Somatic Symptoms and Related Disorders

Introduction

Somatic Symptoms and Related Disorders are a group of psychiatric conditions characterized by prominent somatic symptoms associated with significant distress and impairment. For the MCCQE1, understanding these disorders is crucial as they are frequently encountered in Canadian primary care settings.

These disorders challenge the Medical Expert and Communicator CanMEDS roles, requiring a balance between ruling out organic pathology and avoiding unnecessary investigations (Choosing Wisely Canada).

Classification and DSM-5-TR Criteria

The key disorders in this category relevant to MCCQE1 preparation include:

1. Somatic Symptom Disorder (SSD)
2. Illness Anxiety Disorder (IAD)
3. Conversion Disorder (Functional Neurological Symptom Disorder)
4. Factitious Disorder
5. Psychological Factors Affecting Other Medical Conditions

Differential Diagnosis: The “Intent” Spectrum

One of the highest-yield concepts for the MCCQE1 is distinguishing between Somatic Symptom Disorders, Factitious Disorder, and Malingering.

Epidemiology in Canada

• Prevalence: Somatic Symptom Disorder prevalence is estimated at 5–7% of the general population.
• Primary Care: Somatic symptoms account for a significant portion of visits to Canadian family physicians.
• Gender: More common in females.
• Comorbidity: High rates of comorbid anxiety and depressive disorders.

Management Approach (Canadian Context)

Management requires a strong physician-patient relationship. The goal is often care, not cure—focusing on functional improvement rather than total symptom elimination.

The CARE MD Approach

A useful mnemonic framework for management in primary care:

Canadian Guidelines and Resources

• Choosing Wisely Canada: Specifically advises against imaging for low back pain unless “red flags” are present. This is highly relevant for Somatic Symptom Disorder patients presenting with chronic pain.
• CANMAT (Canadian Network for Mood and Anxiety Treatments): While focused on mood/anxiety, their guidelines on first-line pharmacotherapy (SSRIs/SNRIs) apply to the comorbid conditions often seen in SSD.
• CPSO (College of Physicians and Surgeons of Ontario) & Other Provincial Colleges: Emphasize the duty to report if a patient is driving dangerously due to a medical condition (relevant for conversion disorder with seizures/syncope).

Key Points to Remember for MCCQE1

1. Diagnosis of Exclusion? No. While you must rule out organic disease, SSD is diagnosed by the presence of maladaptive thoughts/feelings regarding symptoms, not just negative tests.
2. Hoover’s Sign: A classic sign for functional weakness (Conversion Disorder). Extension of the “normal” leg occurs when the patient is asked to flex the “paralyzed” leg against resistance.
3. La Belle Indifférence: A classic (though not sensitive) sign in Conversion Disorder where the patient seems unconcerned about a serious symptom (e.g., blindness or paralysis).
4. Counter-transference: Be aware of your own frustration. These patients can be perceived as “difficult.” The exam may test your ability to maintain professionalism.
5. Factitious vs. Malingering: Look for the reward. If it’s to be a “patient,” it’s Factitious. If it’s for money/work avoidance, it’s Malingering.

Sample Question

Case Presentation

A 28-year-old female presents to her family physician complaining of “unbearable” abdominal bloating, intermittent joint pain, and “tingling” in her hands. She brings a binder of internet printouts regarding autoimmune diseases. Over the past 8 months, she has visited the Emergency Department six times and seen three different specialists (Gastroenterology, Rheumatology, Neurology), all of whom found no organic pathology. Her physical exam today is unremarkable. She states, “I spend all day thinking about what disease I might have; I can’t focus on my job.” She is tearful and insists on an MRI.

Question

Which one of the following is the most appropriate initial management step?

• A. Refer to a fourth specialist (Immunology) to reassure the patient.
• B. Order a full body MRI to definitively rule out pathology.
• C. Schedule regular, brief follow-up appointments with the family physician.
• D. Prescribe a high-dose benzodiazepine for anxiety.
• E. Confront the patient stating that her symptoms are not real.

Explanation

The correct answer is:

• C. Schedule regular, brief follow-up appointments with the family physician.

Detailed Explanation: The patient meets the criteria for Somatic Symptom Disorder (somatic symptoms causing distress, excessive time/energy devoted to symptoms, duration > 6 months).

• Option C is the gold standard for management in primary care. Regular, time-contingent visits (e.g., every 4 weeks) prevent the patient from needing to generate new symptoms to “earn” a doctor’s visit. It builds a therapeutic alliance and allows for gradual education on coping mechanisms.
• Option A reinforces the patient’s maladaptive behavior (doctor shopping) and fragments care.
• Option B violates Choosing Wisely principles. Unnecessary testing leads to incidentalomas and increased anxiety.
• Option D is incorrect. Benzodiazepines have a high risk of dependence and do not treat the core cognitive distortions. SSRIs would be the preferred pharmacotherapy if indicated.
• Option E damages the therapeutic alliance. The patient’s suffering is real, even if the cause is not organic.

References

1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
2. Medical Council of Canada. (n.d.). MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives.
3. Kurlansik, K., & Maffei, M. S. (2016). Somatic Symptom Disorder. American Family Physician, 93(1), 49-54.
4. Choosing Wisely Canada. (n.d.). Family Medicine Recommendations. Retrieved from choosingwiselycanada.org 
5. Toronto Notes. (2023). Psychiatry Chapter: Somatic Symptom and Related Disorders.