Somatic Symptoms and

Related Disorder

Dr Anila Sadaf
 What is somatic symptoms and related disorders?

• Somatic symptom and related disorders is the name for a group of conditions in which the
physical pain and symptoms a person feels are related to psychological factors.

• Somatoform disorders are a set of psychological conditions where a person experiences

bodily symptoms that cannot be accounted for by a medical or neurological diagnosis.

• Symptoms can range in severity from mild and infrequent to chronic and severe and are out of
the individual's conscious control.

• These symptoms can't be traced to a specific physical cause.

 Categories:
1. Somatic Symptom Disorder

2. Illness Anxiety Disorder

3. Conversion Disorder

4. Factitious Disorder
 Somatic Symptom Disorders
• Excessive concerns about physical symptoms or health
• ‘Soma’ means body

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Somatic Symptom Disorder
Diagnostic criteria:

 One or more somatic symptoms that are distressing or disruption of daily life.

 Excessive thoughts , feelings , or behaviors related to somatic symptoms or associated

health concerns as manifested by at least on of the following:
1. Disproportionate and persistent thoughts about seriousness of disorder.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms.

 The state of symptomatic being is persistent ( typically more than 6 months)

 DSM-5 Criteria for Somatic Symptom Disorder
• At least one somatic symptom that is distressing or disrupts daily life.

• Excessive thoughts, feelings, and behaviors related to somatic symptom(s) or health concerns, as indicated by
at least one of the following:
• health-related anxiety

• disproportionate concerns about the medical seriousness of symptoms

• excessive time and energy devoted to health concerns.

• Duration of at least 6 months.

• Specify: predominant

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Specifiers:
 With predominant pain
 Persistent
 Specify current severity:
1. Mild
2. Moderate
3. Severe

Prevalence and Prognosis

• The prevalence of disorder in adult population is around 5-7 %

• Female tend to report more somatic symptoms than do males

• The disorder may be under-diagnosed in older adults because certain somatic symptoms are
considered part of normal aging .

• Concurrent depressive disorder is more common in older people who present with numerous somatic
symptoms.
 Etiology
• Temperamental-personality trait of neuroticism has been identified as an independent factor for disorder.

• Environmental- factors like low socio-economic status , few years of education and stressful life events.

Differential Diagnosis
 Co-morbidity
Disorder maybe co-morbid with

• Medical disorders

• Anxiety disorders

• Depressive disorders
 Illness Anxiety Disorder
Diagnostic criteria and symptoms:

1)Preoccupation with having or acquiring a serious illness

2)Somatic symptoms are not present, or if present are only mild in intensity.

3)High level of anxiety about health, individual is easily alarmed about personal health status.

4)Excessive health related behaviors(repeated checks his/her body for her signs of illness)or exhibits
maladaptive avoidance.

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

• No more than mild somatic symptoms are present

• Not explained by other psychological disorders

 Specifiers
Specify whether:

• Care-seeking type

• Care-avoidant type

Prevalence and Prognosis

• 1 to 2 years prevalence of health anxiety ad 1.3 -10% in population based samples.

• In ambulatory medical populations, 6-month/1 year prevalence rates are between 3% and 8%.

• The disorder is generally thought to be chronic and relapsing condition with an age at onset in early and middle adulthood.
 Etiology
• Environmental- disorder may sometime be precipitated by major life stress or serious but ultimately threat to
individual’s health. Childhood abuse or a serious childhood illness may predispose to development of the disorder in
adulthood.

• Course modifiers- one-third to one-half of the individuals have a transient form, which is associated with less
psychiatric and more medical comorbidity and less illness anxiety disorder.

Differential diagnosis
 Comorbidity
Disorder may co morbid with:

• Major mental disorder( two-third)

• Personality disorder

• Somatic symptom disorder

 Conversion Disorder
Diagnostic criteria and symptoms:
1. One or more symptoms of altered voluntary motor or sensory function.

2. Clinical findings provide evidence of incompatibility between symptom and recognized neurological or medical condition.

3. People do not consciously want or purposely produce their symptoms. Symptoms cause significant distress or
impairment.
4. Usually begins between late childhood and young adulthood

5. Very rare disorder, occurring in at most 5 of every 1000 persons

 Conversion Disorder
• Hippocrates
• Believed disorder only occurred in women

• Attributed it to a wandering uterus

• Originally known as hysteria
• Greek word for uterus

• Freud
• Coined term conversion

• Anxiety and conflict converted into physical symptoms

• Famous case of Anna O.

 DSM-5 Criteria for
Conversion Disorder
• One or more symptoms affecting voluntary motor or sensory function

• The symptoms are incompatible with recognized medical disorders

• Symptoms cause significant distress or functional impairment or warrant medical evaluation

• Onset typically adolescence or early adulthood
• Often follows life stress

• Prevalence less than 1%

• More common in women than men

• Often comorbid with:

• Other somatic symptom disorders
• Major depressive disorder
• Substance use disorders
 DSM-5 Criteria:
Factitious Disorder
1. Fabrication or induction of physical or psychological symptoms, injury, or disease.

2. Deceptive behavior is present in the absence of obvious external rewards.

3. Behavior is not explained by another psychological disorder.

4. In Factitious Disorder Imposed on Self, the person presents himself or herself to others as ill, impaired, or
injured.

5. In Factitious Disorder Imposed on Another, the person fabricates or induces symptoms in another person
and then presents that person to others as ill, impaired, or injured
 Etiology of Somatic Symptoms Disorders:
Neurological Factors
• No support for genetic influence
• Concordance rates in MZ twin pairs do not differ from DZ twin pairs

• Why are some people more aware and distressed by bodily sensation?
• Anterior insula and anterior cingulate hyperactive
• Somatic symptoms influenced by emotions and stress

Etiology of Somatic Symptoms Disorders: Cognitive Behavioral

Factors
• Two important cognitive variables:
• Attention to bodily sensations
• Automatic focus on physical health cues
• Attributions (interpretation) of those sensations
• Overreact with overly negative interpretations
• Two important consequences:
• Sick role limits healthy life alternatives
• Help-seeking behaviors reinforced by attention or sympathy
 Figure 8.2:

Mechanisms Involved in
Somatic Symptom Disorders

© 2015 John Wiley & Sons, Inc. All rights reserved.

 Etiology of Conversion Disorder: Psychodynamic Perspective
• Unconscious psychological factor cause

• Blindsight
• Not consciously aware of visual input

• Failure to be explicitly aware of sensory information

Etiology of Somatic Symptoms Disorders: Social and Cultural Factors

• Decrease in incidence of conversion disorders since last half of 19 th century
• Higher incidence may have been due to more repressed sexual attitudes or low tolerance for anxiety symptoms

• More prevalent
• In rural areas

• In individuals of lower SES

• In non-Western cultures
 Treatment of Somatic Symptoms Disorders
• Few controlled treatment outcome studies

• Cognitive Behavioral Treatment

• Identify and change triggering emotions

• Change cognitions about symptoms

• Replace sick role behaviors with more appropriate social interactions

• Antidepressants

• Tofranil
• Effective even at low dosages that do not alleviate depressive symptoms
 Prevalence and
Specifiers prognosis
Specify symptom type

1. With weakness or paralysis • Transient symptoms are common but precise prevalence is unknown.

2. With abnormal movement

• Incidence of individual persistent conversion symptom is estimated to
3. With swallowing symptoms
be 2-5/100000 per year.
4. With speech symptom

5. With attacks or seizures • The symptoms can be transient or persistent.

6. With anesthesia or sensory loss

• The prognosis may be better in younger children than in adolescents
7. With special sensory symptom
and adults.
8. With mixed symptom
 Etiology
• Temperamental- Maladaptive personality traits are commonly associated with conversion disorder.

• Environmental- May be a history of childhood abuse and neglect. Stressful life events are often, but not always, present.

• Genetic-presence of neurological disease that causes similar symptoms is a risk factor.(non-epileptic seizures are common in
patients who also have epilepsy).

Differential diagnosis
 Comorbidity
Disorder maybe co morbid with;

1.Anxiety disorder

2.Panic disorder

3.Depressive disorder

4.Somatic symptom disorder

5.Personality disorder

6.Neurological or other medical condition.

 Factitious Disorder
Criteria and symptoms:

(factitious disorder imposed on self)

 Falsification of physical or psychological signs or symptoms, or induction of injury or disease associated with
identified deception.

 Individual presents himself to others as ill, impaired or injured.

 Deception behavior is evident even in the absence of external rewards.

Specify:
 Single episode
 Recurrent episodes
 Prevalence and Prognosis
• The prevalence of disorder is unknown because of deception in population.

• Among patients in hospital settings,1 % have the presentations that meet the criteria for factitious disorder.

• In individuals with recurrent episodes of falsification of signs and symptoms of illness , the patter of successive deceptive
contact with medical personnel, may become lifelong.

Differential diagnosis
Disorder may look alike :

1.Somatic symptom disorder

2.Malingering

3.Conversion disorder

4.Borderline personality disorder

5.Medical condition or mental disorder not associated with intentional symptom falsification.
 What are the common treatments for somatic and related
disorders?

• Cognitive behavior therapy and mindfulness-based therapy are effective for the treatment of
somatic symptom disorder.

• Amitriptyline, selective serotonin reuptake inhibitors,and St. John's wort are effective
pharmacologic treatments for somatic symptom disorder