Diagnosis and Differential Diagnosis
As shown in Figure 54.1, after it is determined that physical symptoms
are not fully explained by a general medical condition or the direct effect of
a substance, somatoform disorders must be differentiated from other mental
conditions with physical symptoms.
In contrast to malingering and factitious disorder, symp-toms in somatoform disorders are not under voluntary control, that is, they are not intentionally produced or feigned. Deter-mination of intentionality may be difficult and must be inferred from the context in which symptoms present. Somatic symptoms may also be involved in disorders in other diagnostic classes. However, in such instances, the overriding focus is on the pri-mary symptom complex (i.e., anxiety, mood, or psychotic symp-toms) rather than the physical symptoms. In panic disorder and in generalized anxiety disorder, physical symptoms such as chest pain, shortness of breath, palpitations, sweating and tremulous-ness may occur. However, such somatic symptoms occur only in the context of fear or anxious foreboding. In general, there is a lack of a consistent physical focus. In mood disorders (particu-larly major depressive disorder) and in schizophrenia and other psychotic disorders, somatic preoccupations, fears, and even
delusions and false perceptions may be evident. In the mood dis-orders,
these are generally mood congruent (e.g., “I’m so worth-less not even my organs
work anymore”), whereas in the psycho-ses, bizarre and mood-incongruent beliefs
are typical (e.g., “Half of my brain was removed by psychic neurosurgery”).