Somatic Symptoms & Related Disorders – DSM 5

Somatic Symptom Disorder Illness anxiety disorder Conversion disorder (functional neurological symptom disorder) Psychological factors affecting other medical conditions Factitious disorder all disorders share a common feature; the presence of somatic symptoms causing distress & impairment These persons are found in general health care services but not psychiatric services

Somatic Symptom Disorder Diagnostic Criteria A. One or more somatic symptoms that are distressing or result in significant disruption of daily life B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: 1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms 2. Persistently high level of anxiety about health or symptoms 3. Excessive time & energy devoted to these symptoms or health concerns When working with client’s remember that the symptoms are not the core of the problem but it is how the person thinks about it feels about and acts in according to his thoughts and feelings (it is how the client presents and interprets the symptoms) The somatic symptoms disorder can be found along with any medical disorder Person might have several symptoms most commonly pain (localized) or relatively nonspecific (fatigue). The client’s pain is real although there is no explanation . The symptoms become the center of the persons life and part of his/her identity and dominates interpersonal relationships The client goes doctor shopping for the same symptoms, they are never satisfied by the treatment

Somatic Symptom Disorder Diagnostic Criteria C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)

Associated Features Focus on somatic symptoms attribution of normal bodily sensation to illness Worry about illness, and fear that any physical activity may damage the body Repeated bodily checking for abnormality Repeated seeking of medical help and reassurance (any reassurance is short lived) Person seek general health services and when referred to psychiatric services they refuse It might be accompanied with depressive disorder, and an increase risk for suicide

Prevalence Female more than males 5-7% of adult population May be under-diagnosed in older adult by considering certain symptoms as part of normal aging In children most symptoms are abdominal pain, headaches, fatigue and nausea. (parents response to illness affects the child’s perception of its seriousness)

Differentiation How somatic symptom disorder is different from each of the following? Other medical disorder Panic disorder GAD Depressive disorders Illness anxiety disorder Conversion disorder Body dysmorphic disorder OCD

Illness Anxiety Disorder Diagnostic Criteria A. Preoccupation with having or acquiring 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 high risk for developing a medical condition (e.g., strong family history if present) the preoccupation is clearly excessive or disproportionate The preoccupation with having a serious undiagnosed illness. The examination and test results does not indicate any physical illness. The person’s distress and anxiety does not come from the physical complaint it self but from the meaning of the complaint (suspected medical diagnosis). If a sign is present it is often a normal physiological sensation (orthostatic dizziness), a benign self limited dysfunction (transient tinnitus) or bodily discomfort (bleching)

Illness Anxiety Disorder Diagnostic Criteria C. there is high 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., avoid doctor appointments & hospitals or avoiding visiting sick family members or avoid exercise) The persons with the illness anxiety disorder are easily affected by any illness they hear about or read about. Their worries of not having the disease does not respond to the reassurance or negative lab results. It affects the ADLS of the client, identity and self image Persons keep examining themselves repeatedly (checking throat in front the mirror)

Illness Anxiety Disorder Diagnostic Criteria E. illness preoccupation has been present for at least 6 months, but specific illness that is feared may change over that period of time F. the illness-related preoccupation is not explained by another mental disorder, such as somatic symptom disorder, generalized anxiety disorder, body dysmorphic disorder, OCD, or delusional disorder, somatic type

Illness Anxiety Disorder Diagnostic Criteria Specify Care seeking type Care avoidant type Prevalence: Rate of prevalence 3-8% in general population Male=female Onset early to middle adulthood

Conversion Disorder (Functional Neurological Symptom Disorder): Diagnostic 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 condition C. The symptom or clinical deficit is not explained by another medical or mental disordert D. The symptom or deficit causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrants medical evaluation Symptoms may include: weakness or paralysis; abnormal movement such as tremors; gait abnormality; reduced or absence of skin sensation. Reduced or absence of speech (aphonia) diplopia . Symptoms are not intentional Usually physical examination findings are contradictory to each other when testing the same body part in diffent ways for example a cleint who is able to walk on tip of toes shows weakness of ankle – planter flexion when tested on bed The onset of the illness may be associated with stressful event, previous illness of another person, From the associated features of conversion disorder is that the person is not concerned or interested about becoming better and does not ask about the exam results or causes of illness (la belle indifference phenomenon) or it is said that the person is having a secondary gain

Conversion Disorder (Functional Neurological Symptom Disorder): Diagnostic Criteria Specify symptom by: With weakness or paralysis With abnormal movement With swallowing symptoms With speech symptoms (dysphonia, slurred speech) With attacks or seizures With anesthesia or sensory loss With special sensory symptoms (visual, olfactory, hearing disturbance)

Conversion Disorder (Functional Neurological Symptom Disorder): Diagnostic Criteria Specify Acute episode : symptoms less than 6 months Persistent : symptoms for 6 months or more With psychological stressor (specify stress) Without psychological stressor Prevalence: 5% of individuals referd to the neurological clinics More common in females

Psychological Factors Affecting Other Medical Conditions: Diagnostic Criteria A. A medical symptom or condition (other than mental disorder) is present B. Psychological or behavioral factors affect the medical condition in one of the following ways: 1. the factors have influenced the course of the medical condition as shown by close temporal association between the psychological factors and the development of exacerbation of, or delayed recovery from, the medical condition

Psychological Factors Affecting Other Medical Conditions: Diagnostic Criteria 2. The factors interfere with the treatment of the medical condition (e.g., poor adherence) 3. the factors constitute additional well-established health risks for the individual 4. The factors influence the underlying patho-physiology, precipitating or exacerbating symptoms or necessitating medical condition C. The psychological and behavioral factors in criterion B are not better explained by another mental disorder (e.g., panic disorder, major depressive disorder, PPTS)

Psychological Factors Affecting Other Medical Conditions: Diagnostic Criteria Specify Mild (inconsistent adherence with antihypertensive medication) Moderate: aggravates underlying medical conditions (anxiety aggravating asthma) Severe: results in hospitalization or ER visit Extreme: results in life threatening risk (ignoring heart attack symptoms)

Factitious Disorder: Diagnostic Criteria Factitious Disorder on Self: A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception B. The individual presents himself/herself 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 other mental disorder, such as delusional disorder or another psychotic disorder Could be single episode or recurrent

Factitious Disorder: Diagnostic Criteria Factitious disorder imposed on another A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception B. The individual 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 other mental disorder, such as delusional disorder or another psychotic disorder Could be single episode or recurrent