What is the prevalence of dissociative disorder as a comorbidity in bodily distress disorder and how is it treated?

Prevalence of Dissociative Disorder as a Comorbidity in Bodily Distress Disorder

Prevalence Data

The prevalence of dissociative disorders as a comorbidity in bodily distress disorder (somatic symptom disorder) is approximately 64%, with patients reporting an average of 12.4 somatic symptoms when dissociative disorders are present. 1

• In a controlled study of psychiatric inpatients with dissociative disorders, 64% met DSM-III criteria for somatization disorder, compared to 0% in matched comparison patients without dissociative symptoms 1
• A significant correlation exists between the degree of dissociation and the degree of somatization, indicating that more severe dissociative symptoms are associated with more severe somatic complaints 1
• Patients with dissociative disorders had significantly more medical hospitalizations and consultations compared to those without dissociative symptoms 1

Overlap with Complex PTSD Presentations

• Among patients with dissociative PTSD (33% of complex trauma patients), more than half (54-66%) meet criteria for one or more comorbid dissociative disorders, depending on assessment methods used 2
• Even among patients without PTSD, 24% had clinically significant dissociative symptoms (DES score ≥20), suggesting dissociation frequently co-occurs with other psychiatric presentations including somatic disorders 2

Treatment Approach

Trauma-focused psychotherapy should be implemented immediately as the primary treatment without delaying for a stabilization phase, as dissociative symptoms in the context of somatic symptom disorder represent a complex trauma presentation that responds best to direct trauma processing. 3

First-Line Psychotherapy

• Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), or Cognitive Processing Therapy (CPT) should be initiated immediately, producing 40-87% remission rates after 9-15 sessions even in complex presentations with dissociation and multiple comorbidities 3, 4
• These trauma-focused interventions work equally well regardless of childhood trauma history or presence of comorbidities, demonstrating no increased dropout rates or symptom worsening in complex cases 3, 4
• Integrate CBT principles specifically targeting medically unexplained somatic complaints concurrently with trauma-focused work, as psychological treatment based on CBT principles has demonstrated effectiveness for somatic symptom disorder 3

Managing Dissociative Symptoms During Treatment

• Alterations in attention and consciousness (dissociation) are part of the complex PTSD presentation and do not contraindicate immediate trauma-focused therapy 3
• Trauma-focused treatments are effective for patients with disturbances in affect regulation, relational capacities, and dissociation without increased risk of adverse effects 3
• Treatment for dissociative disorders is associated with decreased symptoms of dissociation, depression, PTSD, distress, and suicidality, with effect sizes in the medium to large range 5
• Patients with dissociative disorders who integrated their dissociated self states had reduced symptomatology compared with those who did not integrate 5

Pharmacotherapy Considerations

• Neither antidepressants nor benzodiazepines should be used as initial treatment for somatic complaints in the absence of a current depressive episode, as medication plays a limited adjunctive role 3
• If comorbid moderate-to-severe depression is present, consider adding an SSRI (fluoxetine or sertraline) or tricyclic antidepressant as adjunctive treatment 3
• Avoid benzodiazepines, as they carry increased risk of abuse/dependence and may worsen PTSD symptoms long-term 3, 4

Critical Clinical Pitfalls

• Delaying trauma-focused treatment is not supported by evidence and communicates to patients that they are "too fragile" for effective treatment, potentially having an iatrogenic effect by reducing self-confidence and motivation for trauma processing 3, 4
• Dissociative disorders are often under-recognized and undertreated despite being more prevalent than some commonly assessed psychiatric disorders (e.g., Bipolar Disorder, OCD, Schizophrenia), with patients spending an average of 5 to 12.4 years in treatment before receiving an accurate diagnosis 6
• Failure to assess for dissociative symptoms in patients presenting with somatic complaints leads to missed diagnoses and inappropriate treatment, as 61.82% of dissociative patients have psychiatric comorbidity including depression and anxiety 7
• Detection and treatment of trauma-related dissociation leads to improved quality of life, treatment outcomes, reduction in health and social risks, and decreased healthcare utilization and costs (25-64% reduction) 6