Download Somatic Symptom and Related Disorder

Seminar Outline
• Introduction
• Classification
• Disorder by Disorder
• Treatment
-Somatic Symptoms: “somatic (from the Greek σωματικός) means 'of the
body'—relating to the body”
-Common feature: The prominence of somatic symptoms with significant
distress and impairment
-It’s what you’re going to encounter more often in medical rather than
psychiatric settings!
-Often not mutually exclusive (e.g. Mood disorders with somatic
symptoms)
Somatic Symptom disorder and others
VS
Factitious Disorder and Malingering
CLASSIFICATION
• Somatic Symptom Disorder
• Illness anxiety Disorder
• Conversion Disorder (Functional neurological symptom
disorder)
• Factitious Disorder
• Other specified somatic symptom and related disorder
• Non-specified somatic symptom and related disorder
-Malingering
Somatic Symptom Disorder
-Patients can express distress in relation to other things in life or express it exclusively to
symptoms.
-In children a single complaint is often present which is often abdominal pain, fatigue,
headache or nausea
*75% of Hypochondriasis is
being diagnosed as somatic
symptom disorder after
criteria change
DDx: (Think Anxiety/OCD and related disorders/Other disorders of
the same category)
1. Other medical conditions (diagnose with both or only as
associated somatic symptoms if criterion B is not met)
2. Panic Disorder (Episodic)
3. GAD (Not only health. Worry about everything)
4. Illness anxiety (Minimal somatic symptoms)
5. Conversion disorder ( Focus in somatic is on distress vs loss of
function)
6. Delusional disorder (Intensity of belief)
7. OCD
8. Body Dysmorphic Disorder
Management Approach
• Presenting the Diagnosis (Summarize and explain)
• Refer to a psychiatrist for diagnosing co-morbidities
• Set a single primary care physician to take care of the
patient’s complaints. His approach should be focused on
limiting investigations but not neglecting carrying them out if
need arises (Risk of associated real medical illness)
• Pharmacotherapy often not yielding
Somatic Symptom Disorder Counseling (Skim and Scan)
• Psychoeducation can be helpful by letting the patient know that physical symptoms may be exacerbated by
anxiety or other emotional problems. However, be careful because patients are likely to resist suggestions that
their condition is due to emotional rather than physical problems.
• The primary care physician should inform the patient that the symptoms do not appear to be due to a lifethreatening, disabling, medical condition and should schedule regular visits for reassessment and reinforcement
of the lacking severity of ongoing symptoms.
• The patient also may be told that some patients with similar symptoms have had spontaneous improvement,
implying that spontaneous improvement may occur. However, the physician should accept the patient's physical
symptoms and not pursue a goal of symptom resolution.
• Indeed, regular, noninvasive, medical assessment reduces anxiety and limits health care–seeking behavior; this
may be facilitated by regularly scheduled visits with the patient's primary care physician.
• Encourage patients to remain active and limit the effect of target symptoms on the quality of life and daily
functioning.
• Family members should not become preoccupied with the patients physical symptoms or medical care. Family
members should direct the patient to report symptoms to their primary care physician.
DDx:
-Other medical conditions (can be mutually exclusive. To tell them
apart think criterion C)
-Somatic Symptom disorder (Criterion B)
-Anxiety Disorder
a. GAD (?)
b. Panic disorder (Episodic)
-OCD (Fear of future disease versus fear of having current disease)
-Major depression (Not made if concern is only there during depressive
episodes)
-Psychotic disorders (often more bizzare, e.g. rotting organs)
Treatment
Pharmacotherapy isn’t the answer
• Physicians should attempt to answer questions and reduce the
patient's fear of a specific illness.
• Group psychotherapy may provide social support and reduce
anxiety.
• Cognitive therapy strategies may help by focusing on distorted
disease-related cognitions*
CONVERSION DISORDER
Have at least one neurological symptoms (eg : blindness,
paralysis, parasthesia)
Usually preceded / exarcebated by psychological stressor
Patient usually calm and unconcerned when describing
their symptoms
Conversion Disorder
- F:M (2-3:1)
- Onset at any age ( adolescence / early adulthood )
- High incidence with comorbid schizophrenia, major depression
or anxiety disorder
TREATMENT & PROGNOSIS
Most patients recover spontaneously 
Insight-oriented psychotherapy, hypnosis, relaxation therapy
Symptoms may be brief / last for several weeks / longer
25% will have future episodes
FACTITIOUS DISORDER
Intentionally produce medical / psychological symptoms in order to assume
the role of a sick patient
Primary gain is a prominent feature
Commonly feigned symptoms :
 Psychiatric : hallucinations, depression
 Medical : fever, abdominal pain, seizures, skin lesions, hematuria
-Exaggeration, fabrication, stimulation and induction (Mechanisms
of falsifying illness)
-DECEPTION IS THE RULE
a. Manipulate lab tests (Adding blood to urine)
b. Cause harm to themselves (Injecting fecal material)
c. Faking seizures/blackouts
d. Falsify records
e. Fake a loved one’s death (Spouse that doesn’t exist)
f. Ingest substances to fake results (e.g. Insulin)
Management
• Establish the presence of any comorbidities
• Treat comorbidities accordingly (possible
Hospitalization)
• Limited benefit of pharmacotherapy or particular
psychotherapy techniques
• Attempting to establish a strong relationship and try
to help the willing patients is the idea approach
• Never ignore assessing the factitious symptoms!
You never know when it’s real!
MALINGERING
Feigning of physical / psychological symptoms in order to achieve personal
gain ( avoiding the police, receiving room and board, obtaining narcotics,
receiving money)
Usually present with multiple vague symptoms that do not conform a known
medical history
Often have long medical history and multiply hospitalization
Generally uncooperative and refuse to accept good prognosis
Symptoms improve once their desired objective is obtained