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The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,

Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org1

Slide show includes«

Topic Headings

Tables and Figures

Key Points

Somatoform DisordersSean H. Yutzy, M.D.,

Brooke S. Parish, M.D.

The American Psychiatric Publishing

TEXTBOOK OF PSYCHIATRYFifth EditionEdited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.

© 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

CHAPTER 13





CHAPTER 13 Topic Headings

SOMATIZATION DISORDER

Definition and Clinical Description

DiagnosisHistory

DSM-IV-TR Criteria

Differential Diagnosis

Natural History

Epidemiology

Etiology

Treatment

UNDIFFERENTIATED SOMATOFORM DISORDER


DiagnosisHistory

DSM-IV-TR Criteria


Epidemiology

Etiology

Treatment

CONVERSION DISORDER


DiagnosisHistory

DSM-IV-TR Criteria


Natural History

Epidemiology

Etiology

Treatment

HYPOCHONDRIASIS


DiagnosisHistory

DSM-IV-TR Criteria


Natural History

Epidemiology

Etiology

Treatment

BODY DYSMORSPHIC DISORDER


DiagnosisHistory

DSM-IV-TR Criteria


Natural History

Epidemiology

Etiology

Treatment

SOMATOFORM DISORDER NOT OTHERWISE SPECIFIED

Definition and Clinical DescriptionDiagnosis

History

DSM-IV-TR Criteria


Epidemiology, Etiology, and Treatment

CONCLUSION





CHAPTER 13 Tables and Figures

Table 13±1. DSM-IV-TR somatoform disorders: a comparison

Table 13±2. DSM-IV-TR somatoform disorders and corresponding categories in previous DSM and

ICD diagnostic systems

Table 13±3. Feighner criteria symptom list for hysteria (somatization disorder)

Table 13±4. DSM-IV-TR diagnostic criteria for somatization disorder

Table 13±5. Features useful in discriminating between somatization disorder and general medical conditions

Table 13±6. General medical conditions that may be confused with somatization disorder

Figure 13±1. Distribution and number of sick leave occasions in Swedish somatizing (³high-frequency´)

subjects and control nonsomatizing subjects.

Table 13±7. Main treatment principles in approaching a patient with somatization disorder

Table 13±8. DSM-IV-TR diagnostic criteria for undifferentiated somatoform disorder

Table 13±9. DSM-IV-TR diagnostic criteria for conversion disorder

Table 13±10. Key terms

Table 13±11. DSM-IV-TR diagnostic criteria for hypochondriasis

Table 13±12. DSM-IV-TR diagnostic criteria for body dysmorphic disorder

Table 13±13. DSM-IV-TR diagnostic criteria for somatoform disorder not otherwise specified

Summary Key Points





TABLE 13±1. DSM-IV-TR somatoform disorders: a comparison

In DSM-IV-TR, the disorders included under the somatoform rubric are somatization disorder,

undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body

dysmorphic disorder, and the residual category somatoform disorder not otherwise specified (NOS).

DSM-IV-TR criteria for these disorders are outlined in Table 13±1.

S ource. Adapted with permission from Martin RL: ³Somatoform Disorders in the General Hospital Setting,´ inH andbook of S tudies on General Psychiatry.

Edited by Judd FK, Burrows GD, Lipsitt DR. Amsterdam, The Netherlands, Elsevier, 1991, pp. 251±266. Copyright 1991 Elsevier Science Publishers.

(continued)





TABLE 13±1. (continued)





TABLE 13±2. DSM-IV-TR somatoform disorders and corresponding categories in

previous DSM and ICD diagnostic systems

Table 13±2 lists the categories best corresponding to DSM-IV-TR somatoform disorders in DSM-I

(American Psychiatric Association 1952), DSM-II (American Psychiatric Association 1968), DSM-III,

and DSM-III-R as well as ICD-9 (World Health Organization 1977) and ICD-10.

S ource. Adapted with permission from Martin RL: ³Somatoform Disorders in the General Hospital Setting,´ in H andbook of S tudies on General Psychiatry.

Edited by Judd FK, Burrows GD, Lipsitt DR. Amsterdam, The Netherlands, Elsevier, 1991, pp. 251±266. Copyright 1991 Elsevier Science Publishers.





TABLE 13±3. Feighner

criteria symptom list for

hysteria (somatization

disorder)

Hysteria was included as one of

the 14 ³canonized´ psychiatric

disorders in the influential criteria

described by Feighner et al.

(1972). For hysteria, the Feighner

criteria required a chronic or recurrent illness beginning before

age 30 that included a dramatic,

vague, or complicated medical

history. The diagnosis required 25

³positive´ medically unexplained

symptoms (from a list of 59) in 9

of 10 groups (Table 13±3); 20

symptoms in the same number of

groups were necessary for aprobable diagnosis.

S ource. Adapted from Perley and Guze 1962.

Reprinted with permission from Cloninger CR:

³Somatoform and Dissociative Disorders,´ in The

Medical Basis of Psychiatry, 2nd Edition. Edited by

Winokur G, Clayton P. Philadelphia, PA, W B

Saunders, 1994, pp. 169±192. Copyright 1994,

WB Saunders Company.





TABLE 13±4. DSM-IV-TR diagnostic criteria for somatization disorder

The DSM-IV criteria for somatization disorder incorporate an empirically derived algorithm requiring

four pain symptoms, two nonpain gastrointestinal symptoms, one nonpain sexual or reproductive

symptom, and one pseudoneurological (conversion or dissociative) symptom (Table 13±4).





TABLE 13±5. Features useful in discriminating between somatization disorder

and general medical conditions

The symptom picture encountered in somatization disorder is frequently nonspecific and can

overlap with a multitude of medical disorders. Cloninger (1994) has suggested several features

useful in discriminating between somatization disorder and physical illness (Table 13±5).





TABLE 13±6. General medical conditions that may be confused with somatization disorder

The clinician should be aware that several medical disorders may be confused with somatization

disorder (Table 13±6).





The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC,Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

12

TABLE 13±7. Main treatment principles in approaching a patient with somatization

disorder

An eclectic approach accords well with the general principles of treatment recommended by

Quill (1985), Cloninger (1994), and Smith et al. (1986). Implementation of these principles may

greatly facilitate clinical management of somatization disorder and prevent potentially serious

complications, including the effects of unnecessary diagnostic and therapeutic procedures.




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TABLE 13±8. DSM-IV-TR diagnostic criteria

for undifferentiated somatoform disorder

The essential aspect of undifferentiated

somatoform disorder is the presence of one or

more clinically significant, medically unexplained

somatic symptoms with a duration of 6 months or

more that are not better accounted for by another

mental disorder (Table 13±8).




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TABLE 13±9. DSM-IV-TR diagnostic criteria

for conversion disorder

As defined in DSM-IV-TR, nonintentional

³symptoms or deficits affecting voluntary motor

or sensory function´ (American Psychiatric

Association 2000, p. 498) are central to conversion

disorder (Table 13±9). The majority of such

symptoms will suggest a neurological condition(i.e., are pseudoneurological), but other general

medical conditions may be suggested as well.




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TABLE 13±10. Key terms

Key terms and definitions used in connection with conversion disorder are listed Table 13±10.




16

TABLE 13±11. DSM-IV-TR

diagnostic criteria for hypochondriasis

Specific criteria for the diagnosis of

hypochondriasis are presented in Table 13±11.




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TABLE 13±12. DSM-IV-TR diagnostic criteria for body dysmorphic disorder

The essential feature of body dysmorphic disorder is a preoccupation with some imagined defect in

appearance or markedly excessive concern with a minor physical anomaly (Table 13±12). Such

preoccupation persists even after reassurance.




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TABLE 13±13. DSM-IV-TR

diagnostic criteria for somatoform disorder not

otherwise specified

The basic DSM-IV-TR requirement for a diagnosis of somatoform disorder NOS is that a disorder with

somatoform symptoms does not meet criteria for a specified somatoform disorder (Table 13±13).




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CHAPTER 13 Key Points

The somatoform disorders are grouped because they suggest a physicaldisorder for which there are no organic findings or known physiological

mechanism or there is a strong presumption that the symptoms are linked

to psychological issues.

Somatization disorder is uncommon, but it is considered one of very few

valid and reliable mental illnesses.

Conversion disorder is a diagnosis that should be applied only after significant effort has been expended to eliminate any possible treatable

organic disorder.

Hypochondriasis is a rather uncommon disorder that usually follows a

fluctuating course.

Body dysmorphic disorder is a diagnosis in evolution, with conflicting data

regarding amenability to treatment.

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