SOMATOFORM

DISORDERS

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Somatization Disorder:
Conversion Disorder
Hypochondriasis
Body dysmorphic Disorder
Pain Disorder
Undifferentiated somatoform disorder
Somatoform disorder not otherwise specified

SOMATIZATION
An illness of multiple somatic com-plaints in
multiple organ systems that occurs over a period
of several years and results in significant
impairment or treatment seeking, or both.
Is chronic and is associated with significant
psychological distress, impaired social and
occupational functioning, and excessive medicalhelp-seeking behavior.

Clinical features
Have many somatic complaints and long, complicated medical
histories:
Nausea and vomiting (other than during pregnancy),
difficulty swallowing,
pain in the arms and legs,
shortness of breath unrelated to exertion,
amnesia,
and complications of pregnancy and menstruation are
among the most common symptoms.
Patients frequently believe that they have been sickly most of
their lives.
Psychological distress and interpersonal problems are
prominent; anxiety and depression are the most prevalent
psychiatric conditions.
Suicide threats are common, but actual suicide is rare. If
suicide does occur, it is often associated with substance abuse.

Epidemiology/Etiology
Common d/o
W>M 5:1 female-male ratio
Beginning before age 30, usually during teenage
years.

DX
REFER TO HANDOUT & TABLE 17-2

Differential DX
REFER TO HANDOUT & TABLE 17-3

Course and Prognosis

Is a chronic, undulating, and relapsing disorder
that rarely remits completely.
It is unusual for the individual with somatization
disorder to be free of symptoms for greater than
1year, during which time they may see a doctor
several times.
Research has indicated that a person diagnosed
with somatization disorder has approximately an
80% chance of being diagnosed with this disorder
5 years later.

TX
Best treated when the patient has a single
identified physician as primary caretaker.
The visits should be relatively brief, although a
partial physical examination should be conducted
to respond to each new somatic complaint.
Additional laboratory and diagnostic procedures
should generally be avoided.
Once somatization disorder has been diagnosed,
the treating physician should listen to the somatic
complaints as emotional expressions rather than
as medical complaints.
Psychotherapy & Psychopharmacological tx

CONVERSION
DISORDER
Is an illness of symptoms or deficits that affect
voluntary motor or sensory functions, which
suggest another medical condition, but that is
judged to be caused by psychological factors
because the illness is preceded by conflicts or
other stressors.
The symptoms or deficits are not intentionally
produced, are not caused by substance use, are
not limited to pain or sexual symptoms, and the
gain is primarily psychological and not social,
monetary, or legal.

Clinical features
Paralysis, blindness, and mutism
are the most common conversion
disorder symptoms.
Depressive and anxiety dis-order
symptoms often accompany the
symptoms of conversion disorder,
and affected patients are at risk for
suicide.

Epidemiology/Etiology
W>M
Among children, an even higher predominance is
seen in girls.
Symptoms are more common on the left than on
the right side of the body in women.
The onset is general from late childhood to early
adulthood and is rare before 10 years of age or
after 35 years of age.
Possible factors: Psychoanalytic, Learning theory,
biological

DX
REFER TO HANDOUT & TABLE 17-5

Differential DX
REFER TO HANDOUT & TABLE 17-6

Course and Prognosis

Acute; Symptoms or deficits are usually of short
duration
One episode is a predictor for future episodes.
Good prognosis=acute onset, presence of clearly
identifiable stressors at the time of onset, a short
interval between onset and the institution of
treatment, and above average intelligence;
Paralysis, aphonia, and blindness.
Poor= tremor and seizures

TX
Psychotherapy

HYPOCHONDRIASIS
Is characterized by 6 months or more of a general
and no delusional preoccupation with fears of
having, or the idea that one has, a serious disease
based on the persons misinterpretation of bodily
symptoms.
Reflects the common abdominal complaints of
many patients with the disorder, but they may
occur in any part of the body.

Clinical features
Believe that they have a serious disease that has not yet
been detected, and they cannot be persuaded to the
contrary.
Convictions persist despite negative laboratory results, the
benign course of the alleged disease over time, and
appropriate reassurances from physicians.
Often accompanied by symptoms of depression and anxiety
and commonly coexists with a depressive or anxiety
disorder.
Although DSM-IV-TR specifies that the symptoms must be
present for at least 6 months, transient hypochondrical
states can occur after major stresses.
Such states that last fewer than 6 months should be
diagnosed as somatoform disorder not otherwise specified.

Epidemiology/Etiology
M=F
Onset 20-30 y/o
More common in blacks than whites
plus medical students

DX
REFER TO HANDOUT & TABLE 17-7

Differential DX
Must be differentiated from nonpsychiatric medical cx,
especially disorder that show sx that are not
necessarily easily dx (AIDS, MG, MS, degenerative d/s
of NS, etc.)
Must also be differentiated from other somatization d/s
by emphasis on fear of having a disease and not by
concerns about many sx.
Less specific age of onset
Also occurs in pxs with depressive and anxiety d/os
plus schizophrenia.

Course and Prognosis

Episodic
Lasts from months to years
Good prognosis= associated with high
socioeconomic status, treatment-responsive
anxiety or depression, sudden onset of symptoms,
the absence of a personality disorder, and the
absence of a related nonpsychiatric medical cx.

TX
Group psychotherapy
Frequent, regular physical exams
Pharmacotherapy

BODY DYSMORPHIC
DISORDER
Characterized by a preoccupation with an
imagined defect in appearance that causes
clinically significant distress or impairment in
important areas of functioning.

Clinical features
Most common concern involves facials flaws. Other body
parts of concerns are hair, breasts, and genitalia.
FEFER TO TABLE 17-9

Epidemiology/Etiology

Cause unknown.
W>M
Common age of onset between 15-30 y/o.
High comorbidity with depressive d/o, a higherthan-expected family history of mood d/os and
OCD, plus serotonin pathophysiology.

DX
REFER TO HANDOUT & TABLE 17-8

Differential DX
Although individuals with body dysmorphic disorder
have obsessional pre-occupations about their
appearance and may have associated compulsive
behaviors (e.g., mirror checking), a separate or
additional diagnosis of OCD is made only when the
obsessions or compulsions are not restricted to
concerns about appearance and are ego dystonic.
An additional diagnosis of delusional disorder, somatic
type, can be made in people with body dysmorphic
dis-order only if their preoccupation with the imagined
defect in appearance is held with a delusional
intensity.
Restricted to concerns in anorexia nervosa and major
depressive episode.

Course and Prognosis

Usually begins adolescence and can be gradual or
abrupt.

TX
Surgical, dermatological, dental, and other med.
Procedures
Pharmacotherapy: Prozac and Anafranil

PAIN DISORDER
Characterized by the presence of, and focus on,
pain in one or more body sites and is sufficiently
severe to come to clinical attention.
Psychological factors are necessary in the
genesis, severity, or maintenance of the pain,
which causes significant distress or impairment,
or both.

Clinical features
Patients with pain disorder are not a uniform
group, but a heterogeneous collection of persons
with low back pain, headache, atypical facial
pain, chronic pelvic pain, and other kinds of pain.
A patients pain may be posttraumatic,
neuropathic, neurological, iatrogenic, or
musculoskeletal.
To meet a diagnosis of pain disorder, however,
the disorder must have a psychological factor
judged to be significantly involved in the pain
symptoms and their complications.

Epidemiology/Etiology
Can begin at any age.
Common; 10-15% adult workers in USA; LBP
Pain disorder is associated with other psychiatric
disorders, especially affective and anxiety
disorders.
Chronic pain appears to be most frequently
associated with depressive disorders, and acute
pain appears to be more commonly associated
with anxiety disorders.

DX
REFER TO HANDOUT & TABLE 17-10

Differential DX
Must be distinguished from other somatoform d/os
and if purely psychogenic.
Physical pain fluctuates in intensity and is highly
sensitive to emotional, cognitive, attentional, and
situational influences.
Px with this d/o are not pretending to be in pain.

Course and Prognosis

Course and Prognosis
Generally begins abruptly and increases in severity for
a few weeks or months.
The prognosis varies, although pain disorder can often
be chronic, distressful, and completely disabling.
Acute pain disorders have a more favorable prognosis
than chronic pain disorders.
A wide range of variability is seen in the onset and
course of chronic pain disorder.
People with pain disorder who resume participation
irregularly scheduled activities, despite the pain, have
a more favorable prognosis than people who allow the
pain to become the determining factor in their
lifestyle.

TX
Pharmacotherapy (Antidepressants &
amphetamines)
Psychotherapy
Pain control Programs
Others: Biofeedback, hypnosis, nerve blocks and
surgical ablative procedures, etc

UNDIFFERENTIATED
SOMATOFORM DISORDER
Characterized by one or more unexplained physical
symptoms of at least 6 months duration, which are
below the threshold for a diagnosis of somatization
disorder.
Two types of symptom patterns may be seen in
patients with undifferentiated somatoform disorder:
those involving the autonomic nervous system and
those involving sensations of fatigue or weakness.
Such patients have complaints involving the
cardiovascular, respiratory, gastrointestinal, urogenital,
and dermatological systems. Other patients complain
of mental and physical fatigue, physical weakness and
exhaustion, and inability to perform many everyday
activities because of their symptoms.

DX
REFER TO HANDOUT & TABLE 17-11

SOMATOFORM DISORDER NOT

OTHERWISE SPECIFIED
Is a residual category for patients who have
symptoms suggesting a somatoform disorder, but
do not meet the specific diagnostic criteria for
other somatoform disorders.
Such patients may have a symptom not covered
in the other somatoform disorders or may not
have met the 6-month criterion of the other
somatoform disorders.

DX
REFER TO HANDOUT & TABLE 17-12