Lecture 3 Disorders Featuring Somatic Symptoms

What is illness in clinical psychology?

A cluster of symptoms or complaints with a specific cause, course, and outcome

Cluster of symptoms or complaints

• It has a specific (organic) cause

• A defined course

• A specific outcome

What can a symptom be part of?

• Disease→biological / medical substrate

• Disorders→of disturbances, typically with a known biomedical underpinning, but not necessarily (e.g., depression)

• Illness→the feeling of being ill (self-report)

• Sickness→not fulfilling social roles, calls sick at work, limited functioning, patient role.

What is a psychological disorder (syndrome)?

• Cluster of symptoms (and signs) that co-occur more often than expected by chance (not ‘at random’); often without a clear cause / pathology.

• Represents non-normal behavior or experiences, the symptoms belong together.

• Clusters are clearly defined (recognizable) and saliently different from other clusters.

• Purely descriptive known. the (somatic) cause is not necessarily known.

What makes a psychological disorder recognizable?

Symptoms belong together, are distinct from other clusters, and describe non-normal experiences

What percentage of general physician patients show symptoms without a physical cause?

17% (Greenberg, 2016), consistent with estimates of ~20% for persistent somatic symptoms

What is are the factors leads to somatic symptom?

What is are the factor of somatic symptoms?

Predisposing, precipitating and perpetuating factors

• Predisposing

• Precipitating

• Perpetuating

What are predisposing factors?

Factors that make someone vulnerable to developing a disorder (“Why me?”)

What are precipitating factors?

Factors that trigger the onset of a disorder at a specific time (“Why now?”)

What are perpetuating factors?

Factors that maintain or worsen a disorder over time (“Why still?”)

Predisposing Factors

• Biological: Genetic vulnerability

• Psychological: Personality traits (e.g., poor self-efficacy)

• Social: Disorganized attachment

Precipitating Factors

• Biological: Poor sleep, substance use/misuse

• Psychological: Stressful life events (stressors)

• Social: Loss of a significant relationship

Perpetuating Factors

• Biological: Poor response to medication due to genetic factors

• Psychological: Rumination, impaired reasoning and memory

• Social: Role of stigma as a barrier to accessing treatment

Protective Factors

Biological: Adequate diet and sleep

Psychological: Cognitive behavioral strategies

Social: Support from family, friends, and community

Somatic symptom disorder (SSD) in DSM-5 300.82 Criteria

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

• Excessive thoughts, feelings, or behaviors related to the somatic symptoms

  • Disproportionate and persistent thoughts about the seriousness of one’s symptoms (cognitions)

  • Persistently high level of anxiety about health or symptoms (affect)

  • Excessive time and energy devoted to these symptoms or health concerns (behavior)

• Complaints present more than 6 months.

What is the DSM-5 specifier:

• With predominant pain

• Persistent

What is the DSM-5 Specify severity:

• Mild→Only one of the symptoms specified in Criterion B is fulfilled.

• Moderate→Two or more of the symptoms specified in Criterion B are fulfilled.

• Severe→Two or more of the symptoms specified in Criterion B are fulfilled, plus multiple somatic complaints or one very severe somatic symptom.

How prevalent is SSD?

• Estimated: 5-7% (exact % still unknown)

• Expectation: higher than that for somatization disorder (<1%)

• Lower than that of the undifferentiated somatoform disorder (19%)

• More common in women than men

• Possibly more common in people with medical disorders

Key Point for SSRD

In the DSM-5, it is no longer required to distinguish whether somatic symptoms are medically explained or unexplained. This reflects a shift in how Somatic Symptom and Related Disorders (SSRD) are defined.

What does the Dutch term "SOLK" stand for?

“SOLK” – Somatisch Onvoldoende verklaarde Lichamelijke Klachten→ Somatic symptoms with insufficient medical explanation

What is the updated Dutch term since 2021 for SOLK?

Since 2021: “ALK” – Aanhoudende Lichamelijke Klachten→Persistent Physical Symptoms (PPS)

What is MUSS or MUPS?

• Medically Unexplained Somatic/Physical Symptoms

• Used when no medical or biological explanation is found after investigation

What is FSD (Functional Somatic Disorder)?

Similar to MUSS; includes functional syndromes like IBS or fibromyalgia.

What is the DSM-5 position on MUSS?

• Persistent somatic symptoms (lasting > weeks)

• No sufficient biological or medical cause

• Must rule out other somatic and psychiatric explanations

• Used in Dutch clinical guidelines: Multidisciplinaire Richtlijn SOLK (2013)

Examples of MUSS / FSD Conditions

• Non-cardiac chest pain

• Fibromyalgia

• Chronic fatigue syndrome

• Irritable bowel syndrome

Patient Perspective for MUSS / FSD conditions

• Many patients prefer somatic explanations

• Often resist psychological framing of their symptoms

• There's ongoing debate about the terminology

• Current preferred term: Persistent Physical Symptoms (PPS)

Prevalence of MUSS / FSD / PPS

• Somatic Symptoms in General Population

• Prevalence of MUSS (Medically Unexplained Somatic Symptoms)

Somatic Symptoms in General Population

85–95% of people report at least one somatic symptom.

Prevalence of MUSS (Medically Unexplained Somatic Symptoms

• General population: 20–26%

• Primary care: 25–84%

• Secondary care: 35–53%

Most Common Symptoms of MUSS / FSD / PPS

• Headache

• Backache

• Pain in joints

• Stomach ache

• Fatigue

• Nausea

Functional Somatic Disorders (MUSS / PPS)

• Pain in joints and muscles→ Fibromyalgia

• Fatigue, feeling drained→ Chronic Fatigue Syndrome

• Abdominal pain, nausea→ Irritable Bowel Syndrome (IBS)

• Headache, dizziness→Tension-related Headache

Comorbidity

• Frequent comorbidity between somatic and psychological symptoms.

• The more somatic symptoms, the higher the risk of anxiety and depressive disorders.

  

Depression and Medically Unexplained Somatic Symptoms (MUSS)

• 69% of patients with Major Depressive Disorder (MDD) present only with physical symptoms

• 31% present with both psychological and physical symptoms

• 11% deny emotional complaints altogether

What is Illness Anxiety Disorder formerly known as in DSM-IV?

Hypochondriasis

What is Criterion A for Illness Anxiety Disorder (DSM-5)?

A. Preoccupation with having or acquiring a serious illness.

What is Criterion B for Illness Anxiety Disorder (DSM-5)?

B. Somatic symptoms are not present or if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.

What is Criterion C for Illness Anxiety Disorder (DSM-5)?

C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.

What is Criterion D for Illness Anxiety Disorder (DSM-5)?

D. The individual performs excessive health-related behaviours (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g, avoids doctor appointments and hospitals).

What is Criterion E for Illness Anxiety Disorder (DSM-5)?

E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time

What is Criterion F for Illness Anxiety Disorder (DSM-5)?

F. The illness-related preoccupation is not better explained by another mental disorder (such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic isorder, obsessive compulsive disorder, or delusional disorder, somatic type).

What is the care-seeking type of Illness Anxiety Disorder?

Medical care, including physician visits or undergoing tests and procedures, is frequently used.

What is the care-avoidant type of Illness Anxiety Disorder?

Medical care is rarely used

What is Criterion A for Conversion Disorder (DSM-5)?

A. One or more symptoms of altered voluntary motor or sensory function (some also include cognitive sx – e.g., memory loss)

What is Criterion B for Conversion Disorder (DSM-5)?

B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.

What is Criterion C for Conversion Disorder (DSM-5)?

C. The symptom or deficit is not better explained by another medical or mental disorder.

What is Criterion D for Conversion Disorder (DSM-5)?

D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation

What are the symptom type specifiers for Conversion Disorder?

• With weakness or paralysis

• With abnormal movement

• With swallowing symptoms

• With speech symptom

• With attacks or seizures

• With anesthesia or sensory loss

• With special sensory symptom (e.g., visual, olfactory, or hearing disturbances)

• With mixed symptoms

What are the Key Characteristics in Conversion Disorder?

• Symptoms are often triggered by an emotional event (trauma)

• The individual does not consciously produce or fake the symptoms→ This distinguishes it from factitious disorder or malingering

What is the assumed mechanism behind Conversion Disorder?

• A stress experience is assumed to be "converted" into somatic symptoms

• This process gives rise to the name “Conversion Disorder”

• However, the term Functional Neurological Disorder (FND) is now seen as more precise and less stigmatizing

What is Criterion A for Factitious Disorder (DSM-5)?

A. Falsification of physical or psychological symptoms, or induction of injury/disease, associated with identified deception.

What is Criterion B for Factitious Disorder (DSM-5)?

B. The individual presents themselves as ill, impaired, or injured, even when there are no external rewards for doing so.

What is Criterion C for Factitious Disorder (DSM-5)?

• C. The behavior is not better explained by another mental disorder=

  • Delusional disorder

  • Another psychotic disorder

What is Munchausen syndrome?

An older term for factitious disorder imposed on self; involves dramatic symptom fabrication and self-harm

What is Factitious Disorder Imposed on Self?

• Fabricates or induces symptoms in oneself

• Often knowledgeable about medicine

• Willing to endure pain or invasive medical procedures

• Frequent visits to multiple hospitals/doctors

What is Factitious Disorder Imposed on Another?

• Fabricates or induces illness in a dependent (commonly a child)

• Done to assume the sick role by proxy and gain attention or sympathy

• Caregiver appears protective, may have medical background

• Considered a form of abuse

What ethical question arises regarding Factitious Disorder?

Should society (healthcare) pay for self-induced problems caused by factitious disorder?

What is the main difference between Factitious Disorder and Malingering?

Both involve falsification or simulation of symptoms, but the motivation is different

Factitious Disorder

• Falsification is intentional

• Motivation: to assume the sick role (i.e., to be seen as a patient)

• No obvious external rewards

• Considered a psychiatric disorder (listed in DSM-5)

Malingering

• Falsification is also intentional

• Motivation: external rewards (e.g., money, avoiding work/military, legal benefits)

• Not about being seen as a patient, but about personal gain

• Not a psychiatric disorder (not included in DSM-5)

What is a common behavioral pattern of SSRD patients?

Long history of searching for an answer; frequently undergoes medical assessments

How do SSRD patients often feel about healthcare providers?

They often show little trust in healthcare and clinicians

What personality traits are common in SSRD patients?

Highly self-critical, perfectionistic, competitive

Which gender is more commonly affected by SSRD?

Women

What is the typical socioeconomic profile of SSRD patients?

Lower socioeconomic status (SES)

How are social networks typically described in SSRD patients?

Smaller or limited

What is a common psychological background factor in SSRD patients?

History of trauma

What cognitive skill is often impaired in SSRD patients?

Mentalization→The ability to understand the mental state of oneself or others that underlies behavior

What is bodily focused mentalization (Spaans, 2017)?

Interpreting or deducing emotions based on bodily sensation

What are common therapeutic challenges with SSRD patients?

• May complain about and reject treatment

• May feel rejected by the therapist

• High risk of misunderstandings

• Difficulties in structuring their narratives

• Often reject psychological perspectives on their symptoms

Psychodynamic Theory

• Psychological factors (conscious or unconscious) influence somatic symptoms

• Little direct evidence supports traditional psychodynamic views (e.g., repressed anger or sexuality)

• Textbooks may be overly supportive of this outdated view, particularly regarding Functional Neurological Disorder (FND)

• However:

  • Emotion regulation is often disturbed in FND

  • Interventions such as hypnosis can help

What does Cognitive Behavioral Theory suggest about symptom maintenance in SSRD?

• Symptoms may be maintained or reinforced by rewards (e.g., attention, relief from obligations)

• Research does not strongly support the reward-maintenance hypothesis

• Secondary gain is acknowledged in both psychodynamic and CBT models

• Alternative CBT view→Symptoms may have a communication function, expressing needs or emotions nonverbally

What is the issue with the CBT reward-maintenance hypothesis?

Research support is limited

What alternative CBT view is proposed for SSRD symptoms?

Symptoms may have a communication function, expressing needs or emotions nonverbally

What does cultural-oriented theory say about SSRD expression?

Cultural differences in how emotions are expressed and pathologized

3 Cultural differences in how emotions are expressed and pathologized

• Industrialized countries: Pathologize somatic expression of emotion

• Chinese culture: Sadness is more stigmatized than somatization

• South America: Somatic expression of emotion is relatively common

What is the purpose of the Drive System?

To motivate us toward goals and resources

What brain areas and neurotransmitter are involved in the Drive System?

Nucleus accumbens, dopamine

What feelings are associated with the Drive System?

• Driven, excited, vitality

• Wanting, pursuing, achieving, progressing, focused

What is the purpose of the Threat System?

Detect and respond to danger — “Better safe than sorry”

What brain areas and chemicals are involved in the Threat System?

Amygdala, adrenaline, cortisol

What triggers the Threat System?

Actual or perceived threats

What feelings are associated with the Threat System?

Anxiety, anger, disgust

What is the purpose of the Soothing System?

To manage distress and promote social bonding

What brain areas and chemicals are involved in the Soothing System?

Prefrontal cortex, opiates, oxytocin

What feelings are associated with the Soothing System?

Content, safe, protected, cared-for, trust

What happens when the Threat System is activated?

It can override both the Drive and Soothing systems

What is the function of the Soothing System in emotional regulation?

It helps down-regulate or calm the Threat System

Why is balance between the three systems important?

Critical for emotional well-being and mental health

What is CLGG?

Center for Body, Mind and Health – a national excellence center for tertiary care in complex SSRD cases

What types of patients are seen at CLGG?

• Have received ineffective secondary care

• Show psychological symptoms resulting from or accompanying somatic symptoms

• May have explained or unexplained symptoms

What is the average duration of somatic symptoms at CLGG?

8.5 years (range: 1–34 years)

What is the average duration of previous treatments before CLGG?

6.9 years, usually without effect

What common challenges do CLGG patients face?

• Conflicts with previous clinicians

• Psychological + physical comorbidity

• Social limitations comparable to severe psychiatric illness

What are the rates of comorbid disorders in CLGG patients?

Depression: 70.1%, Anxiety: 62.4%

What assessments are performed during CLGG intake?

• Medical intake

• Physical, psychological, neuropsychological assessments

• Psychiatric evaluation

• Routine questionnaires

What professionals are on the CLGG multidisciplinary team?

• Psychiatrists, GPs, internists

• Clinical and neuropsychologists

• Psychomotor therapists

• Psychosomatic physiotherapists

Which psychotherapies are used at CLGG?

• CBT (Cognitive Behavioral Therapy)

• ACT (Acceptance & Commitment Therapy)

• PST (Problem-Solving Therapy)

• Schema Therapy

• Cognitive rehabilitation therapy

• Pharmacotherapy (for comorbid depression/anxiety)

What is the Gevolgenmodel ("Consequences Model")?

Somatic symptoms have cognitive, emotional, behavioral, physical, and social consequences that reinforce the problem.