SN11 SHORT NOTE 5M

Write a short note on somatoform disorders.

General Medicine · Final Professional

Definition

Somatoform disorders are a group of conditions in which the patient presents with physical symptoms that suggest a medical disorder but are not fully explained by organic disease, and which cause significant distress or impairment. The symptoms are not intentionally produced — this is the crucial distinction from factitious disorder and malingering. Under DSM-5 the category was reorganised as somatic symptom and related disorders, with emphasis shifted from "medically unexplained" to the presence of excessive thoughts, feelings and behaviours about the symptoms.

Types

Disorder	Key Features
Somatic symptom disorder	One or more distressing somatic symptoms with disproportionate thoughts, anxiety and time devoted to them, for > 6 months. Symptoms may or may not be medically explained
Illness anxiety disorder (hypochondriasis)	Preoccupation with having or acquiring a serious illness, with minimal or no somatic symptoms; high health anxiety, repeated checking or avoidance of medical care; persistent despite reassurance
Conversion disorder (functional neurological disorder)	Loss or alteration of voluntary motor or sensory function — paralysis, aphonia, blindness, non-epileptic seizures, gait disturbance — with internal inconsistency on examination and findings incompatible with recognised neurological disease
Body dysmorphic disorder	Preoccupation with an imagined or trivial defect in appearance, with repetitive checking or camouflaging; high risk of depression and suicide
Pain disorder	Persistent severe pain in which psychological factors have a major role

Related Conditions — Distinguish Clearly

Condition	Symptom production	Motivation
Somatoform disorder	Unconscious	None — no external gain
Factitious disorder (Munchausen syndrome)	Deliberate — symptoms feigned or induced	Unconscious — to assume the sick role, obtain care and attention
Malingering	Deliberate	Conscious external gain — compensation, avoiding work, obtaining drugs, evading legal proceedings. Not a psychiatric diagnosis

CLINICAL PEARL

The distinction rests on two questions — is the symptom produced deliberately, and is there external gain? Somatoform: neither. Factitious: deliberate production, no external gain. Malingering: deliberate production, clear external gain. Examiners ask this repeatedly.

Clinical Features Suggesting a Functional Disorder

Symptoms that are internally inconsistent — for example Hoover's sign in functional leg weakness (hip extension is weak on direct testing but normal on contralateral hip flexion), or give-way weakness.
Multiple symptoms across multiple systems, with a long history and thick case records.
Repeated normal investigations, multiple specialist consultations, and previous unnecessary surgery.
Onset temporally related to psychosocial stress; comorbid anxiety and depression are very common.
La belle indifférence — apparent lack of concern — is classically described in conversion disorder but is unreliable and should not be used to make the diagnosis.

Management

Positive diagnosis, not a diagnosis of exclusion. Explain the diagnosis clearly using the demonstrable positive signs; the diagnosis is made on what is present, not merely on the absence of disease.
Validate the symptoms as real. Telling the patient "there is nothing wrong" or "it is all in your mind" is the commonest cause of treatment failure and of doctor-shopping.
Establish one consistent doctor with regular scheduled appointments rather than symptom-triggered visits, which reinforce illness behaviour.
Limit further investigation — repeated normal tests increase anxiety and risk iatrogenic harm — while remaining alert to genuine new disease, which these patients also develop.
Cognitive behavioural therapy is the treatment of choice, with graded exercise and physiotherapy for functional motor symptoms.
Treat comorbid depression and anxiety — antidepressants help both mood and pain symptoms.
Explore and address underlying psychosocial stressors; involve family in the explanation.

Prognosis

Better with acute onset, identifiable stressor, early diagnosis and absence of comorbid personality disorder. Chronic multi-symptom presentations tend to persist and require long-term supportive management rather than cure.

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