Somatoform Disorders

Somatic Disorder, Pain Disorder, and Undifferentiated Somatoform disorder were all
merged into a new diagnosis called” Somatic Symptoms Disorder”.

Somatic Symptom Disorder

Diagnostic Criteria

A. One or more somatic symptoms that are distressing or result in significant disruption of
daily life.

B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated

health concerns as manifested by at least one of the following:

1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.

2. Persistently high level of anxiety about health or symptoms.

3. Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously present, the state of being
symptomatic is persistent (typically more than 6 months).

Specify if:

With predominant pain (previously pain disorder): This specifier is for individuals whose
somatic symptoms predominantly involve pain.

Specify if:

Persistent: A persistent course is characterized by severe symptoms, marked impairment,

and long duration (more than 6 months).

Specify current severity:

Mild: Only one of the symptoms specified in Criterion B is fulfilled.

Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

 Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are
multiple somatic complaints (or one very severe somatic symptom).

Diagnostic Features

Individuals with somatic symptom disorder typically have multiple, current, somatic
symptoms that are distressing or result in significant disruption of daily life (Criterion A),
although sometimes only one severe symptom, most commonly pain, is present. 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. Somatic symptoms without an evident medical explanation are not sufficient
to make this diagnosis. The individual’s suffering is authentic, whether or not it is medically
explained.

The symptoms may or may not be associated with another medical condition. 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.
If another medical condition or high risk for developing one is present (e.g., strong family
history), the thoughts, feelings, and behaviors associated with this condition are excessive
Criterion B).

Individuals with somatic symptom disorder tend to have very high levels of worry about
illness (Criterion B). 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.

Individuals typically experience distress that is principally focused on somatic symptoms and
their significance. When asked directly about their distress, some individuals describe it in
relation to other aspects of their lives, while others deny any source of distress other than the
somatic symptoms. Health-related quality of life is often impaired, both physically and
mentally. In severe somatic symptom disorder, the impairment is marked, and when
persistent, the disorder can lead to invalidism.

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. These individuals often seem unresponsive to medical interventions, and
new interventions may only exacerbate the presenting symptoms. Some individuals with the
disorder seem unusually sensitive to medication side effects. Some feel that their medical
assessment and treatment have been inadequate.

Prevalence

The prevalence of somatic symptom disorder is not known. However, the prevalence of
somatic symptom disorder is expected to be higher than that of the more restrictive DSM- IV
somatization disorder (<1%) but lower than that of undifferentiated somatoform disorder
(approximately 19%). 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.
 BRIEF HISTORY

Somatoform Disorders

Somatoform means taking the form of (or in) soma, which implies that these illnesses
are non-somatic.
The general category of somatoform disorders is better thought of as unexplained
symptoms. Hippocrates and the Greeks believed that abdominal organs were the source of
emotional disorders.
The 1600s brought increased understanding of the central nervous system (CNS) and
ideas that unexplained symptoms were a product of the brain. The father of neurology,
Thomas Willis (1621 to 1675), regarded hysteria in women and hypochondriasis in men as
nervous disorders of the brain and advocated hitting affected patients with a stick to the head
as one treatment.
Thomas Sydenham (1624 to 1689) may have had the most impact on the shift to
consider hysteria and hypochondriasis as psychological diseases of the mind and not the
body.
Debate raged about the mechanism of hypochondriasis in men and hysteria in women,
which continued to be considered nervous disorders of the brain or mind, or both.
William Cullen (1712 to 1790) is widely quoted as having coined the term
neurosis, and he wrote that all disorders considered to be related to hypochondriasis and
hysteria was of just one primary. Hysteria, he held, was a separate disorder that had been
confused with hypochondriasis.
Later, in the 1800s, hypochondriasis was considered to be a form of insanity, which
could begin in the abdominal organs but would progress to cause a general inflammation of
all organs, including the brain.
Jean-Martin Charcot and his pupils were certain that hysteria in women and
hypochondriasis in men were disorders of the nervous system and it centers throughout the
body, but they were not sure of its nature or location.
The early 20th century brought about a paradoxical shift in which unexplained
physical symptoms were thought of as primarily psychological. It was paradoxical because it
was the students of Charcot, including Sigmund Freud, who were the motivation for this
shift.
 They were certain that these were disorders of the CNS and were due to repressed
physical energy caused by psychological conflict. The paradoxical shift occurred because of
the lack of good physical treatments and the development of psychological treatments,
including psychoanalysis, which demonstrated treatment success.

Formal psychiatric classification divided unexplained physical symptoms in the

second edition of the DSM (DSM-II) (1968) into the categories neuroses, psychophysiologic
disorders (ten types), and special symptoms. Neuroses were further divided into hysterical
neuroses (divided into conversion and dissociative types), neurasthenia, depersonalization,
hypochondriasis, and other neuroses. There was also a hysterical personality disorder.
The third edition of the DSM (DSM-III) (1980) made the shift to separating the
disorders with physical symptoms (subtyped organic mental disorders and somatoform
disorders) from the dissociative disorders, a new category. Hysterical personality disorder
was replaced with histrionic personality disorder. Conversion disorder was classified with
somatization, psychogenic pain, and hypochondriasis under somatoform disorders.

Somatoform disorders overlap with anxiety, affective, dissociative, and personality

disorders. Somatic symptoms are more common manifestations of anxiety, depression, and
trauma syndromes throughout the world than are psychological symptoms.
Inclusion of a broader range of international and cultural conceptualization is needed.
However, there is not much debate about the importance of this set of disorders to psychiatry
and the rest of medicine. Unexplained physical symptoms associated with high distress and
high health care use are a common problem for clinical medicine. More than one-half of the
most common symptoms in primary care are not adequately explained by a current
biomedical paradigm.
 Illness Anxiety Disorder (Hypochondriasis)

HYPOCHONDRIASIS

Definition
Hypochondriasis is characterized by 6 months or more of a general and non-
delusional preoccupation with fears of having, or the idea that one has, a serious disease
based on the person's misinterpretation of bodily symptoms. This preoccupation causes
significant distress and impairment in one's life, it is not accounted for by another psychiatric
or medical disorder, and a subset of individuals with hypochondriasis has poor insight about
the presence of this disorder.

Diagnostic Criteria

A. Preoccupation with having or acquiring a serious illness.

B. Somatic symptoms are not present or, if present, are only mild in intensity. If another
medical condition is present or there is a high risk for developing a medical condition (e.g.,
strong family history is present), the preoccupation is clearly excessive or disproportionate.

C. There is a high level of anxiety about health, and the individual is easily alarmed about
personal health status.

D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or
her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor
appointments and hospitals).

E. Illness preoccupation has been present for at least 6 months, but the specific illness that is
feared may change over that period of time.

F. The illness-related preoccupation is not better explained by another mental disorder, such
as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic
disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
Specify whether:

Care-seeking type: Medical care, including physician visits or undergoing tests and
procedures, is frequently used.

Care-avoidant type: Medical care is rarely used.

Diagnostic Features

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. Illness anxiety disorder entails a preoccupation with having or acquiring a serious,
undiagnosed medical illness (Criterion A). Somatic symptoms are not present or, if present,
are only mild in intensity (Criterion B). A thorough evaluation fails to identify a serious
medical condition that accounts for the individual’s concerns. While the concern may be
derived from a nonpathological physical sign or sensation, the individual’s distress emanates
not primarily from the physical complaint itself but rather from his or her anxiety about the
meaning, significance, or cause of the complaint (i.e., the suspected medical diagnosis). If a
physical sign or symptom is present, it is often a normal physiological sensation (e.g.,
orthostatic dizziness), a benign and self-limited dysfunction (e.g., transient tinnitus), or a
bodily discomfort not generally considered indicative of disease (e.g., belching). If a
diagnosable medical condition is present, the individual’s anxiety and preoccupation are
clearly excessive and disproportionate to the severity of the condition (Criterion B).
Empirical evidence and existing literature pertain to previously defined DSM
hypochondriasis, and it is unclear to what extent and how precisely they apply to the
description of this new diagnosis.

The preoccupation with the idea that one is sick is accompanied by substantial anxiety
about health and disease (Criterion C). Individuals with illness anxiety disorder are easily
alarmed about illness, such as by hearing about someone else falling ill or reading a health-
related news story. Their concerns about undiagnosed disease do not respond to appropriate
medical reassurance, negative diagnostic tests, or benign course. The physician’s attempts at
reassurance and symptom palliation generally do not alleviate the individual’s concerns and
may heighten them. Illness concerns assume a prominent place in the individual’s life,
affecting daily activities, and may even result in invalidism. Illness becomes a central feature
of the individual’s identity and self-image, a frequent topic of social discourse, and a
characteristic response to stressful life events. Individuals with the disorder often examine
themselves repeatedly (e.g., examining one’s throat in the mirror) (Criterion D). 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. In some cases,
the anxiety leads to maladaptive avoidance of situations (e.g., visiting sick family members)
or activities (e.g., exercise) that these individuals fear might jeopardize their health.

Prevalence

Prevalence estimates of illness anxiety disorder are based on estimates of the DSM-III and
DSM-IV diagnosis hypochondriasis. 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.

Course and Prognosis

The course of hypochondriasis is usually recurrent and chronic.

Poor prognostic factors include severity and duration of symptoms, comorbid

psychiatric disorders, and neuroticism, including affective instability and interpersonal
vulnerability.
Acute onset, medical comorbidity, the absence of a current or past Axis I or II
psychiatric disorder, and the absence of secondary gain are favourable prognostic indicators.

Treatment
Reassurance
Reassurance that is delivered confidently by a competent doctor using multiple
modalities, including skilful examination, effective communication, and helpful education, is
the cornerstone of treatment of the hypochondriacal patient.

Cognitive-Behavioral Therapy (CBT)

Pharmacological
Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake
inhibitors (SNRIs) have been shown to be useful for hypochondriasis in a few small, open-
label studies.
 Conversion Disorder (Functional Neurological Symptom Disorder)

CONVERSION DISORDER
Definition
Conversion disorder is an illness of symptoms or deficits that affect voluntary motor
or sensory functions, which suggest another medical condition, but that is judged to be due to
psychological factors because the illness is followed by conflicts or other stressors. The
symptoms or deficits of conversion disorder are not intentionally produced, are not due to
substances, are not limited to pain or sexual symptoms, and the gain is primarily
psychological and not social, monetary, or legal.

Diagnostic Criteria

A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of mismatch between the symptom and recognized
neurological or medical conditions.

C. The symptom or deficit is not better explained by another medical or mental disorder.

D. The symptom or deficit causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning or warrants medical evaluation.

Specify symptom type:

With weakness or paralysis

With abnormal movement (e.g., tremor, dystonic movement, myoclonus, gait disorder)

With swallowing symptoms

With speech symptom (e.g., dysphonia, slurred speech)

With attacks or seizures

With anesthesia or sensory loss

 With special sensory symptom (e.g., visual, olfactory, or hearing disturbance)

With mixed symptoms

Specify if:

Acute episode: Symptoms present for less than 6 months.

Persistent: Symptoms occurring for 6 months or more.

Specify if:

With psychological stressor (specify stressor)

Without psychological stressor

Diagnostic Features

Many clinicians use the alternative names of “functional” (referring to abnormal central
nervous system functioning) or “psychogenic” (referring to an assumed etiology) to describe
the symptoms of conversion disorder (functional neurological symptom disorder). In
conversion disorder, there may be one or more symptoms of various types. Motor symptoms
include weakness or paralysis; abnormal movements, such as tremor or dystonic movements;
gait abnormalities; and abnormal limb posturing. Sensory symptoms include altered, reduced,
or absent skin sensation, vision, or hearing. Episodes of abnormal generalized limb shaking
with apparent impaired or loss of consciousness may resemble epileptic seizures (also called
psychogenic or non-epileptic seizures). There may be episodes of unresponsiveness
resembling syncope or coma. Other symptoms include reduced or absent speech volume
(dysphonia/aphonia), altered articulation (dysarthria), a sensation of a lump in the throat
(globus), and diplopia.

Although the diagnosis requires that the symptom is not explained by neurological disease,
it should not be made simply because results from investigations are normal or because the
symptom is “bizarre.” There must be clinical findings that show clear evidence of
incompatibility with neurological disease. Internal inconsistency at examination is one way to
demonstrate incompatibility (i.e., demonstrating that physical signs elicited through one
examination method are no longer positive when tested a different way). Examples of such
examination findings include
• Hoover’s sign, in which weakness of hip extension returns to normal strength with
contralateral hip flexion against resistance.

• Marked weakness of ankle plantar-flexion when tested on the bed in an individual who is
able to walk on tiptoes;

• Positive findings on the tremor entrainment test. On this test, a unilateral tremor may be
identified as functional if the tremor changes when the individual is distracted away from it.
This may be observed if the individual is asked to copy the examiner in making a rhythmical
movement with their unaffected hand and this causes the functional tremor to change such
that it copies or “entrains” to the rhythm of the unaffected hand or the functional tremor is
suppressed, or no longer makes a simple rhythmical movement.

• In attacks resembling epilepsy or syncope (“psychogenic” non-epileptic attacks), the

occurrence of closed eyes with resistance to opening or a normal simultaneous
electroencephalogram (although this alone does not exclude all forms of epilepsy or
syncope).

• For visual symptoms, a tubular visual field (i.e., tunnel vision).

It is important to note that the diagnosis of conversion disorder should be based on the overall
clinical picture and not on a single clinical finding.

Prevalence

Transient conversion symptoms are common, but the precise prevalence of the disorder is
unknown. This is partly because the diagnosis usually requires assessment in secondary care,
where it is found in approximately 5% of referrals to neurology clinics. The incidence of
individual persistent conversion symptoms is estimated to be 2–5/100,000 per year.

Risk and Prognostic Factors

Temperamental. Maladaptive personality traits are commonly associated with conversion

disorder.

Environmental. There may be a history of childhood abuse and neglect. Stressful life events
are often, but not always, present.
Genetic and physiological. The presence of neurological disease that causes similar
symptoms is a risk factor (e.g., non-epileptic seizures are more common in patients who also
have epilepsy).

Course modifiers. Short duration of symptoms and acceptance of the diagnosis are positive
prognostic factors. Maladaptive personality traits, the presence of comorbid physical disease,
and the receipt of disability benefits may be negative prognostic factors.

Gender-Related Diagnostic Issues

Conversion disorder is two to three times more common in females.

Functional Consequences of Conversion Disorder

Individuals with conversion symptoms may have substantial disability. The severity of
disability can be similar to that experienced by individuals with comparable medical diseases.

Differential Diagnosis

If another mental disorder better explains the symptoms, that diagnosis should be made.

Neurological disease

Somatic symptom disorder

Factitious disorder and malingering

Dissociative disorders

Body dysmorphic disorder

Depressive disorders

Panic disorder

Comorbidity

Anxiety disorders, especially panic disorder, and depressive disorders commonly co-occur
with conversion disorder. Somatic symptom disorder may co-occur as well. Psychosis, sub-
stance use disorder, and alcohol misuse are uncommon. Personality disorders are more
common in individuals with conversion disorder than in the general population. Neurological
or other medical conditions commonly coexist with conversion disorder as well.
Treatment
In acute cases with a history of conversion, reassurance and suggestion of
recovery coupled with early rehabilitation are the treatments of choice. If symptoms
continue, more aggressive rehabilitation is indicated.
Chronic cases are more difficult to treat.

Second, pharmacotherapy may be useful. Anxiolytic and antidepressant medications

may decrease some of the symptoms to allow the patient to engage in physical
rehabilitation or psychotherapy. Medication-induced sedation therapy, such as an
amobarbital (Amytal) interview

Videotaping may be useful as feedback to the patient, when appropriate, to augment

therapist interpretation.
 PAIN DISORDER
Definition
A pain disorder is characterized by the presence of and focuses on pain in one or more
body sites and is severe enough to come to clinical attention. Psychological factors are
necessary in the origin, severity, or maintenance of the pain, which causes significant distress
or impairment, or both. The physician does not have to judge the pain to be “inappropriate”
or “in excess of what would be expected”.

Pain disorder
A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation
and is of sufficient severity to warrant clinical attention.
B. The pain causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
C. Psychological factors are judged to have an important role in the onset, severity,
exacerbation, or maintenance of the pain.
D. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder
or malingering).
E. The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not
meet criteria for dyspareunia.
Pain disorder associated with psychological factors: Psychological factors are judged to
have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a
general medical condition is present, it does not have a major role in the onset, severity,
exacerbation, or maintenance of the pain.) This type of pain disorder is not diagnosed if
criteria are also met for somatization disorder.
 Acute: duration of less than 6 months
  Chronic: duration of 6 months or longer

Pain disorder associated with both psychological factors and a general medical
condition: Both psychological factors and a general medical condition are judged to have
important roles in the onset, severity, exacerbation, or maintenance of the pain.
 Acute: duration of less than 6 months
 Chronic: duration of 6 months or longer

Pain disorder associated with a general medical condition: A general medical condition
has a major role in the onset, severity, exacerbation, or maintenance of the pain. (If
psychological factors are present, they are not judged to have a major role in the onset,
severity, exacerbation, or maintenance of the pain.) The diagnostic code for the pain is
selected based on the associated general medical condition if one has been established or on
the anatomical location of the pain if the underlying general medical condition is not yet
clearly established—for example, low back, pelvic, headache, facial, chest, joint, bone,
abdominal, breast, renal, ear, eye, throat, tooth, and urinary.
 Somatization disorder

A. A history of many physical complaints beginning before 30 years of age that occur over a
period of several years and result in treatment being sought or significant impairment in
social, occupational, or other important areas of functioning.
B. Each of the following criteria must have been met, with individual symptoms occurring at
any time during the course of the disturbance:

1. Four pain symptoms. A history of pain related to at least four different sites or
functions (e.g., head, abdomen, back, joints, chest, rectum, during menstruation,
during sexual intercourse, or during urination).
2. Two gastrointestinal symptoms. A history of at least two gastrointestinal symptoms
other than pain (e.g., nausea, swelling, vomiting other than during pregnancy,
diarrhea, or intolerance of several different foods).
3. One sexual symptom. A history of at least one sexual or reproductive symptom other
than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular
menses, excessive menstrual bleeding, or vomiting throughout pregnancy).
4. One pseudoneurological symptom. A history of at least one symptom or deficit
suggesting a neurological condition not limited to pain (conversion symptoms, such as
impaired coordination or balance, paralysis or localized weakness, difficulty
swallowing, urinary retention, loss of touch or pain sensation, double vision,
blindness, deafness, and seizures; dissociative symptoms, such as amnesia; or loss of
consciousness other than fainting).

C. Either (1) or (2):

 1. After appropriate investigation, each of the symptoms in Criterion B cannot be fully
explained by a known general medical condition or the direct effects of a substance
(e.g., a drug of abuse, a medication).
2. When there is a related general medical condition, the physical complaints or
resulting social or occupational impairment are in excess of what would be expected
from the history, physical examination, or laboratory findings.

D. The symptoms are not intentionally produced or feigned (as in factitious disorder or
malingering).
Undifferentiated somatoform disorder
A. One or more physical complaints (e.g., fatigue, loss of appetite, or gastrointestinal or
urinary complaints).
B. Either (1) or (2):

1. After appropriate investigation, the symptoms cannot be fully explained by a known

general medical condition or the direct effects of a substance (e.g., a drug of abuse or
a medication).
2. When there is a related general medical condition, the physical complaints or
resulting social or occupational impairment is in excess of what would be expected
from the history, physical examination, or laboratory findings.

C. The symptoms cause clinically significant distress or impairment in social, occupational,

or other important areas of functioning.
D. The duration of the disturbance is at least 6 months.
E. The disturbance is not better accounted for by another mental disorder (e.g., another
somatoform disorder, sexual dysfunction, mood disorder, anxiety disorder, sleep disorder, or
psychotic disorder).
F. The symptom is not intentionally produced or feigned (as in factitious disorder or
malingering).
General Phenomenology of Somatoform Disorders

Temperament may influence the degree to which a child is focused on sensory

systems as a cue for danger. For example, young children of parents with panic disorder are
more likely than children of parents without panic disorder to inhibit their exploring
behaviour in novel situations.
Second, there is strong evidence that young children learn how to express their
distress.
Third, psychiatric disorders are associated with an increase in bodily sensation, and
successful treatment of the disorder, such as an anxiety or affective illness, can markedly
reduce the somatic preoccupation and distress.
Fourth, ongoing life stressors coupled with poor coping skills lead to generalization
across multiple situations of the general stress response and the flight, fight, or freeze
response. This generalizing phenomenon is strongly conditioned by the recurrent and random
nature of the life stressors and is mitigated by resolution of the fear response by adequate
coping.

Fifth, early-life adverse experiences may cause changes in psychobiology, such as

persistent hyper adrenalism and hyper- or hypocortisolism, which have an impact on sensory
perception and reflex behaviour. There is good evidence in animal and human research
indicating that adverse experiences, such as maternal separation, isolation, and
deprivation, and overt forms of trauma influence the development and functioning of central
and peripheral nervous system components and the immune system and are associated with
worse health perception and worse health by objective measures. The phenomenon of re-
experiencing in posttraumatic stress disorder (PTSD) is perhaps the best example of how
trauma becomes embodied.

Perception and Cognition

They often have high negative self-appraisal and self-concepts of being weak and unable
to tolerate stress.

People with somatization disorders tend to over report symptoms during minor illnesses
and during medical tests.

Interaction with Anxiety and Depression

Eighty-eight to 95 percent of people who come to primary care settings around the
world and who are subsequently diagnosed with an anxiety or depressive disorder present
with only somatic symptoms as their chief complaint.

Relationship to Factitious and Malingering Disorders

Physicians often only consider symptoms authentic if they can be measured in the
context of the biomedical culture. In fact, the realness of a given symptom has to do with
whether it is produced consciously or unconsciously by the patient. In somatoform disorders,
symptoms are produced unconsciously and are thus as authentic as a symptom of diabetes
mellitus.

The somatoform-disordered patient is not making the symptom up for any reason for
which he or she is aware, and he or she is rightfully offended when it is suggested that the
symptom is being faked.

In factitious disorders, the patient has some awareness that he or she intentionally
produces the symptom, although this awareness is usually less than complete.

In malingering disorders, the person is clearly and consciously fabricating the

symptom to obtain external incentives.
In somatoform disorders, the patient has no awareness of why this symptom has been
produced, even if psychological factors are responsible for its production
In factitious disorders, the reason for the symptoms is also generally unconscious and is
thought to be due to the need to assume the sick role and to obtain the benefits that go along
with being ill.

In malingering, the person is fully aware of why he or she is producing the illness, and the
gain is said to be secondary, or external, to the self. The malingering person is conscious of
using symptoms to obtain money or medications or to avoid duties.

The difference is that the somatoform and factitious patient thinks they deserve what they are
requesting to gain based on an illness, whereas the malingerer has no illusions that symptoms
are the reason for the attempted gain

Learning and Socio- cultural

Children's symptoms are often a copy of other family members' symptoms. Adult
somatoform symptoms are similar to those symptoms that were given attention by parents in
childhood.

Culture also teaches people what is acceptable to express and what is not, and this
influences the manifestation of emotion and body sensation. Socioeconomic class, education
level, and subculture influence the rates of expressing emotional distress as somatic
complaint.

Stressors and Coping

The relationship between life events, trauma, and subsequent somatic symptoms and
physical health.
Adverse life events

Day-to-day stressors

Coping style then predicts individual response to stressors. If stressors are many,
persistent, or of high-impact quality, somatic responses occur and may be learned. If one's
coping style is inadequate to resolve the physiological consequences of the stressors, then
persistent somatic responses may be learned.
Individuals who are burdened with an unusually high number of persistent and high-
impact stressors and poor coping mechanisms are at the highest risk of somatoform disorders,
as well as some other psychiatric disorders.
 Anger, impulsivity, hostility, isolation, and lack of confiding in others are some
coping styles that have been associated with an increased risk for somatic symptoms and
somatoform disorders. There are many empirical reports that link anger and hostility to
somatization.

TREATMENT PRINCIPLES
Somatoform Disorders
Patient–Physician Relationship and Structure of Treatment
The first of these elements is attention

It is not the disease, but the man or the woman, who needs to be seen and treated.

The second important element is unconditional care:

Which is characterized by

 Acceptance and respect for the person, his or her symptoms, and how the symptoms
are adversely affecting the person, which is why he or she comes to the doctor as a
patient.
 Reflecting back to the patient what has been said via all forms of communication and
letting him or her know that he or she is attended to.
 Not expecting or needing appreciation, as many patients with somatoform disorders
assumed a parental role early in life for parent or other authority figure. Requiring this
of a somatoform patient may make his or her symptoms worse.

The third element is skilful treatment

Some are general modalities that are more specific to somatoform disorders than to other
psychiatric illness.
 Attend to transference and counter-transference.

Formulate without labels when the diagnosis is uncertain.

Evaluate appropriately with standard and limited workup

Frame and make boundaries

Connect for the patient the languages of psyche and soma.

Reassure appropriately and carefully

Communicate clearly

Reassurance
Reassurance is a general technique for all of medicine and is also a specific technique
to be used skilfully with the somatoform-disordered patient.

Cognitive-Behavioural and Other Psychotherapies

The value of the psychotherapies for somatoform disorders are just beginning to be
understood. (CBT) -8 to 20 sessions.

Pharmacotherapy
There is mounting evidence for the usefulness of antidepressant medications in
somatoform disorders.