Chapter 59: Somatic Symptom Disorder (Previously Somatoform Disorder), Factitious Disorder, & Malingering

Somatic symptom disorder (SSD) involves unexplained physical symptoms that bring significant functional impairment. It presents one of the more common and most difficult problems in primary care. SSD is seldom “cured” and should be approached as a chronic disease. Recognition, a patient-centered approach, and specific treatments may help alleviate symptoms and distress. Factitious disorder and malingering, although not true SSD, are addressed separately in this chapter because of their similarity in the form of medically unexplained symptoms.

Somatic symptom disorder (SSD) is a new diagnostic term that replaces somatoform disorder in DSM-5, the latest ­version of the diagnostic manual published by the American Psychiatric Association. Use of SSD as the prevalent term will likely increase after DSM-5 becomes widely disseminated following publication in May 2013. The diagnostic labels previously subsumed by somatoform disorders in DSM-4 will also be subsumed by SSD in DSM-5. These disorders have specific courses, symptoms, complaints, and treatments, listed in Table 59-1.

Features that characterize SSD include the following:

• Physical symptoms or irrational anxiety about illness or appearance, for which biomedical findings are not consistent with a general medical condition.

• Symptoms develop with or are worsened by psychological stress, and are not intentional.

• Extensive utilization of medical care. Paradoxically, treatment and attempts to reassure patients can be counterproductive.

• Feelings of frustration on the part of the provider. Patients are often seen as “difficult patients.”

Somatic expression of psychological distress can be normal, and degree of dysfunction determines whether the symptoms constitute a disorder. Furthermore, symptoms may be sufficient to suggest that the patient’s condition is better described by a primary mental disorder (eg, somatic delusions) that may respond to specific therapies.

Presentations of illness without complete physical explanation have a significant impact on practice. For instance, 10% of all medical services are provided to patients with no organic disease, 26% of primary care patients meet criteria for somatic “preoccupation”; 19% of patients have medically unexplainable symptoms and 25–50% of visits involve symptoms that have no serious cause. Where true SSD is present, symptoms persist much longer and the cost of ambulatory care is 9–14 times greater than in controls. Patients with SSD undergo numerous medical examinations, diagnostic procedures, surgeries, and hospitalizations. They risk increased morbidity from these procedures, and 82% stop working at some point because of their difficulties. With appropriate recognition and treatment, costs of care may be reduced by 50%.

To some degree, somatic symptoms related to psychological and emotional states are common and should be considered normal. Examples include anger experienced through jaw tightening, tension through shoulder stiffening, loss or grief through chest discomfort, disappointment or fear through a “sinking feeling in the gut,” and shame through a reddening of the face, and so on. Children often feel ill when they learn that a friend is sick or when family stress is high. An example of nonpathologic fear of having a disease is “student’s syndrome,” perception of medical students in pathology class that every symptom they experience could represent a serious diagnosis.

Genetic factors, demonstrated in adoption studies, appear to play a role in the development of somatic sensitivities and obsessive tendencies. Traumatic experiences in the form of sexual, physical, and emotional abuse and witnessing violence are predictive of SSD. Operant reinforcements and classically conditioned associations will also play a role, both in changes in perception of physical sensations and in pain-related behaviors. In particular, some individuals are susceptible to overexperiencing sensations. This phenomenon may occur through a difference in neuron gating, in which the threshold of firing is reduced by anxiety or psychological stress. Patients with hypochondriasis can experience a cycle of symptom amplification whereby obsession about the body focuses attention on sensations, which causes anxiety, increasing sensations and further worsening obsessiveness. Other disorders, such as body dysmorphic disorder, may be related to obsessive-compulsive disorders or even a mild thought disorder.

Because families differ in how they respond to symptoms and illnesses, individual differences in health beliefs and illness-related behaviors are to be expected. Families also shape the tendency to experience, display, and magnify somatic symptoms; thus, SSD or malingering in children may be modeled or reinforced by adults. Social risk factors include single parenthood, living alone, unemployment, and marital and job difficulties.

Gender ratios and prevalence of SSD differ across cultures. In North America, somatization, conversion, and pain disorders are more frequent in women whereas hypochondriasis and body dysmorphic disorder involve men and women equally. Somatic symptoms are more prevalent among Chinese American, Asian, and South American patients. These differences are most likely due to Western/empirical explanatory models contrasted with culturally based understandings in which ancient people’s associations of phenomena and symptoms still affect the beliefs and expectations of modern populations.

Disorders with somatoform characteristics specific to certain cultures include the dhat syndrome in India, which is a concern about semen loss, and koro in Southeast Asia, a preoccupation that the penis will disappear into the abdomen. A sense of having worms in the head or burning hands is sometimes reported by people in Africa and Southeast Asia. Cultures influence how emotions should be expressed and sanction religious and healing rituals that may look like conversion disorders. Thus, somatoform-type symptoms should be evaluated for appropriateness to the patient’s social context. Behaviors sanctioned by the culture are typically not considered pathologic.

A. Symptoms and Signs

Diagnosis of SSD involves both exclusion of general medical conditions and inclusion of somatoform features. The following features should increase suspicion of SSD:

• Unexplained symptoms that are chronic or constantly change.

• Multiple symptoms. Fainting, menstrual problems, headache, chest pain, dizziness, and palpitations are the symptoms most likely to be somatoform.

• Vague or highly personalized, idiosyncratic complaints.

• Inability of more than three physicians to make a diagnosis.

• Presence of another mental disorder, especially depressive, anxiety, or substance use disorders.

• Distrust toward the physician.

• Physician experience of frustration.

• Paradoxic worsening of symptoms with treatment.

• High utilization, including repeated visits, frequent telephone calls, multiple medications, and repeated subspecialty referrals.

• Disproportionate disability and role impairment.

B. Diagnostic Criteria

Somatic symptom disorder is a mental disorder that involves physical symptoms or irrational anxiety about illness or appearance, and for which biomedical findings are not consistent with a general medical condition. Specific diagnosis requires that the symptoms have brought unneeded medical treatment or significant impairment in social, occupational, or other important areas of functioning. SSD cannot be caused by a general medical condition or by direct effects of substances. If the disorder occurs in the presence of a general medical condition, complaints or impairment must be in excess of what would be expected from the physical findings and history. Although SSD may occur concurrently with other mental disorders, other diagnoses such as depression or anxiety may be sufficient to supersede the SSD diagnosis.

1. Somatic Symptom Disorder

Prior to DSM-5, formal diagnosis of somatization required identification (counts) of multiple symptoms from different body sites or functions. Current diagnosis focuses on the distress or disruption experienced by patients over somatic symptoms. Patients often do have multiple symptoms. Symptoms maybe specific or general (e.g., fatigue) and may sometimes represent normal bodily sensations that do not signify significant disease. Patients with this disorder have the thoughts, feelings or behaviors associated with the symptoms that are excessive, persistent, and dysfunctional.

2. Conversion disorder

This diagnosis consists solely of pseudoneurologic symptoms [ie, deficits affecting the central nervous system (CNS), voluntary motor, or sensory functions]. Psychological factors in the form of stressors or emotional conflicts are expected and precede the symptoms. Depending on the medical naiveté of the patient, symptoms are often quite implausible, not conforming to anatomic pathways or physiologic mechanisms. The symptoms, however, are not considered volitional. Symptoms may symbolically represent emotional conflicts, such as arm immobility as an expression of anger and impotence. Other clues indicating that the symptoms are pseudoneurologic include worsening in the presence of others; noninjuries despite dramatic falls; normal reflexes, muscle tone, and pupillary reactions; and striking inconsistencies on repeated examinations. Groups of symptoms also tend to not fit together physiologically. Symptoms may be experienced with a relative lack of concern (so-called la belle indifference), but dramatic presentations are more common. Course is an important consideration. Conversion disorder is rare before age 10 or after age 35 years. Symptoms are transient, rarely lasting beyond 2 weeks, and respond to reassurance, suggestion, and psychological support. Although primary and secondary gains may result from conversion disorder, these gains are not the motivating factor as they would be with factitious disorder or malingering.

3. Pain disorder associated with psychological factors

This disorder is the psychiatric equivalent of chronic nonmalignant pain syndrome, except that no minimum duration of symptoms is required. Psychological factors play a significant role in the pain picture, including its onset, severity, exacerbation, and maintenance. Physical pathologies are possible and frequent, but organic findings are insufficient to explain the severity of the pain. Functional deficits are common, including disability, increased use of the healthcare system, abuse of medications, and relational and vocational disruptions. Depression or anxiety may be secondary or may also be primary or comorbid, predisposing the patient to an increased experience of pain as well as a deficient ability to cope.

4. Hypochondriasis

The individual is preoccupied with fears of having a serious disease. The preoccupation may originate in an overfocus on and misinterpretation of normal physiologic sensations (eg, orthostatic dizziness), erroneous attributions about the body (eg, “aching veins”), or obsession about minor physical abnormalities. Patients are easily alarmed by contact with ill persons or media coverage of disease. Fears persist despite medical reassurance. More global symptoms may suggest a primary diagnosis of panic disorder, while more specific body-related concerns may be better explained by a diagnosis of body dysmorphic disorder. The key to this diagnosis is primary fear of disease rather than generalized worry or fear of a specific defect or disorder.

5. Body dysmorphic disorder

This disorder involves excessive preoccupation with a minor or imagined defect of one or more body parts, excluding the diagnosis of a primary eating disorder. Although many people are concerned about their appearance, the concerns and behaviors associated with this disorder are extreme, distressing, time-consuming, and debilitating. Self-consciousness is significant, and ­avoidance of public exposure, hiding of defects, and nondisclosure to the physician are common. Medical, dental, and surgical treatments are sought but may only worsen preoccupations. Concern cannot focus exclusively on a false belief that one is obese, which would indicate an eating disorder. Similarly, a belief that sexual characteristics are incorrect may be better represented in a diagnosis of gender identity disorder. Transient or more generalized concerns about appearance may indicate major depressive episodes. Patients who insist that an imagined defect is real and hideous will meet the criteria for delusional disorder, somatic type.

6. Malingering, factitious disorder, and factitious disorder by proxy

These are not SSDs; symptoms are voluntary and deceptive. Deception is obtained by feigning or self-inducing symptoms or by falsifying histories or laboratory findings. Common symptoms include fever, self-mutilation, hemorrhage, and seizures. Persons connected to health professions are common perpetrators. Malingering and factitious disorder differ by whether symptom gain is primary or secondary. In malingering, symptoms are produced to gain rewards or avoid punishments (secondary gains). Factitious disorder involves production of symptoms in order to assume the sick role (primary gain). Unlike malingering, factitious disorder is considered a mental disorder principally because the need to be in the sick role is abnormal. Factitious disorder by proxy occurs when illness is caused by a caregiver, typically to meet a need for drama and to be a rescuer of the patient. Signs of factitious disorder include direct evidence, such as inconsistent laboratory or physical findings or observations (eg, injection of bacteria), as well as vague clues, such as patients who are migratory or have no visitors, are comfortable with more aggressive treatments, including extended hospitalization, or whose presentation is exaggerated and quite dramatic (Munchausen syndrome).

C. Screening and Diagnostic Measures

Keeping SSD in the differential is the key to making the correct diagnosis over time. Valid diagnostic and screening questionnaires exist, but often lack clinical utility because of the length and training required for interpretation. A directed interview with specific questions based on patient complaints is most effective for primary care providers. When doubts remain, referral to a specialist skilled in use of diagnostic questionnaires is indicated. Patients should be screened for depression.

Diagnosis should be considered provisional until there is considerable external support. General medical conditions characterized by multiple and confusing somatic symptoms (eg, hyperparathyroidism, porphyria, multiple sclerosis, and systemic lupus erythematosus) should be considered. Conversion disorder, in particular, is often misdiagnosed. Daum et al. (2013) have described the high specificity of weakness, sensory, and gait symptoms in determining whether conversion presentations are pseudoneurologic. Onset of multiple physical symptoms in early adulthood suggests somatization disorder but in the elderly suggests a general medical condition. Primary or secondary depression should be considered in any patient suspected of having SSD. Personality disorders are also frequently associated with SSD. It is important to determine the primary disorder in order to choose effective treatment. Clinical factors, such as context, duration of symptoms, and age of the patient, may be able to distinguish SSD from other disorders.

Failure to recognize and properly treat SSD can lead to excessive diagnostic procedures and treatments, which perpetuate patient preoccupations and place the patient at risk for iatrogenic harm. Use of unidentified, unconventional, or alternative treatments by SSD patients may interact negatively with prescribed medications. Dependences on sedative, analgesic, or narcotic agents are common iatrogenic complications.

Primary care patients who present with undifferentiated symptoms are best addressed with a comprehensive approach that includes continuity of care and attention to the physician-patient relationship. “Pathologizing” makes patients feel illegitimate, in itself a major source of distress, and produces stereotypes of patients as “crocks, whiners, or difficult.” Patient characteristics considered as difficult include extensive or exaggerated complaints, nonadherence with treatment recommendations, and behaviors that raise suspicion of seeking drugs. When patients are so labeled, the relevance of the patient’s experience and the potential of partnership between patient and physician are both obviated. A patient-centered method, so important to family practice, becomes impossible. Even without attributions of a mental disorder, SSD presents one of the most difficult challenges in primary care. Uncertainties associated with the diagnosis, the sense that the focus is not medical and therefore the interaction is inappropriate, patient symptom amplification, and the sense that services are being overused inappropriately contribute to the perception that the patient is difficult.

A. General Recommendations

Symptoms of SSD exist on a continuum. Comprehensive, continuous, patient-centered care appropriately addresses most primary care patient presentations. The general recommendations presented in the following paragraphs apply to such an approach.

1. First visits

A therapeutic alliance should be built by a thorough history and physical examination and a review of the patient’s records. The physician should show curiosity and interest in the patient’s complaints and validate the patient’s suffering. Psychogenic attributions should be avoided. To appear puzzled initially is a good strategy. Delivery of a diagnosis is a key treatment step with SSD. Different disorders require different types of information.

2. Management

The disorder should be treated as a chronic illness, with the focus on functioning rather than cure. Gradual change should be expected, with periods of improvement and relapse. Physicians should try to avoid excessive and/or invasive diagnostics and treatment in order to minimize iatrogenic harm. When procedures or treatments are undertaken, they should be selected only on the basis of objective evidence, not subjective complaints. When new symptoms arise, at least a limited physical examination should be performed to avoid misdiagnosis and assure the patient that his/her concerns are taken seriously. The need for unnecessary tests and procedures can be avoided by having the patient feel “known” by the physician.

3. Management when controlled drugs are involved

Berland et al. (2012) have described a comprehensive approach for managing somatoform pain disorder where patient preferences for opioids complicate treatment. They recommend a structured approach that includes a comprehensive biopsychosocial evaluation and a treatment plan that encourages patients to set and reach functional goals.

4. Patient-centered care

Feelings of illegitimacy by patients and common physician attitudes toward patients contribute to power differentials and struggles. Physicians should speak with patients as equals, listen well, ask and answer many questions, explain things understandably, and allow patients to make decisions about their care. A collaborative relationship should be developed in which the physician works together with the patient to understand and manage patient problems. The “common ground” shared by the physician and the patient should be monitored and differences discussed.

5. Office visits

Regular, brief appointments should be scheduled, thus avoiding “as-needed” medications and office visits that render medical attention contingent on symptoms. Practical time-related strategies include negotiating and setting the agenda early in the visit, paying attention to the emotional agenda, practicing active listening through appropriate reactions and follow-up questions, soliciting the patient’s attributions for the problems, and communicating empathetically.

6. Psychosocial issues

Reassurance should be provided to the patient, but not before a thorough exploration of symptoms. Psychosocial questions should be interspersed with biomedical ones to explore all issues: physiologic, anatomic, social, family, and psychological. The physician should inquire about trauma and abuse. As trust builds, the patient should be encouraged to explore psychological issues that may be related to symptoms. In this way, symptoms can be linked to the patient’s life and feelings. Physicians should avoid using the term stress too liberally, as it may be misconstrued as the cause of the patient’s symptoms or an excuse for an incomplete evaluation. Eventually and subtly, patients are likely to reveal their personal issues and concerns.

7. Family involvement

With the patient’s permission, family members should be invited to participate in patient visits. An occasional family conference can be valuable. Each person’s opinion about the illness and treatment can be solicited, and family members can be asked how family life would differ if the patient were without symptoms. Physicians should solicit and constantly return to the patient’s and family’s strengths and areas of competence.

B. Pharmacotherapy

Because these patients may be extremely sensitive to side effects, psychopharmacologic agents generally should not be used unless the patient has demonstrated pharmacologically responsive mental disorder such as major depression, generalized anxiety disorder, panic disorder, or obsessive-compulsive disorder. (For further discussion of these disorders, see Chapters 52, 53 and 54.) Selective serotonin reuptake inhibitors (SSRIs), other nontricyclic antidepressants, and benzodiazepines are the medications most frequently used for coexisting psychiatric conditions. Treatment should be initiated at subtherapeutic doses and increased very gradually, as described in Chapters 52, 53 and 54. Exceptions to this general rule are hypochondriasis and body dysmorphic disorders. They are more similar to obsessive-compulsive disorder, and patients with these disorders may benefit from slow increases to higher doses of SSRIs if side effects are tolerated. Those with extreme but transitory dysmorphic concerns may benefit from temporary treatment with an atypical antipsychotic medication.

C. Consultation or Referral

Involvement of a mental health clinician may be helpful in diagnosing comorbid mental conditions, offer suggestions for psychotropic medications, and engage some patients in psychotherapy. Patients, however, are unlikely to see the value of consultation or may experience referral as an accusation that their symptoms are not authentic. Pressuring the patient to accept a consultation is unlikely to be effective and may render the consultant encounter unproductive. Trust must first be established, and psychological issues must be made a legitimate subject for discussion. The idea of referral can be introduced later. When possible, it can be more effective to see the patient along with the mental health clinician so that a comprehensive approach continues to be emphasized, the patient does not feel abandoned, and worry that the patient’s concerns are not taken seriously are alleviated. Extreme distress or preoccupations worsening to delusional levels may require inpatient hospitalization.

D. Psychotherapeutic Interventions

Standardized group or individual cognitive behavioral therapies (CBTs) can be an effective treatment for chronic somatoform disorders, reducing somatic symptoms, distress, impairment, and medical care utilization and costs. Cognitive interventions train the patient to identify and restructure dysfunctional beliefs and assumptions about health. Behaviorally, the patient is encouraged to experiment with activities that are counter to usual habits such as avoidance, “doctor shopping,” or excess seeking of reassurance. In addition, patients can learn relaxation and meditation techniques to manage symptoms of anxiety. Patients with high emotional distress respond more rapidly to psychotherapy, and patients able to at least partially attribute symptoms to psychological factors show better therapeutic outcomes than patients who firmly believe that their physical symptoms have a physical cause.

E. Complementary and Alternative Therapies

It is to be expected that patients with somatoform symptoms often try alternative treatments such as herbal remedies, mind-body interventions, and other non-Western medical approaches. In these patients, conventional treatments appear to have failed, distrust of physicians may be high, and distress is great. Federal regulations require that label claims and instructions on herbal products and supplements address symptoms only; therefore, there are no specific herbal agents for SSD, per se. Given the plethora of symptoms that can exist in patients with SSD, it is not surprising that there are numerous alternative medications that patients may try.

Patients with pain disorder or primary or comorbid anxiety may benefit from body and mind-body interventions such as massage, movement therapies, manipulations, relaxation, guided imagery, and hypnosis. The placebo effect of various remedies may be helpful, particularly if the agents are largely inert, as bothersome side effects seen in conventional medicines may be avoided. Alternative therapies often include “nonspecific therapeutic effects” that go beyond the placebo effect and can be beneficial. Nonspecific effects include warmth and listening skills of the ­practitioner, empowerment that comes from legitimization of the patient’s problem, and an egalitarian approach to care. Physicians may wish to recommend alternative treatments and collaborate with alternative practitioners but should also be prepared to protect the patient by cautioning against treatments that are potentially harmful, excessively expensive, or that circumvent conventional treatments that are needed for demonstrated medical conditions.

F. Patient Education

The American Academy of Family Physicians has developed a patient education page for somatoform disorders. The web address for the page is http://familydoctor.org/familydoctor/en/diseases-conditions/somatoform-disorders.html.