Somatic Symptom & Related Disorders – Comprehensive Study Notes

Overview of Somatic Symptom & Related Disorders

• Family of conditions in which bodily (somatic) phenomena dominate a person’s thoughts, feelings, and behaviours.
  • Pervasive preoccupation → clinically significant distress / functional impairment.
  • DSM-5 abandoned the older “medically unexplained” criterion; focus is now on excessive thoughts, feelings, or behaviours around symptoms.
  • ICD-10 still uses the traditional model, but ICD-11 is planned to align more with DSM-5.
• Disorders included:
  • Somatic Symptom Disorder (SSD)
  • Illness Anxiety Disorder (IAD)
  • Conversion Disorder / Functional Neurologic Symptom Disorder (CD/FND)
  • Psychological Factors Affecting Other Medical Conditions (PFAMC)
  • Factitious Disorder (FD) – imposed on self OR on another
  • Other Specified / Unspecified Somatic Symptom & Related Disorders

Historical Evolution & Nosology

• DSM-IV & ICD-10: emphasis on “somatoform” disorders, required that symptoms be medically unexplained.
  • Problems: unreliability, adversarial “symptoms real vs imaginary” debate.
• DSM-5 (2013):
  • Introduced new nomenclature (SSD, IAD, FND).
  • Removed requirement for absence of medical explanation.
  • Added behavioural/psychological criteria (excessive thoughts, anxiety, time/energy).
• ICD-10 key term: “Somatization Disorder”; duration \ge 2\;\text{years}, requires medically unexplained symptoms.

Core Clinical Presentation (Across Disorders)

• Presence of one or more bodily symptoms (pain, neurologic deficits, autonomic sensations, etc.).
• Excessive concerns manifest as:
  • Disproportionate thoughts of seriousness.
  • Persistently high anxiety.
  • Excessive time/energy devoted.
• Frequently coexist with anxiety, depressive, personality disorders.
• High health-care utilisation, repeated tests, doctor shopping, internet “cyberchondria”.

SOMATIC SYMPTOM DISORDER (SSD)

• Definition (DSM-5):
  • ≥1 somatic symptom causing distress / disruption \ge 6\;\text{months}.
  • Excessive thoughts / anxiety / behaviours related to symptom.
• Key features
  • Symptoms may or may not be medically explained.
  • Symptom pattern often shifts over time.
  • Specifiers: with predominant pain; persistence (>6 mo); severity (mild = 1 criterion, moderate = ≥2, severe = ≥2 + multiple complaints or marked impairment).
• ICD-10 counterpart: Somatization Disorder
  • Requires \ge 2\;\text{years}, more symptom count, must be unexplained.
• Case Example – Mr K
  • 55-y-o man with 20-year history of GI complaints; multiple negative surgeries; internet searches, disability, somatic focus; diagnosed with severe SSD; refused CBT/meds except low-dose benzodiazepine.
• Differential
  • Rule out medical diseases (AIDS, MS, SLE, malignancy, endocrinopathies).
  • Distinguish from IAD (fear of disease, minimal symptoms), CD (acute focal neuro symptoms), FD (intentional production), malingering (external incentives).
• Comorbidity: anxiety, depression, medical illness.
• Course / Prognosis
  • Episodic; 1⁄3 – 1⁄2 improve over time.
  • Good prognostic factors: high SES, treatable anxiety/depression, sudden onset, no personality disorder.
• Treatment
  • Cornerstone = Cognitive-Behavioural Therapy.
  • Primary-care “gatekeeper” model, scheduled visits, brief focused exams, avoid unnecessary tests.
  • Behavioural activation, relaxation, yoga, exercise.
  • Pharmacology only for comorbid depression/anxiety (TCAs, SNRIs > SSRIs for pain).

ILLNESS ANXIETY DISORDER (IAD)

• Definition
  • Preoccupation with having/acquiring serious illness for \ge 6\;\text{months}.
  • Minimal/no somatic symptoms.
  • Excessive health-related behaviours (care-seeking) OR maladaptive avoidance (care-avoidant).
• ICD-10 analogue: Hypochondriacal Disorder.
• Clinical pearls
  • Internet addiction to medical info (“Dr Google”).
  • May avoid appointments or seek repeated reassurance.
• Specifiers: care-seeking vs care-avoidant.
• Differential: SSD (prominent symptoms), OCD (obsessions + compulsions beyond health), delusional disorder (fixed intensity), anxiety/depressive disorders.
• Comorbidity: GAD, panic disorder, depression.
• Course/Prognosis: Limited data; extrapolated episodic course similar to SSD.
• Treatment
  • Strong evidence for CBT (individual or group).
  • Adjunct SSRIs (fluoxetine trial showed benefit); combined CBT+SSRI slightly better.

CONVERSION DISORDER / FUNCTIONAL NEUROLOGIC SYMPTOM DISORDER

• Definition
  • ≥1 altered voluntary motor or sensory function inconsistent with recognized neurologic/medical conditions.
  • Symptom types: weakness/paralysis, abnormal movement, speech, seizures (NES), anesthesia, special sensory symptoms, swallowing issues.
• Specifiers: acute (<6 mo) vs persistent, with/without psychological stressor, symptomatic subtype.
• Pathophysiology hypotheses
  • Functional MRI: altered connectivity/activation (thalamus, motor, limbic networks).
  • Psychodynamic: unconscious conflict “converted” into symptom (primary gain), plus secondary gain.
  • Behavioural: learned response reinforced by relief from obligations.
• Common Exam Signs (see Tables 12-4 & 12-5)
  • Hoover sign, give-way weakness, midline split anesthesia, hand drop test, tunnel vision inconsistencies.
• Case Example – Mr J (acute transient blindness after volleyball stress).
• Differential
  • Neurologic disorders (up to 25–50\% re-diagnosed later) → full work-up required.
  • Factitious / malingering (intentional), SSD (multiple symptoms, not necessarily neuro-specific).
• Course / Prognosis
  • 95\% of acute cases remit within \approx 2 weeks in hospital.
  • Chronic >6 mo → <50\% recovery; recurrence 20–25\% in 1 yr.
  • Good outcome: acute onset, identifiable stressor, short delay to treatment, high intelligence, symptoms of paralysis/aphonia/blindness.
• Treatment
  • Early reassurance, education, suggestion, physical therapy.
  • CBT, hypnosis, biofeedback, sodium-amytal/lorazepam interview for resistant cases.
  • Address comorbid depression/anxiety.

PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITIONS (PFAMC)

• Criteria: A bona-fide medical illness is present AND psychological/behavioural factors adversely influence course (exacerbation, delayed recovery, poor adherence, added risk).
• Examples: denial of MI leading to refusal of treatment, anxiety-triggered asthma, insulin manipulation in diabetes.
• Case Example – Mr A (post-MI denial, attempted discharge)
• Treatment: psychoeducation, liaison with medical team, address underlying psychopathology, low-dose anxiolytics if needed.

FACTITIOUS DISORDER (FD)

• Core concept: intentional feigning / induction of illness in absence of obvious external reward (motivation = assume sick role).
• Two forms:
  • Factitious Disorder Imposed on Self.
  • Factitious Disorder Imposed on Another (formerly “by proxy”); perpetrator gets diagnosis.
• Typical behaviours
  • Fabrication of history, self-injury, medication manipulation (insulin, anticoagulants, laxatives), pseudologia fantastica, impostorship.
  • Eager for invasive procedures, extensive medical vocabulary.
• Red Flags (Table 12-7; for FD by Proxy see Table 12-9)
  1. Multiple facilities (“hospital shopping”) 🚑
  2. Symptoms exceed objective findings.
  3. Inconsistent history, refuses outside records.
  4. Self-induced/worsened findings; predicts deterioration before discharge.
  5. Healthcare employment background, demands specific meds (opioids), resists psych consult.
• Etiology: affinity for medical system + maladaptive coping; possible childhood illness, resentment toward physicians.
• Course/Prognosis: early adulthood onset; chronic, poor prognosis, high morbidity/mortality from iatrogenic harm.
• Management Principles (Table 12-10)
  • PRIORITY: minimise harm – limit tests/procedures.
  • Interdisciplinary meetings; one primary gatekeeper.
  • Empathic, non-confrontational stance; avoid direct “exposure” that triggers flight.
  • Treat comorbid disorders; consider legal/ethical issues.
  • For FD Imposed on Another: ensure victim safety, notify child-protective services, gatekeeper paediatrician (Table 12-11).

OTHER SPECIFIED / UNSPECIFIED SOMATIC SYMPTOM & RELATED DISORDERS

• Subthreshold presentations – e.g., brief IAD (<6 mo), limited symptom clusters, insufficient info (ER settings).
• Must still cause clinically significant distress/impairment and not be better explained by another disorder.

EVALUATION & CLINICIAN APPROACH

• Build therapeutic alliance: validate suffering, neutral stance, tolerate repetition.
• Independent assessment despite “thick chart” bias.
• Comprehensive PE incl. neurologic; selective investigations.
• Gradual exploration of psychosocial issues; avoid “all in your head” statements.
• For suspected FD: corroborate data with collateral sources; subtle inquiry to avoid confrontation.

DIFFERENTIAL DIAGNOSIS – QUICK COMPARISON

• SSD: many symptoms + excessive focus; symptoms may be explained or not.
• IAD: minimal symptoms; fear of illness.
• CD/FND: acute neuro-type symptoms incompatible with disease.
• PFAMC: real medical illness worsened by psyche.
• FD: intentional production, no external reward.
• Malingering: intentional + external incentive (money, evasion).

TREATMENT SUMMARY ACROSS DISORDERS

• Psychotherapy (particularly CBT) has strongest evidence across SSD & IAD.
• Pharmacotherapy: TCAs/SNRIs for pain syndromes; SSRIs for health anxiety; treat comorbidities.
• Liaison & stepped-care model (primary physician gatekeeper).
• Education, relaxation, graded activity, mindfulness, biofeedback.
• For CD: physical therapy plus psychological interventions.
• For PFAMC: integrate medical & mental health teams.
• FD: focus on harm reduction, legal/ethical actions; cure rarely feasible.

PROGNOSIS SNAPSHOT

• SSD: 33–50 % significant improvement; childhood cases often remit by adulthood.
• IAD: Data pending; likely episodic like SSD.
• CD/FND: Acute cases \approx 95\% remit rapidly; chronic persistent cases <50\% resolve.
• PFAMC: variable, tied to medical illness course.
• FD: poor; cycles of hospitalisation and iatrogenic harm.

EPIDEMIOLOGY QUICK FACTS

• SSD (DSM-5) prevalence unknown; DSM-IV somatization disorder lifetime 0.1–0.8\% (strict), 5–19\% (abridged).
• IAD/hypochondriasis: 4–6\% in primary care; up to 10\% report high health worry.
• CD/FND:
• PFAMC, FD: true prevalence unknown; FD roughly 1\% of patients; FD by Proxy <0.04\% of child-abuse reports.

ETIOLOGY HIGHLIGHTS

• SSD: genetic/learning links to antisocial traits, low threshold for bodily sensations, cognitive amplification, benefits of sick role.
• IAD: similar social learning / cognitive distortions.
• CD/FND: neuro-functional changes + psychodynamic conflict conversion + behavioural reinforcement; mixed evidence on childhood trauma.
• PFAMC: psychological distress modifies physiology (e.g., sympathetic activation) & behaviour (non-adherence).
• FD: unconscious need to occupy patient role; history of illness exposure; maladaptive coping.

ETHICAL & PRACTICAL IMPLICATIONS

• Balance validating distress with avoiding iatrogenic harm.
• High healthcare costs → need for systematic management plans.
• FD by Proxy: mandatory reporting; child safety paramount.
• Avoid stigma – DSM-5 wording shift emphasises legitimacy of suffering.

KEY EXAM & INVESTIGATION PEARLS (Conversion Disorder)

• Hoover test: absent hip extension force paradoxically appears when contralateral leg flexes.
• Strict midline demarcation of anesthesia suggests non-neurologic basis.
• Tunnel vision field testing reveals changing patterns.
• Non-epileptic seizures: preserved gag/pupillary reflexes, no postictal prolactin rise.

RESEARCH & FUTURE DIRECTIONS

• fMRI studies exploring thalamic volume loss, altered motor-limbic connectivity in CD.
• Ongoing trials of mindfulness & acceptance therapies for IAD.
• ICD-11 alignment with DSM-5 may enhance cross-system reliability.
• Need for long-term outcome data on IAD and SSD under new criteria.