- *Professor, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences; Director, Adolescent Medicine Fellowship Program, Children’s National Medical Center, Washington, DC
- †Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health; Clinical Assistant Professor of Psychiatry, The George Washington University School of Medicine and Health Sciences, Washington, DC
After completing this article, readers should be able to:
Describe the various manifestations of somatization disorders in children and adolescents.
Delineate the association of psychosomatic disorders with stress, parental anxiety, or pressure for a child to perform.
Distinguish between primary and secondary gain.
Explain why school attendance should be assessed with every recurrent complaint.
Explain why pediatricians should establish a partnership with patients and their parents when addressing their symptoms.
Develop a cost-effective investigation of suspected somatoform disorders and an approach to insurance companies regarding reimbursement of services.
The diagnosis and treatment of children and adolescents who have somatization disorders constitute a challenge for pediatricians: On one hand, they raise the specter of “missing something”; on the other, any “false step” in explaining the condition risks alienating both the patient and the family. Many clinicians rise to the challenge, but many more are baffled by the onslaught of symptoms, become annoyed by the time consumed in caring for patients who are “not really sick,” or feel frustrated by the never-ending recurrent complaints.
To make matters worse, these disorders have been scantly researched; neither meta-analysis nor evidence-based medicine has contributed significantly to the field. Paradoxically, although somatoform disorders in children have been defined as psychiatric disorders, psychiatrists seldom see these patients except for the most extreme, unusual, and bizarre cases. Most children and adolescents who have functional symptoms are seen by primary care physicians. This review, therefore, focuses on understanding and assessing somatization as well as developing strategies for the day-to-day management of these conditions.
Definition and Classification
Somatization has been defined as the occurrence of one or more physical complaints for which appropriate medical evaluation reveals no explanatory physical pathology or pathophysiologic mechanism. Somatization also can coincide with a physical illness. Somatization is deemed to exist in conjunction with a physical illness whenever the physical complaints resulting in impairment are grossly in excess of what would be expected from the known illness or findings. Thus, the central feature of somatoform disorders is that they present with symptoms suggestive of an underlying medical condition, yet such a condition either is not found or does not fully account for the level of functional impairment.
The diagnostic criteria for somatoform disorders originally were established for adults and are applied to children because no child-specific alternative system has been developed. This is unfortunate because the current classification lacks a pediatric research base. Nevertheless, some progress has been made with a recent classification of child and adolescent mental diagnosis in primary care, which takes into account developmentally appropriate considerations. This review focuses on somatic complaint variation, somatic complaint problem, undifferentiated somatoform disorder, pain disorder, and conversion disorders (Table 1). Factitious disorder (300.16), which sometimes is included in the classification, does not fit very well because the signs and symptoms presented to the physician have been staged deliberately, rather than experienced, by the patient.
Somatoform disorders seem to follow a developmental sequence. Children appear to experience affective distress in the form of somatic sensations. Initially, these are monosymptomatic, with recurrent abdominal pain and headaches predominating in early childhood. Limb pain, neurologic symptoms, insomnia, and fatigue tend to emerge with increasing age. The prevalence of somatic symptoms is high in the pediatric population: Recurrent abdominal pain accounts for 5% of pediatric office visits, and headaches have been reported to affect 20% to 55% of all children. During adolescence,10% of teenagers report frequent headaches, chest pain, nausea, and fatigue. A general teenage population survey (ages 12 to 16 y) found that distressing somatic symptoms were present in 11% of girls and 4% of boys. This gender disparity seems to persist into adulthood. There is a higher rate of somatization among lower socioeconomic groups.
Pathogenesis: Genetic and Family Factors
Information on the genetics of somatoform disorders is limited. However, recent genetic studies have shown that somatoform disorders are concordant in twins. They also cluster in families in which there is attention deficit disorder and alcoholism above what would be expected by chance.
More commonly, clinicians consider somatization to be a learned behavior. It probably begins with the experience that children’s somatic complaints are more acceptable in many households than is the expression of strong feelings. When children cannot get attention for emotional distress, they may gain attention for the physical symptoms that often accompany the disturbed emotional state. This reinforcing “psychosomatic pathway” can manifest through a spectrum of somatization disorders, ranging from the mild “somatic complaint variation” (transient complaints that do not interfere with normal functioning) to the severe “somatoform disorder” (associated with significant social and academic problems).
The importance of psychosocial factors in the family of origin is highlighted by the finding that if a family member had a chronic physical illness, there were more somatic symptoms among the children. Even more striking is the finding that somatizing children often live with family members who complain of similar physical symptoms. Theoretic contributions stemming from systemic family therapy also indicate the importance of the family. The symptoms are proposed to be displayed by the child as a way of protecting distressed parents who, when galvanized into caring for their suffering child, are distracted from their own personal concerns. Stress has been implicated as a triggering factor that often is bound to parental anxiety. The most common form of stress consists of pressure on the child to perform. Finally, adolescents who have histories of physical or sexual abuse often present with somatic complaints, develop a somatization disorder, and score higher on measures of somatizations than do controls.
Children and adolescents readily report pain and somatic complaints in their sick visits. These complaints often result from a disease such as tonsillitis, gastroenteritis, or urinary tract infection. However, they can voice similar complaints in the absence of physical disease, and these reports must be approached as possible somatization. The diagnosis of a somatization disorder involves a continuum that ranges from everyday aches and pains to disabling “functional symptoms.” Symptoms are spontaneous and not feigned (which distinguishes them from malingering and factitious disorder) and are not better explained by another mental illness (such as depression or anxiety disorder).
Somatic Complaint Variation
This variation involves discomfort and complaints that do not interfere with everyday functioning. It is a universal experience. In infancy, the complaints probably manifest as transient gastrointestinal distress. In childhood, classic recurrent abdominal pain, headaches, and “growing pains” make their appearance. Adolescents may experience menstrual discomfort and other transient aches and pains, but these characteristically do not impair their ability to function. Females report more somatic complaints after puberty.
Somatic Complaint Problem
This consists of one or more physical complaints that do cause sufficient distress and impairment (physical, social, or school) to be considered a problem. In infancy, this would occur when gastrointestinal symptoms seriously interfere with feeding and sleep. In childhood, it entails avoiding or refusing to undertake expected activities (eg, increased school absences). As adolescence approaches, in addition to the somatic complaints, more emotional distress, social withdrawal, and academic difficulties begin to appear. More severe complaints may result in refusal to attend school, aggressive behavior, and recurrent pain syndromes.
Undifferentiated Somatoform Disorder
This condition emerges during adolescence, causing significant impairment. Multiple severe symptoms of at least 6 months’ duration are required to make the diagnosis. They include, but are not limited to, pain syndromes, gastrointestinal or urogenital complaints, fatigue, loss of appetite, and pseudoneurologic symptoms. To qualify for this diagnosis, the symptoms should not be explained better by another mental disorder, such as a mood or anxiety disorder, and should not be feigned or intentionally produced. A more severe form, the classic somatization disorder, usually is an adult condition.
Somatoform Disorder, Not Otherwise Specified
This classification encompasses adolescents who have somatoform symptoms that do not meet the criteria for any specific somatoform disorder, such as pseudocyesis, in which the false belief of being pregnant often is accompanied by endocrine changes. Another common example is unexplained physical complaints (eg, fatigue, weakness) of fewer than 6 months’ duration.
There are three types of pain disorder: pain associated with psychological factors, pain associated with both a psychological and general medical condition, and pain associated with a general medical condition. The onset of pain may be related to psychological stressors or avoidance of something threatening. Pain disorders frequently begin as a mild pain syndrome. Pain can worsen due to the inadvertent secondary gain achieved by avoiding stress or academic pressures. These symptoms may be associated with frequent visits to the pediatrician and parental pressure for unnecessary testing and interventions.
In conversion disorders, one or more symptoms or deficits affects a sensory or voluntary motor function (eg, blindness, paresis), suggesting a medical or neurologic condition, yet the findings are not consistent with any known neuroanatomic/pathophysiologic explanation. The symptoms tend to have a “symbolic meaning,” dealing with an unsolved and unconscious conflict (often relating to themes of aggression or sexuality). The symptoms appear to be an attempt to resolve the conflict (primary gain), although they often result in increased attention for the patient (secondary gain). This form of somatization disorder frequently, but not always, is accompanied by “la belle indifference,” an attitude of disinterest by the patient despite the serious symptoms experienced. Although the symptoms are usually self-limited, resolving within 3 months, they may be associated with chronic sequelae, such as contractures. There is frequently a model for the symptoms, with the patient sometimes serving as his or her own model, as is the case with pseudoseizures in patients who have epilepsy. However, over time, up to one third of patients in whom conversion disorder is diagnosed develop a neurologic disorder.
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) from the American Psychiatric Association includes additional disorders in the list of somatization disorders: hypochondriasis (preoccupation with the idea of having a serious disease) and body dysmorphic disorder (overpreoccupation with an imagined or exaggerated defect in physical appearance). They are uncommon and seen primarily during adolescence and young adulthood.
It is beyond the scope of this review to address specifically the large variety of common symptoms that may have a psychogenic origin or component, such as constipation and encopresis, enuresis, vomiting, headaches, syncope, and fainting. All have been reviewed in detail in Pediatrics in Review (see Suggested Reading).
Psychiatric Disorders and Somatic Complaints
Psychiatric disorders such as depression and anxiety disorder often present initially with physical complaints such as poor concentration; fatigue; weight loss; and an increase in headaches, stomachaches, and chest pains. They must be considered as primary or possibly comorbid conditions in the evaluation of somatoform disorders. This is important to look for because epidemiologic studies show that 14% to 20% of American children have one or more moderate-to-severe psychiatric disorders, with the overall prevalence rising.
Establishing the diagnosis of a somatoform illness evolves over time along three simultaneous tracks: 1) Ruling out an organic disease as the cause of the symptoms, 2) Identifying psychosocial dysfunction, and 3) Containing and alleviating stressors. A concomitant biopsychosocial assessment by itself is therapeutic and often is followed by improvement and sometimes even resolution of symptoms. It also is important to highlight that the differential diagnosis is not based solely on a process of exclusion, but incorporates instead a set of positive findings (Table 2).
It can be unclear whether a particular complaint eventually will be functional or reflect an underlying disease. Therefore, it is important to consider explicitly psychosomatic etiology in the initial patient evaluation. This will make any future “disclosure” easier.
Findings that are highly suggestive of a somatization disorder include a history of multiple somatic complaints, multiple physician visits and specialty consultations, a family member who has chronic and recurrent symptoms, and dysfunction in the primary areas of life (family, peers, and school). Additional inquiry should include: Does the parent have any concern about the child’s behavior or emotional well-being? Is there a family history of psychiatric disorder or “bad nerves”? A detailed school history that reviews each year and the numbers of days missed is essential.
In the process of evaluating somatic complaints, the clinician should avoid the temptation to perform unnecessary, repetitive, or extensive testing in an attempt to demonstrate to the family that the presenting complaint is of psychosomatic origin.
A cost-effective method of determining the extent of laboratory and radiographic evaluation is to base it on the presence of “red flags”; that is, the detection of complaints and findings that suggest an organic pathology, such as syncope on exercise, asymmetric location of pain, anemia, or weight loss. When the history and physical examination findings are suggestive of somatization, a basic laboratory screening consisting of a complete blood count, an erythrocyte sedimentation rate or assessment of C-reactive protein, a urine dipstick evaluation, and sometimes a blood chemistry and occult blood stool test is sufficient. More extensive assessments are reserved for the “red flags.”
Eventually, the clinician needs to “bite the bullet,” so it is important to present initially to the family a differential diagnosis that includes the possibility that the symptoms may be related to stress, temperamental sensitivity, anxiety, or whatever term may be tolerated by the family to accept a behavioral intervention or even a request for psychological assessment. The best method of persuasion is to precede any disclosure with a clear demonstration that one has taken the complaint very seriously. This is best accomplished with a careful history and a detailed physical examination of much longer duration than the patient has been used to. The aim is to convey a sense of specialness to the child and family, which may serve as a buffer to the narcissistic injury stemming from having to recognize that “something is wrong” in the child’s life. Finally, it is necessary to reassess the course of illness and remain alert to the presence of the most common psychiatric disorders, which frequently present initially to the pediatrician. Therefore, pediatricians treating children who have recurrent somatic complaints need to become familiar with screening for anxiety disorder, depression, attention-deficit/hyperactivity disorder, substance use disorder, and conduct disorder.
Correct identification of somatization disorders may not be sufficient to provide help to patients and families, who often are reluctant to accept the explanation. Therefore, successful communication about the condition and the needed treatment is a crucial but sometimes elusive goal (Table 3). In preparation for disclosure of concerns about a possible somatization disorder, it is very important to ask the child and family about their fear or “fantasy of disease.” This may elicit surprising answers, such as fear that the child may have cancer or heart disease. Conversely, the reply may convey an already harbored suspicion or understanding of the problem, such as “It may be stress or nerves.” In any case, patients will be willing to listen to the pediatrician only if he or she first listens to them. A clear, supportive, matter-of-fact explanation also should assure families that the pediatrician will be available to help with the onslaught of feelings that many families experience at the time of diagnosis.
It is important for pediatricians to recognize their own response to the family resistance and reluctance to lay aside the “search for disease” and not inadvertently transmit their own frustration about the difficult and time-consuming task they are facing.
A primary reason that patients are angry and reject the diagnosis of somatization disorder is that they feel disrespected and not believed: “You think it is all in my head, but I know I hurt and that there is something wrong.” In part, this relates to the unfortunate term “psychosomatic,” which conveys the mistaken notion of a body-mind duality, and for some still has the connotation of craziness (“psycho”). Therefore, it is important to explain that a “functional versus organic” paradigm is old-fashioned and does not reflect current thinking, which suggests a more complex interplay of multiple factors underlying the patient’s symptoms.
Essentially, the pediatrician must convey understanding that the patient’s pain is real. That is, the doctor has learned that pain is due to a neural nociceptive component and an affective component, both processed by the central nervous system and influenced by personal experience, genetics, and the environment.
To help patients and parents become more open to the concept of somatization, they can be reminded of how themes in language acknowledge the connection between emotions and bodily processes. For example, we talk about having a “gut reaction,” having “butterflies in my stomach,” feeling “all choked up,” and that something “makes me vomit.” In addition, we also note that embarrassment can manifest as blushing, fear as cold sweat, and anger as stiffening muscles and clenching teeth, thus facilitating explanations such as “blushing of the gut” and “spastic colon.” Another strategy is to help them view somatization as a sensitivity, a phenomenon of “amplification” of otherwise normal body sensations.
At the center of any successful program is the untiring effort to motivate patients and parents toward a partnership in dealing with the symptoms and complaints. It could be argued that the risk of antagonizing patients with a diagnosis of somatization and the subsequent running away and “doctor shopping” calls for simply helping patients by medicating them with analgesics, tranquilizers, anxiolytics, and other agents from the pharmacopeia, including placebos. Although this may be tempting and certainly is easier, such an approach should be avoided when possible because it may reinforce the search for the “magic pill” and a never-ending pursuit of a technological solution. At a deeper level, the reason for informing patients and families of the nature of the disorder involves the principle of respect for persons; it is an ethical duty, with few exceptions, to share with patients our understanding of their situation. The primary exception to this rule, which allows for justified paternalism and “face-saving” suggestive therapies, is patients who have conversion disorders and cannot make use of the information. This may be due to the nature of the disorder, which often does not allow them to realize that they are experiencing stress or that their response to the stressor is dysfunctional.
The diagnosis of somatization never should lead a patient or parent to the perception that this diagnosis will be raised as a barrier to preempt future complaints. Instead, it should become clear that the diagnosis is made in the spirit of offering an interpretation that may call for newer and more effective treatments such as stress management and individual or family counseling. Somatoform disorders do respond to treatment and rehabilitation. Cognitive and behavioral interventions; use of positive and negative reinforcements; and self-monitoring techniques such as hypnosis, relaxation, and biofeedback have been proven successful. Family counseling and good communication between the clinician and the school often can “turn things around.”
An important consideration when treating patients who have somatization disorders is that although the presence of a concomitant psychiatric disease is much lower in children than in the adult population, children can be afflicted by comorbidities such as mood disorders, anxiety disorders, and substance abuse, which should be sought to assure successful treatment. Patients who have a comorbid condition do not respond to treatment unless the psychiatric condition is addressed. Conversely, a patient not responding to intensive treatment should be evaluated for the possibility of comorbidity.
Judicious use of psychopharmacologic treatment in somatoform disorders may be appropriate when comorbid depression or anxiety is suspected or the severity of symptoms has led to significant and prolonged impairment (>3 mo). If the pediatrician can convince the patient and family to seek additional treatments such as therapy and evaluation for the use of medication, it is important that the consulting psychiatrist be asked to provide feedback directly to the pediatrician. Families often otherwise report that the psychiatrist said there was “nothing wrong, it was all medical.” The consultant should be expected to tell the referring pediatrician what services will be provided and what the pediatrician is expected to monitor. For pediatricians who are sophisticated in the use of psychotropic medications, a psychiatric referral might not be necessary.
Often families worry that the diagnosis of somatization will be followed by abandonment by the physician. This concern can be dispelled by arranging frequent follow-up visits, which have the potential to “preempt” the frequent emergence of new symptoms, prevent emergency department visits, and ease the overall management of symptoms. It is helpful to emphasize that all forthcoming symptoms will be examined with the attention they deserve because somatizing under stress is very common and does not “provide immunity” against appendicitis, lupus, diabetes, and other conditions. Most families, even when disagreeing with their physicians, can accept (albeit grudgingly) treatment recommendations if they are assured of an attentive, open-minded, and regularly scheduled follow-up.
The structure of medical services conspires against optimal care for patients afflicted by somatization disorders, in part because procedural interventions historically have been valued above spending time with patients and in part because many organizations “carve out” these types of disorders for treatment through the mental health coverage. Frequently, such “carve outs” mean that patients have to pay their pediatrician out of pocket or from their mental health benefits. At other times, services simply go unpaid.
Depending on contractual arrangements, pediatricians currently have three less-than-satisfying options: 1) accept the rate of reimbursement for their services and bill the rest to the family, 2) refer the family to a consultant and coordinate care, or 3) negotiate directly with the payer about the case (armed with the DSM-IV).
With appropriate intervention, the prognosis for most somatization disorders in children and adolescents is very good. However, many untreated children risk continuous somatization as adults. On occasion, somatization is the proverbial “tip of the iceberg” that calls attention to a psychiatric disorder that requires mental health consultation and treatment. The most severe form, the undifferentiated somatoform disorder, probably is related closely to personality disorders, is of long duration, and has a persistent course, continuing into adulthood.
From a professional development perspective, advocacy work must continue to emphasize that changes in medical economics and the recognition of the financial impact of somatization on utilization call for increased funding for research and training in this area.
Appendix: Sections of the Relevant Criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)
The purpose of this appendix is to provide details on the diagnostic categories for the DSM-IV disorders pertinent to children. The disorders are listed in alphabetical order.
Diagnostic Criteria for Conversion Disorder 300.11
A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other general medical condition.
B. 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.
C. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
D. 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.
E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
F. 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.
Specify type of symptom or deficit:
With Motor Symptom or Deficit
With Sensory Symptom or Deficit
With Seizures or Convulsions
With Mixed Presentation
Diagnostic Criteria for Pain Disorder 307.80
A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
D. The symptom or deficit is not intentionally produced or feigned (as factitious disorder or malingering).
E. The pain is not better accounted for by a mood, anxiety, or psychotic disorder, and does not meet criteria for dyspareunia.
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
307.89 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 is coded.
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
Note: The following is not considered to be a mental disorder and is included here to facilitate differential diagnosis.
Pain Disorder Associated With a General Medical Condition
A general medical condition has a major role in the onset, severity, exacerbation, or maintenance of the pain. (If psychological factors are present, they are not judged to have a major role in the onset, severity, exacerbation, or maintenance of the pain.) The diagnostic code for the pain is selected based on the associated general medical condition if one has been established or on the anatomical location of the pain if the underlying general medical condition is not yet clearly established - for example, low back (724.2), sciatic (724.3), pelvic (625.9), headache (784.0), facial (784.0), chest (786.50), joint (719.4), bone (733.90), abdominal (789.0), breast (611.71), renal (788.0), eye (379.91), throat (784.1), tooth (525.9), and urinary (788.0).
Diagnostic Criteria for Somatization Disorder 300.82
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:
(1) Four pain symptoms: a history of pain related to at least four different sites or functions (eg, 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 (eg, 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 (eg, sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
(4) One pseudoneurological symptoms: 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)
C. 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 (eg, a drug of abuse, a 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.
D. The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).
Diagnostic Criteria for Somatoform Disorder, Not Otherwise Specified 300.82
This category includes disorders with somatoform symptoms that do not meet the criteria for any specific somatoform disorder. Examples include:
(1) Pseudocyesis: a false belief of being pregnant that is associated with objective signs of pregnancy, which may include abdominal enlargement (although the umbilicus does not become everted), reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, nausea, breast engorgement and secretions, and labor pains at the expected date of delivery. Endocrine changes may be present, but the syndrome cannot be explained by a general medical condition that causes endocrine changes (eg, a hormone-secreting tumor).
(2) A disorder involving nonpsychotic hypochondriacal symptoms of less than 6 months’ duration.
(3) A disorder involving unexplained physical complaints (eg, fatigue or body weakness) of less than 6 months’ duration that are not due to another mental disorder.
Diagnostic Criteria for Undifferentiated Somatoform Disorder 300.82
A. One or more physical complaints (eg, fatigue, loss of appetite, gastrointestinal or urinary complaints)
B. Either (1) or (2):
(1) After appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (eg, a drug of abuse, a medication).
(2) When 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.
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important 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 (eg, 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).
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