Somatic symptom disorder

Question 1

what is a somatic symptom disorder?

Answer 1

a condition composed of multiple,recurrent, medically unexplained physical symptoms
- usually starting in early adult life

Question 2

Aietiology

Answer 2

1. Chronic and/or acute (emotional/psychological) stress or conflict,

• in combination with either emotional processing deficits
  avoidance tendencies
• social, cultural, or family taboos against emotional expression,

2. Somatic presentation of psychological distress
3. General sensory amplification of bodily system

Question 3

diagnosis of Somatisation disorder

DSM IV

Answer 3

A. History of many physical complaints before the age of 30
- occur over a period of several years
- significant social/occupatinal/areas of functioning
B. Each of the following criterea
- 4 x pain symptoms ( history of pain in atleast 4 different sites)
- 2 x GI symptoms
- 1 x sexual symptoms
- 1 x pseudoneurological symptom e.g. impaired coordination/balance/sight etc

C. EITHER

• After appropriate investigations of each of the symptoms - cannot be medically explained
• or symptoms are excessive compared to condition

D. Symptoms are not feigned

Question 4

Clinical features of somatization disorder

Answer 4

1. teenage onset
2. female
3. vague or dramatic history
4. emphasis on suffering
5. sceptical/hostile attitude
6. personality or mood disorders
7. History of substance abuse ( sedatives/analgesia)
8. recent or remote life stressors
9. emotional processing problems

Question 5

Diagnosis of somatisation disorder (DSM V)

Answer 5

A. The patient has one or more somatic symptoms that are distressing or result in significant disruption of daily life.

B. Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

• Disproportionate and persistent thoughts about the seriousness of one’s symptoms
• Persistently high levels of anxiety about health or symptoms
• Excessive time and energy devoted to these symptoms or health concerns.

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

Specify if

With predominant pain (previously pain disorder): this specifier is for individuals whose somatic symptoms predominantly involve pain.
Specify if

Persistent: a persistent course is characterised by severe symptoms, marked impairment, and long duration (more than 6 months).

Question 6

physical symptoms of somatisation disorder

Answer 6

1. distractible symptoms - go away when distracted during examination
2. unusual neurological deficit -
   - distribution of deficit which doesn’t conform to roots or nerves
   - inconsistent paralysis : weakness varies
3. Psychogenic movement disorders
   - erratic, flailing which is outside of organic cause
   - gait disorders
4. Psychogenic non epileptic seizures
5. cognitive complaints - short term memory problems/loss of skills
6. Hoover’s sign

Question 7

Hoover’s sign

Answer 7

Involuntary extension of the pseudoparalysed leg when the unaffected leg is flexing against resistance can indicate functional (psychogenic) aetiologies

Question 8

DSM5 Severity scale

Answer 8

1. Mild: only one of the symptoms in criterion B is fulfilled.
2. Moderate: two or more of the symptoms specified in criterion B are fulfilled.
3. Severe: two or more of the symptoms specified in criterion B are fulfilled. Plus there are multiple somatic complaints (or one very severe somatic symptom).

Question 9

Main methods of management

Answer 9

1. Cognitive behavioral therapy

2. Second line : further antidepressants