12. Somatic Symptom and Related Disorders

Question 1

Describe general characteristics: Somatic Symptom and Related Disorders (5)

Answer 1

• physical signs and symptoms lacking objective medical support in the presence of psychological factors that are judged to be important in the initiation, exacerbation, or maintenance of the disturbance
• cause significant distress or impairment in functioning
• symptoms are produced unconsciously and are not the result of malingering or factitious disorder, which are disorders of voluntary presentation of symptoms (or intentionally inducing, i.e. injecting feces) for secondary gain
• primary gain: somatic symptom represents a symbolic resolution of an unconscious psychological conflict; serves to reduce anxiety and conflict with no external incentive
• secondary gain: the sick role; external benefits obtained or unpleasant duties avoided (i.e. work)

Question 2

Describe: Malingering (2)

Answer 2

• intentional production of false or grossly exaggerated physical or psychological symptoms
• motivated by secondary gain/external reward (i.e. avoiding work, obtaining financial compensation, or obtaining drugs)

Question 3

Define: Factitious Disorder (2)

Answer 3

• intentional production or feigning of physical or psychological signs or symptoms.
• Unlike malingering patients are not motivated by secondary gain but rather may seek sympathy, nurturance, and attention

Question 4

Describe: Management of Somatic Symptom and Related Disorders (7)

Answer 4

• brief, regular scheduled visits with GP to facilitate therapeutic relationship and help patient feel supported
• good, clear communication among all involved care providers
• limit number of physicians involved in care, minimize medical investigations, coordinate necessary investigations
• emphasis on what the patient can change and control; the psychosocial coping skills, not their physical symptoms (functional recovery > explanation of symptoms)
• focus on functional improvement (physiotherapy, occupational therapy), provide psychoeducation to validate suffering in the face of medically unexplained symptoms
• psychotherapy: CBT, mindfulness interventions, biofeedback
• minimize psychotropic drugs: anxiolytics in short-term only, antidepressants for comorbid depression and anxiety

Question 5

Name DSM-5 diagnostic criteria: Somatic Symptom Disorder (3)

Answer 5

1. one or more somatic symptoms that are distressing or result in significant disruption of daily life
2. excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
   
   1. disproportionate and persistent thoughts about the seriousness of one’s symptoms
   2. persistently high level of anxiety about health or symptoms
   3. excessive time and energy devoted to these symptoms or health concerns
3. although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 mo)

• somatic symptom disorder with predominant pain (previously pain disorder) for those whose somatic symptom is primarily pain
• patients have physical symptoms and believe these symptoms represent the manifestation of a serious illness
• persistent belief despite negative medical investigations and may develop different symptoms over time
• lifetime prevalence may be around 5-7% in the general adult population
• females tend to report more somatic symptoms than males do, cultural factors may influence sex ratio
• complications: anxiety and depression commonly comorbid (up to 80%), unnecessary medications, or surgery
• often a misdiagnosis for an insidious illness so rule out all organic illnesses (i.e. multiple sclerosis)

Question 6

Describe: Illness Anxiety Disorder (9)

Answer 6

• preoccupation with fear of having, or the idea that one has, a serious disease, to the point of causing significant impairment
• convictions persist despite negative investigations and medical reassurance
• somatic symptoms are mild or not present
• there is a high level of anxiety about health and the individual is easily alarmed about personal health status
• person engages in maladaptive behaviour such as excessive physical checking or total healthcare avoidance
• duration is ≥6 mo; onset in 3rd-4th decade of life
• a new diagnostic entity so epidemiology is not well known; however, it is likely less common than somatic symptom disorder
• possible role for SSRIs due to generally high level of anxiety
• specifiers: care-seeking type or care-avoidant type

Question 7

Describe: Conversion Disorder (Functional Neurological Symptom Disorder) (7)

Answer 7

• ≥1 symptoms or deficits affecting voluntary motor or sensory function that mimic a neurological or GMC (i.e. impaired coordination, local paralysis, double vision, seizures, or convulsions)
• does not need to be preceded by a psychological event as per previous DSM criteria, however this is still worth exploring as many patients will present after such an event or related to a medical diagnosis in a first-degree relative
• 2-5/100,000 in general population; 5% of referrals to neurology clinics
• more common in rural populations and in individuals with little medical knowledge
• spontaneous remission in 95% of acute cases, 50% of chronic cases (>6 mo)
• incompatible findings detected from specific neurological testing can help differentiate between functional and neurological origin (i.e. Hoover’s sign and dermatome testing)
• specifiers: acute episode (<6 mo symptom duration), chronic episode (>6 mo symptom duration), with psychological stressor, without psychological stressor

Question 8

Differentiate according to: Somatic Symptoms

• Somatic Symptom Disorder
• Illness Anxiety Disorder
• Conversion Disorder
• Factitious Disorder
• Malingering Disorder

Answer 8

• Somatic Symptom Disorder: Present
• Illness Anxiety Disorder: Mild or absent
• Conversion Disorder: Neurologic, voluntary motor or sensory
• Factitious Disorder: Psychological or physical
• Malingering Disorder: Psychological or physical

Question 9

Differentiate according to: Symptoms Produced

• Somatic Symptom Disorder
• Illness Anxiety Disorder
• Conversion Disorder
• Factitious Disorder
• Malingering Disorder

Answer 9

• Somatic Symptom Disorder: Unconsciously
• Illness Anxiety Disorder: Unconsciously
• Conversion Disorder: Unconsciously
• Factitious Disorder: Consciously
• Malingering Disorder: Consciously

Question 10

Differentiate according to: Physical Findings

• Somatic Symptom Disorder
• Illness Anxiety Disorder
• Conversion Disorder
• Factitious Disorder
• Malingering Disorder

Answer 10

• Somatic Symptom Disorder: Absent
• Illness Anxiety Disorder: Absent
• Conversion Disorder: Incompatible
• Factitious Disorder: Possible, attempts to falsify
• Malingering Disorder: Possible, attempts to falsify