Somatoform Disorder

Aka: Somatoform Disorder, Somatic Symptom Disorder, Somatization, Somatizing Patient, Multiple Somatic Complaints, Hysteria, Somatization Disorder, Briquet's Syndrome, Undifferentiated Somatoform Disorder

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II. Epidemiology

  1. Prevalence: 5-7% in United States
  2. Women predominate by a factor of 10:1

III. Background

  1. Somatizers generate 9 times the average medical cost
  2. Despite medical attention, somatizers highly disabled
  3. Physicians report frustration in treating somatizers
    1. Lack sense of effectiveness
    2. Patient does not fit into standard diagnoses
    3. Patient does not fit into standard office schedule

IV. Pathophysiology

  1. Sensory amplification
    1. Preoccupation with disease focuses on body Sensations
    2. Normal variations in senses interpreted as abnormal
    3. Exacerbates anxiety and panic, as well as discomfort
  2. Identified patient within a dysfunctional family
    1. Family dysfunction transferred to the patient
    2. Patient's "illness" stabilizes family
    3. Other family member's anxiety relieved
  3. Need to be sick
    1. Patient pursues sick role to relieve stressors
    2. Not the same as Malingering or faking symptoms
      1. Somatizing Patient unaware of symptom generation
  4. Dissociation
    1. Activation of Pain Sensation without physical pain

V. Types: Somatoform Disorders (or Somatic Symptom Disorder)

  1. Conversion Disorder
    1. At least one symptom altered voluntary motor or sensory function inconsistent with known condition
  2. Factitious Disorder
    1. Falsification of physical or psychological symptoms or induced injury or disease in self or another
    2. Unlike Malingering, not for personal gain
  3. Illness Anxiety Disorder (previously part of Hypochondriasis)
    1. Preoccupation with either contracting or having a serious medical disorder
    2. Includes care-seeking subtype and care-avoidant subtype
  4. Body Dysmorphic Disorder
  5. Pain Disorder
    1. Now included in Somatic Symptom Disorder
    2. Predominant pain (previously known as Pain Disorder)

VI. Diagnosis: DSM-V Somatic Symptom Disorder (replaces Somatization Disorder)

  1. At least one somatic symptom that is distressing or significantly disrupting life
  2. At least one of the following excessive thoughts, feelings or behaviors related to somatic symptoms
    1. Disproportionate and persistent thoughts about the seriousness of one's own symptoms
    2. Persistently high level of anxiety about health or symptoms
    3. Excessive time and energy devoted to these symptoms or health concerns
  3. Symptomatic state persists regardless for at least 6 months (even if one symptom is not continuously present)
  4. Additional characteristics
    1. Predominant pain (previously known as Pain Disorder)
    2. Persistent (severe with marked Impairment for >6 months)
    3. Severity
      1. Mild
        1. Only 1 symptom from the excessive thoughts, feelings or behaviors list
      2. Moderate
        1. Two or more symptoms from the excessive thoughts, feelings or behaviors list
      3. Severe
        1. Two or more symptoms from the excessive thoughts, feelings or behaviors list AND
        2. Multiple Somatic Complaints OR one very severe somatic symptom
  5. References
    1. (2013) DSM-V, APA, p. 311

VII. Diagnosis: DSM-IV Somatization Disorder (old diagnostic criteria, more restrictive than DSM-V)

  1. Must meet criteria for a Somatoform Disorder
    1. Unexplained physical symptoms
    2. Not due to condition of Secondary Gain (Malingering or Factitious Disorder)
    3. Causes dysfunction
  2. Specific criteria for Somatization Disorder
    1. Chronic course of symptoms longer than 2 years
    2. Unexplained physical symptom onset before age 30 years
    3. Vague or exaggerated physical symptoms dispersed over multiple organ symptoms
      1. See Somatization Symptoms
      2. Gastrointestinal (at least 2 symptoms)
      3. Pain (at least 4 symptoms)
      4. Neurologic or pseudoneurologic (at least one symptom)
      5. Sexual (at least one symptom)
    4. Other diagnostic clues suggestive of Somatization
      1. Prior non-diagnostic extensive diagnostic testing
      2. Dissatisfaction with previous physicians

VIII. Diagnosis: Evaluation Scales

  1. Patient Health Questionnaire 15 (PHQ-15)
  2. Somatic Symptom Scale 8

IX. Differential Diagnosis

  1. Organic disease (exclude completely before making Somatization diagnosis)
  2. Other mental health conditions
    1. Major Depression
    2. Generalized Anxiety Disorder
    3. Panic Disorder
    4. Chemical Dependency
  3. Reported symptoms adopted by patient for Secondary Gain
    1. Factitious Disorder (Adoption of physical symptoms for unconscious internal gain)
    2. Malingering (Purposeful feigning of physical symptoms for external gain)

X. Risk Factors

  1. See Somatization Risk Factors
  2. Underlying mental health condition
  3. History of physical abuse or sexual abuse

XI. Definition

  1. Emotional distress experienced as physical symptoms

XII. Symptoms

  1. See Somatization Symptoms

XIII. Associated Conditions: Syndromes

  1. Vague Food Allergy
  2. Vague Vitamin Deficiency
  3. Multiple chemical sensitivity
  4. Atypical Chest Pain
  5. Temporomandibular Joint Syndrome (TMJ)
  6. Hypoglycemia
  7. Chronic Fatigue Syndrome
  8. Fibromyalgia
  9. Premenstrual Syndrome

XIV. Associated Conditions: Psychiatric

  1. Major Depression (60%)
  2. Anxiety Disorder (50%)
    1. Panic Disorder
    2. Obsessive Compulsive Disorder
  3. Personality Disorder (60%)
  4. Substance Abuse

XV. Precautions

  1. Reassess for underlying medical condition

XVI. Management

  1. See Somatization Management

XVII. Prognosis

  1. Up to 25% of those with acute somatic symptoms develop into chronic somatic illness

XVIII. References

  1. Kurlansik (2015) Am Fam Physician 93(1): 49-54 [PubMed]
  2. McCahill (1995) Am Fam Physician 52(1):193-203 [PubMed]
  3. Oyama (2007) Am Fam Physician 76(9):1333-8 [PubMed]
  4. Ringel (April 1998) Patient Care, p.131-56 [PubMed]
  5. Schwer (March 1999) Hosp Med, p.38-43 [PubMed]
  6. Servan-Schreiber (2000) Am Fam Physician 61(4):1073-8 [PubMed]
  7. Servan-Schreiber (2000) Am Fam Physician 61(5):1423-8 [PubMed]

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