Most of us have had that “OH NO! I think I have that!” moment, after poking around online, trying to figure out the cause of our vague physical symptoms. A 2004 study by the Pew Internet and American Life Project found that 79 percent of Internet users — roughly 95 million Americans — have researched health information online. People now have access to incredibly complex medical information, with little ability to sift through it or interpret it accurately. The abundance of health information available online, valid or not, has contributed to what the media have coined ‘cyberchondria’ (researching diseases on the internet, and then worrying that you have the symptoms of that disease.) These people are often frustrated when their self-diagnosis does not prompt their doctor to order the tests and/or medications they feel necessary.
Yet after getting checked out by a doctor and getting a clean bill of health, most of us feel reassured, and are then ready to move on. For hypochondriacs however, relief does not come, and the fear of serious illness continues to fester. Hypochondria falls under the umbrella category of Somatoform Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) and is defined as a preoccupation with the belief that one has an illness, based on a misinterpretation of bodily symptoms. To qualify as hypochondria, this preoccupation must cause distress in the person’s daily life and persist for at least six months — despite medical evidence discounting the perceived illness. About 1 to 5 percent of the population suffers from hypochondria, and the disorder is believed to strike men and women equally.
In the professional world of mental health, “Somatization” is a term that describes the expression of psychological or mental difficulties through physical symptoms. Somatization can range from preoccupation with potential or genuine but mild physical problems (as previously described in Hypochondria), to the development of perceived or actual physical pain, or dysfunction. This article addresses some of the other major diagnoses that the DSM-IV-TR defines within the Somatoform Disorders category.
Somatization disorder is characterized by a history of multiple unexplained medical problems or physical complaints beginning prior to age 30. People with somatization disorder report symptoms affecting multiple organ systems or physical functions, including pain, gastrointestinal distress, sexual problems, and symptoms that mimic neurological disorders. Although medical explanations for their symptoms cannot be identified, individuals with somatization disorder experience genuine physical discomfort and distress. Review of their medical histories will usually reveal numerous visits to medical specialists, second and third opinions, and numerous medications prescribed by different doctors, often putting them at risk for drug interactions.
Conversion disorder is marked by unexplained sensory or motor symptoms that resemble those of a neurological or medical illness or injury. Common symptoms include paralysis, loss of sensation, double vision, seizures, inability to speak or swallow and problems with coordination and balance. Symptoms often reflect a naive understanding of the nervous system, and physicians often detect conversion disorder when symptoms do not make sense anatomically. The name conversion disorder reflects a theoretical understanding of the disorder as a symbolic ‘conversion’ of a psychological conflict into a concrete physical representation. Ironically, patients with conversion disorder may not always express the level of concern one would expect from someone with their described condition.
Pain Disorder is physical pain that causes significant distress or disability or leads an individual to seek medical attention. Pain may be medically unexplained, or it may be associated with an identifiable medical condition, but it is experienced as far more severe than the actual physical condition would warrant. Common symptoms include headache, backache and generalized pain in muscles and joints. Pain disorder can be severely disabling, causing immobility that prevents patients from working, fulfilling family responsibilities or engaging in social activities. Like patients with somatization disorder, people with pain disorder often have a long history of consultations with numerous physicians.
Body dysmorphic disorder is characterized by preoccupation with a defect in physical appearance. Often the defect of concern is not apparent to other observers, or if there is a genuine defect it is far less disfiguring than the patient imagines. Common preoccupations include concerns about the size or shape of the nose, skin blemishes or color, body or facial hair, hair loss, or “ugly” hands or feet. Individuals with body dysmorphic disorder may be extremely self-conscious, avoiding social situations because they fear others will notice their physical defects or even make fun of them. They may spend hours examining the imagined defect or avoid mirrors altogether. Time-consuming efforts to hide the defect, such as application of cosmetics or adjustments of clothing or hair, are common. Many people with body dysmorphic disorder undergo permanent procedures like plastic surgery or cosmetic dentistry, but are seldom satisfied with the results.
Note that Somatoform disorders should be distinguished from Factitious disorder, in which patients intentionally act physically or mentally ill without obvious benefits such as monetary gain. What motivates people with Factitious disorder is being able to play the role of a sick person. Further, the DSM-IV-TR distinguishes Factitious disorder from Malingering, a disorder which is defined as feigning illness when there is a clear motive—usually to economic gain, or to avoid legal trouble.
Causes. One longstanding theory about the cause of Somatoform disorders suggests that it is a way of avoiding psychological distress. Rather than experiencing depression or anxiety, some individuals will develop physical symptoms. According to this model, their preoccupation with the body allows them avoid the stigma of a mental health/psychiatric disorder. They end up getting the care and nurturing they need from doctors and other people in their lives who are responsive to their physical illnesses.
Treatment. Cognitive-behavioral therapy (CBT) is considered an effective treatment for Somatoform disorders, focusing on changing negative patterns of thoughts, feelings, and behavior that contribute to somatic symptoms. The cognitive component of the treatment focuses on helping patients identify dysfunctional thinking about physical sensations. With practice, patients learn to recognize catastrophic thinking and develop more rational explanations for their feelings. The behavioral component aims to increase activity and self-care. Many of these patients have reduced their activity levels as a result of discomfort or out of fear that activity will worsen their symptoms. Patients are instructed to increase activity gradually while avoiding overexertion that could reinforce fears. Other important types of treatment include relaxation training, sleep hygiene, and communication skills training. Preliminary findings suggest that CBT may help reduce distress and discomfort associated with somatic symptoms; however, it has not yet been systematically compared with other forms of therapy.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.
Phillips, Katherine A. The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York: Oxford University Press, 1996.
Pilowsky, Issy. Abnormal Illness Behavior. Chichester, UK: John Wiley and Sons, 1997.