Somatic Symptom Disorder
Illness anxiety disorder was formerly known as
“hypochondriasis”, which is still the term
widely used among the public.
In illness anxiety disorder as we know it today,
physical symptoms are either not experienced
at the present time or are very mild, but severe
anxiety is focused on the possibility of having
or developing a serious disease.
For many years, this disorder was called If one or more physical symptoms are
Briquet’s syndrome, but now would be relatively severe and are associated with
considered somatic symptom disorder. anxiety and distress the diagnosis would be
somatic symptom disorder.
People with somatic symptom disorder do not
always feel the urgency to take action but In illness anxiety disorder the concern is
continually feel weak and ill, and they avoid primarily with the idea of being sick instead of
exercising, thinking it will make them worse. the physical symptom itself.
Another common example of a somatic Anxiety and mood disorders are often
symptom disorder would be the experience of comorbid with somatic symptom disorders;
severe pain in which psychological factors play that is, if individuals with somatic symptom
a major role in maintaining or exacerbating disorders have additional diagnoses, these most
the pain whether there is a clear physical likely are anxiety or mood disorders.
reason for the pain or not. Somatic symptom disorder and illness anxiety
disorder are characterized by anxiety or fear
that one has a serious disease.
Illness Anxiety Disorder
Because a key feature of this disorder is
preoccupation with physical symptoms,
individuals with these disorders almost always
go initially to family physicians.
Many of these individuals mistakenly believe
they have a disease, a difficult-to-shake belief
sometimes referred to as “disease conviction”.
Therefore, along with anxiety focused on the
possibility of disease or illness, disease
conviction is a core feature of both disorders.
Although all disorders include characteristic These kinds of events may predispose men
concern with physical symptoms, patients with to focus their attention on their sexual
panic disorder typically fear immediate organs, which could exacerbate anxiety
symptom-related catastrophes that may occur and emotional arousal, much as it does in
during the few minutes they are having a panic the anxiety disorders.
attack, and these concerns lessen between
Another culture-specific disorder, prevalent in
attacks.
India, is an anxious concern about losing
Individuals with somatic symptom disorders, semen, something that obviously occurs during
on the other hand, focus on a longterm process sexual activity.
of illness and disease (for example, cancer or
The disorder, called dhat, is associated
AIDS).
with a vague mix of physical symptoms,
including dizziness, weakness, and fatigue.
Statistics These low-grade depressive or anxious
symptoms are simply attributed to a
The prevalence of DSM-IV hypochondriasis,
physical factor, semen loss.
which would encompass illness anxiety disorder
and part of somatic symptom disorder, has
been estimated to be from 1% to 5%.
When the problem is severe enough to meet
It was thought for a long time that somatic criteria for disorder, the sex ratio is
symptom disorders were more prevalent in approximately 2:1 female to male.
elderly populations, but this does not seem to
be true.
Causes
The proportion of all those seeing a doctor
with these disorders is about the same. Faulty interpretation of physical signs and
sensations as evidence of physical illness is
Linda’s disorder developed during adolescence,
central, so almost everyone agrees that these
which is the typical age of onset.
disorders are basically disorders of cognition or
A number of studies have demonstrated that perception with strong emotional
individuals with what would now be somatic contributions.
symptom disorder tend to be women,
Using procedures from cognitive science such
unmarried, and from lower socioeconomic
as the Stroop test, a number of investigators
groups.
have confirmed that participants with these
Obviously, individuals with somatic symptom disorders show enhanced perceptual
disorders overuse and misuse the health-care sensitivity to illness cues.
system, with medical bills as much as 9 times
Smeets, de Jong, and Mayer demonstrated that
more than the average patient.
individuals with these disorders, compared with
As with anxiety disorders, culture-specific “normals,” take a “better safe than sorry”
syndromes seem to fit comfortably with approach to dealing with even minor physical
somatic symptom disorders. Among these is the symptoms by getting them checked out as
disorder of koro, in which there is the belief, soon as possible.
accompanied by severe anxiety and sometimes
It is therefore quite possible, as in panic
panic, that the genitals are retracting into the
disorder, that individuals who develop somatic
abdomen.
symptom disorder or illness anxiety disorder
Why does koro occur in Chinese cultures? have learned from family members to focus
Rubin points to the central importance of their anxiety on specific physical conditions
sexual functioning among Chinese males. and illness.
He notes that typical sufferers are guilty
The “benefits” of being sick might contribute to
about excessive masturbation,
the development of the disorder in some
unsatisfactory intercourse, or promiscuity.
people. A “sick person” who receives increased A related somatic symptom disorder is called
attention for being ill and is able to avoid work psychological factors affecting medical
or other responsibilities is described as condition. The essential feature of this disorder
adopting a “sick role.” is the presence of a diagnosed medical
condition such as asthma, diabetes, or severe
In its severe form, a somewhat startling finding
pain clearly caused by a known medical
emerges from studies of somatic symptom
condition such as cancer that is adversely
disorder. This disorder is strongly linked in
affected (increased in frequency or severity) by
family and genetic studies to antisocial
one or more psychological or behavioral
personality disorder (ASPD), which is
factors.
characterized by vandalism, persistent lying,
theft, irresponsibility with finances and at work,
and outright physical aggression.
Individuals with ASPD seem insensitive to
Conversion Disorder (Functional Neurological
signals of punishment and to the negative
Symptom Disorder)
consequences of their often impulsive
behavior, and they apparently experience
little anxiety or guilt.
Treatment
Surprisingly, clinical reports indicate that
reassurance and education seems to be
effective in some cases “surprisingly” because,
by definition, patients with these disorders are
not supposed to benefit from reassurance
about their health.
Taking the time to explain in some detail the
nature of the patient’s disorder (explanatory
therapy) in an educational framework was The term conversion has been used off and on
associated with a significant reduction in fears since the Middle Ages but was popularized by
and beliefs about somatic symptoms and a Freud, who believed the anxiety resulting from
decrease in health-care usage, and these gains unconscious conflicts somehow was
were maintained at the follow-up. “converted” into physical symptoms to find
expression.
In DSM-5, “functional neurological symptom
CBT focused on identifying and challenging disorder” is a subtitle to conversion disorder
illness-related misinterpretations of physical because the term is more often used by
sensations and on showing patients how to neurologists who see the majority of patients
create “symptoms” by focusing attention on receiving a conversion disorder diagnosis, and
certain body areas. Bringing on their own because the term is more acceptable to
symptoms persuaded many patients that such patients.
events were under their control.
“Functional” refers to a symptom without an
Not surprisingly, these same types of drugs organic cause.
(antidepressants) are useful for anxiety and
depression. In one study, CBT and the drug Conversion disorders generally have to do with
paroxetine (Paxil), a selective-serotonin physical malfunctioning, such as paralysis,
reuptake inhibitor (SSRI), were both effective, blindness, or difficulty speaking (aphonia),
but only CBT was significantly different from a without any physical or organic pathology to
placebo condition. account for the malfunction.
Most conversion symptoms suggest that some this is an area of the brain that functions to
kind of neurological disease is affecting compare internal predictions with actual
sensory–motor systems, although conversion events. In other words, if an individual wants to
symptoms can mimic the full range of physical move her arm and then she decides to go
malfunctioning. ahead and move it, this area of the brain
determines if the desired action has occurred.
Malingerers are fully aware of what they are
In addition to blindness, paralysis, and
doing and are clearly attempting to manipulate
difficulty speaking (aphonia), conversion
others to gain a desired end.
symptoms may include
It can also be difficult to distinguish
total mutism and the loss of the sense of touch.
between individuals who are truly
Although she was not paralyzed, her specific experiencing conversion symptoms in a
symptoms included weakness in her legs and seemingly involuntary way and malingerers
difficulty keeping her balance, with the result who are good at faking symptoms.
that she fell often. This particular type of
They are either trying to get out of
conversion symptom is called astasia-abasia.
something, such as work or legal
Another relatively common symptom is globus difficulties, or they are
hystericus, the sensation of a lump in the
attempting to gain something, such as a financial
throat that makes it difficult to swallow, eat,
settlement.
or sometimes talk.
More puzzling is a set of conditions called
It was long thought that patients with
factitious disorders, which fall somewhere
conversion reactions had the same quality of
between malingering and conversion
indifference to the symptoms thought to be
disorders.
present in some people with severe somatic
symptom disorder. This attitude, referred to as The symptoms are under voluntary
la belle indifférence, was considered a control, as with malingering, but there is
hallmark of conversion reactions, but, no obvious reason for voluntarily
unfortunately, this turns out not to be the case. producing the symptoms except, possibly,
to assume the sick role and receive
Conversion symptoms often seem to be
increased attention.
precipitated by marked stress. Often this stress
takes the form of a physical injury. When an individual deliberately makes
someone else sick, the condition is called
It is possible that at least some people who
factitious disorder imposed on another. It
experience miraculous cures during religious
was also known previously as Munchausen
ceremonies may have been suffering from
syndrome by proxy. In any case, it is really
conversion reactions.
an atypical form of child abuse.
Individuals with the conversion symptom
of blindness can usually avoid objects in
their visual field, but they will tell you
they can’t see the objects.
Similarly, individuals with conversion
symptoms of paralysis of the legs might
suddenly get up and run in an emergency
and then be astounded they were able to
do this.
The investigators found that the conversion
tremor, as compared with the voluntary
tremor, was associated with lower activity in
the right inferior parietal cortex. Interestingly,
