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Somatic Symptom Disorders

DSM-5 includes a category called somatic symptom disorders. This is a label for distress over bodily symptoms that may or may not be due to an under­lying medical disorder. Regardless, they cause a person to be excessively concerned, preoccupied, or fearful.

People with this disorder are seldom pleased with medical treatment. "Al­though patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate." ("DSM-5 redefines hypochondriasis", 2017).

The classification is based on distress over physical symptoms, not a judgment about whether underlying medical problems are imagined or real. Health concerns play a central role in such a person's life.

What is somatic symptom disorder?

Somatic symptom disorder replaced a disorder in previous versions of the DSM called somatization disorder. A person with a somatization disorder had many vague medical complaints, but repeated medical investigations revealed no known physical cause.

Diagnosing that disorder required "proving a negative" which is logically impossible (for example, one cannot prove that Santa Claus does not exist). The new diagnosis of Somatic Symp­tom Disorder puts the emphasis on distressing symptoms, which are known to exist, rather than proving there is no underlying disorder.

Prior to DSM-5 it was said that somati­zation disorder frequently in early child­hood or adolescence. The new definition of somatic symptom disorder (SSD) specifies that it begins before age 30.

SSD commonly involves multiple complaints, such as headaches, dizziness, chest pain, abdominal pain, and limb pain. If the only complaint is pain, it is categorized as SSD with Predominant Pain.

Under DSM-5, the symptoms need not be medically unexplained (as in the old somatization disorder) but they must be disproportionate or excessive. That is a judgment call, but the guidelines in DSM specify six months or more of distressing or disrupting symptoms, severe enough to require medical intervention.

The common element in cases of SSD is excessive concern over the body or health. Whether or not there are psych­ological causes of the disorder, the sufferer seeks medical help first.

Commonly a person with this disorder has spent considerable time in the medical system, bouncing between different clinics or specialists, before coming to the attention of a psychiatrist. Effective treatments include CBT (cognitive behavior therapy).

What is hypochondriasis?

Hypochondriasis was previously defined as an obsession with imagined illnesses. It was characterized not by a fear of sickness but a certainty one is sick.

Hypochondriasis was replaced in DSM-5 with illness anxiety disorder. This took the focus off proving a negative (doctors no longer need to prove there is no real illness) and put the emphasis on the patient's distress and how to deal with it.

A person with illness anxiety disorder is intensely anxious about the possibility of an undiagnosed illness. He or she may research the illness obsessively, despite mild or absent symptoms.

DSM-5 defines a "care-seeking type" and a "care-avoidant type" of illness anxiety disorder. A care-seeking type may become a doctor shopper looking for a physician willing to confirm the suspected diagnosis.

Mild versions of hypochondria are widespread in the normal, non-clinical population. So-called closet hypochon­driacs are health-conscious individuals who may perform daily self-checking rituals that consume hours.

They examine their bodies in detail, looking for lumps or other signs of disease, monitoring the frequency and quality of their bowel movements, and otherwise administering to themselves. They tend to become involved in health fads. Meister (1980) reported another characteristic trait:

What sorts of things do "closet hypochondriacs" do?

...One common denominator of the hypochondriac personality has been noted by observers almost without exception: hypochondriacs are highly unsure of themselves, and they live in a striking dependency relationship to a parent or parent substitute.

What is distinctive about conversion disorder?

A conversion disorder occurs when physical symptoms make no medical sense, but there is a symbolic relation­ship between physical symptoms and a trauma. For example, a person with normal eyes suddenly goes blind after witnessing a traumatic scene.

Typically the physical symptoms of a conversion disorder involve a loss of functioning. For example, a limb may become paralyzed, or a person may lose the ability to use one of their senses.

One student had an uncle who "made himself deaf" to avoid recurrent memories of war sounds. His case would now be diagnosed as post-traumatic stress disorder (PTSD). The student wrote:

My uncle was one of the men who went to the Vietnam War and was fortunate enough to come home alive. He was not quite the same person that he was when he left, though. You see, there were times when he would have flash­backs of what I guess were bad experiences.

These, at first, were very mild. Even though they were being treated, as time went by they got worse (or so it seemed to all of us). I never heard him say so myself, but my other uncles said that he claimed to hear people screaming over and over and loud war-like sounds. When this happened he would go into a mental hospital in Missouri.

We were later informed that he was losing his sense of hearing without a reason. That didn't mean much to me before but after reading this chapter, I realized that maybe he made himself go deaf in order not to hear these sounds he heard.

Unfortunately his deafness did not prevent what he was hearing, which was all in his mind. His sight was also being affected but he never really went blind. About six months later my uncle committed suicide. [Author's files]

What treatments often work with conversion disorder?

Conversion Disorder often responds well to treatments that emphasize belief or involvement of imagination, such as hypnosis and placebo treatments. An example is the case of "Anna O." described in Chapter 13.

Somatic Symptom Disorder with Primary Pain was formerly known as pain disorder. It is chronic (long-term) pain without known biological cause. The disorder often starts with a genuine injury but continues after wounds are healed.

In some cases, pain is a learned response. (We saw in Chapter 4 how it is strongly influenced by psychological factors.)

Behavior therapies based on unlearning pain have been very successful in eliminating long-term, chronic pain. However, they typically involve discon­tinuing social reinforcement of pain complaints, and they require phasing out pain medications, so drop-out rates from these programs are high.

In recent years, new attention has been paid to the unintended consequences of pain treatment with opiate drugs. The phenomenon of opioid-induced hyper­algesia was described in Chapter Two.

People who receive opiate medications for pain can actually become more sensitive to pain and less able to bear it. Weaning such patients off opiates is necessary to eliminate chronic pain.

Newly added to the category of somatic symptom disorders are factitious disorders. These are people who fake their problems, aiming to achieve the patient role.

Motives range from "addiction to the patient role" to attempts to gain attention or access to drugs. Spitzer, Forman and Nee (1979) describe factitious patients this way:

Such patients are frequently hostile, demanding treatment. They show no obvious anxiety and can switch their symptoms on or off at will. This category is one of the hardest to diagnose because the patients are masters at deception (Spitzer, Forman and Nee, 1979).

What are factitious disorders?

Patients with Munchausen syndrome seek to gain admission to hospitals. One famous example, Stewart McIlroy, man­aged 207 admissions in 68 hospitals, costing the British taxpayers several million pounds through charges to the national health insurance system.

Munchausen syndrome is classified in DSM-5 as "factitious disorder imposed on self." Frequently such people have an expert knowledge of medical symptoms, including those most useful for gaining admission to a hospital.

What widely reported case brought Munchausen syndrome by proxy to public attention?

"Factitious disorder imposed on another" (or factitious disorder by proxy) is the new name for the disorder previously called Munchausen syndrome by proxy. This is a situation in which one person makes another person sick deliberately to gain attention or engagement with the medical system.

The person who practices the deception is the one diagnosed with the disorder. The victim is often a child or elderly person.

The syndrome was highlighted in the United States media in 1996 when a mother in Florida, whose child suffered from a long string of medical problems, was found to be causing the problems deliberately. Authorities charged that she had injected fecal matter into the daughter's intravenous tubing.

Apparently the motivation was the public attention that the woman and her daughter received. For example, she was able to obtain a photograph of herself and her wheelchair-bound daughter standing next to the President's wife during a hospital fund-raiser.

What is the difference between malingering and factitious disorders?

Malingering occurs when a person acts sick for ulterior motives such as collect­ing insurance money or escaping from a bad situation at home or school. Unlike factitious disorders, malingering is not an addiction to the patient role.

Malingering is described under factitious disorders in DSM-5 but is not treated as a diagnostic category. It requires legal rather than clinical attention.

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References:

"DSM-5 redefines hypochondriasis" (2017, February 3) Mayo Clinic Clinical Updates. Retrieved from: http://www.mayoclinic.org/medical-professionals/clinical-updates/psychiatry-psychology/diagnostic-statistical-manual-mental-disorders-redefines-hypochondriasis

Meister, R (1980, January). Closet hypochondriacs. Psychology Today, pp.28-37

Spitzer, R. L., Forman, J. B., & Nee, J. (1979). DSM-III field trials: I. Initial interrater diagnostic reliability. American Journal of Psychiatry, 136, 815-817.


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