Chapter 12 Gordon J. G. Asmundson, Michel A. Thibodeau, and Daniel L. Peluso The somatic symptom and related disorders, as described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5, American Psychiatric Association [APA], 2013), include somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder. The somatic symptom and related disorders reconceptualize and replace the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR; APA, 2000) somatoform disorders. Changes were made in an effort to eliminate overlap and clarify boundaries between diagnosable disorders, and to recognize that people meeting diagnostic criteria for one of these disorders may or may not have an identifiable medical condition. The following changes were made in the DSM-5: (a) conversion disorder (functional neurological symptom disorder) remains but now emphasizes the importance of the neurological exam; (b) body dysmorphic disorder was reconceptualized as a DSM-5 obsessive-compulsive and related disorder (thereby moving it to a different category); (c) psychological factors affecting other medical conditions and factitious disorder, each included in different sections of the DSM-IV, have been added to this category; and (d) each of somatization disorder, undifferentiated somatization disorder, pain disorder, and hypochondriasis have been removed as diagnosable conditions and are subsumed under one of somatic symptom disorder, illness anxiety disorder, or psychological factors affecting other medical conditions. Importantly, unlike somatization disorder and hypochondriasis as defined in the DSM-IV-TR, the key disorder included in this new category (i.e., somatic symptom disorder) no longer requires medically unexplained symptoms as a core feature; instead, emphasis is placed on the impact of symptoms on cognition, emotion, and behavior. Although not without controversy (e.g., Frances, 2013; Frances & Chapman, 2013; Sirri & Fava, 2013; Starcevic, 2013), the Somatic Symptom Workgroup has suggested that aforementioned changes were made in an effort to increase utility for the primary care and other medical (nonpsychiatric) clinicians to whom patients with somatic sensations or changes often present, to reduce stigma, to reduce promotion of mind-body dualism, to improve therapeutic alliance, and to facilitate correct diagnosis and good treatment outcomes (e.g., Dimsdale et al., 2013). The common feature of the somatic symptom and related disorders is prominent somatic sensations (e.g., dyspnea, pain) or changes (e.g., subcutaneous lumps, rash)—called “symptoms” in DSM-5 terminology—that are associated with significant emotional distress and functional impairment and often interpreted by the person as being symptomatic of some disease process or physical anomaly. Bodily sensations and changes are a common experience of day-to-day living for most people, and they typically remit without medical attention; however, about 25% of the population seeks medical attention when these sensations and changes persist (Kroenke, 2003). Up to 30% of those seeking medical attention will exhibit clinically significant distress about having an unidentified disease when there is no medical explanation for presenting “symptoms” (Fink, Sørensen, Engberg, Holm, & Munk-Jørgensen, 1999); yet, many remain distressed despite identifiable medical explanation (APA, 2013; Taylor & Asmundson, 2004). This distress is associated with substantial impairment of personal, social, and professional functioning as well as considerable costs to health care (Hessel, Geyer, Hinz, & Brahier, 2005), even after controlling for medical and psychiatric comorbidity (Barsky, Orav, & Bates, 2005). Despite prevalence and cost of distressing somatic sensations and changes, as well as a substantive increase in empirical attention during the past decade, their presentation remains not well understood. Likewise, although there are some data on the validity, reliability, and clinical utility of somatic symptom disorder (Dimsdale et al., 2013), there have been few studies on the diagnostic category as a whole. In the sections that follow, we provide an overview of the general clinical profile, diagnostic considerations, and epidemiology of the DSM-5 somatic symptom and related disorders. We then turn attention to issues of assessment, etiological considerations, and course and prognosis. In each of these latter sections, we touch on issues germane to the collective category as well as its specific disorders. In the case study, we focus more specifically on an illustration of uncomplicated somatic symptom disorder. As there is currently little data on epidemiology, etiology, course, prognosis, assessment, or treatment of the disorders included in this new DSM-5 category, much of the data presented below is borrowed from pre-DSM-5 knowledge of related conditions and disorders. The clinical profile for each somatic symptom and related disorder is unique, although each disorder is predicated on the prominence of somatic sensations or changes associated with distress and impairment. A brief overview of the clinical profile of each somatic symptom disorder is provided, along with reference to DSM-5 diagnostic criteria. Somatic symptom disorder is the cornerstone diagnosis of the somatic symptom and related disorders category. The main feature of somatic symptom disorder is the presence of one or more somatic symptoms or features that cause distress and impairment in daily living (Criterion A). The concern ranges from highly specific (e.g., “This pain in my gut is so bad. I must have stomach cancer”) to vague and diffuse (e.g., “My whole body is aching. What could it be? Maybe it’s ALS.”). Individuals with somatic symptom disorder exhibit excessive thoughts, feelings, or behaviors related to their somatic symptoms (Criterion B). An individual meets Criterion B if he or she: (a) exhibits disproportionate thoughts about the seriousness of their symptoms, (b) experiences persistently high levels of anxiety regarding their symptoms or about their health, or (c) devotes an excessive amount of time to their health (e.g., seeking reassurance from health professionals, doing research about their somatic sensations or changes, perusing body parts to find potential lumps). Excessive somatic concerns must persist for at least 6 months (Criterion C), although somatic symptoms do not need to be present for this entire period. Individuals with somatic symptom disorder may often resist the idea that they are suffering from a mental health disorder and may come to rely on reassurance seeking and checking behaviors (e.g., palpating subcutaneous lumps, searching for information about disease in medical textbooks and on the Internet) to placate concerns about having a serious disease. Although these behaviors can be effective in providing short-term relief, they perpetuate the condition in the long term (Taylor & Asmundson, 2004). Somatic symptom disorder can be associated with a few diagnostic specifiers. An individual whose somatic complaints revolve largely around pain can receive a with predominant pain specifier. This specifier replaces the pain disorder diagnosis from DSM-IV. A persistent specifier can apply in cases wherein severe symptoms and impairment last for longer than 6 months. Finally, severity can be specified as mild, moderate, or severe when an individual meets one, two, or three of the Criterion B symptoms, respectively. For example, a moderate severity specifier could be assigned to an individual who reports debilitating anxiety due to bodily symptoms and who checks their body for hours a day to ensure no new blemishes have appeared. Illness anxiety disorder involves preoccupation with having or acquiring a serious illness (Criterion A). For example, an individual may fear contracting HIV or having recently contracted the virus. Illness anxiety disorder differs from somatic symptom disorder in that somatic symptoms are not present or are only minor (Criterion B). If minor somatic symptoms are present (e.g., light pain, minor bruising), the individual’s distress is clearly out of proportion to the actual threat and focuses more on the meaning of the symptoms (e.g., consequences of having diabetes) rather than the somatic symptoms themselves. Individuals with illness anxiety disorder experience a great deal of distress rooted in their disease-related preoccupations and are easily alarmed about health-related matters (Criterion C). To illustrate, an individual with illness anxiety disorder may be excessively distressed when learning that a colleague or stranger has contracted cancer. Individuals with illness anxiety disorder participate in excessive behaviors aimed at reducing their anxiety (Criterion D), often bodily checking (e.g., looking for lesions that could be signs of an infection), reassurance seeking (e.g., repeatedly seeking medical testing), health-related research (e.g., reading about HIV on the Internet), and avoidance (e.g., avoiding hospitals as these could house harmful germs). These behaviors may placate concerns in the short term but, ultimately, serve to reinforce disease-related preoccupation (Taylor & Asmundson, 2004). A diagnosis of illness anxiety disorder is contingent on illness anxiety lasting at least 6 months (Criterion E), although the focus of the anxiety may change during this time (e.g., from HIV to syphilis). Finally, the symptoms of illness anxiety disorder must not be better explained by another diagnosis (Criterion F), such as somatic symptom disorder, panic disorder, or obsessive-compulsive disorder. Illness anxiety disorder can be associated with one of two contrasting specifiers. The care-seeking type specifier can be applied when individuals frequently seek medical care. The care-avoidant type specifier can be applied when individuals rarely use medical care. Conversion disorder involves the manifestation of altered voluntary motor or sensory functioning (Criterion A). Motor symptoms can include paralysis, paresthesia, tremors, convulsions, and abnormal movements or posture. Sensory symptoms can include blindness, altered or reduced hearing, unusual or inconsistent skin sensations, and altered speech patterns. The hallmark of conversion disorder is a lack of correspondence between signs and symptoms and medical understanding of the possible neurological condition (Criterion B). For example, an individual may display symptoms very consistent with epileptic seizures, but lack electrical activity in the brain consistent with epilepsy. Such an inconsistency is needed for a diagnosis. A lack of neurological evidence for reported or observed symptoms is not sufficient (e.g., trembling without any apparent brain damage). Symptoms of conversion disorder must not be better explained by another mental health or medical disorder (Criterion C) and the symptoms must cause clinically significant distress or impairment or warrant medical evaluation (Criterion D). People with conversion disorder are often unaware of psychological factors associated with their condition, and many report an inability to control their symptoms. Although not a criterion for diagnosis of conversion disorder, lack of worry or concern about symptoms (i.e., la belle indifference) is mentioned in the DSM-5 list of associated features. The available literature, however, fails to support the use of la belle indifference as a means of discriminating between conversion disorder and symptoms of organic pathology (Stone, Smyth, Carson, Warlow, & Sharpe, 2006). Observed signs and symptoms of conversion disorder often appear to represent patient beliefs about how neurological deficits should present, rather than how neurological diseases actually function (Hurwitz, 2004). Onset typically follows a period of distress, such as that stemming from trauma (McFarlane, Atchison, Rafalowicz, & Papay, 1994; Roelofs, Keijsers, Hoogduin, Naring, & Moene, 2002; Van der Kolk et al., 1996) or physical injury (Stone et al., 2009). Diagnosis of conversion disorder can be associated with the specifiers with psychological stressor or without psychological stressor. Moreover, a specifier of acute episode or persistent can be applied when an individual’s symptoms present for less or more than six months, respectively. A diagnosis of psychological factors affecting other medical conditions can apply in individuals who suffer from a medical condition (Criterion A) that is adversely affected by psychological or behavioral factors (Criterion B). The effects on the medical condition can increase the odds of suffering, disability, or death. Psychological or behavioral factors can be deemed as detrimental if meeting one of the following conditions: (a) the psychological or behavioral factors preceded the development or worsening of the medical condition, or delayed recovery from the condition (e.g., repeatedly exacerbating an injury following discharge from hospital), (b) the factors interfere with treatment, (c) the factors are well established health-risks, or (d) the factors influence medical pathology, thereby exacerbating symptoms or requiring medical attention. Psychological or behavioral factors can include distress, maladaptive interpersonal patterns, and poor treatment adherence. The psychological or behavioral factors must not be subsumed within another mental disorder (Criterion C); thus, worsening of a medical condition due to panic disorder or due to substance abuse would not meet criteria for psychological factors affecting other medical conditions. Clinicians can apply specifiers reflecting mild (increases medical risk), moderate (aggravates medical condition), severe (results in hospitalization or emergency attention), or extreme (life threatening risk) influence of psychological factors on a medical condition. Factitious disorder imposed on self is a condition wherein an individual acts as if they have physical or psychological signs of an illness by producing, feigning, or exaggerating symptoms (Criterion A). The individual must present himself or herself as ill or impaired (Criterion B) and a diagnosis is contingent on identifying that the individual is actively misrepresenting their condition. Moreover, the deceptive behavior must occur without any obvious external rewards (Criterion C), such as monetary compensation or reduced responsibilities. A diagnosis of factitious disorder can be assigned to individuals who have a medical condition; but, in this case, the deceptive behavior is intended to make the person appear even more ill. The deceptive behavior cannot be better explained by another disorder, such as schizophrenia or delusional disorder (Criterion D). Individuals with factitious disorder may produce or exaggerate symptoms by consuming drugs (e.g., insulin, hallucinogens), injecting themselves with noxious substances (e.g., bacteria), contaminating blood and urine samples, or reporting symptoms that have never occurred (e.g., seizures). A specifier of recurrent episodes applies in cases wherein individuals have exhibited deceptive behavior more than once. A separate diagnosis, referred to as factitious disorder imposed on another, can also be assigned. The criteria for this diagnosis are the same as factitious disorder, but a person other than the victim conducts the deceptive behavior. For example, a father may tamper with the urine sample of his child to misrepresent the child’s health status. In this case, the parent would be assigned the diagnosis, not the child. Other specified somatic symptom and related disorder applies to individuals who present with distressing or impairing symptoms that are similar to one of the somatic symptom and related disorders but that do not fully satisfy the criteria for a diagnosis. The DSM-5 presents four examples of specific disorders that can be used with the other specified disorder diagnosis. These include brief somatic symptom disorder, which can be assigned when an individual meets diagnostic criteria for somatic symptom disorder, but for less than 6 months; brief illness anxiety disorder, which can be assigned when symptoms of illness anxiety disorder last for less than 6 months; illness anxiety disorder without excessive health-related behaviors, which can be assigned when an individual meets all criteria for illness anxiety disorder except Criterion D; and, pseudocyesis, which can be assigned in individuals with a false belief of being pregnant that is associated with objective and reported signs of pregnancy (e.g., morning sickness, breast tenderness). A diagnosis of unspecified somatic symptom and related disorder can be applied when an individual presents with distressing or impairing symptoms that are similar to a somatic symptom and related disorder, but that do not meet the diagnostic criteria for any of the somatic symptom and related disorders. To qualify for a somatoform disorder diagnosis under the DSM-IV-TR, somatic signs and symptoms were required to be medically unexplained; that is, somatic signs and symptoms could not be explained by organic pathology or physical deficit (APA, 2000). Sykes (2006) has argued that default attribution of medically unexplained somatic symptoms to psychopathology is untenable and has contributed to unjustified diagnoses of conditions characterized by somatic complaints as mental rather than physical disorders. In addition to supporting the perspective offered by Sykes (2006), and suggesting that diagnoses based on the absence of medically explained symptoms promoted stigma, the Somatic Symptom Workgroup pointed out that the reliability of establishing that somatic symptoms are not due to a general medical condition is low (e.g., Dimsdale et al., 2013). In the new classification system, somatic symptom disorder is now defined on the basis of positive symptoms (i.e., distressing somatic symptoms that present along with “observable” cognitions, emotions, and behaviors in response to the somatic symptoms); consequently, it is possible for people presenting with and without a diagnosable general medical condition to satisfy diagnostic criteria for the disorder. Medically unexplained symptoms only remain relevant to conversion disorder and other specified somatic symptom and related disorder (i.e., pseudocyesis) where it is possible to demonstrate inconsistency between presenting symptoms and medical pathology. In arriving at a diagnosis of one of the somatic symptom and related disorders it is important to consider that there are multiple sources of distressing somatic sensation and changes. First, a number of mental health disorders are characterized by somatic symptoms (e.g., depression, panic disorder, posttraumatic stress disorder) and may either account for or accompany the somatic symptoms. In the former case a somatic symptom and related disorder diagnosis would not be warranted, whereas in the latter case a dual diagnosis would be warranted. Likewise, given that distressing somatic symptoms often occur in response to a general medical condition such as cancer or multiple sclerosis, considerable care is warranted in establishing whether the response is psychopathological in nature. Some critics of the DSM-5 fear that diagnostic thresholds have been loosened to the point where clinicians will be challenged in distinguishing normal from psychopathological responses in those with distressing somatic symptoms stemming from a medical condition, resulting in overdiagnosis of somatic symptom disorders (Frances, 2013). Finally, it is important to recognize that many benign physical factors can give rise to somatic signs and symptoms. Consider, for example, physical deconditioning. People concerned by somatic sensations often avoid physical exertion, including aerobic and anaerobic exercise, for fear that it will have harmful consequences. As a result, they become physically deconditioned. Physical deconditioning is associated with postural hypotension, muscle atrophy, and exertion-related breathlessness and fatigue, all of which can promote further inactivity and reinforce beliefs that one is ill (Taylor & Asmundson, 2004). Further research is required to determine whether the modifications made in the DSM-5 will facilitate accuracy of diagnoses relative to that attainable with the DSM-IV-TR somatoform disorders. The importance of diagnosis cannot be overstated, as any diagnosis carries significant implications for individuals receiving the diagnosis and their related experiences (e.g., stigmatization, interpretation of symptoms, nature of treatment, response to treatment). As Kirmayer and Looper (2007) note, diagnosis is a form of intervention and, as such, is a crucial element in shaping treatment and outcome. Somatic symptom and related disorders are often associated with true or perceived organic pathology; consequently, this class of disorders is a challenge to diagnose and to study from an epidemiological standpoint due to difficulties in thoroughly assessing the mind and body. Given the substantial changes in diagnostic criteria between the DSM-III and DSM-5, providing precise epidemiological prevalence rates for somatic symptom and related disorders is extremely challenging. Indeed, the somatoform disorders were not included in the large-scale national comorbidity surveys based on DSM-III-R (Kessler, 1994) and DSM-IV-TR criteria (Kessler, Chiu, Demler, Merikangas, & Walters, 2005), nor were they examined in the World Health Organization World Mental Health Surveys initiative (Kessler & Üstün, 2008), which further limits inferences regarding the somatic symptom and related disorders. Moreover, epidemiological researchers have often paired somatoform disorders with other disorders (e.g., anxiety disorders; Bland, Orn, & Newman, 1988) or have excluded specific disorders from analyses due to low or high base rates or differences in classification methodologies (Leiknes, Finset, Moum, & Sandanger, 2008). As such, the prevalence of somatic symptom and related disorders as a class of disorders remains almost entirely unstudied and our knowledge at this time can only be extrapolated from earlier research on the somatoform disorders. The somatic symptom and related disorders are substantially different from the somatoform disorders described in DSM-IV-TR; however, some of the broader epidemiological findings likely still hold true. For example, presentation of somatic concerns that do not meet diagnostic criteria for a somatoform disorder or medical condition account for approximately half of all physician visits (Nimnuan, Hotopf, & Wessely, 2001), suggesting that subsyndromal somatic symptoms are highly prevalent and costly (Barsky et al., 2005; Kirmayer & Robbins, 1991). Somatic symptom and related disorders are likely more common in women (Wittchen & Jacobi, 2005), with perhaps the exception of somatic symptom disorder, which appears to have similar prevalence in both genders based on the rates of hypochondriasis (Asmundson, Taylor, Sevgur, & Cox, 2001; Bleichhardt & Hiller, 2007). People with a somatic symptom and related disorder are also very likely to frequently experience co-occurring mood disorders (Leiknes et al., 2008), anxiety disorders (Lowe et al., 2008), personality disorders (Bornstein & Gold, 2008; Sakai, Nestoriuc, Nolido, & Barsky, 2010), as well as other somatic symptom and related disorders (Leiknes et al., 2008). Somatic symptom disorder encapsulates approximately 75% of individuals who previously met diagnostic criteria for hypochondriasis (APA, 2013), and likely represents the most prevalent of the somatic symptom and related disorders. Somatic symptom disorder has a prevalence of approximately 5% to 7% in the general population (APA, 2013), which is consistent with the 12-month prevalence rate of 4.5% for hypochondriasis (Faravelli et al., 1997). Research on hypochondriasis suggests that somatic symptom disorder is likely more common in primary care settings. Reported prevalence rates of hypochondriasis in primary care settings have varied considerably based on methodology. Studies using diagnostic interviews have reported a point prevalence of 3% (Escobar et al., 1998) and a 12-month prevalence of 0.8% (Gureje, Üstün, & Simon, 1997), whereas a study using cutoff scores from self-report measures followed by interviews suggests a 12-month prevalence of 8.5% (Noyes et al., 1993). The inclusion of the with predominant pain specifier to somatic symptom disorder, which subsumes a portion of the DSM-IV pain disorder diagnosis, may increase the prevalence of somatic symptom disorder beyond the prevalence of hypochondriasis. The prevalence of illness anxiety disorder is relatively unknown, but can be estimated based on other phenomena. The 1- to 2-year prevalence of health anxiety and disease conviction (i.e., the belief that one has a disease) in community-based samples ranges from 1.3% to 10% (APA, 2013). A strong fear of contracting a disease, which is relatively similar to illness anxiety disorder, has a point prevalence of approximately 3% to 4% (Agras, Sylvester, & Oliveau, 1969; Malis, Hartz, Doebbeling, & Noyes, 2002). Together these findings suggest that illness anxiety disorder is relatively common.
Somatic Symptom and Related Disorders
Description of the Disorders
Clinical Picture
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder (Functional Neurological Symptom Disorder)
Psychological Factors Affecting Other Medical Conditions
Factitious Disorder
Other Specified Somatic Symptom and Related Disorder and Unspecified Somatic Symptom and Related Disorder
Diagnostic Considerations (Including Dual Diagnosis)
Epidemiology
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