Somatoform Disorders

Behavioral Science II
"For each ailment that doctors cure with medications (as I am told
they do occasionally succeed in doing) they produce 10 others in
healthy individuals by inoculating them with that pathogenic agent
1000 times more virulent than all the microbes--the idea that they are
ill."
---Marcel Proust

Objectives
Review diagnostic criteria for Somatoform
Disorders
Identify symptom presentation of
somatoform and somatization
Review patient management and treatment
strategies for somatoform and somatization
symptoms

Case example #1
A 46 year old divorced female with no history of chronic medical illness
presents to the ER with right side upper and lower extremity weakness,
shortness of breath, unsteady gait, fainting spells, and difficulty speaking.
Neurological insult is ruled out and medical tests are unremarkable. Her
normal personality style is shy and soft spoken. She reports a recent
traumatic, severely emotional experience at work. You should explore which
of the following?
A. Malingering
B.

Conversion
C. Hypochondriasis
D. Factitious disorder
E. Panic disorder

Case example #2

Harold is a 30-year-old male. For the past 5 years he has become more
and more worried about the shape and size of his nose. He feels it is too
big for his face and is asymmetrical, this results in feelings of
embarrassment. He has recently refused to go to several work parties
because of the way his nose looks. He has started growing a mustache
which he hopes will help to hide the problem. What is his most likely
diagnosis?
A. Hypochondriasis
B . Body Dysmorphic Disorder
C. Somatization Disorder
D. Conversion Disorder
E. Undifferenitated Somatoform Disorder

Somatoform Disorders
The blind spot of medicine
Physical symptoms without identified
pathology or beyond expected medical
findings
NOT factitious and NOT malingering
NOT intentionally produced.
{keep in mind that many conditions are misdiagnosed and
symptoms can be progressive}

Somatoform Disorders in DSM

IV TR
Somatization Disorder (hysteria, Briquets
syndrome) polysymptomatic, begins before age
30, extends for a period of years, involves a
combination of pain, gastrointestinal, sexual, and
psueudoneurological symptoms.

Undifferentiated Somatoform Disorder

unexplained physical complaints for at least 6
months below threshold for somatization disorder

DSM IV TR
Conversion Disorder unexplained symptoms or
deficits affecting voluntary motor or sensory functions
that suggest neurological or general medical condition.
Psychological issues are thought to play a key role.

Pain Disorder pain is focus of clinical attention

psychological factors have key role in onset, severity,
exacerbation, and maintenance. Can include the
presence of medically documented pain.

DSM IV TR
Hypochondriasis preoccupation with fear of
having, or the idea that one has a serious disease.
Based on misinterpretation of bodily symptoms or
functions.

Body Dysmorphic Disorder preoccupation

with imagined or exaggerated defect in physical
appearance.

Somatoform Disorder NOS symptoms that

do not meet criteria for specific disorder but are
focus of clinical attention.

Somatization
Somatization is the primary characteristic of
somatoform disorders and is characterized by:
1. In the absence of identified organic etiology, to
experience somatic distress in response to
psychological stress
2. To attribute this distress to physical illness or
physical disorder
3. To seek medical attention for these symptoms
(Stern & Herman, Massachusetts General Hospital, 2004)

The extreme of normal

behvaior
Most of us somatize at times, but its frequency, the
intensity of the stressor eliciting somatization, and
the symptoms experienced often vary. Somatization
is the connection that reveals the interdependence
of the mind and body stress effects cause physical
symptoms!
Somatization becomes clinically significant when it
is associated with significant occupational and
social dysfunction or excessive health care use.

Medically Unexplained
Symptoms
Medically unexplained symptoms, also known as functional
somatic symptoms, are extremely common in patients in
both community and clinic settings.
In a study of 14 common symptoms in 1,000 patients in an
ambulatory medical clinic, 74% were medically unexplained
(Kroenke and Mangelsdorff 1989).

Kroenke K, Mangelsdorff
D. Common symptoms in
ambulatory care:
incidence, evaluation,
therapy and outcome. Am J
Med, 1989:86: 2626.

Sexual and Physical Abuse

Both sexual and physical abuse have been
linked with somatization
1. Sexual Abuse
Chronic pelvic pain
Gastrointestinal disorders
2. Physical Abuse
Hypochondriasis
Gender
The relationship between gender and somatization is complex and
poorly understood. Generally women report more unexplained
symptoms than men.

Diagnosis of Somatoform
Symptoms
We can only estimate symptoms severity based on samples
and experience and must be careful when judging
exaggeration or behavioral style.
Tremendous variability in medical symptoms and pain
experience can be so pervasive that we can only try to
understand this individual, with this history, under these
conditions.
Observation over time has best diagnostic validity.
Adaptive element in somatic behavior seeking the patient
role, defenses not working, limited coping skills,
emotionally overwhelmed, etc.
Large percentage of cases misdiagnosed medical conditions.

Diagnostic Processes
Collaborate with Referral Sources
TAKE A COMPLETE HISTORY how does this make sense?
Review the Medical Records carefully
Collaborate with the patients family and friends if possible
Build an Alliance With the Patient
- Use of empathic comments such as:
The symptoms sound very difficult or
How has this illness or symptom affected your life?
How has your life affected this illness?
Perform a Mental Status Examination screen for neurological
conditions

Principles of Management
(Abbey, 1996)

Emphasize explanation, education, and formulation

of symptom presentation explore possibilities and
build collaboration with patient.
Arrange for regular follow-up decreases
escalation.
Treat mood or anxiety disorders where indicated.
Minimize polypharmacy avoid medication effects
increasing symptoms.
Provide specific therapy when indicated stress
management, exercise, emotional support.

Principles of Management cont.

Change social dynamics social skill
building, life skills, assertiveness training,
family interactions, etc. (Psychotherapy).
Group therapy may be useful if available.
Recognize and control provider negative
reactions and dualistic (mind-body) thinking.
These are complex patients and can evoke
significant counter transference when we do
not know what to do. Threatens our control

Somatization Disorder (Hysteria,

Multisymptomatic Hysteria, or Briquets
Disease)
DSM-IV Criteria
A history of multiple and recurring physical complaints over several
years, which begin before the age of 30. The physical complaints
result in medical treatment or cause significant impairment in social,
occupational, or other important areas of function.
To make the diagnosis all four of the following criteria have to be
met at some time during the course of the patients history:
Four pain symptoms
Two non-pain related gastrointestinal symptoms
One sexual symptom
One pseudoneurological symptom
The symptoms, after appropriate investigation, are not caused by a
known medical condition or substance.
The symptoms are neither intentionally produced nor feigned

Somatization Disorder
Epidemiology
women have a 0.2-2% lifetime prevalence of somatoform
disorders.
In men the overall prevalence is 0.2%
Psychiatric Co-Morbidity
Axis I: 50% of patients are likely to have comorbid mood
disorders. Anxiety disorders, substance abuse, and posttraumatic stress disorder are also common.
Axis II: 72% of patients with somatization disorder have
personality disorders, most commonly histrionic, borderline, and
antisocial personality disorders.
The co-morbidity of a history of childhood sexual abuse and
neglect
DSM-IV-TR,
2000. and somatoform disorder is high (30-70%).

Somatization Disorder:
Treatment
The best treatment occurs in the context of a long-term
relationship with an empathetic primary care provider
(PCP). The PCP should be encouraged to:

Allow the patient to maintain the sick role.

Schedule regular follow-up appointments of a set length.
Set the agenda of the visit.
Limit work-ups to objective findings and not complaints
Set limits on contacts outside of visit time.
Introduce psychosocial issues slowly
Do no more and no less for the somatic patient than for any
other patient avoid reinforcing sick role behavior positively or
negatively.

Somatization Disorder:
Treatment cont.
Psychiatric referral is useful to treat and manage co-morbid psychiatric
disorders.
Psychiatric consultation decreases health care costs and unnecessary
utilization of services.
The goal of psychiatric consultation is to provide a framework for
treatment. It should not be viewed as the end of the relationship
with the PCP.
Co-morbid psychiatric disorders should be treated and managed by
the PCP or psychiatric consultant.
Individual or group psychotherapy can be useful
Stress reduction
A small number of studies report symptom improvement with
antidepressant use (independent of depression).

Distinguishing Somatization Disorder from

General Medical Conditions
(general guidelines)
1. Involvement of multiple organ systems
2. Early onset and chronic course without
development of physical signs or structural
abnormalities.
3. Absence of lab abnormalities that are
characteristic of the suggested gen med condition.
However, the onset of multiple physical symptoms
late in life is almost always due to a gen med
condition.

Undifferentiated Somatoform Disorder

(Somatization Syndrome or Subthreshold
Somatization Disorder)
DSM Criteria
One or more physical complaints (such as fatigue, loss of

appetite, a gastrointestinal complaint or urinary complaint) must

persist for 6 months or longer.
Either:
The symptoms, after appropriate evaluation, cannot be fully
explained by a known medical condition or substance or
The complaints or impairments are grossly in excess of
what would be expected on the basis of the existing medical
condition.
The symptoms must cause significant distress or impairment in
social, occupational, or another important area of functioning.
The symptoms are neither intentionally produced nor feigned.

Undifferentiated Somatoform Disorder

(Somatization Syndrome or Subthreshold
Somatization Disorder)

Epidemiology
Its lifetime prevalence is 4-11%. (DSM-IVTR, 2000.)
Treatment
Treatment is similar to that of Somatization
Disorder.

Conversion Disorder
Conversion disorder involves the presence of
symptoms or deficits that affect voluntary motor or
sensory function in a fashion that suggests a
neurological condition but which is not explained
by the medical findings.
Clinical Features
Conversion-disordered patients are more likely
to have had prior conversion symptoms or
symptoms of dissociation.
One-third of patients with Conversion Disorder
have concurrent neurological illness.

Conversion Disorder
Etiology
A dynamic hypothesis suggests that the conversion
symptom is a solution to an unconscious conflict. For
example, a woman whose husband had an affair may
become paralyzed rather than walk away from the marriage.
Epidemiology
Conversion disorder is the most common somatoform
disorder. Approximately 33% of female psychiatric
outpatients report an episode of conversion.
A gender bias exists, with a ratio of 2-10:1, women to men.
Left-handed women have a higher incidence.

Conversion Disorder
Psychiatric Co-Morbidity
Conversion disorders can be a precursor to depression,
somatization, and/or dissociative disorders.
Symptoms
As opposed to the patient with somatization disorder or the
patient with hypochondriasis who believes they are gravely
ill, the patient with conversion disorder often presents with la
belle indifference conversion provides relief.
Symptoms are more likely to occur following extreme stress.
Symptoms are inconsistent with the physical examination.
The symptoms rarely cause longer term physical disability.
The symptoms tend to recur.

Conversion Disorder
DSM-IV Criteria
One or more symptoms or deficits affecting voluntary motor or
sensory function that suggest a neurological or other general
medical condition
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 conflicts or other stressors
The symptom or deficit is not intentionally produced or feigned
The symptom or deficit cannot, after appropriate investigation be
fully explained by a general medical condition or by the effects
of a substance or as a culturally sanctioned behavior or
experience.

Conversion Disorder
DSM-IV Criteria cont.

The symptom or deficit causes clinically significant distress or

impairment in social, occupational, or other important areas of
functioning or warrants medical evaluation.
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.
Specify type of symptom or deficit
With Motor Symptom or Deficit
With Sensory Symptom or Deficit
With Seizures or Convulsions
With Mixed Presentation

Conversion Disorder
Course
Conversion disorder is rarely reported in patients
younger than 10 years, or older than 35 years of age;
however, cases have been seen in people of all ages,
including 90-year olds.

The syndrome usually remits within 2-4 weeks after

hospitalization, but it has a recurrence rate of 20-25%
within the first year.
Prior episodes increase the rate of recurrence.
20% of patients with conversion disorder develop
Somatization Disorder within 4 years of their first episode.

Conversion Disorder:
Treatment
A good prognosis is associated with an acute onset of disease, a
clear stressor, a short interval between the onset of symptoms
and initiation of treatment, rapid improvement in the hospital, an
above-average intelligence, and a presenting symptom of
paralysis, aphonia, or blindness.
A poor prognosis is associated with a presenting symptom of
tremor and/or seizure, an increased interval between symptom
onset and treatment, and a reduced intelligence level.
Confrontation of the patient is not helpful, as it results in a loss
of face.
Indirect examination of stressors can lead to relief
Behavioral techniques should be instituted; referral to family
therapy is often indicated.

Pain Disorder
DSM-IV Criteria

Pain occurs in one or more anatomical sites as the

focus of attention presence of medical evidence of
pain.
Pain causes significant distress or impairment in
social, occupational, or other areas of function.
Psychological factors have a role in the onset,
severity, exacerbation, and maintenance of the pain.
The pain is not intentionally produced.
Pain disorder is not totally due to a mood, anxiety,
or psychotic disorder, or to dyspareunia.

Pain Disorder
DSM-IV Criteria cont.

Specifiers

1. Pain Disorder Associated with Psychological Factors

(acute < 6 months; chronic > 6 months)
2. Pain Disorder Associated with Both Psychological Factors
and a General Medical Condition (acute < 6 months; chronic
> 6 months)
3. Pain Disorder Associated with a General Medical
Condition (Note: This is not a mental disorder but is included
to assist in differential diagnosis and pain type should be
coded on Axis III) questionable issues here when does
significant pain NOT effect emotion or behavior?

Pain Disorder
Clinical Features

Pain described as severe and constant, the pain may or

may not be consistent with known anatomic pathways.
The severity is disproportionate to clinical findings
Pain is the main life focus of a patients energy
This behavior can lead to disability and complications
that include

Iatrogenic substance abuse (opiates/benzodiazepines)

Depression (which occurs in 30-50% of those with chronic
pain)
Anxiety (with acute pain)
Insomnia.

Pain Disorder
Epidemiology

The prevalence of these disorders is unknown.

The peak incidence occurs in individuals in their 30s
and 40s.
Women complain of more headaches, men complain
more of back pain.
Course

The course is variable; the syndrome can persist for

years
A good prognosis is associated with continued work
and the absence of pain as a focus of life.

Pain Disorder
Treatment Pain is what the patient says it is!!!!
Emphasize living with pain and not removal of pain. Teach
skills of functional movement, weight loss, sleep hygiene.
The physician should also explain how brain regions involved with
emotion (i.e., the limbic system) may influence sensory pain
pathways.

Employ a multi-modal treatment approach, combining

physical, family, group and cognitive-behavioral therapy.
Avoid iatrogenic complications. Medications do not cure
structural damage or stop pain.
Treat concomitant problems as they arise sleep deprivation,
depression, anxiety, etc.

Physical Pain Versus Psychogenic Pain

The three gross categories of pain which are not mutually exclusive.
Neurogenic pain results from damage to the CNS can be unrelenting and
not exacerbated by movement. Physical in origin.
Structural (mechanical) pain fluctuates in intensity and movement. Is highly
sensitive to emotional, cognitive, attentional, and situational influences.
Physical in origin.
Psychogenic pain does not vary and is insensitive to any of these cognitive
and behavioral factors.
When pain does not wax and wane and is not even temporarily relieved by
distraction or analgesics, clinicians can suspect that there is a major
psychogenic component to the pain.

Hypochondriasis
DSM-IV Criteria

Hypochondriasis is a preoccupation with fears of having, or the

idea that one has, a serious disease based on ones
misinterpretation of bodily symptoms.
This preoccupation persists despite appropriate medical
evaluation and reassurance
The preoccupation is not of delusional intensity and is not
restricted to a circumscribed concern about appearance
This preoccupation causes significant distress or impairment.
Hypochondriasis lasts at least 6 months.
Specify: With Poor Insight

Hypochondriasis
Clinical Course
The preoccupation with bodily functions (e.g., heartbeat, sweating,); with minor physical
abnormalities (e.g., a small sore or an occasional cough); or vague and ambiguous
physical sensations (e.g., feeling worn out, aching veins).

The onset is generally in early adulthood

A chronic waxing and waning course is typical
Episodes may be precipitated by stress, especially the death of someone
close.
Epidemiology
Hypochondriasis occurs in about 3-13% of the general population in the
United States. In Africa it occurs in 1% of the population.
The incidence is approximately equal in males and females
The history often includes a childhood illness or illness of a significant
family member when the patient was a child.

Hypochondriasis
Treatment
A good prognosis for hypochondriasis is associated with an
acute onset and high levels of general medical co-morbidity.
They may be more accepting of psychiatric treatment if it takes
place in a medical setting and is focused on stress reduction and
education regarding coping with a chronic illness.
Regular contact with a caring medical physician should be
maintained with palliation, and not cure, as the goal.
Work-ups should be based only on objective findings.
Cognitive-educational group treatments work for some.
Use of selective serotonin reuptake inhibitors (SSRIs) may have
some benefit in these patients.

Body Dysmorphic Disorder (BDD)

Definition
BDD is a disease of imagined ugliness.
DSM-IV Criteria
Preoccupation with an imagined deficit in appearance. If a slight
physical anomaly is present, the persons concern is markedly
excessive
The preoccupation causes clinically significant distress or
impairment in social, occupational or other important areas of
functioning.
The preoccupation is not better accounted for by another mental
disorder

Body Dysmorphic Disorder

Clinical Features
Patients complain often of a facial deformity (e.g., asymmetry,
size of nose), but it can be anything.
Patients feel too ashamed to present for treatment
Patients may frequently check and groom themselves
They may try to compensate for the imagined anomaly, e.g.,
wearing a hat if hair loss is imagined or wearing gloves to
cover ugly fingers
Complications include social isolation, suicide and Iatrogenic
complications (7-9% of patients who undergo cosmetic surgery
meet criteria for BDD).

Body Dysmorphic Disorder

Clinical Course

30 is the mean age for diagnosis. It can become chronic.

Research from the Feb. 2010 issue of the Archives of General
Psychiatry found differences in the areas of the brain involved
in visual processing
Epidemiology

The frequency is equal in males and females

Depression, delusional disorder, social phobia, and/or OCD are
often co-morbid conditions.
Treatment

The use of SSRIs can be helpful. Relapse is common when the

drug is discontinued.
Cognitive Behavioral Therapy

Somatoform Disorder
Not Otherwise Specified
Definition
These disorders are residual categories for disorders where
physical symptoms are the focus of treatment but which do
not meet criteria for another somatoform disorder.
Examples
Pseudocyesis, or the belief that one is pregnant.
Couvade Syndrome in males: sympathy symptoms
Hypochondriasis lasting less than 6 months
Unexplained physical complaints lasting less than 6 months.

Functional Somatic Syndromes

(aka, Medically Unexplained Conditions)
Broad group of disorders that have the
common component of physical complaints
which cannot be verified by medical
examination.
Not listed in the current DSM as somatoform
disorders.

Functional Somatic Syndromes

(aka, Medically Unexplained Conditions)

Fibromyalgia
Chronic Fatigue Syndrome
Irritable Bowel Syndrome
Multiple Chemical Sensitivity

Chronic Fatigue Syndrome

(Myalgic Encephalomyelitis Canada, UK)

Not a DSM diagnosis. Not considered a mental illness,

however, has no known physical cause.
Main characteristics are persistent and unexplained fatigue resulting
in severe impairment in daily functioning.
The illness is defined by means of symptoms, disability, and exclusion
of explanatory illnesses, and not by means of physical signs or
abnormalities or in lab test results.
Prevalence rates in the US are around 0.23% - 0.42%
More common in women.

CDC Criteria: Chronic Fatigue Syndrome

Chronic Fatigue Syndrome Notes:

Many individuals with this disorder complain of pain and
cognitive dysfunction that is just as severe as the fatigue.
Depressive Disorders are frequently co-morbid. Depression
and anxiety are frequent premorbid diagnoses.
An acute psychological stressor often triggers the onset of the
syndrome.
No known viral or neuroendocrine etiologies explain the
breadth of symptoms.
Antidepressants are not helpful in the treatment of Chronic
Fatigue symptoms.
However, Cognitive Behavioral Therapy designed to
change cognitions and behaviors regarding the fatigue
symptoms is the treatment of choice.

Fibromyalgia
Fibromyalgia is a controversial polysymptomatic syndrome of unknown
etiology characterized by chronic widespread musculoskeletal pain,
multiple tender points, abnormal pain sensitivity, and additional
symptoms such as:
fatigue
irritable bowel (e.g., diarrhea, constipation, etc.)
sleep disorder (or sleep that is unrefreshing)
chronic headaches (tension-type or migraines)
jaw pain (including TMJ dysfunction)
cognitive or memory impairment
post-exertional malaise and muscle pain
morning stiffness (waking up stiff and achy)
menstrual cramping
numbness and tingling sensations
dizziness or lightheadedness
skin and chemical sensitivities

Fibromyalgia Notes: The etiology of the disorder

is unknown. Its existence as a disease entity remains
controversial.
Much more common in women than men.
Anecdotally, often co-morbid with a personality
disorder (typically borderline or histrionic may be
chicken or egg issue high prevalence of childhood
physical or sexual abuse).
Prevalence is 2% in the US.
Best treatment seems to be a combination of SNRI and
aerobic exercise.

A word about Munchausen

Extreme form of factitious disorder noted by chronic pattern.
Many somatoform characteristics.
Person intentionally fakes, simulates, worsens, or self-induces
injury or illness for the purpose of being treated as a medical
patient. Dramatic symptom presentation.
Often requires hospitalization eager for invasive procedures.
Can be by proxy
Patients move from doctor, hospital, towns to seek care.
Follow Abbey mgmt guidelines + SSRI for mood and Low dose
antipsychotic for severe personality disorder (borderline).
Rule out all possible medical conditions.

DSM V Somatic Symptom Disorder

Criteria A, B, and C must all be fulfilled to make the diagnosis:
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 one of the following must
be present.
C.Chronicity: Although one symptom may not be continuously present, the
state of being symptomatic is persistent (typically more than 6 months).
1.
Disproportionate and persistent thoughts about the seriousness of
ones symptoms.
2.
Persistently high level of anxiety about health symptoms.
3.
Excessive time and energy devoted to these symptoms or health
concerns

Somatic Symptom Disorder (cont)

Specifiers
Predominant Pain (previously pain disorder).
This category is reserved for individuals presenting
predominantly with pain complaints who also
satisfy category B and C of this diagnosis. Some
patients in pain may better fit other psychiatric
diagnoses such as adjustment disorder or
psychological factors affecting medical condition.

DSM V changes cont.

Somatic Symptoms and Related Disorders new title.
Focus on positive symptoms rather than medically
unexplained Ex/distressing somatic symptoms plus
abnormal thoughts, feelings, and behaviors in response
to symptoms.
Hypochondriasis no longer diagnosis Illness Anxiety
Disorder.
Psychological Factors Affecting Other Medical
Conditions and Factitious Disorder now in this section.
Conversion Disorder (Functional Neurological
Symptom Disorder) importance of neuro exam.

Case example #1
A 46 year old divorced female with no history of chronic medical illness
presents to the ER with right side upper and lower extremity weakness,
shortness of breath, unsteady gait, fainting spells, and difficulty speaking.
Neurological insult is ruled out and medical tests are unremarkable. Her
normal personality style is shy and soft spoken. She reports a recent
traumatic, severely emotional experience at work. You should explore which
of the following?
A. Malingering
B.

Conversion
C. Hypochondriasis
D. Factitious disorder
E. Panic disorder

Case example #2

Harold is a 30-year-old male. For the past 5 years he has become

more and more worried about the shape and size of his nose. He feels
it is too big for his face and is asymmetrical, this results in feelings of
embarrassment. He has recently refused to go to several work parties
because of the way his nose looks. He has started growing a
mustache which he hopes will help to hide the problem. What is his
most likely diagnosis?
A.
Hypochondriasis
B.
Body Dysmorphic Disorder
C.
Somatization Disorder
D.
Conversion Disorder
E.
Undifferentiated Somatoform Disorder