Somatoform disorders

Question 1

Functional symptoms

Answer 1

Politically correct term for medically unexplained symptoms (as opposed to symptoms with a structural or pathological cause). Note that just because we don’t know the cause, doesn’t mean there isn’t one

Question 2

How may you be able to identify functional symptoms?

Answer 2

Involve multiple systems

Are clearly associated with a great deal of anxiety or obvious psychosocial stressor

Are clearly not typical of any known physical condition

Are associated with an absence of any physical signs or structural abnormalities

Are associated with an absence of any abnormalities in comprehensive laboratory, imaging and invasive investigations

Question 3

Somatoform disorders

Answer 3

A class of disorders whose symptoms are suggestive of, or take the form of, physical illness but with no detectable structural or neurophysiological abnormalities to explain them

Note that these symptoms are not under voluntary control, and any distress or functional impairment is genuine

Question 4

Somatisation disorder

Answer 4

Multiple, recurrent and frequently changing physical symptoms with the absence of identifiable physiological explanation

Systems commonly affected:

• GI (nausea, D&V, constipation, food intolerance, abdo pain)
• Sexual/reproductive (loss of libido, ejaculatory/erectile dysfunction, irregular menses, menorrhagia, dysmenorrhoea)
• Urinary (dysuria, frequency, retention, incontinence)
• Neurological (paralysis, paraesthesia, sensory loss, seizures, difficulty swallowing, impaired coordination/balance)

Question 5

Briquet’s syndrome

Answer 5

Somatisation disorder

Question 6

ICD-10 criteria for diagnosis of somatisation disorder

Answer 6

• At least 2 years of symptoms with no physical explanation found.
• Persistent refusal by the patient to accept reassurance from several doctors that there is no physical cause for the symptoms.
• Some degree of functional impairment due to the symptoms and resulting behaviour.

Question 7

Hypochondriacal disorder

Answer 7

Patients misinterpret normal bodily sensations, which lead them to believe they have a serious and progressive physical disease. Patients ask for investigations and refuse to accept reassurance from numerous doctors, in contrast to somatisation disorder where patients seek relief from symptoms

Over-valued idea rather than a delusion, as they are open to some explanation and their fears can be allayed (if only for a short time)

Question 8

Body dysmorphic disorder

Answer 8

Variant of hypochondriacal disorder, in which patients are preoccupied with an imagined or minor defect in their physical appearance, which causes significant distress or impairment of social functioning

Question 9

Somatic delusional disorder

Answer 9

If a hypochondriacal belief is held with delusional intensity

Question 10

Somatoform autonomic dysfunction

Answer 10

Objective evidence of autonomic arousal (sweating, palpitations, tremor…) and subjective symptoms (pain, burning, heaviness, tightness, feeling bloated…)
Patients normally attribute these to one organ or system

Question 11

Da Costa’s syndrome

Answer 11

Somatoform autonomic dysfunction with symptoms attributed to the cardiovascular system

Question 12

Psychogenic hyperventilation

Answer 12

Somatoform autonomic dysfunction with symptoms attributed to the respiratory system

Question 13

Irritable bowel syndrome

Answer 13

Somatoform autonomic dysfunction with symptoms attributed to the gastrointestinal system

Question 14

Persistent somatoform pain disorder

Answer 14

Severe and persistent pain that cannot be fully explained by physical illness, usually occurring in association with emotional difficulties or psychosocial stressors

Question 15

Factitious disorder

Answer 15

A.k.a. Munchausen’s syndrome

Symptoms are produced intentionally or feigned. Focus on the primary (internal) gain of assuming the sick role. Although symptoms are feigned, this care-seeing behaviour is usually a manifestation of psychological distress

Question 16

Malingering

Answer 16

Symptoms are produced intentionally or feigned. Focus on secondary (external) gain of the secondary consequence of being diagnosed with an illness (avoidance of military service, evading criminal prosecution, obtaining illicit drugs, obtaining benefits or compensation)

Question 17

Munchausen syndrome by proxy

Answer 17

A.k.a. fabricated or induced illness

Form of abuse where the carer will seek help for fabricated or induced symptoms in a dependent (usually a child), with the psychological aim that the dependent be cared for like a patient.

This can be very dangerous (e.g. covert poisoning), and the dependent should be removed from the carer and social services involved

Question 18

Differential diagnosis for patients presenting with medically unexplained symptoms

Answer 18

Somatoform disorders
• Somatization disorder
• Hypochondriacal disorder (including body dysmorphic
disorder)
• Somatoform autonomic dysfunction
• Persistent somatoform pain disorder 
Factitious disorder
Malingering
Other psychiatric conditions
• Anxiety disorders
• Mood disorders
• Psychotic disorders
• Dissociative disorders
Insidious multi-systemic disease (SLE, MS, AIDS...)