Patients with somatoform disorders have long been known to disproportionately access medical care, with resultant increase in treatment costs and risk of iatrogenic complications of treatment.1
Although it has been suggested2 that psychiatrists overall tend to ignore such patients, when admitted to general medical services, they are often referred for psychiatric consultation,3,4 and indeed in the hospital setting it has been shown that if the condition is properly recognized and addressed, functional outcomes can be improved and inappropriate treatment-seeking decreased.5,6 However, proper diagnosis of such patients can be difficult, for both conceptual and practical reasons. Partly this is due to continuing disagreement about what, precisely, “somatization” means — a long-running debate that has had significant impact on diagnostic classification.
The History of Hysteria
“Hysteria” (in the sense of the patient who presents with somatic complaints for which no clear organic pathology is evident) has been traced back at least to the Hippocratic school of medicine, and perhaps as far as ancient Egypt.7 Over the centuries, it has often been lumped with a rather different phenomenon: Excessive worry over the possibility of having a serious illness, generally on the basis of trivial objective findings (“hypochondriasis”). But while (perhaps) related, and generally considered within the same group of illnesses, the distinction between these two conditions has been recognized for centuries. Sydenham, among others, is said to have accepted that hysteria was due to uterine pathology, whereas the source of hypochondriasis was a disordered spleen.8
A somewhat more recent conceptualization holds that, rather than being a specific disease entity, somatization should instead be seen as a process: a means by which some patients “experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them.”9 This formulation is deeply indebted to psychoanalytic thought, implying both the activity of a psychological defense against feelings of dysphoria and anxiety and a potential approach to treatment by clarifying the link between psychological and physical symptoms. It also implies that liability to somatization lies on a continuum in the general population.10,11
Although less attention has been paid to why some patients are more likely to experience and express psychological discomfort in this way, a more recent elaboration of this theoretical approach, building on reports of higher rates of early childhood abuse and adversity in this population, suggests that somatic symptoms represent dissociated memories of early trauma,12,13 though this proposed mechanism would not seem to fit neatly with a continuum of symptoms.
Very much in line with that theory is the observation that some individuals present, often (though by no means always) in the context of identifiable stressors, with symptoms or deficits affecting voluntary motor or sensory function. Narrowly defined in this way, it has been suggested that “conversion symptoms” (the term can be traced to Freud’s early career) may be the result of unconscious conflict; alternatively, it has been proposed that some manifestations may represent nonverbal communication of otherwise unacceptable feelings, acceptance of the “sick role,” or perhaps simply a learned coping skill.14
In the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV),15 this phenomenon has been further split into conversion disorder proper, manifested by motor or sensory symptoms or deficits or by nonepileptic seizures, and pain disorder, where the primary presentation is one of clinically significant pain (see Sidebar 1). Thus, in the “somatizing-as-process” tradition, manifestation of medically unexplained symptoms can be seen as occurring on a clinical spectrum anchored on one end by the patient who perhaps reports only a single such symptom, and on the other by the patient whose medical record might document a multitude of presentations over time for which proper evaluation has failed to identify a clear physical cause.
Somatoform Disorders in DSM-IV
Proposed Categories in DSM-5
- Somatization disorder
- Undifferentiated somatization disorder
- Conversion disorder
With motor symptom or deficit
With sensory symptom or deficit
With seizures or convulsions
With mixed presentation
- Pain disorder
- Body dysmorphic disorder
- Somatoform disorder not otherwise specified
- Somatic symptom disorder
- Conversion disorder (functional neurological symptom disorder)
Single conversion symptoms, however, have been known to occur in many psychiatric illnesses as well as in isolation.16 Rather than focusing on the significance (if any) of individual symptoms, another approach has eschewed etiological theories and instead focused on those latter individuals, ie those who recurrently present to their physicians with a wide variety of physical complaints for which no clear organic basis can be found (“medically unexplained symptoms”).
This tradition is generally traced back to Briquet17 and was substantially elaborated on by Guze and colleagues18 who, over a period of many years, conducted a number of family and follow-up studies of what was termed “Briquet’s syndrome.” To qualify for this diagnosis, patients were required to have “a chronic or recurrent illness beginning before age 30, presenting with a dramatic, vague, or complicated medical history” and to have reported at least 25 medically unexplained symptoms (of a possible 59) in at least nine of 10 symptom groups19 over their lifetimes.
Generally, establishing this diagnosis required use of the Perley-Guze checklist20 — not an interview, but a means by which medical records (often voluminous) could be systematically reviewed. In addition to classical “pseudoneurological” symptoms (blindness, paralysis, and the like), a variety of other symptoms (gastrointestinal problems, gynecological and sexual complaints, unexplained pain) were specified.
Symptoms relating to anxiety and depression, classically part of the concept of “hysteria,” were also included in the symptom groups, and indeed, because of the requirement that at least nine such groups be represented, it was unusual to make the diagnosis without presence of some psychological complaints.
Characterized in this way, Briquet’s syndrome has convincingly been shown to be a temporally stable diagnosis distinct from other psychiatric syndromes, to aggregate within families, and to have a predictable course. As defined, it was observed also to overwhelmingly affect women — though male relatives were found to have markedly elevated rates of antisocial personality disorder.21–23 Thus, as much as any psychiatric disorder, Briquet’s syndrome can be said to have met the requirements for a validated psychiatric diagnosis.24
But despite this extensive research base, Briquet’s syndrome was not included in the DSM-III.25 A cognate diagnosis, somatization disorder, was included, but differed radically from Briquet’s syndrome. Rather than requiring 25 of 59 possible symptoms (occurring over the patient’s lifetime), the reformulated diagnosis required only 14 (12 for men) of a possible 37; the lower requirement for diagnosis in men was presumably to adjust for different thresholds by gender to express the condition — an approach not followed for other disorders such as depression that are known to differ in prevalence by gender. In order to reduce the overlap with other disorders, psychological symptoms were no longer included (though concurrent diagnoses of mood or anxiety disorders could be made); instead, the diagnosis was based solely on “pseudoneurological” symptoms, gynecological and sexual problems, and cardiopulmonary complaints.
Concordance between Briquet’s syndrome and DSM-III somatization disorder was found to be disappointingly low and it did not appear to aggregate in families – a threat to the validity of the construct.13,26 However, only minor revisions to the diagnostic criteria were made in the DSM-III-R27 (for example, the number of symptoms was reduced to 35 and the threshold for diagnosis was set at 13 for both men and women).
In recognition of the poor performance of earlier criteria sets, the current diagnostic criteria, as set out in DSM-IV, are an attempt to simplify the diagnostic process while building on the earlier validation studies of Briquet’s syndrome. Rather than requiring a very time-consuming review of a large number of symptoms (as required previously), the DSM-IV criteria require presence of only four groups of symptoms (see Sidebar 2) and in the DSM-IV field trial performed well as compared to the Perley-Guze criteria.28 Nonetheless, proposed DSM-5 diagnostic criteria for somatization disorder represent a radical change; indeed, even the name has been altered (see Table 1).
DSM-IV Criteria for Somatization Disorder
A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment of functioning.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance.
Four pain symptoms: a history of pain related to at least four different sites or functions (eg, head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
Two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (eg, nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
One sexual symptom: a history of at least one sexual or reproductive symptom other than pain (eg, sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
One pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)
Either A or B:
After appropriate investigation, each of the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (eg, a drug of abuse, a medication)
When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings
The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).
Table 1. Proposed Criteria for Somatic Symptom Disorder in DSM-5
Problems in Diagnosis
There are four major difficulties in diagnosing somatization disorder. First is the requirement that symptoms be “medically unexplained.” Everyone has transient physical aches and pains of no real significance; this experience therefore cannot represent the medically unexplained symptoms of interest. Thus, as a threshold requirement, such symptoms must have led to some sort of presentation to a medical professional or led to taking medication other than over-the-counter pain medicine and to have significantly interfered with day-to-day function.
To consider a symptom medically unexplained requires a certain amount of clinical judgment and, thus, one would predict some degree of disagreement between raters. According to current diagnostic rules, to be counted toward the diagnosis, symptoms “cannot be fully explained by a known general medical condition or the direct effects of a substance.” Implied, but rarely (if ever) explicitly stated, is that syndromes such as irritable bowel syndrome, fibromyalgia, and the like do not “fully explain” the complaint (much less other “functional somatic syndromes” whose popularity have waxed and waned over time, such as “multiple chemical sensitivity,” Lyme disease, mitral valve prolapse, Candida hypersensitivity, etc.).29
Moreover, symptoms can be counted toward the diagnosis even if they are believed to be related to a general medical condition — as long as the associated complaints or impairment are judged to be in excess of what would be expected based on objective findings such as history, physical examination, or laboratory studies.
A second difficulty is that the diagnosis is one that is profoundly difficult to make on the basis of clinical interview alone. Unfortunately, patients with Briquet’s syndrome or somatization disorder tend to be strikingly unstable in describing their medical histories30 and it can be a laborious and very time-consuming task to systematically inquire about dozens of symptoms of medical complaints, some of which may have occurred decades earlier. Even if the patient recalls a given symptom, it may be impossible for the interviewer to confidently classify it as having been medically unexplained based only on interview of the patient.
In settings when accurately making the diagnosis of somatization disorder, such as a general medical or surgical hospital unit, is particularly important, it seems that the environment conspires to place additional barriers. Interviews may have to be curtailed because the patient is scheduled for various tests; privacy is minimal; and the evaluation is conducted when the focus of all medical attention is on the current presentation — making it even more difficult to focus on symptoms that may have occurred long before and at best may be incompletely and inaccurately recalled.
A third difficulty is the wealth of reported psychiatric comorbidity that often accompanies the diagnosis, and which may well obscure the clinical salience of somatoform symptoms. It has long been recognized that complaints of anxiety and dysphoria are a prominent feature of hysteria as classically understood: The majority can also be diagnosed with a depressive syndrome, for example.31 In addition, in keeping with a response style that favors reporting of symptoms, such patients not infrequently report having had symptoms suggestive of mania or psychosis (though such syndromes are rarely substantiated clinically).32,33 And, of course, the overlap with somatization disorder and personality disorders, particularly those in Cluster B, is well known.34,35
Finally, establishing the diagnosis virtually always requires a careful and time-consuming review of medical records. This is often not practical because of lack of time or because the requisite records are not available, and the busy practitioner who attempts to do such a review will find his or her time poorly compensated by third-party payers.
Somatization Disorder and DSM-5
Perhaps because of these difficulties, in practice, the diagnosis of somatoform disorders has proven so unsatisfactory that it was concluded by the DSM-5 Somatic Symptom Disorder Work Group that “… the current DSM-IV somatoform diagnoses (somatization disorder, somatoform disorder not otherwise specified [NOS], undifferentiated somatoform disorder, hypochondriasis and the pain disorders) are so flawed that complete restructuring of these diagnoses is required.”
The work group further concluded that these diagnoses “are resented by many patients” and that the criteria for somatization disorder have proven “too restrictive,” whereas the threshold for diagnosis of either undifferentiated somatoform disorder or somatoform disorder NOS could be applied to a large number of patients in primary care settings.36
As a result, all of these disorders are to be eliminated; presumably, many patients who would have been assigned one or the other of these diagnoses would instead be diagnosed with somatic symptom disorder (see Table 1, page 82). While the diagnostic criteria do not specify a duration for any specific symptom, it is noted that “the state of being symptomatic is persistent,” generally more than 6 months.
Thus, it appears that, consistent with prior formulations of somatoform disorders, the next iteration of diagnosis will exclude symptoms of anxiety, mood or personality disorders. It breaks new ground in that it will unify hypochondriacal concerns with medically unexplained symptomatology in a single diagnostic category.
Consistent with the overall approach taken in DSM-5 to focus more on disease continua and process rather than categorical assignment, it also appears that the disorder is implicitly characterized as a unified entity, with cases differing primarily only on a spectrum of severity — a position more consistent with the “somatization-as-process” conceptualization than with the existence of a separate disorder characterized by multiple and varied physical symptoms as in Briquet’s syndrome or somatization disorder.
Clinical Approach to the Patient
Despite this conceptual and diagnostic shift, the consulting psychiatrist will still be faced with the challenge of managing the patient with multiple physical complaints (or who focuses intensely on one specific complaint) for which no clear organic etiology can be identified. The approach outlined in Murphy’s classic article37 is a conservative one that he admits is based primarily on clinical experience rather than research. However, long-term treatment seems not to have substantially changed in the three decades since his paper appeared, though there is evidence that cognitive-behavioral approaches may be of benefit in addressing specific symptoms.38
Most important is to correctly make the diagnosis — which, for reasons set out above, can be a difficult task. But it should be kept in mind that patients in whom the diagnosis cannot be established after proper effort tend to follow a much different course, and falsely assigning a diagnosis of somatization disorder can impede proper evaluation and treatment. But in those cases where a diagnosis can be established, the clinician armed with this information can then make informed predictions about course and response to treatment.
In such cases, regular, albeit brief, visits are key; though the time between visits can gradually be extended, the nature of the condition is such that the patient will surely seek help in some fashion, and it is better for care to be given by a single clinician who is familiar with the patient than by many who are faced with a new (and often puzzling) patient. Murphy37 advocates attentive listening, without focusing on the somatic symptoms and avoidance of prescription of psychotropic medication unless there is clear indication. This advice, it should be noted, was directed toward outpatient care, but is equally applicable to the inpatient for whom consultation is recommended, and in my clinical experience it has proven effective.
In that case, the goal (of course) is discharge with outpatient follow-up as soon as medically appropriate. Patients may initially be hesitant to see a psychiatrist, but an empathic stance acknowledging that the patient’s suffering is real and that psychiatric follow-up can help in dealing with it can be quite effective.
In the outpatient setting (but also in the setting of inpatient consultation), the patient can be rendered great service by avoiding invasive, expensive evaluations or interventions with low prior probabilities of finding or relieving pathology. In contrast to the vague and often dramatically described symptoms typical of the illness, when such patients develop syndromes that are more likely to be identified by such tests, they are often able to describe their manifestations in ways much like any other patient. Typical signs of the illness, as well as symptoms, will generally be present.
Conveying this information to the primary team as a consultant, and to the primary care physician once the patient is discharged, is vital, and my experience is that simply communicating in the chart may not suffice. It is generally more effective to educate the entire treatment team if possible; as part of that process, it is often helpful to participate in the primary team’s rounds on the patient, or even to set aside a specific time for all caregivers to meet and discuss the patient’s care.
During this process, it is not uncommon to find that the patient has become perceived as demanding and unreasonable and, thus, has provoked negative attitudes that can interfere with care. After properly ruling out medically or surgically etiologies, placating the patient by agreeing to additional interventions is unlikely to be effective; contrariwise, clinicians may withdraw and minimize contact, thus provoking increasingly vigorous attempts at gaining the team’s attention — leading to a vicious cycle and treatment impasse.
In this regard, it is vital that all members of the treatment team stay “on message” with the patient, conveying a compassionate awareness and acknowledgment of the reality of the suffering caused by the illness, while emphasizing that optimal care should be focused on a longer-term strategy aimed at symptom management rather than continuing to pursue unrevealing, expensive, and invasive procedures that have little likelihood of a dramatic cure.
Regardless of the impending change in diagnostic practices with the publication of DSM-5, it can be confidently predicted that the consulting psychiatrist will continue to be asked to assist in the management of patients who present with physical complaints for which no clear cause can be found. Proper assessment of such patients is labor-intensive, but has significant benefit to patients and to the health care system. Rather than reacting to the patient’s repeated presentations as if they represent a series of acute and unconnected events, by conceptualizing the condition as having a fluctuating but chronic course, unnecessary evaluation and treatment can be minimized. Instead, the patient will benefit more by transitioning to a plan that emphasizes frequent, supportive contacts and minimizes attention on physical complaint, instead focusing on a pragmatic, problem-solving approach to everyday stressors.
- Barsky AJ, Orav J, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. ArchGen Psychiatry. 2005;62(8):903–910. doi:10.1001/archpsyc.62.8.903 [CrossRef]
- Bass C, Peveler R, House A. Somatoform disorders: severe psychiatric illnesses neglected by psychiatrists. Br J Psychiatry. 2001;179:11–14. doi:10.1192/bjp.179.1.11 [CrossRef]
- Clarke DM, Smith GC. Consultation-liaison psychiatry in general medical units. Aust N Z J Psychiatry. 1995;29(3):424–432. doi:10.3109/00048679509064950 [CrossRef]
- Thomassen R, van Hemert AM, Huyse FJ, van der Mast RC, Hengeveld MV. Somatoform disorders in consultation-liaison psychiatry: a comparison with other mental disorders. Gen Hosp Psychiatry. 2003;25(1):8–13. doi:10.1016/S0163-8343(02)00248-7 [CrossRef]
- Smith GR, Monson RA, Ray DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med. 1986;314(22):1407–1413. doi:10.1056/NEJM198605293142203 [CrossRef]
- Smith GR, Miller LM, Monson RA. Consultation-liaison intervention in somatization disorder. Hosp Commun Psychiatry. 1986;37(12):1207–1210.
- Purtell JJ, Robins E, Cohen ME. Observations on clinical aspects of hysteria. JAMA. 1951;146:902–909. doi:10.1001/jama.1951.03670100022006 [CrossRef]
- Sydenham T. De Affectione Hysterica. London, 1682. (cited in Whitlock FA. The aetiology of hysteria. Acta Psychiatr Scand. 1967;43(2):144–162.)
- Lipowski ZJ. Somatization: medicine’s unsolved problem. Psychosomatics. 1987;28(6):294–297. doi:10.1016/S0033-3182(87)72518-3 [CrossRef]
- Liu G, Clark MR, Eaton WW. Structural factor analyses for medically unexplained somatic symtoms of somatization disorder in the Epidemiologic Catchment Area study. Psychol Med. 1997;27(3):617–626. doi:10.1017/S0033291797004844 [CrossRef]
- Katon W, Lin E, Von Korff M, Russo J, Lipscomb P, Bush T: Somatization. A spectrum of severity. Am J Psychiatry. 1991;148(1):34–40.
- Brown RJ. Medically unexplained symptoms: a new model. Psychiatry. 2006; 5:43–47. doi:10.1383/psyt.2006.5.2.43 [CrossRef]
- Brown RJ, Schrag A, Trimble MR. Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder. Am J Psychiatry. 2005;162(5):899–905. doi:10.1176/appi.ajp.162.5.899 [CrossRef]
- Ford CV, Folks DG. Conversion disorders: an overview. Psychosomatics. 1985;26(5):371–383. doi:10.1016/S0033-3182(85)72845-9 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
- Sar V, Akyüz G, Kundakçı T, Kızıltan E, Dogan O. Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder. Am J Psychiatry. 2004;161(12):2271–2276. doi:10.1176/appi.ajp.161.12.2271 [CrossRef]
- Mai FM, Merskey H. Briquet’s Treatise on Hysteria. A synopsis and commentary. Arch GenPsychiatry. 1980;37(12):1401–1405. doi:10.1001/archpsyc.1980.01780250087010 [CrossRef]
- Guze SB. The validity and significance of the clinical diagnosis of hysteria (Briquet’s Syndrome). Am J Psychiatry. 1975;132(2):138–141.
- Feighner JP, Robins E, Guze SB, Woodruff RA, Winokur G, Munoz R. Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. 1972;26(1):57–63. doi:10.1001/archpsyc.1972.01750190059011 [CrossRef]
- Perley MJ, Guze SB. Hysteria—the stability and usefulness of clinical criteria. A quantitative study based on follow-up period of six to eight years in 39 patients. N Engl J Med. 1962;266:421–426. doi:10.1056/NEJM196203012660901 [CrossRef]
- Woodruff RA, Clayton PJ, Guze SB. Hysteria: Studies of diagnosis, outcome and prevalence. JAMA. 1971;215(3):425–428. doi:10.1001/jama.1971.03180160025006 [CrossRef]
- Cloninger CR, Reich T, Guze SB. The multi-factorial model of disease tramsmission: III. Familial relationship between sociopathy and hysteria (Briquet’s Syndrome). Br J Psychiatry. 1975;127:23–32. doi:10.1192/bjp.127.1.23 [CrossRef]
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- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition. Washington, DC: American Psychiatric Association; 1980.
- Cloninger CR, Martin RL, Guze SB, Clayton PJ. A prospective follow-up and family study of somatization in men and women. Am J Psychiatry. 1986;143(7):873–878.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Washington, DC: American Psychiatric Association; 1987.
- Yutzy SH, Cloninger CR, Guze SB, Pribor et al. DSM-V Field Trial: testing a new proposal for somatization disorder. Am J Psychiatry. 1995;152(1):97–101.
- Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Medicine. 1999;130(1):910–921.
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Proposed Criteria for Somatic Symptom Disorder in DSM-5
|Somatic Symptom Disorder
Criteria A, B, and C must all be fulfilled to make the diagnosis:
Somatic symptoms:One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
Excessive thoughts, feelings, and behaviors related to these somatic symptoms or associated health concerns: At least one of the following must be present.
Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
Persistently high level of anxiety about health or symptoms.
Excessive time and energy devoted to these symptoms or health concerns.
Chronicity:Although any one symptom may not be continuously present, the state of being symptomatic is persistent (typically> 6 months).
Predominant pain (previously pain disorder). This category is reserved for individuals presenting predominantly with pain complaints who also satisfy criteria B and C of this diagnosis. Some patients with pain may better fit other psychiatric diagnoses such disorder or psychological factors affecting a medical condition.
Severity Specifiers (mild, moderate, severe):
“Somatic symptom disorder” is characterized by persistency, symptom burden, and excessive or maladaptive response to somatic symptoms. There is a considerable range of severity. Typically, the disorder is more severe when multiple somatic symptoms are present.
In addition to fulfilling criteria A and C, the following metrics may be used to rate severity:
Patient Health Questionnaire–Somatic Symptom Short Form (PHQ-SSS)
Mild - only one of the B criteria fulfilled
Moderate - two or more B criteria fulfilled
Severe - two or more B criteria fulfilled plus multiple somatic
|During the past 7 days, how much have you been bothered by….
||Not at all
||A little bit
||Quite a bit
||Stomach problems or irregularity?
||Pain in your back?
||Pain in your arms, legs, or joints?
||Chest pain or getting out of breath?
||Feeling tired or having low energy?