Vignette 1. An 11-year-old girl was admitted to the pediatrics service for inability to walk due to paralysis of her left lower extremity. One morning, upon awakening, she found that she was unable to move her left thigh and leg and had to stay in bed. On admission, she had flaccid paralysis of her thigh and legs as well as stocking-like hypoesthesia. All labs and imaging studies were within normal limits except for slight anemia. Hoover sign (Chap. 34) was positive. The patient told the psychiatric consultant that she and her family had recently moved from another city, and she had enrolled in a new school where she had no friends. She missed her old friends, particularly a boy with whom she was close, which she kept a secret from her parents. As she talked about how much she missed her old school, she felt that she was beginning to feel some more sensation in her left leg and thigh. The consultant recommended physical therapy. In 2 days’ time, the patient recovered enough movement and sensation in her left extremity that she was able to be discharged. In the meanwhile, she and her parents agreed that she could phone her old friends frequently. A psychiatric follow-up appointment was made.

Vignette 2. A 35-year-old woman who works as a nurse’s aide in a convalescent home was admitted to the medical service with high fever of unknown origin. Labs revealed neutrophilic leukocytosis with shift to left. Vital signs revealed sinus tachycardia with high fever (104 F). Blood culture revealed E. coli septicemia. During the night, the nurse happened to notice that she was injecting something into her IV line. The syringe the patient used to inject into her IV line turned out to contain fecal material.

Vignette 3. A 43-year-old woman, who is on disability from long-standing epilepsy, was admitted to the hospital for increasing seizures. During a previous hospitalization, a 24-h EEG showed generalized seizure activity while she was having a grand mal seizure. Lately, however, she was also experiencing seizures during which she was “thrashing about” and at least partly conscious. Another 24-h EEG revealed only movement artifacts and no seizure activity. A psychiatric consultation was requested for “pseudoseizures.” During interview, the patient told the consultant that she had increased stress at home because her daughter had lost her job and moved in with her with her three young children. The daughter was addicted to drugs and the patient found herself having to care for the young children as well as her husband, who was disabled with advanced complications of diabetes mellitus.

The classical diagnosis of hysteria involved physical symptoms, which were postulated to be caused by wandering uterus (hystera in Greek) by Hippocrates (b. 460 BCE) (Meyer 1997). It was considered to be confined to females. According to this theory, various symptoms of hysteria were caused by the interaction of the uterus with other organs. For example, if the uterus comes towards the liver, the female suddenly becomes speechless and clenches her teeth. The treatment was pushing beneath the liver with the hand and tightening a bandage below the ribs, and by opening the mouth and administering a most fragrant wine, followed by the application of malodorous fumigations into the nostrils (Olsen, 1994). More “definitive” treatments included attempts to tie down the uterus through pregnancy or keeping it moist through frequent intercourse so that it would not try to seek out the moisture of other organs (Meyer 1997).

During the dark ages and early Renaissance, irrationality and misogyny prevailed. Malleus Maleficarum (The Witches’ Hammer, 1487), written by two Dominican inquisitors, Spenger and Kramer, set forth the procedure for diagnosis (torture) and treatment (execution) of witches, many of whom were suffering from mental disorders including hysteria. For example, a sign of being a witch was to have an anesthetic spot on the skin.

Hysteria became the subject of intense investigation in the nineteenth century, when it seems the prevalence was quite high. Jean Martin Charcot (1825–1893), Professor of Neuropathology and Physician in Charge at Salpetriere Hospital in Paris, obtained worldwide renown for his use of hypnosis in diagnosing and treating hysteria. He believed that susceptibility to hypnosis was pathognomonic of hysteria, a condition that he believed was caused by a degeneration of the brain. His pupils included Sigmund Freud, Joseph Babinski, Pierre Janet, Georges Gilles de la Tourette, and Alfred Binet.

Sigmund Freud (1856–1939) learned hypnosis under Charcot, returned to Vienna to practice its use in treating hysteria, and wrote, with his colleague and mentor, Josef Breuer, Studies on Hysteria (1895), which postulated that the patient’s psychological traumas and conflicts caused the symptoms of hysteria. Freud eventually gave up the use of hypnosis in favor of free association, and founded psychoanalysis.

The term, conversion, is based on psychoanalytic theory. If an external stimulus or situation threatens to awaken a repressed psychological conflict, the ego converts the psychological conflict into a somatic symptom that represents a symbolic resolution of the conflict. For example, someone a person meets may unconsciously remind him of his father, toward whom he has murderous impulses. The impulse must be repressed because it can cause overwhelming anxiety if it became conscious. The patient’s right arm becomes paralyzed, the arm with which the patient might have attacked the father figure. The resolution is that he cannot strike the person (father symbol) as the arm is paralyzed, appeasing the superego, but at the same time the paralysis draws attention to the instrument of aggression, thus partly serving the id’s murderous impulse. The primary gain in the conversion syndrome is the prevention of the overwhelming anxiety that would arise if the psychological conflict were to become conscious. The secondary gain, a commonly used term, is any potential benefit arising from being sick (in this case, paralyzed), such as attention, not having to go to work, etc. Conversion disorder is the only diagnosis in the DSM III/IV and DSM-5 that, at least in name, presumes a psychodynamic etiology.

Conversion symptoms are now considered to be body language expressions of a psychological distress that may be determined by many factors including psychodynamic, cultural, socio-economic, and genetic-constitutional factors (Maisami and Freeman 1987).

DSM II used the term, psychophysiologic disorders, to denote emotional factors affecting physical symptoms, especially those resulting from autonomic activation due to stress. The term was used in contradistinction to conversion disorder which denoted symptoms attributable to motoric, somatosensory, and special senses. Psychophysiologic disorders were what remained of the “psychosomatic” illnesses (See Chap. 1).

DSM-5 recognizes that, while the “classical psychosomatic” illnesses such as ulcerative colitis and peptic ulcer are no longer believed to be any more “psychosomatic” than immunologic/infectious, there is wide acceptance of the notion that psychological factors such as stress and coping styles contribute to the state of immunocompetence and even cellular aging (Entringer et al. 2013; Epel et al. 2004; Shalev et al. 2013). DSM-5 now includes these syndromes within Psychological Factors Affecting Other Medical Conditions discussed below.

Strictly speaking, conversion symptoms should be considered to be a subset of psychological factors affecting medical condition, and we use the latter broad diagnostic term for both syndromes although this is not exactly correct use of the terminology according to DSM-5 as it splits off neurologic symptoms into conversion (functional neurological symptom) disorder. Thus, we would diagnose both Vignette 1 and Vignette 3 as psychological factors affecting medical condition, although they would both qualify for conversion disorder in DSM-5.

DSM-5 defines somatic symptom disorder as one or more somatic symptoms that are distressing or result in significant disruption in daily life and excessive thoughts, feelings, or behaviors related to the symptoms or related health concerns with at least one of the following: (a) excessive and persistent thoughts about the seriousness of the symptoms, (b) persistently high level of anxiety about health or symptoms, or (c) excessive time and energy spent on these symptoms or health concerns. It also specifies that the state of being symptomatic should be persistent (typically more than 6 months) even if any one somatic symptom may not be continuously present. The specifiers may be: with prominent pain, persistent, and severity specifiers or mild, moderate, and severe.

According to DSM-5, patients with these disorders typically have multiple symptoms including pain, and the symptoms may be specific or general (e.g., fatigue). The symptoms may or may not be associated with another medical condition, e.g., a patient may be disabled with somatic symptom disorder following an uncomplicated myocardial infarction.

The prevalence of somatic symptom disorder is estimated to be 5–7 % in the general population, and more in females than in males (APA 2013).

Many factors underlie the predisposition to somatic symptom disorder including genetic factors interacting with experiential factors such as childhood abuse, the development of temperamental neuroticism (Laceulle et al. 2013; Vinberg et al. 2013), and the trait of somatic amplification (Barsky et al. 1988; Freyler et al. 2013; Geisser et al. 2008; Yavuz et al. 2013). Other contributing factors include recent stress, low socioeconomic and educational status (thus lower coping skills), and cultural influences (e.g., emotional distress expressed as somatic discomfort/pain).

There is high comorbidity with both medical diseases and depression and anxiety.

Treatment of somatic symptom disorder should be multifaceted and include a recognition of the distress experienced by the patient, an explanation of the mind’s tendency for somatic amplification in some individuals, reassurance that there will be careful medical observation and follow-up of the symptoms, stress management and relaxation training including mindfulness training (Reif et al. 2013; Zangi et al. 2012), activity/exercise therapy, and cognitive behavioral therapy (Hoerster et al. 2012; Nakao et al. 2001; Voigt et al. 2013). Antidepressants, hypnotics, and anxiolytics may be judiciously utilized when target symptoms are present. Duloxetine may be particularly useful in patients with prominent pain symptoms (and it is advertized as a pain medication), and mirtazapine may be useful in patients who have both insomnia and depressive symptoms.

Secondary gain can be prominently influencing symptoms in certain settings, such as chronic pain treatment settings and disability compensation. In these settings, medications should be used very cautiously due to the likelihood that target symptoms may be exaggerated, and drugs can psychologically reinforce them. See Chap. 22 for further discussion of treatment of chronic pain.

As discussed earlier, about 3/4 of patients diagnosed previously with hypochondriasis who have physical symptoms of some kind now belong to the somatic symptom disorder category, and the remaining 1/4 of patients without any physical symptoms but who have excessive worries about being sick now attain the diagnosis of illness anxiety disorder.

A more detailed discussion of hypochondriasis, which is no longer a DSM diagnosis, is found in Chap. 23.

DSM-5 defines illness anxiety disorder as preoccupation with having or acquiring a serious illness and somatic symptoms are not present, or if present, are only mild in intensity. If another medical condition or a high risk of developing a medical condition (e.g., strong family history) is present, the preoccupation is clearly excessive or disproportionate. There is a high level of anxiety about health and the person is easily alarmed about health status, and engages in excessive health related behaviors (e.g., repeated checks for signs of illness) or engages in maladaptive avoidance (e.g., doctor’s appointments, hospitals). DSM-5 further requires that an illness preoccupation has been present for at least 6 months. Two specifiers are provided: care-seeking type and care-avoidant type.

Illness anxiety disorder is quite frequently seen in medical and primary care settings. The prevalence ranges from 1.3 to 10 % in community surveys, and in ambulatory medical populations, 3–8 % (DSM-5). There is no gender difference.

This disorder may be precipitated by major life stress or threat to health. About 1/3–1/2 of patients with this disorder have a transient form (DSM-5).

Basic principles of treatment for somatic symptom disorder discussed above apply to illness anxiety disorder, including careful monitoring and follow-up, cognitive behavioral therapy, mindfulness training, psychoeducation, as well as SSRIs (Greeven et al. 2009; Hedman et al. 2010; Lovas and Barsky 2010; Williams et al. 2011).