• Clinical science

Somatic symptom and related disorders

Abstract

Somatic symptom and related disorders are characterized by prominent somatic symptoms that are associated with significant distress and psychosocial impairment. These symptoms are usually characterized by prominent somatic symptoms that are not explained by a medical condition and that are exacerbated by personal stress, depression, and interpersonal conflicts. Depending on the specific disorder, the origin of the symptoms may be conscious or unconscious and may be fueled by a desire to assume the role of a sick patient. Somatic symptom and related disorders can be differentiated from malingering (i.e., intentionally faking symptoms for an external benefit such as avoiding work). Management of somatic symptom and related disorders involves psychotherapy and pharmacotherapy (most commonly antidepressants). It is crucial to schedule regular visits with the same physician in order to avoid unnecessary tests and procedures.

Overview

  • Definition
    • Disorders that are characterized by prominent somatic symptoms associated with significant distress and psychosocial impairment that cannot be explained by a medical condition
    • Symptoms are exacerbated by stress and interpersonal conflicts.
  • Dealing with patients with somatic symptom disorders
    • Set clear time limits for appointments
    • Separation of presentation of symptoms and medical care → fixed appointments independent of the patient's symptoms
    • Calm approach towards the patient: A distant yet empathetic approach improves the physician-patient relationship.
    • Note: A suspected psychological etiology should not be voiced before a sound physician-patient relationship has been established. Premature confrontation may cause the patient to reject the physician's opinion and stop seeing him/her.
    • Note: Avoid obsession with a somatic disorder.

Somatic symptom disorder

  • Summary: Patients with somatic symptom disorder often have multiple physical symptoms that cause significant distress and have a history of extensive (and fruitless) diagnostic testing and medical procedures; . Affected patients maintain a preoccupation with their symptoms and health concerns over an extended period.
  • Epidemiology
  • Diagnostic criteria (according to DSM-5)
    • ≥ 1 somatic symptom that causes significant distress or impairment
    • The patient exhibits excessive thoughts, feelings, or behaviors related to the somatic symptoms or health manifested by ≥ 1 of the following:
      • Disproportionate and constant thinking about the severity of symptoms
      • Constant anxiety about symptoms or general health
      • Excessive amounts of time and energy attending to symptoms or health concerns
    • Duration: ≥ 6 months
  • Management
    • Establish regular visits with a single primary care physician; in order to minimize unnecessary testing and procedures.
    • Gradually begin to address psychological issues with psychotherapy.

Patients with somatic symptom disorder usually bring a multitude of reports from various physicians!

References:[1][2]

Conversion disorder

  • Summary: Patients with conversion disorder (also known as functional neurological symptom disorder) present with neurological symptoms that cannot be fully explained by a neurological condition.
  • Epidemiology
    • >
    • Age of onset: 10-35 years
    • Strongly associated with comorbid psychiatric or neurological disorders
  • Diagnostic criteria (according to DSM-5)
    • ≥ 1 neurological symptom (altered motor or sensory function)
    • Reported symptoms must be incompatible with recognized neurological or medical conditions.
    • Reported symptoms are not explained better by another medical disorder.
    • Symptoms cause significant distress or psychosocial impairment.
  • Management

References:[1][3]

Illness anxiety disorder

  • Summary: : In illness anxiety disorder (previously known as hypochondriasis), patients present with a persistent preoccupation with having or developing a serious illness; . Somatic symptoms are usually absent or mild, but patients spend large amounts of time and energy obsessing over their health and over the possibility of developing a disease.
  • Epidemiology
    • =
    • Age of onset: usually early adulthood
    • Strongly associated with comorbid anxiety or depressive disorders
  • Diagnostic criteria (according to DSM-5)
    • Preoccupation with having or acquiring an illness
    • Somatic symptoms absent or mild
    • Significant anxiety over health
    • Excessive health-related behaviors (e.g., constantly checking for minor signs of illness) or maladaptive avoidance (e.g., frequently switching doctors)
    • Duration: ≥ 6 months
    • Not better explained by another mental disorder
  • Management
    • Cognitive behavioral therapy
    • Schedule regular visits to one primary care physician.
    • Treat comorbid disorders (e.g., depression), if present.

References:[1][4][3]

Psychological factors affecting other medical conditions

  • Summary: Psychological factors affecting other medical conditions refer to psychological or behavioral factors (such as maladaptive coping styles or distress) that adversely affect a medical condition by increasing the risk of severe symptoms, disability, or death.
  • Diagnostic criteria (according to DSM-5)
    • A medical symptom or condition (that is not a mental disorder) must be present.
    • The patient exhibits psychological or behavioral factors that adversely affect the following aspects of the medical condition:
      1. The course of illness
      2. Adequate treatment of the condition (e.g., poor adherence to prescribed medication)
      3. Add further risk factors for the individual (e.g., an asthmatic who starts smoking)
      4. Influence the underlying pathophysiology or clinical features (e.g., chronic work stress increasing severity of hypertension)
    • The psychological or behavioral factors must not be better explained by another mental disorder.
  • Management
    • Patient education
    • Schedule regular visits to one primary care physician.
    • Treat the underlying medical condition.

References:[1]

Factitious disorders

Factitious disorder imposed on self Factitious disorder imposed on another
Summary
  • Previously known as Münchhausen syndrome
  • Patients intentionally falsify signs and symptoms, even through self-harm (e.g., injecting insulin), to assume the role of a patient
  • Subtype of factitious disorder
  • Patients intentionally produce symptoms in someone else (usually their child).
Epidemiology
Diagnostic criteria (according to DSM-5)
A Intentionally deceptive falsification of disease signs or symptoms, inducing injury, or promoting disease in self Intentionally deceptive falsification of disease signs or symptoms or intentional induction of injury or disease in another individual
B Presents himself, herself to others as ill, impaired, or injured Presents another individual (victim e.g., a pet, child, or another adult) to others as ill, impaired, or injured
C Even occurs in the absence of external rewards
D Behavior is not better explained by another mental disorder.
  • Management
    • Confront the patient in a non-threatening manner.
    • Avoid unnecessary referral to avoid unnecessary procedures.
    • Treat the perpetrator (if imposed on self or on another).
      • Psychotherapy and/or parenting classes
      • Assess for comorbid conditions.
      • Monitor pharmacotherapy intake.
    • Treat the victim (if imposed on another).
      • Provide a safe place from the perpetrator (e.g., call child protective services).
      • Psychotherapy, depending on the child's age
      • Exclude other forms of abuse or neglect if suspected.

In factitious disorders, there is evidence that the individual is intentionally falsifying injury or disease in the absence of external rewards. They can be contrasted with somatic symptom disorder, in which there is no evidence that the individual is behaving deceptively and malingering and external rewards are an incentive!

In factitious disorder imposed on another, the perpetrator receives the diagnosis. An abuse and neglect diagnosis should be considered for the victim!

References:[1][5][6][4]

Differential diagnoses

Factitious disorder imposed on self
  • Evidence of intentional production or exaggeration of somatic complaints to themselves or others
  • No secondary gain; goal is rather to assume the role of a patient
Somatic symptom disorder
  • Excessive somatic complaints and worry
  • Absence of a serious medical condition
  • No evidence of production or exaggeration of somatic complaints
  • No secondary gain
  • Relieved by regularly scheduled appointments and tests
Conversion disorder
  • Calm, indifferent patient
  • Neurological symptoms that are incompatible with recognized neurological or medical conditions
Malingering
  • Intentional vague, inconsistent somatic complaints
  • Secondary gain (e.g., to avoid working)

Malingering

  • Summary: Individuals displaying malingering behavior present with vague complaints, either false or grossly exaggerated, that do not conform to a known medical condition. This is an intentional behavior motivated by an external reward (e.g., avoiding the police; obtaining narcotics, insurance money, sympathy from others, time off work, etc.). Malingering individuals are typically uncooperative and insist on undergoing an extensive medical evaluation.
    • Not classified as a mental disorder
  • Epidemiology: >
  • Diagnostics: Any combination of the following are suggestive of the condition.
    • The individual presents under medicolegal circumstances (e.g., self-referral while criminal charges are pending).
    • Clinical findings do not match up with the individual's complaints.
    • Lack of patient cooperation during diagnostic evaluation and/or treatment
    • Features of antisocial personality disorder
  • Management
    • Confront the patient in a nonthreatening manner (give the patient the opportunity to be honest).
    • Avoid unnecessary referral (which perpetuates malingering).

Malingering is not classified as a somatic symptom and related disorder or another mental illness in the DSM-5!

References:[4]

The differential diagnoses listed here are not exhaustive.

  • 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). https://www.psychiatry.org/psychiatrists/practice/dsm. Accessed May 26, 2017.
  • 2. Kurlansik SL, Maffei MS. Somatic Symptom Disorder . Am Fam Physician. 2016; 93(1): pp. 49–54A. url: http://www.aafp.org/afp/2016/0101/p49.html.
  • 3. Oyama O, Paltoo C, Greengold J. Somatoform disorders. Am Fam Physician. 2007; 76(9): pp. 1333–8. pmid: 18019877.
  • 4. Sadock BJ, Sadock VA, Ruiz P. Synopsis of Psychiatry. New York, NY: Wolters Kluwer Health; 2014.
  • 5. Brannon GE, Xiong GL. Factitious Disorder Imposed on Another (Munchausen by Proxy). In: Factitious Disorder Imposed on Another (Munchausen by Proxy). New York, NY: WebMD. http://emedicine.medscape.com/article/295258-overview#a1. Updated November 11, 2015. Accessed July 18, 2017.
  • 6. Elwyn TS, Xiong GL. Factitious Disorder Imposed on Self (Munchausen's Syndrome). In: Factitious Disorder Imposed on Self (Munchausen's Syndrome). New York, NY: WebMD. http://emedicine.medscape.com/article/291304-overview#a1. Updated December 1, 2016. Accessed July 18, 2017.
last updated 11/16/2018
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