Somatoform Disorders

Table of Contents
  1. Introduction to Somatoform Disorder
  2. Body Dysmorphic Disorder (300.7)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments
  3. Conversion Disorder (300.11)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments
  4. Hypochondriasis (300.7)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments
  5. Pain Disorder (This is not considered a mental disorder so it is coded on Axis III with general medical conditions.)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments
  6. Somatization Disorder (300.81)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments
  7. Undifferentiated Somatoform Disorder (300.82)
    • DSM-IV-TR criteria
    • Associated features
    • Child vs. adult presentation
    • Gender and cultural differences in presentation
    • Epidemiology
    • Etiology
    • Empirically supported treatments
  8. Somatoform Disorder NOS (300.81)

2. Body Dysmorphic Disorder (300.7)
    • DSM-IV-TR criteria
      • A. Preoccupation with an imagined defect in appearance. If slight physical anomaly is present, the person’s concern is markedly excessive.
      • B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      • C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).
    • Associated features
      • The preoccupations associated with body dysmorphic disorder (BDD) are commonly described as being repetitive, excessive, obsessive, compulsive, ritualized, distressing, impairing, time-consuming, and somewhat less often, delusional. The similarities in descriptions of preoccupation frequently cause a misdiagnosis of obsessive-compulsive disorder (OCD), however, the comorbidity of OCD and BDD is relatively common. Other common comorbidities include, but not limited to; mood disorders (major depressive disorder), anxiety disorders (social phobia), substance use, eating disorders (anorexia nervosa), and personality disorders (borderline personality disorder). Examples of preoccupations include behaviors that seek to examine, improve, or hide perceived defects leading to time consuming functional impairments. Activities associated with preoccupations include obsessions in: grooming; mirror checking, hair brushing, hair styling, hair cutting, shaving, washing, and application of makeup. Camouflaging: wearing wigs, hats, make-up, sunglasses, extra clothing and changing body position to hide perceived defect. Medical procedures: numerous dermatological visits, and multiple cosmetic surgeries. Need for reassurance: mirror checking, asking others opinion, and excessive comparison to other people. Diet and exercise: excessive exercise, muscle dysmorphia, steroid usage; excessive diet, anorexia nervosa, and bulimia nervosa (eating disorders). The most common preoccupations of the body focus primarily on the skin, hair, and nose. People diagnosed with BDD typically have poor self-image/esteem, express shame in appearance, feel ugly, unlovable, and have a strong fear of rejection. Suicide ideation, attempts, and completion are significantly high in comparison to other mental disorders; however, the studies are few and only preliminary. Reasons for results suggest that suicidal risk is higher in patients with BDD. High suicidal risks are due to high rates of psychiatric hospitalization, comorbidity prevalence, being single and divorced, low self-esteem, poor social support, and having high levels of anxiety, depression, and hostility.
    • Child vs. adult presentation
      • Most research suggests that the onset of BDD begins in early adolescents, although, little research has been done regarding definite onset. The role of body image during pubertal change increases body focus and dissatisfaction. Adolescents typically present more often with body shape and weight concerns related to distress, as opposed to adult presentation of dissatisfaction of specific body parts (i.e., face and hair).
    • Gender and cultural differences in presentation
      • Most research suggest BDD in non-discriminative across gender lines. Some research suggests females are more likely to present with associated features resembling weight and shape concerns, eating disorders, and depressive disorders. Sociocultural influences include appearance related pressures. Socially constructed conceptions of perfection and/or beauty portrayed through the media affect both genders without bias. BDD exists in many cultures around the world. The areas having the most research conducted include the United States, Italy, and the United Kingdom. Studies pertaining to prevalence rates cross-cultures have been insignificant in number; the studies done suggest prevalence rate to be very similar.
    • Epidemiology
      • Several sources of research agree prevalence rates in the general population vary from 1% - 2%. Prevalence rates tend to increase in clinical settings. Prevalence rates in the medical population of dermatology increase to 11.9%, and in the cosmetic surgery population, an increase of 2% - 7%. People suffering with BDD typically present to cosmetic surgeons for correction of perceived bodily flaw, and inevitably receive no satisfaction or relief from disorder.
    • Etiology
      • The onset of BDD generally begins around the pubertal time of adolescents. The disorder is more commonly chronic and unremitting than it is not. The course of this disorder follows a continuous lifetime course, in that it is very unlikely for full remission to occur with treatment. Suicidal have higher rates for this disorder than other mental disorders. However, there are some evidence that the etiology of Body Dysmorphic Disorder is still unknown. There has been links made to OCD due to some similarities in serotonin malfunction and though preoccupation.
    • Empirically supported treatments
      • Serotonin dysregulation seems to be common among patients with BDD. Selective serotonin reuptake inhibitor (SSRI) (i.e., fluoxetine hydrochloride, otherwise known as Prozac) drugs have been empirically proven to decrease the symptoms associated with BDD. Another empirically supported approach is cognitive behavioral therapy (CBT). A combination of SSRI and CBT is the common approach to BDD.
      • Behavioral and/or cognitive-behavioral techniques are typically used to change abnormal activities like avoidance behavior, reassurance seeking, checking, and excessive grooming. For example, exposure in vivo can be used to help people with BDD become more comfortable exposing themselves to social situations.
      • Another treatment that is sort of under the radar is the idea of plastic surgery. Almost 50% of people with BDD go under the knife to correct what they have a problem with on their body too.

3. Conversion Disorder (300.11)
    • DSM-IV-TR criteria
      • A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
      • B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflict or other stressors.
      • C. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
      • D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.
      • E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of function or warrants medical evaluation.
      • F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.
    • Associated features
      • Some people with Conversion Disorder may display la belle indifference. This is a relative lack of worry about their condition or its implications. Other people may act in a dramatic or histrionic manner though.
      • Individuals being treated for Conversion Disorder may develop dependency issues and embrace an ailing role during the course of their treatment.
      • Symptoms caused by Conversion Disorder usually conflict with established anatomical or physiological knowledge and explanations. Therefore, objective signs that indicate the presence of a traditional abnormality are frequently absent.
      • Laboratory analyses of the condition typically do not yield any findings as well. The absence of any findings is a feature that may indicate that Conversion Disorder is the actual source of the problem(s).
      • Dissociative Disorders, Major Depression, and Histrionic, Antisocial, Borderline, and Dependent Personality Disorders are mental disorders than can be associated with Conversion Disorder.
      • Child vs. adult presentation
        • The symptoms that children with conversion disorder experience are frequently limited to seizure or gait problems. There is a wide range of symptoms that adults with Conversion Disorder may experience. These symptoms may include the loss of sensation, paralysis, blindness, seizures, or a mixed presentation.
    • Gender and cultural differences in presentation
      • Conversion disorder is diagnosed more frequently in women than in men. An exact ratio has not been established, but most studies indicate that the ratios range between 2:1 and 10:1. It is more common for women with Conversion Disorder to eventually develop Somatization Disorder, but there is a strong relation between Conversion Disorder and Antisocial Personality Disorder among men. It is common for men who experience Conversion Disorder to have suffered an industrial accident or to have been in the Military. It is much more common for women to experience symptoms on the left side of their body than in their right side.
      • There are various links between Conversion Disorder and cultural factors. People in rural settings, lower socioeconomic levels, and with relatively less knowledge of psychology and medicine are diagnosed with Conversion Disorder more frequently than other populations. There is a higher incidence of Conversions Disorder in developing regions than in developed regions, and reports from the developing regions decrease as further development occurs. The conversion symptoms displayed by patients may vary based on their culturally accepted means of demonstrating distress. One must be aware that the religious and healing rituals of certain cultures may include characteristics that could be confused with symptoms of Conversion Disorder.
    • Epidemiology
      • The prevalence of Conversion Disorder varies according to multiple reports, but the rates generally range from 11/100,000 to 500/100,000 in samples from the general population. About 3% of mental health clinic referrals are due to Conversion Disorder. Conversion Disorder is more likely to develop among older adolescents or young adults, women, and people from lower socioeconomic classes.
    • Etiology
      • The exact cause of Conversion Disorder has not been established by empirically supported data, but there are some theories about its development. Many contemporary theories claim that the development of Conversion Disorder is often sudden, and it is triggered by subconscious conflict, unresolved grief, sexual trauma, or other stressful situations. In essence, these theories state that people with Conversion Disorder convert their psychological distress into physical symptoms to avoid any further mental anguish. Disturbances in the central nervous system may increase the likelihood and/or severity of any somatic symptoms.
      • Other factors may influence the development of Conversion Disorder. There is some evidence that Conversion Disorder may be genetically transmitted, but there is not enough data to prove this conclusively. Socioeconomic factors are also known to influence the development of this disorder, but the exact manner in which they impact an individual has not been definitively identified.
    • Empirically supported treatments
      • There are no empirically supported treatments for Conversion Disorder, but there are a couple of methods that are believed to help people with this disorder. The most common methods are behavioral or cognitive behavioral treatments. Treatment plans need to be individualized due to the varying symptoms of each person, but there are some general guidelines. It is important to discover any psychological stressors an individual may have that precipitate somatic symptoms to cope with them. It is vital to help individuals recognize these stressors and to help them learn more adaptive methods for dealing with them. Manipulation of the patient’s social environment may be necessary in order to reinforce the patient’s non-symptomatic behavior. Physiotherapy is also a technique used to treat Conversion disorder. This therapy involves maintaining and restoring maximum movement and ability throughout life.

4.Hypochondriasis (300.7)
  • DSM -IV-TR criteria
    • A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms B. The preocupation persists despite appropriate medical evaluation and reassurance.
      C. The belief in Criteria A is not a delusional intensity ( as in Dulusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearace(as in Body Dysmorphic Disorder).
      D. The preoccupation cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
      E. Duration of disturbance at least six months.
      F The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obssessive- Cumpulsive Disorder, Panic Disorder, a Major Depressive episode, Separation Anxiety or other Somatoform Disorder.
    • Specify if: With Poor Insight**:if for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is execessive or unreasonalble..
  • Associated Features
    • fear of aging and death. They place a greater importance on physical health, but they do not have better health habits than someone who does not have a disorder. Doctor relationships deteriorate with frustration and anger towards each other. This deterioration could be due to the fact that even when a medical examination proves that there is nothing wrong, the patient continues to believe he or she is sick Social relationships become strained.
    • A person interprets physical symptoms and feelings as signs of a serious medical illness in spite of medical assurance that they are not.
    • May be especially concerned about a particular organ system (such as the cardiac or digestive system).
    • They usually present their medical record in great detail.
    • Individuals suffering from Hypochondriasis generally need to be under constant reassurance from family, friends, and doctors. Certain individuals suffering from this disorder rarely speak about there anxieties whereas other individuals constantly talk about there anxieties.
    • Anxiety, clinical depression, phobias, somatization disorder and obsessive-compulsive personality traits are frequently observed.
  • Epidemiology
    • The prevalence of Hypochondriasis in the general population is 1%-5%. Among primary care outpatients, estimates of current prevalence range from 2% to 7%.
  • Etiology
    • Serious illnesses, particularly in childhood, and past experience with disease in a family member are associated with the occurrence of Hypochondriasis. Psychosocial stressors, in particular the death of someone close to the individual, are thought to precipitate the disorder in some cases.
  • Empirically supported treatments
    • The physician and his or her team's attention, concern, interest, careful listening, and nonjudgmental stance, which can potentially break a pathological cycle of maladaptive interactions between the patient and movement from physician to physician. Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs such as fluoxetine and paroxetine) are also treatments that have proven to be useful in treating Hypochondriasis. SSRIs generally diminish the anxiety through changing the nuerotransmitter levels to a more compatible level.

6. Somatization Disorder (300.81)
DSM-IV-TR criteria
A. History of multiple medical complaints that persits for several years, beginning before age 30.
B. At least 13 symptoms from the list below which meet the following criteria:
1. no organic pathology or pathophysiological mechanism to account for symptoms, or, when organic pathology is present, the complaint or impairment is frossly in excess of what would be expected.
2. has not occurred only during a panic attack.
3. has caused the individual to take medication(other than over the counter pain medication), see a doctor, or alter lifestyle.
Associated features