Somatic Symptom Disorders

Key Features

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

General Considerations

• This diagnostic grouping includes

  • Conversion disorder (functional neurologic disorder)

  • Somatic symptom disorder (hypochondriasis)

  • Somatization disorder

  • Pain disorder secondary to psychological factors

• Vulnerability in an organ system and exposure to family members with somatization problems are thought to interact in the development of symptoms

• Clinicians should suspect psychiatric disorders in several somatic conditions

  • 45% of patients describing palpitations had lifetime psychiatric diagnoses

  • Similarly, 33–44% of patients undergoing coronary angiography for chest pain but have negative results have been found to have panic disorder

Demographics

• Conversion disorder is more common in lower socioeconomic classes and certain cultures

• Somatic symptom disorder usually occurs before age 30 and is ten times more common in women

  • There is a significant relationship (20%) to a lifetime history of panic-agoraphobia depression

Clinical Findings

Symptoms and Signs

• A precipitating emotional event often precedes somatic symptoms

• Conversion disorder

  • Psychic conflict is converted into physical neurologic symptoms

  • The somatic symptom is often paralysis

  • The dysfunction may have symbolic meaning (eg, arm paralysis in marked anger so the individual cannot use the arm to strike someone)

• Somatic symptom disorder

  • One or more somatic symptoms are associated with significant distress or disability

  • Symptoms are associated with disproportionate and persistent thoughts about the seriousness of the symptoms, a high level of anxiety about health, or excessive time and energy devoted to symptoms

  • Anxiety, panic disorder, and depression are often present

  • Preoccupation with medical and surgical issues often precludes other life activities

  • Patients have often undergone multiple surgeries and have evidence of long-standing symptoms

  • Multiple symptoms that frequently change and have eluded diagnosis by three or more physicians support this diagnosis

Differential Diagnosis

• Depression must be considered in any patient with a condition judged to be somatoform

• Factitious disorders, which differ from this grouping in that symptom production is intentional

• Intoxication states

• Disorders with unusual presentations (eg, multiple sclerosis, systemic lupus erythematosus)

Diagnosis

Diagnostic Procedures

• In conversion disorder with psychogenic nonepileptic seizures (pseudoseizures), video-electroencephalography may be necessary to rule out epilepsy

• Since all somatic disorders are diagnoses of exclusion, a workup sufficient to rule out physical illness is required

Treatment

Medications

• Medications should not be prescribed in place of frequent appointments

Therapeutic Procedures

• Behavioral ...