What is Somatic Symptom Disorder? - Chapter 13

How can Somatic Symptom Disorder be characterized and diagnosed?

Somatic symptom disorders are characterized by psychological problems that manifest as physiological distress or psychological distress caused by physiological symptoms or characteristics. The DSM-5 criteria are:

• Demonstrate at least one somatic symptom for at least six months that causes distress or disruption in daily life
• Unwarranted thoughts, feelings, or behaviors related to the somatic symptoms or associated with health concerns, manifested in at least one of the following:

1. Disproportionate and persistent thoughts about how serious the symptoms are
2. Constant high levels of anxiety about the symptoms or health in general
3. Devoting unnecessary amounts of time and energy to the symptoms or health concerns.

The lifetime prevalence of somatic symptom disorders is estimated to be around or just above 1%. These disorders are strongly related to other psychiatric diagnoses, such as anxiety disorders and depression.

What is Illness Anxiety Disorder?

Individuals with an anxiety disorder have a preoccupation with fear of having a serious illness through misinterpretation of physical signs and symptoms. This disorder was first known as hypochondriasis, but the criteria for this were different (DSM-IV-TR). Approximately 75% of people diagnosed with hypochondriasis are re-diagnosed with an anxiety disorder based on the DSM-5. The DSM-5 criteria for this disorder are:

• Obsession with having a serious illness
• Somatic symptoms are mild or absent
• High level of anxiety about health and easily worried about health
• Performs excessive health checks or shows maladaptive avoidance
• The illness preoccupation has been present for at least six months
• The symptoms are not better explained by another mental disorder

The lifetime prevalence of hypochondriasis has been estimated at 1% to 5%.

What is Conversion Disorder?

In conversion disorder, psychological symptoms or impairments affect voluntary motor and sensory functions, which would indicate an underlying medical or neurological condition. The DSM-5 criteria for this disorder are:

• At least one symptom of altered voluntary and sensory function;
• Evidence of incompatibility between the symptoms and known neurological or medical conditions;
• The symptoms are not better explained by another mental disorder; and
• The symptoms cause distress or impairment in key areas of function.

Common motor symptoms include paralysis and imbalance. Common sensory symptoms include loss of pain sensation and deafness.

Glove anaesthesia is a symptom where numbness begins in the wrist and is experienced evenly in the hand and all fingers. Individuals also often show la belle indifference, meaning they are indifferent to the real symptoms, especially if the symptoms are distressing to others. In psychodynamic circles, conversion disorder was also known as hysteria. The lifetime prevalence of conversion disorder is estimated to be less than 1%. There are significantly more women than men with the disorder.

What is Factitious Disorder?

A factitious disorder is a set of physical or psychological symptoms that are deliberately produced to assume a disease role. DSM-5 criteria for this disorder are:

• Making up physical or psychological symptoms or signs of an injury or illness
• presenting oneself to others as ill or injured
• The cheating is obvious, despite no clear reward
• The behavior is not better explained by another mental disorder, such as delusional disorder.

What drives caregivers and parents to deliberately cause illness, pain, and sometimes even death when they suffer from a factitious disorder imposed on another? Often these people are emotionally needy and need attention and praise. This is what they get when they behave caringly and lovingly towards their sick child. They often have a great deal of knowledge about drugs and medical procedures, which allows them to cause the disease without being suspected.

What is the aetiology of Somatic Symptom Disorders?

Four questions are important in explaining these disorders:

1. Are physical symptoms a manifestation of underlying psychological conflict and stress?
2. Were physical symptoms produced in an involuntary way?
3. What is the role of childhood stress and abuse in the development of the symptoms?
4. How do clients get the distorted thinking and dysfunctional beliefs about health that perpetuate the symptoms?

What are the psychodynamic interpretations?

The basis of the psychodynamic view of somatic symptom disorders is conflict resolution, in which disturbing memories, inner conflict, fear, and unacceptable thoughts are suppressed in the conscious mind, but emerge outwardly as somatic symptoms. However, the idea that expressing the symptoms would relieve anxiety or conflict management does not seem to be correct. There is a high degree of anxiety involved in somatic symptom disorders.

What about consciousness and behaviour?

There seems to be a dissociation between an individual's behavior and their awareness of that behavior. In conversion disorder, the client genuinely appears to be experiencing no sensory input, although research has shown that they can experience it but are unaware of it. An old-fashioned explanation for this is also that attention narrows after experiencing a trauma. Oakley shows that there are many similarities between the behavior of somatic symptom disorders and hypnosis: a therapeutic technique in which a patient is put into a trance. In both situations, there is no voluntary control over movements and sensations.

What are risk factors for somatic symptom disorders?

Important risk factors are trauma or abuse or periods of severe stress and anxiety. For example, childhood trauma increases the vulnerability for developing conversion disorder. Family factors such as parents with somatization characteristics and insecure attachment are also risk factors for developing somatic symptom disorders. However, all the factors mentioned are risk factors in all kinds of different forms of psychopathology.

What learning approaches are there?

Many individuals learn to interpret emotional symptoms as indications of physical illness. First, many individuals have family members with an illness who express negative feelings about it, which can be replicated by modeling. Second, expressing emotional symptoms of illness can be reinforced by parents. For example, parents can view underlying psychological problems as physical and encourage their children to express them in this way. As a result, an individual may finally assume a so-called disease role in extreme cases. In this, the role of being ill as determined by the society to which the individual belongs is played. Taking on this role can become a coping style to help cope with adult life.

What are the cognitive factors?

Somatic symptom disorders are perpetuated by several factors:

• Attentional biases towards physical threats
• Interpretational biases: cognitive biases in which an individual interprets ambiguous events as threatening and as evidence of possible negative outcomes
• Memory bias: a bias toward recalls and retrieval of disease-relevant material
• Reasoning bias: Individuals with illness anxiety disorder tend to reject diagnoses that are inconsistent with their own beliefs about their health. They will continue to look for other options on the assumption that someone will eventually agree with their own view
• Catastrophizing symptoms.

However, these things do not explain how these biases are acquired. Brown argues that 'rogue representations' are developed, which form inappropriate models through which information about body shapes and health are selected and interpreted. These representations can be created by past illnesses, by having experienced emotional states in the past with strong physical manifestations (anxiety is associated with tremors), and by exposure to illness in others, creating a memory model through which one's own physical sensations are interpreted turn into.

What are the sociocultural approaches?

Sociocultural factors appear to influence both the prevalence and nature of somatic symptoms. In some cultures, expressing physical pain is an accepted way to communicate psychological distress, and in such cultures the prevalence of somatic symptom disorders tends to be higher as well. In addition, with conversion disorder there is something known as 'contagion' where the symptoms affect different people in the same social setting or social group.

What are the biological factors?

It is known that a percentage of people with conversion disorder actually have medical conditions that may contribute to the disorder and that individuals with somatic symptom disorder often have a history of illness in their family.

Twin studies suggest that there appears to be a genetic component that contributes to the development of somatic symptom disorders. However, more research is needed into the genetics.

Brain research suggests that sensory information goes to the right brain areas but is not registered in consciousness. In addition, there appears to be a relationship between somatic symptom disorders and increased activity in areas associated with unpleasant bodily sensations, reducing the tendency to be aware of these sensations.

How can somatic symptom disorder be treated?

One of the main problems with treatment is that there is often a long period of medical treatment first, because somatic symptoms manifest themselves as physical or medical symptoms. This can provide anchoring of the symptoms and resistance to psychological therapy. In addition, somatic symptom disorders are highly comorbid with anxiety disorders and depression, raising the question of exactly what causes what.

What is psychodynamic therapy?

Psychodynamic therapy uses procedures designed to bring repressed thoughts and memories to consciousness so that they can be dealt with effectively. However, symptoms are quite resistant to the psychodynamic approach. However, it is more effective than no treatment and the greater the therapist's competence, the more successful the treatment.

What is behaviour therapy?

Since the attention that the individual's environment often has on the symptoms, thereby perpetuating them, the family, among others, is often asked to stop giving this attention. In addition, relaxation training and behavioral techniques are often useful in reducing the anxiety the individual has about the symptoms. This form of behavioral stress management appears to be effective.

What is Cognitive Behaviour Therapy?

CBT is an effective form of therapy for treating dysfunctional beliefs and thought patterns, especially in an anxiety disorder. It is more effective than normal medical help, but not more effective than other treatments such as gradual muscle relaxation. The first results of research with mindfulness-based cognitive therapy show that this form is more beneficial than CBT.

How can drug treatments be used?

Drug treatments use pharmacological treatments to relieve symptoms of psychopathology. In somatic symptom disorders, antidepressants (tricyclic antidepressants, SSRIs and SNRIs) have been shown to be most effective.