ORIGINAL ARTICLES
Somatoform Dissociation and Adverse Childhood
Experiences in the General Population
Päivi Maaranen, MD, Antti Tanskanen, MD, Kaisa Haatainen, MHSc, Heli Koivumaa-Honkanen, MD,
Jukka Hintikka, MD, and Heimo Viinamäki, MD
Abstract: Childhood trauma has been associated with psychological
dissociation, but there is evidence that trauma may also result in
somatoform dissociation. We performed a general population study
with 1739 subjects, using the Somatoform Dissociation Question-
naire, measures of adverse childhood experiences, and sociodemo-
graphic background. The prevalence of high somatoform dissocia-
tion (Somatoform Dissociation Questionnaire ⱖ30) was 9.4% in the
Finnish general population. Unemployment, a reduced working
ability, and a poor financial situation were associated with high
somatoform dissociation. Of the adverse childhood experiences,
high somatoform dissociation was strongly linked to physical pun-
ishment but not associated with domestic violence, including sexual
and physical abuse. The odds of high somatoform dissociation were
also increased among men by a poor relationship between their
parents, and among women by alcohol abuse in their childhood
home. We found a strong, graded relationship between an increasing
number of adverse childhood experiences and high somatoform
dissociation.
(J Nerv Ment Dis 2004;192: 337–342)
S omatoform dissociation is manifested in a loss of the
normal integration of somatoform components of experi-
ence, bodily reactions, and functions (Nijenhuis, 2000). The
symptoms can be divided into negative and positive disso-
ciative symptoms. The negative symptoms include several
types of sensory and motor control loss, such as insensitivity
to pain or difficulties with swallowing. The positive symp-
toms include intrusions such as side-specific pain or alter-
ations of senses (Nijenhuis et al., 1999; Nijenhuis, 2000).
Somatoform dissociation is not, however, a somatic disorder,
but like psychological dissociation, it involves a disturbance
of mental function. The descriptor somatoform indicates that
Department of Psychiatry, Kuopio University Hospital, Kuopio, Finland.
Send reprint requests to Dr. Päivi Maaranen, MD, Research and Develop-
ment Unit, Department of Psychiatry Kuopio University Hospital, P. O.
Box 1777, FIN-70211, Kuopio, Finland.
Copyright © 2004 by Lippincott Williams & Wilkins
ISSN: 0022-3018/04/19205-0337
DOI: 10.1097/01.nmd.0000126700.41047.83
The Journal of Nervous and Mental Disease • Volume 192, Number 5, May 2004
the physical symptoms resemble, but cannot be explained by,
a medical symptom or the direct effect of a substance (Ni-
jenhuis, 2000).
Earlier studies of psychological dissociation have
shown that patients with dissociative disorder have many
somatic symptoms (Ross et al., 1989, 1990; Saxe et al.,
1994), and somatization has been strongly associated with
psychological dissociation (Nemiah, 1991; Van der Kolk et
al., 1996). Through the development of a 20-item self-report
questionnaire, the Somatoform Dissociation Questionnaire
(SDQ; Nijenhuis et al., 1996, 1998a, 1999), it has become
possible to study the somatoform component of dissociation.
It has been shown that somatoform dissociation is a unique
construct unrelated to general levels of psychopathology
(Nijenhuis et al., 1999). To our knowledge, there have been
no earlier studies of somatoform dissociation in a general
population sample, and the previous findings of the sociode-
mographic factors associated with somatoform dissociation
have come from clinical samples (Sar et al., 2000).
The SDQ has been used in a number of trauma studies,
and the results have shown associations between somatoform
dissociation and physical and sexual abuse (Nijenhuis et al.,
1998b; Waller et al., 2000). These studies have been per-
formed using small patient groups. The relationship between
childhood traumatic experiences and somatoform dissocia-
tion has also been examined in patients with conversion
disorder (Roelofs et al., 2002) and chronic pain (Yüsel et al.,
2002).
Relatively little is known about the impact of adverse
childhood experiences (ACEs) on mental health in a general
population. In a large ACE study (Felitti et al., 1998), the
categories of ACEs were strongly interrelated, and people
with multiple categories of childhood exposure were likely to
have multiple health risk factors in later life. A positive,
graded relationship between ACEs and hopelessness (Haa-
tainen et al., 2003) and attempted suicide (Dube et al., 2001)
has been found at the population level. However, the rela-
tionship between somatoform dissociation and ACEs has not
been examined in the general population.
337
Maaranen et al. The Journal of Nervous and Mental Disease • Volume 192, Number 5, May 2004
The purpose of our study was as follows: to 1) measure
the prevalence of high somatoform dissociation in the general
population using the SDQ, 2) characterize basic sociodemog-
raphy associated with high somatoform dissociation, and 3)
assess the relationship between high somatoform dissociation
and both single and cumulative ACEs.
MATERIALS AND METHODS
Subjects
The study was conducted in the district of Kuopio,
which is located in central-eastern Finland. Our population
sample included 2,945 subjects living in that area, ages 26 to
65 years, randomly selected from the National Population
Register. Study questionnaires were mailed in May to June
1999. A total of 1,767 questionnaires were returned, for a
response rate of 60.0%. Because of incomplete data, 28
subjects were excluded from the analysis. Thus, the final
sample (N ⫽ 1739) included 742 (42.7%) men and 997
(57.3%) women. The mean age of the respondents was higher
than that of the nonrespondents (45.0 关SD ⫽ 10.5兴 years vs.
41.9 关SD ⫽ 10.6兴 years; t ⫽ 8.0; df ⫽ 2943; p ⬍ .001). More
men than women did not participate (48.8% vs. 33.7%;
chi-square ⫽ 70.7; df ⫽ 1; p ⬍ .001). The nonresponding
men were significantly younger than the responding men
(41.9 关SD ⫽ 10.4兴 vs. 45.6 关SD ⫽ 10.1兴 years; t ⫽ – 6.9; p ⬍
.001), but no such difference was found among women.
Approval for the study was obtained from the Ethics Com-
mittee of Kuopio University Hospital and the University of
Kuopio.
Methods
Somatoform Dissociation
The level of somatoform dissociation was estimated
with a Finnish version of the SDQ (Nijenhuis et al., 1996).
The SDQ is a 20-item self-report questionnaire in which a
people are asked to identify to what extent each statement is
applicable to them. Items include such statements as, “My
body, or part of it, feels numb,” “I can’t swallow, or only with
great effort,” and “My body, or part of it, is insensitive to
pain.” The score corresponding to the response to each
statement ranges from 1 to 5, and the total score ranges from
20 to 100. The SDQ has not been used in general population
studies, but there are some indications from studies with
different patient groups of the cutoff point that could be
optimal (Nijenhuis et al., 1999; Sar et al., 2000). These
studies have included patients with dissociative disorder,
patients from other diagnostic categories, and nonclinical
participants. With a cutoff point of 30 in a patient study,
patients with DSM-IV dissociative disorders were discrimi-
nated from psychiatric patients with other disorders with a
sensitivity of 0.90 and a specificity of 0.75 (Sar et al., 2000).
We also selected a cutoff point of 30 in the SDQ to divide the
338
sample into subjects with high somatoform dissociation
(SDQ ⱖ30) and subjects with normal somatoform dissocia-
tion (SDQ ⬍30).
Adverse Childhood Experiences
Six questions were used to assess ACEs (Haatainen et
al., 2003). The alternative answers and their classification are
presented in parentheses after each question.
Poor Relationship Between Parents
The relationship between parents was determined with
the question, “What was the relationship between your par-
ents like in your childhood and adolescence?” (good, fairly
good, versus don’t know, fairly poor, poor, and quarrelsome).
Unhappy Childhood Home
Happiness of childhood home was defined with the ques-
tion, “Was your childhood home happy?” (no versus yes).
Hard Parenting
Hard parenting was assessed with the question, “What
was the parenting like?” (gentle, fairly gentle, versus fairly
hard, hard).
Physical Punishment
Physical punishment (e.g., pulling one’s hair, spanking,
birching) was investigated with the question, “If you were
physically punished under 15 years of age, by whom did it
happen?” (yes, by father, by mother, by both parents, by
somebody else, versus no, I was not physically punished).
Domestic Violence
Domestic violence was estimated with the question,
“Have you suffered from domestic violence directed to you in
your childhood or adolescence?” (yes, physical violence,
sexual violence, both physical and sexual violence, versus no,
I have not suffered from domestic violence).
Alcohol Abuse at Home
Alcohol abuse at home was assessed with the question,
“Did anybody misuse or abuse alcohol in your childhood
home?” (yes, father, mother, both parents, somebody else,
versus no, nobody).
Correlation analysis showed the strongest correlations
between unhappiness of the childhood home and poor rela-
tionship between parents (r ⫽ 0.61, p ⬍ .01) and between
unhappiness of the childhood home and domestic violence
(r ⫽ 0.39, p ⬍ .01). In multiple logistic regression analysis,
all ACEs mentioned were studied independently and by cluster-
ing them into three categories (none, one to three, four to six).
Sociodemographic Background
Questions were asked about the sociodemographic
background (age, sex, marital status, and place of residence)
of the subjects. In addition, one question was asked about
© 2004 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 192, Number 5, May 2004 Somatoform Dissociation and Childhood

each of the following factors: years of education (high, ⱖ9, TABLE 1. Prevalence (%) of high somatoform dissociation
versus low, ⬍9); employment status (employed, on sick (SDQ ⱖ30) according to sex and selected sociodemographic
leave, or student, versus unemployed); working ability (good variables
versus reduced or unable to work); and financial situation
(good or fairly good versus fairly poor or poor). Prevalence, %
Men Women Total
Statistical Analysis Variable (N ⴝ 742) (N ⴝ 997) (N ⴝ 1739)
The statistical methods included the Pearson chi-square
Age (y)
test for categorical variables, the independent samples t test for
26–35 7.4 6.4 6.7
continuous variables, and the Mantel-Haenszel test for linear-
36–45 8.5 8.2 8.3
by-linear associations. The nonparametric Mann-Whitney U test
46–55 11.4 8.1 9.6
was used to analyze the between-group difference in the mean
56–65 16.8** 10.5 13.2**
SDQ scale score because of the skewed distribution of this
Marital status
variable. The Pearson correlation was measured between the
Married 10.0 8.5 9.2
ACEs. Multiple logistic regression analysis was used to identify
Single, divorced, 14.5 7.8 10.3
factors independently associated with high somatoform dissoci- widowed
ation. Data analysis was conducted with SPSS 11.0. Place of residence
Urban 11.4 7.5 9.1
RESULTS Rural 10.2 10.4 10.3
The prevalence of high somatoform dissociation was Education
9.4% in the total sample and was higher among men than High (ⱖ9 y) 9.5 7.6 8.4
women (Table 1). The prevalence of high somatoform disso- 18.2**
Low (⬍9 y) 13.0* 15.7***
ciation in the total sample increased with age, low education, Employment status
unemployment, a reduced working ability, and a poor finan- Employed, on sick leave, 9.8 7.6 8.5
cial situation. or student
The mean SDQ score was 23.3 (SD ⫽ 6.1) in the total Unemployed 22.1** 14.3* 17.5**
sample, and the mean score of men was higher than that of women Working ability
(23.8 关SD ⫽ 6.9兴 vs. 22.9 关SD ⫽ 5.3兴; p ⫽ .002; data not shown). Good 5.2 4.3 4.7
High somatoform dissociation was more prevalent Reduced 22.1*** 15.7*** 17.9***
among women with different ACEs, except for a poor rela- Financial situation
tionship between parents (Table 2). Among men, high so- Good 8.1 6.2 7.0
matoform dissociation was associated with a poor relation- Poor 21.5* 17.4*** 19.4***
ship between the parents, an unhappy childhood home, and Total 11.1a 8.2a 9.4
physical punishment. *
p ⬍ .05.
In multiple logistic regression models (Table 3), when **
p ⬍ .01.
both the sociodemographic variables and ACEs were in- ***
p ⬍ .001.
cluded, a reduced working ability, a poor financial situation,
a
Difference between men and women, p ⫽ .047.
and physical punishment were associated with high somato-
form dissociation in both sexes. There were some differences
between men and women: A poor relationship between par- tween high somatoform dissociation and an increasing num-
ents increased the odds of high somatoform dissociation ber of ACEs in both genders. As a large ACE study (Dube et
among men and alcohol abuse in their childhood home al., 2001; Felitti et al., 1998) has shown, simultaneously
among women. considering the impact of multiple experiences is important,
The prevalence of high somatoform dissociation in- because ACEs are strongly interrelated and also related to
creased linearly with an increasing number of ACEs in both poor mental health. A review article in which adult retrospec-
sexes (Table 4). The adjusted relative risk of high somato- tive reports of more than one form of child maltreatment were
form dissociation increased threefold in men and more than assessed also showed that the maltreatment types do not
fivefold in women with four to six ACEs. occur independently, and that a significant proportion of
people do not just experience repeated episodes of one type
DISCUSSION of maltreatment but are likely to be victims of other forms of
In addition to the associations between single ACEs abuse and neglect (Higgins and McCabe, 2001). In a recent
and somatoform dissociation, we measured the impact of study (Roelofs et al., 2002), patients with conversion disorder
multiple ACEs and found a strong, graded relationship be- with multiple traumatization had more severe somatoform

© 2004 Lippincott Williams & Wilkins 339

Maaranen et al. The Journal of Nervous and Mental Disease • Volume 192, Number 5, May 2004

TABLE 2. Prevalence (%) of ACEs according to sex and level of somatoform dissociation

Men Women
Somatoform dissociation Somatoform dissociation
Normal High All Normal High All
ACEs N ⴝ 660 N ⴝ 82 N ⴝ 742 p-Valuea N ⴝ 915 N ⴝ 82 N ⴝ 997 p-Valuea

Poor relationship between parents 17.8 29.3 19.1 .013 21.7 30.4 22.4 NS
Unhappy childhood home 11.7 21.0 12.8 .019 16.3 33.8 17.7 ⬍.001
Hard parenting 39.5 50.0 40.6 NS 41.5 61.0 43.1 .001
Physical punishment 69.2 81.7 70.6 .019 53.0 72.0 54.6 .001
Domestic violence 10.3 17.1 11.1 NS 9.8 24.4 11.0 ⬍.001
Alcohol abuse at childhood home 28.9 30.9 29.1 NS 27.6 42.7 28.8 .005
a
Differences between normal and high somatoform dissociation.

TABLE 3. Adjusted odds ratios (AORs) for high somatoform dissociation (SDQ ⱖ30) in separate multiple logistic regression
models for men, women, and all subjects

Men (N ⴝ 719)a Women (N ⴝ 951)b All (N ⴝ 1670)c

Variable AOR (95% CI)d p-Value AOR (95% CI) p-Value AOR (95% CI) p-Value

Age, y 1.00 (0.97–1.03) NS 1.00 (0.97–1.01) NS 1.00 (0.98–1.02) NS

Single, divorced, widowed 1.08 (0.61–1.94) NS 0.82 (0.48–1.43) NS 0.91 (0.61–1.34) NS
Rural residence 0.69 (0.38–1.24) NS 1.33 (0.57–2.28) NS 0.96 (0.65–1.41) NS
Low education 1.35 (0.72–2.55) NS 1.14 (0.57–2.29) NS 1.12 (0.78–1.96) NS
Unemployed 1.41 (0.67–2.98) NS 1.80 (0.92–3.53) NS 1.64 (1.00–2.67) .048
Reduced working ability 4.36 (2.35–8.10) ⬍.001 3.68 (2.04–6.65) ⬍.001 3.96 (2.59–6.03) ⬍.001
Poor financial situation 2.19 (1.25–3.84) .006 2.31 (1.33–4.01) .003 2.26 (1.54–3.32) ⬍.001
Poor relationship between parents 2.18 (1.08–4.42) .030 0.51 (0.23–1.13) NS 1.10 (0.65–1.85) NS
Unhappy childhood home 0.94 (0.41–2.11) NS 2.11 (0.93–4.80) NS 1.36 (0.77–2.40) NS
Hard parenting 0.90 (0.51–1.60) NS 1.31 (0.74–2.36) NS 1.05 (0.71–1.56) NS
Physical punishment 2.29 (1.17–4.50) .016 2.12 (1.17–3.83) .013 2.26 (1.46–3.48) ⬍.001
Domestic violence 1.04 (0.46–2.35) NS 1.24 (0.60–2.58) NS 1.13 (0.66–1.92) NS
Alcohol abuse at home 0.71 (0.39–1.28) NS 1.77 (1.03–3.03) .039 1.14 (0.77–1.69) NS
a
Missing cases because of incomplete data (N ⫽ 23).
b
Missing cases because of incomplete data (N ⫽ 46).
c
Missing cases because of incomplete data (N ⫽ 69).
d
Confidence interval.

dissociative symptoms than those who reported only one type
of traumatization.
Previous research has shown a relationship between
physical and sexual abuse and adult somatoform dissociation
(Nijenhuis et al., 1998b). Recently, it has been suggested that
somatoform dissociation would be more clearly associated
with physical abuse in cases in which there is a threat of
inescapable physical injury, and somatoform dissociation
could be understood as a set of adaptive psychophysiological
responses to trauma (Waller et al., 2000). Our results partly
support these findings, because we found a strong relation-
ship between somatoform dissociation and physical punish-
ment among both men and women. However, domestic vio-
lence, including both sexual and physical violence in
childhood, was not associated with high somatoform disso-
ciation in our population-based sample. Domestic violence
had statistically a significant bivariate association with high
somatoform dissociation among women, but the relationship
was not found in multiple logistic regression analysis.
In previous childhood trauma studies, physical abuse
has included all kinds of physical violence and punishment in
childhood (Roelofs et al., 2002; Waller et al., 2000), or
culturally accepted physical punishment has not even been
rated as abusive (Pasquini et al., 2002). Physical (or corporal)

340 © 2004 Lippincott Williams & Wilkins

The Journal of Nervous and Mental Disease • Volume 192, Number 5, May 2004
TABLE 4. Prevalence (%) and adjusteda relative risk of high somatoform dissociation (SDQ ⱖ30) according to sex and the
number of ACEs
Number of adverse Prevalence of
childhood high somatoform
experiences dissociation, % p-Valueb
Men (N ⫽ 733)d
0 5.1
1–3 10.9
4–6 19.4 .001
Women (N ⫽ 982)e
0 3.4
1–3 8.0
4–6 16.6 ⬍.001
a
Adjusted for age, marital status, place of residence, education, employment status, working ability, and financial situation.
b
p-Value for linear association.
c
p-Value compared with the reference category.
d
Missing cases because of incomplete data (N ⫽ 9).
e
Missing cases because of incomplete data (N ⫽ 15).
punishment is defined as the use of physical force with the
intention of causing a child to experience pain, but not injury,
for the purpose of correction or control of the child’s behavior
(Straus, 2000). In Finland, physical punishment has been
criminalized, and we consider it abusive for the child. Phys-
ical punishment has been shown to increase a risk of the child
developing major social and psychological problems, such as
antisocial behavior (Straus et al., 1997), depression, and
alcoholism (Holmes and Robins, 1988). Physical punishment
is also a risk factor for physical abuse (Straus, 2000). It can
be considered a long-term childhood adversity that exposes a
child to recurrent experiences of pain and a threat to physical
well being. Somatoform dissociative symptoms can be un-
derstood as adaptive responses to repeated episodes of phys-
ical punishment.
Adverse childhood experiences other than physical
punishment also revealed significant associations with high
somatoform dissociation. A poor relationship between par-
ents predicted high somatoform dissociation among men and
parental alcohol abuse predicted it among women. It has been
found that children in alcoholic households are more likely to
suffer from other forms of ACEs, and depression among adult
children of alcoholics appears to be largely, if not solely, a
result of the greater likelihood of having had ACEs in a home
with alcohol-abusing parents (Anda et al., 2002). In our
study, women were more vulnerable to parental alcoholism,
showing more somatoform dissociative symptoms in adult-
hood. According to our results, factors other than just a
specific threat of physical injury also have implications for
high somatoform dissociation.
To our knowledge, no previous studies have examined
somatoform dissociation in a general population. The preva-
© 2004 Lippincott Williams & Wilkins
Somatoform Dissociation and Childhood
Adjusted relative risk of high
somatoform dissociation (95%
confidence interval) p-Valuec
1.00 (Reference)
2.03 (0.83–4.95) NS
3.05 (1.11–3.36) .030
1.00 (Reference)
2.65 (1.16–6.04) .021
5.43 (2.22–13.28) ⬍.001
lence of high somatoform dissociation was quite high, sug-
gesting that somatoform dissociative symptoms are rather
common at the population level. To compare our results with
those of clinical studies is difficult. We found that men scored
significantly higher than women in the SDQ, and the scores
increased with age, findings contrary to previous studies in
which gender and age did not affect the SDQ scores (Nijen-
huis et al., 1996, 1998a). More men than women did not
participate in the study, and the nonresponding men were
younger than the responding men, but no such difference was
found among women. This might have influenced the sex
difference observed by raising the mean SDQ score among
men. There is also a possibility that older, less educated
subjects could report more frequent somatic symptoms, and
this might also have influenced the results, although it has
been shown in a previous study that somatoform dissociation
cannot be equated with a tendency to report physical com-
plaints (Nijenhuis et al., 1999). The oldest subjects in our
sample were born just before and during World War II. The
traumatization of World War I combat soldiers with an
unprecedented incidence of somatoform dissociation disor-
ders and symptoms has been studied (Van der Hart et al.,
2000). The years during World War II were also a time of
suffering and fear for civilians, including children. In this
respect, the high prevalence of somatoform dissociation in
the elderly subjects could be partly a result of wartime
traumatization. There was a similar trend with the sociode-
mographic factors to our results in a Turkish patient study
(Sar et al., 2000), in which a weak positive correlation
between high somatoform dissociation and older age was
found, with negative correlations between high somatoform
dissociation and education or socioeconomic status. In our
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Maaranen et al. The Journal of Nervous and Mental Disease • Volume 192, Number 5, May 2004
study, high somatoform dissociation associated bivariately
with older age, unemployment, low education, a reduced
working ability, and a poor financial situation.
Earlier studies with different diagnostic patient groups
gave some indications of the optimal cutoff point to identify
subjects in a general population with a significant level of
somatoform dissociation. A higher cutoff point would prob-
ably have increased the specificity in discriminating subjects
with dissociative disorders, which is more appropriate for
selected patient samples (Yüsel et al., 2002).
The use of a random, general population-based sample
and a satisfactory response rate were strengths in our study.
Clinical samples have often included mainly female subjects
(Nijenhuis et al., 1998a, 1998b; Waller et al. 2000), which
may give different results for associations between dissocia-
tion and its risk factors. Another strength of our study was
that we included multiple types of childhood adverse expe-
riences, all assessed individually and in clusters. This design
revealed a strong association between multiple ACEs and
high somatoform dissociation.
Our method of assessing the ACEs may contain some
weaknesses. Instead of asking only one question about each
of the ACEs, multiple questioning could have given more
information on the nature of the relationships between single
ACEs and somatoform dissociation. However, false-positive
answers to the questions concerning ACEs are unlikely, and
we have more reason to believe underreporting took place,
because it might have been difficult to answer intimate
questions concerning family history. There is always a pos-
sibility of recall bias in remembering and reporting childhood
experiences. A cross-sectional study design has its own
limitations, especially in giving theoretical explanations for
the results. Our findings represent associations between vari-
ables that are not necessarily causal relationships, and con-
clusions must be drawn with caution.
CONCLUSIONS
We found a graded, positive relationship between an
increasing number of the ACEs and high somatoform disso-
ciation. There was a strong relationship between physical
punishment and high somatoform dissociation among both
men and women. Factors associated with family pathology
were also significant, providing evidence of the complex
issue of somatoform dissociation and ACEs. Somatoform
dissociative symptoms should be assessed more often among
treatment-resistant patients with somatization in mental
health care.
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