Diagnostic Criteria for Somatization Disorder* A A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. B Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

Diagnostic Criteria for Somatization Disorder* (Continued) 1 four pain symptoms : a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination) 2 two gastrointestinal symptoms : a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)

Diagnostic Criteria for Somatization Disorder* (Continued) 3 one sexual symptom : a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) 4 one pseudoneurological symptom : a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

Diagnostic Criteria for Somatization Disorder (Continued) C Either (1) or (2): 1after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication) 2 when there is a related general medical condition, the physical complaints or resulting social or occupational impairment area in excess of what would be expected from the history, physical examination, or laboratory findings D The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering) *DSM-IV criteria (American Psychiatric Association)

Diagnostic Criteria for Conversion Disorder u One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. u Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

Diagnostic Criteria for Conversion Disorder (Continued) u The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering). u The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. u The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Diagnostic Criteria for Conversion Disorder (Continued) u The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder. u Specify type of symptom or deficit: with Motor Symptom or Deficit; with Sensory Symptom or Deficit; with Seizures or Convulsion; with Mixed Presentation *DSM-IV criteria (American Psychiatric Association, 1994)

Diagnostic Criteria for Pain Disorder *† u Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. u The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. u Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.

Diagnostic Criteria for Pain Disorder (Continued) u The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering). u The pain is not better accounted for by a Mood, Anxiety, or Psychotic Disorder and does not meet criteria for Dyspareunia.

Diagnostic Criteria for Pain Disorder (Continued) Code as follows : Pain Disorder Associated with Psychological Factors : psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This type of Pain Disorder is not diagnosed if criteria are also met for Somatization Disorder. Specify if : Acute : duration of less than 6 months; Chronic : duration of 6 months or longer

Diagnostic Criteria for Pain Disorder (Continued) Pain Disorder Associated with Both Psychological Factors and a General Medical Condition : both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical site of the pain (see below) is coded on Axis III. Specify if: Acute : duration of less than 6 months; Chronic : duration of 6 months or longer *Pain per se may be associated with psychological factors and/or a general medical condition; it may be acute with a duration of less than 6 months or chronic. The anatomical site(s) is coded Axis III of DSM-IV. † DSM-IV criteria (American Psychiatric Association, 1994)

Diagnostic Criteria for Hypochrondriasis * u Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms. u The preoccupation persists despite appropriate medical evaluation and reassurance. u The belief in Criterion A is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).

Diagnostic Criteria for Hypochondriasis (Continued) u The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. u The duration of the disturbance is at least 6 months u The preoccupation is not better accounted for by Generalized Anxiety Disorder, Obsessive- Compulsive Disorder, Panic Disorder, a Major Depressive Episode, Separation Anxiety, or another Somatoform Disorder.

Diagnostic Criteria for Hypochondriasis (Continued) u Specify if : With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable. † *DSM-IV criteria (American Psychiatric Association, 1994). † The patient’s level of insight is of prognostic significance and may be specified.

Diagnostic Criteria for Body Dysmorphic Disorder u Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. u The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. u The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa). *DSM-IV criteria (American Psychiatric Association, 1994).

Diagnostic Criteria for Undifferentiated Somatoform Disorder* A One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints). B Either (1) or (2): 1after appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication) 2when there is a related general medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical examination, or laboratory findings

Diagnostic Criteria for Undifferentiated Somatoform Disorder* (Continued) C The symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning. D The duration of the disturbance is at least 6 months. E The disturbance is not better accounted for by another mental disorder (e.g., another Somatoform Disorder, Sexual Dysfunction, Mood Disorder, Anxiety Disorder, Sleep Disorder, or Psychotic Disorder). F The symptom is not intentionally produced or feigned (as in Factitious Disorder or Malingering) *DSM-IV criteria (American Psychiatric Association, 1994)

Munchausen’s Syndrome: Diagnostic Features* u Essential Features u Pathologic lying (pseudologia fantastica) u Peregrination (traveling or wandering) u Recurrent, feigned, or simulated illness

Munchausen’s Syndrome: Diagnostic Features* (Continued) u Supporting Features † u Borderline and/or antisocial personality traits u Deprived childhood u Equanimity for diagnostic procedures u Equanimity for treatments or operations u Evidence of self-induced physical signs u Knowledge of or experience in a medical field

Munchausen’s Syndrome: Diagnostic Features* (Continued) u ( Continued ) Supporting Features † u Most likely to be male u Multiple hospitalizations u Multiple scars (usually abdominal) u Police record u Unusual or dramatic presentation *Patients will meet criteria for a chronic factitious disorder or an atypical factitious disorder. †May also support the diagnosis of other factitious disorders. (Reprinted with permission from Folks DG, Freeman AM: Munchausen’s syndrome and other factitious illness. Psychiatr Clin North Am 8: , 1985

Commonly Presenting Features of Chronic Factitious Illnesses Organ System Subtypes u Abdominal* u Cardiac u Dermatological † u Genitourinary u Hematological* † u Infectious u Neurological* u Psychiatric u Self-medication* ‡ Demeanor or Behavior u Bizarre u Demanding u Dramatic u Evasive u Medically sophisticated u Self-mutilating u Unruly *Original subtypes identified † Recently reported to be more common ‡Especially insulin, thyroid, vitamins, diuretics, and laxatives. (Reprinted with permission from Folks DG, Freeman AM: Munchausen’s syndrome and other factitious illness. Psychiatr Clin North Am 8: , 1985)

Key Features of Factitious Disorder* † u Intentional production of clinical signs or symptoms. u Primary intent is to assume the sick role. u The patient does not benefit from or have external incentives for the production of signs or symptoms. *Factitious disorder may occur predominantly with psychological and/or physical signs and symptoms. † Summarized from DSM-IV (American Psychiatric Association, 1994)

Somatization: Principles of Clinical Management u The clinical presentation is considered in the context of psychosocial factors, both current and past. u The diagnostic procedures and therapeutic interventions are based on objective findings. u A therapeutic alliance is fostered and maintained involving the primary care and/or psychiatric physician. u The social support system and relevant life quality domains are carefully reviewed during each patient contact.

Somatization: Principles of Clinical Management (Continued) u A regular appointment schedule is maintained for outpatients, irrespective of clinical course. u The patient dialogue and examination and the assessment of new symptoms or signs are engaged judiciously, and usually primarily address somatic rather than psychological concerns. u The need for psychiatric referral is recognized early, especially for cases involving chronic symptoms, several psychosocial consequences, or morbid types of illness behavior.

Somatization: Principles of Clinical Management (Continued) u Any associated, coexisting, or underlying psychiatric disturbance is assiduously evaluated and steadfastly treated. u The significance of personality features, addictive potential, and self-destructive risk is determined and addressed. u The patient’s case is redefined in such a way that management rather than cure is the goal of treatment.