CRACKCast E113 – Somatoform Disorders

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This 113th episode of CRACKCast covers Rosen’s 9th edition, Chapter 103, Somatoform Disorders. The diagnosis of SSD is made when there are persistent and clinically significant physical complaints that are accompanied by excessive and disproportionate health-related thoughts, feelings, and behaviors regarding these symptoms. Recent publications refer to “medically unexplained physical or somatic symptoms,” rather than somatization.

Shownotes – PDF here

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Rosen’s In Perspective

“Somatic symptom disorders (SSDs), formerly known as somatoform disorders, are described as the borderland between psychiatry and medicine and are responsible for some of the most frustrating and the least understood patient encounters in the emergency department (ED).

SSD patients present with multiple physical symptoms in the absence of detectable physical disease, and harbor excessive health concerns that are expressed emotionally, cognitively, and behaviorally.

These patients perceive a wide range of severe symptoms including pain, gastrointestinal, cardiovascular, sexual, and pseudo-neurological symptoms, which cause inappropriate and persistent worry, distress, and social dysfunction.” – Rosen’s 9th Edition, Chapter 103

The major diagnosis in this diagnostic class, of which SSD is the most prominent, hinges on the existence of the patient’s distinctive abnormal thoughts, feelings, and behaviors in response to somatic symptoms.

The diagnosis of SSD is made when there are persistent and clinically significant physical complaints that are accompanied by excessive and disproportionate health-related thoughts, feelings, and behaviors regarding these symptoms. Recent publications refer to “medically unexplained physical or somatic symptoms,” rather than somatization.

[1] List 5 somatic symptom and related disorders

The definition of somatic symptom disorders is… “the experience of physical symptoms associated with significant distress and impairment that cannot be adequately explained by demonstrable physical pathology despite appropriate medical investigation…”  – Rosen’s 9th Edition, Chapter 103

Here’s a list of some of these disorders. See Rosen’s Box 103.1 for full details.

Somatic Symptom and Related Disorders

Conditions manifested by abnormal thoughts, feelings, and behaviors in response to distressing somatic symptoms causing impairment:

  • Somatic symptom disorder (SSD)
  • Illness anxiety disorder (formerly hypochondriasis)
  • Functional neurological symptom disorder (formerly conversion disorder)
    • weakness/paralysis, abnormal movements, swallowing symptoms, slurred speech, seizures/attacks, anesthesia, sensory disturbances
  • Factitious disorder
  • Psychological factors affecting other medical conditions
  • Other specified somatic symptom and related disorders
  • Unspecified somatic symptom and related disorders

[2] List 5 common presentations of conversion disorders

Subcategorized into

  • weakness or paralysis;
  • abnormal movements;
  • swallowing symptoms;
  • dysphonia or slurred speech;
  • attacks or seizures;
  • anesthesia; and
  • visual, olfactory, or hearing disturbances.

Typically, there is a sudden dramatic onset of a single symptom, simulating some non-painful neurologic disorder for which there is no pathophysiologic or anatomic explanation.

[3] List 6 ddx of somatic symptom disorder

See Rosen’s Box 103.2 for full details.

  • Differential Diagnosis of Somatic
  • Symptom Disorder
  • Major depressive disorder
  • Anxiety disorders
  • Multiple sclerosis
  • Porphyria
  • Hyperparathyroidism
  • Systemic lupus erythematosus
  • Thyroid disease
  • Wilson’s disease
  • Substance abuse disorder
  • Personality disorder
  • Malingering
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Wisecracks

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[1] List 6 organic diseases that may be mistaken for somatoform disorders

So, to recap! There are several medical diagnoses that can have very subtle presentations with multiple physical symptoms, including:

  • multiple sclerosis
  • porphyria
  • hyperparathyroidism
  • systemic lupus erythematosus
  • thyroid disorders
  • Wilson’s disease

Testing should only be performed for diagnoses that are supported by a carefully performed history and physical examination.

[2] Describe the treatment goals of somatoform disorders

The major diagnosis in this diagnostic class, somatic symptom disorder, SSD, emphasizes that the diagnosis is made on the basis of distressing somatic symptoms plus maladaptive thoughts, feelings, and behaviors in response to these symptoms.

Us ER docs focus on patients’ symptoms because we want to diagnose and treat life threats, but recognizing “recurrent unexplained symptoms” as potential SSD may help avoid unnecessary, unhelpful and sometimes dangerous diagnostic testing.

After developing a sound rapport, legitimize the patient’s complaints and then limit diagnostic investigations to address only clear-cut findings of medical illness that are based on a careful history and physical examination.

One should avoid confronting or challenging the SSD patient and instead, agree that there is a problem, and work with the patient to formulate a plan of care and referral.

The priority is to listen and communicate an understanding of what the patient is feeling and the extent of the functional impairment that they are experiencing.

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If you made it through this podcast you’re a hard-core ER doc!

Excellent communication is crucial to helping patients with somatoform disorders and having a fulfilling ER career. Please check out these amazing podcasts:

This post was uploaded and copyedited by Kevin Lam (@KevinHLam)

Chris Lipp

Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine (Innovative Sport Medicine Calgary). His interests are in paediatrics, endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.

Larissa Hattin

Larissa is a medical student at McMaster University.

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