| IHS | Diagnosis | ICD-10 |
|---|---|---|
| 12.1 | Headache attributed to somatisation disorder [F45.0] | R51 |
Diagnostic criteria:
- Headache, no typical characteristics known, fulfilling criterion C
- Presence of somatisation disorder fulfilling DSM-IV criteria:
- history of many physical complaints beginning before age 30 that occur over a period of several years and result in treatment being sought and/or in significant impairment in social, occupational or other important areas of functioning
- at least four pain symptoms, two non-pain gastrointestinal symptoms, one sexual or reproductive symptom and one pseudoneurological symptom
- after appropriate investigation, each of these symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance or medication; or, if there is a related medical condition, the complaints or impairment are in excess of what would be expected from the history, examination or laboratory findings
- Headache is not attributed to another cause
Comments:
Somatisation disorder, as defined in DSM-IV, is a polysymptomatic disorder characterised by multiple recurring pains and gastrointestinal, sexual and pseudoneurological symptoms occurring for a period of years with onset before age 30. These symptoms are, by definition, considered to be somatoform: that is, they are complaints of physical symptoms suggestive of, but not fully explained by, a medical condition or the direct effect(s) of a substance. In the United States, it is found predominantly in women, in whom the lifetime risk is estimated to be 2.0%, with a female/male ratio of approximately 10:1. This ratio is not as large in some other cultures (eg, in Greeks and Puerto Ricans).
It should be noted that the symptom requirement laid out in DSM-IV is quite extensive: a minimum of eight somatoform symptoms must have occurred over the patient's lifetime, each one severe enough to result in the seeking of medical help or the taking of a medication (prescribed or over-the-counter), or to affect the person's functioning (eg, causing missed days at work). DSM-IV has set such a high threshold in order to reduce false positives, most particularly the possibility that the "unexplained" symptoms are in fact part of a complex and as yet undiagnosed medical condition with variable symptom presentation such as multiple sclerosis or systemic lupus erythematosus. Somatoform disorders with fewer than eight symptoms are diagnosed in DSM-IV as Undifferentiated somatoform disorder. Because of the difficulty and uncertainty associated with this diagnosis, A12.6 Headache attributed to undifferentiated somatoform disorder is included only in the appendix.
To ascertain whether headache is part of the presentation of somatisation disorder, it is important to ask whether the patient has a history of multiple somatic complaints, since at any one time the patient may be focused on one particular complaint. Consider the following case scenario (from Yutzy, 2003):
A 35-year-old woman presented with a complaint of extreme headaches, "like a knife being stuck through the back of my head into my eye," as well as other headaches virtually every day. After medical and neurological examinations failed to suggest any specific aetiology for either headache, it was important to take a careful history of past symptoms. In this case, the woman also reported a history of other pains, including abdominal pain associated at times with nausea and vomiting, periods of constipation followed by diarrhoea which had resulted in investigation for gallbladder and peptic ulcer disease with no significant findings, and pain "in all of my joints" but particularly in her knees and her back that she said had been diagnosed as degenerative arthritis at age 27 years yet no deformities had developed since. She had had menstrual problems since menarche, with pain that put her to bed and excessive flow with "big blue clots", which had resolved only after hysterectomy two years earlier at age 33 years. The mother of four, she reported a long history of sexual problems including pain with intercourse. She had been told that she had a "tipped uterus". Throughout her life, she was seldom orgasmic and had not enjoyed sex "for years". She reported episodes of blurred vision with "spots" in front of her eyes, which caused her to stop work, and other episodes when she just could not hear anything, "like someone put their hands over my ears." She also reported periods of uncontrollable shaking and a feeling that she was losing control of her body, for which she had been investigated for seizures. She reported that, at times, she had feared having some serious medical disease but "with all the work-ups I have had, I am sure they would have found something by now."
As was evident after a complete medical history, the headaches were part of a much more involved syndrome. This woman had had multiple physical complaints with onset before age 30 that had no adequate medical explanation, were severe enough to cause her to seek medical attention and affected a variety of organ systems meeting the DSM-IV criteria for Somatization disorder (ie, at least four pain symptoms [headaches, abdominal pain, back pain and knee pain], at least two non-pain gastrointestinal symptoms [nausea, vomiting, diarrhoea and constipation], at least one sexual or reproductive symptom [pain on intercourse, excessive menstrual flow, loss of sexual enjoyment] and at least one pseudoneurological symptom [muffled hearing, uncontrollable shaking, blurred vision, spots in visual field]). Thus, her headaches would be correctly diagnosed as 12.1 Headache attributed to somatisation disorder.
