Somatic Symptom and Related Disorders Chapter 12 Somatic Symptom and Related Disorders

Somatic Symptom Disorder: DSM-5 Cornerstone diagnosis of this category Main feature is the presence of one or more somatic symptoms that cause distress or impairment in daily living Excessive thoughts, feelings, or behaviors related to the somatic symptoms Disproportionate thoughts about the seriousness of the symptoms Persistent high levels of anxiety related to symptoms or health Devotes excessive amount of time to health

Somatic Symptom Disorder: DSM-5 cont. Excessive somatic concerns must persist for at least 6 months Diagnostic specifiers: With predominant pain (replaces pain disorder) Persistent (severe symptoms, marked impairment, and long duration) Severity: mild, moderate, severe

Illness Anxiety Disorder: DSM-5 Preoccupation with having or acquiring a serious illness Somatic symptoms are not present (or minor) High level of anxiety about health and easily alarmed about health-related matters Performs excessive health-related behaviors (checking body) or exhibits maladaptive avoidance (avoids doctors/hospitals)

Conversion Disorder: DSM-5 One or more symptoms of altered voluntary motor or sensory function Motor symptoms can include paralysis, paresthesia, tremors, convulsions Sensory symptoms can include blindness, unusual skin sensations, altered speech Hallmark is a lack of correspondence between signs and symptoms and medical understanding of the possible neurological condition

Conversion Disorder: DSM-5 cont. People with conversion disorder are often unaware of the psychological factors associated with their condition, and many report an inability to control their symptoms Lack of worry or concern (la belle indifference) is not a criterion for diagnosis but is mentioned in the DSM-5 list of associated features

Psychological Factors Affecting Other Medical Conditions A medical symptom or condition is present Psychological or behavioral factors affect the medical condition by way of: Close temporal relationship between psychological factors and the development or exacerbation of symptoms Interference with treatment (poor adherence) Additional health risks Influence underlying pathophysiology, precipitating or exacerbating symptoms or need for medical treatment

Factitious Disorder: DSM-5 Falsification of physical or psychological symptoms, or induction of injury or disease; associated with deception Presentation to others as ill, impaired, or injured Deceptive behavior is evident even in the absence of obvious external rewards, such as monetary compensation or reduced work

Epidemiology Given the substantial changes in diagnostic criteria (DSM-III to DSM-5), precise epidemiological data are challenging Somatic symptom disorder: 5% to 7% Anxiety illness disorder: 1.3% to 10% Conversion disorder: Low prevalence rates (less than 0.1%) Medically unexplained neurological symptoms are present in 11% to 35% of neurology patients

Assessment Patients believe their condition is organic, thus might refuse mental health referral and psychological testing Ruling out organic pathology is not needed for diagnosis according to DSM-5 criteria (change from DSM-IV-TR) Structured/semistructured interviews Structured Clinical Interview for the DSM-IV Composite International Diagnostic Interview Somatoform Disorders Schedule Schedules for Clinical Assessment in Neuropsychiatry

Assessment cont.) Self-report measures Screening for Somatoform Symptoms Symptom Checklist–90 , Revised Patient Health Questionnaire–15 Health Attitude Survey Health Anxiety Questionnaire Whiteley Index Medical service utilization and visual analogue scales pertaining to distressing thoughts and maladaptive behaviors can also be used Measures of depression and anxiety

Etiology: Behavioral and Molecular Genetics Somatic symptom concordance rates between monozygotic twins are higher than between dizygotic twins, even when controlling for co-occurring psychiatric symptoms The role of specific genetic markers in the development of somatoform symptoms remains unclear Genetic factors are now being considered within the context of psychological models of various somatoform disorders

Etiology: Neuroanatomy and Neurobiology The hypothalamic-pituitary-adrenal (HPA) axis has been a focus of research in this area Cortisol deregulation HPA axis controls glandular and hormonal responses to stress; this may lead to hypocortisolism, which induces greater stress and enhances experiences of pain and fatigue The second somatosensory area (SII) of the cerebral cortex has also been implicated

Etiology: Learning, Modeling, and Life Events Childhood physical and sexual abuse and neglect have been associated with physician visits during adulthood and hypochondriasis Early childhood experiences of illness and perceptions of significant illness in others are associated with the experience of medically unexplained symptoms in adulthood Parents who fear disease, who are preoccupied with their bodies, and who overreact to minor ailments experienced by their children are more likely to have children with the same tendencies

Etiology: Cognitive Influences When attention is directed to the body, the intensity of perceived sensations increases People with somatoform disorders spend a considerable amount of time focusing on their bodies, thereby increasing their chances of noticing somatic sensations and changes Tendency to believe that somatic sensations and changes are indicative of disease or are harmful in some way

Sex and Racial/Ethnic Considerations More prevalent in women than men Cultural factors, such as socially transmitted values, beliefs, and expectations, can influence how a person interprets somatic sensations and changes and whether treatment seeking is initiated Those of Chinese, African American, Puerto Rican, and other Latin American descent present with more medically unexplained somatic symptoms than those from other groups

Treatment Cognitive-behavioral therapy (CBT) has been shown to be superior to standard medical care in: Improving somatic complaints/somatization Reducing health-related anxiety Psychiatric consultation letters to primary care physicians describing somatization and providing recommendations have been shown to improve physical functioning and reduce costs of medical care