Somatoform Disorders

Definition

Somatoform disorders are mental illnesses that cause physical pain and other symptoms without any physical explanation. These disorders can be very challenging and distressing for both patient and doctor. For a patient, it is very frustrating to experience pain and discomfort that has no known explanation. This frustration can turn into a vicious cycle, leading people to seek out diagnoses and imagine that they have diseases that they do not have.

For doctors it can be difficult to search and search for an explanation and find nothing. Doctors and psychologists are reluctant to assert that a patient's pain is psychological because it can be very difficult to rule out all possible causes of physical pain. It is also challenging to deal with a patient who keeps complaining of symptoms - patients will often become increasingly agitated over time and may even question an attending physician's competence.

Someone with a true somatoform disorder will often become increasingly preoccupied with his/her own health, display negative emotions towards doctors and healthcare workers, demand unncessary tests and fail to comply with doctor recommendations.

Diagnosis of Somatoform Disorders

Diagnosis combines the medical and the psychological. A patient who visits a healthcare provider with unexplained symptoms must be thoroughly examined to rule out any possibilities of physical illness or trauma.

A medical doctor confronted with a patient who is preoccupied with inexplicable symptoms may recommend a mental health evaluation if he suspects a somatoform disorder.

A mental health evaluation must be conducted carefully to rule out other diagnoses. The perceived symptoms, the preoccupation with the symptoms, and the repeated search for help may be part of a larger mental health problem. Additionally, two related disorders must be ruled out.

Factitious Disorder and Malingering

Factitious disorder and malingering must both be ruled out before moving on to a somataform disorder.

A patient with factitious disorder takes on physical symptoms for internal gain. For example, someone who longs for sympathy may exaggerate or feign stomach pain.

A patient who is malingering takes on physical symptoms for external gain. External gain can be something like money (in the form of disability payments, for example) or something a little more subtle such as avoidance of situations (such as family gatherings).

Two related disorders, factitious disorder and malingering, must be excluded before diagnosing a somatoform disorder. In factitious disorder, patients adopt physical symptoms for unconscious internal gain (i.e., the patient desires to take on the role of being sick), whereas malingering involves the purposeful feigning of physical symptoms for external gain (e.g., financial or legal benefit, avoidance of undesirable situations). In somatoform disorders, there are no obvious gains or incentives for the patient, and the physical symptoms are not willfully adopted or feigned; rather, anxiety and fear facilitate the initiation, exacerbation, and maintenance of these disorders.

Criteria for Somatoform Disorders

It is important to remember that someone who plays sick for a day does not have a somatoform disorder. Three criteria are required for diagnosis:

1. The physical symptoms cannot be fully explained by a medical condition, another mental illness, or by the effects of a substance
2. The diagnosis is not factitious disorder or malingering
3. The symptoms significantly impair in social, occupational, or other daily life functioning.

Types of Somatoform Disorders

Somatization Disorder (a.k.a. Briquet's syndrome)

Somatization disorder patients usually have a pretty long history of doctor visits for a variety of symptoms. There are specific criteria in the DSM for somatization disorder: a history of somatic symptoms prior to the age of 30; pain in at least four different sites on the body; two gastrointestinal problems other than pain such as vomiting or diarrhea; one sexual symptom such as lack of interest or erectile dysfunction; one pseudoneurological symptom similar to those seen in conversion disorder such as fainting or blindness.

Undifferentiated somatoform disorder

This is a somewhat vague version of somatization disorder, requiring only one symptom for 6 months.

Conversion disorder

The DSM describes conversion disorder with the following criteria: one or more symptoms or deficits are present that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition; psychological factors are judged to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit; a diagnosis where the stressor precedes the onset of symptoms by up to 15 years is not unusual; the symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering); the symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally sanctioned behavior or experience; the symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation; the symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.

Pain disorder

As its name suggests, patients with pain disorder report pain that has no apparent physical cause; in pain disorder the patient is not "faking" the pain as in malingering. They have chronic pain for several months that causes stress and disrupts daily life. The pain may or may not be associated with a medical condition.

Hypochondriasis

The term "hypchondriac" is a familiar one that is often used casually. However, it relates to this specific mental illness. The DSM lists the following criteria for hypochondriais: a preoccupation with fears of having a serious disease based on the misinterpretation of bodily symptoms; the preoccupation persists despite medical evaluation and reassurance; the belief in the presence of disease and symptoms is not of delusional intensity and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder); the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; the duration of the disturbance is at least 6 months; the preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

Body dysmorphic disorder

A person with body dysmorphic disorder obsesses over a physical imperfection or deformity that may or may not exist. For example, a small scar on a hand might cause someone to constantly wear gloves and take extreme measures to prevent anyone from seeing their hands. The DSM-IV defines body dysmorphic disorder as a somatoform disorder marked by a preoccupation with an imagined or trivial defect in appearance that causes clinically significant distress or impairment in social, occupational or other important areas of functioning. The individual's symptoms must not be better accounted for by another disorder; for example, weight concern is usually more accurately attributed to an eating disorder.

Somatoform Disorder not Otherwise Specified ( NOS )

This diagnosis is reserved for those conditions that are characteristic of somatoform disorders but fail to meet the criteria for more specific diagnosis.

Somatoform Disorders Treatment

Treatment for somatoform disorders is usually therapy based. Medical treatments can be used, especially when another disorder is being treated in conjunction, but there is not much evidence that they are very effective for somatoform disorders by themselves. A 2007 research survey found that cognitive behavioral therapy was the most effective form of treatment.

Some common forms of therapy that may be used to treat somatoform disorders include:

• Adlerian Therapy
• Behavior Therapy
• Existential Therapy
• Gestalt Therapy
• Person-centered Therapy
• Psychoanalytic
• Rational-emotive Therapy
• Reality Therapy
• Transactional Analysis

Related Pages

• Somatoform Diagnosis Flow Chart
• FREE Testing
• Somatoform Disorders at Wikipedia

Resources

• Efficacy of Treatment for Somatoform Disorders: A Review of Randomized Controlled Trials, Kurt Kroenke, MD, Psychosomatic Medicine 69:881-888 (2007)
• American Family Physician, Somatoform Disorders