eMedicine Specialties > Psychiatry > Psychosomatic

Somatoform Disorders

William R Yates, MD, Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa

Updated: Feb 4, 2008

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.

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.
• 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.

Differential Diagnoses

Other Problems to Be Considered

Somatoform disorders must be differentiated from medical illnesses as well as from other psychiatric conditions; consider medical conditions that cause vague and diffuse symptoms. Also, consider somatization as part of a mood or anxiety disorder.

Cerebrovascular accident
Encephalopathy
Dialysis encephalopathy
Hepatic encephalopathy
Hypertensive encephalopathy, uremic
Goiter, chronic
Toxic hallucinogens
Heroin abuse
Lyme borreliosis
Multiple sclerosis

Workup

Laboratory Studies

• If indicated, specific studies used to rule out somatization due to general medical conditions include the following:
  • Thyroid function studies - Thyroid stimulating hormone (TSH) at 0.4-10 mIU/L and thyroxine at 5.0-12.5 ng/dL
  • Pheochromocytoma screen - Urine catecholamines, homovanillic acid (HVA) 2-12 mg per 24 hours, vanillylmandelic acid (VMA) 2-7 mg per 24 hours, metanephrines less than 1.6 mg per 24 hours, and norepinephrine plus epinephrine less than 100 mcg per 24 hours
  • Urine drug screen - Including cannabis, amphetamine, hallucinogens, cocaine, opioids, benzodiazepines
  • Blood studies - To screen for occult alcoholism
  • Psychological testing - Minnesota Multiphasic Personality Inventory (MMPI) may provide insight into the likelihood of a somatoform disorder. (Negative MMPI studies should encourage further pursuit of a medical cause for the symptoms.)

Imaging Studies

• Imaging studies are not routinely used in diagnosing the somatoform disorders. However, functional MRI may be of use in the diagnosis of some conditions such as unexplained visual loss.
• Imaging studies may be helpful to rule out unexplained physical symptoms due to a medical disorder.

Procedures

• Avoid invasive diagnostic procedures and aggressive surgical assessment.

Treatment

Medical Care

• Emergency department care: Somatoform disorders may present to the emergency room for assessment and treatment during periods of acute increase in symptom severity.
  • Electroconvulsive therapy is not effective for somatoform disorders, but it may successfully treat depression occurring in the context of a somatoform disorder.
  • Obtain necessary studies to rule out physical causes such as myocardial infarction or appendicitis.
  • Intravenous or oral acute sedation with benzodiazepines may be used.
  • Avoid long-term benzodiazepines for somatoform disorders.
  • Avoid acute or long-term narcotic analgesics for somatoform disorders.
• Treatment of conversion disorder in the emergency room: Conversion disorder may be interpreted by the patient and family as a sign of an acute and potentially catastrophic medical condition. ER personnel should quickly rule out potential life-threatening, disabling, or treatable causes for the symptoms. Emotional support should be provided to patient's family members. Early consultation with a psychiatrist may limit unnecessary medical or surgical interventions. Referral to psychiatrist may be prefaced by stating that the cause for the medical symptoms have not been found and that in similar cases, assessment of the role of stress by a medical psychiatrist may be helpful in reducing the discomfort experienced by the patient.
• Psychosocial interventions (primary care management)
  • Randomized trials have demonstrated the value of physician education in the management of the patient with somatization.^2,3
  • Cognitive-behavioral psychotherapy strategies may be specifically helpful in reducing distress and high medical use.
  • Psychosocial interventions directed by physicians form the basis for successful treatment.
  • A strong relationship between the patient and the primary care physician can assist in long-term management.
  • Psychoeducation can be helpful by letting the patient know that physical symptoms may be exacerbated by anxiety or other emotional problems. However, be careful because patients are likely to resist suggestions that their condition is due to emotional rather than physical problems.
  • The primary care physician should inform the patient that the symptoms do not appear to be due to a life-threatening, disabling, medical condition and should schedule regular visits for reassessment and reinforcement of the lacking severity of ongoing symptoms.
  • The patient also may be told that some patients with similar symptoms have had spontaneous improvement, implying that spontaneous improvement may occur.
  • However, the physician should accept the patient's physical symptoms and not pursue a goal of symptom resolution.
  • Indeed, regular, noninvasive, medical assessment reduces anxiety and limits health care–seeking behavior; this may be facilitated by regularly scheduled visits with the patient's primary care physician.
  • Encourage patients to remain active and limit the effect of target symptoms on the quality of life and daily functioning.
  • Family members should not become preoccupied with the patients physical symptoms or medical care.
  • Family members should direct the patient to report symptoms to their primary care physician.
• Psychosocial interventions for specific somatoform disorders
  • Somatization disorder: Patients may resist suggestions for individual or group psychotherapy because they view their illness as a medical problem. Patients who accept psychotherapy may be able to reduce health care utilization. Psychosocial interventions that focus on maintaining social and occupational function despite chronic medical symptoms may be helpful.
  • Conversion disorder: Limited studies about specific psychotherapy exist for conversion disorder. Behavior therapy or hypnosis may be effective. Symptoms often resolve spontaneously.
  • Hypochondriasis: Physicians should attempt to answer questions and reduce the patient's fear of a specific illness. Group psychotherapy may provide social support and reduce anxiety. Cognitive therapy strategies may help by focussing on distorted disease-related cognitions. Individual insight-oriented psychotherapy has not been proven effective.
  • Pain disorder: Behavior therapy, including biofeedback, can be helpful. Hypnosis also may be considered for chronic pain syndromes. Some outcome data supports the effectiveness of individual psychotherapy. Exploration of interpersonal effects of chronic pain may reduce social complications of pain.

Consultations

• Psychiatrist

Medication

Somatization disorder: For people with somatization disorder, medication approaches rarely are successful. Physicians should search for evidence of psychiatric comorbidity, such as depression or an anxiety disorder. If present, medication interventions specific to the diagnosis can be attempted. Successful treatment of a major depression or an anxiety disorder, such as panic disorder, also may produce significant reduction in somatization disorder. Nonmedication strategies are the most successful. See psychosocial treatment in Medical Care for more details.

Hypochondriasis: Hypochondriasis may be a feature of a mood or anxiety disorder. Pharmacologic treatment of the mood or anxiety disorder may reduce hypochondriacal symptoms. If a mood or anxiety disorder is present, see Medical Care. Group psychotherapy is very effective in a medical setting.

Conversion disorder: No specific pharmacological interventions have been shown to be effective for conversion disorder.

Pain disorder: Analgesic therapy often is ineffective for somatoform disorders characterized a pain disorder. Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI) may be helpful.

Body dysmorphic disorder: Randomized controlled trials demonstrate that selective serotonin reuptake inhibitors reduce symptoms in as many as one half of individuals with body dysmorphic disorders. Case reports have suggested improvement with other agents, including monoamine oxidase inhibitors, tricyclic antidepressants, and the pimozide (an antipsychotic).

Antidepressants

Imipramine is a tricyclic antidepressant that has demonstrated clear superiority over the placebo in double-blind trials for treating specific symptoms of bulimia nervosa. However, SSRIs (eg, fluoxetine) probably should be first-line agents.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

Imipramine (Tofranil)

Inhibits reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT), at presynaptic neuron. One of the oldest agents available for the treatment of depression and has established efficacy in the treatment of panic disorder. Geriatric and adolescent patients may need lower dosing or slower titration.

Dosing

Adult

50-75 mg PO qd initial; titrate gradually to 150 mg qd according to tolerance; range, 75-300 mg/d hs or in divided doses

Pediatric

Not established

Interactions

Increases toxicity of sympathomimetic agents (eg, isoproterenol, epinephrine) by potentiating effects and inhibiting antihypertensive effects of clonidine

Contraindications

Documented hypersensitivity; narrow-angle glaucoma; acute recovery phase following myocardial infarction; history of bipolar disorders; avoid in patients taking MAOIs or fluoxetine or in patients who took them in the previous 2 wk

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May impair mental or physical abilities required for performance of potentially hazardous tasks; caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, or patients receiving thyroid replacement; an ECG prior to initiation of therapy with imipramine may be warranted, also repeating once on a stable dose, to monitor any potential widening of QRS

Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.

Dosing

Adult

10-20 mg/d PO initial; 20-60 mg PO maintenance

Pediatric

10-20 mg/d PO

Interactions

Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs

Contraindications

Documented hypersensitivity; patients concurrently taking MAOIs or patients who took them in the last 2 wk

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Some patients may experience increased anxiety and agitation, especially with first dose; caution in preexisting seizure disorders, recent myocardial infarction, unstable heart disease, and hepatic or renal impairment

Follow-up

Further Inpatient Care

• Somatoform disorders rarely require inpatient management. Consider inpatient care if a patient appears suicidal or requires detoxification from comorbid substance dependence. Additionally, inpatient care may be needed for patients whose somatoform disorder is incapacitating, ie, conversion disorder with motor symptoms of such severity to impair ambulation. The principles of inpatient care for somatization disorder include the following:
  • Rapid medical assessment to rule out a medical cause for the patient's symptoms
  • Assessment for evidence of psychiatric comorbidity and initiation of management for the comorbid psychiatric illness
  • Patient and family education regarding the somatoform disorder
  • An expectation of return to complete normal functioning with rehabilitation if necessary to restore function
  • Establishment of a primary care physician familiar with the management of somatoform disorders if one is not already present
  • A detailed discharge plan including primary care follow-up and psychiatric follow-up if necessary

Complications

• Iatrogenic complications due to invasive diagnostic or surgical procedures
• Dependence on prescription-controlled substances
• Development of a helpless and dependent lifestyle

Prognosis

• Somatoform disorders can range from mild and transient to severe and chronic. Early treatment improves prognosis and limits social and occupational impairment.

Patient Education

• The key issues of patient education have been outlined in Psychosocial intervention in the Medical Care section. Key patient educational issues include the following:
  • The physician acknowledges the patient's symptoms and suffering.
  • The physician takes on the role of evaluation and monitoring of symptoms.
  • Not all symptoms indicate evidence of a pathological disease.
  • The patient should attempt to maintain interpersonal function despite symptoms.
  • Physical symptoms not due to a defined disease often remit spontaneously.
  • Indentifying key life stressors and sources of anxiety can be important.
  • Stress reduction may produce improvement in physical symptoms.
  • Aggressive surgical approaches should be used cautiously and only with the approval of a primary care physician who knows the patient well.
• Family education is often crucial for the successful management of somatoform disorders. For the patient's family members, this education should include the following:
  • Discuss the somatoform diagnosis.
  • Expect the patient to improve and return to normal function.
  • Direct the patient to discuss any somatic symptoms with the primary care provider. Patients should not seek assistance from family members in assessing the seriousness of their symptoms or the diagnosis relating to their symptoms
  • The primary care provider should direct any need for subspecialty evaluation.
  • Family members should spend time with and pay attention to the patient when symptoms are absent. For the patient, this reinforces the idea that their symptoms do not bring special attention from others.
  • Family members may help by providing distraction activities if somatic symptoms are present, eg, going for a walk or going out to a movie.
• For excellent patient education resources, visit eMedicine's Muscle Disorders Center. Also, see eMedicine's patient education articles Fibromyalgia, Chronic Fatigue Syndrome, and Chronic Pain.

Miscellaneous

Medicolegal Pitfalls

• Failure to identify a medical cause for physical symptoms
• Use of unnecessary and invasive diagnostic testing for physical symptoms caused by somatization
• Adverse effects of multiple medications used in attempt to control symptoms
• Prescription drug abuse for controlled substance
• Lack of coordination of care by multiple physicians who may be unaware of other physicians treating the patient

Multimedia

Media file 1: Somatoform diagnoses in a series of university hospital psychiatric consultations.

References

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2. Martin A, Rauh E, Fichter M, Rief W. A one-session treatment for patients suffering from medically unexplained symptoms in primary care: a randomized clinical trial. Psychosomatics. Jul-Aug 2007;48(4):294-303. [Medline].

3. Smith GR Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med. May 29 1986;314(22):1407-13. [Medline].

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Text Revision. Washington, DC, American Psychiatric Association. 2000.

5. Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA. Mar 24 2004;291(12):1464-70. [Medline].

6. Baumeister H, Härter M. Prevalence of mental disorders based on general population surveys. Soc Psychiatry Psychiatr Epidemiol. May 21 2007;[Medline].

7. Bleichhardt G, Timmer B, Rief W. Cognitive-behavioural therapy for patients with multiple somatoform symptoms--a randomised controlled trial in tertiary care. J Psychosom Res. Apr 2004;56(4):449-54. [Medline].

8. Chioqueta AP, Stiles TC. Suicide risk in patients with somatization disorder. Crisis. 2004;25(1):3-7. [Medline].

9. de Waal MW, Arnold IA, Eekhof JA, van Hemert AM. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry. Jun 2004;184:470-6. [Medline].

10. Dickinson WP, Dickinson LM, deGruy FV. A randomized clinical trial of a care recommendation letter intervention for somatization in primary care. Ann Fam Med. Nov-Dec 2003;1(4):228-35. [Medline].

11. Fink P, Sorensen L, Engberg M. Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition. Psychosomatics. Jul-Aug 1999;40(4):330-8. [Medline].

12. Kroenke K, Spitzer RL, deGruy FV 3rd. A symptom checklist to screen for somatoform disorders in primary care. Psychosomatics. May-Jun 1998;39(3):263-72. [Medline].

13. Morriss RK, Gask L, Ronalds C. Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. Br J Gen Pract. Apr 1999;49(441):263-7. [Medline].

14. Phillips KA. Body dysmorphic disorder: diagnostic controversies and treatment challenges. Bull Menninger Clin. Winter 2000;64(1):18-35. [Medline].

15. Phillips KA, Albertini RS, Rasmussen SA. A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder. Arch Gen Psychiatry. Apr 2002;59(4):381-8. [Medline].

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Keywords

somatization, body dysmorphic disorder, conversion disorder, hypochondriasis, somatization disorder, somatoform disorder NOS, somatoform disorder not otherwise specified, unexplained physical symptoms

Contributor Information and Disclosures

Author

William R Yates, MD, Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa
William R Yates, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Academy of Family Physicians, and American Psychiatric Association
Disclosure: Forest Laboratories Grant/research funds Other

Medical Editor

Mohammed A Memon, MD, Medical Director of Geriatric Psychiatry, Department of Psychiatry, Spartanburg Regional Hospital System
Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories
Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

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