Dissociative and Somatoform Disorders 373
disorder: Patients never have an opportunity to test their (irrational) beliefs.
Through negative reinforcement, the behavior persists (see Chapters 2 and 7).
Social Factors: Cultural Emphasis on Certain Body Features
Although the features of body dysmorphic disorder are similar across cultures, the
specifi c body parts that are the focus of patients’ attention can vary, depending on
the bodily attributes that are valued or emphasized in a given culture or subculture.
For instance, many men with body dysmorphic disorder in the United States focus on
the perception that they have small or inadequate muscles (Pope et al., 1997, 2000),
whereas women tend to focus on their hips and weight (Phillips & Diaz, 1997).
Is Somatoform Disorder a Useful Concept?
Some researchers criticize the concept of somatoform disorders as a category
(Mayou et al., 2005; Noyes et al., 2008). They point out that other disorders, such
as mood and anxiety disorders, can also be accompanied by bodily symptoms,
and so the distinction between bodily symptoms in those disorders and those in
somatoform disorders is not clear. In fact, medically unexplained symptoms most
frequently occur with depression and anxiety disorders (Smith, et al., 2005). More-
over, many cultures reject the concept of somatoform disorders because body and
mind are viewed as interrelated; the fact that there is no medical explanation for a
bodily symptom is irrelevant (Lee, 1997).
Other researchers point out that different clinicians often decide on differentdiagnoses for the same patient with somatoform symptoms, making diagnos-
tic reliability a problem (Simon & Gureje, 1999). Moreover, all four somatoform
disorders are rare, particularly SD and hypochondriasis, which decreases their diag-
nostic usefulness for clinicians using the DSM-IV-TR classifi cation system (Creed,
2006; Creed & Barsky, 2004; Gureje, Ustun, & Simon, 1997; Lynch et al., 1999).
Another criticism notes that the relevant neurological, psychological, and socialfactors are all apt to contribute to many medical disorders (Bradfi eld, 2006), and
that somatoform disorders are not necessarily best conceived of as psychological
disorders. The primary symptoms of somatoform disorders are medical, and the fact
that some of the other symptoms are psychological does not imply that the disorders
themselves are psychological (Sykes, 2006). For instance, psychological factors may
contribute to a heart attack, but heart attack is not included among the DSM-IV-TR
list of psychological disorders.
Others point out that relying on the existence of medically unexplainedsymptoms—which underlies the diagnostic category of somatoform disorders—
may only refl ect the present state of knowledge about a particular set of symptoms
(Merskey, 2004). That is, “medically unexplained” means “with present techniques,
medically unexplained”—not “in principle, forever impossible to explain medi-
cally.” With the passage of time, two sorts of developments may lead the category
of somatoform disorders to disappear. First, as more becomes known about the
factors that contribute to each somatoform disorder, some of them may be moved
to other categories, such as anxiety disorders or dissociative disorders. Second, as
medical technology and diagnostic techniques improve, some patients who are cur-
rently diagnosed with a somatoform disorder may be shown to have an underlying
medical problem that explains their symptoms, and thus this category of psycho-
logical diagnosis would no longer be appropriate.
Treating Somatoform Disorders
When treating any of the four somatoform disorders (SD, conversion disorder,
hypochondriasis, or body dysmorphic disorder), clinicians target neurological,
psychological, and social factors—individually or in combination. As we explain
below, cognitive-behavioral therapy is generally the treatment of choice for soma-
toform disorders. Let’s examine similarities and differences in treatment for the
four disorders.
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