AssessmentsSomatic symptom disorders: Clinical practice
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 25-year-old woman comes to the clinic because of abdominal, shoulder, and head pain for the past year. This is her first time being seen at this clinic, but she brings copies of her medical charts from 3 other clinics, all within the past year. She states that the three other physicians were unable to diagnose her, “even though they ran all kinds of laboratory tests and scans.” She states that she may be fired from her job for missing too many days at work to attend medical visits. She does not like to take pain medication and really wants to be diagnosed “before it is too late.” Temperature is 37.0°C (98.6°F), pulse is 70/min, respirations are 10/min, and blood pressure is 126/78 mm Hg. Physical examination shows no abnormalities. Routine laboratory studies are within normal limits. Which of the following is the most likely diagnosis?
Content Reviewers:Rishi Desai, MD, MPH
Somatic symptom disorders, formerly known as somatoform disorders, are unexplained physical symptoms that are recurrent and cause significant distress and impairment to someone’s daily life.
The exact cause of somatic symptom disorders isn't clear, but there may be biological causes like having an increased sensitivity to pain.
Many symptoms are also affected by a person’s emotional response to symptoms - so they’re affected by attitude and personality.
Some conditions may also be learned behaviors like learning that being sick attracts attention. And this can especially happen when a person develops the condition in early childhood.
Somatic symptom disorders are more commonly seen in people with a history of substance abuse, anxiety, and depression.
Somatic symptoms can be wide-ranging like pain, tingling, shortness of breath, to general fatigue and weakness.
In somatic symptom disorder, the history, physical exam, test results, and imaging are either normal or don’t explain a person's symptoms.
Often, in addition to the symptoms themselves, individuals have a lot of anxiety about the symptoms.
The complaints are recurrent and should occur for at least six months.
Finally, the symptoms should not be better explained by another mental disorder, and it should cause significant distress or impairment in all areas of functioning.
The seven conditions in the category in DSM-5 called somatic symptom and related disorders include somatic symptom disorder, illness anxiety disorder, conversion disorder, psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and finally, unspecified somatic symptom and related disorder.
The most studied condition in this category is somatic symptom disorder.
First, individuals must have at least one somatic symptom which causes significant interference with daily life.
Second, they must have persistent and excessive thoughts, feelings, or behaviors related to the somatic symptoms as shown by at least one of the following three features: disproportionate thoughts about the seriousness of the symptoms, major anxiety about health or symptoms, and devoting excessive time and energy to them.
For example, one might feel a dull pain in the right forearm and might spend hours thinking that they have cancer.
Lastly, although the somatic symptom may not be permanent, it should appear and reappear for more than 6 months.
Second, is illness anxiety disorder.
The first criterion is a preoccupation with having or developing a serious illness.
Second, there should be no somatic symptoms, or only mild somatic symptoms.
Third, if the individual does suffer from a medical condition or is at risk for developing one, there should be an excessive preoccupation with the condition.
Fourth, there must be a lot of anxiety regarding health, and individuals should be easily alarmed about their health.
Fifth, individuals should perform excessive health-related behaviors like repeatedly checking their body for signs of illness, or, alternatively, they avoid situations that make them confront their illness like doctor appointments and hospitals.
Next, the illness preoccupation must occur for at least 6 months, even if the illness they believe they have changed over time.
So next up is conversion disorder, also known as functional neurological symptom disorder.
First, one or more symptoms is related to voluntary movement or to the sensory function like sight and hearing.
Second, the symptom should not be due to a known medical condition. For example, one might feel weak and fatigued only when they are wearing shorts, but have no trouble when wearing pants, with no other psychological symptoms or findings.
Fourth, are psychological factors affecting other medical conditions.
The diagnosis requires a medical symptom or condition that is negatively affected by psychological or behavioral factors like anxiety and depressive mood, in one of the following four ways.
First, the psychological factors appear at the same time as the medical condition or appear soon after, and delay the recovery. For example, the individual might feel anxiety associated with taking medication, which might lead to poor treatment adherence.
Second, the psychological factors interfere with the treatment of the medical condition.
Third, the psychological factors must worsen the condition.
And fourth, psychological factors must influence the underlying pathophysiology, and precipitate or exacerbate symptoms. For example, if the individual suffers from obstructive lung disease, having anxiety can worsen the condition by leading to shortness of breath.