The term “psychosomatic disorder” is mainly used to mean “a physical disease that is thought to be caused, or made worse, by mental factors.” ... For example, chest pain may be caused by stress and no physical disease can be found.

1. Mukesh sah, MD, JI
Region 1 Medical Center
SOMATIC SYMPTOMS AND
RELATED DISORDERS

2. INTRODUCTION
• Present with prominent somatic symptoms associated with significant
distress or impairment in social, occupational or other areas of
functioning
• Patients may or may not have an associated medical condition
• Patients focus is on their distressing somatic symptoms as well as their
thoughts, feelings and behaviours in response to these symptoms.
• More common in women

3. PAIN DISORDER
• A pain disorder is characterized by the presence of, and focus
on, pain in one or more body sites and is sufficiently severe to
come to clinical attention.
• The physician does not have to judge the pain to be
“inappropriate” or “in excess of what would be expected.”
• The disorder has been called somatoform pain disorder,
psychogenic pain disorder, idiopathic pain disorder, and atypical
pain disorder.
• Pain disorder is diagnosed as “Unspecified Somatic Symptom
Disorder” in DSM-5 or it may be designated as a “specifier”
under that heading.

4. EPIDEMIOLOGY
• The prevalence of pain disorder appears to be common. Recent
work indicates that the 6-month and lifetime prevalence is
approximately 5 and 12 percent, respectively.
• Approximately 3 percent of people in a general practice have
persistent pain, with at least 1 day per month of activity
restriction because of the pain.
• Pain disorder can begin at any age.
• Chronic pain appears to be most frequently associated with
depressive disorders, and acute pain appears to be more
commonly associated with anxiety disorders.

5. Etiology
• Psychodynamic Factors Patients who experience bodily aches and pains
without identifiable and adequate physical causes may be symbolically
expressing an intrapsychic conflict through the body.
• Behavioral Factors Pain behaviors are reinforced when rewarded and are
inhibited when ignored or punished.
• Interpersonal Factors Intractable pain has been conceptualized as a means
for manipulation and gaining advantage in interpersonal relationships, for
example, to ensure the devotion of a family member or to stabilize a fragile
marriage.
• Biological Factors
• Serotonin is probably the main neurotransmitter in the descending inhibitory
pathways, and endorphins also play a role in the central nervous system
modulation of pain.

6. Diagnosis And Clinical Features
• Patients with pain disorder are not a uniform group, but a heterogeneous collection
of persons with low back pain, headache, atypical facial pain, chronic pelvic pain,
and other kinds of pain.
• A patient’s pain may be posttraumatic, neuropathic, neurological, iatrogenic, or
musculoskeletal; to meet a diagnosis of pain disorder, however, the disorder must
have a psychological factor judged to be significantly involved in the pain symptoms
and their ramifications.
• Major depressive disorder is present in about 25 to 50 percent of patients with pain
disorder, and dysthymic disorder or depressive disorder symptoms are reported in
60 to 100 percent of the patients.
• The most prominent depressive symptoms in patients with pain disorder are
anergia, anhedonia, decreased libido, insomnia, and irritability; diurnal variation,
weight loss, and psychomotor retardation appear to be less common.

7. Treatment
Pharmacotherapy
Analgesic medications do not generally benefit most patients with
pain disorder.
• The success of SSRIs supports the hypothesis that serotonin is
important in the pathophysiology of the disorder.
• Amphetamines, which have analgesic effects, may benefit some
patients, especially when used as an adjunct to SSRIs, but
dosages must be monitored carefully.
Psychotherapy
• The first step in psychotherapy is to develop a solid therapeutic
alliance by empathizing with the patient’s suffering.

8. Differential Diagnosis
• Conversion disorder
• Malingering
• Muscle contraction (tension) headaches

9. TYPES OF SOMATIC DISORDERS
1. Somatic symptoms disorder
2. Conversion disorder (functional neurological symptom disorder)
3. Illness anxiety disorder
4. Psychological factors affecting other medical condition
5. Factious disorder
6. Other specified somatic symptoms and related disorder
7. Unspecified somatic symptom and related disorder

10. 1. SOMATIC SYMPTOM DISORDER
Diagnosis and DSM- criteria
• One or more somatic symptoms (may be predominantly pain) that are distressing or result
in significant disruption.
• Excessive thoughts, feelings, or behaviors related to the somatic symptoms
or associated health concerns.
• Lasts at least 6 months.
Epidemiology
■■ Incidence in females likely greater than that of males.
■■ Prevalence in general adult population: 5–7%.
■■ Risk factors include older age, fewer years of education, lower socioeconomic status,
unemployment, and history of childhood sexual abuse.

11. Risk Factors/ Etiology
• Somatization disorder affects women more than men and is usually
• Usually begins by the age of 30.
• Data suggest that there may be a genetic linkage to the disorder.
Physical and Psychiatric Presenting Symptoms
• Many physical symptoms affecting many organ systems
• Excessive thoughts, feelings, or behaviors related to the somatic symptoms
• Long, complicated medical histories
• Interpersonal and psychologic problems are usually present.
• Patients will usually seek out treatment and have significant impairment in their level of
functioning.
• Commonly associated with major depressive disorder, personality disorders, substance-
related disorders, generalized anxiety disorders, and phobias

12. Treatment
• Must have a single identified physician as the primary caretaker.
• Patient should be seen during regularly scheduled brief monthly visits.
• Should increase the patient’s awareness of the possibility that the symptoms are
psychological in nature.
• Individual psychotherapy is needed to help patients cope with their symptoms and
develop other ways of expressing their feelings.
Differential diagnosis
• Medical: MS, myasthenia gravis, SLE, AIDS, thyroid disorders, and
chronic systemic infections
• Psychiatric: Major depression, generalized anxiety disorder,
schizophrenia

13. 2. CONVERSION DISORDER (FUNCTIONAL
NEUROLOGICAL SYMPTOM DISORDER2.
• ■■ Patients with conversion disorder have at least one
neurological symptom (sensory or motor).
• ■■ Cannot be fully explained by a neurological condition.
• ■■ Patients are often surprisingly calm and unconcerned (labelle
indifference) when describing their symptoms.
• ■■ Examples of neurological symptoms include blindness,
paralysis, and paresthesia.

14. DIAGNOSIS AND DSM- CRITERIA
• ■■ At least one symptom of altered voluntary motor or sensory
function.
• ■■ Evidence of incompatibility between the symptom and
recognized neurological or medical conditions.
• ■■ Not better explained by another medical or mental disorder.
• ■■ Causes significant distress or impairment in social or
occupational functioning or warrants medical evaluation.
• ■■ Common symptoms: Paralysis, weakness, blindness, mutism,
sensory complaints (paresthesia), seizures, Globus sensation
(Globus hystericus or sensation of lump in throat)

15. Epidemiology
• ■■ Two to three times more common in women than men
• ■■ Onset at any age, but more often in adolescence or early adulthood
• ■■ High incidence of comorbid neurological, depressive, or anxiety
disorders
Risk Factors/Etiology
• Seen more frequently in young women.
• Also more common among the lower SES, rural populations, low IQs, and
military personnel.
• Commonly associated with passive-aggressive, dependent, antisocial, and
histrionic personality disorder.

16. Psychiatric And Physical Presenting
Symptoms
• One or two neurologic symptoms affecting voluntary or sensory function
• Must have psychologic factors associated with the onset or exacerbation of the symptoms
Mutism, blindness, and paralysis are the most common symptoms.
• Sensory system: Anesthesia and paresthesia
• Motor system: Abnormal movements, gait disturbance, weakness, paralysis, tics,
jerks, etc.
• Seizure system: Pseudoseizures
• Primary gain: Keeps internal conflicts outside patient’s awareness
• Secondary gain: Benefits received from being “sick”
• La belle indifference: Patient seems unconcerned about impairment.
• Identification: Patients usually model their behavior on someone who is important
to them.

17. Treatment
• Psychotherapy to establish a caring relationship with treater and focus on
stress and coping skills.
• Brief monthly visits with partial physical examinations.
• Differential diagnosis
• Neurologic: Dementia, tumors, basal ganglia disease, and optic neuritis
• Psychiatric: Schizophrenia, depressive disorders, anxiety disorders,
factitious
• Other: Malingering

18. 3. ILLNESS ANXIETY DISORDER
• A disorder characterized by the patient’s belief that he/she has
some specific disease.
• Despite constant reassurance, the patient’s belief remains the
same.
• Symptoms must occur for >6 months.
Risk factors/ Epidemiology
• Men and women are affected equally.
• Most common onset is between the ages of 20 and 30.
• Approximately 67% have a coexisting major mental disorder

19. DIAGNOSIS AND DSM- CRITERIA
• Preoccupation with having or acquiring a serious illness
• Somatic symptoms are not present or, if present, are mild in
intensity
• High level of anxiety about health
• Performs excessive health-related behaviors or exhibits
maladaptive behaviors
• Persists for at least 6 months
• Not better explained by another mental disorder (such as
somatic symptom disorder)

20. Physical And Psychiatric
Presenting Symptoms
• Preoccupation with diseases
• The preoccupation persists despite constant reassurance by
Physicians.
• The belief is not delusional.
• The preoccupation affects the individual’s level of functioning.
• Duration at least 6 months

21. Treatment
• Regularly scheduled visits to one primary care physician.
• CBT is the most useful of psychotherapies.
• Comorbid anxiety and depressive disorders should be treated with selective
serotonin reuptake inhibitors (SSRIs) or other appropriate psychotropic
medications.
Prognosis
• Chronic but episodic—symptoms may wax and wane periodically.
• Can result in significant disability.
• Up to 60% of patients improve significantly.
• Better prognostic factors include fewer somatic symptoms, shorter duration
of illness, and absence of childhood physical punishment.

22. 4. PSYCHOLOGICAL FACTORS AFFECTING
OTHER MEDICAL CONDITIONS
• ■■ A patient with one or more psychological or behavioral
factors (e.g., distress, coping styles, maladaptive health
behaviors) adversely affecting a medical symptom or condition.
• ■■ Examples include anxiety worsening asthma, denial of need
for treatment for acute chest pain, and manipulating insulin
doses in order to lose weight

23. Epidemiology
• ■■ Prevalence and gender differences are unclear.
• ■■ Can occur across the life span
Treatment
• Includes education and frequent contact with a primary care
physician.
• SSRIs and/or psychotherapy (especially CBT) should be used to
treat underlying anxiety or depression.

24. 5. FACTITIOUS DISORDER
• ■■ Patients with factitious disorder intentionally falsify medical
or psychological signs or symptoms in order to assume the role
of a sick patient.
• ■■ They often do this in a way that can cause legitimate danger
(central line infections, insulin injections, etc.).
• ■■ The absence of external rewards is a prominent feature of
this disorder.

25. DIAGNOSIS AND DSM-5 CRITERIA
• ■■ Falsification of physical or psychological signs or symptoms, or induction of injury
or disease, associated with identified deception.
• ■■ The deceptive behavior is evident even in the absence of obvious external
rewards (such as in malingering).
• ■■ Behavior is not better explained by another mental disorder, such as delusional
disorder or another psychotic disorder.
• ■■ Individual can present him/herself, or another individual (as in factitious disorder
imposed on another).
• ■■ Commonly feigned symptoms:
• ■■ Psychiatric—hallucinations, depression
• ■■ Medical—fever (by heating the thermometer), infection, hypoglycemia, abdominal
pain, seizures, and hematuria

26. E P I D E M I O L O G Y
• ■■ May be at least 1% of hospitalized patients.
• ■■ More common in women.
• ■■ Higher incidence in hospital and health care workers (who
have learned how to feign symptoms).
• ■■ Associated with personality disorders.
• ■■ Many patients have a history of illness and hospitalization,
as well as childhood physical or sexual abuse.

27. TREATMENT AND PROGNOSIS
• ■■ Collect collateral information from medical treaters and
family.
• ■■ Collaborate with primary care physician and treatment team
to avoid unnecessary procedures.
• ■■ Patients may require confrontation in a nonthreatening
manner; however,
• patients who are confronted may leave against medical advice
and seek hospitalization elsewhere.
• ■■ Repeated and long-term hospitalizations are common.

28. 6. MALINGERING
• ■■ Malingering involves the intentional reporting of physical or psychological
symptoms in order to achieve personal gain.
• ■■ Common external motivations include avoiding the police, receiving room
and board, obtaining narcotics, and receiving monetary compensation.
• ■■ Note that malingering is not considered to be a mental illness.
• Risk Factors/Etiology.
• Seen more frequently in men, especially in prisons, factories, the military,
etc.

29. Presentation
• ■■ Patients usually present with multiple vague complaints that
do not conform to a known medical condition.
• ■■ They often have a long medical history with many hospital
stays.
• ■■ They are generally uncooperative and refuse to accept a
good prognosis even after extensive medical evaluation.
• ■■ Their symptoms improve once their desired objective is
obtained.

30. Epidemiology
• ■■ Not uncommon in hospitalized patients
• ■■ Significantly more common in men than women
• Treatment
• Allow the patient to save face by not confronting the patient and by allowing
the physician–patient relationship to work. If confronted, patient will become
angry and more guarded and suspicious.
• Differential Diagnosis.
Psychiatric: somatoform disorders

31. 7. BODY DYSMORPHIC DISORDER
• A disorder characterized by the belief that some body part is
abnormal, defective, or misshapen.
Risk Factors/Etiology
• Affects women more than men, typically ages 15–20.
• These women are unlikely to be married.
• Other disorders that may be found include depressive disorders,
anxiety disorders, and psychotic disorders. Family history of
depressive disorders and OCDs.
• May involve serotonergic systems.

32. Physical And Psychiatric Presenting
Symptoms
• • Most common concerns involve facial flaws
• • Constant mirror-checking
• • Attempt to hide the alleged deformity
• • Housebound
• • Avoids social situations
• • Causes impairment in their level of functioning

33. Treatment
• Individual psychotherapy to help deal with stress of alleged
imperfections as well as reality testing.
• Pharmacotherapy may include the use of SSRIs, TCAs, or
MAOIs.
Differential Diagnosis
• • Medical: Some types of brain damage, such as neglect
syndrome
• • Psychiatric: Anorexia, narcissistic personality disorder, OCD,
schizophrenia, delusional disorder

34. REVIEW OF DISTINGUISHING FEATURES
• ■■ Somatic symptom disorders: Patients believe they are ill and
do not intentionally produce or feign symptoms.
• ■■ Factitious disorder: Patients intentionally produce symptoms
of a psychological or physical illness because of a desire to
assume the sick role, not for external rewards.
• ■■ Malingering: Patients intentionally produce or feign
symptoms for external rewards.