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Key Features

Essentials of Diagnosis

  • Prominent physical symptoms may involve one or more organ systems and are associated with distress, impairment, or both

  • Sometimes able to correlate symptom development with psychosocial stresses

  • Combination of biogenetic and developmental patterns

General Considerations

  • This diagnostic grouping includes

    • Conversion disorder (functional neurologic disorder)

    • Somatic symptom disorder (hypochondriasis)

    • Somatization disorder

    • Pain disorder secondary to psychological factors

  • Vulnerability in an organ system and exposure to family members with somatization problems are thought to interact in the development of symptoms

  • Clinicians should suspect psychiatric disorders in several somatic conditions

    • 45% of patients describing palpitations had lifetime psychiatric diagnoses

    • Similarly, 33–44% of patients undergoing coronary angiography for chest pain but have negative results have been found to have panic disorder


  • Conversion disorder is more common in lower socioeconomic classes and certain cultures

  • Somatic symptom disorder usually occurs before age 30 and is ten times more common in women

    • There is a significant relationship (20%) to a lifetime history of panic-agoraphobia depression

Clinical Findings

Symptoms and Signs

  • A precipitating emotional event often precedes somatic symptoms

  • Conversion disorder

    • Psychic conflict is converted into physical neurologic symptoms

    • The somatic symptom is often paralysis

    • The dysfunction may have symbolic meaning (eg, arm paralysis in marked anger so the individual cannot use the arm to strike someone)

  • Somatic symptom disorder

    • One or more somatic symptoms are associated with significant distress or disability

    • Symptoms are associated with disproportionate and persistent thoughts about the seriousness of the symptoms, a high level of anxiety about health, or excessive time and energy devoted to symptoms

    • Anxiety, panic disorder, and depression are often present

    • Preoccupation with medical and surgical issues often precludes other life activities

    • Patients have often undergone multiple surgeries and have evidence of long-standing symptoms

    • Multiple symptoms that frequently change and have eluded diagnosis by three or more physicians support this diagnosis

Differential Diagnosis

  • Depression must be considered in any patient with a condition judged to be somatoform

  • Factitious disorders, which differ from this grouping in that symptom production is intentional

  • Intoxication states

  • Disorders with unusual presentations (eg, multiple sclerosis, systemic lupus erythematosus)


Diagnostic Procedures

  • In conversion disorder with psychogenic nonepileptic seizures (pseudoseizures), video-electroencephalography may be necessary to rule out epilepsy

  • Since all somatic disorders are diagnoses of exclusion, a workup sufficient to rule out physical illness is required



  • Medications should not be prescribed in place of frequent appointments

Therapeutic Procedures

  • Behavioral ...

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