Somatoform disorders are a group of disorders characterized by the occurrence of somatization, a term that describes the expression of psychological or mental difficulties through physical symptoms. Somatization takes a number of forms, ranging from preoccupation with potential or genuine but mild physical problems to the development of actual physical pain, discomfort, or dysfunction. Somatization appears to be fairly common,
but a somatoform disorder diagnosis is not warranted unless symptoms cause significant distress or disability.
Somatization disorder is characterized by a history of multiple unexplained medical problems or physical complaints beginning prior to age 30. In the nineteenth and early twentieth centuries, somatization disorder was known as Briquet's syndrome or hysteria—a more generic term for such a condition. People with somatization disorder report symptoms affecting multiple organ systems or physical functions, including pain, gastrointestinal distress, sexual problems, and symptoms that mimic neurological disorders. Although medical explanations for their symptoms cannot be identified, individuals with somatization disorder experience genuine physical discomfort and distress. Review of their medical histories will usually reveal visits to a number of medical specialists, and many patients take numerous medications prescribed by different doctors, running the risk of dangerous drug interactions.
The revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the professional handbook clinicians use to diagnose mental disorders, describes seven disorders under the category of somatoform disorders. These disorders are somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder not otherwise specified.
- Undifferentiated somatoform disorder is similar to somatization disorder but may involve fewer symptoms, have a shorter duration, or begin after the age of 30. Common symptoms include chronic fatigue, loss of appetite, gastrointestinal distress, or problems involving the genitals or urinary tract. This diagnosis is appropriate for patients with symptoms of somatization disorder who do not meet all diagnostic criteria.
- Conversion disorder is marked by unexplained sensory or motor symptoms that resemble those of a neurological or medical illness or injury. Common symptoms include paralysis, loss of sensation, double vision, seizures, inability to speak or swallow, and problems with coordination and balance. Symptoms often reflect a naive understanding of the nervous system, and physicians often detect conversion disorder when symptoms do not make sense anatomically. For instance, a patient may report loss of both touch and pain sensation on one side of the body, when a genuine lesion would result in loss of touch and pain sense on opposite sides of the body. The name conversion disorder reflects a theoretical understanding of the disorder as a symbolic conversion of a psychological conflict into a concrete physical representation. Patients with conversion disorder may not express the level of distress one would expect from someone with a disabling neurological condition. This phenomenon is traditionally called la belle indifference.
- The primary feature of pain disorder is physical pain that causes significant distress or disability or leads an individual to seek medical attention. Pain may be medically unexplained, or it may be associated with an identifiable medical condition but manifest more severely than the condition would warrant. Common symptoms include headache, backache, and generalized pain in muscles and joints. Pain disorder can be severely disabling, causing immobility that prevents patients from working, fulfilling family responsibilities, or engaging in social activities. Like patients with somatization disorder, people with pain disorder often have a history of consultations with numerous physicians.
- Hypochondriasis is diagnosed when a person is excessively concerned by fears of having a physical disease or injury. Individuals with hypochondriasis usually do not complain of disabling or painful symptoms. Instead, they tend to overreact to minor physical symptoms or sensations, like rapid heartbeat, sweating, small sores or fatigue. Many people with hypochondriasis develop fears in response to the illness or death of a friend or family member, or after reading about a condition or seeing a feature on television. Hypochondriacal fears can be confined to a single disease or involve a number of different physical concerns. Individuals with hypochondriasis seek frequent reassurance by consulting with physicians or talking about their fears, yet these efforts provide only temporary relief from their fears. Although hypochondriasis is usually not as disabling as somatoform disorders involving the development of actual physical symptoms, it can put stress on relationships or reduce work productivity through time lost to frequent medical appointments and tests.
- Body dysmorphic disorder is characterized by preoccupation with a defect in physical appearance. Often the defect of concern is not apparent to other observers, or if there is a genuine defect, it is far less disfiguring than the patient imagines. Common preoccupations include concerns about the size or shape of the nose, skin blemishes, body or facial hair, hair loss, or “ugly” hands or feet. Individuals with body dysmorphic disorder may be extremely self-conscious, avoiding social situations because they fear Page 1461 | Top of Articleothers will notice their physical defects or even make fun of them. They may spend hours examining the imagined defect or avoid mirrors altogether. Time-consuming efforts to hide the defect, such as application of cosmetics or adjustments of clothing or hair, are common. Many people with body dysmorphic disorder undergo procedures like plastic surgery or cosmetic dentistry, but are seldom satisfied with the results.
- Somatoform disorder not otherwise specified is diagnosed when somatoform symptoms are present but criteria for another somatoform disorder are not met. DSM-IV-TR includes several examples of symptoms that could merit this diagnosis, including false pregnancy and hypochondriacal fears or unexplained physical symptoms of recent onset or short duration.
There is some disagreement among researchers about the DSM-IV-TR somatoform disorders category. Some have argued that hypochondriasis and body dysmorphic disorder are more similar to obsessive compulsive disorder than to other somatoform disorders, while others think hypochondriasis may be more appropriately classified with the anxiety disorders. Proposed changes for the fifth edition of the DSM (DSM-5, 2013) have addressed some of these concerns by reorganizing the category of somatoform disorders under the new name of somatic symptom disorders. If approved, the new category will include seven disorders, with body dysmorphic disorder moved to the category of obsessive-compulsive and related disorders:
- complex somatic symptom disorder (subsumes diagnoses of pain disorder, somatization disorder, undifferentiated somatoform disorder, and some aspects of hypochondriasis)
- simple somatic symptom disorder (includes previous diagnosis of somatoform disorder not otherwise specified)
- illness anxiety disorder (hypochondriasis)
- functional neurological disorder (conversion disorder)
- psychological factors affecting medical condition
- other specified somatic symptom disorder
- unspecified somatic symptom disorder
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text rev. Washington, DC: American Psychiatric Publishing, 2000.
Phillips, Katherine A. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, 2005.
Pilowsky, Issy. Abnormal Illness Behaviour. Chichester, UK: John Wiley and Sons, 1997.
Neziroglu, Fugen, Dean McKay, and Jose A. Yaryura-Tobias. “Overlapping and Distinctive Features of Hypochondriasis and Obsessive-Compulsive Disorder.” Journal of Anxiety Disorders 14, no. 6 (November–December 2000): 603–614.
Danielle Barry, M.S.