Chapter 15
Somatic Symptom and Related Disorders

I am sick and tired of being sick and tired. I have to work to get through the day. The doctors tell me it's all in my head. If I get agitated during an appointment, they use that as more evidence that I'm nuts. Of course I'm upset a lot—I am in pain all the time, and nobody will do nothing about it. I just don't know what to do anymore. —Ayana

Previously known as somatoform disorders, the somatic symptom and related disorders in this chapter are characterized by the presence of physical or somatic complaints; problematic thoughts, feelings, and behaviors in relation to the complaints; and resulting distress and impairment. Individuals who experience these disorders almost always present for medical care to address their very real physical experiences and distress. As many as one third to one half of medical complaints cannot be explained (Sharma & Manjula, 2013). Mergl et al. (2007) investigated prevalence rates of patients in one general health setting and found that more than one quarter met the DSM-IV-TR criteria for somatoform disorders. Despite strong evidence of symptoms in everyday practice, very few physicians diagnose these disorders (Dimsdale, 2013).

Given the focus on finding medical explanations for symptoms, individuals with distress regarding somatic concerns may only turn to professional counselors at the urging of multiple physicians and after long, frustrating, unsuccessful attempts to identify the source of their ailments. Substantial comorbidity among depressive disorders, anxiety disorders, and somatic concerns (Mergl et al., 2007; Sharma & Manjula, 2013; Tófoli, Andrade, & Fortes, 2011; Wollburg, Voigt, Braukhaus, Herzog, & Löwe, 2013) means that counselors may find themselves working with clients who experience physical distress alongside other mental health concerns. For better or worse, major changes to these disorders within the DSM-5 may increase the frequency with which medical and mental health professionals diagnose somatic symptom and related disorders (Dimsdale, 2013; Frances & Chapman, 2013).

Major Changes From DSM-IV-TR to DSM-5

The name of this chapter was changed from Somatoform Disorders in the DSM-IV-TR to Somatic Symptom and Related Disorders in the DSM-5. Extensive revisions to this section of the DSM-5 were designed to address concerns related to stigmatizing and ambiguous terminology, problematic focus on medically unexplained symptoms rather than experiences, unclear boundaries among disorders, unnecessarily complex criteria for somatization disorder, and rare use in practice despite prevalence in the general population (APA, 2013; Dimsdale, 2013). Counselors will find two new disorders in this section: somatic symptom disorder and illness anxiety disorder. These new disorders replace somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder. In addition, the category psychological factors affecting other medical conditions was moved from the Other Conditions That May Be a Focus of Clinical Attention chapter of the DSM-IV-TR, and factitious disorder was relocated from its own chapter. In all, changes to DSM-5 criteria may increase the probability that counselors diagnose these disorders.

Clients who have somatic concerns with or without co-occurring medical conditions may be diagnosed with the new somatic symptom disorder if they have both unexplained somatic symptoms and maladaptive responses to those symptoms (APA 2013; Dimsdale 2013; Sirri & Fava, 2013). This diagnosis, discussed in depth below, is intended to replace somatization disorder and undifferentiated somatoform disorder; many individuals who carried previous diagnoses of hypochondriasis and pain disorder will fall within this new diagnosis. Criteria include less emphasis on counting medically unexplained symptoms and more focus on positive symptoms in which a client experiences distressing or disruptive somatic symptoms alongside “excessive thoughts, feelings, or behaviors related to the somatic symptoms” (APA, 2013, p. 311). Although some researchers expressed valid concerns that the changes “mislabel medical illness as mental disorder” (Frances & Chapman, 2013, p. 483), others provided preliminary evidence that the new somatic symptom disorder has increased construct, descriptive, predictive, and clinical utility when compared with DSM-IV-TR nosology (Dimsdale, 2013; Voigt et al., 2012; Wollburg et al., 2013).

The APA Somatic Symptoms Disorders Work Group eliminated the diagnosis of hypochondriasis because it believed this nomenclature was stigmatizing to clients (APA, 2013). Clients who have concerns regarding meaning of physical symptoms or experiences will now be diagnosed with somatic symptom disorder (if somatic symptoms are present) or illness anxiety disorder (if no somatic symptoms are present), both new to the DSM-5. Similarly, the work group eliminated pain disorder because one cannot reliably determine whether experiences of pain are due to physical or psychological causes (APA, 2013). Clients with pain concerns may be diagnosed with somatic symptom disorder or psychological factors affecting other medical conditions. Finally, conversion disorder carries an additional title of functional neurological symptom disorder, DSM-5 criteria emphasize neurological examination and deemphasize the assumption that one will readily recognize psychological factors leading to concerns upon initial presentation (Stone et al., 2011).

Differential Diagnosis

Because the signs of somatic symptom and related disorders are medical, initial diagnostic focus must be on medical examination to determine the specific nature of the concern. DSM-5 criteria allow for the presence of diagnosable health concerns alongside distressing reactions to the concerns. Thus, primary differential diagnosis includes determination regarding (a) which medical conditions are present and (b) whether one's response to the medical concerns are in excess of what would be considered normal. For an individual who is experiencing concerns related to a significant medical diagnosis, an adjustment disorder may be more appropriate (Frances & Chapman, 2013). If one's reaction to medical concerns or symptoms is simply a culturally expected response to a situation, assignment of a V or Z code may be more appropriate.

There is substantial overlap and comorbidity among depressive disorders, anxiety disorders, and somatoform disorders. Mergl et al. (2007) suggested that depressive disorders may be overlooked in many medical settings because these disorders are masked by anxiety or somatic symptoms. In a sample of individuals in a general health setting, 11.9% met the criteria for somatoform disorder whereas only 6.1% met criteria for depressive, anxiety, and somatoform disorders; 5.3% for depressive and somatoform disorders; and 2.3% for anxiety and somatoform disorders. There is strong evidence of a cultural component to expressing anxious or depressive distress somatically (Brown & Lewis-Fernández, 2011; So, 2008; Tófoli et al., 2011). Thus, counselors should consider anxiety and depressive disorders as differential and comorbid diagnoses. Hassan and Ali (2011) found evidence that somatic and anxiety symptoms are common among individuals with substance use concerns. Finally, given evidence that somatic symptoms are a typical response to trauma, counselors should consider the possibility of PTSD as a differential diagnosis (Gupta, 2013).

Etiology and Treatment

Initially, somatoform disorders were viewed as psychodynamic responses to stressors in which an individual converted psychological concerns into physical symptoms as a way of coping or expressing distress. Today, there are various models and explanations regarding etiology of somatic symptom and related disorders, and the APA (2013) identified genetic and biological vulnerability, early traumatic experiences, learning, and cultural/social norms as likely underlying factors. Still,

Ethnographic fieldwork has long indicated the presence of a specific type of culturally mediated illness where an individual suffering from psychological issues expresses distress in the form of physical symptoms and somatic complaints, with no known organic cause. In western psychiatry, this phenomenon is commonly labeled somatization disorder. (So, 2008, p. 168)

Some argue these disorders are more likely to develop in individuals who do not have strong insight and those who fear psychiatric stigmatization (Hurwitz, 2004). So (2008) advocated for movement toward empirical, neurobiological evidence regarding somatization experiences.

Because somatic symptom and related disorders were considered quite rare, there is a relatively small body of literature regarding treatment considerations. Sharma and Manjula (2013) posited,

The basic premise of any psychological intervention in disorders with somatic symptoms is that somatization is a universal phenomenon and is a direct consequence of common psychological disorders such as anxiety or depression resulting in autonomic arousal symptoms or somatic complaints; it may be an idiom for help-seeking for severe social adversities such as poverty, domestic violence, stigma, associated with mental illness. (p. 117)

Treatment of somatic symptom disorder in primary care settings may include psychiatric consultation and intervention, reattribution therapy, problem-solving approach, and CBT (Sharma & Manjula, 2013). Among all these treatments, CBT has been found to be most effective for somatic concerns. Similarly, treatment for the DSM-IV-TR disorder hypochondriasis (now somatic symptom disorder or illness anxiety disorder) includes psychoeducation, CBT, and medication (Taylor, Asmundson, & Coons, 2005). Psychoeducation may be appropriate for responding to mild concerns and includes a focus on coping strategies, role of stress in bodily sensations, and relaxation training rather than attempts to convince clients their symptoms are not real or provide reassurance regarding medical concerns. Magariños, Zafar, Nissenson, and Blanco (2002) recommended CBT as a first-line treatment for hypochondriasis given findings that it can reduce “disease conviction, need for reassurance, time spent worrying about health, frequency of checking, global problem ratings, and general measures of anxiety and depression” (p. 15). Antidepressants, especially fluoxetine, may be helpful for primary and secondary hypochondriasis; however, providers must be alert to interpretation of side effects in this sensitive population (Magariños et al., 2002; Taylor et al., 2005).

Implications for Counselors

As with all aspects of counseling, strong therapeutic relationships are essential when working with individuals who have somatic symptom and related disorders, especially given the stigma and lack of understanding they may face by frustrated health care providers (Taylor et al., 2005). Because individuals are distressed regarding their symptoms, feeling sensitive, and, in some situations, misunderstood, clients with these concerns may be quick to discontinue treatment if they sense they are not being taken seriously (Sharma & Manjula, 2013). Magariños et al. (2002) encouraged empathy through understanding symptoms as a form of emotional communication.

Frances and Chapman (2013) expressed concerns that in developing a “wildly over-inclusive” diagnostic category, APA “opened the floodgates to the overdiagnosis of mental disorder and promote the missed diagnosis of medical disorder” (p. 483). Counselors can best serve clients in this population by ensuring they receive appropriate medical evaluation and support, remaining alert to potential harms of this diagnosis in terms of access to services, and recognizing that clients who have medically unexplained symptoms can and do develop other medical concerns (Frances & Chapman, 2013; Magariños et al., 2002). Professional counselors will need to take care when determining what types and levels of expression regarding health concerns are “excessive” and “maladaptive” enough to warrant diagnosis (Voigt, 2012).

Hurwitz (2004) suggested mental health professionals conceptualize somatic symptom concerns in three domains: disease (observable medical concerns), illness behavior (subjective experiences, consequences, and symptoms), and predicaments (psychosocial consequences). Counselors can focus interventions on illness behavior and predicaments, regardless of the medical foundations of concerns (Dimsdale, 2013). These may include cognitive, emotional, physical, behavioral, medical, and social experiences (Sharma & Manjula, 2013). For example, somatization is linked to problems such as missed time from work, health care utilization, hypervigilance in detecting and expressing symptoms, and dissatisfaction with treatment (Sharma & Manjula, 2013; Wollburg et al., 2013). The most beneficial approach for an individual with a somatic symptom disorder may be to frame services as focused on helping to cope with stress related to their medical problems (Magariños et al., 2002).

Finally, somatic concerns may be universal phenomena, and there is evidence that specific symptoms experienced vary by culture. Furthermore, symptoms may be culturally normal and expected responses (Brown & Lewis-Fernández, 2011). Somatization is quite stigmatized in Western cultures that focus on mind–body duality; however, a degree of somatization experiences are quite common in cultures in which mind–body holism are accepted and expected (So, 2008). Counselors must be careful not to stigmatize culturally specific ways of expressing distress or difficulties differentiating feelings from bodily sensations as somehow less developed or having less validity. This is particularly important given higher rates of concerns among vulnerable populations, including those with lower socioeconomic status, lower education, poor working conditions, and exposure to violence (Tófoli et al., 2011).

300.82 Somatic Symptom Disorder (F45.1)

Essential Features

Somatic symptom disorder is characterized by the presence of distressing or disruptive somatic symptoms for 6 or more months and “excessive thoughts, feelings, or behaviors related to the somatic symptoms” (APA, 2013, p. 311). These can be considered excessive based on the proportion of time spent thinking about the concern, level of anxiety surrounding the concern, or degree of time and energy devoted to the concern. Counselors may make this diagnosis for cases in which somatic symptoms are or are not medically explained.

Special Considerations

Because somatic symptom disorder is new to the DSM-5, there is limited research regarding its prevalence. Lifetime prevalence of DSM-IV-TR somatization disorder was as low as 0.13% in general settings and 1.0% in primary care settings (So, 2008), and lifetime prevalence of DSM-IV-TR undifferentiated somatoform disorder was approximately 19% (APA, 2013). Dimsdale (2013) cited evidence that prevalence rate of this new disorder may be approximately 6.7% among the general population, and presence of a major medical diagnosis did not inflate this rate. Women are more likely to be diagnosed than men, and the disorder is more common and persistent in individuals who have lower socioeconomic status, lower educational attainment, and more pronounced experiences of stressors (APA, 2013).

There is just one code for somatic symptom disorder, 300.82 (F45.1). The DSM-5 includes specifiers for with predominant pain (replaces DSM-IV-TR pain disorder) and persistent (for use with severe symptoms, marked impairment, and long duration). Counselors characterize severity as mild, moderate, or severe depending on degree of concern related to Criterion B.

300.7 Illness Anxiety Disorder (F45.21)

Essential Features

Illness anxiety disorder is characterized by a 6-month period in which an individual is preoccupied “with having or acquiring a serious illness” (APA, 2013, p. 315) even though somatic symptoms are absent or very mild. The individual has a high level of anxiety about his or her health and engages in excessive or maladaptive health-related behaviors. Those with illness anxiety disorder are more distressed about having a diagnosis than experiencing the symptoms.

Special Considerations

Approximately 25% of individuals who were previously diagnosed with hypochondriasis will meet criteria for illness anxiety disorder; the remainder may be diagnosed with somatic symptom disorder (APA, 2013; Sirri & Fava, 2013). There is little research regarding prevalence of the new disorder and characteristics of those affected, so the following is based on findings related to hypochondriasis. Prevalence of hypochondriasis ranged from 0.8% to 4.5% in primary care settings, and findings showed few demographic risk factors (Magariños et al., 2002). Although hypochondriasis is chronic for most individuals, one third experience only transient concerns. Differential diagnosis includes medical disorder, phobia of disease exposure, somatic symptoms associated with depressive and anxiety disorders, BDD, and delusional disorder (Magariños et al., 2002). The DSM-5 also includes the following differential diagnoses: adjustment disorders, somatic symptom disorder, and OCD; APA (2013) estimated that two thirds will have a comorbid mental disorder.

There is just one code for illness anxiety disorder: 300.7 (F45.21). Counselors may use specifiers to note whether an individual has care-seeking type or care-avoidant type.

300.11 Conversion Disorder (Functional Neurological Symptom Disorder) (F44._)

Essential Features

Conversion disorder, also known as functional neurological symptom disorder, is characterized by symptoms suggesting problems with voluntary motor or sensory function (e.g., paralysis, problems swallowing, speech problems, seizures) in which there is no neurological evidence for the condition. The problem cannot be explained by another concern and must lead to impairment, distress, or medical evaluation (APA, 2013).

Special Considerations

The DSM-5 criteria removed the requirement that symptoms be preceded by a psychological stressor because stressors may not be evident to or reported by clients (Stone et al., 2011). Focus on medical examination and clinical assessment becomes all the more important when making this diagnosis (Sirri & Fava, 2013; Stone et al., 2011), especially because up to 30% of those diagnosed with conversion disorder have an undetected illness (Hurwitz, 2004). The prevalence of conversion disorder is unknown; however, it appears to account for approximately 5% of neurology clinic referrals (APA, 2013). Brown and Lewis-Fernández (2011) noted that prevalence among men and women varies culturally; however, conversion disorder is consistently more common among women and those with lower socioeconomic status. It is often comorbid with dissociative, depressive, and anxiety disorders. Although there is some evidence in North America that suggests conversion disorder is of short duration, a body of literature shows longer effects in other cultural contexts (Brown & Lewis-Fernández, 2011). Persistent conversion disorder is found in just 0.002% to 0.005% of the population each year.

The ICD-9-CM code for conversion disorder is 300.11. The ICD-10-CM code (F44._) will vary based on subtype: with weakness or paralysis, with abnormal movement, with swallowing symptoms, with speech symptom, with attacks or seizures, with anesthesia or sensory loss, with special sensory symptom, or with mixed symptoms. Counselors may specify whether a client is experiencing an acute episode (less than 6 months) or persistent episode (longer than 6 months) and whether the concern is with psychological stressor (specify stressor) or without psychological stressor (APA, 2013).

316 Psychological Factors Affecting Other Medical Conditions (F54)

Essential Features

This diagnosis is used when an individual has a medical condition for which psychological or behavioral factors exacerbate symptoms, interfere with treatment, or compound risks. APA (2013) stipulated that the psychological factors cannot be another diagnosable mental disorder. Examples provided in the DSM-5 include asthma made worse by anxiety, manipulation of insulin for weight loss, or denial of need for treatment of chest pain.

Special Considerations

APA (2013) noted that prevalence for this diagnosis is unknown; psychological factors must be differentiated from cultural differences in help-seeking and may occur throughout the life span. Sirri and Fava (2013) expressed concerns regarding lack of specificity for this diagnosis and, thus, lack of clinical implications. There is one code for this disorder: 316 (F54). Clinicians may use impact on health to rate the disorder as mild, moderate, severe, or extreme.

300.19 Factitious Disorder (F68.10)

Essential Features

Factitious disorder is characterized by falsification of an illness in the absence of external rewards and other mental disorders explaining the behavior (APA, 2013). Factitious disorder may be diagnosed for individuals who present themselves as ill (factitious disorder imposed on self) as well as individuals who represent others as ill (factitious disorder imposed on another).

Special Considerations

Prevalence of factitious disorder is unknown, although it may present in about 1% of individuals in hospital settings (APA, 2013). There is just one diagnostic code for factitious disorder: 300.19 (F68.10). Clinicians can specify the diagnosis as single episode or recurrent episode. In cases in which the disorder is imposed on another, the perpetrator receives the diagnosis of factitious disorder, and the victim may be assigned an abuse diagnosis.

Case Example

Marcos is a single, 34-year-old Latino man who holds a college degree. He presented to counseling for “support and stress management” at the suggestion of his physician. Over the past year, Marcos has experienced a number of medical concerns, especially headaches and light-headedness. He sought assistance from a physician who, upon noting normal blood chemistries and metabolic functioning, prescribed migraine control medication and advised him to be careful about not going too long between meals. When the medication did not bring relief, the physician ordered a complete diagnostic workup including more extensive blood work, an MRI (magnetic resonance imagine), and a CT (computed tomography). All tests were within normal limits; however, Marcos became convinced he had an undiagnosed brain tumor or aneurism. As his work performance decreased because of the effects of the symptoms and worry regarding their implications, Marcos began spending hours each night researching his symptoms and discussing them with others. Convinced his physician did not understand his concerns, he sought a second opinion. At his insistence, the second physician referred him to a neurologist for further evaluation. The neurologist reviewed test results, completed several additional procedures, and did not detect any concerns.

Over the next few months, Marcos developed additional concerns including gastrointestinal upset, shortness of breath, and sleep disturbance. He missed more work, withdrew from family and friends, and stopped going to the gym out of concern that the exertion may not be in his best interest. At this time, his blood pressure became elevated, heightening his concern regarding the possibility of a severe underlying disorder. Referral to a gastroenterologist led to an endoscopy that was normal with the exception of slight esophageal irritation, which the specialist recommended treating with over-the-counter heartburn medication.

In the meantime, Marcos's employer became increasingly frustrated with his lack of reliable attendance and frequent distraction at work. She warned Marcos that she would need to take disciplinary action if the behaviors continued without supporting documentation from his physician. Distraught at the potential loss of health insurance, Marcos visited his physician to explore his options. During a particularly difficult visit, his physician expressed her doubts that they would ever find the “root of the concern” and advised Marcos to attend counseling to learn how to manage his symptoms and distress related to them. Although offended at the suggestion that it was “all in his head,” Marcos made the call. After all, he said, the symptoms were distressing and he was realizing he might just have to deal with a lifelong illness.

Diagnostic Questions

1. Do Marcos's presenting symptoms appear to meet the criteria for a somatic concern or related disorder? If so, which disorder?
2. Based on your answer to Question 1, which symptom(s) led you to select that diagnosis?
3. What would be the reason(s), if any, a counselor may not diagnose Marcos with that disorder?
4. Would Marcos be more accurately diagnosed with an anxiety disorder? If so, why? If not, why not?
5. What rule-outs would you consider for Marcos's case?
6. What other information may be needed to make an accurate clinical diagnosis?