The American Psychiatric Publishing

TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.
© 2008 American Psychiatric Publishing, Inc. All rights reserved. [Link]

CHAPTER 13

Somatoform Disorders
Sean H. Yutzy, M.D.,
Brooke S. Parish, M.D.

Slide show includes…

Topic Headings
Tables and Figures
Key Points

The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. [Link]
 CHAPTER 13 • Topic Headings
SOMATIZATION DISORDER HYPOCHONDRIASIS
Definition and Clinical Description Definition and Clinical Description
Diagnosis Diagnosis
History History
DSM-IV-TR Criteria DSM-IV-TR Criteria
Differential Diagnosis Differential Diagnosis
Natural History Natural History
Epidemiology Epidemiology
Etiology Etiology
Treatment Treatment
UNDIFFERENTIATED SOMATOFORM DISORDER BODY DYSMORSPHIC DISORDER
Definition and Clinical Description Definition and Clinical Description
Diagnosis Diagnosis
History History
DSM-IV-TR Criteria DSM-IV-TR Criteria
Differential Diagnosis Differential Diagnosis
Epidemiology Natural History
Etiology Epidemiology
Treatment Etiology
Treatment
CONVERSION DISORDER
Definition and Clinical Description SOMATOFORM DISORDER NOT OTHERWISE SPECIFIED
Diagnosis Definition and Clinical Description
History Diagnosis
DSM-IV-TR Criteria History
Differential Diagnosis DSM-IV-TR Criteria
Natural History Differential Diagnosis
Epidemiology Epidemiology, Etiology, and Treatment
Etiology
CONCLUSION
Treatment

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 CHAPTER 13 • Tables and Figures

Table 13–1. DSM-IV-TR somatoform disorders: a comparison

Table 13–2. DSM-IV-TR somatoform disorders and corresponding categories in previous DSM and
ICD diagnostic systems
Table 13–3. Feighner criteria symptom list for hysteria (somatization disorder)
Table 13–4. DSM-IV-TR diagnostic criteria for somatization disorder
Table 13–5. Features useful in discriminating between somatization disorder and general medical conditions
Table 13–6. General medical conditions that may be confused with somatization disorder
Figure 13–1. Distribution and number of sick leave occasions in Swedish somatizing (“high-frequency”)
subjects and control nonsomatizing subjects.
Table 13–7. Main treatment principles in approaching a patient with somatization disorder
Table 13–8. DSM-IV-TR diagnostic criteria for undifferentiated somatoform disorder
Table 13–9. DSM-IV-TR diagnostic criteria for conversion disorder
Table 13–10. Key terms
Table 13–11. DSM-IV-TR diagnostic criteria for hypochondriasis
Table 13–12. DSM-IV-TR diagnostic criteria for body dysmorphic disorder
Table 13–13. DSM-IV-TR diagnostic criteria for somatoform disorder not otherwise specified
Summary Key Points

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In DSM-IV-TR, the disorders included under the somatoform rubric are somatization disorder,
undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body
dysmorphic disorder, and the residual category somatoform disorder not otherwise specified (NOS).
DSM-IV-TR criteria for these disorders are outlined in Table 13–1.

TABLE 13–1. DSM-IV-TR somatoform disorders: a comparison

(continued)
Source. Adapted with permission from Martin RL: “Somatoform Disorders in the General Hospital Setting,” in Handbook of Studies on General Psychiatry.
Edited by Judd FK, Burrows GD, Lipsitt DR. Amsterdam, The Netherlands, Elsevier, 1991, pp. 251–266. Copyright 1991 Elsevier Science Publishers.

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TABLE 13–1. (continued)

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Table 13–2 lists the categories best corresponding to DSM-IV-TR somatoform disorders in DSM-I
(American Psychiatric Association 1952), DSM-II (American Psychiatric Association 1968), DSM-III,
and DSM-III-R as well as ICD-9 (World Health Organization 1977) and ICD-10.
TABLE 13–2. DSM-IV-TR somatoform disorders and corresponding categories in
previous DSM and ICD diagnostic systems

Source. Adapted with permission from Martin RL: “Somatoform Disorders in the General Hospital Setting,” in Handbook of Studies on General Psychiatry.
Edited by Judd FK, Burrows GD, Lipsitt DR. Amsterdam, The Netherlands, Elsevier, 1991, pp. 251–266. Copyright 1991 Elsevier Science Publishers.

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 Hysteria was included as one of
the 14 “canonized” psychiatric
disorders in the influential criteria
described by Feighner et al.
(1972). For hysteria, the Feighner
criteria required a chronic or
recurrent illness beginning before
age 30 that included a dramatic,
vague, or complicated medical
history. The diagnosis required
25 “positive” medically
unexplained symptoms (from a
list of 59) in 9 of 10 groups (Table
13–3); 20 symptoms in the same
number of groups were
necessary for a probable
diagnosis.

TABLE 13–3. Feighner

criteria symptom list for
hysteria (somatization
disorder)

Source. Adapted from Perley and Guze 1962.

Reprinted with permission from Cloninger CR:
“Somatoform and Dissociative Disorders,” in The
Medical Basis of Psychiatry, 2nd Edition. Edited by
Winokur G, Clayton P. Philadelphia, PA, WB
Saunders, 1994, pp. 169–192. Copyright 1994,
WB Saunders Company.

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The DSM-IV criteria for somatization disorder incorporate an empirically derived algorithm requiring
four pain symptoms, two nonpain gastrointestinal symptoms, one nonpain sexual or reproductive
symptom, and one pseudoneurological (conversion or dissociative) symptom (Table 13–4).

TABLE 13–4. DSM-IV-TR diagnostic criteria for somatization disorder

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The symptom picture encountered in somatization disorder is frequently nonspecific and can
overlap with a multitude of medical disorders. Cloninger (1994) has suggested several features
useful in discriminating between somatization disorder and physical illness (Table 13–5).

TABLE 13–5. Features useful in discriminating between somatization disorder

and general medical conditions

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The clinician should be aware that several medical disorders may be confused with somatization
disorder (Table 13–6).

TABLE 13–6. General medical conditions that may be confused with somatization disorder

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Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. [Link]
 Familial aggregation in somatization disorder
could result from genetic factors,
environmental influences, or both. Bohman
et al. (1984) used comprehensive lifetime
medical records in an adoption study in
Sweden to identify two discrete types of
somatoform disorders in women. One form,
described as “high-frequency somatization,”
was characterized by frequent headaches,
backaches, gastrointestinal disturbances, and
gynecological complaints associated with
psychiatric disability (Figure 13–1).

FIGURE 13–1. Distribution and

number of sick leave occasions
in Swedish somatizing (“high-
frequency”) subjects and control
nonsomatizing subjects.

Source. Reprinted with permission from Cloninger CR: “Somatoform and

Dissociative Disorders,” in The Medical Basis of Psychiatry, 2nd Edition.
Edited by Winokur G, Clayton PJ. Philadelphia, PA, WB Saunders, 1994,
pp. 169–192. Copyright 1994, WB Saunders Company.

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Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. [Link]
An eclectic approach accords well with the general principles of treatment recommended by
Quill (1985), Cloninger (1994), and Smith et al. (1986). Implementation of these principles may
greatly facilitate clinical management of somatization disorder and prevent potentially serious
complications, including the effects of unnecessary diagnostic and therapeutic procedures.

TABLE 13–7. Main treatment principles in approaching a patient with somatization

disorder

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 The essential aspect of undifferentiated
somatoform disorder is the presence of one or
more clinically significant, medically unexplained
somatic symptoms with a duration of 6 months or
more that are not better accounted for by another
mental disorder (Table 13–8).

TABLE 13–8. DSM-IV-TR diagnostic criteria

for undifferentiated somatoform disorder

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 As defined in DSM-IV-TR, nonintentional
“symptoms or deficits affecting voluntary motor
or sensory function” (American Psychiatric
Association 2000, p. 498) are central to conversion
disorder (Table 13–9). The majority of such
symptoms will suggest a neurological condition
(i.e., are pseudoneurological), but other general
medical conditions may be suggested as well.

TABLE 13–9. DSM-IV-TR diagnostic criteria

for conversion disorder

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Key terms and definitions used in connection with conversion disorder are listed Table 13–10.

TABLE 13–10. Key terms

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 Specific criteria for the diagnosis of
hypochondriasis are presented in Table 13–11.

TABLE 13–11. DSM-IV-TR

diagnostic criteria for
hypochondriasis

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The essential feature of body dysmorphic disorder is a preoccupation with some imagined defect in
appearance or markedly excessive concern with a minor physical anomaly (Table 13–12). Such
preoccupation persists even after reassurance.

TABLE 13–12. DSM-IV-TR diagnostic criteria for body dysmorphic disorder

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The basic DSM-IV-TR requirement for a diagnosis of somatoform disorder NOS is that a disorder with
somatoform symptoms does not meet criteria for a specified somatoform disorder (Table 13–13).

TABLE 13–13. DSM-IV-TR

diagnostic criteria for
somatoform disorder not
otherwise specified

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 CHAPTER 13 • Key Points

 The somatoform disorders are grouped because they suggest a physical

disorder for which there are no organic findings or known physiological
mechanism or there is a strong presumption that the symptoms are linked
to psychological issues.
 Somatization disorder is uncommon, but it is considered one of very few
valid and reliable mental illnesses.
 Conversion disorder is a diagnosis that should be applied only after
significant effort has been expended to eliminate any possible treatable
organic disorder.
 Hypochondriasis is a rather uncommon disorder that usually follows a
fluctuating course.
 Body dysmorphic disorder is a diagnosis in evolution, with conflicting data
regarding amenability to treatment.

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