Trauma/Stressor-Related, Dissociative, and Somatic Symptom Disorders

Understanding Trauma, Dissociation, and Somatic Symptoms: A Practical Guide

When someone walks into your office complaining of paralysis that no medical test can explain, or a combat veteran who can't stop reliving the moment his convoy was attacked, or a parent who reports memory gaps around a childhood trauma. You're dealing with some of psychology's most challenging presentations. These disorders sit at the intersection of mind and body, often blurring the lines between physical symptoms and psychological pain.

This lesson will walk you through three major categories that frequently appear on the EPPP: Trauma/Stressor-Related Disorders, Dissociative Disorders, and Somatic Symptom Disorders. Understanding these conditions isn't just about memorizing criteria. It's about recognizing how the human mind protects itself, sometimes in ways that create more problems than they solve.

Why These Disorders Matter for Your Practice

These three categories share a common thread: they all involve the body and mind responding to overwhelming experiences in ways that significantly disrupt daily functioning. Whether someone is re-experiencing trauma, disconnecting from reality, or experiencing unexplained physical symptoms, these presentations require careful assessment and evidence-based treatment. For the EPPP, you'll need to distinguish between similar-sounding disorders and understand which treatments actually work based on research evidence.

Trauma and Stressor-Related Disorders: When Bad Events Leave Lasting Marks

All disorders in this category require exposure to a traumatic or stressful event as part of the diagnosis. This is crucial for the EPPP. You can't diagnose any of these conditions without establishing that a triggering event occurred.

Reactive Attachment Disorder (RAD)

This diagnosis applies when a child's early caregiving was so inadequate that it fundamentally disrupted their ability to form healthy emotional connections. You're looking for two core features:

1. The child consistently pulls away from adult caregivers emotionally. They don't seek comfort when upset and don't respond when comfort is offered
2. Persistent social and emotional problems that include at least two symptoms: minimal emotional responsiveness, limited positive emotions, or unexplained fear/sadness/irritability around adult caregivers

Critical diagnostic requirements:

• History of extreme insufficient care (neglect, frequent caregiver changes, institutional settings with poor care)
• Symptoms started before age 5
• Child has a developmental age of at least 9 months (so you know they're developmentally capable of attachment)

{{M}}Think of attachment like learning your first language. There's a critical window when the brain is primed to develop these connections. When that window closes without proper input, catching up becomes much harder.{{/M}}

Disinhibited Social Engagement Disorder (DSED)

This disorder also stems from inadequate early care, but manifests differently. Instead of withdrawing, these children show inappropriately friendly behavior with strangers. They need at least two of these four symptoms:

• Little to no hesitation approaching or interacting with unfamiliar adults
• Overly familiar behavior (verbal or physical) with strangers
• Doesn't check back with caregivers after separation
• Willingly goes off with strangers with minimal hesitation

The key distinction for the EPPP: RAD involves emotional withdrawal; DSED involves indiscriminate sociability. Both require a history of insufficient care and a developmental age of at least 9 months.

Posttraumatic Stress Disorder (PTSD)

This is the heavyweight of trauma disorders and deserves your focused attention for the exam. PTSD requires exposure to actual or threatened death, serious injury, or sexual violence. The exposure can be direct, witnessed, learned about (when it happened to a close family member or friend), or through repeated exposure to details (like first responders experience).

Symptoms must last more than one month and fall into four categories:

Brain Changes in PTSD

The neuroscience here is testable, so pay attention:

• Hyperactive amygdala: The brain's alarm system is stuck in overdrive
• Hyperactive anterior cingulate cortex: Increased emotional processing
• Hypoactive ventromedial prefrontal cortex: The "brake pedal" that normally calms the amygdala isn't working properly. This creates a runaway fear response
• Reduced hippocampal volume: The memory center is actually smaller
• Neurotransmitter changes: Increased dopamine, norepinephrine, and glutamate; decreased serotonin and GABA

{{M}}Picture a car alarm system that's become so sensitive it goes off at the slightest vibration, while the off-switch has stopped working properly. That's essentially what's happening with the amygdala-prefrontal cortex relationship in PTSD.{{/M}}

Risk Factors for Developing PTSD

Not everyone who experiences trauma develops PTSD. Pre-trauma factors that increase risk include:

• Prior trauma exposure
• Prior psychiatric disorders
• Negative affectivity (tendency toward negative emotions)
• Female gender
• Low education and socioeconomic status
• Lack of social support
• Exposure to racial/ethnic discrimination

Evidence-Based PTSD Treatment

The APA Clinical Practice Guideline (2025) provides clear hierarchy you need to know:

First-line psychological treatments (recommended):

• Cognitive Processing Therapy (CPT)
• Prolonged Exposure (PE)
• Trauma-focused CBT

Second-line psychological treatments (suggested):

• Cognitive Therapy (CT)
• Eye Movement Desensitization and Reprocessing (EMDR)
• Narrative Exposure Therapy (NET)

Medication: No first-line medication recommendations exist. Second-line options include:

• SSRIs: fluoxetine, paroxetine, sertraline
• SNRI: venlafaxine

These medications help with comorbid depression and may reduce re-experiencing, avoidance/numbing, and hyperarousal symptoms.

Critical EPPP Point: Single-session psychological debriefing (critical incident stress debriefing) is NOT effective and may worsen symptoms. If you see this as an answer choice for treating PTSD, it's wrong.

PTSD with Comorbid Substance Use Disorder

This combination is common and important. Traditional approaches treated the substance use first, then the PTSD. Research now shows integrated (concurrent) treatments work better:

1. COPE (Concurrent treatment Of PTSD and SUD using Prolonged Exposure)
2. Prolonged exposure for PTSD + treatment as usual for SUD
3. Trauma-focused CBT + treatment as usual for SUD

For Children and Adolescents: Trauma-Focused CBT (TF-CBT) is the go-to treatment for ages 3-18. Originally designed for sexual abuse, it now addresses various trauma types and includes family therapy, parenting skills, and conjoint parent-child sessions. It effectively reduces PTSD, depression, anxiety, and grief symptoms.

Acute Stress Disorder

Think of this as "PTSD's shorter-term cousin." The trauma exposure requirement is identical, but the timeline differs:

• Symptoms last 3 days to 1 month (if they last longer, consider PTSD)
• Need at least 9 symptoms from any of five categories: intrusion, negative mood, dissociative symptoms, avoidance, arousal
• Must cause significant distress or impairment

Prolonged Grief Disorder

This is a newer addition to the DSM. Requirements include:

• Death of someone close occurred at least 12 months ago (adults) or 6 months ago (children/adolescents)
• Intense yearning for the deceased and/or preoccupation with thoughts about them
• At least 3 of 8 symptoms nearly every day for the past month: disbelief about the death, avoidance of reminders, emotional numbness, intense loneliness, etc.

The key distinction: Normal grief is painful but gradually improves. Prolonged grief disorder involves persistent, intense symptoms that significantly impair functioning well beyond typical bereavement timelines.

Dissociative Disorders: When the Mind Disconnects

The DSM-5-TR describes these as disruptions in the normal integration of consciousness, memory, identity, emotion, and behavior. {{M}}It's like your mental operating system experiencing a serious glitch where different programs can't communicate with each other properly.{{/M}}

Dissociative Amnesia

This involves an inability to recall important personal information that goes way beyond normal forgetting and causes significant distress or impairment.

Types of Amnesia (know these for the EPPP):

Dissociative Fugue: This is a specifier for dissociative amnesia that involves purposeful travel or aimless wandering combined with memory loss. {{M}}Imagine someone who suddenly finds themselves in a different city with no memory of how they got there or why they left. That's dissociative fugue.{{/M}}

Dissociative amnesia typically relates to victimization or trauma exposure.

Depersonalization/Derealization Disorder

This disorder involves persistent or recurrent episodes of:

• Depersonalization: Feeling unreal, detached, or like an outside observer of your own thoughts and actions
• Derealization: Feeling that your surroundings are unreal or distant

Critical requirement: Reality testing remains intact. The person knows these experiences aren't real. They just feel that way. Symptoms must cause significant distress or impairment.

{{M}}Some people describe depersonalization as feeling like they're watching themselves in a movie, or like they're operating their body remotely. Derealization is often described as feeling like the world is behind a fog or glass wall.{{/M}}

Somatic Symptom and Related Disorders: When Physical Symptoms Don't Match Medical Findings

These disorders involve physical symptoms and/or health concerns that cause significant distress or impairment, but medical evaluation doesn't fully explain the symptoms.

Somatic Symptom Disorder

This diagnosis requires:

1. One or more somatic symptoms that are distressing or disrupt daily life
2. Excessive thoughts, emotions, or behaviors about the symptoms or health concerns, shown by at least one of:
   • Disproportionate thoughts about symptom seriousness
   • Persistently high anxiety about health/symptoms
   • Excessive time and energy devoted to health concerns

Specifiers indicate severity (mild, moderate, severe), whether pain predominates, and if the disorder is persistent (severe, marked impairment, lasting over 6 months).

Important: You don't need to prove the symptoms are "psychological in origin." The diagnosis focuses on the person's response to their symptoms, not whether the symptoms have a medical explanation.

Illness Anxiety Disorder

This is what used to be called hypochondriasis. Key features:

• Preoccupation with having a serious illness
• No or mild somatic symptoms present
• Excessive health anxiety
• Either excessive health-related behaviors (frequent doctor visits, checking) or maladaptive avoidance (avoiding medical care)
• Symptoms present at least 6 months

The distinction from Somatic Symptom Disorder: In Illness Anxiety Disorder, somatic symptoms are absent or mild. The focus is on the fear of having an illness, not on distressing physical symptoms.

Functional Neurological Symptom Disorder (Conversion Disorder)

This is one of the most fascinating diagnoses for many clinicians. The person has one or more symptoms involving disturbed voluntary motor or sensory functioning (paralysis, blindness, seizures, etc.), but:

• Symptoms are incompatible with any known neurological or medical condition
• Symptoms cause significant distress or impairment

Psychogenic Non-Epileptic Seizures (PNES)

This is a specific presentation worth knowing. PNES look like epileptic seizures behaviorally, but:

• They're NOT accompanied by abnormal brain electrical activity
• Video EEG is the gold standard for identification. It records behavior and brain activity simultaneously
• When EEG patterns don't correspond to seizure-like behaviors, PNES is likely

{{M}}Think of PNES like a fire alarm going off without any actual fire, the alarm system (behavior) activates, but the trigger (abnormal brain electrical activity) isn't present.{{/M}}

Factitious Disorder: The Intent to Deceive

This disorder comes in two forms:

Factitious Disorder Imposed on Self:

• Person falsifies or induces physical/psychological symptoms
• Presents themselves as ill or impaired
• Engages in deception even without obvious external rewards

Factitious Disorder Imposed on Another:

• Same as above, but symptoms are induced in another person (often a child by their parent)

Malingering: Not a Mental Disorder

This is crucial for the EPPP: Malingering is NOT a mental disorder. It's listed under "Other Conditions That May Be a Focus of Clinical Attention."

Key Distinction:

When to Suspect Malingering:

• Medical evaluation sought for legal reasons
• Marked discrepancy between reported symptoms and objective findings
• Uncooperative with evaluation or treatment
• Presence of Antisocial Personality Disorder

Detecting Feigned Symptoms

The forced-choice method is valuable for detecting malingering. It presents test items requiring selection from alternatives. {{M}}It's based on a simple principle: even random guessing should produce about 50% correct answers with true/false items. If someone scores significantly below chance (well under 50%), they must be deliberately choosing wrong answers.{{/M}}

Distinguishing Genuine from Feigned Memory Loss:

Assessment Tools:

Test of Memory Malingering (TOMM): Uses forced-choice format with images. Malingering is suggested when performance is significantly below chance (below 50% correct) or shows excessive impairment patterns atypical for genuine memory problems.

Common Misconceptions Students Have

Misconception 1: "PTSD only happens to combat veterans." Reality: PTSD can develop after any trauma involving actual or threatened death, serious injury, or sexual violence. Car accidents, assaults, natural disasters, medical emergencies, etc.

Misconception 2: "Dissociative amnesia is just 'forgetting' due to not paying attention." Reality: This is an inability to recall important personal information that far exceeds ordinary forgetting and is typically trauma-related.

Misconception 3: "People with Somatic Symptom Disorder are faking their symptoms." Reality: Their physical symptoms are real and distressing. The issue is excessive thoughts, feelings, and behaviors about these symptoms.

Misconception 4: "Critical incident stress debriefing helps prevent PTSD." Reality: Research shows it's ineffective and may actually worsen symptoms. This is a common wrong answer on the EPPP.

Misconception 5: "Factitious disorder and malingering are the same thing." Reality: Factitious disorder is a mental disorder involving deception without obvious external rewards. Malingering is intentional symptom production for external gain and is NOT a mental disorder.

Practice Tips for Remembering

For Trauma Disorders, remember the timeline:

• Acute Stress Disorder: 3 days to 1 month
• PTSD: More than 1 month
• Prolonged Grief: 12 months (adults) or 6 months (children/adolescents) after death

For RAD vs. DSED: Think withdrawal vs. indiscriminate friendliness

• RAD: child pulls away
• DSED: child goes toward everyone

For PTSD treatment hierarchy:

• First-line: CPT, PE, trauma-focused CBT (remember "CPT-PE-CBT")
• Second-line: CT, EMDR, NET
• NO first-line medications
• Avoid critical incident stress debriefing

For Dissociative Amnesia types, use the acronym LSSGC:

• Localized (most common)
• Selective
• Systematized
• Generalized
• Continuous

For Somatic vs. Illness Anxiety:

• Somatic Symptom Disorder = distressing physical symptoms PRESENT
• Illness Anxiety Disorder = symptoms absent or MILD, fear of disease dominates

For Factitious vs. Malingering:

• Factitious = no obvious external reward (internal psychological need)
• Malingering = clear external reward (money, drugs, avoiding consequences)
• Only factitious is a mental disorder

For detecting malingering: Remember forced-choice scoring below chance = deliberate wrong answers

Key Takeaways

• All Trauma/Stressor-Related Disorders require trauma/stress exposure as a diagnostic criterion
• PTSD involves four symptom categories: intrusion, avoidance, negative mood/cognition, and altered arousal/reactivity
• First-line PTSD treatments are CPT, PE, and trauma-focused CBT; no medications are first-line
• Critical incident stress debriefing is ineffective and potentially harmful
• Integrated treatments work better than sequential approaches for PTSD with comorbid substance use
• Dissociative disorders involve disruption in consciousness, memory, identity, or perception
• Localized amnesia (inability to recall events during a specific period) is the most common type
• Depersonalization/Derealization Disorder requires intact reality testing
• Somatic Symptom Disorder focuses on excessive responses to symptoms, not whether symptoms are "real"
• Conversion Disorder symptoms are incompatible with known medical/neurological conditions
• Video EEG distinguishes PNES from true epileptic seizures
• Factitious Disorder (a mental disorder) involves deception without obvious external rewards
• Malingering (NOT a mental disorder) involves intentional symptom production for external gain
• Forced-choice testing showing below-chance performance suggests malingering
• Genuine memory loss has gradual onset/termination; feigned memory loss often has sudden onset/termination

Understanding these disorders requires appreciating how trauma, stress, and psychological distress can manifest in diverse ways. From intrusive memories to disconnection from reality to unexplained physical symptoms. For the EPPP, focus on distinguishing similar disorders, knowing treatment hierarchies, and understanding the role of trauma exposure in diagnosis.