Somatic Symptom Disorders
- Author: William R Yates, MD, MS; Chief Editor: Eduardo Dunayevich, MD more...
The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) category of Somatic Symptom Disorders and Other Related Disorders represents a group of disorders characterized by thoughts, feelings, or behaviors related to somatic symptoms. This category represents psychiatric conditions because the somatic symptoms are excessive for any medical disorder that may be present.
Somatic symptom disorders and other related disorders challenge medical providers. Clinicians need to estimate the relative contribution of psychological factors to somatic symptoms. A somatic symptom disorder may be present when the somatic symptom is a focus of attention, is distressing, or is contributing to impairment.
Anxiety disorders and mood disorders commonly produce physical symptoms. Clinicians need to rule out somatic symptoms due another primary psychiatric condition before considering a somatic symptom disorder diagnosis. Somatic symptoms can dramatically improve with successful treatment of the anxiety or mood disorder.
The DSM-5 includes 5 specific diagnoses in the Somatic Symptom Disorder and Other Related Disorder category. Specific Somatic Symptom Disorders diagnoses include (1) somatic symptom disorder, (2) conversion disorder, (3) psychological factors affecting a medical condition, (4) factitious disorder, and (5) other specific and nonspecific somatic symptom disorders.
DSM-5 produced significant changes in this category of disorders. This category had previously been named Somatoform Disorders in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Somatic symptom disorder replaces the DSM-IV-TR diagnosis of somatization disorder. Hypochondriasis, pain disorder, and body dysmorphic disorder, conditions listed in the Somatoform Disorders category in DSM-IV-TR have been removed. Psychological factors affecting a medical condition and factitious disorder have been added to the new Somatic Symptom Disorders category. Finally, a residual category of other specific and nonspecific somatic symptom disorder has been created with DSM-5.
The newly defined structure of this category means few research studies of the new disorders have been completed. To address this weakness, this article will continue to include review of some of the older somatoform disorders research literature.
See the chart below.
Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician.
Ms. J's primary care physician has followed her for many years and has made the diagnosis of somatic symptom disorder. The treatment plan includes regular frequent visits to monitor her chronic pain complaints. Use of medication with addictive potential is restricted. Physical symptoms are monitored with limited use of invasive diagnostic procedures. Outpatient visits focus on identifying sources of stress and encouraging healthy coping mechanisms.
The pathophysiology of somatic symptom disorder is unknown. Primary somatic symptom disorders may be associated with a heightened awareness of normal bodily sensations. This heightened awareness may be paired with a cognitive bias to interpret any physical symptom as indicative of medical illness. Autonomic arousal may be high in some patients with somatization. This autonomic arousal may be associated with physiologic effects of endogenous noradrenergic compounds such as tachycardia or gastric hypermotility. Heightened arousal also may induce muscle tension and pain associated with muscular hyperactivity, as is seen with muscle tension headaches.
Brain imaging studies support an association between one or more of the somatic symptom disorders, with reduced volume of the brain amygdala and brain connectivity between the amygdala and brain regions controlling executive and motor function.
Prevalence rates for the most restrictive previous diagnosis of somatization disorder appear low in community samples (0.1%). Low community prevalence rates for somatic symptom disorder may be due to a reporting bias.
Medical record studies suggest the rate of somatic symptom disorder in the community among women may be as high as 2%. More liberal case assignment criteria result in rate estimates of the prevalence of a broader somatic symptom syndrome to be as high as 11.6% of the population.
Other somatic symptom disorders may have significant rates in specific clinical populations. In general medical clinic populations, the prevalence rates of hypochondriasis may approach 4-6%. Body dysmorphic disorder may be present in as many as 2% of patients of plastic surgery clinics. In psychiatric consultations at general hospitals, some studies document high rates (5-15%) of conversion disorder.
A study in Belgium reported that somatization syndrome is the third highest psychiatric disorder, with a prevalence rate of 8.9%. The first and second most common psychiatric disorders were depression and anxiety disorders.
Somatic symptom disorders contribute a significant economic burden to the costs of brain disorders. A European survey estimated the cost of somatic symptom disorders across Europe to be 22 billion Euro/year (approximately $30 billion US dollars per year). This makes the cost of somatic symptom disorders in the range of that for multiple sclerosis, Parkinson disease, or traumatic brain injury.
Somatic symptom disorders do not appear to independently increase the risk of death. Some evidence exists that somatization disorder is associated with increased risk for suicide attempts. Patients with somatic symptom disorders may be misdiagnosed as having a medical condition and therefore experience iatrogenic complications due to invasive diagnostic procedures or surgical operations.
In most somatic symptom disorder categories, a female preponderance exists. The female-to-male ratio has been estimated to be 10:1 for somatization disorder, from 2:1 to 5:1 for conversion disorder and from 2:1 for pain disorder.
Somatic symptom disorders may begin in childhood, adolescence, or early adulthood. New onset of unexplained somatic symptom disorders in older adults should prompt a search for occult medical illness or evidence of major depression associated with somatization.
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