Psychopathology II @Imaran2
UNIT 9. SOMATIC SYMPTOM AND RELATED DISORDER
1 SOMATIC SYMPTOM DISORDER
Note: include somatization, pain disorder, some patients with hypochondriasis of the DSM-IV.
Somatic Symptom Disorder is a psychological condition in which a person experiences one or more real physical symptoms (such as pain,
fatigue, or other bodily discomforts)
The patient that areasvery
is described distressing.
a very sick person. In fact, she is known in the Health Centre in her hometown
for the many hospitalizations and specialist consultations she has required over the past few years. Her
What makes the disorder specific is not the symptoms themselves, but the way the person thinks about and responds to them. There is a
health
strong and persistent problems
focus began in adolescence,
on the symptoms, with irregular
often with excessive worry and painful
about havingmenstruation, which
a serious illness andwas
highaccompanied
levels of anxiety about health.
by pain in her legs and arms, as well as abdominal discomfort, nausea, vomiting, and difficulty in
Even if a medical cause is not found (or does not fully explain the intensity of the distress), the symptoms are still very real to the person, and
maintaining
they can significantly her daily
interfere with balance...
life. Any sickness justifies these symptoms, for which there is no apparent
improvement.
In short: it is a condition where real bodily symptoms are present, but they are accompanied by an intense and overwhelming preoccupation
with health and illness.
The symptoms cannot be explained by a medical illness or other mental disorder. Although they may be
accompanied by medical illness.
Main concern: concern about somatic symptoms (with or without medical explanation). Differential
elements with depression and other MD with physical symptoms.
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behavior related to somatic symptoms or associated health
concerns as manifested by at least one of the following three.
a. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
b. Persistent high level of anxiety about health or symptoms.
c. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being
symptomatic is persistent (generally, more than six months).
Specifications:
- With predominant pain (previously pain disorder): this category is used only for individuals that
symptoms involve predominantly pain.
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Psychopathology II @Imaran2
- Persistent: persistent course is characterized by persistent severe symptoms, marked
impairment and a long duration (more than six months).
- Severity: mild (just one symptom), moderated (two or more), severe (two or more + multiple
somatic complains or one very severe somatic symptom).
Somatic symptoms without an evident medical explanation are not sufficient to make this diagnosis. The
individual’s suffering is authentic, whether or not it is medically explained. The symptoms of somatic
symptom disorder are not simulated or self-induced, and these individuals suffer authentically and
seriously from their somatic complaints.
The diagnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive,
and these frequently occur together. They appraise their bodily symptoms as unduly threatening, harmful,
or troublesome and often think the worst about their health.
There is often a high level of medical care utilization, which rarely alleviates the individual’s concerns. Any
reassurance by the doctor that the symptoms are not indicative of serious physical illness tends to be
short-lived and/or is experienced by the individuals as the doctor not taking their symptoms with due
seriousness.
In children, the most common symptoms are recurrent abdominal pain, headache, fatigue, and nausea.
In older individuals, pain localized in several body regions appears to be the most common symptom
Persistent somatic symptoms are associated with:
- demographic features (women, older age, fewer years of education, lower socioeconomic status,
unemployment)
- a reported history of sexual abuse or other childhood adversity
- concurrent chronic physical illness or mental disorder (depression, anxiety, persistent depressive
disorder, panic)
- social stress
- reinforcing social factors such as illness benefits.
Cognitive factors that affect clinical course include: These are thinking patterns that influence how
the disorder develops and stays.
- sensitization to pain
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Psychopathology II @Imaran2
- heightened attention to bodily sensations
- attribution of bodily symptoms to a possible medical illness rather than recognizing them as a
normal phenomenon or psychological stress
Prevalence:
- Between 4-6%.
- More women.
Course:
- It is likely to be chronic and fluctuating and influenced by the number of symptoms, individual’s
age, level of impairment, and any comorbidity. (other mental or physical conditions)
- Frequently co-occurs with other medical conditions.
- Comorbidity with depression when many somatic symptoms.
- Onset: Adolescence or early adulthood.
DIFFERENTIAL DIAGNOSIS
- Distressing somatic symptoms characteristic of a medical condition. The presence of somatic
symptoms of unclear etiology is not in itself sufficient to make the diagnosis of somatic symptom
disorder. Conversely, the presence of somatic symptoms of an established medical condition
(e.g., diabetes or heart disease) does not exclude the diagnosis of somatic symptom disorder if
the criteria are otherwise met.
- Psychological factors affecting other medical conditions. Presence of a medical condition, as
well as psychological factors that adversely affect its course or interfere with its treatment.
- Illness anxiety disorder. If the individual has extensive worries about health but no or minimal
somatic symptoms, it may be more appropriate to consider illness anxiety disorder.
- Conversion disorder. The presenting symptom is loss of function (e.g., of a limb), whereas in
somatic symptom disorder, the focus is on the distress that particular symptoms cause.
- Delusional disorder. In somatic symptom disorder, the individual’s beliefs that somatic
symptoms might reflect serious underlying physical illness are not held with delusional intensity.
- Body dysmorphic disorder. In somatic symptom disorder, the concern about somatic symptoms
reflects fear of underlying illness, not of a defect in appearance.
2 ILLNESS ANXIETY DISORDER
Note: Anxiety
Illness include Disorder
hypochondriasis of the DSM-IV
is a psychological condition in which a person is highly preoccupied with the idea of
having or developing a serious illness, even when they have few or no physical symptoms.
"I've been worried for months about discomfort and irritation in my throat, difficulty swallowing some
The main issue is not the body, but the constant fear and anxiety about health. Normal sensations or minor
foods. I have
changes in thevisited many
body are doctors
often and noas
interpreted one is able
signs of atoserious
solve my problem.
disease, They
which tell to
leads merepeated
that I have nothing
worry,
checking,
or that it or
is seeking
becausereassurance.
of the anxiety... But I think that something serious is happening to me, I constantly
think that I may have cancer of the larynx and I get angry that nobody takes my current state seriously
Even when medical tests show nothing wrong, the person may still feel convinced that something serious is
enough".
being missed.
In short: it is a condition where health anxiety is extreme and persistent, despite little or no actual physical
symptoms. 67
Psychopathology II @Imaran2
It is not hypochondriasis (preoccupation with having a serious disease based on the individual’s
misinterpretation of bodily symptoms).
- 75-80% has somatic symptoms -> somatic symptom disorder
- 20-25% has not somatic symptoms or are mild -> illness anxiety disorder
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical
condition is present or there is a high risk for developing a medical condition (e.g., strong family
history is present), the preoccupation is clearly excessive or disproportionate.
C. There is a high level of anxiety about health, and the individual is easily alarmed about personal
health status.
D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her
body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments
and hospitals).
E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared
may change over that period of time.
F. The illness-related preoccupation is not better explained by another mental disorder, such as
somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic
disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.
Specify if:
- Care-seeing type: medical care, including physician visits or undergoing tests and procedures, if
frequently used.
- Care-avoidant type: medical care is rarely used.
Thoughts (distorted interpretation) Explain why the ilness anxiety disorder is mantained
- Catastrophism: “If my head hurts it means that I have a tumor.”
- Intolerance to uncertainty: “I need to be certain that nothing bad happens to me.”
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Psychopathology II @Imaran2
- Overestimation the importance of thoughts/worries “If I cannot take it out of my mind it is
because it is important.”
They generally have elevated rates of utilization of medical and mental health services compared with the
general population. In a minority of cases of illness anxiety disorder, individuals are too anxious to seek
medical attention and avoid medical health care.
Individuals with the disorder are generally dissatisfied with their medical care and find it unhelpful, often
feeling they are not being taken seriously by physicians.
The presence of a medical condition does not rule out the possibility of coexisting illness anxiety disorder.
If a medical condition is present, the health-related anxiety and disease concerns are clearly
disproportionate to its seriousness. Transient preoccupations related to a medical condition do not
constitute illness anxiety disorder.
Prevalence:
- Annual prevalence rates of hypochondria: general population 1.3-10%.
- Similar in men and women.
Course:
- Generally chronic, episodic, and relapsing.
- Starts in early and middle adulthood
- Illness anxiety disorder co-occurs with anxiety disorders (in particular, generalized anxiety
disorder and panic disorder), OCD, and depressive disorders -> 2/3 comorbidity
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Psychopathology II @Imaran2
Early experiences: dysfunctional assumptions
about symptoms, disease, and health
behaviors “Body symptoms are a sign that
something is wrong” “I should find an
explanation for my symptoms”.
DIFFERENTIAL DIAGNOSIS
- Distressing somatic symptoms characteristic of a medical condition. The presence of somatic
symptoms of unclear etiology is not in itself sufficient to make the diagnosis of somatic symptom
disorder. Conversely, the presence of somatic symptoms of an established medical condition
(e.g., diabetes or heart disease) does not exclude the diagnosis of somatic symptom disorder if
the criteria are otherwise met.
- Psychological factors affecting other medical conditions. Presence of a medical condition, as
well as psychological factors that adversely affect its course or interfere with its treatment.
- Illness anxiety disorder. If the individual has extensive worries about health but no or minimal
somatic symptoms, it may be more appropriate to consider illness anxiety disorder.
- Conversion disorder. The presenting symptom is loss of function (e.g., of a limb), whereas in
somatic symptom disorder, the focus is on the distress that particular symptoms cause.
- Delusional disorder. In somatic symptom disorder, the individual’s beliefs that somatic
symptoms might reflect serious underlying physical illness are not held with delusional intensity.
- Body dysmorphic disorder. In somatic symptom disorder, the concern about somatic symptoms
reflects fear of underlying illness, not of a defect in appearance.
- Adjustment disorders. Health-related anxiety is a normal response to serious illness and is not a
mental disorder. Such nonpathological health anxiety is clearly related to the medical condition
and is typically time-limited. If the health anxiety is severe enough to cause clinically significant
distress or impairment in one or more important areas of functioning, an adjustment disorder
may be diagnosed. However, if disproportionate health-related anxiety persists for longer than
6 months, a diagnosis of illness anxiety disorder may apply.
- Somatic symptom disorder. Somatic symptom disorder requires the presence of somatic
symptoms that are distressing or result in significant disruption of daily life, whereas in illness
anxiety disorder, somatic symptoms either are not present or, if present, are only mild in
intensity.
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Psychopathology II @Imaran2
- OCD. In illness anxiety disorder, the preoccupations are usually focused on having a disease,
whereas in obsessive-compulsive disorder (OCD), the thoughts are intrusive and are usually
focused on fears of getting a disease in the future.
3 CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER)
1 or + symptoms of impaired voluntary motor or sensory function (neurological) with no medical
explanation and no intentionality. Not better explained by other medical or MD. It causes significant
discomfort.
Types:
- Motor symptoms: paralysis, abnormal movements (e.g., tremor, walking disturbances), speech
(e.g., aphonia, poorly articulated speech).
- Crisis or seizures: convulsions or attacks.
- Sensory symptoms: loss of touch, blindness, hearing disturbances, anaesthesia, loss of sensitivity.
- Mixed.
May depend on frequent suggestibility. Changing symptoms depending on the situation (e.g., paralysis of
the hand before an exam, paralysis of the leg before a change of job).
It may be associated – temporally – with a stressful event:
- Situational specificity: symptoms may change in the same direction as the stressful situations.
- Often previous traumatic events (or experienced as such).
In about
Note: not 50%
always of cases,situation
a stressful there is no clear or identifiable stressful trigger
(50%).
Specify:
- Type of symptom or deficit.
- Acute episode (<six months) or persistent (>six months).
- With or without psychological stressor.
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Psychopathology II @Imaran2
DSM-5 CRITERIA
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized
neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning or warrants medical evaluation.
Specify the type of symptomatology:
- With weakness or paralysis
- With abnormal movement (e.g. Tremor, dystonia,...)
- With swallowing symptoms
- With speech symptom (e.g., dysphonia, slurred speech...)
- With attacks or seizures
- With anaesthesia or sensory loss
- With special sensory symptoms
- With mixed symptoms
Specify if:
- Acute episode: symptoms present for less than six months
- Persistent: symptoms occurring for six months or more
Specify if:
- With psychological stressor (specify)
- Without psychological stressor
DATA
Prevalence:
- 5% of the referrals to neurology.
- 2-3 times more in women.
Course:
- Onset: usually psychological (e.g. before an exam), but also after physical injuries 37% (traffic
accident)
- Late adolescence, early adulthood
- Transient symptoms but can also be persistent. → Abrupt symptoms, short duration, relapses
- Better prognosis in children.
- Common traumatic event: 44.7% physical abuse of children; 26.3% sexual abuse
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Psychopathology II @Imaran2
DIFFERENTIAL DIAGNOSIS
Medical/neurological disorder The main differential diagnosis is to have a recognized neurological
disease that might better explain the symptoms.
Somatic symptoms disorder Functional neurological symptom disorder may be diagnosed in
addition to somatic symptom disorder. Most of the somatic
symptoms encountered in somatic symptom disorder cannot be
demonstrated to be clearly incompatible with recognized neurological
or medical disease, whereas in functional neurological symptom
disorder, such incompatibility is required for the diagnosis.
Illness anxiety disorder In illness anxiety disorders there are no symptoms or they are mild
Depressive disorder In depressive disorders, individuals may report general heaviness of
their limbs, whereas the weakness of functional neurological
symptom disorder is more focal and prominent.
Dissociative disorder Dissociative symptoms are common in individuals with functional
neurological symptom disorder. If both functional neurological
symptom disorder and a dissociative disorder are present, both
diagnoses should be made.
Factitious disorder or Functional neurological symptom disorder describes genuinely
malingering experienced symptoms that are not intentionally produced (i.e., not
feigned). Evidence of feigning (e.g., marked discrepancy between
reported and observed activities of daily living) would suggest
malingering if the individual’s apparent aim is to obtain an obvious
external reward, or factitious disorder in the absence of such reward.
4 PSYCHOLOGICAL FACTOR THAT INFLUENCE MEDICAL CONDITIONS
Note: other problems that may be subject to medical attention in the DSM-IV.
- For the first time in DSM-5 as a mental disorder and in somatic disorders.
- Biopsychosocial approach.
- Recognize the role of psychological factors in the natural history of illnesses (e.g., hypertension).
- It allows to analyse factors that can affect: development and evolution of the illness.
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Psychopathology II @Imaran2
A. Presence of a medical symptom or condition (other than a mental disorder).
B. Psychological or behavioural factors adversely affect the medical condition in one of the following
ways:
a. The factors have influenced the course of the medical condition as shown by a close
temporal association between the psychological factors and the development or
exacerbation of, or delayed recovery from, the medical condition.
b. The factors interfere with the treatment of the medical condition (e.g., poor adherence).
c. The factors constitute additional well-established health risks for the individual.
d. The factors influence the underlying pathophysiology, precipitating or exacerbating
symptoms or necessitating medical attention.
C. Psychological or behavioural factors in Criterion B are not better explained by another mental
disorder (e.g., panic disorder, major depressive disorder, or post-traumatic stress).
Specify the severity:
- mild (increases medical risk)
- moderate (worsens underlying medical condition),
- serious (leads to hospitalization or visit to the emergency department),
- extreme (life-threatening risk)
Prevalence: unknown.
Course: during all lifetime.
DIFFERENTIAL DIAGNOSIS
Mental disorder due to a The medical condition is judged to be causing the mental disorder
medical condition through a direct physiological mechanism. In psychological factors
affecting other medical conditions, the psychological or behavioral
factors are judged to affect the course of the medical condition.
Adjustment disorders Abnormal psychological or behavioral symptoms that develop in
response to a medical condition are more properly coded as an
adjustment disorder (a clinically significant psychological response to
an identifiable stressor).
Another mental disorder that If an individual has a coexisting major mental disorder (e.g., major
worsens a medical condition depression) that adversely affects or causes another medical
condition, diagnoses of the mental disorder and the medical
condition are usually sufficient. Psychological factors affecting other
medical conditions is diagnosed when the psychological traits or
behaviors do not meet criteria for a mental diagnosis.
Somatic symptoms disorder In psychological factors affecting other medical conditions, the
emphasis is on the exacerbation of the medical condition (e.g., an
individual with angina that is precipitated whenever he becomes
anxious). In somatic symptom disorder, the emphasis is on
maladaptive thoughts, feelings, and behavior (e.g., an individual with
angina who worries constantly that she will have a heart attack, takes
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Psychopathology II @Imaran2
her blood pressure multiple times per day, and restricts her
activities).
Illness anxiety disorder The focus of clinical concern is the individual’s worry about having a
disease; in most cases, no serious disease is present. In psychological
factors affecting other medical conditions, anxiety may be a relevant
psychological factor affecting a medical condition, but the clinical
concern is the adverse effects on the medical condition.
5 FACTICIOUS DISORDER
Note: in another chapter in the DSM-IV.
Factitious disorder:
A. Falsification of physical or psychological signs or symptoms or induction of injury or illness
associated with an identified deception.
B. The patient presents himself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external reward.
D. The behavior is not best explained by another mental disorder, such as delusional disorder or
other psychotic disorder.
Specify if: single/recurrent episodes.
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Psychopathology II @Imaran2
Factitious disorder imposed on another (previously “by proxy”):
A. Falsification of physical or psychological signs or symptoms or induction of injury or disease, in
another, associated with an identified deception.
B. The patient presents another individual (victim) to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or
other psychotic disorder.
Note: The diagnosis applies to the perpetrator, not the victim.
Specify: Single/recurrent episodes (two or more events...)
Note: Munchhausen syndrome (no in the DSM-5, only ICD) old name not use anymore
Prevalence:
- Unknown.
- Around 1% of hospitalized patients.
- More in women
Course:
- Intermittent episodes.
- Onset in early adulthood. Between 30-50 years of age.
- Often after a medical problem or mental disorder.
DIFFERENTIAL DIAGNOSIS
Somatic symptoms disorder In somatic symptom disorder and the care-seeking type of illness
anxiety disorder, there may be excessive attention and treatment
seeking for perceived medical concerns, but there is no evidence that
the individual is providing false information or behaving deceptively.
Malingering Malingering is differentiated from factitious disorder by the intentional
reporting of symptoms for personal gain (e.g., money, time off work).
In contrast, the diagnosis of factitious disorder requires that the illness
falsification is not fully accounted for by external rewards. Factitious
disorder and malingering are not mutually exclusive, however. The
motives in any single case might be multiple and shifting depending on
the circumstances and reactions of others.
Conversion disorder Functional neurological symptom disorder is characterized by
neurological symptoms that are inconsistent with neurological
pathophysiology. Factitious disorder with neurological symptoms is
distinguished from functional neurological symptom disorder by
evidence of deceptive falsification of symptoms.
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Differences between factitious disorder or simulation or malingering:
- Included in the category of “other problems that may not be the subject of clinical care”.
- Not considered a mental disorder.
- Malingering objective is to obtain personal benefits, external incentives (e.g., money, sick-leave,
avoidance of criminal responsibility).
Presence of symptoms that cannot be explained by medical illness:
- Is the objective of the person to assume the role of a sick person and undergo examinations?
(factitious disorder)
- Does he/she not know why he/she needs to be ill? (factitious disorder)
- Does he/she invent the symptoms in order to obtain an external benefit and is he/she aware of
what the benefit is (e.g. reduction of a court sentence)? (simulation)
- Are the symptoms not deliberated? (somatic symptoms disorder/illness anxiety
disorder/conversion disorder) intentional?
ANOTHER DISORDER OF SOMATIC SYMPTOMS AND SPECIFIED AND UNSPECIFIED RELATED
6
DISORDERS
OTHER SPECIFIED SOMATIC SYMPTOM AND RELATED DISORDERS
It does not fulfil criteria of any somatic symptom disorder. Examples:
- Brief somatic symptom disorder: Duration of symptoms is less than 6 months.
- Brief illness anxiety disorder: Duration of symptoms is less than 6 months.
- Illness anxiety disorder without excessive health-related behaviors or maladaptive avoidance:
Criterion D for illness anxiety disorder is not met.
- Pseudocyesis: A false belief of being pregnant that is associated with objective signs and reported
symptoms of pregnancy.
UNSPECIFIED SOMATIC SYMPTOM AND RELATED DISORDERS
Presentations in which symptoms characteristic of a somatic symptom and related disorder that cause
clinically significant distress or impairment in social, occupational, or other important areas of functioning
but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders
diagnostic classification.
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