D, a 10-year-old boy, presented with deteriorating vision but no medical cause was found. During the consultation, it was revealed he lived with a stepfather he did not like and had family relationship issues. After discussing his difficult family situation, D reported that his vision had returned to normal. This suggests he may have been experiencing a somatoform disorder where psychological or emotional factors were affecting his physical symptoms.

1. Case example
• D, a ten-year-old, arrived in the eye clinic complaining his
vision was deteriorating. He was a bright boy and his family
looked worried. He had thorough medical assessments, and
was found to have reduced distance vision (6/18 in both
eyes). No medical cause for this sight loss was found.
1
• He attended the eye clinic with his mother and father. It
transpired his parents were divorced and had remarried. D
lived with the stepfather he did not care for, and a new baby
half-sister. Towards the end of the consultation, the mother
volunteered that her father had a neurological disease. On
airing these difficult emotional issues, D then said “I see
better”. He left the clinic with his vision normal and age-
appropriate.

2. By: Ismah Haron
2
• Somatoform disorder
- Pain disorder
- Undifferentiated somatoform disorder
- Somatoform disorder not otherwise
specific (NOS)
• Psychosomatic disorder
OUTLINE

3. PAIN DISORDER
• Definition:
Preoccupation with pain in the absence of
physical disease. The pain doesn’t follow a
neuroanatomic distribution. [1]
• Epidemiology:
1 month prevalence is 0.15-1.26%, >Female [2]
3

4. Etiology
behavioral
interpersonal
biological
psychodynamics
4
Pain  can escape
from dislike activity
Pain  stabilize
relationship
Pain threshold
Emotional pain 
body pain

5. DSM IV diagnostic criteria for pain disorder
A. Pain in one or more anatomical sites is the predominant
focus of the clinical presentation and is of sufficient
severity to warrant clinical attention
B. The pain causes clinically significant distress or impairment
in social, occupational, or other important areas of
functioning.
C. Psychological factors are judged to have an important
role in the onset, severity, exacerbation, or maintenance
of the pain.
D. The symptom or deficit is not intentionally produced or
feigned.
E. The pain is not better accounted for by a Mood, Anxiety,
or Psychotic Disorder and does not meet criteria for
Dyspareunia.
5

6. •Antidepressant
•Analgesia
Biological
•Psychoeducation
•Cognitive
behavioral
therapy
•Massage
Psychosocial
6
Treatment:

7. UNDIFFERENTIATED SOMATOFORM DISORDER
7
D
S
M
I
V

8. SOMATOFORM DISORDER NOS
• Cannot be classified in any category
• Duration is <6 months
• Examples:
- Pseudocyesis
- Fatigue or body weakness in less than 6 months and
not due to other mental illness
8

9. PSYCHOSOMATIC DISORDER
Definition
Prevalence
Classification
Diagnosis
Etiology
Treatment
9
1. Psychological
factor  medical
condition
2. Physical illness 
emotional/ mental
disorder
Psyche (mind)
& Soma (body)
12.5% [3]

10. Physical condition affected by psychological factors
10
• Hypertension
- Psychological theories: inhibit anger, guilt
over hostile impulse, need to gain approval
from authority
- Acute stress, chronic stress
- Hormonal changes

11. Medical problems that present with psychiatric symptoms
Disease Psychiatric symptoms Impaired
performance and
behavior
AIDS • Depression
• Anxiety
Dementia
Hypothyroidism • Thought disorder
• Somatic delusion
• Hallucinations
Myxedema madness;
• Delusional
• Paranoid
• Aggressive
behavior
Pheochromocytoma • Anxiety
• Panic
• Trembling
Inability to function
during attack
11

12. Diagnosis
12
DSM IV criteria for psychological factor
affecting medical condition:

13. • Examples:
- MDD delaying recovery from MI
- Anxiety exacerbating asthma
- Pathological denial of the need of surgery in
cancer patient
- Stress related exacerbation of ulcer
13

14. Etiology
14
A. Stress factors
 Prolonged
stress +
organ that
genetically
vulnerable to
stress
B. Neurotransmitter
response
 Catecolamines,
serotonin,
dopamine
C. Endocrine
response
 Cortisol
D. Immune response
 Cytokines 
increase
glucocorticoids
E. Physiological
factors
 General
adaption
syndrome;
stress affect
HPA axis

15. Treatment
• Collaborative approach
• Biological
• Psychosocial
- Supportive psychotherapy
- Dynamic insight oriented psychotherapy
- Group therapy
- Family therapy
- Cognitive behavioral therapy
15

16. Case example
• D, a ten-year-old, arrived in the eye clinic complaining his
vision was deteriorating. He was a bright boy and his family
looked worried. He had thorough medical assessments, and
was found to have reduced distance vision (6/18 in both
eyes). No medical cause for this sight loss was found.
16
• He attended the eye clinic with his mother and father. It
transpired his parents were divorced and had remarried. D
lived with the stepfather he did not care for, and a new baby
half-sister. Towards the end of the consultation, the mother
volunteered that her father had a neurological disease. On
airing these difficult emotional issues, D then said “I see
better”. He left the clinic with his vision normal and age-
appropriate.

17. SUMMARY
• Pain disorder
- Preoccupation with pain in the absence of physical
disease.
- Treatment
• Undifferentiated somatoform disorder (≥6 months)
vs. somatoform disorder NOS (<6 months)
• Psychosomatic disorder
- Mind & body
17
Biological
Psychosocial

18. THANK YOU
References:
1. KAPLAN & SADOCK; Pocket Handbook of Clinical Psychiatry 5th Edition
2. LIU, L., BI, B., QIN, X., WEI, S., WANG, W., LI, Y., JIN, Q., AI, L., PHILLIPS, M. R.
& DONG, G. 2012. The prevalence of somatoform disorders in internal
medicine outpatient departments of 23 general hospitals in Shenyang,
China. General Hospital Psychiatry
3. HIDAYAT, D., INGKIRIWANG, E., ANDRI, A., ASNAWI, E., WIDYA, R. S. &
SUSANTO, D. H. 2011. The Usage of Two Minutes Method (M2M) to
Determine Mental Disorder Prevalence in Primary Care. Journal of the
Indonesian Medical Association, 60.
4. DSM IV TR
18