Key Concepts
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Several conditions previously classified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as somatoform disorders are now classified under DSM-V as Somatic Symptom and Related Disorders (SSRD). These include somatic symptom disorder (SSD), illness anxiety disorder (IAD), and conversion disorder. They share a common feature of patients’ maladaptive and inappropriate psychological response to somatic (bodily) symptoms.
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SSRD patients have approximately twice the rate of medical disease seen in the general population. It is unclear whether this is the consequence of more frequent health care use or whether an increased disease burden prompts these patients to have a greater concern for bodily sensations.
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SSD is characterized by disproportionate or persistent health-related thoughts, anxiety, and time and energy devoted to somatic (bodily) symptoms, resulting in disruption of daily life.
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Patients with IAD, formerly known as hypochondriasis, have excessive anxiety regarding the possibly having or acquiring a serious medical illness in the presence of minimal or absent somatic symptoms.
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Conversion disorder , also known as functional neurologic symptom disorder , is characterized by abnormal sensory or voluntary motor function that is found to be incompatible with known neurologic or medical conditions, and that causes significant distress or life impairment.
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The differential diagnoses for SSRD may be broadly divided between (a) psychiatric disorders that manifest somatic symptoms and (b) medical conditions with signs or symptoms that might be attributed to psychiatric disorders.
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A “positive review of systems” in an emergency department (ED) evaluation is similar to a high score on SSRD symptoms severity scales and thus may serve as an inadvertent screen for SSRD. Further research is needed to ascertain whether this is clinically reliable.
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ED care goals for patients with SSRD include establishment of rapport, building a therapeutic alliance, legitimizing the patient’s distress, and enhancing the patient’s ability to function despite the symptoms.
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Multiple care modalities are available for SSRD treatment. These are typically managed by the patient’s primary care physician or psychiatrist.
Foundations
Somatic symptom and related disorders (SSRD), formerly known as somatoform disorders , are described as the borderland between psychiatry and medicine and are responsible for some of the most challenging and the least understood patient encounters in the emergency department (ED). Individuals who suffer from these disorders must be identified and treated appropriately to avoid patient suffering, inappropriate resource use, and iatrogenic injuries.
Box 99.1 lists the disorders classified in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as SSRD. They include somatic symptom disorder (SSD), illness anxiety disorder (IAD, formerly known as hypochondriasis), conversion disorder, psychological factors affecting medical illness, and factitious disorder (discussed separately in Chapter 100 ). Body dysmorphic disorder (excessive concern for a perceived defect in physical features) is no longer included in this group.
BOX 99.1
Somatic Symptom and Related Disorders
Somatic symptom and related disorders share a common feature of patients’ maladaptive and inappropriate psychological response to somatic (bodily) symptoms
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Somatic symptom disorder
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Illness anxiety disorder
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Conversion disorder (functional neurologic symptom disorder)
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Psychological factors affecting other medical conditions
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Factitious disorder
Although prior versions of the DSM emphasized medically unexplained symptoms and their putative psychological causes, current descriptions of these disorders focus on patients’ maladaptive and inappropriate cognitive and affective responses to somatic symptoms rather than the lack of explanation for them. , These disorders are thought to be mediated by abnormal sensory perception, processing, interpretation, attribution to pathologic causes, and subsequent hypervigilance toward further sensations.
SSRD are common, with a prevalence of approximately 5% to 7% of the adult population, and are present in many patients with medically unexplained symptoms. , The defining features of these disorders, a maladaptive response to bodily sensations, cause patients to seek help for their illness through medical routes rather than psychiatric avenues. However, the SSRD are typically formally diagnosed only via structured psychiatric interview, and these disorders may take many years to diagnose even in longitudinal primary care settings. The disorders are even more challenging to diagnose during a brief ED encounter prioritizing life-threatening illness.
Difficulty identifying the root cause of patients’ distress may cause frustration for both patients and physicians. For example, patients with SSD may have excessive anxiety regarding nonpathologic sensations, whereas patients with IAD may be certain they have a serious medical condition despite contradictory evidence. Thus, after a negative ED work-up, the very nature of the patients’ psychiatric condition may leave them feeling that their concerns have not been adequately addressed, prompting pursuit of extensive, expensive, and invasive medical evaluations. SSRD patients have approximately twice the rate of medical disease seen in the general population. It is unclear whether this is the consequence of more frequent health care use or whether an increased disease burden prompts these patients to have a greater concern for bodily sensations.
Clinicians may also feel frustrated by encounters with patients with SSRD. Frequent ED use by patients with unrealistic expectations and subsequent frustrations may cause physicians to feel these encounters were suboptimal. These patients frequently exhibit an extensive “positive review of symptoms,” which clinicians may feel obligated to evaluate. Even when clinicians suspect SSRD, they are often unwilling to ascribe patient concerns to psychiatric illness at the exclusion of rare but consequential medical diagnoses with nonspecific presentations. However, if the patients’ concerns are recognized and addressed within a patient-centered framework, clinicians may recognize that the “difficult patient” with a “positive review of systems” may have a psychiatric illness requiring further evaluation in an outpatient medical or psychiatric setting.
Clinical Features
Patients with SSRD experience physical symptoms associated with significant distress and impairment that cannot be adequately explained by demonstrable physical pathology despite appropriate medical investigation. These disorders are most common in women of lower socioeconomic status in their 20s and 30s but may be present in any demographic group. Depressive and anxiety disorders are common comorbid conditions, as are nonpsychiatric medical diagnoses.
Somatic Symptom Disorder
Patients with SSD have disproportionate or persistent health-related thoughts, anxiety, and time and energy devoted to somatic (bodily) symptoms, resulting in disruption of daily life. Previous editions of the DSM described a causal relationship between a patient’s emotions and subsequent symptoms (termed somatization). The disorder criteria now focus upon the abnormal psychological response to bodily sensations rather than to a lack of medical explanation for symptoms. Research indicates these patients have abnormal autonomic activity and reactivity, as well as measurably altered emotional processing and bodily awareness. A subset of SSD patients includes patients for whom pain is the primary concern. Previously called pain disorder, this diagnosis is now termed SSD with predominant pain . For these patients, pain may represent normal bodily function in conjunction with spinal or higher-CNS sensitization from prior experience and genetic factors. , Of note, because the diagnosis of SSD depends upon the maladaptive psychological response to bodily sensations rather than the lack of medical explanation alone, the symptoms alone from fibromyalgia, irritable bowel syndrome, or multiple chemical sensitivities do not meet criteria for SSD.
Illness Anxiety Disorder
Patients with IAD have minimal or absent somatic symptoms but present with excessive anxiety regarding possibly having or acquiring a serious medical illness. Formerly known as hypochondriasis, IAD is now the preferred nomenclature to avoid pejorative connotations . IAD persists despite repeatedly negative medical evaluations, and the anxiety associated with this condition can produce either excessive health-related behaviors or maladaptive health care avoidance, resulting in care-seeking and care-avoidant subtypes, respectively. Care-seeking subtypes are at risk for iatrogenic complications of excessive testing.
Conversion Disorder
Patients with conversion disorder, now commonly referred to as functional neurologic symptom disorder , have altered sensory or voluntary motor function that is found to be incompatible with known neurologic or medical conditions and that causes the patient significant distress or life impairment. This disorder may have a variety of presentations, including seizure-like activity, focal weakness, memory disturbances, dysphonia, blindness, or alterations of any sensory system. Upon medical examination, however, no pathologic correlates are identified, and serial neurologic examinations often demonstrate inconsistent disability. For example, in the Hoover test, a supine patient may demonstrate normal hip extension (pushing down) with a “paralyzed” leg when asked to flex (lift) the contralateral hip. Similarly, patients may demonstrate inability to turn their head toward a “paralyzed” side but use the “paralyzed” sternocleidomastoid to turn from it. Coincident life stress is associated with but not essential for the diagnosis. The presence of la belle indifference (i.e., an inappropriate lack of concern regarding a seemingly profound disability) is also associated with but not specific to this disorder. Proven intentionality is not necessary for the diagnosis.
Factitious Disorder
In contrast to conversion disorder, factitious disorder is characterized by purposefully deceptive falsification of disease signs or symptoms for the sole purpose of causing others to see the person with the disorder as ill. In the case of Munchausen by proxy, the person induces symptoms in another patient, typically a child. , These disorders are discussed in greater detail in Chapter 100 .
Psychological Factors Affecting Medical Illness
Psychological factors affecting medical illness is a separate category included in SSRD due to the predominance of somatic symptoms and propensity to present in medical settings. This includes psychological factors that exacerbate or delay recovery from medical conditions, reduce adherence to medical treatment, or pose additional risk harm. Examples include anxiety-exacerbated asthma, or stress-induced Takotsubo cardiomyopathy.
Differential Diagnoses
Other psychiatric disorders may initially present with somatic symptoms, including major depressive disorder and anxiety disorders. The differential diagnoses for the SSRD may be broadly separated into two groups: psychiatric disorders that manifest somatic symptoms and medical conditions with signs or symptoms that might be attributed to psychiatric disorders ( Box 99.2 ). , For example, psychiatric patients with panic disorder may present with complaints of palpitations and dyspnea, and patients with major depressive disorder might present with sleep disturbances. Alternatively, many medical diagnoses can have subtle or variable presentations which might be attributed to psychiatric disorders (e.g., hypothyroidism-induced fatigue attributed to depression, sensory loss due to multiple sclerosis, or behavioral disturbances secondary to anti-N-methyl-d-aspartate (NMDA) receptor encephalitis).
BOX 99.2
Differential Diagnosis of Somatic Symptom Disorder
| Psychiatric Conditions | Medical Conditions |
|---|---|
| Depression disorders | Transient ischemic attack |
| Anxiety disorders | Multiple sclerosis |
| Obsessive-compulsive disorder | Systemic lupus erythematosus |
| Schizophrenia | Thyroid and parathyroid disorders |
| Personality disorders | Electrolyte disorders |
| Substance abuse disorders | Human immunodeficiency virus (HIV) |
| Malingering | Anti-NMDA receptor encephalitis |
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