26.2.1 Somatization Disorder

Somatization disorder was referred to historically as “hysteria” or Briquet’s syndrome. The physical complaints appear before the age of 30 years and persist over several years. Patients living with somatization disorder usually present exaggerated, inconsistent, yet complicated medical histories with individual symptoms that include the following at any time during its course: four pain symptoms, two gastrointenstinal symptoms, one sexual symptom, and one pseudoneurological symptom. Patients often seek treatment from multiple healthcare providers when their physical complaints are not addressed to their satisfaction.

The conceptualization of somatization disorder is diagnostically complex and cumbersome as described in the DSM, hence the category may be underused and the diagnosis under-reported. In addition, the term “somatization” has acquired a pejorative connotation. Clinicians are reluctant to so label a patient, and to diagnose more readily treatable symptoms such as anxiety and depressive syndromes and downplay the underlying illness. Moreover, authorization and reimbursement for treatment of this chronic condition are often challenged or denied. It is relatively easier to obtain approval for an intervention on the basis of major depressive disorder, for example, than on the basis of a disorder that is much more likely to be poorly understood by case reviewers.

Somatization disorder is rare in children younger than 9 years. Characteristic symptoms begin in adolescence, and the full criteria as designated by DSM-IV-TR are met by the mid twenties. The active symptomatic phase of the condition occurs during early adulthood and aging does not appear to lead to remission. The course is chronic and full remission is rarely, if ever achieved.

26.2.2 Undifferentiated Somatoform Disorder

As defined by DSM-IV-TR, the persistent, unexplained physical symptoms that characterize undifferentiated somatoform disorder last for at least 6 months and do not fully meet the criteria for somatization disorder or any other somatoform disorder. Common complaints include fatigue, loss of appetite, and gastrointestinal or urinary symptoms. This category includes one or more unintentional, clinically significant, medically unexplained physical complaints. In a sense it is a residual category, subsuming syndromes with somatic complaints that do not meet criteria for any of the “differentiated” somatoform disorders yet are not better accounted for by any other mental disorder.

People suffering from undifferentiated somatoform disorder experience negative repercussions in interpersonal, occupational, or other aspects of functioning. The patient’s history, physical examination, and laboratory tests do not explain or verify the physical symptoms or disruption in life experiences. The course and prognosis of this disorder are exceedingly variable.

26.2.3 Conversion Disorder

Conversion disorders are characterized by symptoms or deficits affecting voluntary motor or sensory function that suggest, yet are not fully explained by, a neurologic or other general medical condition or the direct effects of a substance. The diagnosis is not made if the presentation is explained as a culturally sanctioned behavior or experience, such as bizarre behaviors resembling a seizure during a religious ceremony. Symptoms are not intentionally produced or feigned; that is, the person does not consciously contrive a symptom for external rewards, as in malingering, or for the intrapsychic rewards of assuming the sick role, as in factitious disorder. Age at onset is typically from late childhood to early adulthood. Onset is rare before the age of 10 years and after 35 years, but cases with an onset as late as the ninth decade have been reported.

Four subtypes with specific examples of symptoms are defined: (1) with motor symptom or deficit (e.g., impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, and urinary retention); (2) with sensory symptom or deficit (e.g., loss of touch or pain sensation, double vision, blindness, deafness, and hallucinations); (3) with seizures or convulsions; and (4) with mixed presentation (i.e., has symptoms of more than one of the other subtypes).

26.2.4 Pain Disorder

The diagnosis of pain disorder is new to DSM-IV-TR. The classic symptom is the unexplained presence of physical pain. Psychologic factors have a prominent role in the genesis. Patients suffering from pain disorder experience pain as a major focus in their lives, frequently access healthcare services, and commonly take medications for the symptoms. Pain disorders are expressed in various body areas (e.g., abdomen, back, bone, breast), each of which is coded individually in DSM-IV-TR. In addition, DSM-IV-TR requires that pain be the predominant focus of the clinical presentation and that it cause clinically significant distress or impairment. Specifiers of acute (duration of less than 6 months) and chronic (duration of 6 months or longer) are provided.

Little literature is available on this condition, its onset, or its course. Habituation with drugs is associated with greater chronicity.

26.2.5 Hypochondriasis

The person with hypochondriasis has an unwarranted fear or belief that he or she has a serious disease, without significant pathology. This is in contrast to somatization disorder, conversion disorder, and pain disorder, in which the symptoms themselves are the predominant focus. Much of the patient’s psychic energy may be bound in unrealistic fears that healthcare providers are missing diagnoses, such as cancer, cardiac disease, or sexually transmitted diseases.

Data are conflicting but it seems that the most common age at onset of hypochondriasis is early adulthood. About 25% of patients have a poor outcome; 65% have a chronic but fluctuating course, and 10% recover.

When patients do not obtain satisfaction from one care provider, they often will go to another or a series of others in an attempt to find an answer to their symptoms. Preoccupation with bodily distress and the accompanying expectation that others also should focus on the patient’s physical well-being may disrupt social relationships and work. In contrast to the lack of anxiety seen in patients with conversion disorder, patients with hypochondriasis often appear anxious about their symptoms. They can sometimes acknowledge that their fear of a dreaded disease is unfounded; however, they are unaware of their anxiety or depression.

26.2.6 Body Dysmorphic Disorder

The primary feature of body dysmorphic disorder is preoccupation with an imagined defect in appearance when no abnormality or disturbance is present. Patients tend to obsess about imagined facial defects, such as wrinkles, spots on the skin, facial asymmetry, or excessive facial hair. Other body parts, such as the genitals, breasts, buttocks, hands, or feet may be the focus of distress and embarrassment. Thinking that others are noticing the imagined flaw may be an associated feature. Because of extreme self-consciousness about the imagined defect, individuals may retreat from usual activities and resort to social isolation and display decreased academic and occupational functioning.