1. Somatic Symptom and Related Disorders
Chapter 12
Somatic Symptom and
Related Disorders

2. 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

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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