal bloating 68 Vomiting all 9 months of

Constipation 64 pregnancy 20
Blindness 20
Anxiety attacks 64
Fits or convulsions 20
Depressed feeling 64
64 Fluctuations in weight 16
Visual blurring
Unconsciousness 16
Anorexia 60
Paralysis 12
Palpitations 60
Visual hallucinations 12
Fainting 56
52 Attempted suicide 12
Dyspareunia
Amnesia 8
Menstrual irregularity 48
Food intolerance 48 Urinary retention 8
Excessive menstrual bleeding 48 Dysmenorrhea
(prepregnancy only) 8
Dysmenorrhea (premarital only) 4

Source. Adapted from Perley and Guze 1962.

 6 INTRODUCTORY TEXTBOOK OF PSYCHIATRY

TABLE 8-4. Complaints from a patient with somatization disorder

Organ system Complaint

Neuropsychiatric "The two hemispheres of my brain aren't working
properly." "I couldn't name familiar objects around the
house when asked." "I was hospitalized with tingling and
numbness all over, and the doctors didn't know why."

Cardiopulmonary "I had extreme dizziness after climbing stairs." "It hurts to
breathe." "My heart was racing and pounding and
thumping....I thought I was going to die."

Gastrointestinal "For 10 years I was treated for nervous stomach, spastic

colon, and gallbladder, and nothing the doctor did
seemed to help." "I got a violent cramp after eating an
apple and felt terrible'the next day." "The gas was awful—
I thought I was going to explode."

Genitourinary "I'm not interested in sex, but I pretend to be to satisfy my

husband's needs." "I've had red patches on my labia, and I
was told to use boric acid." "I had difficulty with bladder
control and was examined for a tipped bladder, but
nothing was found." "I had nerves cut going into my
uterus because of severe cramps."
"I have learned to live with weakness and tiredness all the
Musculoskeletal
time." "I thought I pulled a back muscle, but my
chiropractor says it's a disc problem."
"My vision is blurry. It's like seeing through a fog, but the
Sensory
doctor said thSt glasses wouldn't help."
"I suddenly lost my hearing. It came back, but now I have
whistling noises, like an echo."
Metabolic/ "I began teaching half days because I couldn't tolerate the
endocrine cold." "I was losing hair faster than my husband."
 Somatoform, Dissociative, and Related Disorders 7

Carol, a 26-year-old homemaker, first presented for medical evaluation with

a chief complaint of weakness and malaise of 1 year's duration. She reported
other symptoms as well: burning pain m her eyes, muscular aches and pains
in her lower back, headaches, a stiff neck, abdominal pain "on both sides and
below the navel," and vomiting "glassy white stuff—as if I were poisoned."
Nine months earlier, Carol was hospitalized for evaluation of the abdominal
pain and had a barium enema and upper gastrointestinal X-ray series. The
test results were normal.
Six months before her clinic visit, Carol developed blurry vision and a sharp
shooting pain in her rectum with walking and reported passing blood and
mucus in her stools. A sigmoidoscopic examination was unremarkable, but
she was nevertheless given a diagnosis of mild ulcerative colitis and started
on sulfasalazine therapy. Another barium enema examination had negative
results. Five months before her clinic visit, she noted “wasting" of her hands
and reported needing a larger glove size for the right hand. She also was
concerned with a pulsating vessel and whitish nodules on her hand.
At her clinic visit, Carol identified additional symptoms: a burning pain in
her pelvis, hands, and feet; heavy vaginal bleeding, passing "clots as large as
a fist"; abdominal bloating; malodorous stools with "bits of sudsy mucus";
urinary urgency; cough incontinence; tingling in hands and feet; and a belief
that her bowel movements "just don't look right." She also disclosed a 10-
year history of recurrent tonsillitis and quinsy during her childhood.
Carol was next seen at the same clinic 21 years later after referral by her
primary care physician for evaluation of multiple somatic complaints. Her
symptoms were remarkably similar to those reported earlier, and it soon
became clear that she had never been free of them. Her complaints included
a right-sided tremor that caused her to spill food, migratory aches and pains,
a feeling of coldness in her extremities, and a heavy menstrual flow ("I used
48 sanitary pads in a single day"). In addition, she reported feeling sick;
having abdominal bloating, flatulence, and frequent nausea and vomiting;
and being constipated. She was concerned that her skin was becoming
darker and that her scalp hair was falling out. An extended medical workup
was negative.
Six years later, she was admitted to the psychiatric sendee. During the
intervening years, she had received a total hysterectomy and oophorectomy,
but apart from menstruation-related symptoms, she continued to have the
same unrelenting physical complaints. Again, a protracted medical workup
was negative.
Carol's remarkable history of illness spanning 27 years leaves little doubt
that she had an unrecognized somatization disorder. Her complaints were
consistent over the years and had led to many unnecessary evaluations and
procedures. Despite the rhultiplicity of her complaints, many quite alarming,
Carol remained fit and physically healthy.

The prevalence of somatization disorder is about 1% in the general

population but is higher in primary care. Many more have symptoms of the
disorder but not the number required for the diagnosis. The disorder is more
common in rural areas and among persons with less education. Many
women with the disorder report histories of sexual abuse as children.
Between one-half and two-thirds of the patients with somatization disorder
meet criteria for an unstable or dramatic personality disorder (e.g..histrionic
personality disorder).
Somatization disorder often leads to repeated surgeries, drug abuse, marital
instability, major depression, and suicide attempts. Few persons with
 8 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
somatization disorder experience significant improvement or
complete remission of symptoms.
Research shows that somatization disorderi runs in family and that within
the same families there is an excess of bothantlsoClalpersonality disorder
and substance abuse. These findings have led to the hypothesis that,
depending on the individual's gender, genetic and/or environmental factors
may lead to one or another overlapping clinical syndrome.
The differential diagnosis of somatization disorder includes panic disorder,
major depression, and schizophrenia. Patients with panic disorder typically
report multiple autonomic symptoms (e.g., palpitations, shortness of breath),
but they occur almost exclusively during panic attacks. Patients with major
depression often present with physical complaints, but dysphoria and
vegetative symptoms of depression (e.g., appetite loss, lack of energy,
insomnia) are prominent. Schizophrenic patients sometimes have physical
complaints, but they are typically bizarre or delusional (e.g., "My spine is a
set of twirling plates").

Conversion Disorder
Conversion disorder involves symptoms that suggest a neurological or
general medical condition; pain is purposely excluded from the definition.
(Patients whose major complaint is limited to pain receive a diagnosis of
pain disorder.) In addition, the physician will have determined that the
symptom is not under voluntary control and cannot, after appropriate
investigation, be explained by a known neurological or medical illness.
Psychological factors are associated with the symptoms, as suggested by
their initiation after stressful events. Furthermore, the symptoms must not be
intentionally produced or culturally sanctioned behaviors (see Table 8-5).
Conversion symptoms are surprisingly common. An estimated 20%-25% of
the patients admitted to neurology wards have conversion symptoms. In a
survey of consecutive psychiatric consultations in a general hospital, 5% of
the patients had conversion symptoms. Conversion symptoms are more
frequent in women than in men, in patients from rural areas, and in persons
with less education or low socioeconomic status.
Typical conversion symptoms include paralysis, abnormal movements,
inability to speak (aphonia), blindness, and deafness. Pseudoseizures are also
common and may occur in patients with genuine epileptic seizures.
Conversion symptoms usually conform to the patient's concept of disease
rather than to recognized physiological patterns. For example, anesthesia
may follow a stocking-and-glove pattern, not a dermatomal distribution.
Conversion symptoms sometimes occur in patients with mood disorders,
somatization disorder, or schizophrenia.
The diagnosis of conversion disorder is established by ruling out medical or
neurological illness and by identifying psychological factors involved in the
initiation of symptoms. This is usually not difficult when a patient's somatic
complaints are inconsistent with physical examination findings and evidence
of psychological stress is clear. Yet research shows that some patients given
diagnoses of conversion disorder are later found to have medical or
neurological illnesses that, in retrospect, accounted for their symptoms.
There are many useful clues that the clinician can use to help establish a
diagnosis of conversion disorder. Studies of patients with conversion
 Somatoform, Dissociative, and Related Disorders 9
symptoms have found that coexisting mood and anxiety disorders,
somatization disorder, schizophrenia, and various personality disorders are
frequent. Thus, an unexplained pseudoneurological symptom in a patient
with a serious psychiatric disorder is likely to represent a new conversion
symptom. Patients sometimes mimic symptoms based on their experience
with an illness or model them on the symptoms of an illness observed in an
important person in their life (e.g., a figure from childhood). Contrary to
common belief, indifference toward symptoms {la belle indifference) is not
typical of patients with conversion disorder; they are generally quite
interested in them.
The etiology of conversion disorder is not well understood, but
psychodynamic, biological, cultural, and behavioral factors have been
suggested to play a role. According to the psychodynamic interpretation,
patients with certain developmental predispositions respond to particular
types of stress with conversion symptoms. The stress awakens unconscious
conflicts, usually involving sexuality, aggression, or dependency. The high
frequency of conversion symptoms in patients with brain injuries, however,
suggests a biological etiology. A study of conversion disorder patients in
Australia and Great Britain found that 64% had coexisting or antecedent
brain disorders, such as epilepsy, tumor, or stroke, compared with only 6%
of control subjects. Sociologists point out that various ethnic and social
(generally non-European) groups are more likely to respond to emotional
stress with conversion symptoms than are other groups.
A favorable outcome is generally associated with acute onset, a precipitating
stressful event, good premorbid adjustment, and the absence of medical or
neurological comorbidity. One follow-up study found that 83% of the
inpatients and outpatients were well or improved at a 4- to 6-year follow-up;
another study found that 100% of the outpatients with conversion symptoms
had an immediate favorable response to treatment, with only 20%
experiencing a relapse by 1-year follow-up. When conversion symptoms
occur in the context of another psychiatric disorder, their outcome reflects
the natural history of the primary disorder, such as major depression,
somatization disorder, or borderline personality disorder.

TABLE 8-5. DSM-IV-TR diagnostic criteria for conversion disorder

A. One or more symptoms or deficits affecting voluntary motor or sensory
function that suggest a neurological or other general medical condition.
B. Psychological factors are judged to be associated with the symptom or
deficit because the initiation or exacerbation of the symptom or deficit is
preceded by conflicts or other stressors.
C. The symptom or deficit is not intentionally produced or feigned (as in
Factitious Disorder or Malingering).
D. The symptom or deficit 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 or deficit causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning or warrants
medical evaluation.
F. The symptom or deficit is not limited to pain or sexual dysfunction, does not
occur exclusively during the course of Somatization Disorder, and is not better
accounted for by another mental disorder.
Specify type of symptom or deficit:
 10 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
With Motor Symptom or Deficit
With Sensory Symptom or Deficit
With Seizures or Convulsions
With Mixed Presentation

Hypochondriasis
Hypochondriasis is a preoccupation with fears of having, or the belief that
one has, a serious disease based on misinterpretation of bodily symptoms
(Table 8-6). This preoccupation persists after appropriate medical evaluation
has ruled out a medical disorder that could account for the symptoms;
furthermore, other mental disorders such as schizophrenia, major
depression, or somatization disorder have been ruled out as a cause of the
disturbance. Hypochondriasis has a duration of 6 months or more.
Hypochondriacal patients show an abnormal concern with their health and
tend to amplify normal physiological sensations and misinterpret them as
signs of disease. These patients ofterf fear a particular disease (e.g., cancer or
AIDS) and cannot be reassured despite careful and repeated examinations.
Their preoccupation with the idea of serious illness directs attention from
other activities and undermines relationships. The following vignette
illustrates a case of hypochondriasis seen in our hospital:

TABLE 8-6. DSM-IV-TR diagnostic criteria for hypochondriasis

A. Preoccupation with fears of having, or the idea that one has, a serious disease
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 (as in Delusional
Disorder, Somatic Type) and is not restricted to a circumscribed concern
about appearance (as in Body Dysmorphic Disorder).
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 Generalized Anxiety
Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major
Depressive Episode, Separation Anxiety, or another Somatoform Disorder.
Specify if: .
With Poor Insight: if, for most of the time during the current episode, the
person does not recognize that the concern about having a serious illness is
excessive or unreasonable

Mabel, an 80-year-old retired schoolteacher, was admitted for evaluation of

an 8-month preoccupation with having colon cancer. The patient had a
history of single vessel coronary artery disease and diabetes mel- litus
(controlled by oral hypoglycemic agents) but was otherwise well.
She had no history of mental illness. On admission, Mabel reported her
concern about having colon cancer, which her two brothers had developed.
As evidence of a possible tumor, she reported having diffuse abdominal pain
and cited an abnormal barium enema examination 1 year earlier. (The
examination had reve'aled diverticulosis.) Because of her concern about
having cancer, Mabel had seen 11 physicians, but each in turn had been
 Somatoform, Dissociative, and Related Disorders 11
unable to reassure her that she did not have cancer.
Mabel was pleasant and cooperated well with the ward team. Her physical
examination and routine admission laboratory tests were unremarkable.
Despite her complaint, Mabel denied depressed mood and displayed a full
affect. She reported sleeping less than usual but attributed this to her
abdominal discomfort. She chose not to socialize with other patients, whom
she characterized as "crazy." She remained preoccupied with the possibility
that she had cancer, despite our reassurance.
A benzodiazepine was prescribed for her sleep disturbance, but she refused
any other type of psychiatric treatment.

Many persons develop illness worry or hypochondriacal concerns

transiently in response to new or unexplained symptoms. Symptoms of this
kind occur in 60%-80% of healthy persons in any given week; intermittent
worry about illness occurs in 10%-20%. However, unlike patients with
hypochondriasis, these people are readily reassured by physicians that their
symptoms are benign.
Unlike somatization disorder, which starts early in life and mainly affects
women, hypochondriasis may begin at any age and appears to be equally
common in men and women. The prevalence of hypochondriasis in the
general population is unknown, but 2%-7% of the patients seen by primary
care physicians have the disorder. Because of repeated visits and failure to
respond to reassurance, physicians find patients with hypochondriasis
frustrating. Patients, on the other hand, often feel rejected when told that
their complaints are not legitimate (e.g., "It's all in your head").
Like patients with somatization disorder, hypochondriacal patients may
have complaints involving many organ systems, "doctor-shop," and receive
multiple workups and unnecessary surgery. They also are at risk for alcohol
or drug addiction as a result of their ongoing physical complaints.
Hypochondriacal symptoms commonly occur in the course of mood and
anxiety disorders, which must be ruled out as a cause of the complaints.
When hypochondriacal symptoms occur in the course of another illness,
such as panic disorder, treatment of the primary disorder often will lead to a
reduction in hypochondriacal symptoms. When hypochondriasis is the
primary disorder, remission appears unlikely, and a waxing and waning
course is typical.

Pain Disorder
Pain in one or more anatomical sites is the major symptom in pain disorder;
unlike other types of pain, psychological factors are believed to have a major
role in its etiology (see Table 8-7). Two subtypes are specified: pain
associated with psychological factors and pain associated with both
psychological factors and a general medical condition. The disorder is
termed acute if the duration is less than 6 months and chronic if the duration
is 6 months or longer. Such pain often appears to be related to environmental
stressors, such as the loss of a loved one. It generally occurs in the absence of
identifiable medical or neurological illness or is grossly out of proportion to
that expected from the physical pathology. A patient seen in our clinic
illustrates this disorder:

Nancy, a 34-year-old schoolteacher, developed disabling lower back pain

coincidental to a work-related lawsuit in which she alleged unfair treatment
by her coworkers. She attributed her back pain to a fall 6 months earlier in
12 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
which she had twisted her ankle; extensive neurological and orthopedic
evaluations had failed to document any physiological abnormality. She
became preoccupied with her back pain and stopped working. Her social
life became constricted and consisted mainly of attending a support group
for persons with chronic pain.
Somatoform, Dissociative, and Related Disorders 13

TABLE 8-7 DSM-IV-TR diagnostic criteria for pain disorder

A. Pain in one or more anatomical sites is the predominant focus of the clinical
presentation and is of sufficient severity to warrant clinical
attention.
B. The pain causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
C. Psychological factors are judged to have an important role in the onset,
severity, exacerbation, or maintenance of the pain.
D. The symptom or deficit is not intentionally produced or feigned (as in
Factitious Disorder or Malingering).
E. The pain is not better accounted for by a Mood, Anxiety, or Psychotic
Disorder and does not meet criteria for Dyspareunia.
Code as follows:
Pain Disorder Associated With Psychological Factors: psychological factors
are judged to have the major role in the onset, severity, exacerbation, or
maintenance of the pain. (If a general medical condition is present, it does not
have a major role in the onset, severity, exacerbation, or maintenance of the pain.)
This type of Pain Disorder is not diagnosed if criteria are also met for
Somatization Disorder.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
Pain Disorder Associated With Both Psychological Factors and a General
Medical Condition: both psychological factors and a general medical condition
are judged to have important roles in the onset, severity, exacerbation, or
maintenance of the pain. The associated general medical condition or anatomical
site of the pain (see below) is coded on Axis III.
Specify if:
Acute: duration of less than 6 monthis ,
Chronic: duration of 6 months or longer
Note: The following is not considered to be a mental disorder and is included
here to facilitate differential diagnosis. Pain Disorder Associated With a
General Medical Condition: a general medical condition has a major role in the
onset, severity, exacerbation, or maintenance of the pain. (If psychological factors
are present, they are not judged to have a major role in the onset, severity,
exacerbation, or maintenance of the pain.) The diagnostic code for the pain is
selected based on the associated general medical condition if one has been
established (see Appendix G) or on the anatomical location of the pain if the
underlying general medical condition is not yet clearly established—for example,
low back, sciatic, pelvic, headache, facial, chest, joint, bone, abdominal, breast,
renal, ear, eye, throat, tooth, and urinary.

Chronic pain is one of the most common reasons that patients consult
physicians. One study found that 13% of the patients in an internal
medicine practice had chronic pain; in a health maintenance organization-
based sample, 8% of the patients had severe persistent pain, and nearly
3% had at least 7 days of pain-related restriction of activity
 14 INTRODUCTORY TEXTBOOK OF PSYCHIATRY

within the past 6 months. Low back pain is estimated to affect more than 7
million persons in the United States. Pain disorders are also costly
economically because of high health care utilization and loss of work
productivity. A proportion of patients with chronic pain meet criteria for
pain disorder, a psychiatric condition. Patients with this disorder are more
likely to be seen by internists and general practitioners than by psychiatrists
because their complaints are viewed as physical. Symptoms of coexisting
mental illness, such as depression or anxiety, are often denied.
Chronic pain is one of the most vexing symptoms a patient can develop. Pain
sensitivity and expression depend not only on personality and prior
emotional adjustment but also on cultural factors affecting how pain is
experienced and biological factors relating to neural pathways. Following
injury, the sensitivity of'pain receptors and the excitability of neurons in the
spinal cord may change. Pain thresholds may change after neurological
injury, and pain-producing substances such as substance P and histamine
can alter them as well.
Patients with pain disorder, like those with somatization disorder, often
have histories of having been abused as children and of having poor coping
skills. Their pain often develops in the context of stressful life circumstances
and is influenced by the gains of illness. These gains may involve escape
from a conflict-provoking situation and sympathy, or financial rewards. The
pain behavior may be reinforced by the response of others.
Unexplained pain often occurs in the course of other psychiatric disorders,
including mood and anxiety disorders and other somatoform disorders. In
one study, 60% of depressed patients reported pain. Depression is a frequent
consequence of chronic pain, although few pain patients have the marked
vegetative symptoms typical of major depression. Thus the clinician must
determine whether a major depression is also present in the patient with a
pain disorder. If present, the depression may respond to antidepressant
medication, and the distress related to the pain may be alleviated. Suicide
always must be kept in mind as a possible consequence of chronic pain.

Body Dysmorphic Disorder

A patient with body dysmorphic disorder (BDD), or dysmorphopho- bia,
usually is preoccupied with an imagined defect in appearance rather than
having more diffuse complaints. For this reason, BDD is sometimes referred
to as a disease of imagined ugliness. This condition must be differentiated
from monohypochondriacal paranoia (delusional disorder, somatic type), in
which a patient has a delusional belief that a body part is grossly deformed
and distorted. In BDD, the patient is not delusional and is willing to
acknowledge that his or her concerns may be exaggerated. Patients with
BDD tend to focus on imagined defects involving their face and head, but
any body part may become a focus of concern. Mirror checking, comparing
oneself with others, camouflaging the affected body part, ritualized
grooming, and requests for reassurance are typical. Patients who are
particularly concerned with their facial appearance sometimes undergo
repeated plastic surgery procedures in their quest for a defect-free
appearance but are rarely satisfied. The following case example is of a
patient with BDD seen in our clinic:
 Somatoform, Dissociative, and Related Disorders 15
Arthur, a 20-year-old man, first began to think of his face as a problem when
he was a senior in high school. He noticed that when his face was in repose,
his brows would droop over his eyes and give him a "devious look." He also
noticed that his jawline seemed weak and receding. He tried to camouflage
these "defects" by keeping his lower jaw jutted forward and his eyebrows
raised. His attempts at camouflage became almost habitual, but he consulted
a surgeon to obtain a jaw augmentation and have his eyebrows raised
because he felt the camouflaging made him self-conscious and decreased his
spontaneity.
Arthur was a good student in high school but participated in relatively few
activities. Although he had occasionally dated, he had not had a close
relationship with a girl. He experienced a brief rebellious period during high
school in which he stopped studying and smoked marijuana. After several
months of this^ehavior, he began to feel depressed, apathetic, guilt-ridden,
and paranoid, although he did not meet criteria for major depression and did
not have any delusions or hallucinations.
The episode passed when he stopped rebelling and using marijuana. He later
completed 1 year of college but then dropped out to work and thus obtain
money for cosmetic surgery. After the surgery, he planned to return to
college. One day he hoped to attend medical school.
Arthur was a rather handsome young man with heavy, dark eyebrows but a
perfectly normal jawline. He related his motivation for seeking surgery to his
general pattern of pursuing perfection in all aspects of life. He considered
himself well adjusted and normal and, in fact, superior to most people. He
saw no need for psychiatric treatment and refused a recommendation for a
medication trial.

Clinical Management of the Somatoform Disorders

There are several important principles that guide the treatment of
somatoform disorders. First, the physician should follow the Hippocratic
oath and "do no harm." Because symptoms are often embellished or
misidentified (e.g., minor spotting during the menses may be reported
 16 INTRODUCTORY TEXTBOOK OF PSYCHIATRY

as "gushing"), physicians frequently overreact and pursue the diagnostic

equivalent of a "wild goose chase." Patients with somatoform disorders
often provoke unnecessary evaluations, surgical procedures, or medication
prescriptions that may have little relevance to the underlying condition.
For that reason, it is essential that physicians who evaluate patients with
multiple unexplained symptoms make a proper diagnosis. The physician
should legitimize the patient's symptoms. The suffering of such patients is
real and to be told that nothing is wrong is taken as rejection.
Second, the physician should see somatizing patients at regular scheduled
visits. Implicit in this approach is the message that new symptoms are not
required in order to see a physician. The purpose of these visits is to listen
attentively and convey concern without inquiring in detail about the
physical symptoms. By avoiding placing the focus on the patient's
symptoms, the physician conveys the message that physical complaints are
not the most important or interesting feature about the patient. The
physician's goal is not to remove symptoms but to help the patient cope
with them and function at as high a level as possible. To this end, patients
will benefit from an explanation for their symptoms and advice about diet,
exercise, and return to meaningful activity and work.
Third, the physician should prescribe psychiatric medications and
analgesics cautiously. Somatoform disorder patients often request
medications, but there is usually little benefit from them. Drug treatment is
rarely indicated unless another psychiatric syndrome develops that may
respond to medication. For example, antidepressants may help relieve
major depression or block panic attacks, yet they have little effect on an
underlying somatization disorder. As a general rule, benzodiazepines
should be avoided because of their abuse potential.
Finally, the most important therapeutic element is an empathic doctor-
patient relationship. Ideally, the doctor should become the patient's
primary and only physician.
These simple measures have been shown to lower health care costs in
patients with somatization disorder. A group of patients receiving a
psychiatric consultation with recommendations for conservative care (i.e.,
essentially these measures) had a 53% decline in health care costs, mostly
as a result of fewer hospitalizations, and improved physical functioning.
The patients' health status or satisfaction with their health care remained
the same. Health care costs of control subjects did not change.
The patient with hypochondriasis may additionally benefit from individual
psychotherapy that involves education about illness attitudes and selective
perception of symptoms. Controlled trials have shown
 Somatoform, Dissociative, and Related Disorders 17

that cognitive-behavioral therapy (CBT) can help to correct misinterpretations

of internal stimuli reported by hypochondriacal persons. Such therapy seeks to
correct faulty beliefs about illness and provide interpretation of the pattern of
reassurance seeking. Another option is medication; serotonin reuptake
inhibitors (SSRls) have been reported to be effective in treating
hypochondriasis. One particular form of hypochondriasis, illness phobia, has
been reported to respond to imipramine, a tricyclic antidepressant.
The treatment of conversion disorder has not been well established, but
symptom removal is the goal. Reassurance and suggestion (that gradual
improvement may be expected) usually are appropriate measures, along with
efforts to resolve stressful situations that may have provoked the symptoms.
The spontaneous remission rate for acute conversion symptoms is high, so that
ev£n without any specific intervention, most patients will improve and
probably not have any serious complications. A treatment approach for
persistent conversion symptoms using behavioral modification for psychiatric
inpatients has been described. The patient is placed at complete bed rest and
informed that use of ward facilities will parallel his or her improvement. As the
patient improves, the time out of bed is gradually increased until full privileges
are restored. Nearly all patients (84%) who had conversion symptoms (ranging
from blindness to bilateral wrist drop) treated in this manner experienced
remission. By allowing the patient to save face, this method has the advantage
of keeping secondary gain (e.g., escaping from noxious activities, obtaining
desired attention from family, friends, and others) to a minimum.
In treating conversion disorder, hospital staff should remain supportive and
show concern while encouraging self-help. The disorder can be explained to
the patient as the body's involuntary response to psychological stress. It is
rarely helpful to confront patients about their symptoms or make them feel
ashamed or embarrassed. The pain or weakness is quite real to patients. The
physician should explain that the treatment will be conservative and will
emphasize rehabilitation rather than medication.
Some experts believe that interviews conducted under the influence of
intravenous amobarbital sodium (i.e., Amytal interviews) or hypnosis will
enable the patient to discuss the stressors that provoked the conversion
symptoms and to then abreact (or express) accompanying emotions.
Posthypnotic suggestions that the patient abandon the symptom can also be
made. Other clinicians have recommended psychotherapy aimed at resolving
internal conflicts that they believe are central to the etiology of conversion.
These techniques may be considered when
 18 INTRODUCTORY TEXTBOOK OF PSYCHIATRY

the conservative approach fails to yield the desired result.

Body dysmorphic disorder may be a variant of obsessive-compulsive
disorder, and the treatment is similar. In one study, 70% of the patients
receiving an SSRI improved. A positive response leads to decreased
distress, less time spent preoccupied with the "defect," and improved social
and occupational functioning. In near-delusional forms of BDD, an
antipsychotic added to the SSRI may be helpful (e.g., olanzapine,
risperidone). CBT also can be beneficial. Patients are instructed to stay
away from mirrors, remove their makeup, or take off their hats. Supportive
counseling can help to boost morale, provide hope, and offer insight into
the disorder. Cosmetic surgery can lead to surgical complications, provides
few benefits, and does not change the patient's preoccupation, so it must be
avoided.

Key points to remember about somatoform disorders

1. The physician should legitimize the patient's symptoms.
2. An empathic relationship should be established to reduce the patient's
tendency to doctor-shop.
• The primary physician should preferably become the patient's only
physician.
3. The patient should be scheduled for brief but frequent visits.
• As the patient improves, the time between visits can be extended.
4. The physician's goal is not to remova l symptoms but to
improve function.
5. The use of psychotropic drugs should be minimized.
• No medication has proven value in somatoform disorders.
Exceptions may be hypochondriasis and BDD, in which SSRIs appear
to be of benefit.
• These patients may become dependent on drugs,
particularly benzodiazepines, so drugs with addiction
potential should be avoided.
6. Medical evaluations should be minimized to reduce expense and
iatrogenic complications.
• Conservative management is proven to reduce health care costs.

Dissociative Disorders
The hallmark of dissociative disorders is a disturbance of or alteration in
the normally well-integrated functions of identity, memory, and con
sciousness. Dissociative disorders include the amnestic states (dissociative
amnesia and dissociative fugue), dissociative identity disorder (formerly
multiple personality disorder), and depersonalization disorder. A residual
category exists for dissociative disorders that do not meet more specific
criteria (see Table 8-8).

TABLE 8-8. DSM-IV-TR dissociative disorders

Amnestic states
Dissociative amnesia
 Somatoform, Dissociative, and Related Disorders 19

Dissociative fugue
Dissociative identity disorder (formerly multiple personality disorder)
Depersonalization disorder
Dissociative disorder not otherwise specified

Amnestic States
Psychologically induced memory loss is called dissociative amnesia (see
Table 8-9). The disorder is defined as one or more episodes of inability to
recall important personal information, usually of a traumatic or stressful
nature, that is considered too extensive to be explained by ordinary
forgetfulness. With dissociative amnesia, the person is typically confused
and perplexed. He or she /nay not recall significant personal information
or even his or her own name. The amnesia typically develops suddenly and
can last from minutes to days, or even longer. In one case series, 79% of the
amnestic episodes lasted less than a week.

TABLE 8-9. DSM-IV-TR diagnostic 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, Posttraumatic Stress Disorder, Acute
Stress Disorder, or Somatization Disorder and is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication) or a
neurological or other general medical condition (e.g., Amnestic Disorder Due
to Head Trauma).
C.The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

TABLE 8-10. DSM-IV-TR diagnostic 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 identity
(partial or complete).
C. The disturbance does not occur exclusively during the course of
Dissociative Identity Disorder and is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.

The prevalence of dissociative amnesia is unknown, but it has been

reported to occur after severe physical or psychosocial stressors (e.g.,
natural disasters, war). In a study of combat veterans, between 5% and 20%
were amnesic for their combat experiences. It has been estimated that from
5% to 14% of all military psychiatric casualties experience amnesia to some
extent.
Dissociative fugue is characterized by amnesia with inability to recall one's
 20 INTRODUCTORY TEXTBOOK OF PSYCHIATRY

past and the assumption of a new identity, which may be partial or

complete (see Table 8-10). The fugue usually involves sudden, unexpected
travel away from home or one's workplace, is not due to a dissociative
identity disorder, and is not induced by a substance or a general medical
condition (e.g., temporal lobe epilepsy). Like dissociative amnesia, fugue
states are reported to occur in psychologically stressful situations, such as
natural disasters or war. Personal rejections, losses, or financial pressures
are reported to have preceded the fugue in some cases. Fugues can last for
months and lead to a complicated pattern of travel and identity formation.
A case example of a woman who had a fugue follows:

Carrie, a 31-year-old attorney from a small Midwestern town, was

reported as missing for 4 days under mysterious circumstances.
Carrie was known to have finished her day at work and to have
exercised at a health spa but had failed to return home. Her car
was found abandoned.
A search was mounted, and it was assumed that she had been
abducted or murdered, especially after a headless corpse was
found. Candlelight vigils were held, psychics were consulted, and
friends blanketed the community with posters offering rewards for
help in locating her.
One month after her disappearance, Carrie called her father from
Las Vegas, where she had been the entire time. She was at a local
hospital and claimed to have had amnesia. Carrie reported that she
had been physically assaulted while jogging on the night of her
disappearance.
During the struggle, she had been knocked unconscious: "When I came to,
1 was dazed, confused, and disoriented." She felt that the assault prompted
the amnesia, leading her to forget her past. She later hitchhiked to Las
Vegas, where she was found wandering aimlessly. The police took her to a
nearby hospital, where she claimed a new identity.
With the help of a psychologist who used hypnosis, Carrie quickly
recovered her memory and her identity. She returned home and resumed
her legal practice. Her family and friends had described her as a "creature
of habit" and were as baffled as was Carrie about her amnesia.
She had no history of mental illness.

The differential diagnosis of dissociative amnesia or fugue includes many

medical and neurological conditions that can cause memory impairment
(e.g., a brain tumor, closed head trauma, dementia) as well as the effects of
a substance (e.g., alcohol-induced blackouts). Before assuming that the
amnesia or fugue is psychologically motivated, medical and neurological
conditions and substance abuse must be ruled out. A workup should
include a thorough physical examination, mental status examination,
toxicological studies, an electroencephalogram, and other tests when
indicated.
As a general rule, the onset and termination of amnestic and fugue states
due to medical illness or a substance are unlikely to be associated with
psychological stress. Memory impairment due to brain injury is likely to be
more severe for recent than for remote events and to resolve slowly if at all;
in these cases, memory only rarely recovers fully. Disturbances in attention,
orientation, and affect are characteristic of many brain disorders (e.g., brain
tumors, strokes, Alzheimer's disease) but are unlikely in dissociative
 Somatoform, Dissociative, and Related Disorders 21

amnesia. Memory loss from alcohol intoxication (blackouts) is

characterized by impaired short-term recall and evidence of heavy
substance abuse. Malingering involves claiming amnesia for behaviors that
are alleged to be out of character when obvious reasons exist for secondary
gain (e.g., claiming amnesia for a crime). Careful observation in a hospital
setting can help to clarify the diagnosis.
There is no established treatment for dissociative amnesia or fugue, though
recovery tends to occur spontaneously. As the name fugue implies, the
condition involves psychological flight from overwhelming circumstances,
and once these circumstances are resolved, the dissociative fugue resolves.
In fugue states, recovery of past memories and the resumption of the
individual's former identity may occur abruptly over several hours but can
take much longer. Both conditions can recur, particularly when the
precipitating stressors remain or return. Hypnosis and interviews
conducted under the influence of intravenous sodium amobarbital
(narcoanalysis) have been reported to help patients recover missing
memories. When memories return, patients should be helped to
understand the reason for their memory loss and to resolve the
circumstances that led to the disturbance.

TABLE 8-11. DSM-IV-TR diagnostic criteria for dissociative identity

disorder
A. The presence of two or more distinct identities or personality states (each with
its own relatively enduring pattern of perceiving, relating to, and 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 important personal information that is too extensive to be
explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance
(e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general
medical condition (e.g., complex partial seizures). Note: In children, the
symptoms are not attributable to imaginary playmates or other fantasy play.

Dissociative Identity Disorder (Multiple Personality

Disorder)
Dissociative identity disorder (DID) is characterized by the presence of two or
more distinct identities or personality states, each with its own relatively
enduring pattern of perceiving, relating to, and thinking about the
environment and self (see Table 8-11). A personality state is not as well
developed or integrated in either thinking or behavior as an identity. In
some cases, there may be at least two fully developed identities, whereas in
others there may be only one distinct identity and one or more personality
states. According to DSM-IV-TR, at least two identities or personality states
recurrently take full control of the person's behavior. Although DID has
been described for centuries, most lay conceptions are based on media
presentations. The most famous portrayals are found in The Three Faces of
 22 INTRODUCTORY TEXTBOOK OF PSYCHIATRY

Eve and Sybil, both of which provide detailed accounts of women with
many strikingly different personalities.
The prevalence of DID is unknown, but it is reportedly rare. However, in
the past few decades the number of reported cases has grown, and some
experts have claimed that the disorder is common in both inpatient and
outpatient settings. This reported increase in frequency has led some to
question whether well-meaning therapists might unwittingly induce the
phenomenon, and to note that through attention, suggestion, and the
process of hypnosis itself, additional personalities can be created in
suggestible patients. These same experts observe that many personalities
disappear when ignored by the therapist.
From 75% to 90% of the patients with DID are women. The disorder is
thought to have a childhood onset, usually before age 9 years, and is
chronic. It may be familial; it has been described as occurring in multiple
generations and among siblings.
The cause of DID is unknown. Some researchers believe that the disorder
results from severe physical and sexual abuse during early childhood. They
contend that DID results from self-induced hypnosis, used by the person to
cope with the abuse, emotional maltreatment, or neglect. Some liken DID to
posttraumatic stress disorder, a condition caused by life-threatening
danger.
In one large case series, the mean number of personalities in DID patients
was 7, and approximately one-half had more than 10. With the disorder,
different personalities are reported to control an individual's behavior for
varying percentages of time. The transition from one personality to another
may be sudden or gradual. Switches have been observed with stressful
situations, disputes among the personalities, and psychological conflicts.
The personalities may or may not be aware of their "alters."
Some of the more common symptoms reported by patients with DID, as
well as characteristics of their alternate personalities, are presented in Table
8-12.
A case example of a relatively typical patient with DID seen at our hospital
follows:

Cindy, a 24-year-old woman, was transferred to the psychiatry service to

facilitate community placement. Cindy had received a diagnosis of
multiple personality disorder, although in the past she had received
diagnoses of chronic schizophrenia, borderline personality disorder,
schizoaffective disorder, and bipolar disorder.
Cindy had been well until 3 years before admission. At that time, she
developed depression, "voices," multiple somatic complaints, periods of
amnesia, and repeated wrist cutting. Her family and friends became
concerned with her abrupt changes in mood and thought that Cindy had
become a pathological liar because she would do or say things that she
would later deny. Her chronic depression and recurrent suicidal behavior
led to frequent hospitalizations. Cindy received trials of antipsychotics,
antidepressants, mood stabilizers, and anxiolytics, all with little or no
benefit. Her condition continued to worsen.
Cindy was friendly, neatly groomed, and diminutive. She reported having
nine separate personalities that ranged in age from 2 to 48 years; two were
masculine. Cindy's main concern was her inability to control the switches
among the personalities, which made her feel out of con trol. She reported
 Somatoform, Dissociative, and Related Disorders 23

having been sexually abused by her father as a child and described visual
hallucinations consisting of visions of him coming at her with a knife. We
were unable to confirm the history of sexual abuse but thought it likely,
based on what we learned of her early chaotic home life.
Cindy was cooperative with the treatment team. Nursing staff observed
several episodes when the patient switched to one of her troublesome
alters. Cindy's voice would change in inflection and tone, and it would
become childlike when Joy, an 8-year-old alter, took control.
Arrangements were made for individual psychotherapy, and Cindy was
discharged.
At a follow-up 3 years later, Cindy still had many personalities but was
functioning better, had fewer switches, and lived independently.
She continued to see a therapist weekly and hoped to one day integrate
her many alters.

Patients with DID often meet criteria for other psychiatric disorders.
Like Cindy, many have unexplained physical complaints and fulfill criteria
for somatization disorder. Headaches and amnesia (“losing time") are
particularly common symptoms. Borderline personality disorder, found in
up to 70% of DID patients, is diagnosed on the basis of mood instability,
identity disturbance, deliberate self-harm, and other symptoms
characteristic of the disorder. Many DID patients report psychotic
symptoms such as auditory hallucinations (voices) and previously received
diagnoses of schizophrenia, schizoaffective disorder, or psychotic mood
disorder; all of these disorders must be ruled out.

TABLE 8-12. Common symptoms in patients with dissociative identity

disorder and characteristics of alternate personalities ("alters'') in 50
patients
Alternate-personality
Symptoms % characteristics %
Markedly different moods 94 Amnestic personalities 100
Exhibiting an alter 84 Personalities with proper
Different accents 68 names (e.g., Nick, Sally) 98
Inability to remember angry Angry alternate personality 80
outbursts 58 Depressed alternate
Inner conversations 58 personality 74
Different handwriting 34 Personalities of different ages 66
Different dress or makeup 32 Syicidal alternate personality 62
Unfamiliar people know them well 18 Protector alternate
Amnesia for a previously learned personality 30
subject 14 Self-abusive alternate
Discovery of unfamiliar 14 personality 30
possessions
Different handedness 14 Opposite-sexed alternate
personality 26
Personality with non-proper
names (e.g., "observer,"
"teacher") 24
Unnamed alternate
personality 18
Source. Adapted from Coons et al. 1988.
24 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
Patients with DID tend to report that voices originate within their heads,
are n6t experienced with the ears (or as a percept), and are not associated
with mood changes; insight generally is preserved. By contrast, patients
with psychotic disorders usually report that auditory hallucinations "come
from the outside," have the quality of a percept (as opposed to one's own
thoughts), and are accompanied by changes in mood; insight is minimal.
Hallucinations that accompany DID are best considered
pseudohallucinations—that is, hallucinations brought about by the exercise
of one's imagination and accompanied by the realization that the
experience is due to illness and is not real.
There is no standard treatment for DID, but many clinicians recommend
long-term psychotherapy to help patients integrate their many
personalities. At least one study has shown that motivated patients treated
by experienced therapists can achieve such integration and remission of
symptoms. Other aspects of treatment remain controversial. Some experts
use hypnosis or narcoanalysis to help access the different personalities in
the context of psychotherapy. CBT has also been used to help patients
achieve reintegration All experts agree that therapy is lengthy and
difficult.
Although the core features of DID do not respond to medication, typical
patients have mood and anxiety symptoms that may respond to drug
therapy. For example, antidepressants may relieve coexisting major
depression and block panic attacks.

Depersonalization Disorder
Depersonalization disorder is characterized by feeling detached from oneself
or one's surroundings, as though one were an outside observer; some
patients experience a dreamlike state (see Table 8-13). A patient with
depersonalization may feel as though he or she were cut off from his or
her thoughts, emotions, or identity. Another may feel like a robot or
automaton. Depersonalization may be accompanied by derealization, a
sense of detachment, unreality, and altered relation to the outside world.
The prevalence of depersonalization disorder is unknown, but it is more
common in women. Many people who are otherwise normal transiently
experience mild depersonalization. For example, depersonalization may
occur when a person is sleep deprived, travels to unfamiliar places, or is
intoxicated with hallucinogens, marijuana, or alcohol. In a study of college
students, from one-third to one-half reported having experienced such
depersonalization. Persons exposed to life-threatening situations, such as
traumatic accidents, may also experience depersonalization. For these
reasons, depersonalization disorder is diagnosed only when it is persistent
and causes distress.
The disorder typically starts in adolescence or early adulthood but rarely
after age 40 years. Many persons vividly recall their first episode of
depersonalization, which is often Abrupt and unexpected. Some report a
precipitating event, such as smoking marijuana. The duration of
depersonalization episodes is highly variable, but they may last hours,
days, or weeks. Although depersonalization disorder is typically
experienced as chronic and continuous, some persons have periods of
remission. Exacerbations may follow psychologically stressful situations,
Index 25

such as the loss of an important relationship.

The cause of depersonalization disorder is unknown. Freud postulated
that depersonalization allows a person to deny painful or unacceptable
feelings. It also could represent an adaptive response to life-threatening
danger, serving as a buffer against extreme emotion (fear). The fact that
depersonalization frequently accompanies several central nervous system
disturbances (e.g., partial complex seizures, tumors, stroke, encephalitis,
migraine) suggests a biological basis. One recent theory holds that the
state of increased alertness seen in depersonalization disorder results from
activation of the prefrontal attentional systems combined with reciprocal
inhibition of the anterior cingulate, which causes "mind emptiness."
Conditions in which depersonalization symptoms may occur must be
ruled out, such as schizophrenia, major depression, phobias, panic
disorder, obsessive-compulsive disorder, drug abuse, and sleep
deprivation. Medical illness (e.g., partial complex seizures, migraine) and
drug-induced states need to be ruled out as well.
There are no standard treatments for this disorder, but benzodiazepines
may be of help in managing the accompanying anxiety (e.g., diazepam, 5
mg three times daily). SSRIs and clomipramine have been reported to
relieve symptoms of depersonalization, although in a controlled trial
fluoxetine proved ineffective. Patients also have been reported to benefit
from hypnotherapy or CBT to help control their episodes of
depersonalization. With CBT, patients learn to confront their distorted
thoughts and challenge their feelings of unreality.

TABLE 8-13. DSM-IV-TR diagnostic 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., feeiing 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 does not occur exclusively
during the course of another mental disorder, such as Schizophrenia,
Panic Disorder, Acute Stress Disorder, or another Dissociative
Disorder, and is not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general medical
condition (e.g., temporal lobe epilepsy).

Key points to remember about dissociative disorders

1. Medical causes must be ruled out as a cause of the amnesia,
dissociation, or depersonalization.
2. The therapist should be patient and supportive. In most cases of
amnesia, return of memory is rapid and complete.
3. Narcoanalysis (sodium amobarbital interview) may be helpful
diagnostically and therapeutically in patients with amnesia.
• The interview will help many patients to recover missing
memories.
• The interview can be helpful diagnostically in separating
psychological from medical causes of amnesia. The patient with
psychologically motivated amnesia may experience a return of
26 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
memory, and the patient with medically induced amnesia will become
more confused.
4. Patients with DID are especially problematic, and therapy may be
longterm. The clinician may want to refer the patient to a therapist
experienced in treating DID.
• It may be best to help the patient gradually learn about the number
and nature of his or her personalities.
• A goal with these patients should be to help them learn how to
control their switches and accept responsibility for their actions.
5. Medications have no proven value in treating dissociative disorders,
although some patients with depersonalization disorder may benefit from
an antidepressant.
• Benzodiazepines may be of help in reducing the anxiety that often
accompanies depersonalization.

■ Factitious Disorders and Malingering

Factitious disorders and malingering are conditions in which physical or
emotional illness or amnesia is mimicked. Factitious disorders have their
own category in DSM-IV-TR, whereas malingering is grouped with the V-
code conditions. These are conditions not attributed to mental illness but
are a focus of attention or treatment.

Factitious Disorders
Factitious disorders involve the intentional production (or feigning) of
physical or psychological symptoms. Patients with factitious disorders
have no obvious external incentive for the behavior, such as economic
gain; rather, they are thought to be motivated by an unconscious desire to
occupy the sick role.
Some persons with the disorder appear to make hospitalization a way of
life and have been called "hospital hobos" or "peregrinating problem
patients." The term Munchausen syndrome also has been used to describe
patients who move from hospital to hospital simulating various illnesses.
The name Munchausen comes from the fictitious wanderings of the
nineteenth-century Baron von Miinchhausen, known for his tall tales and
fanciful exaggeration. Cases of Munchausen syndrome by proxy have also
been observed; in this instance, a parent induces illness or simulates illness
in his or her child so that the child is repeatedly hospitalized.
The frequency of factitious disordertis unknown because many cases go
undetected. In one study involving persons with a fever of unknown
origin, up to 10% of the fevers were diagnosed as factitious. The variety of
maladies induced by patients with such disorders is limited only by their
imagination. Patients with factitious disorders typically use one of three
strategies: 1) they report symptoms suggesting an illness, without having
them; 2) they produce false evidence of an illness (e.g., a factitious fever
produced by applying friction to a thermometer to raise the temperature);
or 3) they intentionally produce symptoms of illness (e.g., by injecting
feces to produce infection or taking warfarin orally to induce a bleeding
disorder). Some of the more common methods for producing symptoms
are presented in Table 8-14.
Most cases of factitious disorder involve the simulation of physical illness.
Index 27

The feigning of mental illness is probably less common, and the diagnosis
can be extremely difficult to make because of the lack of objective physical
or laboratory abnormalities associated with psychiatric disorders. In a
follow-up of nine patients with factitious psychosis, the patients remained
emotionally disturbed and had poor social functioning. All had severe
personality disorders.
Factitious disorders are chronic and begin in early adulthood. They often
develop in persons who have had experience with hospitalization or
severe illness involving either themselves or someone close to them (e.g., a
parent). The disorder can severely impair social and occupational
functioning and is usually associated with serious character pathology
(e.g., antisocial personality disorder). In one study, most of the factitious
disorder patients had worked in health care occupations. Most subjects
had abnormal personality traits, but none had a diagnosis of a major
mental disorder, such as depression or schizophrenia. Nearly all were
women.
Some experts believe that the patient with factitious disorder consciously
produces the signs or symptoms of physical illness to obtain medical care.
Patients are aware of their role in producing signs and symptoms of illness
yet are typically unaware of their motivation for doing so. According to
one interpretation, factitious disorder patients experienced emotional
deprivation at the hands of absent or inattentive parents but received love
and attention from health care givers. By producing illness, these patients
re-create the nurturing atmosphere that they experienced earlier in their
lives from caregivers.
The differentiation of factitious disorder from somatoform disorders and
malingering, based on presumed psychological mechanisms, is shown in
Table B-15.

The diagnosis of a factitious disorder requires almost as much in

ventiveness as is shown by the patient in producing symptoms. Clues to
the diagnosis include a lengthy and involved medical history that does not
correspond to the patient's apparent health and vigor, a clinical
presentation that too closely resembles textbook descriptions, a
sophisticated medical vocabulary, demands for specific medications or
treatments, and a history of excessive surgeries. Previous hospital charts
should be gathered and prior clinicians contacted when a factitious
disorder is suspected. In one intriguing case reported in the literature, the
authors were able to document at least 15 different hospitalizations in a 2-
year period and found that medical evaluations had included repeated
cardiac catheterizations and angiograms; complications from the
procedures had eventually resulted in the loss of a limb. In this particular
patient, clues to the diagnosis included the manner in which the patient
presented 4iis story, the absence of family or friends at the hospital, the
presence of multiple surgical scars, and an absence of distress despite
complaints of crushing retrosternal pain.
The treatment of factitious disorder is difficult and frustrating. The first
task is to make the diagnosis so that additional and potentially harmful
procedures may be avoided. Because many of these patients are
hospitalized on medical and surgical wards, a psychiatric consultation
should be obtained. The psychiatrist can help make the diagnosis and
28 INTRODUCTORY TEXTBOOK OF PSYCHIATRY
educate the treatment team about the nature of factitious disorders. Once
sufficient evidence has been gathered to support the diagnosis (but not
before), the patient should be confronted in a nonthreatening manner by
the attending physician and the consulting psychiatrist. In a follow-up of
42 patients with factitious disorder, 33 were confronted. None signed out
of the hospital or became suicidal, but only 13 acknowledged causing their
disorders. However, most improved after the confrontation, and 4 became
asymptomatic. The authors reported that their lawyers had advised that
room searches could be justified legally and ethically in the pursuit of a
diagnosis. Like the suicidal patient whose belongings may be searched for
dangerous objects, the factitious disorder patient also has a potentially life-
threatening condition that justifies such measures.

TABLE 8-14. Methods used to produce symptoms in patients with a

factitious disorder
Method %
Injection or insertion of contaminated substance 29
Surreptitious use of medications 24
Exacerbation of wounds 17
Thermometer manipulation 10
Urinary tract manipulation 7
Falsification of medical history 7
Self-induced bruises or deformities 2
Phlebotomy , 2
Source. Adapted from Reich and Gottfried 1983.

TABLE 8-15. Differentiating among the somatoform disorders, factitious

disorders, and malingering
Mechanism of Motivation for illness
Disorder illness production production
Somatoform disorders8 Unconscious Unconscious
Factitious disorder Conscious Unconscious
Malingering Conscious Conscious

“Includes somatization disorder, conversion disorder, hypochondriasis, and pain disorder.

Source. Adapted from Eisendrath 1984.

Malingering
Malingering is the intentional production of false or grossly exaggerated
physical or psychological symptoms motivated by external incentives,
such as avoiding military conscription or duty, avoiding work, obtaining
financial compensation, evading criminal prosecution, obtaining drugs, or
securing better living conditions.
Index 29

Unlike factitious disorder, in which symptoms are produced for

presumably unconscious reasons, malingering is intentional for reasons
that are apparent to the malingerer. Most malingerers are male, and most
have obvious reasons to feign illness. They are often prisoners, factory
workers, or persons living in unpleasant settings where an illness may
provide an escape from harsh responsibilities or the hospital a temporary
sanctuary.
Malingering should be suspected when any of the following clues are
present: medicolegal context of presentation (e.g., the person is being
referred by his or her attorney for examination); marked discrepancy
between the person's claimed disability and objective findings; lack of
cooperation during the diagnostic evaluation and noncompliance with the
treatment regimen; and the presence of an antisocial personality disorder.
Symptoms reported by malingering patients are often vague, subjective,
and unverifiable.
There is some debate about the correct approach to take with the
malingerer. Some experts believe that malingering patients should be
confronted after sufficient evidence has been collected to confirm the
diagnosis. Others feel that confrontations will simply disrupt the doctor-
patient relationship and make the patient even more alert to possible
future detection. Clinicians who take the second position feel that the best
approach is to treat the patient as though the symptoms were real. The
symptoms can then be given up in response to treatment without the
patient losing face.

Self-Assessment Questions
1. How is somatization disorder diagnosed?
2. What do family studies of somatization disorder show?
3. What are the risk factors for conversion disorder?
4. What is the natural history of the different somatoform disorders?
5. How does somatization disorder differ from hypochondriasis?
6. How are the somatoform disorders managed?
7. How does dissociative amnesia differ from dissociative fugue?
8. What is the differential diagnosis of the dissociative disorders?
9. What is the current etiological theory of DID?
10. What is depersonalization, and how common is it?
11. How are the somatoform disorders, factitious disorders, and
malingering similar? Different?