The name of this chapter was changed from Somatoform Disorders in the DSM-IV-TR to Somatic Symptom and Related Disorders in the DSM-5. Extensive revisions to this section of the DSM-5 were designed to address concerns related to stigmatizing and ambiguous terminology, problematic focus on medically unexplained symptoms rather than experiences, unclear boundaries among disorders, unnecessarily complex criteria for somatization disorder, and rare use in practice despite prevalence in the general population (APA, 2013; Dimsdale, 2013). Counselors will find two new disorders in this section: somatic symptom disorder and illness anxiety disorder. These new disorders replace somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder. In addition, the category psychological factors affecting other medical conditions was moved from the Other Conditions That May Be a Focus of Clinical Attention chapter of the DSM-IV-TR, and factitious disorder was relocated from its own chapter. In all, changes to DSM-5 criteria may increase the probability that counselors diagnose these disorders.

Clients who have somatic concerns with or without co-occurring medical conditions may be diagnosed with the new somatic symptom disorder if they have both unexplained somatic symptoms and maladaptive responses to those symptoms (APA 2013; Dimsdale 2013; Sirri & Fava, 2013). This diagnosis, discussed in depth below, is intended to replace somatization disorder and undifferentiated somatoform disorder; many individuals who carried previous diagnoses of hypochondriasis and pain disorder will fall within this new diagnosis. Criteria include less emphasis on counting medically unexplained symptoms and more focus on positive symptoms in which a client experiences distressing or disruptive somatic symptoms alongside “excessive thoughts, feelings, or behaviors related to the somatic symptoms” (APA, 2013, p. 311). Although some researchers expressed valid concerns that the changes “mislabel medical illness as mental disorder” (Frances & Chapman, 2013, p. 483), others provided preliminary evidence that the new somatic symptom disorder has increased construct, descriptive, predictive, and clinical utility when compared with DSM-IV-TR nosology (Dimsdale, 2013; Voigt et al., 2012; Wollburg et al., 2013).

The APA Somatic Symptoms Disorders Work Group eliminated the diagnosis of hypochondriasis because it believed this nomenclature was stigmatizing to clients (APA, 2013). Clients who have concerns regarding meaning of physical symptoms or experiences will now be diagnosed with somatic symptom disorder (if somatic symptoms are present) or illness anxiety disorder (if no somatic symptoms are present), both new to the DSM-5. Similarly, the work group eliminated pain disorder because one cannot reliably determine whether experiences of pain are due to physical or psychological causes (APA, 2013). Clients with pain concerns may be diagnosed with somatic symptom disorder or psychological factors affecting other medical conditions. Finally, conversion disorder carries an additional title of functional neurological symptom disorder, DSM-5 criteria emphasize neurological examination and deemphasize the assumption that one will readily recognize psychological factors leading to concerns upon initial presentation (Stone et al., 2011).

Because the signs of somatic symptom and related disorders are medical, initial diagnostic focus must be on medical examination to determine the specific nature of the concern. DSM-5 criteria allow for the presence of diagnosable health concerns alongside distressing reactions to the concerns. Thus, primary differential diagnosis includes determination regarding (a) which medical conditions are present and (b) whether one’s response to the medical concerns are in excess of what would be considered normal. For an individual who is experiencing concerns related to a significant medical diagnosis, an adjustment disorder may be more appropriate (Frances & Chapman, 2013). If one’s reaction to medical concerns or symptoms is simply a culturally expected response to a situation, assignment of a V or Z code may be more appropriate.

There is substantial overlap and comorbidity among depressive disorders, anxiety disorders, and somatoform disorders. Mergl et al. (2007) suggested that depressive disorders may be overlooked in many medical settings because these disorders are masked by anxiety or somatic symptoms. In a sample of individuals in a general health setting, 11.9% met the criteria for somatoform disorder whereas only 6.1% met criteria for depressive, anxiety, and somatoform disorders; 5.3% for depressive and somatoform disorders; and 2.3% for anxiety and somatoform disorders. There is strong evidence of a cultural component to expressing anxious or depressive distress somatically (Brown & Lewis-Fernández, 2011; So, 2008; Tófoli et al., 2011). Thus, counselors should consider anxiety and depressive disorders as differential and comorbid diagnoses. Hassan and Ali (2011) found evidence that somatic and anxiety symptoms are common among individuals with substance use concerns. Finally, given evidence that somatic symptoms are a typical response to trauma, counselors should consider the possibility of PTSD as a differential diagnosis (Gupta, 2013).

Initially, somatoform disorders were viewed as psychodynamic responses to stressors in which an individual converted psychological concerns into physical symptoms as a way of coping or expressing distress. Today, there are various models and explanations regarding etiology of somatic symptom and related disorders, and the APA (2013) identified genetic and biological vulnerability, early traumatic experiences, learning, and cultural/social norms as likely underlying factors. Still,

Ethnographic fieldwork has long indicated the presence of a specific type of culturally mediated illness where an individual suffering from psychological issues expresses distress in the form of physical symptoms and somatic complaints, with no known organic cause. In western psychiatry, this phenomenon is commonly labeled somatization disorder. (So, 2008, p. 168)