Somatoform disorder (somatic

symptom and related disorders)

Moges Ayehu, MD, Assistant Professor of
Psychiatry, HUCMHS

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 Subtypes of somatoform disorder(DSM-IV)
1. Somatization disorder
2. Conversion disorder
3. Pain disorder
4. Hypochondriasis
5. Body dysmorphic disorder
6. Undifferentiated somatoform disorder
7. Somatoform disorder NOS

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 DSM V
1. Somatic symptom disorder
2. Illness anxiety disorder
3. Conversion disorder (functional neurological
symptom disorder)
4. Psychological factors affecting other medical
conditions
5. Factitious disorder,
6. Other specified somatic symptom and related
disorder, and unspecified somatic symptom and
related disorder.

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 Difference B/n DSM-IV and V
The DSM-IV term somatoform disorders was
confusing and is replaced by somatic symptom and
related disorders.
In DSM-IV there was a great deal of overlap across
the somatoform disorders and a lack of clarity about
the boundaries of diagnoses.
Although individuals with these disorders primarily
present in medical rather than mental health settings,
non-psychiatric physicians found the DSM-IV
somatoform diagnoses difficult to understand and use.

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 1. Somatic symptom disorder
Characteristic features
typically have multiple, current, somatic symptoms that are distressing
or result in significant disruption of daily life.
Symptoms may be specific (e.g., localized pain) or relatively
nonspecific (e.g., fatigue). The symptoms sometimes represent normal
bodily sensations or discomfort that does not generally signify serious
disease.
The diagnoses of somatic symptom disorder and a concurrent medical
illness are not mutually exclusive, and these frequently occur together.
 For example, an individual may become seriously disabled by
symptoms of somatic symptom disorder after an uncomplicated
myocardial infarction even if the myocardial infarction itself did not
result in any disability.
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 Somatic symptom disorder
They appraise their bodily symptoms as unduly
threatening, harmful, or troublesome and often think
the worst about their health. Even when there is
evidence to the contrary, some patients still fear the
medical seriousness of their symptoms.
In severe somatic symptom disorder, health concerns
may assume a central role in the individual's life,
becoming a feature of his or her identity and
dominating interpersonal relationships.

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 Somatic symptom disorder
There is often a high level of medical care utilization,
which rarely alleviates the individual's concerns.
Consequently, the patient may seek care from multiple
doctors for the same symptoms. (Doctor shopping)
These individuals often seem unresponsive to medical
interventions, and new interventions may only
exacerbate the presenting symptoms.

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 Somatic symptom disorder
Attention focused on somatic symptoms, attribution of
normal bodily sensations to physical illness (possibly
with catastrophic interpretations), worry about illness,
and fear that any physical activity may damage the
body.
The relevant associated behavioral features may
include repeated bodily checking for abnormalities,
repeated seeking of medical help and reassurance, and
avoidance of physical activity.
Frequent requests for medical help for different
somatic symptoms.
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 Somatic symptom disorder
Any reassurance by the doctor that the symptoms are
not indicative of serious physical illness tends to be
short-lived and/or is experienced by the individuals as
the doctor not taking their symptoms with due
seriousness.
The suggestion of referral to a mental health specialist
may be met with surprise or even frank refusal by
individuals with somatic symptom disorder.

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 Prevalence of somatic symptom disorder
The prevalence of somatic symptom disorder in the
general adult population may be around 5%-7%.
Females tend to report more somatic symptoms than
do males, and the prevalence of somatic symptom
disorder is consequently likely to be higher in females.

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 Somatic symptom disorder…in children
In children, the most common symptoms are recurrent
abdominal pain, headache, fatigue, and nausea. A single
prominent symptom is more common in children than in
adults.
While young children may have somatic complaints, they
rarely worry about "illness“ per se prior to adolescence.
The parents' response to the symptom is important, as
this may determine the level of associated distress.
It is the parent who may determine the interpretation of
symptoms and the associated time off school and medical
help seeking

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 2. Conversion disorder (functional
neurological symptom disorder)
Symptoms of deficits affecting voluntary motor or
sensory function
Symptom occurrence temporally related to
psychological stresses
Patient is not consciously or intentionally
producing symptoms
The gain is primarily psychological and not
social, monetary, or legal

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 Clinical features
 Motor Symptoms
 Involuntary movements,
Tics, Blepharospasm, Torticollis, Opisthotonos,
 Abnormal gait, Falling, Astasia-abasia,
 Paralysis, Weakness
 Aphonia

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 Clinical features cont’d
 Sensory Deficits
 Anesthesia, especially of extremities, Midline anesthesia
 Blindness, Tunnel vision
 Deafness

 Seizures or convulsions

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 Clinical features cont’d
 Visceral Symptoms
 Psychogenic vomiting,
 Pseudocyesis(in DSM-V …Other Specified Somatic Symptom and
Related Disorder)
 Globus hystericus,
 Swooning or syncope,
 Urinary retention,
 Diarrhea
 Vaginismus

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 Clinical features
Additional features
 Symptoms
 Do not conform to known anatomical path way
 Are inconsistent
 La belle indifferent
 Patient seems to be unconcerned about what appears to be a major
impairment (not pathnognomonic)
 Histrionic personality

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 Differential Diagnosis
 25 to 50 percent of patients classified as having
conversion disorder eventually be diagnosed as
 Neurological disorders
 Nonpsychiatric medical disorders

 Thorough medical and neurological workup is

essential

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 Differential Diagnosis cont’d
E.g.
 Weakness
 Myasthenia gravis
 Polymyositis,
 Acquired myopathies,
 MS
 Blindness
 Optic neuritis

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 3. Hypochondrias(Illness Anxiety Disorder)
Most individuals with hypochondriasis are now classified as having
somatic symptom disorder; however, in a minority of cases, the diagnosis
of illness anxiety disorder applies instead.
Clinical features
 Preoccupation with fear of having serious disease e.g. cancer, cardiac disease,
venereal disease, etc.
 If a diagnosable medical condition is present, the individual's anxiety and
preoccupation are clearly excessive and disproportionate to the severity of the
condition.
 The belief persists despite medical evaluation and reassurance
They research their suspected disease excessively (e.g., on the
Internet) and repeatedly seek reassurance from family, friends, or
physicians.
This incessant worrying often becomes frustrating for others and
may result in considerable strain within the family.
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 Medical attention leads to a paradoxical
exacerbation of anxiety or to iatrogenic
complications from diagnostic tests and
procedures.
Individuals with the disorder are generally
dissatisfied with their medical care and find it
unhelpful, often feeling they are not being taken
seriously by physicians.
At times, these concerns may be justified, since
physicians sometimes are dismissive or respond
with frustration or hostility.
The belief is not delusional
Symptoms not accounted by other psychiatric
disorders e.g. Depression, GAD, OCD
At least 6 months in duration
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 Prevalence of health anxiety
The 1- to 2-year prevalence of health anxiety and/or
disease conviction in community surveys and
population-based samples ranges from 1.3% to 10%. In
ambulatory medical populations, the 6-month/1-year
prevalence rates are between 3% and 8%.
The prevalence of the disorder is similar in males and
females.(M=F in hypochondriasis )

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 5. Body dysmorphic disorder
Common body sites by frequencies:
1. Hair: 63%
2. Nose: 50%
3. Skin: 50%
4. Eye: 30%
5. Face: 20%
6. Breast < 10
7. < 5%: Neck, forehead and
facial muscle.

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 Clinical features
 Preoccupation with an imagined defect in appearance
 Imagined or slight flaws of face or head
 Hair thinning, wrinkles, scars, vascular markings
 Facial asymmetry or disproportion
 Facial hair
 Shape, size, or other aspects of
 Nose, eye, eye lids, mouth, lips, teeth, jaw, chin, ear
 Other parts of body
 Breasts, genitals, buttocks, hip
 Variant of dysmorphic disorder among men is the desire to bulk
and develop large muscle mass

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 Clinical features cont’d
 For minor physical anomaly excessive concern
 More than normal concern - excessively time consuming
 Excessive mirror watching
 Use magnifying glass to scrutinize “defect”
 Excessive grooming - ritual of make up
 Frequent request for reassurance
 Frequently comparing their “ugly parts” with others

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 Clinical features cont’d
 Preoccupation causes significant distress or impairment in
functioning
 Avoidance of work
 Avoidance of public situations, etc.
 One third of the patients may be housebound
 Associated symptoms include ideas or frank delusions of
reference
 One fifth attempt suicide(20%)
 Not accounted by other mental disorder e.g. anorexia
nervosa

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 6. Psychological factors affecting other
medical conditions
Is the presence of one or more clinically significant psychological
or behavioral factors that adversely affect a medical condition by
increasing the risk for suffering, death, or disability.
Common clinical examples are anxiety-exacerbating asthma,
denial of need for treatment for acute chest pain, and manipulation
of insulin by an individual with diabetes wishing to lose weight.
Many different psychological factors have been demonstrated to
adversely influence medical conditions—for example, symptoms
of depression or anxiety, stressful life events, relationship style,
personality traits, and coping styles.

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 Cause…
Higher levels of physiologic arousal
Less likely to habituate to a stressful task than control
subjects .
Amplify somatosensory information;
 that is, these patients are hypersensitive to bodily
sensations that are experienced as intense, noxious, and
disturbing .

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 Cause…
Negative cognitive appraisals of their physical
sensations.
 E.g. they may believe that pain, fatigue, and/or
discomfort of any kind are signs of disease.
Think catastrophically to the extent that they imagine
persistent physical sensations to be a sign of some
potentially fatal disease, such as cancer or AIDS.

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 Sociocultural Factors
The stigmatization of psychiatric distress may be a
powerful factor promoting somatization.
Somatization may be the only form of
communication permissible for the socially
powerless.

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 Developmental Factors
Physical symptoms are a major form of interpersonal
communication in some families (Stuart and Noyes
1999).
Childhood exposure to parental chronic illness or
abnormal illness behavior appears to increase the risk
of somatization in later life (Bass and Murphy 1995;
Craig et al. 1993).

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 Management…
Most somatizing patients, however, would not accept
the notion that their physical symptoms are entirely a
direct product of stress.
Therefore, it is important that therapists clarify that
stress is only one factor contributing to patients’
physical discomfort.

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 Cognitive restructuring
Aims to help patients differentiate and understand
their thoughts and feelings so that they can interact
more effectively with their environments.
Are based on cognitive treatment programs for stress
management and pain management .
Cognitive errors
Think catastrophically about somatic symptoms.

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 Behavioral management
Behavioral methods are based largely on the
principles of classical and operant conditioning.
Encourage patient to come to the clinic regularly.
Encourage them also to avoid unnecessary
investigation.

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Pseudo-seizure Genuine seizure
No history of seizure History of seizure
Anxiety and absence of aura
 Aura
Induced by stress
 Not induced by stress
Conscious during seizure
 Unconscious during seizure
Occurs in front of witnesses to seek attention
 May have not witness
Asymmetrical body movements during seizure
 Symmetrical body movements
during s
No delirium
 Post-ictal confusion
No increase in prolactin
 Raised prolactin after seizure if
blood is taken within 30minutes
No injury as a result of seizure
 Injury as a result of seizure
No incontinence
 Incontinence after seizure
Normal EEG
 Abnormal EEG

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