SOMATIC SYMPTOM

DISORDER
Placer, Selorio & Vuelga
 OVERVIEW

SOMATIC SYMPTOM AND RELATED DISORDERS

• Called Somatoform disorders in DSM IV-TR
• Diagnoses:
Somatic symptom disorder
Illness anxiety disorder
Conversion disorder (Functional neurological symptom disorder)
Pyschological factors affecting other medical conditions
Factitious disorder
Other specified somatic symptom and related disorder
Unspecified somatic symptom and related disorder

Common feature: The prominence of symptomatic symptoms associated with

significant distress and impairment.
Major diagnosis in somatic symptom disorder emphasizes diagnosis made on the basis of
positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts,
feelings, and behaviors in response to these symptoms).
 OVERVIEW

SOMATIC SYMPTOM AND RELATED DISORDERS

Change from Somatoform Disorder (DSM-IV) to Somatic symptom and related disorders (DSM-5)

Somatoform Disorder Somatic symptom and related

• Grounding a diagnosis on the absence
of an explanation is problematic and
reinforces a mind-body dualism. It is
not appropriate to give an individual
a mental disorder diagnosis solely
because a medical cause cannot be
diagnosed.
disorder
• Defines somatic symptoms and related
disorder on the basis of positive
symptoms (distressing somatic
symptoms plus abnormal thoughts,
feelings, and behaviors in response to
these symptoms).
 OVERVIEW

SOMATIC SYMPTOM AND RELATED DISORDERS

• Factors may contribute to somatic symptom disorder and related disorders:
Genetic and biological vulnerbility (e.g., increased sensitivity to pain)
Early traumatic experiences (e.g., violence, abuse, deprivation)
Learning (e.g., attention obtained from illness, lack of reinforcement of
nonsomatic expressions of distress)
Cultural/social norms that devalue and stigmatize psychological
suffering as compared with physical suffering

Somatic symptom and related disorders are characterized by the prominent

focus on somatic concerns and their initial presentation mainly in medical
rather than mental health care settings.
 1

SOMATIC SYMPTOM
DISORDER
300.82 (F45.1)
SOMATIC SYMPTOM DISORDER

DIAGNOSTIC CRITERIA

• Most commonly, pain is present

• Symptoms may be specific (e.g.,
localized pain) or relatively non-
specific (e.g., fatigue)
• Individuals with SSD tend to have a
very high levels of worry about illness
(Criteria B).
• In severe cases, health concerns may
assume a central role in the
individual’s life. Also, the impairment
is marked, and when persistent, can
lead to invalidism.
• There is often a high level of medical
care utilization, seeking care from
multiple doctors.
 SOMATIC SYMPTOM DISORDER

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Attention focused on somatic symptoms
COGNITIVE • Attribution of normal bodily sensations to physical illness
FEATURES • Worry about illness
• Fear that any physical activity may damage the body

• Repeated bodily checking for abnormalities

BEHAVIORAL
FEATURES • Repeated seeking of medical help and reassurance
• Avoidance of physical activity

• These features are usually associated with frequent requests for medical help for different
somatic symptoms.
• Individuals with SSD typically present to general medical health services rather than mental
health services.
• There is an increased suicide risk since SSD is associated with depressive disorders.
 SOMATIC SYMPTOM DISORDER

PREVALENCE

• Not known
• SSD is expected to be higher than Somatization disorder
• Prevalence of SSD is 5%-7% in general adult population
• Females tend to report more somatic symptoms

DEVELOPMENT AND COURSE

• Older adults: underdiagnosed because certain somatic symptoms (e.g., pain)
are considered part of aging
• Adult: somatic symptoms and concurrent medical illness are common
• Children: a single prominent symptom (e.g., recurrent abdominal pain) is more
common. Parents’ response determine the level of associated distress.
 SOMATIC SYMPTOM DISORDER

RISK AND PROGNOSTIC FACTORS

• Temperamental. Personality trait of negative affectivity (neuroticism) is a risk

factor
• Environmental. SSD is more frequent in individuals with few years of
education, low socioeconomic status, and those who recently experienced
stressful life events .
• Course Modifiers. Demographic features, childhood adversity, social stress, etc.

CULTURE-RELATED DIAGNOSTIC ISSUES

• Somatic symptoms are prominent in various “culture-bound syndromes”
• The differences in somatic presentations have been described as “idioms of
distress” because they may have special meanings and shape patient-clinician
interactions in the particular contexts.
• There may also be differences in medical treatment seeking among cultural groups
 SOMATIC SYMPTOM DISORDER
DIFFERENTIAL DIAGNOSIS
Other Medical Conditions
The presence of somatic symptoms of
unclear etiology is not in itself
sufficient to make diagnosis of SSD.
Panic Disorder
Somatic symptoms and anxiety about
health tend to occur in acute episodes
Somatic Symptom Disorder
The presence of somatic symptoms of
an established medical disorder (e.g.,
diabetes, or heart disease) does not
exclude the diagnosis of somatic
symptom disorder if the criteria are
otherwise met.
Somatic Symptom Disorder
Anxiety and somatic symptoms are
more persistent
 SOMATIC SYMPTOM DISORDER

Generalized Anxiety Disorder Somatic Symptom Disorder

Individuals with GAD worry about The main focus is somatic symptoms or
multiple events, situations or activities, fear of illness
only one of which may involve their
health.

Depressive Disorder vs. Somatic Symptom Disorder

• Depressive disorders are commonly accompanied by somatic symptoms.

• Depressive disorders are differentiated with SSD by the core depressive
symptoms of low (dysphoric) mood and anhedonia.
 SOMATIC SYMPTOM DISORDER

Illness Anxiety Disorder Somatic Symptom Disorder

Extensive worries about health but no Focus is on somatic symptoms and fear
other minimal somatic symptoms of illness

Conversion Disorder (Functional Somatic Symptom Disorder

Neurological Symptom Disorder)
The presenting symptom is loss of The focus is on the distress that
function (e.g., of a limb) particular symptoms cause.

Delusional Disorder Somatic Symptom Disorder

In delusional disorder, somatic The individual’s beliefs that somatic

subtype, the somatic symptom beliefs symptoms might reflect serious
and behaviors are stronger than those underlying physical illness are not held
found in SDD with delusional intensity.
 SOMATIC SYMPTOM DISORDER

Body Dysmorphic Disorder Somatic Symptom Disorder

Individual is excessively concerned The concern about somatic symptoms

about, and preoccupied by, a perceived reflects fear of underlying illness, not
defect in his or her physical features. of a defect in appearance.
Obsessive-compulsive Disorder Somatic Symptom Disorder

Exhibit repetitive behaviors aimed at The recurrent ideas about somatic

reducing anxiety. symptoms or illness are less intrusive.
Individuals with SSD do not exhibit the
repetitive behaviors aimed at reducing
anxiety.

COMORBIDITY

• SSD is associated with high rates of comorbidity with medical disorders as well
as anxiety and depressive disorders.
 2

ILLNESS ANXIETY DISORDER

300.7 (F45.21)
 ILLNESS ANXIETY DISORDER

DIAGNOSTIC CRITERIA

• A minority of the cases individuals

with Hypochondriasis are now
classified as having IAD.
• Preoccupation with having or
acquiring a serious, undiagnosed
illness (Criterion A).
• Somatic symptoms are not present
or, if present, are only mild in
intensity (Criterion B).
• The individual’s distress emanates
not primarily from the physical
complaint itself but rather from
his/her anxiety about the meaning,
significance, or cause of the
complaint.
 ILLNESS ANXIETY DISORDER

DIAGNOSTIC CRITERIA

• The preoccupation with the idea that

one is sick is accompanied by
substantial anxiety about health and
disease (Criterion C).
• Individuals with the disorder often
examine themselves repeatedly
(Criterion D).
• The incessant worrying often
becomes frustrating for others and
may result in considerable strain
within the family.
 ILLNESS ANXIETY DISORDER

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Individuals with IAD are encountered more frequently in medical than in mental
health setting.
• They often consult multiple physicians for the same problem and obtain
repeatedly negative diagnostic results.
• Medical attention leads to a paradoxical exacerbation of anxiety or to iatrogenic
complications from diagnostic tests and procedures.
PREVALENCE

• Based on the estimates of DSM-III and DSM-IV diagnosis of hypochondriasis

• Ranges from 1.3% to 10% in community surveys and population-based samples
• Between 3% and 8% is the range of the prevalence in ambulatory medical
populations for 6 months/1-year period.
 ILLNESS ANXIETY DISORDER

DEVELOPMENT AND COURSE

• Unclear
• Age at onset in early and middle adulthood
• Health-related anxiety increases with age; focuses on memory loss in older
individuals
• Rare in children

RISK AND PROGNOSTIC FACTORS

• Environmental. May precipitated by a major life stress or serious but
ultimately benign threat to the individual’s health. A history of childhood abuse
or of a serious childhood illness is a risk factor.
• Course modifiers. Transient form, associated with less psychiatric
comorbidity, more medical comorbidity, and less severe illness anxiety
disorder.
 ILLNESS ANXIETY DISORDER

CULTURE- RELATED DIAGNOSTIC ISSUES

• Prevalence appears to be similar across different countries with diverse
cultures
• Rare in children

FUNCTIONAL CONSEQUENCES OF ILLNESS ANXIETY DISORDER

• Health concerns often interfere with interpersonal relationships, disrupt
family life, and damage occupational performance.
 ILLNESS ANXIETY DISORDER

DIFFERENTIAL DIAGNOSIS

Other medical conditions Illness Anxiety Disorder

Underlying medical condition, If a medical condition is present, the

including neurological or endocrine health-anxiety and disease concerns
conditions, occult malignancies, and are clearly disproportionate to its
other diseases that affect multiple body seriousness.
systems.

Adjustment disorder Illness Anxiety Disorder

Health-related anxiety is a normal Requires the continuous persistence of

response to serious illness. If the health disproportionate health-related anxiety
anxiety is severe enough, adjustment for at least 6 months.
disorder may be diagnosed.
 ILLNESS ANXIETY DISORDER
DIFFERENTIAL DIAGNOSIS
Somatic symptom disorder
Diagnosed when significant somatic
symptoms are present.
Anxiety disorders
In GAD, individuals worry about
multiple events, situations, or activities,
only one of which may involve health.
In panic disorder, individual may be
concerned that the panic attacks reflect
the presence of medical illness; their
anxiety is typically very acute and
episodic.
Illness anxiety disorder
Individuals with IAD have minimal
somatic symptoms and are primarily
concerned with the idea that they are
ill.
Illness anxiety disorder
The health anxiety and fears are more
persistent and enduring.
Individual with IAD may experience
panic attacks that are triggered by their
illness concerns.
 ILLNESS ANXIETY DISORDER
DIFFERENTIAL DIAGNOSIS
Obsessive-compulsive disorders
The thoughts are intrusive and are
usually focused on fears of getting a
disease in the future.
Major depressive disorder
Individuals may ruminate about their
health and worry excessively about
illness.
Illness anxiety disorder
Individuals with IAD may have
intrusive thoughts about having a
disease and also may have associated
compulsive behaviors (e.g., seeking
reassurance). The preoccupations are
usually focused on having a disease.
Illness anxiety disorder
IAD is considered if excessive illness
worry persist after remission of an
episode of MDD.
 ILLNESS ANXIETY DISORDER

DIFFERENTIAL DIAGNOSIS

Psychotic disorder Illness anxiety disorder

Ideas are more rigid and more intense
seen in somatic delusions occurring
psychotic disorders. True somatic
delusions are generally more bizarre
(e.g., that an organ is rotting or dead)
than the concerns in IAD.
Individuals with IAD are not delusional
and can acknowledge the possibility
that the feared disease is not present.
The concerns experienced in IAD,
though not founded in reality, are
plausible.

COMORBIDITY
• Unknown because IAD is a new disorder
• Hypochondriasis co-occurs with anxiety disorders
• Individuals with IAD may have an elevated risk for somatic symptom disorder
and personality disorders.
 3

CONVERSION DISORDER
(FUNCTIONAL NEUROLOGICAL
SYMPTOM DISORDER)
CONVERSION DISORDER

DIAGNOSTIC CRITERIA

• Symptoms
• Episodes of psychogenic or non-
epileptic seizures.
• Other symptoms: reduced or absent
speech volume (dysphonia/aphonia),
altered articulation (dysarthia) a
sensation of a lump in the throat
(globus), and diplopia.
• There must be clinical findings that
show clear evidence of incompatibility
with neurological disease.
• Internal consistency at examination is
one way to demonstrate
incompatibility.
CONVERSION DISORDER

DIAGNOSTIC CRITERIA

• Clinicians use the alternative names

of “functional” (abnormal central
nervous system functioning) or
“psychogenic” (assumed etiology) to
describe the symptoms of conversion
disorder.
• There may be one or more
symptoms
• Motor symptoms: weakness or
paralysis, abnormal movements
(tremor or dystonic movements), gait
abnormalities, and abnormal limb
posturing
• Sensory symptoms: altered, reduced,
or absent skin sensation, vision, or
hearing.
 CONVERSION DISORDER

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Onset may be associated with stress or trauma, either psychological or physical in
nature.
• CD is often associated with dissociative symptoms (depersonalization,
derealization, and dissociative amnesia
• The phenomenon of la belle indifférence (i.e., lack of concern about the nature
or implications of the symptom) has been associated with CD but it is not specific
for CD.
• The concept of secondary gain (i.e., when individuals derive external benefits
such as money or release from responsibilities) is not specific to CD.
PREVALENCE
• Transient conversion symptoms are common, but precise prevalence of the
disorder is unknown.
• Incidence of individual persistence conversion symptoms is 2-5/100,000 per year
 CONVERSION DISORDER

DEVELOPMENT AND COURSE

• Onset: throughout the life course
• Symptoms can be transient or persistent.
• Prognosis may be better in younger children than in adolescents and adults.

RISK AND PROGNOSTIC FACTORS

• Temperamental. Maladaptive personality traits are commonly associated.

• Environmental. History of childhood abuse and neglect. Stressful events are
often, but not always, present.
• Genetic and physiological. The presence of neurological disease that causes
similar symptoms is a risk factor.
• Course modifiers. Short duration of symptoms and acceptance of the
diagnosis are positive prognostic factors.
 CONVERSION DISORDER

CULTURE-RELATED DIAGNOSTIC FEATURES

• If the symptoms are fully explained within the particular cultural context and
do not result in clinically significant distress or disability, then the diagnosis of CD
is not made.

GENDER-RELATED DIAGNOSTIC ISSUES

• Conversion disorder is two to three times more common in females.

FUNCTIONAL CONSEQUENCES OF CONVERSION DISORDER

• The severity of disability can be similar to that experienced by individuals with

comparable medical disease.
 CONVERSION DISORDER
DIFFERENTIAL DIAGNOSIS
Neurological disease
After a thorough neurological
assessment, an unexpected
neurological disease cause for the
symptoms is rarely found at follow up.
Somatic symptom disorder
Most of the somatic symptoms
encountered in SDD cannot be
demonstrated to be clearly
incompatible with pathophysiology
Conversion disorder
May coexist with neurological disease.
Conversion disorder
May be diagnosed in addition to SSD.
Incompatibility with pathophysiology
is required for the diagnosis. There is
also an absence of excessive thoughts,
feelings, and behaviors that
characterized SSD
 CONVERSION DISORDER

DIFFERENTIAL DIAGNOSIS

Factitious disorder and malingering Conversion disorder

Definite evidence of feigning would The diagnosis of CD does not require

suggest a diagnosis of factitious
disorder (if the individual’s apparent
aim is to assume the sick role) or
malingering (if the aim is to obtain an
incentive such as money)
the judgement that the symptoms are
not intentionally produced (i.e., not
feigned)

Dissociative disorders vs. Conversion Disorder

Dissociative symptoms are common in individuals with conversion disorder.

If both CD and dissociative disorder are present, both diagnoses should be made.
 CONVERSION DISORDER

DIFFERENTIAL DIAGNOSIS

Depressive disorders Conversion disorder

Individuals may report general The weakness of CD is more focal and

heaviness of their limbs. There is also a prominent.
presence of core depressive symptoms.

Body dysmorphic disorder vs. Conversion Disorder

Individuals with body dysmorphic disorder are excessively concern about a

perceived defect in their physical features but do not complain of symptoms of
sensory or motor functioning in the affected body part.
 CONVERSION DISORDER

DIFFERENTIAL DIAGNOSIS

Panic disorders Conversion disorder

Neurological symptoms are typically Loss of awareness with amnesia for the
transient and acutely episodic with attack and violent limb movements
characteristic cardiorespiratory occur in non-epileptic attacks.
symptoms.

COMORBIDITY

• Anxiety disorders, especially panic disorders, depressive disorders, somatic

symptom disorder , neurological and other medical conditions may co-occur.
• Personality disorders are more common in individuals with CD than in general
population.
• Psychosis, substance use disorder, and alcohol misuse are uncommon.
 4

PSYCHOLOGICAL FACTORS
AFFECTING OTHER MEDICAL
CONDITIONS
316 (F54)
CONVERSION DISORDER

DIAGNOSTIC CRITERIA

• Essential feature: the presence of

one or more clinically significant
psychological or behavioral factors
that adversely affect a medical
condition by increasing the risk for
suffering, death, or disability
(Criterion B).
• These factors can adversely affect
the medical condition by influencing
its course of treatment, by
constituting an additional well-
established health risk factor, or by
influencing the underlying
pathophysiology to precipitate or
exacerbate symptoms or to
necessitate medical attention.
CONVERSION DISORDER

DIAGNOSTIC CRITERIA

• Psychological or behavioral factors:

psychological distress, patterns of
interpersonal interaction, coping
styles, and maladaptive health
behaviors, such as denial of
symptoms of poor adherence to
medical recommendations.
• Clinical examples: anxiety-
exacerbating asthma, denial of need
for treatment for acute chest pain,
and manipulation of insulin by an
individual with diabetes wishing to
lose weight.
CONVERSION DISORDER

DIAGNOSTIC CRITERIA

• This diagnosis should be reserved

for situations in which the effect of
the psychological factor on the
medical condition is evident and the
psychological factor has clinically
significant effects on the course or
outcome of the medical condition.

• Abnormal psychological or
behavioral symptoms that develop in
response to a medical condition are
more properly coded as an
adjustment disorder
 PSYCHOLOGICAL FACTORS AFFECTING
OTHER MEDICAL CONDITIONS

PREVALENCE
• Unclear
• In U.S. private insurance billing data, it is more common diagnosis than somatic
symptom disorder.
DEVELOPMENT AND COURSE
• Psychological factors affecting other medical conditions can occur across the
lifespan.
CULTURE-RELATED DIAGNOSTIC ISSUES
• Differences between cultures may influence psychological factors and their
effects on medical conditions, such as those in language and communication style,
explanatory models of illness, patterns of seeking health care, service availability
and organization doctor-patient relationships, and other healing practices, family
and gender roles, and attitudes toward pain and death.
 PSYCHOLOGICAL FACTORS AFFECTING
OTHER MEDICAL CONDITIONS

DIFFERENTIAL DIAGNOSIS

Mental disorder due to another Psychological factors affecting other

medical condition medical conditions
The medical condition is judged to be The psychological or behavioral factors
causing the mental disorder through a are judged to affect the course of the
direct physiological mechanism. medical condition.

Adjustment disorder Psychological factors affecting other

medical conditions
Abnormal psychological or behavioral Diagnosed when the psychological
symptoms that develop in response to a traits or behaviors do not meet criteria
medical condition are more properly for a mental diagnosis.
coded as an adjustment disorder.
 PSYCHOLOGICAL FACTORS AFFECTING
OTHER MEDICAL CONDITIONS

DIFFERENTIAL DIAGNOSIS

Somatic symptom disorder Psychological factors affecting other

Characterized by a combination of
distressing somatic symptoms and
excessive or maladaptive thoughts,
feelings and behavior in response to
health concerns. The emphasis is on
maladaptive thoughts, feelings, and
behavior.
medical conditions
The individual’s thoughts, feelings, and
behavior are not necessarily excessive.
The emphasis is on the exacerbation of
the medical condition.
 PSYCHOLOGICAL FACTORS AFFECTING
OTHER MEDICAL CONDITIONS

DIFFERENTIAL DIAGNOSIS

Illness anxiety disorder Psychological factors affecting other

Characterized by high illness anxiety
that is distressing and/or disruptive to
daily life with minimal somatic
symptoms. The clinical concern is the
individual’s worry about having a
disease.
medical conditions
Anxiety may be a relevant
psychological factor affecting a medical
condition. The clinical concern is the
adverse effects on the medical
condition.

COMORBIDITY

• Relevant psychological or behavioral syndrome or trait and comorbid

conditions.
 5

FACTITIOUS DISORDER
300.19 (F68.10)
FACTITIOUS DISORDER

RECORDING PROCEDURE
• Factitious disorder imposed on
another is the diagnosis given to the
perpetrator who falsifies illness in
another.
• The victim may be given abuse
diagnosis

DIAGNOSTIC CRITERIA
• Essential feature: falsification of medical
or psychological signs and symptoms in
oneself or others that are associated with
the identified deception.
• Individual is taking surreptitious actions
to misrepresent, simulate, or cause signs
or symptoms of illness or injury in the
absence of obvious external rewards.
 FACTITIOUS DISORDER

ASSOCIATED FEATURES SUPPORTING DIAGNOSIS

• Individuals with FD imposed on self or FD imposed on another are at risk for
experiencing great psychological distress or functional impairment by causing
harm to themselves and others.
• There is persistence of behavior and the intentional efforts to conceal the
disordered behavior through deception
• The diagnosis of FD emphasizes the objective identification of falsification of signs
and symptoms of illness, rather than an inference about intent or possible
underlying motivation such as in criminal behaviors.
PREVALENCE

• Unknown.
• In hospital settings, it is estimated that about 1% of individuals have presentations
that meet criteria for FD.
 FACTITIOUS DISORDER

DEVELOPMENT AND COURSE

• Course: usually one of intermittent episodes.
• Onset: in early childhood, after hospitalization for a medical condition or a
mental disorder
• When imposed on another, the disorder may begin after hospitalization of the
individual’s child or other dependent.
• In individuals with recurrent episodes of falsification of illnesses, pattern of
successive deceptive action may become lifelong.
 FACTITIOUS DISORDER

DIFFERENTIAL DIAGNOSIS

Somatic symptom disorder Factitious disorder

There may be excessive attention and The symptoms are produced

treatment seeking for perceived intentionally to assume the sick role or
medical concerns, but there are no without obvious external reward.
evidence that the individual is
providing false information or
behaving deceptively

Malingering Factitious disorder

Intentional reporting of symptoms for Requires the absence of obvious
personal gain (e.g., money, time off rewards.
work)
 FACTITIOUS DISORDER

DIFFERENTIAL DIAGNOSIS

Conversion disorder (functional Factitious disorder

neurological symptom disorder)
Characterized by neurological FD with neurological symptoms
symptoms that are consistent with emphasized evidence of deceptive
neurological pathophysiology. falsification of symptoms.

Borderline personality disorder Factitious disorder

Deliberate physical self-harm in the Requires that the induction of injury
absence of suicidal intent can also occur in association with deception.
occur in BPD
 FACTITIOUS DISORDER

DIFFERENTIAL DIAGNOSIS

Medical condition or mental disorder not associated with intentional

symptom falsification vs. Factitious Disorder
The diagnosis of Factitious disorder does not exclude the presence of true
medical condition or mental disorder, as comorbid illness often occurs in the
individual along with factitious disorder.
 6

OTHER SPECIFIED SOMATIC

SYMPTOM AND RELATED
DISORDER
300.89 (F45.8)
OTHER SPECIFIED SOMATIC SYMPTOM
AND RELATED DISORDER
 7

UNSPECIFIED SOMATIC SYMPTOM

AND RELATED DISORDER
300.82 (F45.9)
UNSPECIFIED SOMATIC SYMPTOM AND
RELATED DISORDER