The document discusses the history and evolution of somatic symptom and related disorders. It describes how concepts like hysteria, hypochondriasis, and psychosomatic disorders developed before being categorized under somatic symptom disorder, illness anxiety disorder, conversion disorder, and other diagnoses in DSM-5. It provides details on the characteristic symptoms, thresholds, and specifiers for each DSM-5 disorder category. Theories on the causes of related conditions like pseudocyesis are also summarized.

1. Somatic Symptom
and Related
Disorders
Zahiruddin Othman
Psychiatry Dept, PPSP USM

2. Ancient
Hysteria (Plato)
Before DSM-IV
Briquet syndrome
(1859)
Conversion
Hypochondriasis
Psychosomatic
DSM-IV
Somatization
Pain disorder

3. DSM 5 Somatic
Symptom and
Related
Disorders
Somatic Symptom
Disorder
Illness Anxiety
Disorder
Conversion
Disorder
Psychological
Factors Affecting
Other Medical
Conditions
Factitious Disorder
Other Specified
SSRD
Unspecified SSRD

4. Characteristic
Symptom
Somatic
Symptoms
Related
symptoms
Persistent
thoughts
Anxiety about
symptom
Time/energy spent
Threshold
Persistent; > 6 mo
Specifier: with predominant pain; persistent; mild/moderate/severe

5. Characteristic
Symptoms
Preoccupation of
having a serious illness
Absent of somatic
symptoms
Anxiety about health
Associated
Behaviour
Excessive health-
related behaviour
Maladaptive avoidance
Threshold &
Exclusion
> 6 months
Not Better Explained
(NBE)
Specifier: care-seeking or care-avoiding

6. (functional neurological symptom disorder)
Characteristic
Symptoms
Voluntary
motor
Sensory
Signs &
Investigations
Incompatible
clinical
findings
Threshold &
Exclusion
Distress &
impairment
NBE
Specifier: symptom type; acute/persistent; with/without psychological stressor

7. Other Medical
Condition
Symptom or
condition is
present
Psychological
Factors
Course
Treatment
Risk
Pathophysiology
Exclusion
NBE
Specifier: mild/moderate/severe/extreme

8. Characteristic
symptoms
Falsification of
symptom/sign
Induction of
injury/disease
Behaviour &
motivation
Deceptive
behaviour
No external
reward
Exclusion
NBE

9. 1. Brief somatic symptom disorder: Duration of symptoms
is less than 6 months.
2. Brief illness anxiety disorder: Duration of symptoms is
less than 6 months.
3. Illness anxiety disorder without excessive health-related
behaviors: Criterion D for illness anxiety disorder is not
met.
4. Pseudocyesis: A false belief of being pregnant that is
associated with objective signs and reported symptoms of
pregnancy.

10. Disorders Key Features
Somatic Symptom
Disorder
Excessive anxiety & preoccupation with ≥ 1
unexplained symptoms
Illness Anxiety Disorder Fear of having a serious illness despite few or no
symptoms & consistently negative evaluation
Conversion Disorder Neurologic symptoms incompatible with any know
neurologic disease; often acute onset associated with
stress
Factitious Disorder Intentional falsification or inducement of symptoms
with goal to assume sick role

11. Diagnosis
Type of
symptom or
motivation
Symptom
production
Presentation
Unexplained
medical symptom
or condition
Involuntary
Physical
symptoms
Somatic symptom
disorder
Neurological
symptoms
Conversion
disorder
Anxiety about
health
Illness anxiety
disorder
Voluntary
Sick role
Factitious
disorder
External
secondary gain
Malingering

12. Involuntary < --------------INTENTION------------- > Voluntary
Malingering
Factitious
Disorder
Compensation
Neurosis
Conversion Disorder
[DSM-5 Functional
Neurological Disorder]
Internal<----MOTIVATION---->External
Malingering is NOT a psychiatric disorder
Exaggeration <-----> Deception
Primarygain<----->Secondarygain

14. Conversion hysteria Malingering
Motivation nonvolitional, unconscious imitation or
exaggeration.
Volitional, deliberate imitation or exaggeration of
illness.
Circumstances Escape extreme psychological or situational conflict
but without purpose or fiscal gain.
Compensation for presumed injury, escape legal
responsibility, escape military service or
endangering situation.
Symptomatology Present in the absence of examiner or observer;
features are relatively consistent but can be
influence by suggestion.
Not present in the absence of examiner or
observer; inconsistent features (i.e., patient forgets
what is wrong with him)
Onset of symptoms Sudden after psychological conflict. Lag period after crisis situation (i.e., time for
planning).
Symptoms without treatment Lasts until ‘unconscious’ ends gained or
spontaneous resolution of conflict.
Lasts until ‘conscious’ ends gained and little danger
of recovery.
Anatomical or physiological
basis for symptomatology
Non-anatomic and non-physiologic basis;
symptomatology corresponds to conception of
disease.
May or may not be present depending on patient’s
knowledge of disease.
Interview responses Answer question without apparent evasion or
guile, but responses general or global.
Vague answers or ‘I don’t know’ to questions about
specific details but positive firm claims about
disability; often inconsistent and contradictory
responses.
Response to treatment Dramatic, sudden but usually temporary
disappearance of symptomatology to hypnotic
suggestion.
Resistant to hypnosis or suggestion.

15. Malingering Factitious disorder
Men > women Women > men; except in
Munchausen's variant
Substance abuse Employment/training in
medical field
Refuses tests,
treatments
Not bothered by invasive
procedure
Antisocial
personality disorder
Borderline personality
disorder

16. • In Briquet’s syndrome (also known as
somatization disorder), first described by
Paul Briquet in 1859, patients feel that
they have been sickly most of their lives
and complain of a multitude of symptoms
referable to numerous different organ
systems. This conviction of illness persists
despite repeatedly negative and
unrevealing consultations,
hospitalizations, and diagnostic
procedures, and patients continue to seek
medical care, to take prescription
medicines, and to submit to needless
diagnostic procedures.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4716311/

17. • Munchausen syndrome is named after a
German military man, Baron von
Munchausen, who traveled around telling
fantastic tales about his imaginary exploits.
In 1951, Richard Asher applied the term to
people traveling from hospital to hospital,
fabricating various illnesses.
• Munchausen syndrome most appropriately
describes people who have a chronic
variant of a factitious disorder with mostly
physical signs and symptoms, although
there are reports in literature regarding
psychological Munchausen syndrome,
meaning that the simulated symptoms are
psychiatric in nature.
https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp-rj.2018.130903

18. Bertha Pappenheim (Anna O.)
was treated by Breuer for
severe cough, paralysis of the
extremities on the right side of
her body, and disturbances of
vision, hearing, and speech, as
well as hallucination and loss
of consciousness. She was
diagnosed with hysteria. Freud
implies that her illness was a
result of the resentment felt
over her father's real and
physical illness that later led to
his death.
https://sci-hub.tw/10.1037/h0035362

19. • The Greek word hypokhondria,
literally means “under the cartilage
(of the breastbone).”
• The upper abdomen, it turns out,
was thought to be the seat of
melancholy at a time when the
now-outdated medical theory of
the 4 humors (blood, phlegm,
yellow bile [choler], and black bile
[melancholy]) was accepted as a
basis for legitimate health practice.
• In the 17th century, hypochondriac
referred to people who suffered
from “depression and melancholy
without cause”.
https://doi.org/10.1176/ajp.141.12.1608

20. Several theories have been postulated regarding the cause
of pseudocyesis, of which the following are widely
accepted.
1. Conflict theory: A desire for or fear of pregnancy
creates an internal conflict and causes endocrine changes
to explain the signs, symptoms and laboratory
findings in pseudocyesis.
2. Wish-fulfillment theory: Minor body changes
initiate the false belief in pregnancy in susceptible
individuals.
3. Depression theory: Pseudocyesis may be initiated by
the neuro-endocrine changes associated with major
depressive disorder