Nov. 15, 2013 Show
The newly approved Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains many revisions, but few are as sweeping as those involving somatoform disorders. In the updated edition, hypochondriasis and several related conditions have been replaced by two new, empirically derived concepts: somatic symptom disorder and illness anxiety disorder. They differ markedly from the somatoform disorders in DSM-IV. To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful. These fears and behaviors cause significant distress and dysfunction, and although patients may make frequent use of health care services, they are rarely reassured and often feel their medical care has been inadequate. Patients with illness anxiety disorder may or may not have a medical condition but have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them. Like people with somatic symptom disorder, they are not easily reassured. Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels. Freeing patients and doctorsThe new classifications have been criticized as overly broad and likely to lead to increased mental health diagnoses in the medically ill. But Jeffrey P. Staab, M.D., of Mayo Clinic in Minnesota, who participated in the somatic symptom disorder field trials, argues that the opposite is the case. "People who have reasonable health concerns will not get the diagnosis," he says. "By eliminating the concept of medically unexplained symptoms, the DSM-5 criteria prevent the easy assumption of a psychiatric diagnosis in patients who present with medical symptoms of unclear etiology." He points out that thousands of patients were diagnosed with stress ulcers before the discovery of Helicobacter pylori. "There are many examples of false assumptions because we couldn't identify a medical problem. Now, the whole concept of medically unexplained symptoms is gone. This is a profoundly fundamental change." Dr. Staab adds that it is a change welcomed by patients. "Health anxiety and body vigilance are much more understandable to patients when they realize they can have these things despite what their medical doctor finds. During the field trials, we found it much easier to engage patients if we identified what the problem was instead of what it was not," he says. He argues that the new constructs are liberating for physicians, too. "Under the old scheme, we never knew if we had done enough. When we couldn't find the cause of certain symptoms, there was always the fear that we simply hadn't searched long enough or hard enough. Now we can acknowledge that a patient's preoccupation with physical symptoms is higher than normal, whether there is a diagnosis or not. It is one of the biggest changes in talking with patients with a set of psychiatric problems in 25 years." The change has been long in coming, Dr. Staab says. "It has taken two decades of research to redefine hypochondriasis. This is not just something people came up with. But now we can identify these symptoms in a positive way and can help patients modify them." Indeed, the new diagnostic criteria allow a different approach to treatment. Most psychiatrists assume that some sort of trauma, tragedy or conflict in the past is driving health-anxious fears and behaviors, Dr. Staab says. "And if we can't find it, and the patient can't find it, it can become a speculative wild goose chase for trauma. Trauma is more likely in these patients, but if we don't find a history of trauma, we can look at stress, and if we don't find that, we can still talk about exaggerated preoccupations with health and help patients reset and reframe that without digging around in the past." The latest edition of DSM 5 has moved away from the need to have no medical explanation in order to make the diagnosis of ‘medically unexplained symptoms’ and gain access to appropriate treatment. The emphasis now is on symptoms that are substantially more severe than expected in association with distress and impairment. The diagnosis includes conditions with no medical explanation and conditions where there is some underlying pathology but an exaggerated response. ‘The major diagnosis in this diagnostic class, Somatic Symptom Disorder, emphasises diagnosis made on the basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviours in response to these symptoms) rather than the absence of a medical explanation for somatic symptoms. A distinctive characteristic of many individuals with somatic symptom disorders is not the somatic symptoms per se, but instead the way they present and interpret them.’(APA, 2013) A new category has therefore been created under the heading ‘Somatic Symptom and Related Disorders’. This includes diagnoses of Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder, Factitious Disorder, and a variety of other related conditions. The term ‘Hypochondriasis’ is no longer included. In two of the conditions the absence of any medical pathophysiology is a criteria for diagnosis; these are Conversion Disorder and Other Specified Somatic Symptom and Related Disorder (which includes Pseudocyesis, a false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy). Somatic Symptom DisorderThe diagnostic criteria for Somatic Symptom Disorder noted in DSM 5 are:
Specify if: With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain. Specify if: Persistent: a persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months). Specify if: Mild: Only one of the symptoms specified in Criterion B is fulfilled. Moderate: Two or more of the symptoms specified in Criterion B are fulfilled. Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom). The expected prevalence of Somatic Symptom Disorder stated in DSM 5 is higher than that for Somatization Disorder (<1%) but lower than that of Undifferentiated Somatoform Disorder (19%). Both are more common in women. Nevertheless, the term Somatic Symptom Disorder is considered by DSM 5 to be broadly equivalent to ICD10 F45.1 and ICD9 300.82 Undifferentiated Somatoform Disorder, and includes most patients with Hypochondriasis ICD 10 F45.21 and ICD 9 300.7. Illness Anxiety DisorderThe diagnostic criteria for Illness Anxiety Disorder noted in DSM 5 are:
Specify whether: Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used. Care-avoidant type: Medical care is rarely used. The important distinction between Illness Anxiety Disorder and Somatic Symptom Disorder is that with the former, the individual’s distress emanates not primarily from the physical complaint itself but rather from his or her anxiety about the meaning, significance, or cause of the complaint. DSM 5 considers the prevalence over 1-2 years to be between 1.3 and 10% of populations, and 6-month to 1 year prevalence to be between 3 and 8%. Illness Anxiety Disorder encompasses those patients with Hypochondriasis, ICD 10 F45.21, ICD 9 300.7 who do not have somatic symptoms. Conversion Disorder (Functional Neurological Symptom Disorder)The diagnostic criteria for Conversion Disorder noted in DSM 5 are:
Specify symptom type: With weakness or paralysis With abnormal movement With swallowing symptoms With speech symptom With attacks or seizures With anesthesia or sensory loss With special sensory symptom With mixed symptoms Specify if: Acute episode: Symptoms present for less than 6 months.
Specify if: With psychological stressor: (specify stressor). Without psychological stressor. Terminology can get confusing when clinicians are describing Conversion Disorder. The concept is often considered so difficult to address with the patient, and much terminology inherently pejorative, that physicians may choose obscure terminology to avoid any appearance of directly challenging the patient. Some will choose ‘psychogenic’, while others chose the more neutral ‘functional’ (as in abnormal central nervous system function). The term ‘functional disorder’ is not the same as ‘functional overlay’ which applies to exaggeration of symptoms as seen in Somatic Symptom Disorder and Factitious Disorder. The diagnosis only includes symptoms of a central neurological disorder when clinical findings demonstrate clear incompatibility with neurological disease. There are many classical examples where an individual shows and describes obvious disorders, but when observed at other times or when tested in other ways, they are clearly normal (such as weakness or absence of plantar flexion when lying down, but the ability to walk on tip-toes when standing, or an apparent Grand Mal seizure while responding to commands). The diagnosis does not include disorders such as chronic pain, but Conversion Disorder may co-exist with Somatic Symptom Disorder. Co-morbidity with anxiety disorders and depressive disorders is common. Conversion disorder is often associated with dissociative symptoms, and it is often associated with stressful life events and maladaptive personality traits. It is important to distinguish it from Factitious Disorder and Malingering. DSM 5 considers the prevalence to be around 5% of referrals to neurology clinics, with an annual incidence in the general population of 2-5/100,000. Conversion Disorder is classified as ICD 10 F44.4-7 (depending on symptom type), ICD 9 300.11. Psychological Factors Affecting Other Medical ConditionsThe diagnostic criteria for Psychological Factors Affecting Other Medical Conditions noted in DSM 5 are:
Specify current severity:
This diagnosis should be reserved for situations in which the effect of the psychological factor on the medical condition is evident, and the psychological factor has clinically significant effects on the course or outcome of the medical condition. Individuals who develop anxiety as a consequence of a condition should be diagnosed with Adjustment Disorder. While the prevalence is not clear, DSM 5 notes that it is more common than Somatic Symptom Disorder. The most frequently seen examples are likely to be avoidance of or poor adherence to treatment because of anxiety, and avoiding investigations when a serious condition is suspected. Psychological Factors Affecting Other Medical Conditions is classified as ICD 10 F54, ICD 9 316. Factitious DisorderThe diagnostic criteria for Factitious Disorder noted in DSM 5 are: Factitious Disorder Imposed on Self
Specify: Single episode Recurrent episodes (two or more events of falsification of illness and/or induction of injury) Factitious Disorder Imposed on Another (Previously Factitious Disorder by Proxy)
Note: The perpetrator, not the victim, receives this diagnosis. Specify: Single episode Recurrent episodes (two or more events of falsification of illness and/or induction of injury) The essential feature is falsification of medical or psychological signs and symptoms. The diagnosis requires demonstrating that the individual is taking surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury in the absence of obvious external rewards. It includes false reporting of facts such as symptoms, events, and investigation results. Individuals are at great risk of harm through inappropriate diagnoses and treatments, as well as from induced injury and disease. The condition is usually one of intermittent episodes. Persistent unremitting episodes, and single episodes, are less common. DSM 5 estimates the prevalence of 1% in hospital settings although it is very difficult to achieve an objective measure in a condition where deception is a key criterion. An important differential diagnosis is malingering, where there is personal gain such as financial gain or time off work. There needs to be an absence of obvious rewards in order to meet the diagnostic criteria. Factitious Disorder is classified as ICD 10 F68.10, ICD 9 300.19. Other Specified Somatic Symptom and Related DisorderDSM 5 notes that this category applies to presentations in which symptoms characteristic of a somatic symptom and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class. Examples include:
These are classified as Other Somatoform Disorders ICD 10 F45.8, ICD 9 300.89. Unspecified Somatic Symptom and Related DisorderDSM 5 reserves this category for rare occasions where there are predominantly somatic symptoms but there is insufficient information to make a more specific diagnosis. These are classified as ICD 10 F45.9 and ICD 9 300.82. APA 2013. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Arlington, VA, American Psychiatric Association. What is the diagnostic criteria for somatic symptom disorder?Somatic symptom disorder is diagnosed when a person has a significant focus on physical symptoms, such as pain, weakness or shortness of breath, to a level that results in major distress and/or problems functioning. The individual has excessive thoughts, feelings and behaviors relating to the physical symptoms.
What is the most common complaint in somatic symptom disorder?Pain is the most common symptom, but whatever your symptoms, you have excessive thoughts, feelings or behaviors related to those symptoms, which cause significant problems, make it difficult to function and sometimes can be disabling.
What are two diagnostic criteria of somatic symptom disorder or hypochondriasis?To meet the criteria for somatic symptom disorder, patients must have one or more chronic somatic symptoms about which they are excessively concerned, preoccupied or fearful.
What makes somatoform disorders difficult to diagnose and treat?There are no specific physical examination findings or laboratory data that are helpful in confirming these disorders; it often is the lack of any physical or laboratory findings to explain the patient's excessive preoccupation with somatic symptoms that initially prompts the physician to consider the diagnosis.
|