ESSENTIALS OF DIAGNOSIS
Prominent physical symptoms may involve one or more organ systems and are associated with distress, impairment, or both.
Sometimes able to correlate symptom development with psychosocial stresses.
Combination of biogenetic and developmental patterns.
Any organ system can be affected in somatic symptom disorders. In DSM-5, somatic symptom disorders encompass disorders that were listed under somatic disorders in DSM-IV, including conversion disorder, hypochondriasis, somatization disorder, and pain disorder secondary to psychological factors. Vulnerability in one or more organ systems and exposure to family members with somatization problems plays a major role in the development of particular symptoms, and the “functional” versus “organic” dichotomy is a hindrance to good treatment. Clinicians should suspect psychiatric disorders in a number of somatic conditions. For example, 45% of patients describing palpitations had lifetime psychiatric diagnoses including generalized anxiety, depression, panic, and somatic symptom disorders. Similarly, 33–44% of patients who undergo coronary angiography for chest pain but have negative results have been found to have panic disorder.
In any patient presenting with a condition judged to be somatic symptom disorder, depression must be considered in the diagnosis.
A. Conversion Disorder (Functional Neurologic Symptom Disorder)
“Conversion” of psychic conflict into physical neurologic symptoms in parts of the body innervated by the sensorimotor system (eg, paralysis, aphonic) is a disorder that commonly occurs concomitantly with panic disorder or depression. The somatic manifestation that takes the place of anxiety is often paralysis, and in some instances the dysfunction may have symbolic meaning (eg, arm paralysis in marked anger so the individual cannot use the arm to strike someone). Nonepileptic seizures can be difficult to differentiate from intoxication states or panic attacks and can occur in patients who also have epileptic seizures. Lack of postictal confusion, closed eyes during the seizure, ictal crying, and a fluctuating course can suggest nonepileptic seizures; some symptoms such as asynchronous movements or pelvic thrusting can occur in both nonepileptic seizures and frontal lobe seizures (see also Chapter 24). La belle indifférence (an unconcerned affect) is not a significant identifying characteristic, as commonly believed, since individuals even with genuine medical illness may exhibit a high level of denial. It is important to identify physical disorders with unusual presentations (eg, multiple sclerosis, systemic lupus erythematosus).
Electroencephalography, particularly in a video-electroencephalography assessment unit, during the attack is the most helpful diagnostic aid in excluding epileptic seizures. A serum prolactin levels rise more than twice baseline abruptly in the postictal state is more likely to be associated with an epileptic seizure.
B. Somatic Symptom Disorder
Somatic symptom disorder is characterized by one or more somatic symptoms that are associated with significant distress or disability. The somatic symptoms are associated with disproportionate and persistent thoughts about the seriousness of the symptoms, a ...