Somatic Symptom Disorders Lecture Notes

Evolution from DSM-IV-TR Somatoform Disorders to Somatic Symptom Disorders in DSM-5.
Includes Body Dysmorphic Disorder.

Eliminates the term 'unexplained'.
Focuses on the positive conceptualization of symptoms based on their presence.
Avoids mind-body dualism.
Encourages a positive therapeutic alliance and reduces stigma by not implying symptoms are 'all in the mind'.

Presence of physical symptoms suggesting a medical condition.
Symptoms are not under voluntary control (unlike malingering or factitious disorders).
Cause significant impairment in functioning.
Underlying causes often unclear.
Illness can be a form of communication, reflecting emotional tone.
Differentiated from patients fabricating symptoms to get financial aid.

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns, as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one's symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
- A persistent course is characterized by severe symptom impairment and longer duration (more than 6 months).

No reliable estimate, but it's estimated that between 30% and 80% of patients consulting physicians present with symptoms lacking a physical basis.
50% of UK secondary care presentations.
High health care utilisation; costs are twice as high as other patients.
Higher rates in women than men.
Approximately 50% of patients have comorbid anxiety and depression.

Persistent or unrelenting fatigue of new or definite origin, lasting at least 6 months.
Similar diagnoses in history, notably 'neurasthenia'.
Also known as ME ('myalgic encephalomyelitis') and 'post-viral syndrome'.
Different diagnostic criteria may or may not include other symptoms; no specific lab or immune symptoms.

CBT focuses on perpetuating factors: avoidance beliefs, physical attributions, catastrophizing about increasing activity, symptom focus, all-or-nothing thinking etc (Cochrane review Price et al., 2008).
Graded exercise: structured exercise programme, usually walking gradually increased (Larun et al., 2016).
No evidence medication or supplements are helpful.
Intensive rest is not helpful
Prognosis without intervention is poor.

Aware of and focusing on relatively low-intensity sensations.
Experiencing non-pathological sensations as intense, noxious, distressing, alarming.
Attributing bodily sensations (physiology, intense affect, benign dysfunction) to disease.
Contributes to medically unexplained symptoms and somatization; could contribute to distress associated with symptoms of major medical disease.
Might also contribute to non-specific medication side effects (Barsky & Klerman, 1983).

Beliefs play a big role as it can feed into a negative feedback loop due to avoidant behaviours
These illnesses are quite difficult to treat
Hypochondriasis/hypochondria - believe that they have a serious illness

"Doctor Shopping".
History of frustrated Doctor-Patient relationships.
Repeated diagnostic procedures - No abnormalities detected (NAD).
Previous history with childhood illness or family illness may precipitate hypochondriasis.
Prevalence in general medical practice estimated at 4-9%.
History of surgery and medical investigations
Series of stressful events, or major events that cause them to feel this way

Interpretation error
Bodily changes are always a sign that something is wrong.
If I don't worry about my health, something will go wrong.
Detailed tests are the only way to really rule out an illness.
If the doctor sends me for any tests, he or she is convinced that there is something wrong.

Defined as a sensory or emotional experience of discomfort usually associated with actual or threatened tissue damage.
No medical complaint is as common. The most pervasive symptom in medical practice and the most compelling reason for patients to seek medical care.
Most frequent cause for disability. Relationship between pain and severity of condition is weak.
Weak relationship in the body

25% will have significant back injury in lifetime, 33% significant joint pain, 25% headache.
Chronic low back pain most expensive condition. Poorly understood, 60-80% of back pain have no physical signs.
Most back pain resolves without intervention. No single cause. Multiple approaches most effective.
Unemployment, disability and family problems common.
Dependence on pain medication a risk.
Depression common.
"Dr shopping" and other pain traps.
Severity

Cardinal symptom limited to neurological symptoms.
Altered voluntary motor, cognitive or sensory function not compatible with any recognised neurological disorder.
Preserved physiological function.
Prognosis poor.
Comorbidities common.
Psychotherapy, physio, hypnosis, multidisciplinary
Minimizing unnecessary investigations and therapy