Somatoform Disordersexternal image c.gif

1. Introduction


  • Somatoform disorders encompass many mental health disorders. People with these disorders believe that they are sick so they are not "faking" the illness. There is no general medical condition present rather psychological problems are being translated into physical complaints. The people that have this disorder have many symptoms that last for a long time due to the specific cause not being found.
  • Somatization, the physical expression of emotional distress, is a process and not a disorder unless it interferes with comfort, work and quality of life to the degree that it leads to consultation with physicians, use of medication, and adoption of the sick role (Lipsitt, & Starcevic, 2006).
  • These disorders cause stress on all of the patient's relationships as the patient is the only one who is able to "see/feel" the afflicting illness. Diagnosis is difficult because the doctors must be completely sure that a real illness is indeed affecting the patient. Those who suffer from these disorders will often never see just one doctor. This distrust may leak into other relationships as well.
  • Somatization gained widespread currency when it was introduced as a psychiatric diagnostic term by the authors of the DSM-III in 1980 (Mai, 2004).
  • It has been proposed that this group of disorders will be renamed Somatic Symptoms Disorder in the DSM-V. These disorders share a common feature in that they all involve both somatic symptoms and psychological concerns for medical condition. Thus, a more appropriate label is proposed.

Quick Facts

  • 1 in every 500 adults report having a Somatoform Disorder.
  • Roughly 544,00 people in the United States.
  • Comorbidty with Substance use/abuse, anxiety disorder, and mood disorders.
  • May also be known as also known as Briquet's syndrome

USMLE - Somatoform Disorder Video


2. Body Dysmorphic Disorder (300.7)


CNN Report With Behavioral Therapist Arie Winnograd

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).
    • BDD has a delusional form that is classified in the psychosis section of DSM-IV (Didie, Kelly, & Phillips, 2010).

  • Barlow and Durand (2009) give an example of BDD:
In his mid-20s, Jim was diagnosed with suspected social phobia; he was referred to our clinic by another professional. Jim had just finished rabbinical school and had been offered a position at a synagogue in a nearby city. However, he found himself unable to accept because of marked social difficulties. Lately he had given up leaving his small apartment for fear of running into people he knew and being forced to stop and interact with them.
Jim was a good-looking young man of about average height, with dark hair and eyes. Although he was somewhat depressed, a mental status exam and a brief interview focusing on current functioning and past history did not reveal any remarkable problems. There was no sign of a psychotic process (he was not out of touch with reality). We then focused on Jim's social difficulties. We expected the usual kinds of anxiety about interacting with people or "doing something" (performing) in front of them. But this was not JIm's concern. Rather, he was convinced that everyone, even his good friends, were staring at a part of his body that he found grotesque. He reported that strangers would never mention his deformity and his friends felt too sorry for him to mention it. Jim thought his head was square! Like the Beast in Beauty and the Beast who could not imagine people reacting to him with anything less than revulsion, Jim could not imagine people getting past his square head. To hide his condition as well as he could, Jim wore soft floppy hats and was most comfortable in winter, when he could all but completely cover his head with a large stocking cap. To us, Jim looked normal.
  • Associated features
    • 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. Many patients with BDD believe that their deformities make them unacceptable as a person (Didie et al., 2010). Suicide idealization, 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. Suicide attempts are as high as 24%-28% with ideation as high as 78%-81% (Didie et al., 2010). BDD lifetime rate of suicide attempts is an estimated 5.2 times higher than in the general U.S. adolescent population (Phillips, Didie, Menard, Pagano, Fay, & Weisberg, 2006).
    • BDD preoccupations are time-consuming, occurring on average 3 to 8 hours per day (Didie et al., 2010).
  • 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).
    • In general adolescents and adults do not differ significantly on most characteristics (Phillips et al., 2006).
  • 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 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 suggest prevalence rate to be very similar.


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    • Epidemiology
      • BDD is relatively common with prevalence rates from 0.7% to 2.4% in the general population (Didie et al., 2010).
      • Prevalence rates tend to increase in clinical settings. Prevalence rates in the medical population of dermatology increase to 9%-12%, and in the cosmetic surgery population, an increase of 3%-53% (Didie et al., 2010).
      • BDD is relatively common in outpatients with OCD (8% to 37%); social phobia (11% to 13%); trichotillomania (26%); and atypical major depressive disorder (14% to 42%) (Didie et al., 2010).
    • Etiology
      • Body Dysmorphic Disorder usually begins during adolescence but can begin during childhood. About 70% of patient's experience onset of BDD before 18 years (Didie et al., 2010). The disorder is more commonly chronic and unremitting than it is not. Suicidal have higher rates for this disorder than other mental disorders.
      • The disorder may not be diagnosed for many years, often because Individuals with the disorder are reluctant to reveal their symptoms. The onset may be gradual or abrupt, and the disorder has a continuous course, with few intervals that are symptom-free, although the intensity of the symptoms may fluctuate over time.
    • Treatments
      • People suffering with BDD typically present to cosmetic surgeons for correction of perceived bodily flaw, and inevitably receive no satisfaction or relief from disorder
      • Serotonin deregulation seems to be common among patients with BDD. Selective serotonin re uptake 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.
      • The key to successful CBT for BDD is engagement of the patient (Veale, 2010).
      • 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.
      • It is recommended that individuals with mild BDD are offered CBT that is specific for BDD or guided self-help based on CBT (Veale, 2010).
      • Individuals with BDD with sever functional impairment should be offered combined treatment with an SRI and CBT (Veale, 2010).
      • 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.
    • Comorbidity
      • Major depressive disorder is the most common comorbid disorder in patients with BDD, with social phobia and OCD the next common (Didie et al., 2010).
      • Lifetime rates of substance abuse disorders are 36% to 48%, with 30% of individuals with BDD having comorbid lifetime substance abuse and 36% having comorbid lifetime substance dependence (Didie et al., 2010).

DSM-V recommended revisions www.dsm5.org

Major Changes:
#1: Clarify the criterion’s meaning and aim to make it more acceptable to patients.
#2: Add examples to increase awareness of some of the common types of distress or impairment in functioning.
#3: Limit criterion to eating disorders.

The work group is recommending that this disorder be reclassified from Somatoform Disorders to Anxiety and Obsessive-Compulsive Spectrum Disorders

  • A. Preoccupation with a perceived defect(s) or flaw(s) in physical appearance that is not observable or appears slight to others.
  • B. At some point during the course of the disorder, the person has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing their appearance with that of others) in response to the appearance concerns.
  • C. The preoccupation causes clinically significant distress (for example, depressed mood, anxiety, shame) or impairment in social, occupational, or other important areas of functioning (for example, school, relationships, household).
  • D. The appearance preoccupations are not restricted to concerns with body fat or weight in an eating disorder.
Specify if:
Muscle dysmorphia form of body dysmorphic disorder (the belief that one’s body build is too small or is insufficiently muscular)
Specify whether BDD beliefs are currently characterized by:
Good or fair insight: Recognizes that BDD beliefs are definitely or probably not true, or that they may or may not be true
Poor insight: Thinks BDD beliefs are probably true
Absent insight (i.e., delusional beliefs about appearance): Completely convinced BDD beliefs are true

60 Minutes Report - Mirror Mirror (part1)

60 Minutes Report - Mirror Mirror (part 2)


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3. Conversion Disorder (300.11)

  • A conversion disorder is a psychiatric disorder with a physical manifestation (Deaton, 1998).
    • It is a specific form of somatization in which the patient presents with symptoms and signs that are confined to the voluntary central nervous system (Hurtwitz, 2004).
    • The disorder's basis is believed to be the substitution of a physical symptom for an emotional conflict that cannot be expressed openly (Deaton, 1998).

  • 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.

  • Barlow and Durand (2009) give an example of conversion disorder:
Eloise sat on a chair with her legs under her, refusing to put her feet on the floor. Her mother sat close by, ready to assist her if she needed to move or get up. Her mother had made the appointment and, with the help of a friend, had all but carried Eloise into the office. Eloise was a 20-year-old of borderline intelligence who was friendly and personable during the initial interview and who readily answered all questions with a big smile. She obviously enjoyed the social interaction.
Eloise's difficulty walking developed over 5 years. Her right leg had given way and she began falling. Gradually, the condition worsened to the point that 6 months before her admission to the hospital Eloise could move around only by crawling on the floor.
Physical examinations revealed no physical problems. Eloise presented with a classic case of conversion disorder. Although she was not paralyzed, her specific symptoms included weakness in her legs and difficulty keeping her balance, with the result that she fell often. This particular type of conversion symptom is called astasia-abasia.
Eloise lived with her mother, who ran a gift shop in the front of her house in a small rural town. Eloise had been schooled through exceptional education programs until she was about 15; after this, no further programs were available. When Eloise began staying home, her walking began to deteriorate.
  • 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.
    • These individuals, often being suggestible, may show symptoms that are modified or resolved by external cues. These symptoms are, however, not specific to this disorder and may also occur with a general medical condition.
    • Symptoms may more commonly follow extreme psychosocial stress.
    • 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. They may, however, develop symptoms that resemble those observed in others or themselves. Individual symptoms generally do not lead to physical changes, but when they do, changes such as atrophy and contractures may occur.
    • Laboratory analysis of the condition typically do not yield any findings either. 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.
    • Conversion disorders are more common in adolescents than either children or adults (Deaton, 1998).
  • Gender and cultural differences in presentation
    • Conversion disorder is diagnosed more frequently in women than in men (Deaton, 1998). 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.
    • Onset is usually from late childhood to early adulthood, usually between the ages of 10 and 35, but onset as late as the ninth decade has been reported. When the disorder first develops in middle or old age, an occult neurological or other general medical condition is highly probable. The onset is usually acute, but the symptoms may also sometimes appear gradually. Individual symptoms are usually short in duration. Recurrence is common, and a single recurrence predicts future episodes. An acute onset, presence of clearly identifiable stress at the time of onset, a short interval between onset and treatment, and above-average intelligence are factors associated with a good prognosis. Symptoms of aphonia, blindness, and paralysis are also associated with a good prognosis, whereas tremors and seizures are not.
  • 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.
    • Research shows that Conversion Disorder is triggered by a significant stressor such as, difficulty with peer relationships, family discord or marital problems, difficulties with academics or economic hardship within the family.
    • Studies have also shown that children whose family members have a chronic illness are more likely to model their symptoms. Also, between 10% and 60% of children with Conversion Disorder had previous illness.
  • Empirically supported treatments
    • Patients referred for the treatment of conversion disorder must first be medically cleared for any neurological condition (Hurtwitz, 2004).
    • 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. Some research has recommended an anxiolytic or antidepressant agent (Tocchio, 2009). 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.
    • CBTs have been shown to improve patient functioning and reduce the cost of care (Tocchio, 2009).
    • Outpatient treatment of patients with conversion symptoms can be attempted using some of the strategies used in the inpatient setting (Hurtwitz, 2004).
    • Patients with chronic and entrenched conversion symptoms usually require admission to an inpatient psychiatric unit that has experience with conversion disorders (Hurtwitz, 2004).

DSM-V recommended revisions www.dsm5.org

Major changes:
#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.
#2: De-emphasize medically unexplained symptoms.
#3: Modify criteria for conversion disorder.

  • Patients with conversion disorder typically present with neurological symptoms that are found, after appropriate medical assessment, to be incompatible with a general medical condition. These presentations may be acute or chronic. Typical symptoms include weakness, events resembling epilepsy or syncope, abnormal movements, sensory symptoms, dizziness, speech and swallowing difficulties. In addition, the diagnosis will usually be supported by confirmatory physical signs or diagnostic investigations consistent with the diagnosis (such as, Hoover’s sign). Psychological factors may be associated with the onset of symptoms, but are not essential for the diagnosis. If there is evidence that the symptoms are intentionally feigned, the condition is not conversion disorder but rather either factitious disorder or malingering. When the symptom is limited to pain or to a disturbance in sexual functioning, it is typically coded elsewhere in the DSM (a different Somatic Symptom Disorder diagnosis or in the Sexual Disorders Section).
  • The work group is recommending this disorder be renamed from Conversion Disorder to Functional Neurological Symptoms.
    Criteria A, B, and C must all be fulfilled to make the diagnosis:
    • A. One or more symptoms are present that affect motor or sensory function or seizure-like episodes.
    • B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior or experience.
    • C. Physical signs or diagnostic findings that provide evidence of internal inconsistency or incongruity with recognized neurological or medical disorder.
    • D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

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4. Hypochondriasis (300.7)

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  • 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 preoccupation persists despite appropriate medical evaluation and reassurance.
      C. The belief in Criteria A is not a delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (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, Obsessive-Compulsive 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 excessive or unreasonable.
  • Barlow and Durand (2009) give an example of hypochondriasis:
Gail was married at 21 and looked forward to a new life. As one of many children in a lower-middle-class household, she felt weak and somewhat neglected and suffered from low self-esteem. An older stepbrother berated and belittled her when he was drunk. Her mother and stepfather refused to listen to her or believe her complaints. But she believed that marriage would solve everything; she was finally someone special. Unfortunately, it didn't work out that way. She soon discovered her husband was continuing an affair with an old girlfriend.
Three years after her wedding, Gail came to our clinic complaining of anxiety and stress. She was working part-time as a waitress and found her job extremely stressful Although to the best of her knowledge her husband had stopped seeing his former girlfriend, she had trouble getting the affair out of her mind.
Although Gail complained initially of anxiety and stress, it soon became clear that her major concerns were about her health. Any time she experienced minor physical symptoms such as breathlessness or a headache, she was afraid she had a serious illness. A headache indicated a brain tumor. Breathlessness was an impending heart attack. Other sensations were quickly elaborated into the possibility of AIDS or cancer. Gail was afraid to go to sleep at night for fear that she would stop breathing. She avoided exercise, drinking, and even laughing because the resulting sensations upset her. Public restrooms and, on occasion, public telephones were feared as sources of infection.
The major trigger of uncontrollable anxiety and fear was in the new in the newspaper and on television. Each time an article or show appeared on the "disease of the month," Gail found herself irresistibly drawn into it, intentionally noting symptoms that were part of the disease. For days afterwards she was vigilant, looking got the symptoms in herself and others. She even watched her dog closely to see whether he was coming down with the dreaded disease. Only with great effort could she dismiss these thoughts after several days. Real illness in a friend or relative would incapacitate her for days at a time.
Gail's fears developed during the first year of her marriage, around the time she learned of her husband's affair. At first, she spent a great deal of time and more money than they could afford going to doctors. Over the years, she heard the same thing during each visit: "There's nothing wrong with you; you're perfectly healthy." Finally, she stopped going, as she became convinced her concerns were excessive, but her fears did not go away and she was chronically miserable.
  • Associated Features
    • Hypochondriasis is characterized by a preoccupation with physical symptoms; however, a key feature is that it combines the fear with the conviction that one has an organic disease (Mai, 2004).
    • Fear of aging and death. They place a greater importance on physical health, but do not have better health habits than someone who does not have a disorder. "Doctor shopping", as well as deterioration with Doctor relationships with frustration and anger towards each other are common. 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. The patient may also believe he or she is not getting proper care, and they may resist referral to mental health professionals. Social relationships become strained.
    • One 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 their anxieties whereas other individuals constantly talk about their anxieties.
    • Anxiety, clinical depression, phobias, somatization disorder and obsessive-compulsive personality traits are frequently observed.
  • Child vs. Adult Presentation
    • This can occur at any age; however it is usually seen in early adulthood.
  • Gender and Cultural Differences in Presentation
    • Males and Females show the same rates through most of the studies.
    • Culturally, some may have a fear of illness that resembles Hypochondriasis, but it is not the same and they are influenced by cultural beliefs and practices.
  • Epidemiology
    • The prevalence of Hypochondriasis in the general population is 1%-5% (community), 2-7% (primary care outpatients).
    • The disorder can begin at any age, but the most common age at onset is early adulthood. The course is typically chronic, and the symptoms fluctuate, but there are some complete recoveries. Acute onset, mild duration, mild symptoms, general medical comorbidity, and the absence of a comorbid mental disorder, and the absence of secondary gain indicate a favorable prognosis. Some view this disorder as having certain "trait like" characteristics.
  • 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.
    • The etiology of this disorder has no exact cause; it is unknown. There are some things that can bring about this disorder such as past abuse, problems expressing emotions, or an inherited susceptibility.
    • One theory as to the cause of this is that people with this are highly sensitive to physical pain. They pay attention more closely to changes in their body. They tend to freak out when something had changed and often make a bigger deal out of it than it really is. Situational factors can play a role in this.
    • Another theory suggests that people with this disorder misinterpret their symptoms. Most people think they are healthy until they have symptoms of a disease. However, this theory suggest that people with Hypochondriasis think they are ill or something is wrong with them, until they have proof that there is not.
  • Empirically supported treatments
    • The physician and his or her team's attention, concern, interest, careful listening, and nonjudgmental stance, 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 re uptake 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 neurotransmitter levels to a more compatible level.
  • Comorbidity
    • Patients with hypochondriasis have high levels of psychiatric distress including anxiety, depressive and somatoform symptoms (Magarnos, Zafar, Nissenson, & Blanco, 2002).

DSM-V recommended revisions www.dsm5.org

Major changes:
#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.
#2: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD).

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder.

The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:

High health anxiety (previously, hypochondriasis) {If patients present solely with health-related anxiety in the absence of somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.} *
*Note: Both the Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are considering the possibility that what was described as Hypochondriasis in DSM-IV may represent a heterogeneous disorder in which some individuals may be better considered to have CSSD and some may be better considered to have an anxiety disorder. There will be ongoing discussion of this issue.

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5. Somatization Disorder (300.81)


DSM-IV-TR criteria
  • A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.
  • B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:
    • (1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
    • (2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
    • (3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
    • (4) one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, halluciantions, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)
  • C. Either (1) or (2):
    • (1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
    • (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would e expected from the history, physical examination or laboratory findings
  • D. The symptoms are not intentionally produced or feigned (as in Factitous Disorder or Malingering).

  • Barlow and Durand (2009) give an example of somatization disorder:
Linda, an intelligent woman in her 30s, came to our clinic looking distressed and pained. As she sat down she noted that coming into the office was difficult for her because she had trouble breathing and considerable swelling in the joints of her legs and arms. She was also in some pain from chronic urinary tract infections and might have to leave at any moment to go to the restroom, but she was extremely happy she had kept the appointment. At least she was seeing someone who could help alleviate her considerable suffering. She said she knew we would have to go through a detailed initial interview, but she had something that might save time. At this point, she pulled out several sheets of paper and handed them over. One section, some five pages long, described her contacts with the health-care system for major difficulties only. Times, dates, potential diagnosis, and days hospitalized were noted. The second section, one-and-a-half single-spaced pages, consisted of a list of all medications she had taken for various complaints.
Linda felt she had any one of a number of chronic infections that nobody could properly diagnose. She had begun to have these problems in her teenage years. She often discussed her symptoms and fears with doctors and clergy. Drawn to hospitals and medical clinics, she had entered nursing school after high school. However, during hospital training, she noticed her physical condition deteriorating rapidly: She seemed to pick up the diseases she was learning about. A series of stressful emotional events resulted in her leaving nursing school.
After developing unexplained paralysis in her legs, Linda was admitted to a psychiatric hospital, and after a yea,r she regained her ability to walk. On discharge, she obtained disability status, which freed her from having to work full time, and she volunteered at the local hospital. With her chronic but fluctuating incapacitation, on some days she could go in and on some days she could not. She was currently seeing a family practitioner and six specialists, who monitored various aspects of her physical condition. She was also seeing two ministers for pastoral counseling.
  • Associated features:
    • Patients possessing Somatization Disorder (SD) typically complain of physical symptoms that seem to have no physical origins. They describe their symptoms in colorful, exaggerated terms, but do not give specific information. They are often inconsistent as historians, so a thorough review of medical treatments and hospitalization may be necessary. They often seek treatment from several physicians at the same time, so there is a risk of complicated and dangerous combination of treatments. Experts believe that unconscious physical symptoms arise due to internal psychological conflicts. Patients will visit numerous doctors and never figure out their problems. As a result, their symptoms worsen and cause social dysfunction. In other words, SD causes it's inhabitant to become very antisocial. They commonly have prominent anxiety symptoms and depressed mood, which symptoms may be the cause of being in a mental health setting. They may exhibit impulsive and antisocial behavior, suicide threats and attempts, and marital discord. Their lives are often chaotic and complicate. Their frequent use of medications may lead to Substance-Related Disorders. They undergo frequent examinations, procedures, surgeries, and hospitalizations. Comorbidity can occur with Major Depressive Disorder, Panic Disorder, and Substance-Related Disorder, as well as some Personality Disorders, most commonly Histrionic, Borderline, and Antisocial Personality Disorders.
  • Child vs. Adult Presentation:
    • Despite the fact that children commonly respond to psychosocial stressors with reported physical and somatic complaints, a diagnosis of Somatization Disorder in children is rare.
  • Gender and Cultural Differences in Presentation:
    • Somatization Disorder occurs in 0.2 % to 2% of females and 0.2% of males. Although the disorder occurs most often in women, the male relatives of affected women have an increased risk of substance-related disorders and antisocial personality disorders. Cross-culturally, certain symptoms of Somatization Disorder present themselves differently. For example, people in African and South Asian countries are more prone to have the symptom of worms or ants crawling in their head than those in North American countries. In addition, boys are prone to report more headaches at a younger age whereas girls are reported to have more headaches with the disorder during their teens.
  • Epidemiology:
    • In the general population, Somatization Disorder is not common. Somatization Disorder is prevalent in 0.02% of the population. Mood and anxiety disorders are typically co-morbid with this disorder.
    • Individuals typical meet diagnostic criteria before 25 years of age. The disorder is chronic and fluctuating, and it rarely remits completely. A year seldom passes without the individual seeking medical attention for some unexplained somatic complaint.
  • Etiology
    • Studies have investigated that several risk are associated with Somatization Disorder. There is evidence that parental divorce is implicated in the risk for Somatization Disorder. Also, research has proven that higher risk for Somatization Disorder occurred in families with Antisocial Personality Disorder.
  • Empirically Supported Treatments
    • Treatments for Somatization are cognitive behavioral therapy and medications. (CBT) consists of focusing on negative thoughts, behaviors, and feelings that contribute to somatic symptoms. This treatment helps patients identify the more dysfunctional thinking. Overall, they will develop a better idea to positive thinking and rational explanations. It also helps them along with being more socially active, because people who suffer from somatization usually avoid social activities. (CBT) also teaches relaxation techniques.
    • Anti-depression medications will sometimes be prescribed in order to help alleviate symptoms.
  • Comorbidity
    • Somatization disorder co-occurs with the majority of Axis II PDs (Bornstein, & Gold, 2008).
    • Clinicians have discussed the connections between SD and at least six Axis II PDs: antisocial, avoidant, borderline, dependent, histionic, and obsessive-compulsive (Bornstein, & Gold, 2008).
    • Effect sizes linking SD with paranoid PD and obsessive-compulsive PD were small, effect sizes for antisocial, borderline, narcissistic, histionic, avoidant and dependent PD yielded effect sizes about or above 0.02 (Bornstein, & Gold, 2008).
    • The co-existence of somatization and abnormal illness behaviour is well known (Chaturvedi,Desai, & Shaligram, 2006). Abnormal illness behaviour is defined as: persistence of an inappropriate or maladaptive pattern of behaviour (Chaturvedi et al., 2006).


DSM-V recommended revisions www.dsm5.org

Major changes:
#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.
#2: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD).

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder.

The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:
1. Multiplicity of somatic complaints (previously, somatization disorder)


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6. Undifferentiated Somatoform Disorder (300.82)

  • DSM-IV-TR Criteria
    • A. One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints).
    • B. Either (1) or (2):
      1. after appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication).
      2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical examination, or laboratory findings.
    • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • The duration of the disturbance is at least 6 months.
    • The disturbance is not better accounted for by another mental disorder.
    • The symptom is not intentionally produced or feigned.
  • Associated Features
    • The most common symptoms are fatigue, loss of appetite, pain, and gastrointestinal problems. There seems to be many different physical symptoms for people with this disorder. No physical or medical causes for the pain is the main characteristic of this disorder. The pain or physical symptoms continue even after the person is told there is no medical cause.
  • Child vs. Adult Presentation
    • Adults are more likely than children to develop undifferentiated somatoform disorder. The elderly are also a common group to develop this disorder.
  • Gender and Cultural Differences in Presentation
    • Women are more likely to have undifferentiated somatoform disorder than men. Those with low socioeconomic status are more likely to develop this disorder than those with high SES. The most common group to develop this disorder are young women who have a low SES status. If symptoms persist for longer than six months, the disordered is classified as "Neurasthenia." In some cultures, medically unexplained symptoms and worry about physical illness do not indicate psychopathology. This disorder is not prone to a certain type of cultural rather than the position that an individual holds in a culture.
  • Epidemiology
    • Approximately four to eleven percent of the population will experience this disorder at some point in their life. About fifty percent of people with this disorder are co-morbid with other disorders such as anxiety or depression.
    • The course is unpredictable.
  • Etiology
    • There is no for sure cause of the disorder. Some studies suggest that it can be genetic. If it runs in a family, then those in that family are more likely to develop it. Other studies suggest that depression and anxiety can play a role. Also, people who give obsessive attention to minor changes or sensations in their body are also said to be likely to develop this disorder.
  • Empirically Supported Treatments
  • Treatments should focus on finding the underlying cause of the psychological or stress problems.
    • Also, if it is co-morbid with some other disorder, treating that first often helps lessen the symptoms.
    • Teaching people how to manage stress effectively has also been shown to help. These kinds of programs teach patients how to cope with criticism, as well as how to stop negative behavior patterns.

DSM-V recommended revisions www.dsm5.org

Major changes:
#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.
#2: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD).

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder.

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7. Somatoform Disorder Not Otherwise Specified (300.81)

  • DSM-IV-TR Criteria
    • This category includes disorders with somatoform symptoms that do not meet the criteria for any specific Somatoform Disorder. Examples include:
      • Pseudocyesis: a false belief of being pregnant that is associated with objective signs of pregnancy, which may include abdominal enlargement (although the umbilicus does not become everted), reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, nausea, breast engorgement and secretions, and labor pains at the expected date of delivery. Endocrine changes may be present, but the syndrome cannot be explained by a general medical condition that causes endocrine changes (e.g., a hormone-secreting tumor)
      • A disorder involving nonpsychotic hypochondriacal symptoms of less than 6 months' duration.
      • A disorder involving unexplained physical complaints (e.g., fatigue or body weakness) of less than 6 months' duration that are not due to another mental disorder.

DSM-V recommended revisions www.dsm5.org

Major changes:
#1: Name change of disorder to Somatic Symptom Disorder Not Elsewhere Classified.
#2: Adding Simple Somatic Symptom Disorder.
#3: Changing qualifications in Pseudocyesis category.
#4: Adding Isolated Health Anxiety category.

The group is recommending changing the disorder name to Somatic Symptom Disorder Not Elsewhere Classified.

11. Simple (or abridged) Somatic Symptom Disorder. This disorder is characterized by one or more highly distressing and disabling somatic symptoms but where the other CSSD criteria (chronicity and cognitions) are not met and where mental health interventions have been shown to be effective.
12. Pseudocyesis. The patient has a false belief of being pregnant that is associated with objective signs of pregnancy, which may include abdominal enlargement, reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, nausea, breast engorgement and secretions, and labor pains at the expected date of delivery. While endocrine changes may be present, the syndrome cannot be explained by a general medical condition that causes endocrine changes (e.g., a hormone-secreting tumor). *
13. Isolated Health Anxiety. This disorder is characterized by a high health anxiety in the absence of somatic symptoms and a diagnosable anxiety disorder, OCD or other psychiatric disorders. *

Please see full disorder descriptions here
* Still under active discussion


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8. Complex Somatic Symptom Disorder (CSSD)

(Not curently located in the DSM-IV-TR)
  • Proposed changes in the DSM-V include grouping the following disorders into a single category: Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, Pain Disorder Associated With Both Psychological Factors and a General Medical Condition, and Pain Disorder Associated With Psychological Factors. This new category would focus on both the physical symptoms and the psychological dysfunctions, with more emphasis on cognitive distortions than previous diagnostic categories.
  • CSSD is characterized by a disproportionate or maladaptive reaction to somatic symptoms or concerns. The disorder can occur in conjunction with a general medical or psychiatric disorders or it can occur alone. Treatment of the symptoms is usually unsuccessful; in fact, treatment may exacerbate symptoms.
  • Symptoms may be either specific, such as localized pain, or more general, such as fatigue or multiple symptoms. Anxiety-causing symptoms are usually ordinary bodily sensations, or discomfort not associated with a known serious medical condition.
  • Interestingly, patients diagnosed with CSSD typically have a poor health-related quality of life as compared to patients diagnosed with other medical conditions or those with similar symptoms.
  • DSM-V Criteria
    • Symptom clusters A, B, and C must be met for a diagnosis of Complex Somatic Symptom Disorder
      • A. Somatic Symptoms
        • One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
      • B. Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:
        • High level of health-related anxiety.
        • Disproportionate and persistent concerns about the medical seriousness of one's symptoms.
        • Excessive time and energy devoted to the symptoms or health concerns.*
      • C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).
  • For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where on of the following dominates the clinical presentation:
    • 1. Predominant somatic complaints (previously, somatization disorder)
    • 2. Predominant health anxiety (previously, hypochondriasis). If patients present solely with health-related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.
    • 3. Predominant Pain (previously pain disorder). This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.

For assessing severity of CSSD, metrics are available for rating the presence and severity of somatic symptoms (see for instance PHQ, Kroenke et al, 2002). Scales are also available for assessing severity of the patient's misattributions, excessive concerns and preoccupations (see for instance Whiteley inventory, Pilowsky, 1967)

*Criteria B is still under active discussion

See here for the DSM-V proposed changes to this category: DSM-V

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9. Pain Disorder

  • DSM-IV-TR criteria
    • A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
    • B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
    • D. The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).
    • E. The pain is not better accounted for by a Mood, Anxiety or Psychotic Disorder and does not meet criteria for Dyspareunia.

  • Code as follows:
307.80 Pain Disorder Associated With Psychological Factors: psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation or maintenance of the pain.) This type of Pain disorder is not diagnosed if criteria are also met for Somatization Disorder.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer

307.89 Pain Disorder Associated With Both Psychological Factors and a General Medical Condition: both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation or maintenance of the pain. The associated general medical condition or anatomical site of the pain (see below) is coded on Axis III.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer

Note: The following is not considered to be a mental disorder is included her to facilitate differential diagnosis.
Pain Disorder Associated With a General Medical Condition: a general medical condition has a major role in the onset, severity, exacerbation or maintenance of the pain. (If psychological factors are present, they are not judged to have a major role in the onset, severity, exacerbation or maintenance of the pain). The diagnostic code for the pain is selected based on the associated general medical condition if one has been established (see Appendix G) or on the anatomical location of the pain in the underlying general medical condition is not yet clearly established- for example, low back (724.4), sciatic (724.3), pelvic (625.9), headache (784.0), facial (784.0), chest (786.50), joint (719.40), bone (733.90), abdominal (789.0), breast (611.71), renal (788.0), ear (388.70), eye (379.91), throat (784.1), tooth (529.9), and urinary (788.0).

DSM-V recommended revisions www.dsm5.org

Major changes:
#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.
#2: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD).

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder.


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Somatoform Disorders Research (pdf study files)





Other External Links




References


  • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author
  • American Psychiatric Association. (2010). DSM-5 development. Washington, DC: Author. Retrieved from www.dsm5.org
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  • Bornstein, R., & Gold, S. (2008). Comorbidity of personality disorders and somatization disorder: A meta-analytic review. Journal of Psychopathology and Behavioral Assessment, 30(2), 154-161. doi:10.1007/s10862-007-9052-2.
  • Chaturvedi, S., Desai, G., & Shaligram, D. (2006). Somatoform disorders, somatization and abnormal illness behaviour. International Review of Psychiatry, 18(1), 75-80. doi:10.1080/09540260500467087.
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  • Magarinos, M., Zafar, U., Nissenson, K., & Blanco, C. (2002). Epidemiology and treatment of hypochondriasis. CNS Drugs, 16(1), 9-22. doi:10.2165/00023210-200216010-00002.
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  • Phillips, K., Didie, E., Menard, W., Pagano, M., Fay, C., & Weisberg, R. (2006). Clinical features of body dysmorphic disorder in adolescents and adults. Psychiatry Research, 141(3), 305-314. doi:10.1016/j.psychres.2005.09.014.
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  • Veale, D. (2010) Cognitive behavioral therapy for body dysmorphic disorder. Psychiatric Annals, 40(7), 333-340. doi:10.3928/00485713-20100701-06.
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