• Clinical science

Somatic symptom and related disorders

Summary

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.

Somatic symptom disorder

  • Summary
    • Individuals with somatic symptom disorder often have multiple physical symptoms that cause significant distress and also have a history of extensive (and fruitless) diagnostic testing and medical procedures.
    • Affected individuals maintain a preoccupation with their symptoms and health concerns over an extended period.
    • Symptoms and motivation are unconscious, symptoms are not intentionally produced (as opposed to factitious disorders).
    • Symptoms may be related to another medical condition.
  • Epidemiology
  • Diagnostic criteria (according to DSM-5)
    • ≥ 1 somatic symptom (e.g., heartburn, fatigue, headache, abdominal pain) 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 often bring a multitude of reports from various physicians!

References:[2][1]

Conversion disorder

  • Summary
  • Epidemiology
    • >
    • Age of onset: ∼ 10–35 years [4]
    • Strongly associated with comorbid psychiatric or neurological disorders
    • Can be associated with past traumatic/stressful events
  • Diagnostic criteria (according to DSM-5) [2]
    • ≥ 1 neurological symptom (altered motor or sensory function): e.g., paralysis, muscle spasms, blindness, mutism, lump in throat, weakness, gait disorder
    • 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:[2][4]

Illness anxiety disorder

  • Summary
    • Previously known as hypochondriasis
    • Affected individuals present with a persistent preoccupation with having or developing a serious illness despite recurrent medical examinations that find otherwise.
    • 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.
    • Motivation is unconscious; symptoms are not intentionally produced (opposite of factitious disorders)
  • Epidemiology
    • = [4]
    • Age of onset: usually early adulthood
    • Strongly associated with comorbid anxiety or depressive disorders
  • Diagnostic criteria (according to DSM-5) [2]
    • 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 behaviors (e.g., avoiding doc­tor appointments and hospitals)
    • 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:[2][5][4]

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) [2]
    • 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.

Factitious disorders

Overview of factitious disorders
Factitious disorder imposed on self Factitious disorder imposed on another
Summary
  • Previously known as Münchhausen syndrome
  • Individuals intentionally falsify physical signs and symptoms, even through self-harm (e.g., injecting insulin), to assume the role of a patient.
  • The goal is to get medical attention and sympathy (primary or internal gain) even though the motivation is unconscious.
Epidemiology
  • >
  • Associated with a history of significant exposure to health care (e.g., profession in health care, significant childhood illness, important relationship with a medical professional) and personality disorders (e.g., narcissistic, borderline, or antisocial personality disorder)
  • Assoiciated with a willingness to undergo invasive or risky treatments
Diagnostic criteria (according to DSM-5) [2]
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:[2][5]

Pseudocyesis

  • Summary: false belief of being pregnant associated with physical signs and symptoms of early pregnancy
  • Epidemiology
    • Age of onset: typically 20–39 years
    • More common among women who wish to conceive and have a history of several prior failed attempts
  • Clinical features: breast tenderness, weight gain, amenorrhea, morning sickness, mild abdominal enlargement
  • Diagnostics: undetectable β-hCG, empty uterus on ultrasound
  • Management: gently inform the patient that she is not pregnant; provide counseling and psychotherapy if needed

Differential diagnoses

Differential diagnoses of somatic symptom and related disorders
Disorders Description
Factitious disorder imposed on self
  • Evidence of intentional production or exaggeration of somatic complaints about oneself
  • No secondary gain; goal is to assume the role of a patient in order to receive sympathy and medical care
  • Medical complaints continue even after medical care has been provided.
Factitious disorder imposed on another
  • Intentional production or fabrication of symptoms in someone else (usually children/elderly)
  • No secondary gain; goal is to become the caregiver of the patient and gain benefits as a result of that.
  • Complaints continue even after medical care has been provided.
Vulnerable child syndrome
  • Child is perceived by parents as prone to getting ill or injured
  • Commonly starts after the child experienced serious illness or a life-threatening accident
  • Multiple absences from school and/or exaggerated use of medical services is common
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
  • Intentionally vague, inconsistent somatic complaints
  • Secondary gain (e.g., to avoid working)
  • Medical complaints stop after the objective of secondary gain has been achieved (e.g., paid medical leave)

Malingering [2]

  • Summary: Individuals with malingering behavior provide 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 (secondary gain; e.g., avoiding the police, obtaining narcotics, insurance money, sympathy from others, time off work). Malingering individuals are typically uncooperative and insist on undergoing an extensive medical evaluation.
  • Epidemiology: >
  • Diagnostics: Any combination of the following is 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, follow-up, 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:[5]

The differential diagnoses listed here are not exhaustive.

  • 1. 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.
  • 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). . 2013. doi: 10.1176/appi.books.9780890425596.
  • 3. Stone J, Smyth R, Carson A, Warlow C. La belle indifférencein conversion symptoms and hysteria. British Journal of Psychiatry. 2006; 188(3): pp. 204–209. doi: 10.1192/bjp.188.3.204.
  • 4. Oyama O, Paltoo C, Greengold J. Somatoform disorders. Am Fam Physician. 2007; 76(9): pp. 1333–8. pmid: 18019877.
  • 5. Sadock BJ, Sadock VA, Ruiz P. Synopsis of Psychiatry. New York, NY: Wolters Kluwer Health; 2014.
last updated 11/03/2020
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