What is Somatoform disorder?

What is Somatoform Disorder?

Somatoform disorder (now termed "somatic symptom and related disorders" in DSM-5) is a group of psychiatric conditions characterized by distressing physical symptoms that cannot be fully explained by organic pathology, accompanied by excessive thoughts, feelings, or behaviors related to these symptoms, resulting in significant functional impairment. 1

Core Definition and Classification

The DSM-5 recognizes 7 distinct somatic symptom and related disorders, replacing the older "somatoform" terminology 1:

• Somatic symptom disorder (the primary category)
• Illness anxiety disorder (preoccupation with having a serious illness)
• Conversion disorder (functional neurologic symptom disorder)
• Psychological factors affecting other medical conditions
• Factitious disorder
• Other specified somatic symptom and related disorder
• Unspecified somatic symptom and related disorder

The term "somatoform" has been largely replaced because functional imaging studies have demonstrated cerebral correlates for disorders previously thought to be purely psychogenic 1.

Essential Diagnostic Features

Three core criteria must be present 1:

1. One or more somatic symptoms that are distressing or significantly disrupt daily life 1

2. Excessive cognitive-emotional response manifested by at least one of the following 1:

   • Disproportionate and persistent thoughts about symptom seriousness
   • Persistently high anxiety about health or symptoms
   • Excessive time and energy devoted to symptoms or health concerns

3. Persistent symptomatic state typically lasting more than 6 months (though individual symptoms may fluctuate) 1

Clinical Presentations

The most common symptom patterns involve 1:

• Neurologic symptoms (weakness, numbness, seizure-like episodes, abnormal movements)
• Pain syndromes (headaches, abdominal pain, musculoskeletal pain)
• Autonomic symptoms (palpitations, dizziness, shortness of breath)
• Gastrointestinal symptoms (nausea, bloating, diarrhea)

Key clinical clues include 1:

• Vague, poorly described complaints
• Symptoms that fluctuate with activity or stress
• Recent or current stressful life events
• Lack of physical findings and laboratory abnormalities
• Multiple healthcare visits for the same complaints

Epidemiology and Impact

These disorders are remarkably common and costly 1:

• 10-15% of adult primary care patients have one of these disorders 1
• In children and adolescents: recurrent abdominal pain accounts for 5% of pediatric visits, headaches for 20-55% 1
• 10% of adolescents report frequent somatic symptoms 1
• 81% of pediatric patients with medically unexplained chest pain meet criteria for anxiety disorders 2

Functional Impairment

All somatic symptom disorders result in significant psychosocial dysfunction 1:

• Impaired relationships with family and friends
• Academic or occupational difficulties
• Reduced quality of life across multiple domains
• Excessive healthcare utilization and costs

Critical Distinctions

What somatic symptom disorder is NOT 1:

• Not malingering: Symptoms are not intentionally produced for material gain (financial or emotional benefit) 1
• Not factitious disorder: Symptoms are not consciously fabricated 1
• Not conversion disorder: While conversion is a subtype, it specifically involves quasi-neurologic symptoms 1

The symptoms in somatic symptom disorder are not associated with material gain and are not intentionally produced 1.

Psychiatric Comorbidities

The majority of patients have comorbid psychiatric conditions 2, 3:

• Anxiety disorders are present in 81% of pediatric patients with medically unexplained symptoms 2
• Depression commonly co-occurs and requires specific treatment 3
• These comorbidities must be screened for and treated appropriately 3

Common Pitfalls in Understanding

Avoid these misconceptions 3:

• Do not dismiss symptoms as "not real" - the symptoms are genuine and cause real distress, even without organic pathology 3
• Do not assume absence of organic disease prematurely - some patients may have both medical conditions and somatic symptom disorder 2
• Do not use dismissive language like "it's all in your head" - this damages the therapeutic relationship and increases healthcare-seeking behavior 3

Severity Specification

Severity is graded based on DSM-5 criteria 1:

• Mild: Only one excessive cognitive-emotional criterion fulfilled
• Moderate: Two or more criteria fulfilled
• Severe: Two or more criteria fulfilled plus multiple somatic complaints or one very severe symptom