134 Undifferentiated Somatoform Disorder (300.82)

DSM criteria

A. one or more physical complaints (e.g. fatigue, loss of appetite, gastrointestinal or urinary complaints).

B. Either 1 or 2:after appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g. a drug of abuse, a medication)

when there is a related general medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical examination, or laboratory findings

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important area of functioning.

D. the duration of the disturbance is at least 6 months.

E. The disturbance is not better accounted for another mental disorder (e.g. another Somatoform Disorder, Sexual Dysfunction, Mood Disorder, Anxiety Disorder, Sleep Disorder, or Psychotic Disorder).

F. The symptom is not intentionally produced or feigned (as in Fictitious Disorder or Malingering).

Associated Features

The symptoms of this disorder vary from person to person. The most common symptoms associated with this disorder are mostly physical complaints. These include:

• pain
• fatigue
• appetite loss
• various gastrointestinal problems

The characteristic that defines this disorder is that although the person complains, no evidence can be found that these physical symptoms actually exist. Even with lab test and exams by doctors, no physical signs can be supported to prove that the person actually has these symptoms.

Child vs. adult presentation

Undifferentiated somatoform disorder is more common in adults than children.

Gender and cultural differences

The highest frequency of unexplained physical complaints occurs in young women of low socioeconomic status, but such symptoms are not limited to any gender, age, or sociocultural group.

Epidemiology

Undifferentiated Somatoform Disorder is relatively common. About four to eleven percent of the population will experience this disorder at some point in their life. This disorder is also comorbid with anxiety and depression. About fifty percent of people also suffer with these comorbid disorders.

Etiology

Some people believe that in the development of Undifferentiated Somatoform Disorder, causes could include problems in the family when the person was a child. Other explanations are that the person experiences stress or depression. A final possible cause is the patient worrying about every little change or sensation their body has.

Empirically Supported Treatments

Most treatments are done via psychotherapy. These treatments focus on the stressors that cause the patient to think something is happening to their body. If the patient already suffers from depression or stress, treating this problem can help lead to making the symptoms of the disorder go away or at least subside for a while. Most treatments will try to help the person manage stress, as well as differentiate between psychological stressors and physiological pain.

Dsm5 Proposed Changes (Dsm5.org)

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder

Major Change #1: Rename Somatoform Disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders

The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism.

Major Change #2: Combine Somatization disorder, hypochondiasis, undiffereniated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD)

Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD) which emphasizes the symptoms plus the patients’ abnormal cognitions (Barsky, Lowe, Rief). The term “complex” is intended to denote that in order for this diagnosis to be made, the symptoms must be persistent and must include both somatic symptoms (criterion A) as well as cognitive distortions (criterion B).
This is a major change in the diagnostic nomenclature, and it will likely have a major impact on diagnosis. It clarifies that a diagnosis of CSSD is inappropriate in the presence of only unexplained medical symptoms. Similarly, in conditions such as irritable bowel syndrome, CSSD should not be coded unless the other criterion (criterion B—attributions, etc) is present.
It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.
The proposal is to group together these heretofore separately recognized disorders because in fact, there are 3 diverse sources suggesting considerable overlap among them.
1. A 2009 study found that 52% of physicians surveyed indicated that there was “a lot of overlap” and an additional 38% thought that there was “some overlap” across these disorders. In contrast, less than 2% of physician respondents felt that these were “distinctly different disorders (Dimsdale, Sharma, & Sharpe, unpublished).
2. There are limited data regarding overlap in clinical settings. One primary care study, for instance, found that 20% of somatization disorder patients also had hypochondriasis (Escobar, 1998). In primary care patients, somatization disorder was 5 times ( Fink et al 2004) to 20 times (Barsky et al 1992) more common in hypochondriasis patients as compared to primary care patients without hypochondriasis.
3. Treatment interventions are similar in this group of disorders. Cognitive behavior therapy (CBT) and antidepressant medications appear to be the most promising therapeutic approaches for hypochondriasis, somatization disorder, and pain disorder (Kroenke 2007; Sumathipala 2007). Although several variations of CBT have been employed, they share many elements in common. These include the identification and modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors and promote more effective coping. The literature on the use of antidepressants is more limited, but it too does not suggest any major distinctions in therapeutic response across these different disorders. In addition to these patient centered commonalities of treatment, all of these disorders benefit from specific interventions with the patient’s non-psychiatric physician (e.g. scheduling regular appointments as opposed to prn appointments, limiting testing and procedures unless clearly indicated) (Allen 2002).
A key issue is whether the guidelines for CSSD describe a valid construct and can be used reliably. A recent systematic review (Lowe, submitted for publication) shows that of all diagnostic proposals, only Somatic Symptom Disorder reflects all dimensions of current biopsychosocial models of somatization (construct validity) and goes beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated.