Approach to somatic symptom and related disorders: Clinical sciences

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Introduction 0:00–0:41

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.

Focused H&P 0:41–1:19

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.

Illness Anxiety Disorder 1:19–2:39

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.

Somatic Symptom Disorder 2:39–5:25

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 Here’s a clinical pearl!
If a patient expresses high health related anxiety along with excessive worry in multiple other areas of life, consider evaluating for a generalized anxiety disorder instead.
Alright, let’s go back to our medical and neurological workup, and discuss cases when there are no conditions that explain the patient’s symptoms.
Your next step here is to assess the possibility of primary and secondary gain, where the patient fabricates symptoms intentionally for some sort of benefit.
Primary gain describes a benefit that is internal and psychological. For example, a patient who believes they get extra care or affection if they are ill.
On the other hand, secondary gain refers to external benefits like monetary compensation or time off work due to their illness.
If a patient has no obvious primary or secondary gain from their symptoms, assess for neurologic symptoms including altered function of voluntary muscle such as weakness, paralysis, abnormal limb movements; or sensory dysfunction like numbness or blindness.
If these neurologic symptoms are absent, consider somatic symptom disorder and assess the DSM-5 criteria. If the criteria are met, diagnose somatic symptom disorder.
If, on the other hand, the neurologic symptoms are present, but workup does not reveal any underlying medical conditions, consider functional neurological symptom disorder, previously known as conversion disorder.

Functional Neurological Symptom Disorder 5:25–7:14

To confirm your diagnosis, assess the patient using the DSM-5 criteria. First, they must have at least one symptom involving voluntary motor or sensory function.
Voluntary muscle dysfunction can present as a tremor, weakness, paralysis, gait disturbance, or even seizure like limb movements.
Sensory dysfunction includes numbness, paresthesia, visual changes, hearing loss, or change to taste or smell. Additionally, there must be clinical evidence that the symptoms are incompatible with a recognized medical condition.
This could be from inconsistent exam findings, specific findings that rule out a neurological condition, or a negative workup for neurologic diseases.
Finally, the symptom must cause either distress or impairment. If all of these are present, you can diagnose functional neurological symptom disorder.
Let’s take a break with a clinical pearl! During your examination, look for signs that indicate neurological symptoms are psychogenic.
An example is a positive Hoover sign, which is weakness of ankle plantarflexion seen on isolated physical exam of the leg, but not seen when patient is walking.
Similarly, patients with seizure-like activity who resist your attempt to open their closed eyes or remain alert and conscious during an episode are likely experiencing psychogenic seizures rather than epileptic seizures.
Psychogenic nonepileptic seizures, or pseudoseizures, are one specific example of functional neurologic symptom disorder.
Finally, let’s go back to your assessment of primary or secondary gain. If either of these are clearly present, consider an alternative diagnosis like factitious disorder.

Consider Alternative Diagnosis 7:14–8:40

In this condition, patients intentionally create symptoms or abnormal exam or laboratory findings in themselves or others, despite having no obvious secondary gain.
This condition was previously called Munchausen disorder, if the patient inflicted symptoms on themselves, or Munchausen by proxy if symptoms were inflicted on another person.
Another alternative diagnosis to consider is malingering, where the patient is fabricating symptoms for an external benefit.
Only diagnose this if you are absolutely certain the patient is fabricating for an external benefit. Here’s one more clinical pearl!
Patients with illness anxiety disorder, somatic symptom disorder, or functional neurological symptom disorder do not intentionally create their symptoms.
Rather, physical symptoms in these conditions often result from internalized anxiety, subconscious conflict, or anxious misinterpretation of normal body sensations.
Make sure to work up new or concerning symptoms as you would in a patient without a somatic symptom or related disorder.
In addition, regularly scheduled appointments to offer gentle reassurance and address the patient’s concerns are important elements of clinical management.
In severe cases, you can consider referral to psychotherapy or treatment with antidepressants. Alright, as a quick recap...

Review 8:40–9:26

Somatic symptom and related disorders are diagnosed when patients report physical symptoms and abnormal thoughts or behaviors about their symptoms.
With mild or absent symptoms, consider illness anxiety disorder. However, if symptoms are causing distress, assess for medical or neurological conditions.
If you find any, diagnose the appropriate condition and if the patient exhibits excessive worry about their condition, consider a comorbid somatic symptom disorder.
If there are no conditions that can explain their symptoms, assess for primary and secondary gain. If both are absent, and there are no neurological symptoms, think somatic symptom disorder, but if you find any neurological symptoms consider functional neurological symptom disorder instead.