Somatic symptom and related disorders

Somatic symptom and related disorders are characterized by prominent somatic symptoms associated with significant distress and psychosocial impairment, and cannot be fully explained by a recognized medical condition. Somatic symptoms may be also present in patients with a known medical condition (e.g., psychogenic nonepileptic seizures in patients with epilepsy). The absence of a medical explanation should not imply that the patient's symptoms are not genuine or that they can consciously control their symptoms. Personal stress, depression, and interpersonal conflicts often exacerbate these disorders; however, psychological stressors are not always evident and may not be significant even when present. More than half of all primary care visits are related to somatic symptom and related disorders, however, diagnosis can be challenging, as it is primarily a diagnosis of exclusion. Management of somatic symptom and related disorders involves patient education and psychotherapy. It is crucial to schedule regular visits with the same physician to avoid unnecessary tests and procedures. Rarely, symptoms may be intentionally induced, invented, or exaggerated either for primary gain (factitious disorder) or secondary gain (malingering). Management of these patients is extremely challenging and involves carefully planned and coordinated intervention.

Risk factors ^[1]

The following risk factors are commonly found in patients with somatic symptom and related disorders:

• Psychiatric disorders (e.g., depression, personality disorder)
• Concurrent physical illness (especially comorbid neurological illness in conversion disorder)
• Gender: Incidence is higher in women than men. ^[2]
• Low socioeconomic status
• History of:
  • Sexual abuse
  • Childhood abuse
• Recent stressful life event

• In the majority of somatic symptom and related disorders:
  • Symptoms are not intentionally induced or invented (unlike in factitious disorders or malingering).
  • Patients are distressed by their symptoms and seek a diagnosis and treatment.
  • There is no deliberate attempt to deceive others, including health care staff.

Diagnostic approach ^[3][4]

• Review the patient's medical record and consider contacting any specialists the patient has consulted in the past.
• Perform a detailed history and physical examination including the following aspects:
  • Diagnostic studies to rule out a treatable medical condition
  • Empathic interview techniques using a trauma-informed approach
  • Risk factors in the patient's history (e.g., history of childhood abuse/neglect or sexual abuse, past psychiatric diagnoses).
  • Cultural context (see “Culture in the health care setting” for more information).
• Ask the patient how their symptoms may be affecting their mood. ^[4]
• Consider using screening tools.
  • Patient health questionnaire-15 (PHQ-15)
  • The somatic symptom scale-8 is an abbreviated version of the PHQ-15 that evaluates the severity of eight somatic symptoms in a 7-day time frame. ^[5]
• DSM-5 criteria must be met to reach a diagnosis of a somatic symptom and related disorder.

Performing extensive diagnostic studies, which are often inconclusive, in patients in whom there is no indication of a medical condition may result in higher levels of patient frustration and excessive health care costs. ^[4]

Apply the BATHE technique to assess for psychosocial factors: Background: “What is going on in your life at the moment?,” Affect: “How does that make you feel?,” Trouble: “What is the most difficult part of this situation?,” Handling: “How are you managing that?,” Empathy: “This must be very challenging for you.” ^[4]

General principles of management ^[3][4][6]

• Challenges can strain the patient-physician relationship and reduce the quality of care.
  • Management of somatic symptoms can be emotionally challenging for clinicians.
  • Patients may become hostile or aggressive in response to a perceived stigmatizing diagnosis.
  • Patients may make a complaint against the clinician.
  • See “Anger and threats from patients” for further information.
• Patient education
  • Involve the patient in the diagnostic and management process.
    • Ask about their expectations from management.
    • Ask what they think may be causing their symptoms.
  • Explain the diagnosis to the patient.
    • Acknowledge symptoms and explain the results of the physical examination and diagnostic studies.
    • Educate patients on brain-body interactions and provide examples of:
      • Psychologically generated symptoms (e.g., racing heart and sweating palms when nervous)
      • Common conditions that are affected by psychological factors (e.g., dyspepsia, hypertension).
    • Emphasize that symptoms are potentially reversible and reassure the patient that it is unlikely that they have a serious illness.
    • Reassure the patient that somatic symptom and related disorders are recognized conditions and that their symptoms are not perceived to be fictitious.
• Medical management
  • Minimize unnecessary studies and procedures
    • Schedule regular visits with the same primary care physician
    • Coordinate with other health care professionals who the patient may be consulting
  • Review symptom severity (consider using screening tools) and perform a physical examination at every visit.
  • Avoid; medication prescriptions, study requests, and patient referrals if they are not needed.
• Psychological and psychiatric management
  • Psychotherapy: primarily cognitive behavior therapy ^[6]
  • Consider prescribing an antidepressant (typically an SNRI, SSRI, or tricyclic). ^[3][4]
  • Treat comorbid psychiatric conditions (e.g., depression, anxiety). ^[1]
  • Consider a psychiatry consultation. ^[7]

Remember the CARE-MD approach for patients with somatic symptoms: Consult with psychiatry/Cognitive behavior therapy, Assess for comorbid diseases, Regular visits, Empathy (trauma-informed approach), explain the Medical and psychiatric interface, Do not harm (avoid unnecessary tests and referrals). ^[3]

Overview

• Individuals with somatic symptom disorder often have:
  • Multiple physical symptoms that cause significant distress
  • A history of extensive (and fruitless) diagnostic testing and medical procedures
  • A preoccupation with their symptoms and health concerns for ≥ 6 months
• Symptoms may be related to an existing medical condition.

Epidemiology

• ♀ > ♂
• Prevalence in adults: ∼ 5–7% ^[3]

Diagnostics

• Clinical and diagnostic study results cannot be fully explained by a recognized medical condition.
• Screening tools may identify patients at risk for somatic symptom disorder.
• All of the following DSM-5 diagnostic criteria must be met: ^[1]
  • ≥ 1 somatic symptom (e.g., heartburn, fatigue, headache, pain) that causes significant distress or impairment
  • Excessive thoughts, feelings, or behaviors related to the somatic symptoms or health concerns, manifesting as ≥ 1 of the following:
    • Disproportionate and constant thoughts of symptom severity
    • Constant and significant anxiety about symptoms or general health
    • Excessive amounts of time and energy spent attending to symptoms or health concerns
  • Duration: ≥ 6 months

Some patients may present with only one severe symptom, most commonly pain. ^[1]

Management

See “Approach to patients with suspected somatic symptom and related disorders” for more information.

• Minimize unnecessary studies and procedures.
• Schedule regular visits with the same primary care physician.
• Psychotherapy: primarily cognitive behavior therapy

Patients with somatic symptom disorder often visit multiple physicians.

Overview

• Conversion disorder is also known as functional neurological symptom disorder.
• Patients present with neurological symptoms that cannot be fully explained by a neurological condition.
• Patients may be calm and unconcerned when describing their symptoms (sometimes referred to as “la belle indifférence”).

A perceived lack of concern about symptoms is not specific to conversion disorder and should not be used to confirm the diagnosis. ^[8]

Epidemiology

• ♀ > ♂
• Age of onset: ∼ 10–35 years of age ^[9]

Clinical features ^[1][10]

• Patients may present with motor and/or sensory deficits affecting single or multiple areas of the body.
• Some clinical features are more commonly found in conversion disorder than in neurological conditions.

Inconsistent examination findings are common in conversion disorder; signs elicited during one examination may not always be present when using a different method.

Diagnostics

• Thorough clinical assessment
  • Evaluate the patient for common physical examination findings.
  • Consider additional studies (e.g., EEG, CT scan, nerve conduction studies) and neurology consultation.
• All of the following DSM-5 diagnostic criteria must be met: ^[1]
  • ≥ 1 neurological symptom (altered motor or sensory function): e.g., paralysis, muscle spasms, blindness, mutism, lump in throat, weakness, gait disorder
  • Clinical features:
    • Are incompatible with any recognized neurological or medical condition
    • Cannot be better explained by another medical disorder
  • Symptoms cause significant distress or psychosocial impairment or require medical evaluation

Patients with neurological conditions (e.g., epilepsy, Parkinson disease, multiple sclerosis) can present with concomitant conversion disorder. ^[10]

Neurological disorders can manifest atypically, particularly in the early stages. Ensure appropriate diagnostic studies are performed and be prepared to revisit a diagnosis of conversion disorder if symptoms worsen. ^[17]

Management

• If present, ensure comorbid neurological conditions are well-managed.
• Physical therapy can help reduce symptoms and prevent secondary complications of inactivity .
• Provide patient education and consider psychotherapy (e.g., cognitive-behavioral therapy)
• See “Approach to patients with suspected somatic symptom and related disorders” for more information.

Overview

• Previously known as hypochondriasis
• Persistent preoccupation with having or developing a serious illness despite no concerning findings on multiple medical examinations
• Somatic symptoms are usually absent or mild, but patients spend large amounts of time and energy obsessing over their health and the possibility of developing a disease.

Illness anxiety disorder in older patients is often focused on memory loss. ^[1]

Epidemiology

• ♀ = ♂ ^[9]
• Prevalence: 1.3–10% ^[1]
• A personal or family history of severe illness during the patient's childhood is common. ^[18]

Diagnosis ^[1]

• No evidence of the illness of concern
• All the following DSM-5 diagnostic criteria must be met: ^[1]
  • Preoccupation with having or developing an illness
  • Absent or mild somatic symptoms
  • Significant anxiety about health
  • The patient exhibits:
    • Excessive health-related behaviors (e.g., constantly checking for signs of illness)
    • OR incongruent avoidance behaviors (e.g., avoiding screening tests, doctor's appointments, attending hospital)
  • Duration: ≥ 6 months
  • Symptoms are not better explained by another mental disorder.

Management

See “Approach to patients with suspected somatic symptom and related disorders” for more information.

• Minimize unnecessary studies and procedures
• Schedule regular visits with the same primary care physician
• Psychotherapy: primarily cognitive behavior therapy

Overview

• Definition: psychological or behavioral factors (such as maladaptive coping styles or distress) that adversely affect a medical condition by increasing the risk of severe symptoms, disability, or death
• Most medical conditions can be affected by psychological and/or behavioral factors
  • Conditions with clear pathophysiology (e.g., CAD, diabetes)
  • Functional syndromes (e.g., IBS, fibromyalgia)
  • Idiopathic medical symptoms (e.g., pain, vertigo)

Diagnostics

All of the following DSM-5 diagnostic criteria must be met: ^[1]

• A confirmed medical symptom or condition (that is not a mental disorder)
• The psychological and/or behavioral factors adversely affect one or more of the following aspects of the medical condition:
  • The course of illness (e.g., failing to seek medical assistance when experiencing acute chest pain)
  • The treatment of the condition (e.g., poor adherence to prescribed medication)
  • Addition of further risk factors (e.g., a patient with asthma who starts smoking)
  • The underlying pathophysiology or clinical features (e.g., chronic stress increasing the severity of hypertension)
• The psychological and/or behavioral factors are not better explained by another mental disorder.

Psychological factors affecting other medical conditions should be differentiated from an adjustment disorder, in which symptoms affect the patient's mood but do not worsen their medical condition. ^[1]

Consider the patient's cultural context and establish how the patient perceives their condition before diagnosing psychological factors affecting other medical conditions.

Management

• Treat the underlying medical condition and provide patient education.
• See “Approach to patients with suspected somatic symptom and related disorders.”

• Definition: the false belief of being pregnant associated with physical signs and symptoms of pregnancy without the presence of a fetus ^[1]
• Epidemiology
  • Peak age: typically 16–39 years of age ^[19]
  • More common in women who wish to and have a history of failure to conceive
• Etiology: not fully understood
  • Somatopsychic hypothesis: body changes (e.g., abdominal distention due to constipation) are misinterpreted as signs of pregnancy, stimulating the psychosomatic development of further signs and symptoms ^[20]
  • Psychophysiologic hypothesis: alterations in neurotransmitters are involved in the development of pseudocyesis ^[21]
• Clinical features ^[19]
  • Breast tenderness, hyperpigmentation of the nipples and areolas
  • Weight gain
  • Menstrual irregularities
  • Morning sickness
  • Mild abdominal enlargement
  • Sensation of fetal movement
  • Increased urinary frequency
  • Abdominal pain mimicking labor
• Diagnostics
  • Signs and symptoms of pregnancy in absence of gestational sac or fetus on ultrasound and undetectable serum β-hCG
  • Diagnostics to identify underlying conditions responsible for signs and symptoms of pregnancy
• Differential diagnosis
  • Other psychiatric conditions, e.g., delusion of pregnancy (manifests without objective signs of pregnancy), factitious disorder
  • Somatic conditions, e.g., prolactinoma, malignant tumors
  • Pregnancy
• Management
  • Be sensitive to patient expectations regarding pregnancy and the potential disappointment in receiving the diagnosis.
  • See “Approach to patients with suspected somatic symptom and related disorders” for more information.
  • Treat underlying conditions (e.g., abdominal distention due to constipation) responsible for signs and symptoms.
  • There is no evidence that psychotropic medication is beneficial in treating pseudocyesis.
• Complications: depression due to the unsuccessful attempt to get pregnant

Performing an ultrasound and informing the patient of the results can be both diagnostic and help the patient to accept that they are not pregnant. ^[19]

• Rarely, patients may intentionally invent or induce symptoms.
• Motivations may vary, e.g., primary gain or secondary gain.
• A diagnosis of a factitious disorder or malingering may be associated with stigma and cause the breakdown of the patient-physician relationship.
  • Discuss each case with other involved health care professionals.
  • Only apply these diagnoses if they are strongly suspected.

Overview ^[1]

• Definition: intentional invention or induction of symptoms either in one's self or another person.
  • The goal is to get medical attention and sympathy (primary gain) even though the motivation is unconscious.
  • Patients are willing to undergo (or allow the person they induce symptoms in) invasive and/or high-risk treatments.
• Characteristic findings
  • Deceptive behavior (key feature)
  • Impairment related to illness perception and somatization (as in other somatic symptom and related disorders)

In factitious disorders, there is evidence of intentional injury or disease falsification in the absence of external reward, in contrast to somatic symptom disorder, in which there is no evidence of deception, and to malingering, in which external reward is an incentive.

Comparison of factitious disorder imposed on self versus another

In factitious disorder imposed on another, the perpetrator receives the diagnosis. An abuse and neglect diagnosis should be considered for the person in whom symptoms have been induced.

Management ^[22]

• Provide appropriate care and ensure safety
  • Treat any induced illness or injury.
  • Avoid unnecessary procedures.
  • In whom symptoms have been induced (in factitious disorder imposed on another)
    • Provide a safe place away from the perpetrator (e.g., call adult or child protective services).
    • Exclude other forms of abuse or neglect if suspected.
    • Refer for psychotherapy, depending on the individual's age.
• If it is safe to do so, discuss the diagnosis with the patient in a supportive, nonthreatening manner. ^[7]
  • Do not discuss the diagnosis with the patient alone; involve a psychiatrist.
  • Gather the facts and establish a strategy that includes continuous patient support and follow-up.
  • Document the meeting and the outcome in the patient's records.
  • Share information with relevant health care services and agencies.
• If the patient is willing to engage with management:
  • Refer for psychotherapy and/or parenting classes.
  • Assess for comorbid conditions.
  • Monitor pharmacotherapy intake.

Very few patients with a factitious disorder acknowledge their condition and engage in management. ^[22]

Involve adult or child protective services if a factitious disorder imposed on another is suspected.

Overview ^[1][22]

• The intentional fabrication or exaggeration of symptoms for secondary gain (e.g., time off work, avoiding the police, obtaining narcotics, insurance money) ; ^[22]
  • Adoption of the sick role may provide the patient with an opportunity to avoid social obligations in a “socially accepted” way.
  • Complaints usually stop after the intended external reward has been obtained (as opposed to in factitious disorders).
  • Malingering individuals may be uncooperative and may insist on undergoing an extensive medical evaluation.
• Symptoms typically do not conform to a known medical or psychological condition.
• Symptoms are:
  • Typically vague and inconsistent
  • False or significantly exaggerated
• Malingering is not classified as a mental disorder.

Epidemiology

• ♂ > ♀ ^[24]
• Often occurs after an accident, particularly if legal proceedings are being started

Diagnostics ^[1]

• Any combination of the following is suggestive of malingering: ^[1]
  • The patient presents under medicolegal circumstances (e.g., via self-referral or referral by an attorney while criminal charges are pending).
  • Clinical findings are markedly inconsistent with the patient's complaints.
  • Lack of patient cooperation during diagnostic evaluation, follow-up, and/or treatment
  • Features of antisocial personality disorder
• Consider using screening tools for malingering such as the structured interview of reported symptoms or the Miller forensic assessment of symptom test (M-FAST). ^[25]

Management ^[22]

• Explain the objective clinical and diagnostic study findings to the patient and make a detailed record in the patient's file.
• Avoid unnecessary referral; , as this perpetuates malingering.
• The diagnosis should only be directly discussed with the patient as part of a supportive confrontation.

Avoid using the term “malingering” in the patient's medical record. ^[22]

Malingering is not classified as a somatic symptom and related disorder or a mental illness in the DSM-5.

The differential diagnoses listed here are not exhaustive.