Somatic symptom disorder

Somatic symptom disorder is defined as the presence of one or more physical symptoms, lasting > 6 months, accompanied by excessive thoughts, emotional distress or behavior related to the symptom that results in significant social and occupational impairment. Physical symptoms include pain, weakness or shortness of birth. It may or may not be associated with a diagnosed medical condition, but the person believes that they are sick. Patients exhibit “somatization”, that is internal conflicts or worries are felt as physical symptoms. It may be associated by history of neglect, sexual abuse or drug and alcohol abuse. It is more commonly seen in avoidant, paranoid and obsessive compulsive personality disorders. Management is by regularly scheduled visits with a primary care physician and cognitive behavioral therapy. Some patients may need anxiolytics or antidepressants.

Illness anxiety disorder: Previously termed hypochondriasis, it is characterized by excessive worry that they have a serious illness or may become ill. Patients may become extremely anxious about minor body symptoms like muscle aches and pains. They may frequently check themselves for signs of illness and may request unnecessary investigations or procedures to make sure that they are not sick. Compared to somatic symptom disorder, anxiety or worry about getting sick is the predominant manifestation of illness anxiety disorder, rather than somatic symptoms.

Conversion disorder: It is a disorder in which a person experiences blindness, paralysis, ataxia, anosmia, seizures, hallucinations or other symptoms affecting the nervous system that cannot be explained solely by a physical illness or injury. Symptoms usually begin suddenly after a period of emotional or physical distress or psychological conflict. It is more common in women and in those in the military. The symptoms are real and are not faked by the patient, although no underlying medical condition can be diagnosed even after thorough examination. Somatization is seen in conversion disorder. Treatment may include psychotherapy, hypnosis and stress management training to help reduce symptoms. Physical or occupational therapy may be needed. Rarely, conversion disorder may occur in a group that shares the same environment like the same college/workplace/neighborhood etc, and is called “mass psychogenic illness”.

Factitious disorder and malingering: Factitious disease is the conscious and intentional feigning or production of symptoms, due to a psychological need to assume the sick role in order to obtain emotional gain. Malingering is the conscious and intentional production or exaggeration of symptoms for material gain, such as money, lodging, food, drugs, avoidance of military service, or escape from punishment.

While both factitious disease and malingering are done consciously, somatic symptom disorder and illness anxiety disorder are unconscious expressions.

Munchausen syndrome is the most extreme form of factitious disorder. Patients mimic serious and life-threatening disease, wander from one hospital to the next and assume different character roles, like an actor, priests, war heroes etc. They may behave in a dramatic, aggressive or uncooperative manner. Patients may present with self-induced infections or injuries and ingest unnecessary medications like laxatives, warfarin to get sick. They may falsify medical records.

Munchausen syndrome by proxy is the intentional production of illness in another person to assume the sick role by proxy. The perpetrators are typically parents of young children and is considered a form of child abuse. Symptoms such as GI bleeding, pseudoseizures are fabricated by the parents.

Body dysmorphic disorder: It is characterized by a distressing or impairing preoccupation with slight or imagined defect(s) in one’s physical appearance like a body part (nose,eyes, skin, hair etc.). Patients may resort to multiple plastic surgeries. It is associated with increased risk of substance abuse and suicide. Treatment is by cognitive behavioral therapy, psychotherapy and SSRIs.

Dissociative disorders

They are characterized by involuntary escape from reality and disconnection between thoughts, identity, consciousness and memory. They are caused by trauma or stressful events. Patients may experience “dissociative fugue”, where they travel to far away places and do not have memory of it or do not remember their identities. Following types are seen:

1. Dissociative amnesia: The main symptom is difficulty remembering important information about one’s self. It may last for minutes to rarely, years.

2. Depersonalization or derealization disorder: Feelings of detachment from self (depersonalization) or feeling like people and things in the world are unreal (derealization).

3. Dissociative identity disorder (previously multiple personality disorder): Two or more distinct identities exist in the same person. Often these identities may have unique names, characteristics, mannerisms and voices. People experience gaps in memory of everyday events, personal information and trauma.

Treatment of dissociative disorders is with psychotherapy like cognitive behavioral therapy, eye movement desensitization and reprocessing and antidepressants.