Changes from DSM-IV to DSM-V
- The classification “Somatoform disorder” has been renamed “somatic symptom and related disorders”
- The total number of disorders has been reduced (some have been moved to other categories)
- Somatic symptom disorder, formerly “somatization disorder”
- The patient need only have one or more somatic symptoms distressing him/her, rather than 4 pain symptoms, one sexual symptom and one pseudo-neurological symptom
- “Pain disorder” as its own entity has been abolished and is now a specifier in somatic symptom disorder (Somatic symptom disorder w/predominant pain)
- Illness anxiety disorder, “formerly hypochondriasis”
- The term hypochondriasis had a negative connotation. Also Illness anxiety to stress that it is an anxiety disorder.
- Can be diagnosed in patients with objective symptoms, provided “the preoccupations clearly excessive or disproportionate” (B)
- Requires that the patient “performs excessive-health related behaviours or exhibit maladaptive avoidance” (D)
- Care-seeking type vs. care-avoidant type
- Conversion disorder
- Body dysmorphic disorder is now classified under “obsessive-compulsive and related disorders”
General Principles
The patient reports physical sx that cannot be explained by a general medical condition or is disproportionate to their general medical condition. Objective testing is normal. Sx interferes with the patient’s quality of life.
Slightly more common in women.
Frequently comorbid with anxiety disorders. Idiopathic (makes it difficult to treat, hence greatly relies on psychotherapy). Diagnosis of exclusions (big medical-legal issues, make sure you r/o actual GMCs/drugs).
| Sx production | Motivation | |
|---|---|---|
| Somatic symptom disorder | Subconscious | Subconscious |
| Illness anxiety disorder | Subconscious | Subconscious |
| Conversion disorder | Subconscious | Subconscious |
| Factitious disorder | Conscious | Subconscious |
| Malingering | Conscious | Conscious |
Unconsciously generated symptoms
Somatic symptom disorder (SSD)
Characterized by a somatic sx that is distressing resulting in a significant disruption of daily life. Diagnosis of exclusion.
- Differentials
- Multiple sclerosis: Visual deficits and eye pain are key, and may need MRI to exclude
- Many other differentials based on specific sx
- Treatment
- Coordinate care with regularly scheduled visits to one primary physician
- Individual psychotherapy
Somatic symptom disorder, with predominant pain
Formerly pain disorder is Characterized by chronic pain in one or more areas that is not explained by a general medical condition. PAIN will be a prominent company. May follow an actual Px trauma but pain will persist after healing. Analgesics are not helpful.
- Comorbidities
- MDD
- Dysthymia
- Differentials
- Fibromyalgia: pain associated with specific trigger points
- Somatic sx disorders: will have a specific complaint not associated with pain
- Treatment
- Validate the patient’s complaints
- Individual psychotherapy
- Biofeedback
- SSRIs
Conversion disorder (CD)
Characterized by one or more neurological sx that cannot be explained by a general medical condition. Diagnosis of exclusion
- La belle indifference
- The beautiful indifference – pt is calm and unconcerned when describing sx (unlike SSD)
- The patient complains of sudden left-sided hemiparesis but is completely okay with it…
- Signs and Symptoms
- Deafness, blindness, or mutism (more common)
- Seizures
- Poor coordination
- Paralysis not fitting w/a specific anatomical injury (MCA stroke, SCI etc.)
- Hysteria
- A historical diagnosis that describes exhibiting overwhelming or unmanageable fear or emotional excess. No longer recognized as a psychiatric diagnosis
- Mass conversion disorder (mass hysteria)
- Mass conversion disorder is the rapid spread of conversion disorder without an organic basis among a group of people.
- Differentials
- Brain tumour
- Dementia
- Optic neuritis
- Myasthenia gravis
- SLE
- Malingering
- Other differentials based on presentation
- Treatment
- Reassure the pt
- Individual psychotherapy (focused on reducing anxiety)
Illness anxiety disorder (IAD)
Characterized by intense preoccupation for at least 6 months with a particular sx or sxs despite repeated professional reassurance.
- Differentials
- Delusional disorder, somatic type: preoccupation will be bizarre
- SSD: IAD is more fixated on the anxiety of the ramifications
- Treatment
- Reassureance with regularly scheduled visits
- Psychotherapy
Pseudocyesis
Pseudocyesis is a disorder in which the patient has physical signs of pregnancy but is not in fact actually pregnant
Couvade syndrome AKA “sympathetic pregnancy” is a disorder where the expectant father experiences some of the same symptoms and behavior as his pregnant partner.
Consciously generated symptoms
Factitious disorder
Characterized by conscious production of sx, but not for secondary gain (financial assistance, shelter, welfare, pain meds, disability, sick leave etc.). Often assume a “sick role” and have attention.
- Munchausen syndrome
- From the fictional Baron Munchausen. The patient describes symptoms in dramatic ways. An extraordinary story with missing records and pseudologia fantastic (self aggrandising lies)
- Common in single males 40 years of age with cluster B disorders (especially Antisocial PD)
- Munchausen syndrome by proxy
- Mother vs child
- Health worker vs patient
- Munchausen syndrome by internet
- The patient fakes illness and attaches themselves to an online support group
- Differentials
- Malingering: motivation is for a secondary gain
- Treatment
- Psychotherapy
Malingering
Characterized by the conscious production of sx in order to obtain a secondary gain. NOT A DISORDER, also not a diagnosis.
- Treatment
- Gentle guidance and polite dialogue (avoid direct and blunt confrontation as it may raise a security threat)
- Do not provide secondary gain