somatic symptom disorders

**Core concept:** Patients experience real (not feigned) physical symptoms or health fears that are out of proportion to medical findings, causing distress and impairment. Symptoms are NOT consciously produced for gain. Diagnosis rests on positive psychological features (excessive thoughts/anxiety/time devoted), not merely the absence of a medical explanation. Medical illness can coexist.

**DSM-5 categories:** 1. **Somatic symptom disorder (SSD):** ≥1 distressing somatic symptom + excessive thoughts, anxiety, or time/energy devoted to symptoms, persistent (typically >6 months). Replaces old somatization and hypochondriasis (with prominent symptoms) and pain disorder. Symptoms may be present in any organ system (pain is most common). Associated with depression and anxiety. 2. **Illness anxiety disorder:** Preoccupation with having or acquiring a serious illness; somatic symptoms are absent or mild; high health anxiety and excessive health-related behaviors (repeated checking, doctor shopping) or avoidance. Duration ≥6 months. Formerly hypochondriasis. 3. **Conversion disorder (functional neurological symptom disorder):** One or more altered voluntary motor or sensory symptoms (paralysis, blindness, aphonia, pseudoseizures, gait disturbance, numbness) incompatible with recognized neurological disease. Often follows a psychological stressor. Exam shows inconsistency (e.g., Hoover sign, normal reflexes, normal EEG during pseudoseizure, no injuries). Classically "la belle indifférence" (inappropriate lack of concern), though not specific. More common in young women; usually self-limited. Treatment: reassurance, PT, CBT, psychotherapy. 4. **Psychological factors affecting other medical conditions:** Psychological or behavioral factors adversely affect a real medical illness (e.g., anxiety worsening asthma, nonadherence in diabetes). 5. **Factitious disorder:** Intentional feigning/production of symptoms to assume the sick role (primary gain), without external reward. *Imposed on self* (Munchausen syndrome) or *imposed on another* (by proxy; e.g., caregiver harming child; report to child protective services).

**Key differentiators (high-yield):** - **Malingering:** Conscious feigning for external/secondary gain (money, avoiding work/jail, drugs). Not a psychiatric disorder (V code). Suspect with legal issues, noncompliance, antisocial personality. - **Factitious disorder:** Conscious feigning, but motive is the sick role (internal/primary gain). Often healthcare workers. - **Somatic symptom, illness anxiety, and conversion disorders:** Unconscious production; not intentional. - **Illness anxiety vs SSD:** Illness anxiety has few or no symptoms but high anxiety; SSD has prominent symptoms. - **Conversion vs neurological disease:** Look for inconsistency, symptoms that don't follow anatomical distribution, normal workup. - **Related older terms:** Somatization disorder (Briquet syndrome) required multiple symptoms across several organ systems (pain, GI, sexual, pseudoneurologic).

**Management:** - Establish a strong, long-term relationship with a **single primary care physician**. - Schedule regular, brief, **fixed-interval visits** (not symptom-contingent). - Avoid unnecessary tests, procedures, and opioids/benzodiazepines. - Acknowledge symptoms as real and validate the patient. - **CBT** is first-line psychotherapy; treat comorbid depression/anxiety (SSRIs, SNRIs; TCAs can help with pain). - Conversion disorder: reassurance, symptom resolution is usually spontaneous; PT/OT, psychotherapy. - Factitious disorder: Nonconfrontational approach, psychiatric referral; manage with supportive psychotherapy.

**Clinical pearls for boards:** - Stem clues: multiple unexplained complaints, many normal workups, frequent ED/doctor visits, patient distressed and convinced of illness. - Next best step for SSD: schedule regular follow-up visits with the same physician (not more testing, not confrontation). - Do not tell the patient the symptoms are "all in your head." - Comorbidity: depression, anxiety, personality disorders, history of childhood trauma/abuse. - Epidemiology: SSD more common in women, lower SES, and those with trauma history. - Distinguish from **body dysmorphic disorder** (OCD spectrum; preoccupation with perceived appearance defects) and **panic disorder**/**depression** with somatic complaints.