SOMATOFORM DISORDERS

The somatoform disorders are a group of conditions that involve physical symptoms and
complaints suggesting the presence of a medical condition but without any evidence of physical
pathology to account for them (APA, 2000). They are characterized by presence of physical or bodily
symptoms without any general medical cause to explain it, i.e., lack of an organic or physical cause.
Soma means “body,” and somatoform disorders involve patterns in which individuals complain of
bodily symptoms or defects that suggest the presence of medical problems but for which no organic
basis can be found that satisfactorily explains the symptoms such as paralysis or pain. Such
individuals are typically preoccupied with their state of health and with various presumed disorders
or diseases of bodily organs.

The somatoform disorders are a confusing diagnostic category because the individual
disorders do not share an underlying emotion or a common aetiology. DSM-5 lists five basic somatic
symptom and related disorders: somatic symptom disorder, illness anxiety disorder, psychological
factors affecting medical condition, conversion disorder, and factitious disorder. In each, individuals
are pathologically concerned with the functioning of their bodies.

Syndromes of somatoform disorders

 Somatic Symptom Disorder

In 1859, Pierre Briquet, a French physician, described patients who came to see him with
seemingly endless lists of somatic complaints for which he could find no medical basis (American
Psychiatric Association, 1980). Despite his negative findings, patients returned shortly with either the
same complaints or new lists containing slight variations. For many years, this disorder was called
Briquet’s syndrome, but now would be considered somatic symptom disorder.

Most people have physical symptoms somewhere along life’s course. It is normal to feel
concerned about one’s physical symptoms and to seek medical attention. However, people with
somatic symptom disorder (SSD) not only have troubling physical symptoms, but they are excessively
concerned about their symptoms to the extent that it affects their thoughts, feelings, and
behaviours in daily life. People with somatic symptom disorder do not always feel the urgency to
take action but continually feel weak and ill, and they avoid exercising, thinking it will make them
worse.

The important factor in this condition is not whether the physical symptom has a clear
medical cause or not, but rather that psychological or behavioral factors, particularly anxiety and
distress, are compounding the severity and impairment associated with the physical symptoms. An
example of a somatic symptom disorder would be the experience of severe pain in which
psychological factors play a major role in maintaining or exacerbating the pain. Whether or not there
is a clear physical reason for the pain is not emphasized. Thus, the diagnosis emphasizes the
psychological features of physical symptoms, not whether the underlying cause or causes of the
symptoms can be medically explained.

 Conversion disorder

The term conversion has been used off and on since the Middle Ages (Mace, 1992) but was
popularized by Freud, who believed the anxiety resulting from unconscious conflicts somehow was
“converted” into physical symptoms to find expression. This allowed the individual to discharge
some anxiety without actually experiencing it.
 Conversion disorder is one of the most intriguing and baffling patterns in psychopathology. The
term conversion disorder is relatively recent, and historically, it was combined with present-day
somatization disorder and collectively referred to as “hysteria”, derived from the Greek word
“hystera” meaning uterus. It was incorrectly thought to affect only women and its cause was
attributed to a “wandering uterus”. The common cure for hysteria included engaging in sexual
intercourse with strong and young men and giving birth to satisfy the “melancholic uterine”. Hysteria
was also extensively studied by neurologist Freud who based his theory on his patients who were
mostly victims of sexual abuse. In his view, conversion disorder, before it was medically termed, was
caused due to psychological conflicts, usually sexual in nature. Even though today the sexual
interpretation is rejected, psychologists agree that conversion disorders may be the result of some
psychological conflict.

Conversion disorder involves a pattern in which symptoms or deficits affecting sensory or

voluntary motor functions lead one to think that a patient has a medical or neurological condition. A
few typical examples include partial paralysis, blindness, deafness, and pseudoseizures.

La belle indifference (beautiful indifference)- defined as substantial emotional indifference to the

presence of these dramatic physical symptoms. Even when unable to walk or move their arms, some
people appear undisturbed by their paralysis. They deny emotional distress from their unusual
symptoms and behave as if nothing is wrong. However, some people with conversion disorder are
distressed by their symptoms; thus, la belle indifference, though often present, is not a necessary
symptom of conversion disorder. Though it has now been dropped as a criterion from recent
editions of the DSM.

In some cases, however, what appears to be conversion disorder actually turns out to be
intentional fabrication or faking of symptoms for some external gain (malingering). Unfortunately,
clinicians lack the ability to reliably determine that someone is faking.

The physical symptoms in conversion disorder usually come on suddenly in stressful situations.
Often this stress takes the form of a physical injury. Since many other disorders are associated with
stressful events and stressful events often occur in the lives of people without any disorders. For this
reason, the diagnostic criterion that conversion disorder is associated with preceding stress does not
appear in DSM-5.

 Illness anxiety disorder

Illness anxiety disorder was formerly known as “hypochondriasis”, is characterized by a constant

fear or excessive worry about having a serious illness. Hypochondriacs misinterpret their physical
bodily sensations as abnormal. They pick up a small bodily dysfunction, such as abdominal pain, and
exaggerate its symptom as indicating a more serious disability or disease, such as cancer. Even
though they cannot find any medical diagnosis that confirms their beliefs, and even after being
reassured of their good health by medical examination, they continue to hold strong convictions of
their perceived illness. For example, a person suffering from headaches may fear that they are a sign
of a brain tumor and believe doctors are wrong when they say these fears are groundless.

In illness anxiety disorder the concern is primarily with the idea of being sick instead of the
physical symptom itself. In any case the threat seems so real that reassurance from physicians does
not seem to help.

People with hypochondriasis do not necessarily suffer from physical symptoms. Rather, they
have a dysfunctional mind-set that leads to worry about health, illness, and physical symptoms. They
constantly seek reassurance from physicians, spend time discussing their symptoms with family and
friends, repeatedly check medical information sources, and monitor their own physical status (e.g.,
take their blood pressure).

These patients may feel real physical discomfort, often involving their digestive system or an
assortment of aches and pains throughout the body. They may be overly sensitive to benign changes
in physical sensations, such as slight changes in heartbeat and minor aches and pains. Anxiety about
physical symptoms can produce its own physical sensations, however— for example, heavy sweating
and dizziness, even fainting. Thus, a vicious cycle may ensue. Patients may become resentful when
their doctors tell them that their own fears may be causing their physical symptoms.

Patients with these disorders also continue to seek the opinions of additional doctors in an
attempt to rule out (or perhaps confirm) disease and are more likely to demand unnecessary medical
treatments. Despite numerous assurances that they are healthy, they remain unconvinced.

Not all worries about illness warrant a diagnosis of hypochondriasis. Some people suffer from
transient hypochondriasis, which may result from contracting an actual acute illness or a life-
threatening illness, or even from caring for someone with a medical condition. Someone recovering
from a heart attack may be reluctant to engage in physical activities, even though the physician has
approved them.