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Seven somatoform disorders are listed in the revised fourth edition of the Diagnostic

and Statistical Manual of Mental Disorders (DSM-IV-TR): (1) somatization disorder,


characterized by many physical complaints affecting many organ systems; (2)
conversion disorder, characterized by one or two neurological complaints; (3)
hypochondriasis, characterized less by a focus on symptoms than by patients'
beliefs that they have a specific disease; (4) body dysmorphic disorder,
characterized by a false belief or exaggerated perception that a body part is
defective; (5) pain disorder, characterized by symptoms of pain that are either
solely related to, or significantly exacerbated by, psychological factors; (6)
undifferentiated somatoform disorder, which includes somatoform disorders not
otherwise described that have been present for 6 months or longer; and (7)
somatoform disorder not otherwise specified, which is the category for somatoform
symptoms that do not meet any of the somatoform disorder diagnoses mentioned
above (Table 17-1). The term somatoform derives from the Greek soma for body,
and the somatoform disorders are a broad group of illnesses that have bodily signs
and symptoms as a major component. These disorders encompass mindbody
interactions in which the brain, in ways still not well understood, sends various
signals that impinge on the patient's awareness, indicating a serious problem in the
body. Additionally, minor or as yet undetectable changes in neurochemistry,
neurophysiology, and neuroimmunology may result from unknown mental or brain
mechanisms that cause illness. From a nosological perspective, somatoform
disorders were grouped together for the first time in 1980 in the third edition of
DSM (DSM-III) as those disorders in which bodily sensations or functions, as the
patient's predominant focus, are influenced by a disorder of the mind. This
clustering was not based on theoretical construct or laboratory findings. In fact,
physical and laboratory examinations persistently fail to show significant
substantiating data about the patient's complaints, which, nevertheless, are
vigorous and sincere. Patients with somatoform disorders are convinced that their
suffering comes from some type of presumably undetected and untreated bodily
derangement. As Charles Beard stated about neurasthenia in 1881: The complaints
are not imaginary. The modern physician who dismisses his or her patient with the
statement that the complaint is imaginary does a disservice to both the patient and
the profession.
Somatization Disorder Somatization disorder is an illness of multiple somatic
complaints in multiple organ systems that occurs over a period of several years and
results in significant impairment or treatment seeking, or both. Somatization
disorder is the prototypic somatoform disorder and has the best evidence of any of
the somatoform disorders for being a stable and reliably measured entity over many
years in individuals with the disorder. Somatization disorder differs from other
somatoform disorders because of the multiplicity of the complaints and the multiple
organ systems (e.g., gastrointestinal and neurological) that are affected. The
disorder is chronic and is associated with significant psychological distress, impaired
social and occupational functioning, and excessive medical-help-seeking behavior.

Somatization disorder has been recognized since the time of ancient Egypt. An early
name for somatization disorder was hysteria, a condition incorrectly thought to
affect only women. (The word hysteria is derived from the Greek word for uterus,
hystera.) In the 17th century, Thomas Sydenham recognized that psychological
factors, which he called antecedent sorrows, were involved in the pathogenesis of
the symptoms. In 1859, Paul Briquet, a French physician, observed the multiplicity
of symptoms and affected organ systems and commented on the usually chronic
course of the disorder. Because of these clinical observations, the disorder was
called Briquet's syndrome until the term somatization disorder became the
standard in the United States.
Epidemiology The lifetime prevalence of somatization disorder in the general
population is estimated to be 0.2 percent to 2 percent in women and 0.2 percent in
men. Women with somatization disorder outnumber men 5 to 20 times, but the
highest estimates may be because of the early tendency not to diagnose
somatization disorder in male patients. Nevertheless, it is not an uncommon
disorder. With a 5-to-1 female-to male ratio, the lifetime prevalence of somatization
disorder among women in the general population may be 1 or 2 percent. Among
patients in the offices of general practitioners and family practitioners, 5 to 10
percent may meet the diagnostic criteria for somatization disorder. The disorder is
inversely related to social position and occurs most often among patients who have
little education and low incomes. Somatization disorder is defined as beginning
before age 30; it usually begins during a person's teenage years. Several studies
have noted that somatization disorder commonly coexists with other mental
disorders. About two thirds of all patients with somatization disorder have
identifiable psychiatric symptoms, and up to half have other mental disorders.
Commonly associated personality traits or personality disorders are those
characterized by avoidant, paranoid, self-defeating, and obsessive-compulsive
features. Two disorders not seen more commonly in patients with somatization
disorder than in the general population are bipolar I disorder and substance abuse.