Somatic symptom disorder is defined as the presence of one or more physical symptoms lasting > 6 months, accompanied by excessive thoughts, emotional distress, or behaviors related to the symptom that result in significant social and occupational impairment. Physical symptoms can include pain, weakness, or shortness of breath. It may or may not be associated with a diagnosed medical condition, but the person believes they are sick. Patients exhibit “somatization,” meaning internal conflicts or worries are experienced as physical symptoms. It may be associated with a history of neglect, sexual abuse, or drug and alcohol abuse. It is more commonly seen in avoidant, paranoid, and obsessive compulsive personality disorders. Management includes 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 a person has 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 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: This 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 a 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 (for example, the same college, workplace, or neighborhood) 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 (for example, 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 or 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 this is considered a form of child abuse. Symptoms such as GI bleeding and pseudoseizures are fabricated by the parents.
Body dysmorphic disorder: This is characterized by a distressing or impairing preoccupation with slight or imagined defect(s) in one’s physical appearance, such as a body part (nose, eyes, skin, hair, etc.). Patients may pursue multiple plastic surgeries. It is associated with an increased risk of substance abuse and suicide. Treatment includes cognitive behavioral therapy, psychotherapy, and SSRIs.
Dissociative disorders are characterized by an involuntary escape from reality and a disconnection between thoughts, identity, consciousness, and memory. They are caused by trauma or stressful events. Patients may experience “dissociative fugue,” in which they travel to far away places and either do not remember the travel or do not remember their identities. The following types are seen:
Dissociative amnesia: The main symptom is difficulty remembering important information about one’s self. It may last for minutes to, rarely, years.
Depersonalization or derealization disorder: Feelings of detachment from self (depersonalization) or feeling like people and things in the world are unreal (derealization).
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 includes psychotherapy such as cognitive behavioral therapy, eye movement desensitization and reprocessing, and antidepressants.
Sign up for free to take 2 quiz questions on this topic