Somatic symptoms and Related Disorders

Dr. Noor Ali Hasan

M.B.Ch.B., F.A.C.M.(Psych)
Objectives

1.To define somatic symptom and related

disorders .
2.To know types and clinical features.
3.To know the differential diagnosis.
4.To know how to treat.
Somatic Symptom and Related Disorders
Patients with somatic symptom and related disorders chronically
experience medically unexplained symptoms, which cause
significant medical and psychiatric disability. Physicians and health
systems are challenged by this patient population, because somatic
symptoms are often long-lasting, are difficult to treat, and are
associated with increased health care utilization.
These disorders include
➢ Somatic symptom disorder.
➢Conversion disorder (functional neurological symptom disorder).
➢Illness anxiety disorder
➢Psychological factors affecting other medical conditions.
➢Factitious disorder (imposed on self or another).
Predisposing factors include:
➢ Beliefs about illness shape a person’s response to sensations and
symptoms. These beliefs may be related to personal experience of illness in
earlier life, to involvement in the illness of family or friends, or to portrayals
of illness in the media.
➢ Adverse experiences in childhood: Adults with medically unexplained
symptoms commonly report adversities in childhood; for example, poor
parenting and various forms of abuse.
✓Somatic symptom disorder: Presence of one or more Somatic
symptoms that are distressing or result in significant disruption to daily life.
✓ Illness anxiety disorder: Preoccupation with having or
acquiring a serious illness (no symptom need be present).
✓ Conversion disorder: Presence of one or more symptoms of altered
voluntary motor or sensory function (neurological symptoms).
✓Factitious disorder (imposed on self or another): Falsification
of physical or psychological signs or symptoms (or induction of injury or
disease) associated with identified deception.
Somatic symptom disorder: clinical features
✓ When a person has a significant focus on physical symptoms, such as pain, fatigue
or shortness of breath, to a level that results in major distress and/or problems
functioning.
✓The physical symptoms may or may not be associated with a diagnosed medical
condition, but the person is experiencing symptoms and believes they are sick (that
is, not faking the illness), lasting 6 months and more.
✓ Excessive health related behavior as frequent medical consultation with persistent
concerns about symptoms despite reassurance from health care providers.
✓ About 80% of patients with this disorder may have coexisting depressive or
anxiety disorders.
❖ Epidemiology:
✓ Men and women are equally affected by this disorder.
✓ Social position, education level, gender, and marital status do not appear to
affect the diagnosis.
✓This disorder’s complaints reportedly occur in about 3% of medical
students, usually in the first 2 years, but they are generally transient.
❖ Etiology:
➢ Social learning model: patients adapt the sick role when facing seemingly
insolvable problems. The sick role offers an escape that allows a patient to avoid
noxious obligations, and to be excused from usual duties and obligations.
➢ The psychodynamic school: aggressive and hostile wishes toward others are
transferred into physical complaints.
➢ Somatic symptom disorder is sometimes a variant form of other mental disorders,
among which depressive disorders and anxiety disorders where 80% of patients
with this disorder may have coexisting depressive or anxiety disorders.
Differential diagnosis
✓Medical conditions with vague symptoms like acquired immunodeficiency
syndrome (AIDS), endocrinopathies, myasthenia gravis, multiple sclerosis,
degenerative diseases of the nervous system, systemic lupus erythematosus,
and occult neoplastic disorders.
✓ Illness anxiety disorder.
✓ Conversion disorder.
✓ Major depressive and anxiety disorders especially panic disorder.
✓ Factitious disorder.
✓ Malingering.
Treatment
✓ Group psychotherapy often benefits such patients, in part because it
provides the social support and social interaction that seem to reduce their
anxiety.
✓ Behavior therapy, cognitive therapy.
✓ Frequent, regularly scheduled physical examinations help to reassure
patients that their physicians are not abandoning them and that their
complaints are being taken seriously.
✓ Pharmacotherapy used only when a patient has an underlying drug-
responsive condition, such as an anxiety disorder or depressive disorder.
Illness Anxiety Disorder
✓ Patients are preoccupied with the false belief that they
have or will develop a serious disease.
✓ Somatic symptoms are not present.
✓ The preoccupation last for 6 months.
✓ Associated with significant distress and dysfunction.
Etiology

✓ Social learning model: sick role.

✓ The psychodynamic school: aggressive and hostile wishes
toward others are transferred into physical complaints.
Differential diagnosis
✓Medical illness
✓Somatic symptom disorder; by the emphasis in illness anxiety disorder on
fear of having a disease versus the emphasis in somatic symptom disorder
on concern about many symptoms; but both may exist to varying degrees
in each disorder.
✓Conversion disorder: is acute, generally transient, and usually involves a
symptom rather than a particular disease.
✓ Obsessive-compulsive disorder: by the singularity of their beliefs and by
the absence of compulsive behavioral traits.
Treatment
✓Group psychotherapy often benefits such patients, in part because it
provides the social support and social interaction that seem to reduce their
anxiety.
✓ Behavior therapy, cognitive therapy.
✓ The role of frequent, regularly scheduled physical examinations is
controversial
✓ Pharmacotherapy used only when a patient has an underlying drug-
responsive condition, such as an anxiety disorder or depressive disorder.
Functional Neurological Symptom Disorder (Conversion Disorder)
➢ Sudden onset of symptoms that affect a voluntary motor or sensory
function, that is, neurological symptoms but are incompatible with
known neurologic conditions.
➢ It is preceded by conflicts or other stressors.
➢ The symptoms are not intentionally produced.
➢ The symptoms are not caused by substance use.
➢ The gain is primarily psychological and not social, monetary, or legal.
Common Symptoms of Conversion Disorder
Motor symptoms Sensory symptoms
Involuntary movements Blindness
Falling Deafness
Abnormal gait Anesthesia of limbs
Paralysis
Weakness
Seizures
Motor symptoms:
Paralysis, blindness, and mutism are the most common conversion disorder symptoms.
Other common motor disturbances are paralysis and paresis involving one, two, or all
four limbs, although the distribution of the involved muscles does not conform
to the neural pathways. Reflexes remain normal; the patients have no
fasciculations or muscle atrophy; electromyography findings are normal.
Seizure Symptoms: are called Pseudoseizures in conversion disorder. Tongue-
biting, urinary incontinence, and injuries after falling are absent in pseudoseizures, no
post seizure increase in prolactin concentrations.
Conversion disorder may be most commonly associated with dependent, antisocial, and
histrionic personality disorders.
Etiology
✓Psychoanalytic Factors: According to psychoanalytic theory, conversion
disorder is caused by repression of unconscious intrapsychic conflict and
conversion of anxiety into a physical symptom.
✓ Psychodynamics Factors: includes
1.Primary gain: refers to the reduction of anxiety by repression of an
unacceptable impulse (e.g., paralysis of arm prevents expression of aggressive
impulse).
2. Secondary gain: benefits as a result of being sick; for example, being excused
from obligations and difficult life situations, receiving support and assistance.
3. La Belle Indifférence: is a lack of concern about illness or obvious
impairment.
Epidemiology
✓ Onset usually in early adulthood but when symptoms onset in middle or
old age, the probability of an occult neurological or other medical
condition is high.
✓Women are affected as twice as men.
✓ It is more frequent in family members and common in persons of low
socioeconomic status, less well-educated persons, rural population, and
military personnel who have been exposed to combat situations.
✓ Conversion disorder is commonly associated with comorbid diagnoses of
major depressive disorder, anxiety disorders, somatic symptom disorder.
Differential diagnosis
Thorough medical and neurological workup is essential in all cases
because an estimated 25 to 50% of patients classified as having
conversion disorder eventually receive diagnoses of neurological or
nonpsychiatric medical disorders that could have caused their earlier
symptoms. If the symptoms can be resolved by suggestion, or
parenteral amobarbital (Amytal) or lorazepam , they are probably the
result of conversion disorder.
1. Neurological disorders: basal ganglia disease, brain tumors, myasthenia
gravis, etc.
Paralysis, It is inconsistent and does not follow motor
pathways. Spastic paralysis, clonus, and cogwheel rigidity are
also absent in conversion disorder.
On examination of paralysed leg --- Hoover test (with the
patient lying in bed put your hand below the paralysed leg
and ask him to move the normal leg up, you will feel the
paralysed leg pressing your hand down against the bed) This
test help in diagnosing not only conversion but also
factitious and malingering disorders.
Aphonia, ask to cough (real aphonia cannot cough).
Coma, resisting eye opening.
Ataxia, Movements are bizarre in conversion disorder.
Blindness, No pupillary response is seen in true neurologic
blindness.
Deafness, Loud noise will awaken sleeping patient with
conversion disorder but not patient with organic deafness.
2. Medical disorders: with confusing symptoms are Guillain-Barré
syndrome, Creutzfeldt- Jakob disease, periodic paralysis, and early
neurological manifestations of acquired immunodefficiency syndrome
(AIDS).
3. Somatic symptom disorder: here there is multiple symptoms of
different organ system.
4. Malingering and factitious disorder
Treatment
Resolution of the conversion disorder symptom is usually spontaneous,
although it is probably facilitated by insight-oriented supportive or behavior
therapy. The most important feature of the therapy is a relationship with a
caring and confident therapist. Telling such patients that their symptoms are
imaginary often makes them worse. Parenteral amobarbital or lorazepam may
be helpful in obtaining additional information, especially when a patient has
recently experienced a traumatic event. Psychoanalysis in which patients
explore intrapsychic conflicts.
Pharmacologic treatment. These include benzodiazepines
for anxiety and muscular tension; antidepressants for
depressive or anxiety symptoms.
Factitious Disorders:
It is defined as intentional report and misrepresentation of
symptoms, or self-infliction of physical signs of symptoms, of
medical or mental disorders. The only apparent objective is to
assume the role of a patient without an external incentive.
Hospitalization is often a primary objective and a way of life. It is
more common in men than in women.
Etiology
Early real illness coupled with parental abuse or rejection is
typical. Patient recreates illness as an adult to gain loving
attention from doctors. Can also express masochistic
gratification for some patients who want to undergo surgical
procedures. No genetic or biologic etiologic factors have
been identified.
Clinical features
1. With predominantly physical signs and symptoms. This
includes intentional production of physical symptoms—nausea,
vomiting, pain, and seizures. Patients may intentionally put blood in
feces or urine, artificially raise body temperature or take insulin to
lower blood sugar.
2. With predominantly psychological signs and symptoms.
This includes intentional production of psychiatric symptoms—
hallucinations, delusions, depression, and bizarre behavior.
3.Factitious disorder by proxy—intentionally feigning
symptoms in another person who is under the person’s care
so as to assume the sick role indirectly). Factitious disorder
by proxy is most common in mothers who feign an illness in
their child.
Differential diagnosis
✓ MEDICAL ILLNESS: Physical examination and laboratory workup
should be performed; results will be negative. The nursing staff should
observe carefully for deliberate elevation of temperature, alteration of body
fluids.
✓ SOMATOFORM DISORDERS.
✓ MALINGERER: It is a difficult differential diagnosis to make.
Malingerers have specific goals (e.g., insurance payments, avoidance of jail
term).
Treatment:
No specific psychiatric therapy has been effective in treating
factitious disorders. Treatment, thus, is best focused on
management rather than on cure. The major goals in the treatment
and management of factitious disorders are (1) to reduce the risk of
morbidity and mortality, (2) to address the underlying emotional
needs or psychiatric diagnosis underlying factitious illness behavior.