Somatizing and dissociative disorders

Most patients consulting physicians have a mixture of physical and mental complaints that require careful differential diagnosis. Somatization is the production of recurrent and multiple physical symptoms in excess of any underlying medical disorder. Patients may have well-documented medical diagnoses, but their complaints are excessive or disproportionate in the judgment of the clinician. In DSM-5 the diagnosis of somatization emphasizes the presence of characteristic positive symptoms and signs for the diagnosis, whereas in DSM-IV the emphasis was on the absence of a medical explanation. DSM-5 makes it clear that the clinician is making a judgment about the complaints being excessive rather than on the absence of any medical diagnosis, but with either criterion, the clinician must make a judgment about the underlying medical basis for the complaints. The assessment and treatment of somatizing disorders requires patience and compassion to maintain a therapeutic alliance, and randomized controlled trials show that treatment with antidepressants, cognitive-behavioral therapy, or mindfulness-based therapies reduce health care utilization and subjective distress. Somatization Disorder is the best-validated prototype of somatizing disorders, so we will use the adjective "somatizing" to specify the group of disorders referred to as "somatoform disorders" in DSM-IV and as "somatic symptom disorders" in DSM-5. Somatization Disorder has been shown to be a chronic and heritable disorder that is clinically manifest with complaints of multiple bodily pains, gastrointestinal, psueudoneurologic symptoms, sexual, and reproductive symptoms. Unfortunately, general medical practitioners found the criteria for Somatization Disorder in DSM-IV to be time-consuming to apply, so for their convenience DSM-5 has introduced an easy-to-use category of Somatic Symptom Disorder that may be diagnosed on the basis of a single somatic complaint that the clinician judges to be excessive, even though much research shows that such subjective judgments are unreliable. Conversion disorders involve acute or chronic loss of voluntary sensorimotor functions, such as psychogenic blindness, paralysis, or tremors, that can be shown to be inconsistent with neuroanatomy and neurophysiology. In DSM-5, conversion disorders may be diagnosed in the absence of a known psychosocial stressor because recent research has shown that the inconsistent neurological signs are a more reliable basis for the diagnosis. In contrast, some somatizing disorders more closely resemble physical phobias (e.g. hypochondriasis) or social phobias (e.g., body dysmorphic disorder). Dissociative disorders involve the disruption or loss of the integrative mechanisms of consciousness, memory, identity, or perception. Dissociative disorders include amnesia (a disruption of memory), fugue (a disruption of identity), depersonalization (a disruption of perception), and Dissociative Identity Disorder (a disruption of consciousness and identity formerly called Multiple Personality Disorder). In dissociative disorders, transitions between personalities or the onset of amnesic or fugue states are usually precipitated by psychosocial stress like those observed in conversion disorders. Thus both conversion and dissociative disorders are typically precipitated by severe psychosocial stress, but it is often difficult to elicit the relevant history before treatment until the clinician can contact collateral informants. Recent brain imaging results suggest that hyperactivity of the anterior cingulate cortex can actively inhibit motor activity (e.g. psychogenic paralysis), sensory perception (e.g., psychogenic anesthesia), memory (e.g., amnesia), or identity (e.g. fugue) as a defensive response to stressors.