Examining the Relationships between PTSD, Somatization, and Disassociation

There are clinically significant relationships that can be drawn between PTSD and Somatization Disorder, first and foremost because dissociative symptoms are included in the criteria for both.  The disassociation spectrum of disorders culminates in Dissociative Identity Disorder, where an individual has two or more distinct personalities that serve different functions in a person’s life.  Although pure cases of Dissociative Identity Disorder are extremely rare, the occurrence of dissociative-like symptoms is relatively common (especially in patients that are diagnosed with Somatization Disorder and PTSD).  We can visualize these symptoms as a form of psychological defense mechanism which results in an inability to recall events; a selective memory of sorts.  Reports of “disturbances in time” are not uncommon, for example when someone is unable to remember how they arrived at a certain location.  Disassociation sometimes manifests in depersonalization, or the sensation of “not being in one’s own body.”  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 519)

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Although the DSM-IV-TR has conveniently compartmentalized diagnoses into categorical systems, we should “apply skilled clinical judgment to establish functional relationships among various symptom clusters in any given patient.”  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression DISCUSSION)  There is no better forum to explore functional relationships between and among specific diagnosis than the exploration of the interrelationship between PTSD, Somatization Disorder, and Dissociative Disorders.  After all, the disassociations associated with these disorders will frequently present at the same time to the extent that it may be difficult to distinguish where one begins and the other ends.

The DSM-IV-TR diagnostic criteria for 309.81 Posttraumatic Stress Disorder (PTSD) include being exposed to a traumatic event that involved a threat to the physical integrity of self or others.  Secondly, the event must be persistently experienced through recurrent recollections, dreams, flashbacks, illusions, or hallucinations.  Third, the client should demonstrate active and persistent avoidance of stimuli associated with the trauma, and/or a general numbing of general responsiveness.  This frequently manifests in dissociative symptoms, serving as a conscious or unconscious effort to avoid thoughts, feelings, conversations, activities, places, or people.  The resulting disassociation results in feelings of detachment or estrangement, restricted range of affect, or a sense of a foreshortened future.  Finally, the client may present with symptoms of increased arousal including difficulty sleeping, irritability, outbursts of anger, difficulty concentrating, hypervigilance, and/or exaggerated startle response.  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 467-468)

In contrast, the DSM-IV-TR diagnostic criterions for 300.81 Somatization Disorder are characterized by a pattern of recurring clinically significant somatic complaints.  The somatic complaints cannot be fully explained by any known general medical condition or the direct effects of a substance.  If they occur in the presence of a general medical condition, the resulting impairment is in excess of what would be expected based on the norm for the general medical condition.  Finally, there are criterions regarding the quantitative and qualitative aspects of the somatic complaints, requiring that individuals present with a relatively wide variance of physical effects.  We could describe this disorder as a form of “somatic dissociation” whereby the client has lost their ability to perceive somatic sensory information, ultimately resulting in a distorted sense of self.  (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000, p. 486)

In a controlled study of Vietnam-era combat veterans, researchers found that combat veterans with PTSD reported and were rated as having a greater number of health problems than combat veterans without PTSD.  They had a greater number of total illnesses across a wider number of medical categories, contributing to the belief that as part of their PTSD, “PTSD patients have difficulty determining the salience of information and that this deficit in information processing may contribute to a patient’s focus on and misinterpretation of somatic sensations.”  (Beckham, Moore, Feldman, & Hertzberg, 1998, expression DISCUSSION)

In another study, researchers attempted to investigate the relationships between exposure to extreme stress, the emergence of PTSD, and the symptoms traditionally associated with “hysteria.”  They found that exposure to extreme stress may result in a variety of combinations of symptoms over time, including symptoms characteristic of somatization disorder and PTSD.  (Van Der Kolk, Pelcovitz, Roth, & Mandel, 1996, expression MODERN TRENDS)

In yet another study that focused primarily on pediatric cancer survivors, researchers found empirical support for the “trauma spectrum model” within which “somatic symptoms may play an instrumental role in the presentation and subsequent detection” of PTSD.  Although we cannot eliminate the possibility that somatic complaints represent true physical symptoms, children with chronic illness typical report higher levels of somatic complaints than healthy peers.  Researchers concluded that “long-term pediatric cancer survivors appear to exhibit somatic symptoms,” as well as PTSD-like symptoms, years after treatment completion.  (Erickson & Steiner, 2000)

Without, all three of these studies strengthen the argument for an interrelationship between stress, the presentation of unexplained physical symptoms, and dissociation.  Despite our best effort to compartmentalize disorders in the DSM-IV-TR, it is critical for us as clinicians to recognize and interrelationships between and among these disorders.  Despite an abundance of applicable research, more study is needed to establish the definitive relationship between and among PTSD, somatization disorder, and the spectrum of disassociation disorders.

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Beckham, J. C., Moore, S. D., Feldman, M. E., & Hertzberg, M. A. (1998, Nov). Health status, somatization, and severity of posttraumatic stress disorder in Vietnam combat veterans with posttraumatic stress disorder.  The American Journal of Psychiatry, 155(11), 1565-1570. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=36011996&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Erickson, S. J., & Steiner, H. (2000, Jul/Aug). Trauma spectrum adaptation: Somatic symptoms in long-term pediatric cancer survivors. Psychosomatics, 41(4), 339-347. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=56303410&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Van Der Kolk, B. A., Pelcovitz, D., Roth, S., & Mandel, F. S. (1996, Jul). Dissociation, somatization, and affect dysregulation. The American Journal of Psychiatry, 153(7), 83-94. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=9840989&sid=3&Fmt=2&clientId=4683&RQT=309&VName=PQD

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