Approach to somatic symptom and related disorders: Clinical sciences

Somatic symptom and related disorders are a group of conditions that are characterized by excessive focus on physical symptoms the patient attributes to non-psychiatric illness, and related abnormal thoughts or behaviors that cause impairment or distress.

These conditions include illness anxiety disorder, somatic symptom disorder, and functional neurologic symptom disorder, previously known as conversion disorder.

Because these conditions present with physical symptoms it is very important to rule out underlying medical conditions first. Keep in mind, illness anxiety disorder and somatic symptom disorder can be diagnosed alongside a medical condition.

Alright, when a patient presents with a chief concern suggesting a somatic symptom disorder, your first step is to obtain a focused history and physical exam. On history, the patient might describe specific somatic symptoms like focal weakness or gastrointestinal distress, or nonspecific ones like fatigue or pain.

Additionally, they might report abnormal thoughts like excessive worry or obsession, or abnormal behaviors such as repeated self-examination or frequent emergency room visits.

On physical exam, you might find the patient to be anxious. If you see these findings, assess the severity of the patient’s current symptoms.

If the symptoms are mild or absent at the time of examination, you should consider illness anxiety disorder. These patients usually express excessive anxiety about the thought of possibly having a medical illness. To confirm your diagnosis, assess for the DSM-5 criteria of illness anxiety disorder.

First, the patient must exhibit excessive preoccupation with the possibility of experiencing a physical illness or symptoms. These symptoms are typically absent or mild at the time of the encounter but may have been experienced by the patient in the past.

The patient must also exhibit high levels of anxiety about health-related topics and worry about developing symptoms in the future.

Additionally, they’ll have abnormal health-related behaviors such as excessive self-examination or obsessive online research. Keep in mind, in some cases, the abnormal behavior might be avoidance of health care appointments likely due to anxiety.

If these symptoms have been present for at least 6 months, you can diagnose the patient with illness anxiety disorder.

Here’s a clinical pearl! Obsessive-compulsive disorder, or OCD, can sometimes have a health or germ related focus. If the patient reports a repeated pattern of obsessive thoughts followed by ritualized behaviors to alleviate the anxiety, consider OCD instead.

Alright, let’s move to patients who report symptoms causing significant distress at the time of the examination. In this case, an important next step is to assess for a medical or neurological condition that might be causing the symptom. The workup will depend largely on the presenting symptom. For example, sudden onset of paralysis or blindness should prompt a stroke workup, including brain imaging.

On the other hand, patients reporting symptoms like chronic fatigue should get labs such as CBC, CMP, thyroid function tests, and vitamin levels.

If your workup reveals a medical or neurological condition, diagnose the patient with the appropriate condition. Keep in mind, this does not rule out somatic symptom disorder. If the patient exhibits excessive worry about their condition, consider a comorbid somatic symptom disorder. Remember, this can occur alongside a physical illness especially if the anxiety is excessive compared to the severity of the condition.

Next, assess using the DSM-5 criteria for somatic symptom disorder. Your patient must report at least one physical symptom that causes either distress or functional impairment. However, in some cases, patients might report several different symptoms.

Additionally, they must also report one of the following abnormal thoughts or behaviors: excessive and pervasive thoughts about having symptoms, persistently high anxiety about their personal health, or excessive time spent addressing symptoms. Finally, these symptoms must be present for at least 6 months for you to be able to diagnose somatic symptom disorder