eMedicine Specialties > Psychiatry > Psychosomatic

Somatoform Disorders

Author: William R Yates, MD, MS, Research Psychiatrist, Laureate Institute for Brain Research; Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa
Contributor Information and Disclosures

Updated: Mar 2, 2010

Introduction

Background

Somatoform disorders represent a group of disorders characterized by physical symptoms suggesting a medical disorder. However, somatoform disorders represent a psychiatric condition because the physical symptoms present in the disorder cannot be fully explained by a medical disorder, substance use, or another mental disorder. These somatoform disorder physical complaints challenge medical providers who must distinguish between a physical and psychiatric source for the patient's complaints. Often, the medical symptoms patients experience may be from both medical and a psychiatric illnesses. Anxiety disorders and mood disorders commonly produce physical symptoms. These physical symptoms can dramatically improve with successful treatment of the anxiety or mood disorder.

The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) includes a specific category for somatic symptoms related to psychiatric origins called the somatoform disorders. Specific somatoform disorders include (1) somatization disorder, (2) conversion disorder, (3) pain disorder, (4) hypochondriasis, and (5) body dysmorphic disorder. Somatization disorder is a relatively rare disorder that is associated with high medical resource utilization. More common somatization syndromes may not reach the diagnostic threshold for somatization disorder but may be clinically and functionally significant.

Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician.

Ms. J's primary care physician has followed her for many years and has made the diagnosis of somatization disorder. The treatment plan includes regular frequent visits to monitor her chronic pain complaints. Use of medication with addictive potential is restricted. Physical symptoms are monitored with limited use of invasive diagnostic procedures. Outpatient visits focus on identifying sources of stress and encouraging healthy coping mechanisms.

Pathophysiology

The pathophysiology of somatization and somatization disorder is unknown. Primary somatoform disorders may be associated with a heightened awareness of normal bodily sensations. This heightened awareness may be paired with a cognitive bias to interpret any physical symptom as indicative of medical illness. Autonomic arousal may be high in some patients with somatization. This autonomic arousal may be associated with physiologic effects of endogenous noradrenergic compounds such as tachycardia or gastric hypermotility. Heightened arousal also may induce muscle tension and pain associated with muscular hyperactivity, as is seen with muscle tension headaches.

Frequency

United States

• Prevalence rates for the most restrictive diagnosis of somatization disorder appear low in community samples (0.1%).
• Low community prevalence rates for somatization disorder may be due to a reporting bias.
• Medical record studies suggest the rate of somatization disorder in the community among women may be as high as 2%. 
• More liberal case assignment criteria result in rate estimates of the prevalence of a somatization syndrome to be as high as 11.6% of the population.
• Other somatoform disorders may have significant rates in specific clinical populations.
• In general medical clinic populations, the prevalence rates of hypochondriasis may approach 4-6%.
• Body dysmorphic disorder may be present in as many as 2% of patients of plastic surgery clinics.
• In psychiatric consultations at general hospitals, some studies document high rates (5-15%) of conversion disorder.

International

A study in Belgium reported that somatization syndrome is the third highest psychiatric disorder, with a prevalence rate of 8.9%. The first and second most common psychiatric disorders were depression and anxiety disorders.¹

Mortality/Morbidity

Somatoform disorders do not appear to independently increase the risk of death. Some evidence exists that somatization disorder is associated with increased risk for suicide attempts. Patients with somatoform disorders may be misdiagnosed as having a medical condition and therefore experience iatrogenic complications due to invasive diagnostic procedures or surgical operations.

Sex

In most somatoform disorder categories, a female preponderance exists. The female-to-male ratio has been estimated to be 10:1 for somatization disorder, from 2:1 to 5:1 for conversion disorder, 2:1 for pain disorder, and 1:1 for hypochondriasis.

Age

Somatization may begin in childhood, adolescence, or early adulthood. New onset of unexplained somatic disorders in older adults should prompt a search for occult medical illness or evidence of major depression associated with somatization.

Clinical

History

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

Physical

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

Causes

• 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.

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