Somatoform Disorders Clinical Presentation

History and symptoms vary depending on the specific anxiety disorder diagnosis.

• Somatization disorder: Somatization disorder is characterized by many somatic symptoms that cannot be explained adequately based on physical and laboratory examinations. Specific characteristics of somatization disorder include the following:

  • Onset of unexplained medical symptoms in persons younger than 30 years
  • Multiple and chronic complaints of unexplained physical symptoms
  • Multiple pain symptoms involving multiple sites, such as the head, neck, back, stomach, and limbs
  • At least 2 or more unexplained gastrointestinal symptoms, such as nausea and indigestion
  • At least 1 sexual complaint and/or menstrual complaint
  • At least 1 pseudoneurological symptom, such as blindness or inability to walk, speak, or move
• Hypochondriasis: Hypochondriasis is a somatoform disorder characterized by unexplained physical symptoms related to fear of a specific medical condition, ie, a complaint of breast pain perceived as being due to breast cancer when no breast cancer is present. Specific characteristics of hypochondriasis include the following:

  • Preoccupation with fear of having a serious medical illness
  • Bodily symptoms reported consistent with patient's conception of specific illness
  • Preoccupation persists despite medical evaluation and reassurance
  • Fear persists for at least 6 months
• Conversion disorder: Conversion disorders are a somatoform disorder characterized by a sudden loss of neurological function, usually in the context of a severe stressor. Specific characteristics of conversion disorder include the following:

  • One or more symptoms of loss of voluntary motor or sensory function, eg, inability to walk, sudden blindness
  • Psychological factors felt important in initiation or exacerbation of loss of function
  • No evidence that the symptom is feigned or intentionally produced
  • Loss of function that is not due to medical illness or culturally expected behavioral response
  • Common conversion symptoms (eg, pseudoseizure, paralysis, becoming mute)
• Pain disorder: Pain disorder is a somatoform disorder characterized by a focussed pain complaint that cannot be entirely attributed to a specific medical disorder. Specific symptoms of pain disorder include the following:

  • Pain in 1 or more anatomical site producing a predominant clinical focus
  • Psychological factors (felt to play an important role in the onset, severity, or course of pain)
  • Pain symptom that is not feigned or intentionally produced
• Body dysmorphic disorder: Body dysmorphic disorder is a somatoform disorder characterized by a focus on a physical defect that is not evident to others. Specific characteristics of body dysmorphic disorder include the following:

  • Preoccupation with an imagined defect in appearance
  • May be associated with multiple, frantic, and unsuccessful attempts to correct imagined defect by cosmetic surgery

By definition, somatoform disorders are not accompanied by physical findings or a medical illness that explains the symptoms. Physical examination may demonstrate multiple operations in unsuccessful attempts to diagnose or relieve symptoms.

• Perform a comprehensive physical examination to rule out physical causes for the patient's somatic complaints. A detailed focus on specific systems, ie, neurological, may be necessary; this is based on the specific complaint.
• Include a full mental status examination. A patient with somatoform disorder displays the following on an examination.

  • Appearance - Normal
  • Attitude and behavior - Attitude is appropriate and behavior demonstrates a preoccupation with physical symptoms and complaints.
  • Mood - Mildly anxious and depressed
  • Affect - Full range and appropriate
  • Thought disorder - None, although thoughts are limited to issues around physical symptoms.
  • Hallucinations - None
  • Delusions - None
  • Obsessions - None
  • Compulsions - None
  • Attention - Within normal range
  • Memory - Within normal range
  • Concentration - Within normal range
  • Orientation - Patient is oriented to time, place, and person.
  • Insight and judgment - Insight appears limited in that nonmedical causes of symptoms are not considered. Judgment appears unimpaired.
  • Suicidal and homicidal ideation - No evidence of such

• No definitive causes for most of the somatoform disorders have been established.

  • Genetic and environmental influences appear to contribute to somatization.
  • Children raised in homes with a high degree of parental somatization may model somatization.
  • Sexual abuse may be associated with an increased risk of somatization later in life.
  • Poor ability to express emotions (alexithymia) may result in somatization.
• Psychodynamic causes for unexplained physical symptoms date back to Freud who coined the term conversion disorder. Freud viewed some unexplained neurologic symptoms as a result of conversion of intrapsychic distress into physical symptoms.
• Psychiatric comorbidity

  • Alcohol and drug abuse are common in patients with somatoform disorders. Patients may attempt to treat their somatic pain with alcohol or other drugs.
  • Additionally, alcohol or drug intoxication or withdrawal may induce somatic symptoms of unclear etiology, unless the physician considers the potential role of substances.
  • Anxiety disorders and mood disorders commonly include physical symptoms as part of the presentation. Hypochondriasis can accompany the symptoms of depression, panic disorder, and other anxiety disorders. Ruling out a primary anxiety disorder or mood disorder is key before reviewing the role of somatoform disorders.