Such symptoms are present to various degrees, particularly in conversion disorder, but so- matic symptom disorders can also accompany diagnosed medical disorders. The reli- ability of determining that a somatic symptom is medically unexplained is limited, and grounding a diagnosis on the absence of an explanation is problematic and reinforces mind-body dualism. It is not appropriate to give an individual a mental disorder diagnosis solely because a medical cause cannot be demonstrated. Furthermore, the presence of a medical diagnosis does not exclude the possibility of a comorbid mental disorder, includ- ing a somatic symptom and related disorder. Perhaps because of the predominant focus on lack of medical explanation, individuals regarded these diagnoses as pejorative and de- meaning, implying that their physical symptoms were not ”real." The new classification defines the major diagnosis, somatic symptom disorder, on the basis of positive symptoms (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms). However, medically unexplained symptoms remain a key feature in order) because it is possible to demonstrate definitively in such disorders that the symp- toms are not consistent with medical pathophysiology.
It is important to note that some other mental disorders may initially manifest with pri- marily somatic symptoms (e.g., major depressive disorder, panic disorder). Such diagno- ses may account for the somatic symptoms, or they may occur alongside one of the somatic symptom and related disorders in this chapter. There is also considerable medical comor- bidity among somatizing individuals. Although somatic symptoms are frequently associ— ated with psychological distress and psychopathology, some somatic symptom and related disorders can arise spontaneously, and their causes can remain obscure. Anxiety ders. The somatic component adds severity and complexity to depressive and anxiety dis- orders and results in higher severity, functional impairment, and even refractoriness to traditional treatments. In rare instances, the degree of preoccupation may be so severe as to warrant consideration of a delusional disorder diagnosis.
A number of factors may contribute to somatic symptom and related disorders. These include genetic and biological vulnerability (e.g., increased sensitivity to pain), early trau- matic experiences (e.g., violence, abuse, deprivation), and learning (e.g., attention ob- tained from illness, lack of reinforcement of nonsomatic expressions of distress), as well as cultural/social norms that devalue and stigmatize psychological suffering as compared with physical suffering. Differences in medical care across cultures affect the presentation, recognition, and management of these somatic presentations. Variations in symptom pre- sentation are likely the result of the interaction of multiple factors within cultural con- texts that affect how individuals identify and classify bodily sensations, perceive illness, and seek medical attention for them. Thus, somatic presentations can be viewed as expres- sions of personal suffering inserted in a cultural and social context.
All of these disorders are characterized by the prominent focus on somatic concerns and their initial presentation mainly in medical rather than mental health care settings. 50- matic symptom disorder offers a more clinically useful method of characterizing individ- uals who may have been considered in the past for a diagnosis of somatization disorder.