Lecture 5: Somatic Symptom Disorders

What topics are discussed?

Somatic symptoms
90% of the general population has at least one symptom per two weeks. Most symptoms are found to be not pathological. One in 40 symptoms leads to consultation of a general practitioner. This usually happens when the symptoms are of longer duration, the symptoms are aggravated, or when people are worried about the meaning of their symptoms. In 16-74% of the consultations, no explanation of the symptoms is found. This is because many symptoms can have my causes. Most people only experience symptoms for a couple of days or weeks, meanwhile in most psychiatric disorders you have to experience symptoms for some months. After medical consultation, 63-75% of the patients recover. The prevalence at the GP for somatic symptom disorder is 15.7%. The total amount of anxiety disorders is 5.5% and the total amount of depression disorders is 4.1%.

SOLK stands for Somatisch Onvoldoende Lichamelijke Klachten (insufficient physical somatic symptoms). The working hypothesis for SOLK is that somatic symptoms exist during some weeks and the symptoms are not explained by appropriate medical examination. Somatic and mental pathology are ruled out on the basis of a legitimate assumption. However, there is some criticism. For example, the time period given is quite vague (‘some weeks’), and there can be an appropriate medical examination.

About 15% of the somatic symptoms is due to somatic insufficiently explained fatigue. Somatic symptoms are said to be pathological if it lasts longer than 6 months, if the symptoms are significantly distressing, and if the symptoms are significantly disrupting daily life.

DSM V criteria

1. Somatic symptom(s) cause distress or malfunctioning
2. Excessive thoughts, feelings, or behaviour associated with somatic symptoms or worries about health, reflected in at least one of the following:
   
   1. Disproportional and persistent thoughts about symptom severity
   2. Persistent high level of anxiety about health or symptoms
   3. Excessive amount of time devoted to symptoms or health concerns

Somatic symptoms are persistent (6 months or longer).

Related disorders
Psychological factors affect other medical conditions. There are other disorders which are related to somatic symptom disorders, but there are some differences. Fears of treatment contribute to mortality or morbidity.

In Illness Anxiety Disorder, the anxiety comes first, instead of the somatic symptoms. There is a strong belief that they have a serious, life threatening illness and they worry about their health. However, there are no or only mild symptoms.

In conversion/functional neurological symptom disorder, the physical symptoms make it look like a neurological conditions. There are symptoms which affect one’s perceptions, sensations, and movement, but these are not due to a disorder. An example of what can happen is when a leg gets paralysed as a result of major stress.

In a factitious disorder, patients intentionally fabricate psychological symptoms to assume the role of patient. It is not the same as malingering. Malingering is differentiated from a factitious disorder by the intentional reporting of symptoms for personal gain, meanwhile in factitious disorder there are no obvious rewards. Besides, malingering is not related to somatic symptom disorder.

Video
A video of a Dutch man, called Rick, is shown. A couple of years ago he got fired from his job and he was suspected of fraud. It took him 7 years to deal with his in court. When showing up to a party of a colleague, he was very nervous and stressed out, because he knew that the people who would be present would think he committed fraud, meanwhile he did not. A couple days after the party, the left side of his body stopped working. He was not interested in figuring out what caused the issue. He did want to know how to solve it.

Treatment
Usually CBT is used in somatic symptoms disorders. According to CBT, symptoms develop if patients think and react in an inadequate manner to important events. In CBT the focus is on changing cognitions and behaviours. The patients’ goals are clinician support (62%), functional improvement (45%), patient coping (43%), symptom alleviation (28%), and cause identification (15%). In CBT, there is also focus on one’s self-efficacy. This is someone’s belief in their own ability to succeed in specific situations and to accomplish a task. Support is seen as the most important goal of the patients. However, likewise in the case of Rick, a lack of a joint problem definition can occur. This happens when e.g. family members want to examine the causes of the conversion disorder and the patient himself wants to examine the consequences.

The consequences model describes how somatic symptoms, beliefs, and consequences all influence one another. The model is shown on the slides. Consequences are divided in five categories. These categories are somatic consequences (muscle tension, over-breathing, physical arousal, loss of physical fitness), behavioural consequences (avoidance, over-activity, habits, medication), emotional consequences (anxiety, sadness, anger), cognitive consequences (preoccupation, selective attention, anticipation), and social consequences (role change, relationships change).

The modified consequences model describes how pain, cognitions and consequences all influence one another. This model is shown on the slides as well.

What topics are discussed which aren’t discussed in the literature?
The video about Rick and the topics about treatment are not (as excessively) discussed in the literature.

How has this topic developed over the past few years?
Like described in the previous lectures, the transition from DSM IV to DSM V has resulted in changes in the criteria.

What comments are made with regard to the exam?

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What questions are being asked which could be asked on the exam? What is the answer?

Which disorder has the highest prevalence in general practice?

1. Somatic symptom disorder
2. Anxiety disorder
3. Depression disorder

Does somatic symptom disorder also include patients whose excessive thoughts, feeling and behaviour worsen a medical condition? 

1. Yes
2. No