Somatisation

Question 1

Define somatisation

Answer 1

Patients experience distressing physical symptoms associated with abnormal thoughts, feelings, and behaviours in response to these symptoms. They may result from psychological stress that is unconsciously (without awareness) expressed somatically.

Question 2

Define conversion disorder

Answer 2

Voluntary motor or sensory function deficits that suggest neurological or medical conditions but are rather associated with clinical findings that are not compatible with such conditions

Question 3

Define somatic symptom disorder

Answer 3

one or more somatic symptoms that are distressing or result in significant disruption of daily life

(multiple, recurrent and frequently changing physical symptoms of ≥2 years duration)

Question 4

What is the DSM criteria for somatisation

Answer 4

Disproportionate and persistent thoughts about the seriousness of one’s symptoms
Persistently high levels of anxiety about health or symptoms
Excessive time or energy devoted to these symptoms or health concerns

Question 5

What are the risk factors for somatisation

Answer 5

Chronic and/or acute intrapsychic (emotional/psychological) stress or conflict
Emotional processing deficits
Avoidance tendencies
Social, cultural, or family taboos against emotional expression
Disturbances in attention and control through dissociation, misattribution, and misinterpretation
Hx sexual/physical abuse, unstable childhood, trauma-related disorders
Female
Alexithymia
Neuroticism

Question 6

What are the common presenting complaints for those with somatic symptoms disorder

Answer 6

Long and complicated history of contact with both primary and specialist medical care services- many negative investigations or exploratory operations

Gastrointestinal: nausea, vomiting, diarrhoea, constipation, food intolerance, abdominal pain
Sexual or reproductive: loss of libido, ejaculatory or erectile dysfunction, irregular menses, menorrhagia, dysmenorrhoea
Urinary: dysuria, frequency, urinary retention, incontinence
Neurological: paralysis, paraesthesia, sensory loss, seizures, difficulty swallowing, impaired coordination or balance
Cardiology: non-cardiac chest pain, palpitations
Rheumatology: fibromyalgia
Swallowing disturbance: Globus hystericus

Question 7

What are the signs of somatic symptoms disorder on examination

Answer 7

Unconventional behaviour during the history
Often inconsistent e.g. severe leg weakness on strength testing in patients who can walk, avoiding objects while claiming to be blind
Hoover’s sign: involuntary extension of the pseudoparalysed leg when the unaffected leg if flexing against resistance
Unusual neurological deficits (sharp demarcation, don’t confirm to nerve groups)
Give-way weakness
False sensory findings
Distractible symptoms
Inconsistent paralysis
Generalised seizure-like motor movements without loss of awareness
Cognitive complaints e.g. forgetting conversations, using wrong words, forgetting how to do activities
Astasia-abasia (paradoxical ability to use the legs normally except when standing or walking), collapsing gait, and non-economical gait
Speech disturbance: Aphonia, dysphonia, stuttering, and foreign accent syndrome

Question 8

What is the initial management for somatic symptoms disorder

Answer 8

Explain and re-assure:
the symptoms are real - but there may be a link between how you are feeling in your mind and what is going on in your life
sometimes the way things are going/ our feelings can manifest as very real physical symptoms
e.g. when you are embarrassed you blush or feel nervous you may feel a pit in your stomach
Use the Reattribution Model: they feel understood, re-iterate it is both physical and psychological

Question 9

What is the long term management for somatic symptom disorder

Answer 9

Bio (second line)
Antidepressants e.g. duloxetine, venlafaxine

Psycho (First line)
CBT: Psychoeducation about mind-body connection and attribution of psychiatric or psychological causes rather than purely neurological or medical causes
Mindfulness, interpersonal/general psychotherapy
Third line: psychodynamic therapy, family therapy, group therapy

Social
Graded physical exercise
Biofeedback training (understanding involuntary bodily functions)
Emotional support: encourage social network involvement
Encourage normal function

Question 10

What is the prognosis for somatic symptom disorder

Answer 10

Somatic symptom disorder: very low remission rates (<10%), likely to have persistent symptoms if comorbidities are present e.g. anxiety or depression