SOMATIC SYMPTOM AND RELATED DISORDERS (somatoform

disorders)
- A group of mental illnesses characterized by physical complaints that appear to be of medical
in origin BUT cannot be well/fully explained in terms of physical disease, the results of
substance abuse or by another mental disorder.

- The physical symptoms are serious enough to interfere with the patient’s functioning (work,
relationships, self).

- The symptoms are NOT under the patient’s control(except factitious)

INCLUDES

1. Somatic symptom disorder (formerly Somatisation disorder)

2. Hypochondriasis (illness anxiety disorder)

3. Conversion disorder

4. Factitious disorder

5. Psychological factors affecting other medical conditions

6. Others- unspecified/specified

NB; due to physical complaints, most are attended/ diagnosed in general medical clinics then
referred to mental health workers (after a lot of investigations, medications, operations-
cost/chronicity/complications)

- Efficient/accurate diagnosis requires; medical work up (physical to r/o medical or neurological

conditions), co morbidity assessment (overlap with other mental disorders)

1. SOMATIC SYMPTOM DISORDER

- Women >men eg lifetime prevalence of upto 2% in women (5;1)

- More common in rural areas, low socio economic status and among the educationally deprived

- Average onset age of 15 years with peak in 20’s then decline/improve (late onset in older
adults- likely to have occult medical illness or a depression with somatisation)

** Complex aetiology(BPS).

Assessment and diagnosis

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- Review patient’s medical records - Full comprehensive psychiatric history

- R/o depression (up to 50% co morbidity) and substance abuse co morbidity

- Personality disorder may predispose one to amplify somatic symptoms eg avoidant, oc,
paranoid features

- Evaluate the abnormal psychosocial stressors during onset of illness or in the past (eg parental
illness during childhood and effect- parent able/unable to care for the patient, physical illness and
hospitalization in childhood with parental over concern/long absence from school)

- Explore patient’s belief or perception about the physical symptoms

DSM dx

A. 0ne or more somatic symptom that are distressing or result in significant disruption of daily
life(pains, fatigue, gastrointestinal , genitourinary, ). physical complaints usually beginning
before age 30 yrs and occur over a period of several years

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(feelings)

- excessive time and energy devoted to these symptoms or health concerns (behavior)

C. the state of being symptomatic is persistent for at least 6 months (although any one symptom
may not be continuously present)

** specify; ** severity;

- After appropriate investigations the symptoms can’t be explain by/find a general medical
condition or direct effects of a substance of abuse

- When there is a related gmc, the physical complaints/ dysfunction are in excess of expected
from hx,pe, lab findings

D. The symptoms are not intentionally produced/feigned (eg in malingering or factitious

disorder)

DDX

 Medical conditions presenting with vague/non specific/multiple symptoms – MS, SLE,

Hyperparathyroidism.. (* involvement of multiple organ systems, early onset, chronic
course without cx, neg lab tests=SSD)

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  SCZ with multiple somatic delusions
 Major depression/severe: Anxiety disorders eg panic attack
 Other SS related D conversion, factitious: Co morbidity- depression, anxiety, substance
abuse

Course and prognosis- often chronic and debilitating

Treatment

Need to make early correct dx and communicating it to the patient in terms which he/she
understands before chronicity sets in

* Reassurance

- Patient/family psychoeducation.

Reassurance very effective in those with anxiety or mild depression

** Psychosocial treatment interventions- helping the patient acknowledge the reality of stressful
factors in his life, reduction of stress factors, encouraging verbal expression of distress and
shaping adaptive strategies to enable him cope with future stress.

- CBT ---- used to alter dysfunctional cognitive processes and behavior. Cognitive helps patient
identify associations btw thoughts and physical symptoms and modify dysfunctional beliefs

- Psychophysiology eg

** Medications.

- withdraw unnecessary medications

- anxiolytics/antidepressants/mood stabilizers in co morbidity

** Doctor shopping common (due to breakdown in therapeutic relationship) but leads to or

worsens chronicity.- Encourage on single identified primary health worker ,

2. ILLNESS ANXIETY DISORDER/”HYPOCHONDRIASIS”

* Characterised by a belief that a real or imagined physical symptoms are signs of a serious
illness despite medical reassurance and other evidence to the contrary

- Not attention seeking or pretending (they honestly believe that they are suffering from a
medical condition. The symptoms are real thus they feel misunderstood)

- Concern mostly not on the pain but rather what the symptom may imply in terms of real disease

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- The physical symptoms are “normal”, “subjective” eg headache, dizziness, nausea, fatigue,
abdomen pain, numbness, bloating, palpitation, sweating BUT are misinterpreted to as more
dangerous/severe than they really are.

- Presence of exaggerated health anxiety or obsessive irrational fear. Need thorough physical
examination to r/o medical condition, psychosocial hx, mse.

- Patients often seek exhaustive batteries of tests, often excessive relative to their symptoms.

- Women to men = 1:1, peak in 20-30yrs age; no social status, education, marital status link;

DSM V dx

- Preoccupation with having or the idea of acquiring a serious disease based on the person’s
misinterpretation of bodily symptoms

- Somatic symptoms are absent or mild in intensity. if another medical condition is present or
there is high risk of developing it, the preoccupation is clearly disproportionate

- There is high level of anxiety about health and the individual is easily alarmed about personal
health status

- the individual performs excessive health related behavior(eg repeatedly checks his/her body for
s&s of illness, internet checks) or exhibits maladaptive avoidance (eg avoids doctor
appointments)

- Disturbance is at least 6 months duration and causes clinically significant distress or

impairment in functioning

RX

- need a supportive relationship with a health worker

- Need one primary medical provider/ avoid doctor shopping( also reduces unnecessary
tests)
- Various psychotherapies and patient education -Medications minimal

NB; generally chronic unless the psychological factors or underlying mood disorder are
addressed. *Most don’t acknowledge the psychological component of their illness and
usually refuse mental health treatment

3. CONVERSION DISORDER (functional neurological symptom disorder)

“hysteria/conversion reaction”

*characterized by a single or more somatised symptom often a pseudo neurological one(s) ie

affect motor or sensory. A disturbance of bodily functioning that doesn’t conform to current

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 concepts of anatomy and physiology of cns/pns (clinical findings provide evidence of
incompatibility btwn the symptom and recognized neurological or medical conditons).

- Individual somatic symptoms represent a symbolic resolution of an unconscious

psychological conflict that reduce anxiety and serve to keep conflict away from awareness
(primary gain)

- Psychological factors associated with the symptoms or deficit as the initiation or

exacerbation of the symptoms (and other stressors)

- Symptoms/deficits are not intentionally produced or feigned and cause clinically significant
distress or impairment in functioning

*Primary vs secondary gain- sg is achieved when the patient has been removed from the
uncomfortable situation by virtue of the symptom

** 11-500/100,000 pple; rural > urban, females> men 2-10:1 but much higher in children;
lower social status > upper; low education levels/low iq; military personnel exposed to
combat situations;

BPS- repression of unconscious instinctual intrapsychic conflicts - Learning theory; classical

conditioning learnt behavior in childhood are called forth as a means of coping with an
otherwise impossible situation

EG= motor- impaired coordination or balance, paralysis or localized weakness, seizures,

aphonia, syncope/falling, abnormal gait etc. sensory- blindness, deafness, anesthesia of
extremities etc. visceral- difficulty in swallowing, lump in throat, urinary retention, diarrhea,
pseudocyesis,

Ddx

A) Medical conditions eg MS(with blindness-optic neurits), Mystenia gravis, myopathies, GBS,

polio

B) Mental conditions eg dissociative, psychotic disorders, mood disorders, factitious disorders,

malingering, pain disorder, somatisation disorder

Course

-Generally self limiting usually lasting for days-weeks and may resolve spontaneously

->90% recover within one month and most don’t have recurrences

- Symptom is not life threatening but the devt of complications as a result of the symptom can be
debilitating.

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Treatment

-need a supportive understanding relationship with a health worker, reassurance on gradual

resolution with specific recommendation for exercise/physiotherapy

- psychoeducation to patient and family, CBT, anxiolytics, hypnosis/abbreaction

- Referral to mental health expert

FACTITIOUS DISORDERS (artificial/false)

- Intentional production or feigning of physical/psychological signs and symptoms of a disease

- External incentives for the behavior are absent eg economic gain, avoiding legal responsibility,
or improving physical well being (unlike in malingering)

- The motivation for the behavior is to play the sick role (may move from hospital to hospital in
search of care for an illness) – hospital addicts/hoboes/ professional patients

* Patient knowingly fake symptoms for psychological reasons

* They usually follow through with medical procedures, are at risk of drug addiction and may
suffer from complications of multiple operations (unlike malingerers)

* Usually loners with an early childhood background of trauma, deprivation and are unable to
establish close interpersonal relationships (affinity for medical system and poor maladaptive
coping skills) –

* Other forms include Munchausen (severe chronic variant) and ganser syndromes, factitious
disorder by proxy/Munchausen’s syndrome by proxy (deliberate production /feigning of
physical or psychological symptoms in another person who is under that individuals care, usually
mother vs a child/health worker vs inpatient/ adults- perpetrator vs victim).

Ddx- malingering, other ss disorders, neurological disorders, other physical disorders

* Clues that should trigger suspicion of F.D

Mgt and Rx

- Appropriate index of suspicion and non judgmental confrontational plus psychiatric

consultation

- redefining/reframing the factitious illness as psychiatric with continued involvement of a

primary clinician + family support are vital in successful mgt (“a cry for help”)

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- treat any underlying psychiatric disorder esp depression, personality disorder,

- mindful of legal and ethical issues

* Psychotherapy- overall not good results thus need to focus on mgt of disorder than on a cure

DISSOCIATIVE DISORDERS
There is alteration in unitary state (self as a single human being with a single personality) which
results in a lack of connection in a person’s thoughts, memories, feelings, actions/behavior or
sense of identity.

Are frequently found in the aftermath of trauma

Includes dissociative amnesia, d.fugue, d.identity disorder, depersonalization disorder

1. Dissociative fugue (psychogenic fugue)

-characterized by sudden unexpected travel away from home/customary place of daily activity.

- Confusion about personal identity or assumes a new identity (partial or complete) and inability
to recall some or all one’s past

- Perplexity and disorientation may occur

** R/o did, gmc eg tle, substance abuse,

** cause clinically significant distress/impairment in s/o functioning

2. Dissociative amnesia

Main feature is reversible memory impairment due to psychological causes usually following a
severe physical or psychological stressor

- One or more episodes of inability to recall important personal information usually of a

traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness

** R/o did, df, ptsd, asd, somatisation disorder, gmc eg tle and brain trauma, substance abuse,

** cause clinically significant distress/impairment in s/o functioning

- can have localized amnesia (events during a circumscribed period of time), selective amnesia
(partial amnesia of the events), generalized amnesia (complete loss of memory for one’s life
history-rare)

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- Many become chronically impaired in their ability to form and sustain satisfactory
relationships. Histories of trauma, child abuse, victimization are common

- Prevalence of 1.8% (USA), male; female 1:2.6

- Duration of forgotten events can range from minutes to decades. Suicidal and other self
destructive behaviors are common

- comorbidity common eg dysthymia, mdd, ptsd, personality disorder (avoidant, dependent,

borderline)

3. Dissociative Identity Disorder

Formerly multiple personality disorder (dsm iv)

- A process whereby repeated dissociation may result in a series of separate entities. The
entities may become the internal “personality states” of a did system. “Switching”- is the
changing between these states of consciousness. These alternate states though different
but are all a manifestation of a single person.
- Presence of ->2 distinct identities or personality states (each with its own relatively
enduring pattern of perceiving, relating to and thinking about external envt and self which
may be reported by self or observed by others). * in some cultures/religion it may be
described as experience of possession/spirits
- There is also inability to recall important information that is too extensive to be explained
by ordinary forgetfulness (everyday life events, trauma, vital personal information)
- R/o effects of substance eg alcohol or a gms eg complex partial seizures,
fantasy/imagination play in children.

*Co mobidity is high (depression, bpd, substance abuse, anxiety, epilepsy, scz, ptsd, personality
disorder -avoidant, borderline)

- Often associated with overwhelming experiences, traumatic events or abuse/neglect occurring

in childhood. > 70% have attempted suicide; males commonly exhibit violent/criminal behavior
than female

4. Depersonalization/derealization disorder

Transient feelings of unreality (normal vs abnormal- as a symptom of a mental/physical illness)

- A change occurs in an individual’s self awareness thus they feel detached from their own
experiences with the self, body and mind. Periods of unreality can last days/weeks/months and
can lead to distress with eventual anxiety or depression.

- there is persistent /recurrent experiences of feeling detached from, and as if one is an outside
observer of one’s mental processes or body (eg feeling like one is in a dream)

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NB: Reality testing remains intact

-Experiences of unreality or detachment with respect to surroundings (eg individuals or objects

are experienced as unreal, dreamlike, foggy, lifeless or visually distorted)

* lifetime prevalence of 2%, , mean age of onset is 16 yrs, duration of episode can vary from
brief hours/days to prolonged weeks/months, association with childhood trauma but not as strong
as in other dissociative disorders

*culture/religion volitionally induced experiences of dep/der can be part of meditative practices

* Co morbidities high with unipolar depression, anxiety disorders, personality disorders

(avoidant, borderline, obsessive compulsive)

R/o scz, mood disorder, substance intoxication/withdrawal eg cannabis, ketamine, ectasy,

hallucinogens; anxiety disorder, personality disorder, epilepsy

Treatment

- identify and eliminate from trauma if still present

- Psychotherapy/talk therapies

- Medication in psychiatric co morbidities

-hypnotherapy/abreaction