Somatoform dissociation and posttraumatic stress syndrome – two sides of the same medal? A comparison of symptom profiles, trauma history and altered affect regulation between patients with functional neurological symptoms and patients with PTSD

Abstract

BackgroundHistory of traumatic experience is common in dissociative disorder (DD), and similarity of symptoms and characteristics between DD and posttraumatic stress disorder (PTSD) encouraged to consider DD as trauma-related disorder. However, conceptualization of DD as a trauma-related syndrome would critically affect diagnosis and treatment strategies. The present study addressed overlap and disparity of DD and PTSD by directly comparing correspondence of symptoms, adverse/traumatic experience, and altered affect regulation between patients diagnosed with dissociative disorder (characterized by negative functional neurological symptoms) and patients diagnosed with PTSD.MethodsSomatoform and psychoform dissociation, symptoms of posttraumatic stress, general childhood adversities and lifetime traumata, and alexithymia as index of altered affect regulation were screened with standardized questionnaires and semi-structured interviews in 60 patients with DD (ICD-codes F44.4, F44.6, F44.7), 39 patients with PTSD (ICD-code F43.1), and 40 healthy comparison participants (HC).ResultsDD and PTSD patients scored higher than HC on somatoform and psychoform dissociative symptom scales and alexithymia, and reported more childhood adversities and higher trauma load. PTSD patients reported higher symptom severity and more traumata than DD patients. Those 20 DD patients who met criteria of co-occuring PTSD did not differ from PTSD patients in the amount of reported symptoms of somatoform dissociation, physical and emotional childhood adversities and lifetime traumata, while emotional neglect/abuse in childhood distinguished DD patients with and without co-occuring PTSD (DD patients with co-occuring PTSD reporting more emotional maltreatment).ConclusionThe pattern of distinctive somatoform and psychoform dissociative symptom severity, type of childhood and lifetime traumata, and amount of alexithymia suggests that DD and PTSD are distinctive syndromes and, therefore, challenges the conceptualization of DD as trauma-related disorder. Together with the detected close correspondence of symptom and experience profiles in DD patients with co-occuring PTSD and PTSD patients, these findings suggest that adverse/traumatic experience may intensify dissociative symptoms, but are not a necessary condition in the generation of functional neurological symptoms. Still, diagnosis and treatment of DD need to consider this impact of traumata and post-traumatic stress symptoms.

Variation of Functional Neurological Symptoms and Emotion Regulation with Time

“…It was hypothesized (1) that groups differed in alexithymia, habitual emotion regulation style, and cortical responses during an experimental emotion regulation task before the treatment period and (2) that in FNSD patients changes in symptom severity and psychological strain after the treatment period varied with changes in emotion regulation indices. In support of the first expectation and in line with previous reports ( 10 – 12 ), FNSD patients exhibited more alexithymia and used less cognitive reappraisal strategies on everyday emotion regulation than controls, Relationships between emotion regulation indices and symptom expression were confirmed for the entire sample, but only for alexithymia and general psychological strain for FNSD patients. In addition, cortical correlates of “emotion” and “regulation” effects were replicated ( 18 ), whereas frontal and more sensorimotor cortex involvement in emotion regulation in FNSD patients ( 16 , 18 ) was not replicated.…”

“…Framing emotion processing in the context of stress and coping extended emotion regulation to cognitive and behavioral strategies that aimed at (explicit or implicit) control of unpleasant feelings in response to external events; major strategies are described and measured as cognitive reappraisal of the upsetting event or suppression of rising unpleasant sensation ( 8 , 9 ). Both alexithymia and altered emotion regulation have been verified for patients with FNS: elevated levels of alexithymia ( 10 – 12 ) were explained as a transformation of emotional expressions into bodily symptoms or as a misperception of autonomic concomitants of emotion (i.e., increased heartbeat during the experience of fear) as signs of physical illness ( 10 ). Altered emotion regulation was verified as stronger tendency for emotion suppression and less cognitive reappraisal in FNSD patients than in healthy controls ( 13 ).…”

Processing of Emotion in Functional Neurological Disorder

“…The presence of traumatic events in the patient's personal history was left out of the main DSM criteria for FND because it is difficult to prove a causal link between life events and symptom onset. Furthermore, some studies question the relevance of traumatic events in the etiology of the disorder because not all patients report a history of traumatic or adverse life events ( 57 , 58 , 64 ).…”

Electrophysiological evidence for changes in attentional orienting and selection in functional somatic symptoms

“…That is, people who experience MUS might process, perceive, or interpret somatic information differently to people who do not suffer these symptoms (see Deary et al, 2007 ). These conditions are often referred to as somatoform dissociation – a dissociation between physical information and its bodily representation ( Kienle et al, 2017 , Nijenhuis, 2004 , Ratcliffe and Newport, 2016 ).…”