Have you ever had the experience, particularly during a time of serious stress, when you felt like you were walking around in a daze or like you just weren’t all there? Or have you known people who constantly complained about being sure they had a serious illness even though medical tests failed to show anything wrong? Both of these are examples of mild dissociative and somatic symptoms experienced at least occasionally by many people. However, when these symptoms become frequent and severe and lead to significant distress or impairment, a somatic symptom or dissociative disorder may be diagnosed. Somatic symptom disorders (formerly known as somatoform disorders ) and dissociative disorders appear to involve more complex and puzzling patterns of symptoms than those we have so far encountered. As a result, they confront the field of psychopathology with some of its most fascinating and difficult challenges. Unfortunately, however, we do not know much about them—in part because many of them are quite rare and difficult to study.
As we have seen , both somatic symptom and dissociative disorders were once included with the various anxiety disorders (and neurotic depression) under the general rubric neuroses, where anxiety was thought to be the underlying cause of all neuroses whether or not the anxiety was experienced overtly. But in 1980, when DSM-III abandoned attempts to link disorders together on the basis of hypothesized underlying causes (as with neurosis) and instead focused on grouping disorders together on the basis of overt symptomatology, the anxiety, mood, somatic symptom, and dissociative disorders each became separate categories.
Somatic Symptom and Related Disorders
The somatic symptom disorders lie at the interface between abnormal psychology and medicine. They are a group of conditions that involve physical symptoms combined with abnormal thoughts, feelings, and behaviors in response to those symptoms (APA, 2013 ). Soma means “body,” and somatic symptom disorders involve patterns in which individuals complain of bodily symptoms that suggest the presence of medical problems but where there is no obvious medical explanation that can satisfactorily explain the symptoms such as paralysis or pain. Despite a wide range of clinical manifestations, in each case the person is preoccupied with some aspect of her or his health to the extent that she or he shows significant impairments in functioning.
In DSM-IV a great deal of emphasis was placed on the idea that the symptoms were medically unexplained. In other words, although the patient’s complaints suggested the presence of a medical condition no physical pathology could be found to account for them (Allen & Woolfolk, 2012 ; Witthöft & Hiller, 2010 ). In DSM-5 this idea is less prominent, because it is recognized that medicine is fallible and that a medical explanation for symptoms cannot always be provided. Nonetheless, medically unexplained symptoms are still a key part of some disorders (such as conversion disorder) that we will describe later.
Equally key to these disorders is the fact that the affected patients have no control over their symptoms. They are also not intentionally faking symptoms or attempting to deceive others. For the most part, they genuinely believe something is terribly wrong with them. Not surprisingly, these patients are frequent visitors to their primary-care physicians.
Sometimes, of course, people do deliberately and consciously feign disability or illness. Also placed in the somatic symptoms and related disorders category in DSM-5 is factitious disorder. In factitious disorder the person intentionally produces psychological or physical symptoms (or both). Although this may strike you as strange, the person’s goal is to obtain and maintain the benefits that playing the “sick role” (even to the extent of undergoing repeated hospitalizations) may provide, including the attention and concern of family and medical personnel. However, there are no tangible external rewards. In this way factitious disorder differs from malingering. In malingering the person is intentionally producing or grossly exaggerating physical symptoms and is motivated by external incentives such as avoiding work or military service or evading criminal prosecution (APA, 2013 ; Maldonado & Spiegel, 2001 ).