Somatoform Disorder Not Otherwise Specified

The diagnostic category of somatoform disorder NOS is provided for those somatoform syndromes that do not meet the criteria for any specific somatoform disorder (see list of criteria in Table 59-3). This diagnosis may be appropriate for hypochondriacal symptoms of less than 6 months' duration and for disorders traditionally associated with hysteria such as pseudocyesis, globus syndrome (i.e., globus hystericus), psychogenic urinary retention, and mass psychogenic illness (i.e., mass hysteria). The diagnostic boundaries of these disorders are indistinct and may overlap at times with other diagnostic categories (e.g., psychological factor affecting medical condition, major depression, delusional disorder).

In this section, I review the treatment of pseudocyesis and mass psychogenic illness as examples of somatoform disorder NOS. However, this is a heterogeneous category, and treatments for one syndrome cannot necessarily be generalized to all other syndromes that might fit into this nonspecific diagnosis.

Pseudocyesis

The false belief that one is pregnant is an uncommon syndrome that was first described by Hippocrates (Whelan and Stewart 1990).

The most common symptoms include abdominal enlargement, amenorrhea or reduced menstrual flow, a subjective sense of fetal movement, nausea, breast engorgement, and labor pains at the expected date of delivery. These symptoms are primarily attributable to an exaggerated lumbar lordosis, gaseous distention, and depression of the diaphragm. The endocrine-effected changes are believed to be secondary to effects caused by depression on the hypothalamus.

Women with true pseudocyesis (i.e., those who do not simply have a mistaken belief of pregnancy that is easily reversed with factual data) may have an intense need to be pregnant, a fear or dread of pregnancy, or, paradoxically, both. Their need may be caused by social pressures, intrapsychic issues, or conflicts concerning sexual abuse (Hennessy and Polk-Walker 1990). The diagnosis of nonpregnancy is usually straightforward. If negative test results for serum or urinary chorionic gonadotropin are not convincing to the patient, then an ultrasound of the uterus, visualized by the patient and carefully interpreted by an experienced clinician, should convince the patient that she is not pregnant (O'Grady and Rosenthal 1989). The major differential diagnoses are erroneous pseudopregnancy (organic disorders), delusional pseudopregnancy (psychosis), and factitious pseudopregnancy (deception) (O'Grady and Rosenthal 1989).

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Treatment of pseudocyesis includes the following:

• A supportive confrontation in which the patient is informed that she is not pregnant
• Gentle exploration of the patient's life situation, hopes, and fears and determination of whether an underlying psychiatric illness is present (collaborative information from a family member may be important)