Somatic Symptom and Related Disorders

Abstract

The prominence of somatic symptoms associated with significant clinical distress and functional impairment is the hallmark of illness within the class of disorders called somatic symptom and related disorders. Patients suffering from these conditions more commonly present in primary care or acute care settings. It is only after initially presenting in this setting that they are able to receive necessary psychiatric mental health support. Somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorders, and unspecified somatic symptom and related disorders belong to this diagnostic class. Due to the diagnostic and treatment challenge that these disorders present, physician awareness becomes crucial for early diagnosis.

Trying to suppress or eradicate symptoms on the physical level can be extremely important, but there’s more to healing than that; dealing with psychological, emotional and spiritual issues involved in treating sickness is equally important.

Marianne Williamson

Appendices

Appendix A: Possible Answers to PBL Tables

Vignette 23.1: Janelle Miller

Table 23.1.1

Facts	Hypotheses	Information needed	Learning issues
Mrs. Miller is a 28-year-old female	Was there any physical injury?	What is her social history?	A complete history is important in patient evaluation
She has bilateral leg paralysis	Is there a metabolic etiology?	What is her psychiatric history?
She has no previous health problems	Is there a psychological etiology?	What is her family history?

Table 23.1.2

Facts	Hypotheses	Information needed	Learning issues
Mrs. Miller is adherent to primary care	Is there a psychological etiology that is stress related?	A physical exam must be conducted	What is the presentation of symptoms in conversion disorders?
She has no psychiatric history	Is there a metabolic etiology?	A mental status exam must be conducted	What are the common aspects of conversion disorder (functional neurological symptom disorder)?
She has no family history of similar presentation		Pertinent lab tests are needed
She had an increased level of responsibility as a child
She is happily married
Her husband is gone often
She acts as a single parent when her husband is gone

Table 23.1.3

Facts	Hypotheses	Information needed	Learning issues
Mrs. Miller’s vitals are within normal limits	There seems to be a psychological etiology	What is the persistence of symptoms?	Conversion disorder can be difficult to recognize
There is no acute distress, and she is alert and oriented	Her anxiety and fear seem to be playing a role	Does she experience resolution of symptoms after hospital admission?	Altered voluntary motor and sensory function are needed for diagnosis
She has bilateral leg paralysis			Must rule out possible medical etiology
She has decreased sensation			Importance of treating and managing possible co-occurring disorders
Ratchet-like weakness
Her physical exam is otherwise unremarkable
She has worried mood
She denies suicidal ideation
She denies psychotic symptoms
Her lab and imaging results unremarkable for acute pathology

Vignette 23.2: Lorraine Chun

Table 23.2.1

Facts	Hypotheses	Information needed	Learning issues
Ms. Chun has “intractable” back pain (> 6 months)	Is the etiology musculoskeletal?	What are the results of prior diagnostic studies?	It is important to be respectful of patient’s beliefs about her symptoms
She frequently seeks medical care at the ER	Is there a neurological etiology?	What do reports from previous specialty consultations indicate?	It is necessary to rule out potential medical etiologies
	Is there a psychiatric etiology?

Table 23.2.2

Facts	Hypotheses	Information needed	Learning issues
Ms. Chun has an extensive history of medical conditions, including chronic pain and severe headaches	Does she have factitious disorder?	A complete history and physical examination are needed	It is important to assess unexplained symptoms
She has had multiple surgeries	Does she have somatic symptom disorder?	A mental status examination is needed	Pay attention to lack of positive findings on physical examination

Table 23.2.3

Facts	Hypotheses	Information needed	Learning issues
Ms. Chun has a history of many physical complaints	Ms. Chun may be depressed	Is there any past history of false information or deceptive behavior?	Criteria of four pain symptoms in somatic symptom disorder
She has multiple pain complaints: abdominal pain, back pain, headaches, and arthralgias	She may have factitious disorder	Is there any medical basis of symptoms?	Centrality of medically unexplained symptoms
	She may be malingering
	She may have somatic symptom disorder

Vignette 23.3: Denise Carson

Table 23.3.1

Facts	Hypotheses	Information needed	Learning issues
Ms. Carson has headaches	Is there any neurological etiology?	Clarification on and confirmation of medical history	It is important to differentiate between symptoms that are produced intentionally and those that are not intentionally produced
She faints frequently	Is there a metabolic etiology?	Lab tests	Somatic symptom disorder versus factitious disorder
She reports a history of stroke		EKG
She has many equally important medical concerns	Is there any psychological etiology?	Echocardiogram

Table 23.3.2

Facts	Hypotheses	Information needed	Learning issues
Ms. Carson agreed to sign a release of information	Is there a neurological etiology?	Is her reported medical history confirmed by her medical record?	Somatic symptom disorder versus factitious disorder
Tests are ordered	Is there a metabolic etiology?	What do lab tests, EKG, and echocardiogram indicate?
	Is there a psychological etiology?

Table 23.3.3

Facts	Hypotheses	Information needed	Learning issues
Her lab tests were within normal limits	A psychological etiology is likely	Why would Ms. Carson alter her symptoms?	How can a diagnostician differentiate between somatic symptom disorder and factitious disorder?
Her EKG was unremarkable for pathology	Does she meet criteria for somatic symptom disorder?	Are her symptoms intentional or unintentional?	How can a diagnostician differentiate between malingering and factitious disorder?
Her echocardiogram was unremarkable for pathology	Does she meet criteria for factitious disorder?	Are the medical records consistent with the patient’s report?	What are the types of factitious disorder?
Her cardiologist is concerned			Careful review of medical records
The tilt-table test was ordered, with inconsistent results

Table 23.3.4

Facts	Hypotheses	Information needed	Learning issues
It has been 2 years since her last visit	Is the etiology psychological?	A repeat blood count is needed	Recognizing overall presentation and pattern of patient symptoms
Your office was unable to obtain medical records	Has she been physical abused?	Additional social history is needed	Intentional versus unintentional symptoms
Her reported history was inconsistent with her prior visit	Does she have a clotting disorder?	Additional medical history is in order	Factitious disorder diagnosis, treatment, and management
She presents a new concern of vaginal bleeding	Does she have leukemia?	Why would the patient alter her symptoms?
She has a normal biopsy result	Did she ingest a poison?	Are the symptoms intentional or unintentional?
She has an additional, new concern at follow-up
She has new bruising
Her blood count is within normal limits
She has no history of alcohol use or liver problems

Appendix B: Answers to Learning Questions

• 1. C

  Rationale: A somatic symptom disorder diagnosis does not require that the somatic symptoms are medically unexplained; symptoms may or may not be associated with another medical condition.

• 2. C

  Rationale: Factitious disorder imposed on self is the falsification of a physical or psychological symptom, or induction of injury associated with an identified deception.

• 3. B

  Rationale: Conversion disorder (functional neurologic symptom disorder) includes one or more symptoms of altered voluntary motor or sensory function that is not compatible with medical explanation.

• 4. Illness anxiety

  Rationale: Illness anxiety disorder includes a preoccupation with having or acquiring a serious illness, and there is a high level of anxiety about health.