This document provides an overview of somatoform disorders, including their history, conceptualization, theories, and specific disorders. It discusses somatization disorder, conversion disorder, pain disorder, hypochondriasis, and body dysmorphic disorder. It covers theories of abnormal illness behavior and deficits in cognitive processing of emotion. It also presents a signal filtering model of somatoform symptoms and explores the psychobiological theories involving the endocrine system, immune system, neurotransmitters, and brain mechanisms.

1. PSYCHOPATHOLOGY
OF SOMATOFORM
DISORDERS

2. OVERVIEW
 HISTORICAL EVOLUTION AND CURRENT CONCEPTUALISATION
 THEORIES OF SOMATOFORM DISORDER
 A SIGNAL FILTERING MODEL OF SOMATOFORM SYMPTOMS
 SOMATIZATION DISORDER
 CONVERSION DISORDER
 PAIN DISORDER
 HYPOCHONDRIASIS
 BODY DYSMORPHIC DISORDER
 FICTITIOUS DISORDER

3. HISTORY OF SOMATOFORM
DISORDERS
• Somatoform disorders are the borderland between ‘medicine and psychiatry’.
In neuroscience it is referred to as ‘body-brain interface’.
• Lipowsky (1986) stated that somatization is a tendency to experience and
express psychological distress in the form of somatic concerns.
• Kellener (1986) is of the opinion that somatization is not a single entity but they
are found in different diagnostic categories such as depression, anxiety and
somatoform disorders.

4. TERMS
Illness: It is a
subjective perception
of being unwell and
maybe unrelated to
the presence of an
objectifiable disease.
Disease: It is defined as
the presence of objective
biological abnormalities
in the structure and/or
function of the bodily
organs or system.
Sick role: A sociological
construct referring to a
role granted to an
individual by society
with accompanying
privileges and
obligations.

5. CONCEPTUALIZATION
 It is conceptualized as a process of responding to stress.
 An important concept to focus here is on somatosensory amplification where the symptoms
are experienced as intense and disturbing.
 It consists of 3 elements
(1) hypervigilance
(2) selecting out some sensations and focusing on them
(3) intensification of this by cognition and affect.

6. Somatization
disorders
clinical and public
health problem
social dysfunction
occupational
difficulties
As a masked psychiatric disorder: depression, anxiety.
Amplified personal perceptual style: as a result of a personality trait or it can be
because of abnormal psychological processing
Seeking care for emotional distress
Somatization disorder can be viewed in 3 ways

7. DIFFERENCE BETWEEN PSYCHOSOMATIC,
SOMATOFORM AND SOMATIZATION
DISORDERS
PSYCHOSOMATIC
Psychosomatic
disorders deals with the
relation between
psychological and
physiological factors in
the causation or
maintenance of disease
states
SOMATOFORM
Somatoform disorders
have in common the
presence of one or more
physical complaints for
which an adequate
physical explanation
cannot he found

8. Psychosomatic illnesses can be classified in
three general forms.
1) Mental illness
and a medical
one
2)Psychiatric
issue
3) Somatoform
disorders

9.  There is a mental aspect to every physical disease.
 There may be physical effects from mental illness.
 Some physical diseases are thought to be especially prone to be worsened by
mental factors such as anxiety and stress
 The term, 'psychosomatic disorder,' when mental factors cause physical
symptoms, but where there is no physical disease.

10. THEORIES OF SOMATOFORM
DISORDERS
1. ABNORMAL ILLNESS BEHAVIOUR
• Pillowsky defined this concept of abnormal illness behavior as the
“persistence of a maladaptive mode of experiencing, perceiving and
evaluating one’s own health status despite the fact that the doctor has
provided a lucid and accurate appraisal of the situation and
management to be followed with opportunities for discussion,
negotiation and clarification based on relevant biological, social and
cultural factors”
• Abnormal illness behavior that is somatically focused is divided into
1. ILLNESS-AFFIRMING
2.ILLNESS-DENYING

11. SOMATICALLY
FOCUSED
PSYCHOLOGIC-
ALLY FOCUSED
ILLNESS
AFFIRMING
ILLNESS
DENYING
ILNESS
AFFIRMING
ILNESS
DENYING
MOTIVATION
PREDOMINANTLY
UNCONSCIOUS
MOTIVATION
PREDOMINANTLY
CONSCIOUS
NEUROTIC PSYCHOTIC
ABNORMAL ILLNESS BEHAVIOUR

12. TABLE 1: Somatically focused abnormal
illness behavior
 A. Motivation predominantly
conscious
• Malingering
• Chronic factitious syndrome with
physical symptoms (Munchausen
syndrome)
• Factitious disorder with physical
symptoms
 B. Motivation predominantly
unconscious
• Neurotic (somatoform disorder)
• Somatization disorder
• Conversion disorder
• Somatoform pain disorder
• Hypochondriasis
• Body dysmorphic disorder
2.Hypochondriacal delusions
associated with
• Major depressive disorder with
mood congruent psychotic features
• Schizophrenic disorder
• Monosymptomatic hypochondriacal
psychoses
ILLNESS AFFRIMING

13. TABLE 2: Somatically focused abnormal
illness behavior.
 A. Motivation predominantly
conscious
• Denial to obtain employment
• Denial to avoid feared therapies
• Denial of illness (e.g.VD)due to
shame and guilt
 B. Motivation predominantly
unconscious
1.Neurotic e.g.:
• Non-compliance following
myocardial infarction
• Counterphobic behavior in
hemophilia
• Non-compliance with
antihypertensive therapy
2. Psychotic:
• Denial of somatic pathology.e.g. as
part of hypomanic or schizophrenic
disorder
3.Neuropsychiatric
• Anosognosia
ILLNESS DENYING

14. TABLE 3: Psychologically abnormal
illness behavior
ILLNESS AFFRIMING
 A. Motivation predominantly
conscious
• Malingering
• Factitious disorder with
psychological symptoms (Ganser
syndrome)
B. Motivation predominantly
unconscious
1. Neurotic
• Psychic hypochondriasis
• Phrenophobia
• Dissociative reactions
• Psychogenic amnesia
2. Psychotic
• Delusions of memory loss or loss of
brain function

15. TABLE 4: Psychologically Focused Abnormal
Illness Behavior
 A. Motivation predominantly
conscious
• Denial of psychotic symptomatology
to avoid stigma, hospital admission,
to gain discharge from care.
• Denial of psychotic illness to avoid
discrimination by health care
professionals or employers.
 B. Motivation predominantly
unconscious
• Neurotic: refusal to accept
'psychological' diagnosis or treatment
in the presence of neurotic illness,
personality disorder of dependency
syndromes (alcohol, opiates, etc.)
• Psychotic: Denial of illness ('lack of
insight') in psychotic depression,
manic states and schizophrenia
syndromes
• Neuropsychiatric: Confabulatory
reaction in Korsakoff s psychosis and
other organic brain syndromes.
ILLNESS DENYING

16.  In neurotic abnormal illness behavior the major forms of recognized patterns
are hypochondriacal reactions, and conversion reactions.
 The main difference between Hypochondriacal and conversion disorder is that
in the former the patient shows concern or worry about his/her symptoms
where in the latter the patient presents no worry or anxiety about the
symptoms and presents it blandly.
 Pilowsky maintains that abnormal illness behavior is not a diagnosis but a
disagreement between the doctor and the patient about the sick role to which
the patient feels entitled.

17. DEFICITS IN COGNITIVE
PROCESSING OF EMOTION
 An important concept of focus here is ‘Alexithymia’. This concept was coined by
Sifenos in 1973.

18.  This specific disability is due to a combination neurophysiological of and psychological defects rather
than purely psychological ones. (Sifneos,1973)
Key features of Alexithymia according to Sifneos
a relative constriction of emotional functioning
poverty of fantasy of life
inability to find appropriate words to describe their emotions
neurophysiological psychological defects

19.  According to a research carried out (Taylor,2000; Taylor, Bagby and Parker,1997) Alexithymia is a
specific disturbance in the affective-emotional processing which has 3 salient features
(a) Difficulty in identifying and describing feelings and emotions verbally
(b) Difficulty in distinguishing between feelings and somatic sensations
that accompany emotional arousal
(c) External oriented thinking and symbolic activity

20.  Because of the deficit in cognitive processing of emotions , the emotions remain undifferentiated
and poorly regulated.
 It has been hypothesized that the limited emotional awareness and cognitive processing of affects
lead to prolonged and amplifies the physiological and neurovegetative reactivity to stress which in
turn can potentially disturb the autonomic, pituitary-adrenal and immune system ( Infrasaca,1997:
Martin &Phil, 1986: Martinez-Sanchez, 1999: Papciak, Feuerstein & Spiegel, 1985)
 Alexithymia individual’s have deficit cognitive functioning which makes it difficult for them to
differentiate the emotions that they are experiencing as well as the intensity of the emotion.
 The disturbance in the cognitive processing of emotional awareness interferes with the subjects
ability to express and experience emotions.

21.  Earlier Alexithymia was seen as a psychodynamic concept which has now evolved into a
deficit in the cognitive processing of emotions. (Taylor, Bagby & Parker, 1990)
 Apart from being a concept of ‘psychosomatic’ problems alexithymia can also be a secondary
feature of any kind of psychological trauma.
PROLONGED STATES OF
EMOTIONAL AROUSAL
INCREASES LIKELIHOOD
OF DISEASES

22. PSYCHOBIOLOGICAL THEORIES
 The psychobiological theory of chronic pain proposed by Flor et.al in 1990
helps us in understanding the complex interactions between the various
systems that leads to the onset and maintenance of somatoform disorders.
 Somatoform disorders are not strictly mental events but they are associated
with a diversity of biological processes.
 Endocrine system, amino acids, immune system, neurotransmitters is involved
in the onset and maintenance of somatoform disorders.

23. SOMATOFORM SYMPTOMS AND IMMUNOLOGY
 Some immune parameters seem to be associated with the subjective feeling of being ill.
 Activation of the immune system seems to induce behavior patterns that are similar to the illness
behavior seen in depression and somatization.
 A study conducted by Danzter on rats showed that injecting the proinflammatory cytokine induced
sickness behavior in the rats such as withdrawal and reduced social activity.
IMMUNE
STIMULATION
ACTIVATES
ANALGESIA -
HYPERALGESIA
CIRCUITRY

24. AUTONOMIC PHYSIOLOGICAL AROUSAL
 Heightened physiological activity can result in somatoform symptoms. When there is an increase
in the physiological activity it can lead to a misattribution of bodily signals.
 Though it is evident that perception is largely influenced by psychological factors, physiological
activation of factors such as a variation in the heart rate can have an independent role.
 Based on this theory Pennebaker suggests that there is a direct relationship between the intensity
of physiological signals and the severity of somatoform symptoms.

25. ENDOCRINE SYSTEM
 The endocrine system, in particular the hypothalamic–pituitary–adrenal axis (HPA), is activated by stress and
also influences pain perception. Stress and pain perception are both relevant to somatoform disorders.
 Cortisol in particular was studied and it was found that distressed patients with ‘unexplained’ physical
symptoms showed a tendency for hypercortisolism.
 Cushing’s syndrome or hypercortisolism is a hormonal disorder caused by prolonged exposure of the body's
tissues to high levels of the hormone cortisol.
 Whereas another study carried out by Gaab and others confirmed normal cortisol concentrations in
somatoform-associated disorders (chronic fatigue syndrome).

26. MONOAMINO ACIDS AND NEUROTANSMITTERS
 The concentration of branched chain amino acids such as valine , leucine differs in patients with
somatoform disorders with reduced concentrations which was more pronounced in people with
somatization than depression.
 These amino acids are competing with other amino acids such as tryptophan in the blood-brain barrier.
These are relevant for energy metabolism in the muscles which might be responsible for the subjective
feeling of weakness which is one of the most common symptom of not just somatization but somatoform
associated disorders.

27. BRAIN MECHANISMS
 The conscious perception of symptoms takes place in the brain.
 Evoked potentials reflect both attention and filtering processes.
 Modern imaging techniques have been used in pain research. These include the spinal cord, brain
stem, hippocampus, amygdala It can be expected that some of these areas are involved in the
perception of somatoform symptoms.
 Attention and perception processes in somatoform disorders have been studied ( Gordon et.al,1986
James et.al; 1990). The results showed that there might be deficits in the filtering process.
 Only recently, brain imaging techniques have been used to somatoform disorders.

28. A SIGNAL FILTERING MODEL OF
SOMATOFORM SYMPTOMS
 Somatoform disorders can be understood as the disorders in the perception of bodily signals.
 A signal filtering model can be used to understand the development of the signal, filtering and processing.
 The assumption is that most body parts send sensory signals to the brain but due to the neural filtering most of the
signals are evaded from the conscious of a healthy person.
 In somatoform disorders physical sensations are perceived and interfere with planned behavior and intentional
thinking.
 Consequently, reasons for these perceptions can be either amplified sensory signals, reduced filtering capacities or
even further factors influencing the strength of the signal or the capacity of sensory filters.

29. BODILY SIGNALS FILTER
SYSTEM
CORTICAL
PERCEPTIONS
Factors increasing
physical signals
• Over arousal
• Distress
• Chronic HPA axis
stimulation.
• Physical
deconditioning.
• Sensitization and
others
Factors decreasing filter
activity
• Selective attention
• Inattention
• Health anxiety
• Depressive mood
• Lacking distractions.

30. SOMATIZATION DISORDER
 Multiple physical symptoms without clear or known physical causes are the
main feature of somatization disorder.
 This condition may last for many years and in some cases the entire adult life
span.
 DSM-IV requires at least 4 pain symptoms, 1 sexual symptom and 1 pseudo
neurological symptom to make the diagnosis.

31. CONTEMPORARY THEORETICAL
PERSEPCTIVES
 Patients with somatization disorder are considered to constitute a relatively small subset of patients with
multiple functional symptoms.
 Selective perception of and attention to somatic symptoms
 Somatosensory amplification.
 Means of communication.

32.  Self-handicapping strategy
 An important factor that contributes to the maintenance of somatic symptoms is the reinforcement of
the sick role.
 Iatrogenic factors
 Perceptual, behavioral mechanisms

33. ETIOLOGY AND COURSE
The onset of somatization disorder lies in early adulthood and the course of problem is often chronic.
 Sexual abuse and traumatization are frequently cited as precursors of somatization disorder.
 Somatization is often correlated with frequent absences from work or school, overuse of medical care
and excessive use of drugs and alcohol.

34. CONVERSION DISORDER
 Patients with conversion disorder present symptoms that suggest neurological
disorder although appropriate medical investigations fail to identify a
neurological.
 These symptoms are inconsistent with general neurological knowledge.
 A classic example is ‘ glove anesthesia’ in with the patient complains of
numbness of the hand however such sensation does not conform with the
body’s innervation pattern.
 DSM-IV describes 4 types of conversion disorder
Motor symptoms or deficits
Seizures or convulsions
Sensory symptom or deficit
A mixed presentation

35.  An important requirement for the diagnosis is the temporal relation between conversion symptoms and a
psychological stressor such as acute grief or victimization.
 Although most patients with CD express acute distress over their symptoms, some manifest an indifference or
lack of worry about their symptoms. This is called as la belle indifference.

36. CONTEMPORARY THEORETICAL PERSPECTIVE
 There are few theoretical accounts of CD that are supported by research
evidence.
 Behavioral model
 Sociocultural influences.
 Fail to habituate to stressful stimuli
 Show more anxious arousal

37.  Conversion symptoms occur more on the left rather than the right side of the body showing they could be
linked to neurophysiological emotional arousal. (refer notes)
 According to the psychodynamic model, the symptoms are a consequence of emotional conflict, with the
repression of conflict into the unconscious.
 Other theory - attachment theory as a means to understanding conversion disorder in terms of the freeze
response and the appeasement defense behavior seen in animal subjects.

38.  The patient has been postulated to derive primary and secondary gain.
 With secondary gain, symptoms allow the patient to avoid unpleasant situations or garner support from
friends, family, and the medical system that would otherwise be unobtainable.
 According to sociocultural theories, the direct expression of emotions is impermissible and somatization
takes its place.
 In behavioral models, conversion symptoms are viewed as a learned maladaptive behavior that is
reinforced by the environment.
UNCONSCIO
USLY
SUPPRESSED
CONFLICTS
ALLOWS
PATIENTS
TO EXPRESS
PRIMARY
GAIN

39.  Preexisting neurologic disease.
 The simultaneous occurrence of organic brain disease with conversion symptoms is also observed,
most notably in observation of high rates of organic seizure syndromes associated with psychogenic
nonepileptic seizures (PNES).
 Familial studies have also shown that conversion symptoms in first-degree female relatives are up to
14 times greater than in the general population.

40. ETIOLOGY AND COURSE
. Although conversion disorder can occur at any age the onset is typically in late childhood
or early adulthood.
 Onset is sudden and in response to conflicts or stressful situations such as unresolved grief
and sexual trauma.
 The course of CD is believed to be vary from very brief to several weeks but longitudinal
studies showing the same is scarce.

41. PAIN DISORDER
 In pain disorder, severe acute or chronic pain in one or more body parts is not
entirely or adequately explained by a known medical condition.
 Pain is a subjective phenomenon and psychological factors such as mood,
anxiety, and attention maybe involved in the onset, maintenance and
exacerbation of pain and complicate differential diagnosis.
 Chronic Pain in particular is associated with major changes in behavior such as
decreased activity and somatic preoccupation.
ACUTE PAIN- LESS THAN 6 MONTHS
CHRONIC PAIN- PERSISTS MORE THAN 6 MONTHS

42. CONTEMPORARY THEORETICAL
PERSEPCTIVES
 Behavioral theory
 Verbal and nonverbal expressions

43. Respondent and operant conditioning in pain disorder
 The two may interact from the onset of pain behavior though its development.
 For example, Avoidance of physical activity can lead to muscle fibers loosing elasticity and
shortening. This can be very painful and as a result people tend to avoid physical activity.
 Such avoidance is negatively reinforced when they lead to the short-term decrease of pain.
 Long term cost is frequently incurred because avoidance and escape may exacerbate the
physical condition of the individual thus resulting in a vicious cycle.
Pain behavior is
reinforced with
alternative behavior
Future pain behavior
increases
Future healthy
behavior decreases.

44. Cognitive-behavioral conceptualization of pain
 Pain behavior is due to negative or unrealistically high expectations about experiencing pain as
well as low levels of perceived competence to deal with pain.
 These cognitions often lead to avoidance of particular situations which may result in further
negative expectations regarding the ability to control future onset and cope with pain
 Differences in the coping styles are particularly important for the resultant perception of pain
and associated mood states and this may also affect the impact of the pain stimulus.
 Coping behavior seems to be directly influenced by a person’s perceived level of competence and
indirectly through pain intensity and pain related anxiety and depression.

45. Example:
 Conversely, individuals who trust in their abilities to cope adequately with pain are more likely to
engage in adaptive behavior irrespective of how anxious they are and such persons do not suffer as
much as individual's with low perceived competence.
Decrease in competence
Increases pain intensity
Increases pain emotion
Leads to maladaptive behavior.

46. BIOPSYCHOLOGICAL MODEL
 A model proposed by Flor et.al (1990) is a particularly promising example of a comprehensive
psychobiological theory of chronic pain.
Psychological
Motor-behavioral
Physiological

47.  Flor and her colleagues proposed that stress may precipitate and facilitate a particular pain disorder to which
the individual is already predisposed on an unlearned and learned basis.
 The learned aspect of this predisposition consists of reduced threshold for nociceptive activation due to
previous trauma or social learning experiences resulting in physiological response stereotype of a specific
body system or group of muscles
Example:
 Individuals with heart focused anxiety and noncardiac chest pain may habitually respond to stress and pain
with increases in muscular tension and sympathetic activation that may over time lead to learned changes in
nociceptive sensitivity and input of chest muscles.

48. Pain episodes
Autonomic and
muscular
reactions
Muscle tensionVasoconstriction
Increases
muscular and
sympathetic
hyperactivity increase the
sensitivity of chemo-
nocireceptors

49. ETIOLOGY AND COURSE
Among pain patients there is a high frequency of prior physical abuse, sexual abuse and other
personality traits.
According to Engel(1959) individuals with pain disorder involve in frequent depression, pessimism
and an unconscious belief that happiness is not deserved.
Occupational factors can also lead to pain when there is the overuse of a single body part.
There is no data yet to show pain patients to be a homogenous group of individuals. So, instead many
researchers have been looking for subgroups with different psychological profiles.

50. HYPOCHONDRIASIS
 It is characterized by unjustified fears or convictions that one has a serious and
often fatal illness such as heart disease, cancer or AIDS.
 Patients frequently seek reassurance, check their bodies and avoid illness-related
situations.
 Merely informing the patients about the lack of any diseases or the benign nature
of their symptoms only causes temporary reassurance and that is followed by
renewed worry over symptoms
 Patients continue the overuse of medical services.
 Should at least last 6 months and should not be of delusional intensity.
 It is currently known as Illness Anxiety Disorder

51. CONTEMPORARY THEORETICAL
PERSPECTIVES
Behavioral Theories
Internal Cues serve as conditioned stimuli
Individual exhibit conditioned response
Reinforced and maintained through operant conditioningReinforced and maintained through operant conditioning

52.  Cognitive perspective
 Previous experience
 Assumptions can also lead the patient to selectively attend to information which appears to confirm the idea of having
an illness, and to selectively ignore or discount evidence indicating good health.
 Thus, particular assumptions often lead to a confirmatory bias in the patient’s thinking once a critical incident has
resulted in the misinterpretation of bodily symptoms and signs as being indications of serious illness.
 Situations which constitute critical incidents and activate previously dormant assumptions include unfamiliar bodily
sensations, hearing details of illness in a friend of a similar age, or new information about illness.
 Further bodily sensations may then be noticed as a consequence of increased vigilance arising from anxiety. In patients
who become particularly anxious about their health, such situations are associated with thoughts which represent
personally catastrophic interpretations of the bodily sensations or signs.

53.  Assumptions can also lead the patient to selectively attend to information which appears to confirm the idea of having
an illness, and to selectively ignore or discount evidence indicating good health.
 Thus, particular assumptions often lead to a confirmatory bias in the patient’s thinking once a critical incident has
resulted in the misinterpretation of bodily symptoms and signs as being indications of serious illness.
 Situations which constitute critical incidents and activate previously dormant assumptions include unfamiliar bodily
sensations, hearing details of illness in a friend of a similar age, or new information about illness.
 Further bodily sensations may then be noticed as a consequence of increased vigilance arising from anxiety. In
patients who become particularly anxious about their health, such situations are associated with thoughts which
represent personally catastrophic interpretations of the bodily sensations or signs.

54. CATASTROPHIC INTERPRETATIONS
SIGNS OR SYMPTOMS DO NOT
INCREASE BECAUSE OF
ANXIETY
HYPOCHONDRIACAL ANXIETY
SYMPTOMS THAT OCCUR AS A PART OF
ANXIETY
PANIC ATTACK

55. Previous Experience
Formation of dysfunctional
assumption
Critical Incident- Incident or symptom
which suggest illness
Activation of Assumption
Negative automatic thought or
imagery
Hypochondriasis, Health Anxiety
BEHAVIORAL
AFFECTIVE
COGNITIVE
PHYSIOLOGICAL

56.  According to a study conducted by Pennebaker found that deficient external stimulation and low levels of distraction
increase the likelihood that individuals pay attention to somatic symptoms and bodily changes.
 Studies of anxiety disorders have revealed that anxious patients show an attentional bias toward threat-stimuli.
 In somatoform disorders empirical evidence for this type of bias has been studied less. Nearly, all studies relate to the
role of attentional bias in hypochondriacal patients or normal subjects with high scores on the hypochondriasis scale.
 Results at present are inconclusive in that normal patients show an attentional bias but others do not.

57. SOMATOSENSORYAMPLIFICATION
 Hypochondriacs, may experience a broad range of somatic sensations as more intense, more noxious, more ominous,
and more disturbing than non hypochondriacs.
 They may be unusually sensitive to, and intolerant of, bodily sensations in general, and be more likely to attribute
them to disease.
 The hypochondriac may amplify a wide range of sensations: normal physiological functions; the benign symptoms of
trivial and self-limited ailments; the somatic concomitants of emotional arousal; as well as the symptoms of serious
disease.
 He or she may thus be characterized as having an amplifying perceptual style entailing a hypervigilance or
heightened attentional focus upon bodily sensation, a tendency to select out and attend to certain relatively weak and
infrequent bodily sensations, and a propensity for responding to them with affect and cognitions which make them
more disturbing and intense.

58.  Because his or her bodily sensations are so intense and so disturbing, the hypochondriac then tends to
misinterpret them and incorrectly attribute them to a serious disease rather than to a more benign cause such as
overwork, insufficient sleep, inadequate exercise, etc.
 Thus, for example, a normal irregularity in the consistency of breast tissue is mistaken for a ‘lump’, or a
stomach-ache is attributed to an ulcer rather than to a recent dietary indiscretion.
 Having hypothesized that he or she is sick, the hypochondriac becomes increasingly vigilant and apprehensive
 This heightens somatic symptoms further, via two mechanisms.

59. INCREASING
ANXIETY
PRODUCES
OWN
SOMATIC
SYMTPOM
PRESUMED
AS A
SERIOUS
DISESE
People screen somatic
perceptions
Selectively attend to
only those that
confirm explanatory
hypothesis
Ignore sensory
output that
disconfirms belief

60.  Neurochemical deficits associated with illness anxiety disorder appear similar to those of mood and anxiety disorders.
 A more recent article highlights the effectiveness of fluoxetine (a serotonin reuptake inhibitor and a mainstay in the
treatment of OCD), as effective in the treatment of hypochondriasis.
 Encountering a patient with more than one of the anxiety spectrum disorders comorbid with illness anxiety disorder is
not unusual.
 Findings of neurochemical deficits in patients with illness anxiety disorder are only preliminary, but such deficits may
explain why symptoms overlap, why the disorders are commonly comorbid, and why effective treatments for OC
spectrum disorders are also effective for illness anxiety disorder (eg, selective serotonin reuptake inhibitors [SSRIs]).

61. ETIOLOGY AND COURSE
 The onset of Hypochondriasis is frequently in early adulthood.
 Although symptoms may wax and wane the course is typically chronic and the condition and it takes on a dominant
role in a person’s life and relationships.
 In children somatic complaints have been shown to be influenced by attention received from parents.
 Adults having hypochondriasis said parents were more caring and overprotective than parents with other psychiatric
disorders.
 Hypochondriacal symptoms in children and adults are influenced

62. BODY DYSMORPHIC DISORDER
 The preoccupation with an imagined or exaggerated body disfigurement or an
excessive concern that there is something wrong with the shape or appearance
of body parts.
 This presumed abnormality is generally not noticeable to others.
 Objects of concern typically include the face, head, sexual characteristics and
the general body appearance.
 Cognitive features of BDD are excessive preoccupation, intrusive thoughts and
sometimes ideas of reference.

63. CONTEMPRARY THEORETICAL
PERSPECTIVE
 Cognitive behavioral formulation of BDD
 According to this formulation cognitive and affective features involve a perceptual disturbance in body
image, plus a preoccupation with the imagined defect especially in social situations.
 Thinking maybe obsessional or delusional about the presumed abnormality in features including the
avoidance of social situations, camouflaging, checking and undertaking beauty remedies.
 This model has clinical backing but it seems to lack further specification and empirical scrutiny.

64. Neuroanatomic approach
 One study detected that orbitofrontal cortex and anterior cingulate cortex volumes of BDD
patients were significantly smaller than healthy individuals. It means that their brain has more
white substance than the control group.
 Besides, there is a tendency of an increase of thalamic volume in BDD patients compared with
that in the control group.
 Neuroanatomic evidence in the limbic system was also found, more specifically in the
amygdalas, between BDD, anxiety, and self-evaluating visual process.
 Self-image is captured by ventral visual system, which is later interpreted by the brain’s
amygdala.
 That structure is involved in emotional control in a higher level, like companionship, love,
affection, mood swings, fear, rage, and hostility. They are involved in some anxiety
manifestations too.
 Interestingly, only the right amygdala volume has shown a significant correlation with BDD
symptom severity, which suggests a different lateral involvement of these brain regions

65.  One study conducted by researchers at the University of California, Los Angeles, shows that
people with BDD may process visual information differently than people without the disorder.
 Researchers showed 25 people, half with BDD and half without the disorder, three different
images of faces in high, regular, and low resolutions.
 Magnetic resonance image (MRI) results showed that participants with BDD used the left side
of the brain (the analytical side) to process all three images.
 The other participants used the brains’ left hemisphere for only the high-resolution images.
This could mean that the minds of people with BDD strive to acutely process visual details,
even when there is nothing to process.
 This might be why they can see flaws in themselves, even when those flaws might not exist.

66.  Another biological factor under consideration is that people with BDD seem to have a chemical
imbalance of the neurotransmitter serotonin, because they often respond well to the selective
serotonin reuptake inhibitor (SSRI) class of antidepressants.
 Many of these are based on evidence that illustrates the effectiveness of selective serotonin
reuptake inhibitors (SSRIs) in the treatment of BDD.
 Overall, the exact role for serotonergic transmission in the etiology of BDD remains the subject of
continuing research.

67. ASSESSMENTS
 The most commonly used diagnostic interviews are the Structured Clinical Interview for DSM-IV (SCID) and
the Composite International Diagnostic Interview (CIDI).
 Somatoform Disorders Schedule (SDS)
 International Diagnostic Checklists (IDCL)

68.  As an alternative approach to diagnostic interviews, Hiller et al. developed the International Diagnostic Checklists
(IDCL) which exist in separate versions for DSM-IV and ICD-10.
 These checklists are recommended by the WHO for use in research and everyday patient examinations.
 The basic IDCL assessment method is very similar to the above-mentioned diagnostic interviews except that the
reading of preformulated questions and a forced step-by-step procedure are not necessary.
 Instead, the diagnostic criteria are listed in a clinically useful order allowing the diagnostician quickly to decide
whether or not a suspected diagnosis can be given.
 The IDCL are to be administered by trained and experienced clinicians. There exists one checklist for all disorders
related to somatic symptoms and another one for hypochondriacal disorder.

69. TREATMENT OF SOMATOFORM
DISORDERS
Psychotherapy
Since physical symptoms can be related to psychological distress and a high level of health anxiety, psychotherapy — specifically,
cognitive behavioral therapy (CBT) — can help improve physical symptoms.
CBT can help you:
•Examine and adapt your beliefs and expectations about health and physical symptoms
•Learn how to reduce stress
•Learn how to cope with physical symptoms
•Reduce preoccupation with symptoms
•Reduce avoidance of situations and activities due to uncomfortable physical sensations
•Improve daily functioning at home, at work, in relationships and in social situations
•Address depression and other mental health disorders
Family therapy may also be helpful by examining family relationships and improving family support and
functioning.

70. Antidepressants in somatoform and related
disorders
 Several reviews indicate that medically unexplained symptoms and functional somatic syndromes respond to
psychological interventions and antidepressants.
 However, fewer studies have focused on somatoform disorders and its subgroups in their own right.
 The studies have examined newer antidepressants such as SSRIs and SNRIs more often than other classes of
antidepressants such as tricyclics, mirtazapine or other antidepressants.
 Open label trails have reported positive outcome with nefazodone and fluvoxamine.
 Significant improvement was noted in somatization disorder with nefazodone 300 mg twice a day (bd) (Menza et al.,
2001).
 Although multiple measures were used to detect the outcome, the trial was short term (8 weeks) and with a small
number (15 patients). Similarly Fluvoxamine 300 mg per day was found to be effective and well tolerated in an 8 weeks
trial on 29 patients.