Somatoform

Disorders
Toni Peters MSN, RN
Wright State University

Types of Somatoform Disorders

DSM-IV-TR
Somatization Disorder
Undifferentiated Somatoform Disorder
Conversion Disorder
Pain Disorder
Hypocondriasis
Body Dysmorphic Disorder
Factitious Disorder

Somatic Symptom and Related Disorders

DSM-5

Somatic Symptom Disorder

Illness Anxiety Disorder
Conversion Disorder
Psychological Factors Affecting Other Medical Conditions
Factitious Disorder
Other Specified Somatic Symptom and Related Disorder
Unspecified Somatic Symptom and Related Disorder

Somatization Disorder DSM-IV-TR

A. A history of many physical complaints beginning before age 30 years that occur
over a period of several years and result in treatment being sought or significant
impairment 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:
4 pain symptoms: a history of pain related to at least 4 different sites or
functions
2 gastrointestinal symptoms: a history of at least 2 gastrointestinal symptoms
other than pain
1 sexual symptom: a history of at least 1 sexual or reproductive symptom other
than pain
1 pseudoneurological symptom: a history of at least 1 symptom or deficit
suggesting a neurological condition not limited to pain
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
OR
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 DO or
Malingering).

Hypochondriasis
DSM-IV-TR
A. Preoccupation with fears of having, or the idea that one has, a serious
disease based on the persons misinterpretation of bodily symptoms.
B. The preoccupation persists despite appropriate medical evaluation and
reassurance.
C. The preoccupation is not of delusional intensity (Delusional Disorder)
and is not restricted to a circumscribed concern about appearance
(Body Dysmorphic Disorder).
D. The preoccupation causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
E. The duration of the disturbance is at least 6 months.

Hypochondriasis
DSM-IV-TR
F. The preoccupation is not better accounted for by
GAD, OCD, Panic DO, a MDE, Separation Anxiety, or
other Somatoform DO
Specify if:
With Poor Insight: if, for most of the time during the
current episode, the person does not recognize that
the concern about having a serious illness is excessive
or unreasonable

Somatic Symptom Disorder

DSM-5
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
ones 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).

Somatic Symptom Disorder

DSM-5
Specify if:
With Predominant Pain (previously pain disorder).
Specify if:
Persistent: 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

Somatic Symptom Disorder

Differential Diagnosis

Other medical conditions (Fibromyalgia, IBS)

Panic Disorder
Generalized Anxiety Disorder
Depressive Disorders
Illness Anxiety Disorder
Conversion Disorder
Delusional Disorder
Body Dysmorphic Disorder
Obsessive-Compulsive Disorder

Illness Anxiety Disorder

DSM-5
A. Preoccupation with having or acquiring an 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 (strong family history), the
preoccupation is clearly excessive or dispropotionate.
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
(repeatedly checks body for signs of illness) or exhibits maladaptive
avoidance (physicians or 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 (SSD, panic DO, GAD, OCD, delusional DO, body
dysmorphic DO)

Illness Anxiety Disorder

DSM-5Specify if:
Care-seeking type: medical care, including
physician visits or undergoing test and procedures, is
frequently used.
Care-avoidant type: Medical care is rarely used.

Illness Anxiety Disorder

Differential Diagnosis
Other medical conditions
Adjustment Disorders
Somatic Symptom Disorder
Anxiety Disorders
Obsessive-compulsive and related disorders
Major Depressive Disorder
Psychotic Disorders

http://www.youtube.com/watch?v=4NFry20WoJ
o

Conversion Disorder
DSM-IV-TR
A. One or more symptoms or deficits affecting voluntary motor or sensory function that
suggest a neurological or other general medical condition
B. Psychosocial factors are judged to be associated with the symptom or deficit because
the initiation or exacerbation of the symptom or deficit is preceded by conflicts or
other stressors
C. The symptom or deficit is not intentionally produced or feigned.
D. The symptom or deficit cannot, after appropriate investigation, be fully explained
by a known general medical condition or the direct effects of a substance, or as a
culturally sanctioned behavior or experience.
E. The symptom or deficit causes clinically significant distress or impairment in
functioning, or warrants medical evaluation.
F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur
during the course of Somatization Disorder, and is not better accounted for by
another medical disorder.

Conversion Disorder (Functional

Neurological Symptom Disorder)
DSM-5
A. One or more symptoms of altered voluntary motor or
sensory function.
B. Clinical findings provide evidence of incompatibility
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 significant distress or
impairment in social, occupational, or other important
areas of functioning or warrants medical evaluation.

Conversion Disorder cont

DSM-5
Specify symptom type:
With weakness or paralysis
With abnormal movements (gait disorder, dystonic, tremor)
With swallowing symptoms
With speech symptoms
With attacks or seizures
With anesthesia or sensory loss
With special sensory symptom (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

Conversion Disorder
Differential Diagnosis

Neurological Disease
Somatic Symptom Disorder
Factitious Disorder and Malingering
Dissociative Disorders
Body Dysmorphic Disorder
Depressive Disorders
Panic Disorder

Conversion Disorder
http://www.youtube.com/watch?v=jV0szS02PGE

Factitious Disorder
DSM-IV-TR
A. Intentional production or feigning of physical or
psychological signs or symptoms.
B. The motivation for the behavior is to assume the sick role.
C. External incentives for the behavior (i.e., economic gain,
avoiding legal responsibility, or improving physical
wellbeing, as in Malingering) are absent.
Specify:
With Predominantly Psychological Signs and Symptoms
With Predominantly Physical Signs and Symptoms
With Predominantly Psychological and Psychological Signs
and Symptoms

Factitious Disorder
DSM-5
A.
B.
C.
D.

Factitious Disorder Imposed on Self

Falsification of physical or psychological signs or symptoms, or
induction of injury or disease, associated with identified deception.
The individual presents himself/herself to others as ill, impaired,
or injured.
The deceptive behavior is evident even in the absence of obvious
external rewards.
The behavior is not better explained by another mental disorder,
such as delusional disorder or another psychotic disorder.

Specify if:
Single episode
Recurrent episodes: two or more events of falsification of illness
and/or induction of injury)

Factitious Disorder
DSM-5 Factitious Disorder Imposed on Another
(previously Factitious Disorder by Proxy)
A. Falsification of physical or psychological signs or symptoms, or induction of
injury or disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired,
or injured.
C. The deceptive behavior is evident even in the absence of obvious rewards.
D. The behavior is not better explained by another mental disorder, such as
delusional disorder or another psychotic disorder.
Note: The perpetrator, not the victim, receives this diagnosis.
Specify if:
Single Episode
Recurrent Episodes: two or more events of falsification of illness and/or
induction of injury

Factitious Disorder
Differential Diagnosis
Somatic Symptom Disorder
Malingering: intentional reporting of symptoms for personal

gain (money, time off work, disability, housing)

Conversion Disorder
Borderline Personality Disorder: deliberate self-harm in the
absence of SI (not associated with deception)
Medical Condition or mental disorder not associated with
intentional symptom falsification
Factitious Disorder
http://www.youtube.com/watch?v=LLyH-98aaYY
Factitious Disorder by Proxy
http://www.youtube.com/watch?v=7qhqUga6wGI

Somatic Symptom and Related Disorders

Risk Factors
Pathophysiology not known
Temperamental: difficulty handling stress, internalizing

stress/anger
Environmental: lower education level, low socioeconomic
status, recent stressful life events, sexual abuse, parents
with somatic behaviors
Females more than males 5:1 (except Illness Anxiety DO)
Symptoms may begin in childhood, adolescence, or early
adulthood. New onset of unexplained somatic symptom
disorders in older adults should be concerning. Consider
medical illness or major depression with somatic symptoms.

Somatic Symptom and Related

Disorders Diagnosis
General medical conditions must be ruled out
Primary anxiety and mood disorders often

present with physical symptoms, therefore

both must be ruled out before the diagnosis of
somatic symptom or related DO can be made
Labs: CBC, UDS, BAL, TSH
Tests: EEG, MRI, CT, X-Ray
Avoid invasive procedures and aggressive
surgical assessment---risk of complications,
validates sick role

Somatic Symptom and Related

Disorders Treatment
Non-medication strategies are the most

effective
CBT
Individual/Family Therapy
Emotional support
Relaxation techniques
SSRIs (effectiveness not proven)
Avoid pain medications and benzodiazepines
risk of dependence or overdose

Questions
1. In DSM-IV-TR a patient with a high level of anxiety about having a disease and many
associated somatic symptoms would be given the diagnosis of hypochondriasis. What DSM-5
diagnosis would apply to this patient?
a) hypochondriasis
b) illness anxiety disorder
c) somatic symptom disorder
d) generalized anxiety disorder
e) somatoform disorder NOS
2. A young woman is hospitalized for evaluation of fits of movement in which she appears to lose
consciousness, rock her head from side to side, and move her arms and legs in a
nonsynchronous, bicycling pattern. The episodes occur a few times a day and last for 2 to 5
minutes. EEG during the episodes does not reveal any ictal activity. After a fit, her sensorium
appears clear. What is the most likely DSM-5 diagnosis?
a) epilepsy
b) malingering
c) somatic symptom disorder
d) conversion (functional neurological symptom disorder), attack-seizure subtype
e) factitious disorder

Questions
3. Which of the following is the key feature of factitious disorder in DSM-5?
a) somatic symptoms
b) conscious misrepresentation and deception
c) external gain associated with illness
d) absence of another medical disorder that may cause the symptoms
e) normal physical exam and laboratory tests
4. Why would you avoid prescribing pain medication or benzodiazepines
to a patient diagnosed with Somatic Symptom Disorder?

5. What three things must you rule out before considering a Somatic
Symptom or Related Disorder?

Videos
Hypocondriasis
http://www.youtube.com/watch?v=4NFry20WoJo
Conversion Disorder
http://
www.youtube.com/watch?v=jV0szS02PGE
Factitious Disorder
http://
www.youtube.com/watch?v=LLyH-98aaYY
Factitious Disorder by Proxy
http://

References
American Psychiatric Association (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: American
Psychiatric Publishing.
American Psychiatric Association (2000). Diagnostic and statistical
manual of mental disorders (4th ed.). Arlington, VA: American
Psychiatric Publishing.
Banks, K. & Bevin, A. (2014). Predictors for somatic symptoms in
children. Nursing Children and Young People, 26(1), 16-20.
Dimsdale, J. E., & Levenson, J. (2013). Whats next for somatic
symptom disorder? American Journal of Psychiatry, 170, 13931395. DOI: 10.1176/appi.ajp.2013.13050589

References
Kroenke, K. (2007). Efficacy of treatment for somatoform
disorders: A review of random controlled trials.
Psychosomatic Medicine, 69, 881-888. Retrieved from
focus.psychiatryonline.org
Mayo Clinic Staff (n.d.). Conversion disorder. Retrieved from
http://www.mayoclinic.org/diseases-conditions/conversion-di
sorder/basics/tests-diagnosis/definition/con-20029533
Yates, W. R. (2014). Somatic symptom disorders. Retrieved
from http://emedicine.medscape.com/article/294908overview