Learning Objectives
- Describe somatic symptom and related disorders.
- Describe how somatic symptom disorder presents.
- Describe how illness anxiety disorder presents.
- Describe how functional neurological symptom (conversion) disorder presents.
- Describe how factitious disorder presents.
Psychological disorders that feature somatic symptoms are often challenging to diagnose due to the internalizing nature of the disorder, meaning there is no real way for a clinician to measure the somatic symptom. Furthermore, the somatic symptoms could take on many forms. For example, the individual may be faking the physical symptoms, imagining the symptoms, exaggerating the symptoms, or they could be real and triggered by external factors such as stress or other psychological disorders. The symptoms also may be part of a real medical illness or disorder, and therefore, the symptoms should be treated medicinally.
All the disorders within this chapter share a common feature: there is a presence of somatic symptoms and/or illness anxiety associated with significant distress or impairment. Oftentimes, individuals with a somatic disorder will present to their primary care physician with their physical complaints. Occasionally, they will be referred to clinical psychologists after an extensive medical evaluation concludes that a medical diagnosis cannot explain their current symptoms. As you will see, despite their similarities, there are key features that distinguish the disorders in this class from one another.
Somatic Symptom Disorder
Individuals with somatic symptom disorder often present with multiple somatic symptoms at one time. These symptoms are significant enough to impact their daily functioning, such as preventing them from attending school, work, or family obligations. The symptoms can be localized (i.e., in one spot) or diffused (i.e., entire body), and can be specific or nonspecific (e.g., fatigue). Individuals with somatic symptom disorder often report excessive thoughts, feelings, or behaviors surrounding their somatic symptoms (APA, 2022). For example, individuals with somatic symptom disorder may spend an excessive amount of time or energy evaluating their symptoms, as well as the potential seriousness of their symptoms. A lack of medical explanation is not needed for a diagnosis of somatic symptom disorder, as it is assumed that the individual’s suffering is authentic. Somatic symptom disorder is often diagnosed when another medical condition is present, as these two diagnoses are not mutually exclusive.
Somatic symptom disorder patients generally present with significant worry about their illness. Their interpretation of symptoms is often viewed as threatening, harmful, or troublesome (APA, 2022). Because of their negative appraisals, they fear that their medical status is more serious than it typically is, and high levels of distress are often reported. Oftentimes these patients will “shop” at different physician offices to confirm the seriousness of their symptoms.
Illness Anxiety Disorder
Illness anxiety disorder, previously known as hypochondriasis, involves an excessive preoccupation with having or acquiring a serious medical illness. The key distinction between illness anxiety disorder and somatic symptom disorder is that an individual with illness anxiety disorder does not typically present with any somatic symptoms. Occasionally an individual will present with a somatic symptom; however, the intensity of the symptom is mild and does not drive the anxiety. Acquiring a serious illness drives concerns and they will even avoid visiting a sick relative or friend for fear of jeopardizing their own health.
Individuals with illness anxiety disorder generally are cleared medically; however, some individuals are diagnosed with a medical illness. In this case, their anxiety surrounding the severity of their disorder is excessive or disproportionate to their actual medical diagnosis. While an individual’s concern for an illness may be due to a physical sign or sensation, most individual’s concerns are derived not from a physical complaint, but their actual anxiety related to a suspected medical disorder. This excessive worry often expands to general anxiety regarding one’s health and disease. Unfortunately, this anxiety does not decrease even after reassurance from a medical provider or negative test results, even when provided by multiple physicians and diagnostic tests.
As one can imagine, the preoccupation and anxiety associated with attaining a medical illness severely impacts daily functioning. The individual will often spend copious amounts of time scanning and analyzing their body for “clues” of potential ailments. Additionally, an excessive amount of time is often spent on internet searches related to symptoms and rare illnesses. Illness becomes a central feature of the person’s identity and self-image. Although extreme, some cases of invalidism have been reported due to illness anxiety disorder (APA, 2022).
Making Sense of the Disorders
In relation to somatic symptom and related disorders, note the following:
- For somatic symptom disorder …… the patient presents with multiple somatic symptoms at one time that are significant enough to impact their daily functioning
- For illness anxiety disorder … the patient does not typically present with any somatic symptoms but if they do, the symptoms are just mild in intensity
Functional Neurological Symptom Disorder (Conversion Disorder)
Functional neurological symptom (conversion) disorder occurs when an individual presents with one or more symptoms of altered voluntary motor or sensory function (APA, 2022). Common motor symptoms include weakness or paralysis, abnormal movements (e.g., tremors), and gait abnormalities (i.e., limping). Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing. Less commonly seen are epileptic seizures and episodes of unresponsiveness resembling fainting or coma (Marshall et al., 2013). The disorder was called “conversion disorder” in prior versions of the DSM and in the psychiatric literature. As noted, “The term “conversion” originated in psychoanalytic theory, which proposes that unconscious psychic conflict is “converted” into physical symptoms” (APA, 2022).
The most challenging aspect of functional neurological symptom disorder is the complex relationship with a medical evaluation. While a diagnosis of conversion disorder requires that the symptoms not be explained by a neurological disease, just because a medical provider fails to provide evidence that it is not a specific medical disorder is not sufficient. Therefore, there must be evidence of an incompatibility of the medical disorder and the symptoms. For example, an individual experiencing a seizure would require a normal simultaneous electroencephalogram (EEG), indicating that there is not epileptic activity during what was previously thought of as an epileptic seizure.
Factitious Disorder
Factitious disorder differs from the three previously discussed somatic disorders in that there is deliberate falsification of medical or psychological symptoms imposed on oneself or on another, with the overall intention of deception. While a medical condition may be present, the severity of impairment related to the medical condition is more excessive due to the individual’s need to deceive those around them. Even more alarming is that this disorder is not only observed in the individual leading the deception— it can also be present in another individual, often a child or an individual with a compromised mental status who is not aware of the deception behind their illness.
Some examples of factitious disorder behaviors include, but are not limited to, altering a urine or blood test, falsifying medical records, ingesting a substance that would indicate abnormal laboratory results, physically injuring oneself, and inducing illness by injecting or ingesting a harmful substance. Although most individuals with factitious disorder seek treatment from health care professionals, some choose to mislead community members either in person or online about the illness or injury (APA, 2022). While it is unclear why an individual would want to fake their own (or someone else’s) physical illness, there is some evidence suggesting that factors such as depression, lack of parental support during childhood, or an excessive need for social support may contribute to this disorder (McDermott, Leamon, Feldman, & Scott, 2012; Ozden & Canat, 1999; Feldman & Feldman, 1995).
Individuals with factitious disorder are at risk for experiencing psychological distress or functional impairment causing harm to themselves and others such as family, friends, heath care professionals, and faith leaders. The DSM-5-TR states, “Whereas some aspects of factitious disorders might represent criminal behavior, such criminal behavior and mental illness are not mutually exclusive” (APA, 2022, pg. 368).
Key Takeaways
You should have learned the following in this section:
- Somatic symptom disorder is characterized by the presence of multiple somatic symptoms, whether localized or diffused and specific or nonspecific, at one time which impact daily functioning.
- Illness anxiety disorder is characterized by concern over having or acquiring a serious illness, and not the actual presence of somatic symptoms. Individuals spend a great deal of time scanning and analyzing their body for “clues” of potential ailments.
- Functional neurological symptom disorder is characterized by one or more symptoms of voluntary motor or sensory function.
- Factitious disorder is characterized by deliberate falsification of medical or psychological symptoms of oneself or another, with the overall intention of deception.
Review Questions
- What are some commonly shared features of somatic disorders?
- Which somatic disorder usually accompanies a medical diagnosis?
- What are the key distinctions between illness anxiety disorder and somatic symptom disorder?
- What are the key differences between factitious disorder and the other somatic disorders?
