Mental Disorders >> Somatoform Disorders

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Somatoform Disorders
M. S. Ahluwalia

Psychopathology

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Psychopathology >> Somatoform Disorders >> Contents
Contents
1. Introduction to Somatoform Disorders
2. Types & Prevalence (Epidemiology)
3. Symptoms & Case Studies
4. Aetiology (Causes)
5. Treatment
10

Psychopathology >> Somatoform Disorders >> Introduction to Somatoform Disorders
11
Somatoform
Disorders
A group of disorders where the person reports physical complaints characteristic of
bodily dysfunction. But, investigation usually fails to elicit any actual physical defect
• There is a stressful situation which is not responded to by overt expression of anxiety. The overt
anxieties are replaced by physical symptoms.
• There is an attempt on the part of the person to escape the unpleasant stressful situation by using a
particular intrapsychic mechanism.
• There is a dramatic expression of the symptoms. But one must not presuppose that these people are
necessarily faking or ‘malingering’. The dramatization occurs at a level below the consciousness, and
the person, at her conscious level actually feels only whatever she reports. This process makes it a
challenge for the mental health professional to differentiate Somatoform Disorders from Malingering
and intentional falsification.
• While in children the symptoms are often transient, in adults these disorders may take a chronic
and disabling form.
• Examples:
• Children in junior schools frequently develop symptoms like stomach ache and nausea in response
to academic or interpersonal stress.
• It is common for some people to faint whenever they encounter any stress.
Malingering
It refers to the deliberate imitation of the symptoms of a physical or psychological
disease by an individual with the purpose of gaining some practical advantage.

Contents
5. Treatment
12

Psychopathology >> Somatoform Disorders >> Types & Prevalence
2. Types & Prevalence
13
1
Somatization
Disorder
• It usually
begins in
adolescence.
• It is more
common in
lower socio-
economic class
• It is more
common in
women.
• Lifetime
prevalence is
0.2%-2% in
women and
0.2% in men.
2
Pain Disorder
• Prevalence in
general
population is
not known.
• It is seen more
often in
women.
3
Hypochondriasis
• It is the most
commonly
seen
Somatoform
disorder -
present in 2-7%
of the general
population.
• It often starts
in early
adulthood
• It is equal in
both sexes.
4
Conversion Disorder
• It was quite common at
one time, but with
knowledge of how this
disorder works and with
the psychological
sophistication of the
general population, its
prevalence has come
down to less than .005%
of the population.
• It is rare in the urban
educated group, and
seen more in the rural
and low socio-economic
status groups where
knowledge of
conversion as a
defence is not
available.
• It is seen more in
women.
5
Body
Dysmorphic
Disorder
• The exact
prevalence is
not known as
many of us
may have slight
preoccupation
with body parts.
• An estimated 2-
5% of general
population
may have
crossed the
limit of normal
preoccupation.
• It is equal
across both
sexes.
Major Types of Somatoform Disorders and their Epidemiology (Prevalence)

Contents
5. Treatment
14

Psychopathology >> Somatoform Disorders >> Symptoms & Case Studies
3.1. Somatisation Disorder - Symptoms
• Somatisation disorder is recognized by the presence of multiple physical symptoms at
different locations of the body.
• DSM IV –TR mandates that that it must begin before 30 years of age.
• There must be:
− at least 4 pain symptoms in different sites of the body (like head, neck, back etc.),
− at least 2 gastrointestinal symptoms (like diarrhoea, nausea etc.),
− 1 sexual symptom other than pain (like erectile dysfunction, lack of desire), and,
− 1 pseudoneurological symptom (like fainting).
• Adequate medical investigation must have been made to exclude all known organic origin
of the symptoms.
• The symptoms of Somatisation disorder are vague.
• The person often goes for doctor shopping and frequent hospitalisation. Sometimes as a
result of unwarranted faulty treatment and invasive interventions, actual physical
symptoms may occur to complicate the issue.
• Depression and anxiety may accompany the Somatisation symptoms.
15

3.1. Somatisation Disorder – Case Study
16
Background
• Ritu is 24 years old, middle class, married woman.
• She lost her mother in her childhood and has been raised by her father.
• Before her marriage she suffered from migraine and frequent cold.
• After marriage, she encountered difficulties at her in-laws’ house. Her mother-in-law expected her to
take some household responsibilities, which she could not complete due to her frequent headaches.
• She disliked her mother-in-law and wished her dead.
• Her husband was initially supportive of her, but gradually became irritated due to her constant
complaints.
Current Issues
• Ritu became depressed and developed pain in her neck and back which prevent her from sitting
straight for long.
• Her headache has become more frequent and severe.
• She has frequent sore throats.
• She has digestion issues and often suffers from diarrhoea and nausea.
• Her hand trembles at the slightest provocation and she has fainted a few times after quarrelling
with her husband.
• Her sexual desire is on the wane and she complains of pain during intercourse.
• Her husband is very dissatisfied with the state of affairs and is contemplating divorce.

3.2. Pain Disorder
Symptoms
• Some people experience
persistent pain in certain
specific areas of the body,
even though no physical
cause can usually be
identified through
investigations.
• Even if some organic
problem is observed, it is
inadequate to explain the
stated subjective degree of
pain.
• The psychological factors
are recognized as
significant precipitator of
the pain symptom.
17
Case Study
Background
• Jai is a 17 year old manual labourer from a tribal area, working in the
city. He is the oldest of three siblings.
• His father was also a labourer but lost his job due to alcoholism. He had
often seen the plight of his mother at home.
• He stayed away from home and wandered around. He attended school
which he liked, especially because of a teacher who loved him. Jai
wanted to study and had an ambition of working in an office.
• As his father lost his job, Jai’s mother asked him to work. One of his
father’s friends arranged the same job for him. He hated leaving school,
but ultimately had to agree. He did not like the work he had to do, but
did it for six months.
Current Issues
• One day he fell from a pile of bricks and hurt his ankle. After treatment
by a doctor he recovered, but developed a pain in the back. He
attributed it to the fall and said that it had been neglected by the doctor.
• The pain increased and he had to leave the job. He saw doctors who
investigated the probable cause of pain, but nothing was found to
explain it.
• Now he sits idly at home while his younger brother goes for work.

3.3. Hypochondriasis – Symptoms
• Hypochondriasis is characterized by fear of physical disease. The
individuals suspect that they have serious diseases like cancer and
cardiac problems. However, investigations reveal that no organic
pathology is present. While normal individuals may also read some
bodily discomfort as a sign of some serious problem, the person with
hypochondriasis is quite convinced about the presence of the disease.
• As per DSM IV–TR, preoccupation with fear of contracting or
having a serious disease is the main criterion of Hypochondriasis.
The conviction is based on misinterpretation of some transitory
bodily symptom.
• Example: an individual may interpret a sore throat as the first sign of
throat cancer.
• The individual with Hypochondriasis visits the doctor often. But, the
assurances of the doctor as to the absence of any pathology do not
change their conviction. Rather they change doctor frequently and
start the investigations afresh.
• The disease they imagine is often fatal like cancer, severe cardiac
problem or HIV/AIDS.
• They often read medical bulletins, self diagnose themselves and
also try to treat themselves. The treatment modes can be magical
or semi scientific.
18
Difference between Somatisation
Disorder and Hypochondriasis
1. The severity of conviction of
a fixed diagnosis is greater in
Hypochondriasis.
2. Hypochondriasis is not
necessarily about many
disorders, but like Pain
disorder may be located in
one or two sites.

3.3. Hypochondriasis – Case Study
19
Background: Raj, 33, is an upper-middle class, educated, employed man from a metropolitan city.
Incident
• Six years back, he had an affair with a girl who later turned out to be a sophisticated prostitute. Raj
learnt it the hard way and was both heartbroken and appalled.
• He was afraid that he might have contracted HIV, and after much deliberation, consulted a doctor who
recommended blood test. He turned out to be negative, to his immediate relief.
• However, this assurance seemed to be short lived, as he didn’t permanently believe that he didn’t have
HIV. After the first test, he had a bout of severe cold which he attributed to the same undetected virus.
• Raj read plenty of information on HIV/AIDS and learnt that a positive finding on the blood test ensures
that you have HIV, but a negative finding may be misleading. He went for retesting and was again
found negative.
Current Issues
• Now Raj interprets every little stomach upset and feverish feeling as indicative of HIV.
• He spends the whole evening scrutinizing his body looking for swollen glands and skin rashes.
• He goes to doctors for every small ailment, though he doesn’t always reveal his suspicion about HIV.
• He insists on being treated with strong antibiotics as he believes that he has low immunity.
• He rejects the doctors who prefer to treat with lesser medicines or recommend natural cure.

3.4. Conversion Disorder – Symptoms (1/2)
20
Hysteria
• The word hysteria comes from the Greek
word ‘hysteros’ which means the womb. It
was wrongly believed at one time that
hysteria occurs only in women because of
their suppressed sexual desire.
• The most common symptom was fainting or
paralysis of the limbs under psychosocial
duress.
• Sigmund Freud’s concept of the unconscious
emerged from his treating of patients with
hysteria. His patient Anna O, a young lady
with paralysis, has been famous in the history
of Psychology and Psychoanalysis for being
key to Freud’s understanding of the nature of
the unconscious.
• Presently, the word hysteria is no more in
scientific use. Conversion disorder is the term
that comes closest to hysteria.
Conversion Disorder
• In Conversion disorder the person suffers
from a real disability – often loss of a sensory
or voluntary motor function.
• DSM IV –TR states that the symptoms would
imply a neurological condition. However,
medical examination would reveal no
neurological problem.
• Examples of conversion: partial paralysis,
blindness, deafness and pseudo-seizures.
• DSM IV–TR further states that psychological
factors should be judged to be associated
with the symptom, as these symptoms often
develop after severe conflict or other
stressors.

3.4. Conversion Disorder – Symptoms (2/2)
21
Conversion Disorder vs. Real Neurological Problems
Even though neurological investigation can establish the existence of the disorder, it
is important to be aware of the signs that distinguish Conversion Disorder from
real neurological problems, because our knowledge of brain functioning is limited,
and it is possible that some indication may have been missed in the physical tests.
Therefore, the clinician must cross check the diagnosis with functional signs.
1. Conversion symptoms are often preceded by a stressor, though the person is
unaware of it and even denies any connection.
2.Symptoms may be in contradiction to the expected neurological situation.
Example: in ‘glove anesthesia’, the person feels her hands numbed up to the wrist,
while the nerves run up to the arm, and any true neurological problem would affect
the entire nerve. This may be induced by hypnosis.
3. There seems to be a peculiar lack of concern and anxiety that should have
happened in case of a real loss of function. A blind person seems unconcerned
about his sudden loss of vision. This is known as ‘la belle indifference’.
4. The paralysis may be selective in time and space. A person with a paralysed leg
may be able to move the legs during sleep.
La Belle
Indifference
A state of mind in Conversion Disorder where the person has lost some sensory or motor
function suddenly, but the affective reaction to this loss is not as intense as it should
be. Rather a kind of indifference is observed.

3.4. Conversion Disorder – Case Study
22
Background:
• 27 year old Amit is from a middle class family. He worked with a government undertaking as a
supervisor responsible for the loading and unloading of goods by the workers.
Incident
• Once when he was on the factory floor an accident happened, wounding many workers.
• Amit was also hurt in the face and on the head and became unconscious.
• He was treated duly and declared fit by the Medical Board of the Company.
Current Issues
• A few days after the accident, Amit started telling that he had become blind.
• He was tested thoroughly by the doctors who declared that there is nothing wrong either in the
peripheral (at the level of the eyes) or central (in the brain) mechanisms of his vision.
• Amit sticks to his claim, and considers himself unfit to do his job.
• He walks with the help of his mother and has to take her help in all matters like finding the shirt and
helping him to eat.
• He stays at his home and spends time in front of the TV saying that he cannot see, but he can listen to
the music and conversations and he enjoys that.
• He wants compensation for his disability and is planning to sue against the Company.

3.5. Body Dysmorphic Disorder
Symptoms
• Body Dysmorphic Disorder refers to an
undue concern over body features.
• As per DSM IV –TR, it is defined as an un-
necessary preoccupation with an imagined
or exaggerated defect in appearance.
• This imagined defect may be anywhere
example nose is big, ears are small, skin has
blemishes, shape of the breasts or genitalia is
not good, limbs are too fat or too thin, etc.
• Sometimes there may be a slight anomaly
or lack of proportion in real, but in the
person’s judgment it has been magnified many
times.
• A person with BDD often sees oneself in the
mirror and asks others for opinion about the
slightest change in that part. However these
assurances don’t reassure them.
• The person also tries to hide the defect under
heavy make up or other accessories, or with
plastic surgery. Unfortunately even plastic
surgery may not always satisfy the person.
23
Case Study
• 20 year old Razia believes that she has - ‘too flat bone
of nose’. She is introvert and immensely soft spoken,
particularly because she doen’t want to draw
anybody’s attention to her ‘ugly nose’. She cannot
speak to anybody spontaneously as she feels that
everybody is looking at her nose and suppressing a
big laugh.
• She looks at the mirror many times a day, and tries to
pull her nose bone up. Sometimes, she covers her nose
with her palm to evaluate her beauty minus the nose.
• Her parents have told her many times that her nose is
well within the normal range of sizes, but she is
inconsolable. She confided the problem to a friend who
also assured her, but to no avail.
• She places her palm on the nose while conversing with
anybody, which makes it difficult for other people to
hear her. This makes her a poor socializer, which in
turn further reduces her self esteem and adds to her
distress.
• She is thinking of visiting a plastic surgeon for remedy,
but knows that she cannot afford the cost.

Contents
5. Treatment
24

Psychopathology >> Somatoform Disorders >> Aetiology
4. Somatoform Disorders – Aetiology
25
Causes of
Somatoform
Disorders
1
Biological Factors .
2
Psychological Factors
2.1
Psychoanalytical
Approach
2.2
Behavioural Approach
2.3
Cognitive Approach
2.4
Vulnerable Personality
and Life Events
1. Biological Factors
• As per the present knowledge
biological factors, are of less
significance than psychological
factors in the aetiology of
Somatoform disorders.
• There has been some overlap
between OCD and Body
Dysmorphic disorder, implying
possible common genetic
disposition.
• However, twin studies have not
been able to provide strong
biological evidence till date.
• At best a vulnerable personality
may have been inherited.

4.2.1. Psychoanalytical Approach (1/2)
26
The concept of unconscious conflict and gain forms the base of psychoanalytical approach. Psychic
pain and distress is projected onto the body for the purpose of some kind of advantage.
Punitive forces of
the ego
Unacceptable
Desire
Guilt, Stress,
Conflict
Primary Gain Secondary Gain
Somatoform
Disorder
Escape from the
conflict by projecting
the stress on the
body
Attention, escape
from work, financial
advantage

4.2.1. Psychoanalytical Approach (2/2)
27
• Conversion Disorder and some instances of Hypochondriasis can be explained by this view.
• While it offers similar explanation for the other Somatoform disorders, however, it fails to explain the
content of Somatisation and Pain disorders, i.e., why do these affect certain specific body parts.
Primary Gain
• The primary unconscious purpose that is served by the disorder –
it helps to protect and maintain the integrity of ego in the face
of a stressful situation.
• When an unacceptable sexual or aggressive impulse attempts to
burst out, the ego is under threat of disruption. To maintain control,
it may use repression, whereby the emotion is disowned and an
escape or a punishment may be arranged by projecting a
physical symptom (sensory/motor disability) onto the body.
• Example: a girl had to stay homebound for long due to her father’s
terminal illness. When her father expired she was free to move
around at will. The realization that she was happy at her father’s
death caused strong guilt in her. Next morning, she could not move
her leg. She was paralyzed. This had two advantages:
1. By being immobilized, she could not go out, so her need for
acknowledging the unacceptable emotion was prevented
2. She could inflict upon herself a punishment for the guilt by not
being able to move at all.
Secondary Gain
• It refers to the interpersonal, social
or material advantage accrued
later, as a result of the symptom.
• It is mostly unconscious.
• Thus, it makes the disorder more
persistent and resistant to
treatment.
• Secondary advantages as a result of
being in the ‘sick role’, may include -
being excused from obligations and
work, receiving company of their
beloved, getting special attention,
financial advantage etc.
• Example: Amit, from the case
discussed earlier, whose blindness
might earn him a fat compensation.

4.2. Psychological Factors
28
3. Cognitive Approach
• Emphasizes problems in information
processing and cognitive bias.
• Persons with Somatoform Disorder
selectively pay greater attention to
and have selectively more accurate
memory of bodily symptoms.
• They tend to consider any passing
mild symptom as catastrophic.
• As per this approach, in Conversion
disorder and Hypochondriasis the
person reflects through the
disorders only what she knows and
expects in a particular disorder.
Example: in ‘glove anaesthesia’, lack
of knowledge about the nerves
running through the hand is crucial.
• Thus, these two disorders come very
close to deliberate malingering.
However, most researchers agree
that there is real difference of these
diseases from malingering per se.
4. Vulnerable Personality
and Life Events
• Persons who are more
suggestible or have labile
emotions are more
vulnerable to certain types of
Somatoform disorders, like
Conversion disorder.
• Obsessive predisposition
overlaps with
Hypochondriasis and Body
Dysmorphic Disorder.
• Often the person with
vulnerable personality
encounters some traumatic
or stressful event and the
disorder ensues as a result
of the interaction.
2. Behavioral Approach
• Emphasizes conditioning and
modelling.
• In the childhood of the patient and
in his/her immediate environment,
the sick role has been reinforced
in various ways.
• They might have been excused
from heavy work or attention had
been showered on them. The
concept of secondary gain is, thus,
used in a different language by the
learning theorists.
• In Hypochondriasis and Pain
disorders there may have been a
patient in the family who actually
suffered from that disease. Ex:
seeing a cancer patient at home
may predispose one to believe that
she too is suffering from cancer.
• Thus imitation and modelling
seems to play a role.

Contents
5. Treatment
29

Psychopathology >> Somatoform Disorders >> Treatment
5. Somatoform Disorders Treatment
30
Treatment of
Somatoform
Disorders
Somatisation
Disorder
1
Supportive Therapy
2
Cognitive Therapy
Conversion Disorder
1
Psychoanalysis and
Hypnotic Therapy
2
Cognitive Behavioral
Therapy
Hypochondriasis,
Body, Dysmorphic
Disorder, and Pain
Disorder
1
Pharmacology
2
Cognitive Behavioral
Therapy

5.1. Somatisation Disorder Treatment
31
• Treatment of Somatisation disorder is difficult as the patient focuses on
multiple loci of discomfort.
• 1. Supportive Therapy:
• Moderately effective treatment
• Try to find a physician whom the person can visit regularly. The
physician would check the client for the complaints but would not
unnecessarily engage her in expensive investigations.
• 2. Cognitive Therapy may be used for dealing with the secondary
gain
• Evidence suggests that over long time the physical complaints subside
to some extent.

5.2. Conversion Disorder Treatment
32
2. Cognitive Behavioral Therapy for
Conversion Disorder
• Behavioral Aspect:
• Non-reinforcement of sick role
and reinforcement of normal
movement/ sensation may be
helpful in some cases.
• Cognitive Aspect:
• Cognitive restructuring approach to
challenge secondary gains.
• Try to enhance coping skills and
cognitive restructuring of the self.
1. Psychoanalysis and Hypnotic Therapy
• Traditionally been used with
Conversion Disorder
• Directed towards unravelling the
unconscious conflict
In many cases of Conversion Disorder - spontaneous recovery occurs
after a certain period, when the primary gain has served its function.

5.3. Hypochondriasis, Body Dysmorphic Disorder
and Pain Disorder Treatment
33
2. Cognitive Behavioral Therapy
• Behavioural Aspect:
• Take help of the family for:
• Withdrawal of reinforcement of unwanted
behaviour, and
• Introduction of reinforcing of desired
behaviour.
• Constant checking for bodily symptoms may be
stopped through behavioural instruction.
• Cognitive Aspect:
• focus on the selective attention and cognitive
bias toward specific bodily symptoms.
• The belief about illness and utility of sick role
may be challenged.
• Point out the misinterpretation, especially the
tendency to catastrophize the bodily symptoms.
1. Pharmacology
Antidepressant medicine may be of
moderate help in most cases of
Hypochondriasis, BDD and pain disorder.

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