Somatic symptoms and related disorders

 Mild dissociative or somatic symptoms are experienced at least occasionally by almost all of
us. Indeed, up to 80 percent of people in the general population say that they have had
somatic (physical) symptoms in the past week (Hiller et al., 2006).

 But when concern about these symptoms is severe and leads to significant distress or
impairment, a somatic symptom disorder may be diagnosed. And when feelings of “being
out of it” become so persistent and recurrent that the person has profound and unusual
memory deficits (such as not knowing who they are), the diagnosis of a dissociative disorder
may be warranted.

 In the past, both somatic symptom disorders (formerly known as somatoform disorders)
and dissociative disorders were included with the various anxiety disorders (and neurotic
depression) and considered to be forms of neurosis.

 Somatic symptoms and related disorders are a new category in DSM-5. The disorders in it lie
at the interface between abnormal psychology and medicine. Included in this category are
conditions that involve physical symptoms combined with abnormal thoughts, feelings, and
behaviors in response to those symptoms.

 Soma means “body.” People with somatic symptom disorders experience bodily symptoms
that cause them significant psychological distress and impairment.

 In DSM-IV a great deal of emphasis was placed on the idea that the symptoms were
medically unexplained. In other words, although the patient’s complaints suggested the
presence of a medical condition, no physical pathology could be found to account for them.

 An important change in DSM-5 is that no distinction is now made between medically

explained and medically unexplained symptoms.

 Affected patients have no control over their symptoms. They are also not intentionally
faking symptoms or attempting to deceive others. For the most part, they genuinely believe
something is terribly wrong with them.
 Four most important disorders in the somatic symptom and related disorders category are
(1) somatic symptom disorder, (2) illness anxiety disorder, (3) conversion disorder, and (4)
factitious disorder.

Somatic Symptom Disorder

• People with somatic symptom disorder (SSD) not only have troubling physical symptoms, but
they are excessively concerned about their symptoms to the extent that it affects their
thoughts, feelings, and behaviors in daily life.
• Thus, the diagnosis emphasizes the psychological features of physical symptoms, not whether
the underlying cause or causes of the symptoms can be medically explained.
• The diagnosis of SSD requires that physical symptoms be persistent, lasting typically for a
period of six months or longer (though any 1 symptom may not be continuously present) and
that they are associated with either significant personal distress or interference with daily
functioning.
• The symptoms may include such complaints as gastric (stomach) distress and various aches
and pains.
• People with SSD may have excessive concerns about the seriousness of their symptoms. Or
they may be bothered by nagging anxiety about what their symptoms might mean and spend a
great deal of time running from doctor to doctor seeking a cure or confirmation that their
worries are valid.
• Their concerns may last for years and become a source of continuing frustration for
themselves, as well as for their families and physicians (HolderPerkins & Wise, 2002).
• A study that tracked the use of medical care by patients with excessive somatic concerns
found them to be heavy users of medical services (Barsky, Orav, & Bates, 2005).
• Previous versions of the DSM included a disorder called hypochondriasis, which applied to
people with physical complaints who believed their symptoms were due to a serious,
undetected illness, such as cancer or heart disease, despite medical reassurance to the
contrary.
• For example, a person suffering from headaches may fear that they are a sign of a brain
tumor and believe doctors are wrong when they say these fears are groundless. At the core of
hypochondriasis is health anxiety, a preoccupation that one’s physical symptoms are signs of
something terribly wrong with one’s health (Abramowitz & Braddock, 2011; Skritskaya et al.,
2012).
• The term hypochondriasis is still in widespread use but is no longer a distinct diagnosis in
DSM-5. The great majority of cases previously diagnosed as hypochondriasis, perhaps as many
as three-fourths, would now be diagnosed as somatic symptom disorder (APA, 2013).
• People with hypochondriasis do not consciously fake their symptoms. They feel real physical
discomfort, often involving their digestive system or an assortment of aches and pains
throughout the body.
• They may be overly sensitive to benign changes in physical sensations, such as slight changes
in heartbeat and minor aches and pains (Barsky et al., 2001).
• Anxiety about physical symptoms can produce its own physical sensations, however—for
example, heavy sweating and dizziness, even fainting. Thus, a vicious cycle may ensue.
• Patients may become resentful when their doctors tell them that their own fears may be
causing their physical symptoms. They frequently go doctor shopping in the hope that a
competent and sympathetic physician will heed them before it is too late.
• About one in four people with hypochondriasis complain of relatively minor or mild
symptoms that they take to be signs of a serious undiagnosed illness.
• Because of the mildness of their symptoms, the diagnosis of somatic symptom disorder would
not apply (APA, 2013).
• However, these individuals express such a high level of health anxiety or concern about their
medical condition that they would likely receive a diagnosis of a newly recognized disorder in
DSM-5 called illness anxiety disorder.
DSM-5 CRITERIA
A. One or more somatic symptoms that are distressing or result in significant disruption of
daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated
health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any 1 somatic symptom may not be continuously present, the state of being
symptomatic is persistent (typically more than 6 months).
Alan Frances, who served as the chair of the task force that developed DSM-IV, has called the
DSM-5 somatic symptom disorder a “loosely defined and fatally flawed” diagnosis and
recommended that clinicians not use it
CAUSES/ETIOLOGY:

 It was long thought that symptoms developed as a defense mechanism against unresolved
or unacceptable unconscious conflicts. Rather than being expressed directly, psychic energy
was instead channeled into more acceptable physical problems.
 Current views take a much more cognitive-behavioral approach.
 The model of somatic symptom disorder:
First, there is a focus of attention on the body. In other words, the person is hyper-vigilant
and has increased awareness of bodily changes.
Second, the person tends to see bodily sensations as somatic symptoms, meaning that
physical sensations are attributed to illness.
Third, the person tends to worry excessively about what the symptoms mean and has
catastrophizing cognitions.
Fourth, because of this worry, the person is very distressed and seeks medical attention for
his or her perceived physical problems.
According to this formulation, somatic symptom disorder can be viewed as a disorder of
both perception (noticing benign sensations such as one’s heart skip a beat) and cognition
(“Does this mean I have a serious heart problem?”). Individuals who are especially anxious
about their health tend to believe that they are very aware of and sensitive to what is
happening in their bodies. But this does not seem to be the case. Rather, experimental
studies show that these individuals have an attentional bias for illness-related information.
In other words, top-down (cognitive) processes, rather than bottom-up processes (such as
differences in bodily sensations), seem to account for the problems that they have.
Although their physical sensations probably do not differ from those of normal controls,
people with somatic symptoms disorders seem to focus excessive attention on their
physical experiences, labeling physical sensations as symptoms. They also perceive their
symptoms as more dangerous than they really are and judge a particular disease to be more
likely or dangerous than it really is. They also perceive their probability of being able to cope
with the illness as extremely low. All this tends to create a vicious cycle in which their
anxiety about illness and symptoms results in physiological symptoms of anxiety, which
 then provide further fuel for their convictions that they are ill. It is also believed that an
individual’s past experiences with illnesses (in both him- or herself and others, and also as
observed in the media) contribute to the development of a set of dysfunctional assumptions
about symptoms and diseases that may predispose a person to develop a somatic symptom
disorder.
Simplified Model of Somatic Symptom Disorder
People with somatic symptom disorder tend to have a cognitive style that leads them to be
hypersensitive to their bodily sensations. They also experience these sensations as intense, disturbing,
and highly aversive. Another characteristic of such patients is that they tend to think catastrophically
about their symptoms, often overestimating the medical severity of their condition.

 Negative affect is regarded as a risk factor for developing somatic symptom disorder.
However, the negative affect alone is not sufficient. Many people tend to be rather gloomy
in their personalities, but only a subset of these people will also be habitual reporters of
physical symptoms.
 Other characteristics that may be important are absorption and alexithymia.
Absorption is a tendency to become absorbed in one’s experiences and is often associated
with being highly hypnotizable.
Alexithymia, on the other hand, refers to having difficulties identifying one’s feelings.
People who report many symptoms but who do not have any medical conditions tend to
score high on all of these traits.
 Although somatic symptom disorders are often accompanied by a lot of misery and
suffering, they may be maintained to some degree by secondary reinforcements. Most of us
learn as children that when we are sick, we get special comforts and attention, as well as
being excused from school or other responsibilities.
 People with hypochondriasis also tend to have an excessive amount of illness in their
families while growing up, which may lead to strong memories of being sick or in pain and
perhaps of having observed some of the secondary benefits that sick people sometimes get.
Having said this, it is important to keep in mind that people with somatic symptom
disorders are not malingering (consciously faking symptoms to achieve a specific goal such
as winning a personal injury lawsuit).

Illness Anxiety Disorder

• The DSM-5 introduced a new diagnostic category of an illness anxiety disorder (IAD), with the
emphasis placed on the anxiety associated with illness rather than the distress the cause of the
symptoms.
• For these patients, it’s not the symptoms they find so troubling—symptoms such as vague
aches and pains or a passing feeling of tightness in the abdomen or chest. Rather, it’s the fear
of what these symptoms might mean.
• In some cases, there are no reported symptoms at all, but the person still expresses serious
concerns about having a serious undiagnosed illness.
• In some cases of illness anxiety disorder, the person has a family history of a serious disease
(e.g., Alzheimer’s disease) but becomes preoccupied with an exaggerated concern that he or
she is suffering from the disease or is slowly developing it. The person may become
preoccupied with checking his or her body for signs of the feared disease.
• There are two general subtypes of the disorder. One subtype, the care-avoidant subtype,
applies to people who postpone or avoid medical visits or lab tests because of high levels of
anxiety about what might be discovered.
• The second subtype, called the care-seeking subtype, describes people who go doctor
shopping, basically jumping from doctor to doctor in the hope of finding the one medical
professional who might confirm their worst fears. These individuals may get angry at doctors
who try to convince them that their fears are unwarranted.
DSM-5 CRITERIA
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another
medical condition is present or there is a high risk of developing a medical condition (e.g.,
strong family history is present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about
personal health status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or
her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor
appointments and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is
feared may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such
as somatic symptom disorder, panic disorder, generalized anxiety disorder, body
dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
It is estimated that around 25 percent of people who would have been diagnosed with
hypochondriasis in DSM-IV will be diagnosed with illness anxiety disorder in DSM-5.

Conversion Disorder
• The prevalence of the disorder in the general population remains unknown, but the diagnosis
is reported in about 5% of patients referred to neurology clinics (APA, 2013).
• Like dissociative identity disorder, conversion disorder is linked in many cases to a history of
childhood trauma or abuse (Sobot et al., 2012).
• According to the DSM, conversion symptoms mimic neurological or general medical
conditions involving problems with voluntary motor (movement) or sensory. Historically this
disorder was one of several disorders that were grouped together under the term hysteria.

DSM-5 CRITERIA
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized
neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder. D.
The symptom or deficit causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning or warrants medical evaluation.
SYMPTOMS/ETIOLOGY:
In describing the clinical picture of conversion disorder, it is useful to think in terms of four
categories of symptoms:
(1) sensory:
 Today the sensory symptoms or deficits are most often in the visual system (especially
blindness and tunnel vision), in the auditory system (especially deafness), or in the
sensitivity to feeling (especially the anesthesias).
 In the anesthesias, the person loses her or his sense of feeling in a part of the body. One
of the most common is glove anesthesia, in which the person cannot feel anything on the
 hand in the area where gloves are worn, although the loss of sensation usually makes no
anatomical sense.
 With conversion blindness, the person reports that he or she cannot see and yet can
often navigate about a room without bumping into furniture or other objects.
 With conversion deafness, the person reports not being able to hear and yet orients
appropriately upon “hearing” his or her own name.
 Such observations lead to obvious questions: In conversion blindness (and deafness), can
affect people actually not see (or hear), or is the sensory information received but
screened from consciousness? In general, the evidence supports the idea that the
sensory input is registered but is somehow screened from explicit conscious recognition
(explicit perception).

(2) motor:
 conversion paralysis is usually confined to a single limb such as an arm or a leg, and the
loss of function is usually selective for certain functions. For example, a person may not
be able to write but may be able to use the same muscles for scratching, or a person may
not be able to walk most of the time but may be able to walk in an emergency such as a
fire where escape is important.
 The most common speech-related conversion disturbance is aphonia, in which a person
is able to talk only in a whisper although he or she can usually cough in a normal manner.
(In true, organic laryngeal paralysis, both the cough and the voice are affected.)
 Another common motor symptom, called Globus, involves the sensation of a lump in the
throat

(3) seizures:
 Another relatively common form of conversion symptom involves seizures. These
resemble epileptic seizures, although they are not true seizures. patients with conversion
seizures often show excessive thrashing about and writhing not seen with true seizures,
and they rarely injure themselves in falls or lose bowel or bladder control as patients
with true seizures frequently do.
CAUSES:

 Conversion disorders are thought to develop as a result of stress or internal conflicts of

some kind. Freud used the term conversion hysteria for these disorders (which were fairly
common in his practice) because he believed that the symptoms were an expression of
repressed sexual energy—that is, the unconscious conflict that a person felt about his or her
repressed sexual desires.
 However, in Freud’s view, the repressed anxiety threatens to become conscious, so it is
unconsciously converted into a bodily disturbance, thereby allowing the person to avoid
 having to deal with the conflict. This is not done consciously, of course, and the person is
not aware of the origin or meaning of the physical symptom.
 Freud also thought that the reduction in anxiety and intrapsychic conflict was the “primary
gain” that maintained the condition, but he noted that patients often had many sources of
“secondary gain” as well, such as receiving sympathy and attention from loved ones.
 Freud’s theory is no longer accepted outside psychodynamic circles. However, many of
Freud’s astute clinical observations about primary and secondary gain are still incorporated
into contemporary views of conversion disorder. For example, when cast in terms of
learning theory, the physical symptoms can be seen as providing negative reinforcement
(relief or removal of an aversive stimulus) because being incapacitated in some way may
enable the individual to escape or avoid an intolerably stressful situation without having to
take responsibility for doing so.
 In addition, they may provide positive reinforcement in the form of care, concern, and
attention from others. It is the case that, in some cultures, expressing intense emotions is
not socially acceptable. When viewed through a sociocultural lens, a diagnosis of conversion
disorder can therefore be seen as a more socially sanctioned way of expressing distress and
escaping an unpleasant situation.
 Given the important role often attributed to stressful life events in precipitating the onset of
conversion disorder, it is unfortunate that little is actually known about the exact nature
and timing of these psychological stress factors. The greater the negative impact of the
preceding life events, the greater the severity of the conversion disorder symptoms (Roelofs
et al., 2005).
 Another study compared levels of a neurobiological marker of stress (lower levels of brain-
derived neurotrophic factor) in individuals with conversion disorder versus major
depression versus no disorder. Both those with depression and those with conversion
disorder showed reduced levels of this marker relative to the non-disordered controls.

FACTITIOUS DISORDER:

 In a factitious disorder the person intentionally produces psychological or physical

symptoms (or both). Although this may strike you as strange, the person’s goal is to obtain
and maintain the benefits that playing the “sick role” (even to the extent of undergoing
repeated hospitalizations) may provide, including the attention and concern of family and
medical personnel.
 In DSM-IV, the factitious disorder was in a category of its own. In DSM-5 it has been moved
into the category of somatic symptoms and related disorders. The reason for the move is
because, in most cases of factitious disorder, the person presents with somatic symptoms
and with an expressed belief that he or she is ill.
 What is the difference between factious disorder and malingering?
 The key difference is that, in a factitious disorder, the person receives no tangible external
rewards. In contrast, the person who is malingering is intentionally producing or grossly
exaggerating his or her physical symptoms and is motivated by external incentives such as
avoiding work or military service or evading criminal prosecution
DSM -5 CRITERIA
A. Falsification of physical or psychological signs or symptoms, or induction of injury or
disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder.

 In factitious disorder, patients may surreptitiously alter their own physiology—for example,
by taking drugs—in order to simulate various real illnesses. Indeed, they may be at risk for
serious injury or death and may even need to be committed to an institution for their own
protection.
 A dangerous variant of factitious disorder is a factitious disorder imposed on another
(sometimes referred to as Munchausen’s syndrome by proxy).
Here, the person seeking medical help has intentionally produced a medical or psychiatric
illness (or the appearance of an illness) in another person. This person is usually someone
(such as a child) who is under his or her care (e.g., Pankratz, 2006).
In a typical instance, a mother presents her own child for treatment for a medical condition
she has deliberately caused. To produce symptoms, the mother might withhold food from
the child, add blood to the child’s urine, give the child drugs to make him or her throw up,
or heat up thermometers to make it seem as if the child has a fever. If the child is
hospitalized, the mother might deliberately infect an intravenous (IV) line to make the child
more ill.
Of course, the health of the victims is often seriously endangered by this form of child abuse
and the intervention of social service agencies or law enforcement is sometimes necessary.
In as many as 10 percent of cases, the actions of the mother may lead to a child’s death.
This disorder may be suspected when the victim’s clinical presentation is atypical, when lab
results are inconsistent with each other or with recognized diseases, or when there are
many frequent returns or increasingly urgent visits to the same hospital or clinic.
DISTINGUISHING BETWEEN DIFFERENT TYPES OF SOMATIC DISORDERS

 It is sometimes possible to distinguish between a conversion (or other somatic symptoms)

disorder and malingering, or factitiously “sick-roleplaying,” with a fair degree of confidence,
but in other cases, it is more difficult to make the correct diagnosis.
 Persons engaged in malingering (for which there are no formal diagnostic criteria) and those
who have the factitious disorder are consciously perpetrating frauds by faking the
symptoms of diseases or disabilities, and this fact is often reflected in their demeanor.
 In contrast, individuals with conversion disorders (as well as with other somatic symptom
disorders) are not consciously producing their symptoms, feel themselves to be the “victims
of their symptoms,” and are very willing to discuss them, often in excruciating detail. When
inconsistencies in their behaviors are pointed out, they are usually unperturbed. Any
secondary gains they experience are by-products of the conversion symptoms themselves
and are not involved in motivating the symptoms.
 On the other hand, persons who are feigning symptoms are inclined to be defensive,
evasive, and suspicious when asked about them; they are usually reluctant to be examined
and slow to talk about their symptoms lest the pretense be discovered. Should
inconsistencies in their behaviors be pointed out, deliberate deceivers as a rule immediately
become more defensive.