Somatoform

Symptom and
Related Disorders

DSM-5-TR
Diagnoses
● The reconceptualized diagnoses, based on a reorganization of DSM-IV somatoform
disorder diagnoses, are more useful for primary care and other medical (nonpsychiatric)
clinicians.
● The major diagnosis in this diagnostic class, somatic symptom disorder, emphasizes
diagnosis made on the basis of the presence of symptoms and signs (distressing somatic
symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms)
rather than the absence of a medical explanation for somatic symptoms.
● A distinctive characteristic of many individuals with somatic symptom disorder is not the
somatic symptoms per se, but instead the way they present and interpret them.
● Incorporating affective, cognitive, and behavioral components into the criteria for
somatic symptom disorder provides a more comprehensive and accurate reflection of the
true clinical picture than can be achieved by assessing the somatic complaints alone.
DSM-IV v/s DSM-5
● The DSM-IV term somatoform disorders was confusing and was replaced by somatic
symptom and related disorders. In DSM-IV there was a great deal of overlap across
the somatoform disorders and a lack of clarity about the boundaries of diagnoses.
● The current DSM-5 classification recognizes this overlap by reducing the total
number of disorders as well as their subcategories.
● The previous criteria overemphasized the centrality of symptoms being unexplained
by recognized pathophysiological processes.
● Such symptoms are present to various degrees, particularly in functional neurological
symptom disorder, but somatic symptom disorders can also accompany recognized
medical conditions (i.e., those disorders related to clearly recognized
pathophysiological processes).
DSM-5 Classification
● The DSM-5 classification defines the major diagnosis, somatic symptom disorder, on
the basis of positive symptoms (distressing somatic symptoms plus abnormal
thoughts, feelings, and behaviors in response to these symptoms).
● In functional neurological symptom disorder and pseudocyesis (other specified
somatic symptom and related disorder), the emphasis is on demonstrating clinical
evidence of incompatibility with recognized pathophysiological processes.
● There is also considerable medical comorbidity among individuals with somatic
symptom and related disorders.
● Although somatic symptoms are frequently associated with psychological distress
and psychopathology, some somatic symptom and related disorders can arise
spontaneously, and their causes can remain obscure.
Causes
● genetic and biological vulnerability (e.g., increased sensitivity to pain),
● early traumatic experiences (e.g., violence, abuse, deprivation),
● medical iatrogenesis (e.g., reinforcement of the sick role, excessive referrals and
diagnostic testing),
● learning (e.g., lack of reinforcement of non-somatic expressions of distress),
● sociocultural norms that minimize or stigmatize psychological suffering as compared
with physical suffering.
Somatic Symptom Disorder v/s Illness Anxiety Disorder

● Somatic symptom disorder and illness anxiety disorder offer more clinically useful methods of
characterizing individuals who may have been considered in the past for a diagnosis of somatization
disorder and hypochondriasis.
● Furthermore, approximately two-thirds to three-fourths of individuals previously diagnosed with
hypochondriasis are subsumed under the diagnosis of somatic symptom disorder.
● However, the remaining one-quarter to one-third of individuals with previously diagnosed
hypochondriasis have high health anxiety in the absence of somatic symptoms, and many such
individuals’ symptoms would not qualify for an anxiety disorder diagnosis.
● The DSM-5 diagnosis of illness anxiety disorder is for this latter group of individuals.
● Illness anxiety disorder can be considered either a somatic symptom and related disorder or an anxiety
disorder.
● Because of the strong focus on somatic concerns, and because illness anxiety disorder is most often
encountered in medical settings, for utility it is listed with the somatic symptom and related disorders.
DSM-5-TR Classification
● F45.1 Somatic Symptom Disorder ● F54 Psychological Factors Affecting Other Medical
○ Specify if: With predominant pain Conditions (364)
○ Specify if: Persistent ○ Specify current severity: Mild, Moderate, Severe,
○ Specify current severity: Mild, Moderate, Severe Extreme
● F45.21 Illness Anxiety Disorder ● ___.__ Factitious Disorder
○ Specify whether: Care-seeking type, Care-avoidant ○ Specify: Single episode, Recurrent episodes
type ○ F68.10 Factitious Disorder Imposed on Self
● ___.__ Functional Neurological Symptom Disorder ○ F68.A Factitious Disorder Imposed on Another
(Conversion Disorder) ● F45.8 Other Specified Somatic Symptom and Related
○ Specify if: Acute episode, Persistent Disorder
○ Specify if: With psychological stressor (specify ● F45.9 Unspecified Somatic Symptom and Related Disorder
stressor), Without psychological stressor
○ Specify symptom type:
■ F44.4 With weakness or paralysis
■ F44.4 With abnormal movement
■ F44.4 With swallowing symptoms
■ F44.4 With speech symptom
■ F44.5 With attacks or seizures
■ F44.6 With anesthesia or sensory loss
■ F44.6 With special sensory symptom
■ F44.7 With mixed symptoms
Somatic Symptom Disorder
A. One or more somatic symptoms that are distressing or result in significant disruption
of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or
associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s
symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
A. Although any one somatic symptom may not be continuously present, the state of
being symptomatic is persistent (typically more than 6 months).
Illness Anxiety Disorder
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is
present or there is a high risk for developing a medical condition (e.g., strong family history is present), the
preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health
status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for
signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may
change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic
symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-
compulsive disorder, or delusional disorder, somatic type.
Functional Neurological Symptom Disorder (Conversion Disorder)

A. One or more symptoms of altered voluntary motor or sensory function.

B. Clinical findings provide evidence of incompatibility between the symptom and
recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or warrants medical evaluation.
Psychological Factors Affecting Other Medical Conditions

A. A medical symptom or condition (other than a mental disorder) is present.

B. Psychological or behavioral factors adversely affect the medical condition in one of the following
ways:
1. The factors have influenced the course of the medical condition as shown by a close
temporal association between the psychological factors and the development or exacerbation
of, or delayed recovery from, the medical condition.
2. The factors interfere with the treatment of the medical condition (e.g., poor adherence).
3. The factors constitute additional well-established health risks for the individual.
4. The factors influence the underlying pathophysiology, precipitating or exacerbating
symptoms or necessitating medical attention.
A. The psychological and behavioral factors in Criterion B are not better explained by another mental
disorder (e.g., panic disorder, major depressive disorder, post-traumatic stress disorder).
Factitious Disorder
Factitious Disorder Imposed on Self Factitious Disorder Imposed on Another

A. Falsification of physical or psychological (Previously Factitious Disorder by Proxy)

signs or symptoms, or induction of injury or
A. Falsification of physical or psychological signs
disease, associated with identified deception.
or symptoms, or induction of injury or disease,
B. The individual presents himself or herself to
in another, associated with identified deception.
others as ill, impaired, or injured.
B. The individual presents another individual
C. The deceptive behavior is evident even in the
(victim) to others as ill, impaired, or injured.
absence of obvious external rewards.
C. The deceptive behavior is evident even in the
D. The behavior is not better explained by
absence of obvious external rewards.
another mental disorder, such as delusional
D. The behavior is not better explained by another
disorder or another psychotic disorder.
mental disorder, such as delusional disorder or
another psychotic disorder.
Other Specified Somatic Symptom and Related Disorder
This category applies to presentations in which
symptoms characteristic of a somatic symptom and
related disorder that cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning predominate but
do not meet the full criteria for any of the disorders
in the somatic symptom and related disorders
diagnostic class.
Examples of presentations that can be specified using
the “other specified” designation include the following:
1. Brief somatic symptom disorder: Duration of
symptoms is less than 6 months.
2. Brief illness anxiety disorder: Duration of
symptoms is less than 6 months.
3. Illness anxiety disorder without excessive
health-related behaviors or maladaptive
avoidance: Criterion D for illness anxiety
disorder is not met.
4. Pseudocyesis: A false belief of being pregnant
that is associated with objective signs and
reported symptoms of pregnancy.
Unspecified Somatic Symptom and Related Disorder

This category applies to presentations in which symptoms characteristic of a somatic

symptom and related disorder that cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning predominate but do not meet
the full criteria for any of the disorders in the somatic symptom and related disorders
diagnostic class. The unspecified somatic symptom and related disorder category should
not be used unless there are decidedly unusual situations where there is insufficient
information to make a more specific diagnosis.
 ICD-10 neurotic, stress-related and
somatoform disorders was split into
five ICD-11 diagnostic groupings:
● anxiety and fear-related disorders;
ICD 11 CDDR ● obsessive-compulsive and related
disorders;
Clinical descriptions and diagnostic ● disorders specifically associated
requirements for ICD-11 mental, with stress;
behavioural and neurodevelopmental ● dissociative disorders; and
disorders ● Bodily distress disorders.
6B23 Hypochondriasis (health anxiety disorder)
● Classified under ‘Obsessive-compulsive and related disorders’

Essential (required) features

● Persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-
threatening illnesses is required for diagnosis.
● The preoccupation is accompanied by either:
○ repetitive and excessive health-related behaviours, such as repeatedly checking of the body for evidence of illness, spending inordinate
amounts of time searching for information about the feared illness or repeatedly seeking reassurance (e.g. arranging multiple medical
consultations); or
○ maladaptive avoidance behaviour related to health (e.g. avoiding medical appointments).
● The symptoms result in significant distress or significant impairment in personal, family, social, educational,
occupational or other important areas of functioning. If functioning is maintained, it is only through significant
additional effort.

Specify level of insight:

● 6B23.0 Hypochondriasis with fair to good insight
● 6B23.1 Hypochondriasis with poor to absent insight
● 6B23.Z Hypochondriasis, unspecified
6C20 Bodily distress disorder
● Classified under Disorders of bodily distress or bodily experience
Essential (required) features
● The presence of bodily symptoms that are distressing to the individual is required for
diagnosis. Typically, this involves multiple bodily symptoms that may vary over time.
Occasionally, the focus is limited to a single symptom – usually pain or fatigue.
● Excessive attention is directed towards the symptoms, which may manifest in:
○ persistent preoccupation with the severity of the symptoms or their negative consequences – in individuals
who have an established medical condition that may be causing or contributing to the symptoms, a degree of
attention related to the symptoms that is clearly excessive in relation to the nature and severity of the medical
condition;
○ repeated contacts with health-care providers related to the bodily symptoms that are substantially in excess of
what would be considered medically necessary.
● Excessive attention to the bodily symptoms persists, despite appropriate clinical
examination and investigations or appropriate reassurance from health-care providers.
6C20 Bodily distress disorder (Contd.)
● Bodily symptoms are persistent; that is, some symptoms are present (although not necessarily
the same symptoms) on most days during a period of at least several months (e.g. 3 months
or more).
● The bodily symptoms and related distress and preoccupation result in significant impairment
in personal, family, social, educational, occupational or other important areas of functioning.
● The symptoms or the associated distress and preoccupation are not better accounted for by
another mental disorder (e.g. schizophrenia or another primary psychotic disorder, a mood
disorder, or an anxiety or fear-related disorder).
Specify level of severity:
● 6C20.0 Mild bodily distress disorder
● 6C20.1 Moderate bodily distress disorder
● 6C20.2 Severe bodily distress disorder
● 6C20.Z Bodily distress disorder, unspecified
6C21 Body integrity dysphoria
Essential (required) features
● An intense and persistent desire to become physically disabled in a significant way (e.g. a major limb
amputation, paraplegia, blindness) accompanied by persistent discomfort or intense negative feelings
about one’s current body configuration or functioning, is required for diagnosis.
● The desire to be disabled results in harmful consequences, manifested in either or both of the following:
○ attempts to actually become disabled through self-injury, which have resulted in the person putting their health or life in
significant jeopardy;
○ preoccupation with the desire to be disabled, resulting in significant impairment in personal, family, social, educational,
occupational or other important areas of functioning (e.g. avoidance of close relationships, interference with work
productivity).
● Onset of the persistent desire to be disabled occurs by early adolescence.
● The disturbance is not better accounted for by another mental disorder (e.g. schizophrenia or another
primary psychotic disorder – in which, for example, a delusional conviction that the limb belongs to
another person may be present – or factitious disorder) or by malingering.
● The symptoms or behaviours are not better accounted for by gender incongruence, by a disease of the
nervous system or by another medical condition.
6C2Y Other specified disorder of bodily distress or bodily experience

Essential (required) features

● The presentation is characterized by disturbances in the person’s experience of their body that share primary
clinical features with other disorders of bodily distress or bodily experience (e.g. distressing bodily symptoms to
which excessive attention is directed, or intense feelings of inappropriateness concerning one’s body
configuration or functioning).
● The symptoms do not fulfil the diagnostic requirements for any other disorder in the disorders of bodily distress
or bodily experience grouping.
● The symptoms are not better accounted for by another mental, behavioural or neurodevelopmental disorder (e.g.
a mood disorder, schizophrenia or another primary psychotic disorder, an eating disorder).
● The symptoms have persisted for at least several months.
● The symptoms or behaviours are not developmentally appropriate (e.g. focused on bodily changes during
puberty) or culturally sanctioned.
● The symptoms or behaviours are not accounted for by gender incongruence or by another medical condition.
● The symptoms result in significant distress or significant impairment in personal, family, social, educational,
occupational or other important areas of functioning.