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Somatic Symptom and Related Disorders

 Everyone experiences somatic symptoms, and most can cope with them effectively. However, some people’s lives are overwhelmed by their somatic concerns. Sometimes the somatic concerns stem from well-established major medical illnesses; sometimes, the origins of the concerns are never quite clear. What is common in both situations are the pervasive and overwhelming thoughts and behaviors centered on these sensations. DSM-5 incorporated this perspective because the older perspective (only counting or cataloging symptoms labeled as medically unexplained) embodied in the previous versions of the disorder was unreliable and such perspective often put the doctor and the patient at odds over the question of the legitimacy and “reality” of the patient’s symptoms and personal suffering. ICD-10 continues the older approach. However, the planned revision will be more in line with DSM-5.

THE CLINICAL PRESENTATION

Persons suffering from one of these disorders have one or more somatic symptoms that become all-consuming or lead to notable impairment in their day-to-day lives. These symptoms are no longer required to be medically unexplained, as such a distinction in itself is unreliable, and because psychiatrists commonly treat patients with medically established diagnoses who are disproportionately troubled by or preoccupied with their physical symptoms.

Somatic Symptom Disorder

Patients with somatic symptom disorder believe that they have some severe yet undetected disease, and evidence to the contrary does not persuade them otherwise. They may maintain a belief that they have a particular disease or, over time, may transfer their belief to another disease. They are fixated on one or more somatic symptoms that they are convinced are evidence of illness. For some individuals, their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians. Others may have a genuine medical condition about which they develop excessive and unreasonable anxiety, and this is also a manifestation of somatic symptom disorder. Patients with somatic symptom disorder often experience symptoms of depression and anxiety, in addition to their somatic symptoms.

Illness Anxiety Disorder

Patients with illness anxiety disorder, like those with somatic symptom disorder, believe they have a serious but undiagnosed disease despite evidence to the contrary. They may maintain a belief that they have a particular disease or, as time progresses, they may transfer their belief to another disease. Their convictions persist despite negative laboratory results, the benign course of the alleged disease over time, and appropriate reassurances from physicians. Their preoccupation with illness interferes with their interaction with family, friends, and coworkers. They are often addicted to internet searches about their feared illness, inferring the worst from information (or misinformation) they find there. Unlike somatic symptom disorder, however, these individuals do not have significant physical symptoms. Sometimes people with this disorder develop a fear of going to medical appointments, while other times, they seek excessive reassurance about their health from medical providers.

Conversion Disorder (Functional Neurologic Symptom Disorder)

Persons with conversion disorder (also called functional neurologic symptom disorder) present with what appears to be a neurologic condition. The symptoms may be motor or sensory but are incompatible with known neurologic conditions. Often the illness is preceded by conflicts or other stressors and may seem to be associated with apparent psychological factors.

Individuals with conversion disorder do not intentionally produce these symptoms or deficits. Conversion motor symptoms mimic syndromes such as paralysis, ataxia, dysphagia, or seizure disorder (nonepileptic seizures [NESs]), and the sensory symptoms mimic neurologic deficits such as blindness, deafness, or anesthesia. There can also be disturbances of consciousness (e.g., amnesia, fainting spells).

Psychological Factors Affecting Other Medical Conditions

Patients with this disorder have physical disorders caused by or adversely affected by emotional or psychological factors. A medical condition must always be present to make the diagnosis. Common clinical examples include denial and refusal of treatment for an acute condition (such as myocardial infarct or abdominal emergencies) by individuals with certain personality styles (e.g., domineering or controlling), the exacerbation of asthma or irritable bowel attacks by anxiety, and the manipulation of insulin by an individual with diabetes, or diuretics in the case of hypertensive patients, in efforts to lose weight.

Factitious Disorder

Patients with factitious disorder feign, misrepresent, simulate, cause, induce, or aggravate illness to receive medical attention, regardless of whether or not they are ill. Thus, they may inflict painful, deforming, or even life-threatening injuries on themselves, their children, or other dependents. The primary motivation is not the avoidance of duties, financial gain, or anything concrete. The motivation is simply to receive medical care and to partake in the medical system.

Factitious disorders can lead to significant morbidity or even mortality. Therefore, even the patients falsify their presenting complaints, health professionals must take the medical and psychiatric needs of these patients seriously, as their self-induced symptoms can result in significant harm or even death. Historically this disorder was called “Munchausen syndrome,” a reference to the Baron Munchausen, legendary for his outrageously exaggerated stories of his military career.

Other Specified and Unspecified Somatic Symptom and Related 

Disorders

Patients with other specified somatic symptom and related disorders present with somatic symptoms that do not meet the threshold for another disorder. For example, they may present with symptoms consistent with illness anxiety disorder, except that the symptoms do not meet the duration criterion; in this case, the diagnosis would be brief illness anxiety disorder.

When there is not enough information to make a specific diagnosis, then clinicians should use the unspecified somatic symptom and related disorder diagnosis.

DIAGNOSIS

Somatic Symptom Disorder

According to the DSM-5, individuals with somatic symptom disorder present with one or more somatic complaints that result in significant angst or functional impairment. Also, they must be anxious about their symptoms or be preoccupied with them. The analogous diagnosis in ICD-10, as well in the previous version of the DSM is somatization disorder. The biggest difference between the two concepts is whether there needs to be evidence that there is no underlying medical cause for the disorder—ICD-10 does, and DSM-IV did require this whereas DSM-5 does not. Table 12-1 compares the approaches to this diagnosis.

Mr. K, a white man in his mid-50s, consulted a general medicine clinic complaining of gastrointestinal problems. He had a long list of physical symptoms and concerns, mostly related to the gastrointestinal system. These included abdominal pain, left lower quadrant cramps, bloating, persistent sense of fullness in stomach hours after eating, intolerance to foods, constipation, decrease in physical stamina, heart palpitations, and feelings that “skin is getting yellow” and “not getting enough oxygen.” A review of systems disclosed disturbances from virtually every organ system, including tired eyes with blurred vision, sore throat and “lump” in the throat, heart palpitations, irregular heartbeat, dizziness, trouble breathing, and general weakness.

The patient reported that symptoms started more than 20 years ago. Over this time, psychiatrists, general practitioners, and other medical specialists evaluated him, including surgeons. He used the internet regularly and traveled extensively in search of expert evaluations, seeking new procedures and diagnostic assessments. He had undergone repeated colonoscopies, sigmoidoscopies, and computed tomographic (CT) scans, magnetic resonance imaging (MRI) studies, and ultrasound examinations of the abdomen that had revealed Barrett esophagus but no other pathology. He was on disability and had been unable to work for more than 2 years due to his condition.

About 3 years before his visit to the medical clinic, his abdominal complaints and his fixed belief that he had an intestinal obstruction led to an exploratory surgical intervention for the first time, apparently with negative findings. However, according to the patient, the surgery “got things even worse,” and since then, he had undergone at least five more operations. During these surgeries, he has undergone subtotal colectomies and ileostomies due to possible “adhesions” to rule out “mechanical” obstruction. However, available records from some of the surgeries do not disclose any specific pathology other than “intractable constipation.” Pathologic specimens were also inconclusive.

A complete physical and neurologic examination showed a well-developed, well-nourished male who was afebrile. A complete physical and neurologic examination was normal except for examination of the abdomen, which revealed multiple abdominal scars. Right ileostomy was present, with soft stool in the bag and active bowel sounds. There was no point tenderness and no abdominal distension. During the examination, the patient kept pointing to an area of “hardness” in the left lower quadrant that he thought was a “tight muscle strangling his bowels.” However, the examination did not disclose any palpable mass. Skin and extremities were all within normal limits, and all joints had a full range of motion and no swelling. Musculature was well developed. Neurologic examination was within normal limits. His primary care physician scheduled brief monthly visits by, during which the doctor performed brief physicals, reassured the patient, and allowed the patient to talk about “stressors.” The physician avoided invasive tests or diagnostic procedures, did not prescribe any medications and avoided telling the patient that the symptoms were mental or “all in his head.” The primary care physician then referred the patient back to psychiatry.

The psychiatrist confirmed a long list of physical symptoms that started in his 20s, most of which remained medically unexplained. The psychiatric examination revealed some anxiety symptoms, including apprehension, tension, uneasiness, and somatic components such as blushing and palpitations that seemed particularly prominent in social situations. Possible symptoms of depression included mild dysphoria, low energy, and sleep disturbance, all of which the patient blamed on his “medical” problems. The mental status examination showed that Mr. K’s mood was rather somber and pessimistic, although he denied feeling sad or depressed. Affect was irritable. He was somatically focused and had little if any, psychological insight. The examination revealed the presence of a few life stressors (unemployment, financial problems, and family issues) that the patient quickly discounted as unimportant. The psychiatrist diagnosed somatic symptom disorder, severe.

Although the patient continued to deny having any psychiatric problems or any need for psychiatric intervention or treatment, he agreed to a few regular visits to continue to assess his situation. He refused to have anyone from his family involved in this process. Efforts to engage the patient with formal therapy such as cognitive-behavioral therapy (CBT) or a medication trial were all futile, so he was seen only for “supportive psychotherapy,” with the hope of developing rapport and preventing additional iatrogenic complications.

During the follow-up period, the patient was operated on at least one more time and continued to complain of abdominal bloating and constipation and to rely on laxatives. The patient continued to believe he had an obstruction of his intestines; this bordered on the delusional. However, he continued to refuse pharmacologic treatment. The only medication he accepted was a low-dose benzodiazepine for anxiety. He continued to monitor his intestinal function 24 hr/day and to seek evaluation by prominent specialists, traveling to high-profile specialty centers far from home in search of solutions. (Courtesy of J. I. Escobar, M.D.)


Although DSM-5 specifies that the symptoms must be present for at least 6 months, transient manifestations can occur after significant stresses, most commonly the death or severe illness of someone important to the patient. It can also occur after a severe illness that resolved but left the patient shaken by the experience. Such states that last fewer than 6 months are diagnosed as “Other Specified Somatic Symptom and Related Disorders” in DSM-5. Transient somatic symptom disorder responses to external stress generally remit with a resolution of the stress, but they can become chronic if friends or healthcare professionals reinforce the concerns.

Illness Anxiety Disorder

The primary DSM-5 diagnostic criteria for illness anxiety disorder are that patients be preoccupied with the false belief that they have or will develop a severe disease in the presence of few if any physical signs or symptoms. With illness anxiety disorder, patients have relatively minor somatic symptoms and instead focus on concerns that they will get sick or have an undiagnosed illness; on the other hand, with somatic symptom disorder, there are significant health concerns along with substantial somatic symptoms. The analogous disorder in ICD-10 and the earlier DSM-IV is hypochondriasis. Table 12-2 compares the two disorders.

Conversion Disorder (Functional Neurologic Symptom Disorder)

A conversion reaction is a rather acute and temporary loss or alteration in

motor or sensory function that requires substantial discordance between the symptoms displayed and any neurologic condition, such that it would be impossible for the patient’s presentation to be consistent with a neurologic disease. Because the onset frequently coincides with psychological issues (conflict), early theorists speculated that such issues were “converted” to neurologic symptoms. The problem is that stress is omnipresent in life, and many patients present with conversion without an obvious stressor. The classic syndromes represent neurologic syndromes such as paralysis, seizures, or blindness. In DSM-5, we can indicate the type of symptom the patient is experiencing. Table 12-3 compares the approaches to diagnosing this disorder in DSM-5 and ICD-10. Table 12-4 lists common symptoms of conversion disorder. Table 12-5 lists examples of significant physical examination findings often found in disorder.

Somatic Symptom and Related Disorders Somatic Symptom and Related Disorders Reviewed by Web of Psychiatry on December 07, 2021 Rating: 5

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