12.1 Headache attributed to somatization disorder

Description:
Headache occurring as part of the symptomatic presentation of a somatization disorder.

Diagnostic criteria:
A. Any headache fulfilling criterion C
B. A diagnosis has been made of somatization disorder characterized by both of the following:

    1. a history of multiple physical symptoms beginning before age 30 yr, which either have not been fully explained by a known medical condition or, when there is a related medical condition, are in excess of what would be expected from the history, physical examination, or laboratory findings
    2. during the course of the disorder, all of the following:

      a) at least four pain symptoms from or during four different sites or functions (eg, from head, chest, back, abdomen, joints, extremities and/or rectum, and/or during menstruation, sexual intercourse and/or urination)
      b) at least two gastrointestinal symptoms other than pain (eg, nausea, bloating, vomiting other than during pregnancy, diarrhoea and/or intolerance of several different foods)
      c) at least one sexual symptom other than pain (eg, sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding and/or vomiting throughout pregnancy)
      d) at least one pseudoneurological symptom not limited to pain (eg, conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in the throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures, dissociation symptoms such as amnesia and/or loss of consciousness other than fainting)

C. Evidence of causation demonstrated by at least one of the following:

    1. headache has evolved or significantly worsened in intensity in parallel with the development of other somatic symptoms attributed to somatization disorder
    2. constant or remitting headache parallels in time the fluctuation of other somatic symptoms attributed to somatization disorder
    3. headache has remitted in parallel with remission of the other somatic symptoms attributed to somatization disorder

D. Not better accounted for by another ICHD-3 diagnosis.

Comments:
Somatization disorder is characterized by a combination of multiple distressing symptoms and an excessive or maladaptive response to these symptoms or associated health concerns. Symptoms include gastric and/or other intestinal problems or dysfunctions, back pain, pain in the arms, legs or joints, headaches, chest pain and/or dyspnoea, dizziness, feeling tired and/or having low energy, and sleep troubles. The patient’s suffering is authentic, whether or not it is medically explained. Patients typically experience distress and a high level of functional impairment. The symptoms may or may not accompany diagnosed general medical disorders or psychiatric disorders. There may be a high level of medical care utilization, which rarely alleviates the patient’s concerns. From the clinician’s point of view, many of these patients seem unresponsive to therapies, and new interventions or therapies may only exacerbate the presenting symptoms or lead to new side effects and complications. Some patients feel that their medical assessment and treatment have been inadequate.

It should be noted that somatization disorder per se is not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the latest revision of the American Psychiatric Association’s diagnostic manual, scheduled for release in May 2013; it has been replaced by the category Somatic Symptom Disorder, characterized by one or more somatic symptoms associated with disproportionate and persistent thoughts about the seriousness of one’s symptoms, persistently high level of anxiety about health or symptoms or excessive time and energy devoted to these symptoms or health concerns. Given the enormous heterogeneity of this category (ie, it includes both individuals with headaches who have disproportionate concerns about the seriousness of the headache as well as classic cases of somatization disorder with a lifelong pattern of multiple somatic symptoms including headache), it was decided that it would be possible to assert attribution only when headache was part of a larger pattern of multiple somatic complaints. Thus, ICHD-3 (beta) continues to refer to the DSM-IV definition of somatization disorder.