Somatic Symptom Disorders Clinical Presentation

History and symptoms vary depending on the specific somatic symptom disorder diagnosis.

Somatic Symptom Disorder

Somatic symptom disorder replaces somatization disorder with the following criteria:

• At least one somatic symptom that results in significant disruption in everyday life
• Significant actions, thoughts, or feelings about the symptoms
• Somatic symptom actions, thoughts, or feelings are excessively time consuming, out of proportion to the degree of seriousness, or accompanied by a high level of anxiety

Hypochondriasis

Hypochondriasis is defined as an excessive worry or anxiety about a presumed (but not present) medical illness. The recent DSM-5 diagnostic reclassification has eliminated hypochondriasis as a specific diagnosis. Patients with features of hypochondriasis are not felt better classified as having a somatic symptom disorder or with the new anxiety disorder know as illness anxiety.

Conversion Disorder

Conversion disorder is a somatic symptom–related disorder that characterized by the following:

• Prominent unexplained neurological symptoms, commonly paralysis or nonepileptic seizures
• Neurological symptoms incompatible with any known neurological or medical disorder

Psychological Factors Affecting Other Medical Conditions

Psychological factors affecting other medical conditions has been moved into the Somatic Disorders category in DSM-5 and is defined by one the following:

• Psychological factors affecting a documented medical condition in an adverse way such as delayed recovery
• Psychological factors interfere with treatment for medical condition (eg, contributing to poor treatment adherence)
• Psychological factors create a unique health risk
• Psychological factors exacerbate a medical condition (eg, anxiety triggering asthma attacks)

Factitious Disorder

The core feature of factitious disorder is the voluntary production of physical or psychological signs or symptoms. The 2 types of factitious disorder are (1) factitious disorder imposed on self and (2) factitious disorder imposed on another.

Key features of factitious disorder imposed on self include the following:

• Falsification of physical or psychological signs or symptoms, injury, or disease identified as deceptive behavior
• Presentation to others as ill, impaired, or injured
• Deception is evident in the absence of obvious external rewards
• Deceptive behavior is not better explained by another mental disorder

Key features for the diagnosis of factitious disorder imposed on another include the following:

• Falsification of physical or psychological signs or symptoms, injury, or disease in another (eg, child) identified as deceptive behavior
• Presentation of another as ill, impaired, or injured
• Deception is evident in the absence of obvious external rewards
• Deceptive behavior is not better explained by another mental disorder

Other Specified or Unspecified Somatic Symptom and Related Disorder

This is aresidual category for somatic symptom disorders of clinical significance failing to meet specific criteria for one of the other disorders in the category.

By definition, somatic symptom disorders are not accompanied by physical findings or a medical illness that explains the symptoms. Physical examination may demonstrate multiple operations in unsuccessful attempts to diagnose or relieve symptoms.

Perform a comprehensive physical examination to rule out physical causes for the patient's somatic complaints. A detailed focus on specific systems (eg, neurological) may be necessary based on the specific complaint.

Include a full mental status examination. A patient with somatic symptom disorder typically displays the following on an examination.

• Appearance - Normal
• Attitude and behavior - Attitude is appropriate and behavior demonstrates a preoccupation with physical symptoms and complaints
• Mood - Mildly anxious and depressed
• Affect - Full range and appropriate
• Thought disorder - None, although thoughts are limited to issues around physical symptoms
• Hallucinations - None
• Delusions - None
• Obsessions - None
• Compulsions - None
• Attention - Within normal range
• Memory - Within normal range
• Concentration - Within normal range
• Orientation - Oriented to time, place, and person
• Insight and judgment - Insight appears limited in that nonmedical causes of symptoms are not considered; judgment appears unimpaired
• Suicidal and homicidal ideation - No evidence of such

No definitive causes for most of the somatic symptom disorders have been established.

Genetic and environmental influences appear to contribute to somatization. Somatic symptom disorders have been linked to internalizing genetic risk factors and share genetic overlap with other mental disorders, including eating disorders. ^[8]

Somatization may involve abnormalities in tryptophan catabolism, resulting in lower serum tryptophan levels than controls. This finding is limited to the research domain at present and is not a diagnostic test. ^[9]

Children raised in homes with a high degree of parental somatization may model somatization. Sexual abuse may be associated with an increased risk of somatization later in life. Poor ability to express emotions (alexithymia) may result in somatization. Somatic symptom disorder may be related to a reduced threshold for tactile and pain perception. ^[10]

Psychodynamic causes for unexplained physical symptoms date back to Freud, who coined the term "conversion disorder". Freud viewed some unexplained neurologic symptoms as a result of conversion of intrapsychic distress into physical symptoms.

Psychiatric comorbidity

Alcohol and drug abuse are common in patients with somatic symptom disorders. Patients may attempt to treat their somatic pain with alcohol or other drugs.

Additionally, alcohol or drug intoxication or withdrawal may induce somatic symptoms of unclear etiology, unless the physician considers the potential role of substances.

Anxiety disorders and mood disorders commonly include physical symptoms as part of the presentation. Hypochondriasis can accompany the symptoms of depression, panic disorder, and other anxiety disorders. Ruling out a primary anxiety disorder or mood disorder is key before reviewing the role of somatic symptom disorders.