The Differential Diagnosis of

Somatoform Disorders
ALLEN FRANCES! and BRANDON VANCE 2

Summary. Somatoform disorders lie on the boundary between medicine and

psychiatry and have been relatively ignored by both. Though quite common, these
disorders have received little systematic research. Misdiagnosing these disorders
results in morbidity, expense, and the possibility of missing more treatable medical
or psychiatric diagnoses. The differential diagnosis of somatoform disorders is a
difficult but important task that we will discuss in some detail.

Key words. Mental illness, Somatoform disorder, Differential diagnosis, DSM -IV

Introduction
In many cultures across the world, a patient who experiences stress and/or has a
psychiatric disorder will often present with somatic complaints. The section of the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV) clas-
sification titled Somatoform Disorders includes Somatization Disorder, Conversion
Disorder, Pain Disorder, Hypochondriasis, and Body Dysmorphic Disorder [1]. These
conditions share the following features: the patient is preoccupied by physical com-
plaints that significantly impair functioning in some important aspect of life; the
symptoms are not intentionally produced or feigned; and the problem is not better
accounted for by other specific medical or psychiatric disorders [2].
By their very nature, these somatoform disorders lie on the boundary between med-
icine and psychiatry. This unique position often leads to difficulties in their differ-
ential diagnosis and treatment in both the medical and the psychiatric settings.
In medical settings, patients with somatoform disorders are often the recipients of
unneeded tests and diagnostic procedures. False positive results from these proce-
dures may lead to erroneous treatments, complications, unnecessary morbidity, and

1 Department of Psychiatry and Behavioral Sciences, Room 4584, Box 3950, Duke South Hospital,

Duke University Medical Center, Durham, NC 27710, USA

2 Department of Psychiatry and Behavioral Sciences, Room 3547, Box 3018, Duke South Hospital,

Duke University Medical Center, Durham, NC 27710, USA

Y. Ono et al. (eds.), Somatoform Disorders
© Springer-Verlag Tokyo 1999 19
20 A. Frances and B. Vance

wasted cost. For example, a woman with abdominal pain as part of a somatization
disorder may have an exploratory laparotomy in which her uninflamed appendix is
removed prophylactically and to make differential diagnosis easier in the future.
On the other hand, doctors sometimes become frustrated with the ever-
complaining patient who seems to be constantly crying wolf. Consequently, they may
end up refusing to embark upon an adequate medical and psychiatric workup and
miss what may be a real problem. New problems that arise in someone labeled with
a somatoform disorder may be written off as being "in the patient's head:' The patient
in the previous example may later develop adhesions from the surgery, causing bowel
obstruction and consequently, more pain. Due to the patient's history of somatic com-
plaints with heavy psychiatric influence, the patient's important new pain may be
ignored. Obviously, these are difficult diagnostic problems that rely significantly on
the clinician's judgment and understanding of the patient's physical and psychologi-
cal functioning.
Because somatoform disorders fall on a boundary between disciplines, there has
been remarkably little research on their diagnosis and treatment. Both medicine and
psychiatry have tended to neglect these disorders, each leaving them for the other field
to handle. As a result, there is little evidence guiding the treatment of most of these
somatoform disorders. Morbidity and cost incurred by overextensive or underexten-
sive workups, problems inherent in labeling patients with somatoform disorders, as
well as lack of good treatments, make appropriate differential diagnosis all the more
important.

Differential Diagnosis of the Somatoform Disorders

Before making the diagnosis of a somatoform disorder, it is important to take into
account the following possible explanations of the symptom presentation: (1) general
medical conditions; (2) primary psychiatric conditions; (3) substance abuse and with-
drawal; (4) cultural factors; and (5) feigned medical conditions.

General Medical Conditions

The clinician must first rule out the possibility that the symptoms are caused by a
general medical condition that has not yet clearly declared itself or that presents with
an atypical course. One should be specifically alert to the possibilities of systemic
lupus erythematosus, multiple sclerosis, acute intermittent porphyria, and hyper-
parathyroidism. All of these are medical conditions that present with a diverse
symptom pattern which may mimic a somatoform disorder. Contact with the patient's
primary medical provider is necessary, especially when this primary doctor has had
long-term experience the patient. Careful review of the patient's medical records also
helps prevent superfluous testing. Clinical judgment based on these factors along with
the patient's presentation will help determine the nature and the extent of the workup.

Primary Psychiatric Disorders

Primary psychiatric disorders must also be ruled out, especially since most of these
are much better defined and more treatable than somatoform disorders. Many psy-