Chapter 7 Diagnostic and Statistical Manual of Mental Disorders and Pain Management

Question 1

Somatoform disorders

Answer 1

grouped together by the presence of physical symptoms suggesting a general medical condition. These symptoms are not explained fully by a general medical condition, or by the effects of substances or other mental disorders. There is no diagnosable medical
condition to fully account for the physical symptoms,
and there must be a significant functional impairment. In contrast to factitious disorders and malingering, the symptoms in somatoform disorders are involuntary

Question 2

Somatization

Answer 2

described as a tendency to experience and communicate somatic distress and symptoms
unaccounted by pathologic findings, to attribute them to physical illness, and to seek medical help for them

Question 3

differential diagnosis of somatoform disorder.

Answer 3

differential diagnosis should also include unrecognized organic disease, anxiety, substance abuse,
cognitive dysfunction, and psychosis

Question 4

essential feature of somatization disorder

Answer 4

a pattern of recurring, multiple, clinically significant somatic
complaints that may result in medical treatment or functional impairments

Question 5

Diagnostic Criteria for Somatization Disorder –Criterion A

Answer 5

A history of many physical complaints beginning before age 30 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

Question 6

Diagnostic Criteria for Somatization Disorder –Criterion B

Answer 6

Each of the following criteria must have been met, with individual symptoms occurring at any time during the course
of the disturbance:
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).
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 pseudoneurologic symptom: a history of at least one symptom or deficit suggesting a neurologic 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)

Question 7

Diagnostic Criteria for Somatization Disorder –Criterion C

Answer 7

Either (1) or (2):
1. After 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 or medication).
2. When there is a related general medical condition, the physical complaints or resulting social or occupational
impairment are in excess of what would be expected from the history, physical examination, or laboratory findings.

Question 8

Diagnostic Criteria for Somatization Disorder –Criterion D

Answer 8

The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).

Question 9

Screening Test for Somatization Disorder

If two or more symptoms are
present, there is a high likelihood of somatization disorder

Answer 9

Mnemonic –> Symptom (System)
Somatization–> Shortness of breath (Respiratory)
Disorder–> Dysmenorrhea (Female reproductive)
Besets–> Burning in sex organ (Psychosexual)
Ladies –> Lump in throat (difficulty swallowing) (Pseudoneurologic)
And –> Amnesia (Pseudoneurologic)
Vexes–> Vomiting (Gastrointestinal)
Physicians–> Painful extremities (Skeletal muscle)

Question 10

Three features that
suggest somatization as opposed to a general medical condition
are

Answer 10

multiple organ system involvement, early onset,
and chronic course without objective signs, and absence
of laboratory abnormalities

Question 11

How do individuals with somatization disorder usually describe complaints?

Answer 11

in exaggerated terms or grandiose fashion, often lacking specific facts. They are often inconsistent historians and may seek evaluation by many physicians concurrently. These patients may also display evidence of mood disturbance such as depression or prominent anxiety symptoms, antisocial behavior, suicidal ideation, and interpersonal problems

Question 12

Undifferentiated Somatoform Disorder

Answer 12

This is a residual category for persistent somatoform presentations that do not meet full criteria for one of the specific somatoform disorders

Question 13

Undifferentiated Somatoform Disorder essential feature

Answer 13

The essential feature of this disorder is one or more physical complaints persisting for at least 6 mo. Frequent complaints include chronic fatigue, loss of appetite, and gastrointestinal or genitourinary symptoms
that cannot be explained by a general medical condition or a
substance, and are often excessive in nature

Question 14

Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion A

Answer 14

One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints)

Question 15

Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion B

Answer 15

Either (1) or (2):
1. After appropriate investigation, the symptoms cannot be fully explained by known general medical condition or
direct effects of a substance (e.g., a drug of abuse or medication).
2. When there is a related general medical condition, the physical complaints or resulting social or occupational
impairment are in excess of what would be expected from the history, physical examination, or laboratory findings

Question 16

Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion C

Answer 16

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of
functioning

Question 17

Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion D

Answer 17

The duration of the disturbance is at least 6 mo

Question 18

Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion E

Answer 18

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)

Question 19

Diagnostic Criteria for Undifferentiated Somatoform Disorder Criterion F

Answer 19

The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering)

Question 20

Diagnostic Criteria for Conversion Disorder Criterion A

Answer 20

One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other
general medical condition. Motor symptoms or deficits include impaired coordination or balance, paralysis, aphonia, dysphagia, and urinary retention. Sensory symptoms include loss of touch or pain
sensation, diplopia, blindness, deafness, and hallucinations.
Symptoms may also include seizures or convulsions

Question 21

Diagnostic Criteria for Conversion Disorder Criterion B

Answer 21

Psychological factors are judged to be associated with symptom or deficit because the initiation or exacerbation of the
symptom or deficit is preceded by conflicts or other stressors

Question 22

Diagnostic Criteria for Conversion Disorder Criterion C

Answer 22

The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering)

Question 23

Diagnostic Criteria for Conversion Disorder Criterion D

Answer 23

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

Question 24

Diagnostic Criteria for Conversion Disorder Criterion E

Answer 24

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning or warrants medical evaluation

Question 25

Diagnostic Criteria for Conversion Disorder Criterion F

Answer 25

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

Question 26

diagnosis of conversion disorder

Answer 26

should only be made after a thorough medical investigation has been performed to rule out
an etiologic, neurologic, or general medical condition. Because a general medical etiology for an apparent diagnosis of conversion disorder may take years to manifest, it is important to re-evaluate this diagnosis periodically.

Question 27

Relationship between conversion disorder and somatization disorder

Answer 27

Women presenting with conversion symptoms may eventually progress to meeting criteria for somatization disorder.

Question 28

Pain Disorder

Answer 28

The essential feature of pain disorder is pain that is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention

Question 29

Diagnostic Criteria for Pain Disorder Criterion A and B

Answer 29

Criterion A
The pain causes clinically significant distress or
impairment in social, occupational, or other
important areas of functioning.
Criterion B
Psychological factors are judged to have an
important role in the onset, severity, exacerbation,
or maintenance of the pain

Question 30

Diagnostic Criteria for Pain Disorder Criterion C and D

Answer 30

Criterion C
The symptom or deficit is not intentionally
produced or feigned.
Criterion D
The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia

Question 31

Common to both factitious disorder and malingering

Criterion A

Answer 31

is the intentional production of physical and/or psychological
symptoms

Question 32

Factitious Disorder

Answer 32

the motivation is the psychological need to assume the sick role (Criterion B); external incentives for the patient’s behavior (e.g., financial gain, avoiding work duties, obtaining opioid medications) should be absent (Criterion C).
Patients may complain about nonexistent symptoms,
create objective signs (e.g., warming skin to create erythema, using psychoactive drugs to suggest a mental disorder), or exaggerate symptoms of a previous diagnosis.

Question 33

Components of the history suggesting diagnosis of Factitious Disorder include the following:

Answer 33

multiple hospital admissions or
office visits, knowledge of medical terminology, vague and unverifiable history, chronic illness at a young age, difficulty
with interpersonal relationships and few visitors in the inpatient setting, comorbid personality disorders, or substance abuse disorder

Question 34

Malingering

Answer 34

the intentional falsification of physical and/or psychological symptoms is motivated by external factors (e.g., economic gain, avoiding legal responsibility, avoiding military service, or avoiding domestic duties

Question 35

Clues that suggest a diagnosis of malingering include

Answer 35

medico-legal context of the presentation, marked discrepancy between claimed stress or disability and objective findings, lack of cooperation during the diagnostic evaluation, and the presence of antisocial personality disorder

Question 36

Three types of malingering

Answer 36

In pure malingering,
patients fabricate symptoms that do not exist at all.
In partial malingering, symptoms that do exist are exaggerated.
Lastly, in false imputation, patients attempt to blame real symptoms on an unrelated event

Question 37

“malingering by proxy”

Answer 37

a parent fabricating an illness in his or her child, again for the purpose of external gain (such as social benefits)

Question 38

Successful identification of the malingering patient remains difficult. Waddell’s Signs maybe useful

Answer 38

Category: Signs
Tenderness: Superficial: light pinching causing pain = positive
Nonanatomic: deep tenderness over a wide area= positive
Simulation: Axial loading: downward pressure on the head causing low back pain = positive
Rotation: examiner holds shoulders and hips in the same plane and rotates patient; pain= positive
Distraction: Straight leg raise causes pain when formally
tested, but straightening the leg with hip flexed 90° to check Babinski does not
Regional: Weakness: multiple muscles not enervated by the
same root. Sensation: glove and stocking loss of sensation
Overreaction: Excessive show of emotion

Question 39

in the absence of objective

evidence of malingering what should be done

Answer 39

psychological testing such as
the Minnesota Multiphasic Personality Disorder, ed 2
or the Symptom Checklist-90-Revision can be helpful
in detecting exaggerations and inconsistencies in a history

Question 40

Diagnostic Criteria for Hypochondriasis Criterion A

Answer 40

Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms

Question 41

Diagnostic Criteria for Hypochondriasis Criterion B

Answer 41

The preoccupation persists despite appropriate medical evaluation and reassurance

Question 42

Diagnostic Criteria for Hypochondriasis Criterion C

Answer 42

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)

Question 43

Diagnostic Criteria for Hypochondriasis Criterion D

Answer 43

The preoccupation causes clinically significant distress

or impairment in social, occupational, or other important areas of functioning

Question 44

Diagnostic Criteria for Hypochondriasis Criterion E

Answer 44

The duration of the disturbance is at least 6 mo.

Question 45

Diagnostic Criteria for Hypochondriasis Criterion F

Answer 45

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

Question 46

Treatment of hypochondriasis

Answer 46

Treatment of hypochondriasis is difficult. Education, cognitive therapy, and behavioral therapy
offer the best chance of remission. Frequent medical
exams and benign therapies (heat, bracing, etc.) can be
helpful. There may also be a role for selective serotonin
reuptake inhibitors (SSRIs) in some patients.

Question 47

Diagnostic Criteria for Dyspareunia

Answer 47

Criterion A
Recurrent or persistent genital pain associated with sexual intercourse in either man or woman.
Criterion B
The disturbance causes marked distress or
interpersonal difficulty.
Criterion C
The disturbance is not caused exclusively by vaginismus of lack of lubrication, is not better
accounted for by another Axis I disorder (except another sexual dysfunction), and is not due
exclusively to the direct physiologic effects of a
substance (e.g., a drug of abuse or medication) or a general medical condition

Question 48

Diagnostic Criteria for Vaginismus

Answer 48

Criterion
A Recurrent or persistent involuntary spasm of the
musculature of the outer third of the vagina that interferes with sexual intercourse.
Criterion B
The disturbance causes marked distress or interpersonal difficulty.
Criterion C
The disturbance is not better accounted for by another Axis I disorder (e.g., somatization disorder) and is not due exclusively to the direct physiologic effects of a general medical condition

Question 49

Treatments for Vaginismus

Answer 49

pelvic floor control exercises, insertion or dilation training, and addressing the emotional component of the disorder