In this chapter, the somatic symptom disturbances and the dissociative disorders will be discussed. In somatic symptom disorders , people have physical complaints, without an organic cause. Often the pain comes through painful emotions, thoughts or memories. In dissociative disorders , people develop several independent personalities, as a result of which they suffer from memory loss. This is because some personalities do not communicate with each other, as it were.

Somatic symptom disorders symptom disturbances

The problem with somatic is that it is difficult to determine whether the symptoms have an organic or psychological cause. Often people’s symptoms do not correspond to a physiological process associated with these symptoms. If this is the case, it is assumed that psychological factors are of influence. Another possibility is that people do have a physical illness, but that they still must be discovered or simply can not be found.

The people who have this disorder really feel the pain. It is not that they can influence or control their symptoms.

5 types of somatic symptom disorders are distinguished:

1. Somatic symptom
2. disorder Illness anxiety disorder (formerly this was hypochondria)
3. Conversive
4. disorder Factitious disorder
5. Psychological factors that influence other medical conditions (sometimes called psychosomatic disorder)

Somatic symptom disorder and Illness Anxiety Disorder

Someone with a somatic symptom disorder has one or more physical symptoms that he or she worries about, and the person spends a lot of time thinking about these symptoms and looking for medical care. It can be pain symptoms, neurological symptoms, gastrointestinal symptoms or symptoms that affect any part of the body. People with somatic symptom disorder have concerns about their health that are excessive given their current physical health. The concerns also continue to exist when they have evidence that they are healthy and interfere with their daily functioning. When they experience a certain symptom, they immediately think the worst, for example that they have cancer.

Illness anxiety disorder is very similar to somatic symptom disorder. The primary distinction in the DSM-V between these two disorders is that people with a somatic symptom disorder actually seek help while people with illness anxiety disorder are afraid that they will get a serious illness, but they do not always experience serious physical symptoms. . When they experience physical symptoms, these people are very concerned, and seek medical help before.

People with somatic symptom disorder or illness anxiety disorder often experience periods of anxiety and depression. They can express their stress in physical symptoms or mask the stress with alcohol abuse or antisocial behavior. Their symptoms and health concerns become their identity. When they are anxious or depressed, they report more physical complaints and then worry when they are not anxious or depressed.

Cognitive factors play a major role in somatic symptom disorder and illness anxiety disorder. People with these disorders have convicted dysfunctional about diseases. They assume that serious illnesses are common, and misinterpret physical changes as a sign of worry. The disorder can also be genetically determined. In addition, children of parents who catalyse their somatic symptoms can adopt the thinking style and health behaviours of their parents.

Somatic symptom disorder and illness anxiety disorder can be part of a posttraumatic stress disorder experienced by someone who has survived a severe stressor.

It is difficult to convince people with these disorders that they need psychological treatment. Psychodynamic therapies focus on providing insight into the connections between emotions and physical symptoms by helping people regain events and memories that may have triggered their physical symptoms. Behavioral therapies try to discover the empowered individuals who receive individuals for their symptoms and health complaints, and to eliminate these reinforcements and to increase positive rewards for healthy behavior. Cognitive therapies help people to correctly interpret their physical symptoms and avoid catastrophizing. Antidepressants can also reduce somatic symptoms.

Conversion disorder (functional neurological disorder)disorder

People with a conversion can suddenly no longer use certain parts of their body, often after a traumatic experience or event. For example, people are suddenly paralyzed or blind. It also happens that people do not even worry about their loss. This is called la belle indifference.

Sigmund Freud studied people with glove anaesthesia, where people lose the feeling in a hand, as if a glove had affected the feeling in that hand. He found that people got the feeling back in their hand when they were under hypnosis and had to think back on the painful feelings or thoughts. Freud thought that conversion disorders were the result of moving suppressed psychic energy to physical symptoms. According to him, the symptoms were symbols of what had been oppressed.

People with a conversion disorder are easy to hypnotize. According to researchers, this can indicate that people with this disorder spontaneously hypnotize themselves in response to extreme stress.

Conversion symptoms were very common during the two world wars. Soldiers were spontaneously blinded or paralyzed, so as not to have to go back to the front. The disorder can also occur in children. Usually their symptoms resemble the symptoms of someone who is close to them and who has a real disease. This happens mainly in children who have been sexually abused. They can imitate someone’s symptoms. For example, if a role model for the child can no longer move his arm, the child can not do that anymore. Conversion disorder is very rare. Nowadays it is thought that many cases where this diagnosis was made earlier, had a physical cause. The techniques used to be simply not good enough to recognize the real cause.

The name ‘conversion disorder’ assumes that psychological stress, often over a traumatic event, is ‘converted’ to a physical symptom. Patients and physicians often disagree with this assumption, and in the DSM-V this disorder is labelled as ‘functional neurological symptom disorder’.

Psychoanalytic treatment of this disorder is about understanding the painful emotions that are the cause of the disorder. Behaviouristic treatments focus on reducing anxiety around the trauma, thereby resolving the disorder. Often people with a conversion disorder are difficult to treat because they themselves do not think there are psychological problems.

Factitious Disorder

A person with a factitious disorder deliberately acts as if he or she has a disease to receive medical attention. This is also called Munchhausen’s syndrome . A factitious disorder is not the same as malingering, where people pretend they have a symptom or disorder to prevent an undesirable situation or to get something, such as payment by the insurance. The difference between factitious disorders and malingering is therefore mainly the motivation for it.

Factitious disorder imposed on another (formerly factitious disorder by proxy) means that someone pretends that another person has a disease, for example with a child, pet or older adult. For example, parents do whether their child has a disease, or they even create a disease with their children, to get attention for themselves.

Somatization disorder and pain disorders

Someone with somatization disorder usually has a long history of complaints about physical symptoms, while no doctor can say what exactly is going on with that person. People with somatization disorder usually have pain in many areas of the body. To get the diagnosis of somatization disorder, the person must have pain symptoms in at least 4 areas of the body, including two gastrointestinal problems, one sexual symptom and one neurological symptom.

It may even be that people lose a function of the body, just as with the conversion disorder.

The symptoms of the imagined illness are often vague, dramatic or exaggerated. This exaggeration takes place to be treated anyway, even though that treatment is often not necessary.

The somatization disorder usually occurs more often within one family. It is not clear if there is a genetic cause. It may very well be that children see the somatising parent as a role model. Parents with this disorder also often ignore their children, which teaches the children to pay attention by feeling sick.

People with a pain disorder complain only about chronic pain. Pain disorder is very similar to somatization disorder, with the difference that in the pain disorder the four previously mentioned symptoms do not have to occur.

Often people with somatisation disorders and pain disorders suffer from anxiety and depression. These disorders are more common in women than in men, and in cultures where it is less accepted to have negative emotions. This may also be because men are more inclined to conceal the symptoms through alcohol abuse or antisocial behavior.

A cognitive theory states that people who have this disorder are more susceptible to pain, pay more attention to what they feel in their body and that they tend to make an elephant out of a mosquito. The interpretation of the symptoms is wrong and the pain is often exaggerated to get more attention from family and doctors. Through this way of thinking, these people express their feelings in an exaggerated way, giving them more attention from doctors and family members. There are also indications that having PTSD has an influence on the occurrence of somatisation disorder.

Many people with a somatization disorder have a history of major depression, anxiety disorder, drugs or a personality disorder.

This disorder is passed on to women in families. Men with a somatization disorder more often have problems with alcohol abuse and antisocial behavior. In families with sebum disorder, women often have depression or anxiety disorder and men with a drinking problem.

Parents with a somatization disorder often neglect their children. As a result, they teach their children that they only get attention when they are ill and therefore the children have an increased chance of getting the disorder themselves.

It is not easy to convince these people that they have a psychological disorder because they feel pain. However, if they finally cooperate with a treatment, the outlook is good. Psychodynamic theories focus on giving insight into the relationship between emotional causes and the pain they feel. They do this by recalling the experience that caused the pain in the memory. Cognitive therapies teach patients to properly assess their physical symptoms so that they are less concerned about their illness. Behavioral therapy looks at the positive reinforcers that people get through the disorder. This mainly concerns attention. These reinforcers are eliminated and positive reinforcers are created for healthy behavior.

Antidepressants also work for people with this disorder, but not as well as therapy.

Hypochondria

Hypochondria and somatization disorder are not very different. The difference between these two is that people with somatisation disorder feel pain and that people with hypochondria are only afraid that they have a disease and do not always have physical symptoms. Once people with hypochondria feel a physical complaint, they immediately go to the doctor, while people with a somatization disorder wait longer to see how the symptoms develop. People with hypochondria often suffer from chronic depression or anxiety and often have family with the same disorders. Their fears about their health usually arise from a general sense of stress.

Cognitive therapy focuses on removing the misinterpretation of a physical feeling.

Disturbed body experience

People with disturbed body experience (body dysmorphic disorder) feel that they have a body part that is completely deformed. There are about as many women as men with this disorder, only the focus of the disorder differs. Women are often concerned about their breasts, legs, hips and weight. Men are often worried or have a small physique, genitalia and lack of body hair.

People with this disorder spend hours trying to cover their ‘deformed’ body parts and often use plastic surgery to correct their problem. People with this disorder are often withdrawn because they are ashamed when other people see their deformity. This disorder is somewhat reminiscent of OCD, because it must be made obsessive that the ‘bad’ body part is covered over.

Psychoanalytic therapy is aimed at providing insight into the backgrounds of the concerns about the body part. Cognitive behavioral therapies are aimed at reducing anxiety about a certain part of the body, by changing negative thoughts  about it and by desensitization. It appears that SSRIs can also help treat body dysmorphic disorder, which also suggests that this disorder may be a form of obsessive-compulsive disorder (SSRIs are also used as treatment in this disorder).

Dissociative disorders

Dissociation is a process whereby parts of a person’s memory, identity or consciousness are separated from each other. Many see it as split ideas of consciousness that are accessible through dreams and hypnosis. According to Hilgard, there are two forms of consciousness: an active and a receptive mode. The active mode-active mode consists of consciously planning and taking actions. The receptive mode consists of the unconscious processing of information, as if there were ‘hidden observers’ . In most people these two different states of being merge into each other without problems, but in people with a dissociative disorder that is a big problem.

Dissociative identity disorder (DID)

Dissociative identity disorder (DID) or multiple personality disorder is a highly controversial disorder. People with this disorder have multiple personalities, sometimes more than twelve. Each of these personalities has a different character. They regularly take over the body from the ‘hostess’ or ‘host’. Each character has its own behavior, way of talking, gestures and the like. Often the different personalities, or alters, have different ages and genders. DID is much more common in women than in men, although there are no gender differences in children. Men with DID are often more aggressive than women.

In this disorder there are different personalities with specific qualities, called ‘alters’. There are different types of alters:

1. Child alters are alters of young children. This form is the most common type of alter. DID is often caused by a trauma in childhood. It is possible that this alter is created during the trauma, as a result of which the alter experiences the trauma and thus the victim remains protected. This alter can also act as a larger sibling that protects the victim from the trauma.
2. Another type of alter is the persecutor personality. This alter tries to destroy the person. It is often the case that these alters throw themselves into dangerous behavior, for example by jumping for a truck, after which another alter takes over again, and thus with the problems. Often the persecutor personality has the idea that he can hurt the rest of the alters without harming himself.
3. A third type of alter is the helper personality. This alter has the function to offer advice to other alters, and to do things that other alters are unable to do. Helper alters can sometimes influence the switching of personalities. It often happens that certain personalities know nothing about what happens when the other alters are active. So it may be that someone suddenly finds things in his house that he does not know, or that people greet her that she does not know.

It may be that the host or hostess is not aware of these alters and therefore suffers from a kind of amnesia (memory loss). Sometimes the alters are aware of each other and thus information goes from one personality to another.

People often come to the therapist because of self-damaging behavior caused by the persecutor personality. They then attempted suicide or caused serious damage to their bodies.

Children can also get this disorder. The symptoms in children are different than in adults. Children often have very many emotional problems. They often suffer from symptoms that resemble the symptoms of PTSD. Children with DID often also suffer from voices in their heads (just like adults).

For 1980 the diagnosis DID was never given, and after 1980 very often. There can be various causes for this. Around 1980, this disorder was included in the DSM-III, as a result of which people were more often diagnosed with the disorder. Furthermore, in the same version, the criteria for schizophrenia were adapted so that people who used to be called schizophrenic could now receive a diagnosis for a multiple personality disorder.

It often happens that people have already received several other diagnoses before they were diagnosed with DID. Sometimes this is because DID often goes along with other disorders, such as depression, anxiety disorders (mostly PTSD) and substance abuse. It is also often associated with an eating disorder. Most people with DID also have a personality disorder. Some of the earlier diagnoses may also have been misdiagnoses of the dissociative symptoms. When people with DID say they hear voices in their heads, for example, they often get the diagnosis schizophrenia. There are a few major changes in the diagnostic criteria for DID in the DSM-V. The DSM-V has added the words ‘or an experience of possession’ to criterion A in order to make the criteria more applicable for various cultural groups. Many features of DID can be influenced by someone’s cultural background. Another change in the DSM-V is that the transition in identity does not have to be directly observed by others, but reporting by the person himself (self-report) is sufficient (criterion A). A final change is that amnesia can also occur in everyday events, and not only in traumatic experiences (criterion B).

Many scientists see DID as a result of coping strategies used in severe trauma, for example, physical or sexual abuse. Most people with DID have been sexually abused as children and have shifted this experience to a personality. This can happen because they relive it as an outsider in dreams. The abuse is often done chronically by parents or family.

In such a case, personalities are often developed that help to deal with the traumatic experience. These personalities then provide security and safety. People with DID are easy to hypnotize, which may mean that they hypnotize themselves to dissociate and escape their traumas.

DID is usually more common in certain families. It could be that the possibility to dissociate as a defence mechanism is inherited to a certain extent.

The goal of treating someone with DID is to ensure that all different personalities are integrated into a single personality. This is done by looking at the different roles of the alters, and having each alter separately process the trauma. There is also negotiation between the different personalities to bring the person back into a whole.

Sometimes antidepressants and other medications are used to help the therapy. Often a treatment of someone with DID is successful, especially if the treatment starts soon after the onset of the trauma.

Dissociative fugue

A person with a dissociative fugue can suddenly move to another city and start a new life without being reminded that he has ever had a different life. The person can behave very normal in his new life, and it is crazy that he no longer remembers his past. He may suddenly return to his old life, where he continues as if he had never been away.

Such a fugue can occur once, but also more often and can take days or even years. It happens that a fugue arises from a traumatic experience, but it is more often the case that people experience a fugue when they are exposed to chronic stress. People are often depressed before the fugue starts. Fugues are more common in people who have previously had a form of amnesia (memory loss). Very little is known about this disorder because it is very rare.

Dissociative amnesia

In the disorders discussed above, people have amnesia (memory loss) for certain parts of their personality or past. People with dissociative amnesia have periods of amnesia, where they lose parts of, or even their entire identity, but do not assume a new identity. People with this form of amnesia are generally aware that they do not know a great deal anymore. They have a dissociative memory loss.

There is a difference between organic and psychogenic amnesia. Organic amnesia is amnesia caused by brain damage caused by, for example, a disease, the use of drugs or an accident. In an organic cause, there is usually anterograde amnesia , which means that no new information can be stored. Psychogenic amnesia has a psychological cause. Anterograde amnesia almost never has a psychological cause. Especially retrograde amnesia (not being able to retrieve old information) occurs with this form. Another difference is usually that people with psychogenic amnesia have forgotten personal information, but still know general information, and that people with organic amnesia often have forgotten both types of information.

Dissociative amnesia is a form of psychogenic, retrograde amnesia. This form of amnesia often occurs after traumatic events. Psychogenic amnesia is often the result of defence systems activating and going against stress towers or against radical memories.

Sometimes people forget a little information, for example what happened before an accident, but they can also forget large amounts of information. You can also lose your memory due to alcohol poisoning, although this is often only the case for the things that happened during your alcohol poisoning. People who are long-term alcohol addicts can get a general form of retrograde amnesia, namely Korsakoff's syndrome. Here they can no longer remember personal information.

It may also be that amnesia arises because a person was in a very high state of arousal during a certain event, so the information is not properly coded in the brain.

Another explanation is that memories of an event are sometimes associated with very painful experiences. Because people do not want to evoke the painful experiences, they cannot remember anything. A complication in the diagnosis of amnesia is that amnesia is often used as a defence argument in court cases, and it is difficult to determine whether there really is amnesia, or whether the suspect is trying to get a lighter punishment.

A subtype of dissociative amnesia is a dissociative fugue. Someone with a dissociative fugue can suddenly move to another city and start a new life without being reminded that he has ever had a different life. The person can behave very normal in his new life, and it is crazy that he no longer remembers his past. He may suddenly return to his old life, where he continues as if he had never been away.

Such a fugue can occur once, but also more often and can take days or even years. It happens that a fugue arises from a traumatic experience, but it is more often the case that people experience a fugue when they are exposed to chronic stress. People are often depressed before the fugue starts. Fugues are more common in people who have previously had a form of amnesia (memory loss). Very little is known about this disorder because it is very rare.

Depersonalization disorder

/ derealization Depersonalization/ derealization disorder is a condition where people often feel that they are disconnected from their thoughts and their bodies. It seems as if they are observing themselves from outside. People with depersonalization disorder regularly feel that they are not mentally or physically connected to their bodies. You only get the diagnosis for this disorder if this experience occurs regularly and if it limits your functioning in daily life. This type of experience is more common in people, but not everyone gets a diagnosis, if it does not limit their lives. The course is provoked by periods of insomnia and drug use. Half of the adults indicate that they have had a brief episode of depersonalization or derealisation, often after a significant stressor.