Somatic Symptom & Dissociative Disorders
Psychiatry · Anxiety · lean revision notes
Somatic Symptom & Dissociative Disorders
A high-yield cluster of disorders where psychological distress is expressed through physical symptoms (somatic) or through disruptions in memory, identity and consciousness (dissociative). NEET PG loves the buzzwords here: la belle indifférence, primary vs secondary gain, and the crucial line between unconscious symptom production (conversion) and conscious deception (factitious/malingering).
Where these disorders sit in DSM-5
DSM-5 abolished the old umbrella term "somatoform disorders" and reorganised them under Somatic Symptom and Related Disorders. The biggest conceptual shift: the new diagnoses are made on the basis of positive psychological features (distorted thoughts, excessive anxiety, maladaptive behaviour) rather than on the absence of a medical explanation. You no longer have to prove "medically unexplained" — you look at the patient's disproportionate response.
| Old (DSM-IV) term | New (DSM-5) term |
|---|---|
| Somatization disorder / Pain disorder / Undifferentiated somatoform | Somatic Symptom Disorder (SSD) |
| Hypochondriasis (with high health anxiety) | Illness Anxiety Disorder |
| Conversion disorder | Conversion Disorder (Functional Neurological Symptom Disorder) |
| Psychological factors affecting medical condition | retained |
| Factitious disorder | retained (now within this chapter) |
High-yield: In DSM-5, "medically unexplained symptoms" is NO LONGER the core requirement for somatic symptom disorder. The diagnosis rests on the excessive thoughts, feelings and behaviours about the symptom. A patient with genuine cancer can still have SSD if their preoccupation is disproportionate.
Dissociative disorders are a separate DSM-5 chapter: dissociative amnesia (with/without fugue), dissociative identity disorder (DID), and depersonalisation/derealisation disorder.
1. Somatic Symptom Disorder (SSD)
Definition
One or more distressing somatic symptoms plus excessive thoughts, feelings or behaviours related to them, persisting typically > 6 months.
Diagnostic criteria (DSM-5)
- A. One or more somatic symptoms that are distressing or disrupt daily life.
- B. Excessive thoughts/feelings/behaviours about the symptoms, shown by at least one of:
- Disproportionate, persistent thoughts about seriousness.
- Persistently high anxiety about health/symptoms.
- Excessive time and energy devoted to symptoms/health concerns.
- C. Symptomatic state is persistent (typically > 6 months), though any single symptom may change.
Specifiers: with predominant pain; persistent; severity (mild/moderate/severe).
Clinical features
- More common in women, lower socioeconomic groups, onset usually before age 30.
- Multiple, recurring symptoms across organ systems; the patient is a frequent attender ("thick file" patient).
- High comorbidity with depression and anxiety.
High-yield: The patient with SSD genuinely experiences the symptoms and is distressed; symptoms are not intentionally produced — this distinguishes it from factitious disorder and malingering.
Management
- Single, regular treating physician ("gatekeeper") with scheduled regular appointments (not symptom-driven visits) — reduces doctor-shopping and unnecessary investigations.
- Brief, supportive consultations; acknowledge symptoms as real.
- CBT is the psychotherapy of choice.
- Antidepressants (SSRIs / TCAs) help, especially with comorbid pain, depression or anxiety.
- Avoid repeated investigations and reassurance-only strategies (reassurance is short-lived).
2. Illness Anxiety Disorder (formerly Hypochondriasis)
Definition
Preoccupation with having or acquiring a serious illness, when somatic symptoms are absent or only mild. The fear, not the symptom, dominates.
Key criteria
- Preoccupation present ≥ 6 months (the specific feared illness may change).
- High level of health anxiety; easily alarmed about health.
- Excessive health-related behaviours (repeated body-checking) OR maladaptive avoidance (avoids doctors/hospitals).
- Two subtypes: care-seeking type vs care-avoidant type.
High-yield: Distinguish from SSD — in SSD the somatic symptoms are prominent; in illness anxiety disorder the symptoms are minimal/absent and the FEAR of disease dominates.
Management
CBT (first-line psychotherapy), SSRIs; regularly scheduled visits with one physician; address the cognitive distortion of catastrophising bodily sensations.
3. Conversion Disorder (Functional Neurological Symptom Disorder) — the exam favourite
Definition
One or more symptoms of altered voluntary motor or sensory function that are incompatible with recognised neurological/medical disease, arising in relation to psychological stressors and not intentionally produced.
Pathophysiology / mechanism
A psychological conflict or stressor is unconsciously converted into a physical (usually neurological) symptom. Symptom onset/exacerbation is typically preceded by a psychosocial stressor or conflict.
Typical presentations
- Motor: paralysis, weakness, abnormal gait (astasia-abasia), tremor, dystonia.
- Sensory: anaesthesia, blindness, deafness.
- Non-epileptic seizures ("pseudoseizures" / psychogenic non-epileptic attacks, PNES).
- Globus (lump in throat), aphonia.
Classic signs (frequently tested)
| Sign | What it shows |
|---|---|
| Hoover's sign | Functional leg weakness: no downward pressure of the "weak" heel when lifting the good leg against resistance; involuntary extension returns when attention is on the good leg |
| La belle indifférence | A surprisingly calm, indifferent attitude to a dramatic deficit (classic but NOT specific or diagnostic) |
| Glove-and-stocking anaesthesia | Sensory loss with sharp non-anatomical borders, not following dermatomes |
| Tubular / tunnel vision | Visual fields do not expand with distance, unlike organic |
| Convergence/optokinetic preserved in "blindness" | Suggests functional visual loss |
High-yield: La belle indifférence (la-bell-an-dif-er-ence) is the classic answer in conversion disorder MCQs, BUT it is neither sensitive nor specific — it can be absent in conversion and present in organic disease. Do not rely on it to diagnose.
Primary vs Secondary gain — must know cold
| Gain | Definition | Example |
|---|---|---|
| Primary gain | The symptom keeps the internal psychological conflict / anxiety out of conscious awareness (intrapsychic relief) | Anxiety about a forbidden impulse is "bound" by developing paralysis |
| Secondary gain | External, real-world advantages gained from being ill | Avoiding work/exams, attention, sympathy, financial compensation, escaping responsibility |
High-yield: Primary gain = internal (reduces anxiety/conflict). Secondary gain = external (tangible benefits). Both occur unconsciously in conversion disorder. Conscious pursuit of external gain = malingering.
Diagnostic approach (flow)
Detailed history + clear psychosocial stressor → neurological exam revealing internal inconsistency / incompatibility (e.g., positive Hoover's sign) → targeted investigations to exclude organic disease (MRI brain, EEG/video-EEG for PNES) → demonstrate symptom is incompatible with known disease → diagnose conversion disorder.
- For suspected non-epileptic seizures the investigation of choice is video-EEG telemetry (captures an attack with a normal ictal EEG and no post-ictal changes; retained awareness, pelvic thrusting, eye closure, side-to-side head movement favour PNES).
Management
- Reassure and explain the diagnosis positively (a real, treatable, reversible condition — not "it's all in your head").
- Physiotherapy for motor conversion; CBT.
- Treat comorbid depression/anxiety.
- Most acute cases (especially in children/adolescents) have a good prognosis and resolve quickly.
High-yield: Good prognostic factors in conversion disorder — acute onset, identifiable stressor, short duration, good premorbid function, early treatment. Poorer prognosis — tremor and seizures (vs paralysis/aphonia which do better).
4. Factitious Disorder vs Malingering — the critical differential
This separation is the single most tested concept in this whole chapter.
| Feature | Conversion / SSD | Factitious disorder | Malingering |
|---|---|---|---|
| Symptom production | Unconscious (not intentional) | Intentional / conscious (deliberately feigned or self-induced) | Intentional / conscious |
| Motivation | Unconscious (primary/secondary gain) | To assume the SICK ROLE (internal psychological need; no external reward) | External incentive (money, drugs, avoiding jail/work/military) |
| Is it a mental disorder? | Yes | Yes (it is a psychiatric diagnosis) | No — it is NOT a disorder; a V-code/behaviour |
High-yield: Factitious disorder = deception is conscious, but the motive is unconscious (to be a patient / sick role). Malingering = both the deception AND the external motive are conscious. This is the exact discriminator MCQs hinge on.
- Factitious disorder imposed on self = the older term Munchausen syndrome (dramatic, travels between hospitals, peregrination; may inject faeces, manipulate thermometers, take warfarin).
- Factitious disorder imposed on another (Munchausen syndrome by proxy) = a caregiver (usually mother) fabricates/induces illness in a child — this is a recognised form of child abuse and is reportable.
5. Body Dysmorphic Disorder (related, classified under OCD-spectrum)
Preoccupation with an imagined or slight defect in appearance (skin, hair, nose), with repetitive behaviours (mirror-checking, reassurance-seeking). Note: in DSM-5 it sits under obsessive-compulsive and related disorders, not somatic — a common trap. High suicide risk; treat with SSRIs (often high dose) + CBT; avoid cosmetic surgery (rarely satisfies).
6. Dissociative Disorders
Dissociation = a disruption in the normally integrated functions of consciousness, memory, identity, emotion, perception and behaviour, usually triggered by severe trauma/stress.
Dissociative Amnesia
- Inability to recall important autobiographical information, usually of a traumatic or stressful nature, too extensive for ordinary forgetfulness.
- The memory loss is typically retrograde and for personal/episodic information; procedural memory and general knowledge are preserved (key clue distinguishing from organic amnesia).
- Localised, selective, generalised or systematised patterns.
Dissociative Fugue (a specifier of dissociative amnesia in DSM-5)
- Sudden, unexpected travel away from home with inability to recall one's past and confusion about identity / assumption of a new identity.
- Recovery is usually rapid; amnesia for the fugue period remains afterward.
High-yield: Dissociative fugue = purposeful travel + amnesia for personal identity in the absence of organic cause. Classically follows a major psychosocial stressor or trauma.
Dissociative Identity Disorder (DID, formerly Multiple Personality Disorder)
- ≥ 2 distinct personality states ("alters") with recurrent gaps in recall.
- Strongly associated with severe, repeated childhood trauma/sexual abuse.
Depersonalisation / Derealisation Disorder
- Depersonalisation = feeling detached from one's own body/mind ("watching myself from outside", like a robot).
- Derealisation = the external world feels unreal, dreamlike or distorted.
- Reality testing remains INTACT (the patient knows the feeling is not real) — distinguishes it from psychosis.
Management of dissociative disorders
- Ensure safety; treat comorbid PTSD/depression.
- Psychotherapy is mainstay (trauma-focused therapy, hypnosis, abreaction).
- A drug-assisted (amobarbital / "Amytal" or lorazepam) interview can help recover memories in dissociative amnesia/fugue.
- No specific drug cures dissociation; medication targets comorbidities.
Organic mimics you must exclude (key differentials)
| Presentation | Must rule out |
|---|---|
| Non-epileptic seizures | True epilepsy (video-EEG) |
| Functional weakness/sensory loss | Stroke, MS, GBS, spinal lesion |
| Dissociative amnesia | Transient global amnesia, head injury, Wernicke–Korsakoff, temporal lobe epilepsy, substance/alcohol blackout |
| Multiple somatic complaints | Early SLE, MS, thyroid disease, porphyria, hyperparathyroidism |
High-yield: A purely retrograde amnesia with preserved ability to learn new information points to dissociative (psychogenic) amnesia; anterograde memory impairment (can't form new memories) points to an organic cause.
Recently asked / exam angle
- La belle indifférence → Conversion disorder (single most repeated one-liner). Remember: not specific.
- Difference between factitious disorder and malingering — motive (sick role vs external gain). Repeatedly asked as a two-statement/matching question.
- Primary vs secondary gain — internal anxiety relief vs external benefit; both unconscious in conversion.
- Munchausen syndrome by proxy asked as a form of child abuse / under forensic-psychiatry overlap.
- Hoover's sign for functional leg weakness.
- Investigation of choice for pseudoseizures = video-EEG.
- Dissociative fugue = travel + identity loss following stress.
- DSM-5 reclassification: hypochondriasis → illness anxiety disorder; somatization → somatic symptom disorder; "medically unexplained" dropped.
- BDD is under OCD-spectrum, not somatic disorders (trap question).
- Depersonalisation/derealisation — reality testing intact (vs psychosis).
Quick mnemonics
- "FACTITIOUS = FAKE for the patient role; MALINGER = MAKE money/material gain."
- Conversion good-prognosis: "SAGE" — Short duration, Acute onset, identifiable stressor, Good premorbid function, Early treatment.
- Dissociative = "identity, memory, consciousness" get disrupted.
Rapid revision
- SSD: distressing somatic symptoms + disproportionate thoughts/anxiety/behaviour, > 6 months; "medically unexplained" no longer required in DSM-5.
- Illness anxiety disorder = fear of having illness with minimal/absent symptoms; care-seeking vs care-avoidant subtypes.
- Conversion disorder = unconsciously produced neurological symptom incompatible with disease; preceded by psychological stressor.
- La belle indifférence is the classic but non-specific sign of conversion disorder.
- Primary gain = internal (reduces unconscious anxiety); secondary gain = external (attention, compensation, escaping duty).
- Factitious disorder — symptoms intentionally produced, motive is the sick role (Munchausen); it IS a mental disorder.
- Malingering — intentional symptoms for external reward; NOT a psychiatric disorder.
- Munchausen by proxy = caregiver fabricates illness in a child = child abuse, reportable.
- Hoover's sign confirms functional leg weakness; video-EEG is the investigation of choice for psychogenic non-epileptic seizures.
- Dissociative amnesia spares procedural memory and general knowledge; dissociative fugue = travel + new/confused identity after stress.
- Depersonalisation/derealisation disorder — distressing detachment with intact reality testing.
- Management across the board: single physician + scheduled visits + CBT + SSRIs; physiotherapy for motor conversion; drug-assisted interview for dissociative amnesia. BDD sits under the OCD-spectrum, not here.