Somatization is the expression of mental phenomena as physical (somatic) symptoms. Disorders characterized by somatization extend in a continuum of intentionality, ranging from those in which symptoms develop unconsciously (nonvolitionally) to those in which symptoms develop consciously (volitionally). This continuum includes somatic symptom and related disorders, where symptoms are organic and distressing and not under voluntary control; and factitious disorders, where symptoms are consciously produced or feigned, but not for external gain (eg, financial gain, legal evasion, work avoidance). Malingering is a related behavior of intentionally falsified symptoms for external gain.
The continuum of disorders expressed through somatization includes somatic symptom disorder and related disorders, where symptoms are organic and distressing and not under voluntary control; and factitious disorders, where symptoms are consciously produced or feigned, but not for external gain (eg, financial gain, legal evasion, work avoidance).
Malingering is a related behavior of intentionally falsified symptoms for external gain, but it is neither a somatic symptom or related disorder nor a factitious disorder.
In these disorders, patients focus prominently on somatic (ie, physical) complaints. Thus, somatization typically leads patients to seek medical evaluation and treatment rather than psychiatric care.
Somatic symptom disorder and related disorders are characterized by persistent physical symptoms that are associated with excessive or maladaptive thoughts, feelings, and behaviors in response to these symptoms and associated health concerns. These disorders are distressing and often impair social, occupational, academic, or other aspects of functioning. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) includes the following disorders in this group (1):
Functional neurological symptom disorder (formerly conversion disorder)
Factitious disorders: Factitious disorder imposed on self; factitious disorder imposed on another (previously factitious disorder by proxy)
Somatic symptom disorder is characterized by 1 or more persistent, distressing physical complaints that are not feigned and are associated with excessive and maladaptive thoughts, feelings, and behaviors related to those symptoms. Additionally, symptoms must have been consistently present for at least 6 months. See table , which can be used to determine how frequently the patient has been bothered by 8 selected symptoms during the previous 7 days.
Illness anxiety disorder is preoccupation with and fear of having or acquiring a serious disorder.
Functional neurological symptom disorder (formerly called conversion disorder) consists of neurologic symptoms or deficits (typically involving motor or sensory function) that develop unconsciously and nonvolitionally and are incompatible with known pathophysiologic mechanisms or anatomic pathways.
Psychological factors affecting other medical conditions is a condition that is diagnosed when psychological or behavioral factors adversely affect the course or outcome of an existing medical condition.
Factitious disorders (formerly Munchausen syndrome) involve the falsification of physical or psychological symptoms and/or signs in the absence of obvious external incentives (eg, obtaining time off from work, disability payments, or prescription medications; avoiding military service or criminal prosecution).
Malingering is not a somatic symptom disorder but may be mistaken for one. It refers to a behavioral pattern characterized by intentional feigning of physical or psychological symptoms motivated by an external incentive. The presence of such an incentive distinguishes malingering from factitious disorders, which are typically driven by internal incentives (eg, a need for attention, sympathy, and/or validation).
Somatic symptom disorder and illness anxiety disorder are the most common.
Somatic Symptom Scale 8*
Symptom | Not at all | A little bit | Somewhat | Quite a bit | Very much |
|---|---|---|---|---|---|
Back pain | 0 | 1 | 2 | 3 | 4 |
Chest pain or shortness of breath | 0 | 1 | 2 | 3 | 4 |
Dizziness | 0 | 1 | 2 | 3 | 4 |
Feeling tired or having low energy | 0 | 1 | 2 | 3 | 4 |
Headaches | 0 | 1 | 2 | 3 | 4 |
Pain in the arms, legs, or joints | 0 | 1 | 2 | 3 | 4 |
Stomach or bowel problems | 0 | 1 | 2 | 3 | 4 |
Trouble sleeping | 0 | 1 | 2 | 3 | 4 |
* Scoring: Patient was not or only minimally bothered (0 to 3). Increasing scores indicate incrementally greater levels of discomfort: low (4 to 7); medium (8 to 11); high (12 to 15); very high (16 to 23). | |||||
Adapted with permission from Gierk B, Kohlmann S, Kroenke K, et al. The Somatic Symptom Scale-8 (SSS-8): A brief measure of somatic symptom burden. JAMA Intern Med. 174(2):400, 2014. doi: 10.1001/jamainternmed.2013.12179 | |||||
Reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, Text Revision. American Psychiatric Association Publishing; 2022.
