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Understanding Somatic Symptom Disorders and Functional Neurological Presentations
Abnormal Psychology · Chapter 14: Somatic Symptom and Related DisordersSection 14.1 · lesson 51 of 9717 min · free with a free account
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In this lesson
Real, involuntary symptoms - diagnosed on what is found.
- Describe the somatic symptom family and how it was reorganized
- Explain why a medical diagnosis doesn't exclude it
- Describe the positive-diagnosis principle
- Explain involuntariness, and how the diagnosis is explained
Transcript
Everything said in the video, section by section (2,270 words). Read along, or search it.
Somatic Symptom and Related Disorders
Somatic Symptom and Functional Neurological Disorders
This chapter moves into conditions where the body is at the center of the presentation. This first section covers two of them. Somatic symptom disorder, and functional neurological symptom disorder. We start with the single most important fact about both, and it will be repeated throughout. Then the history behind the terminology, and how the diagnoses were recently reorganized. Then the controversy, stated at full strength. And we finish with how these conditions are assessed, explained to the people who have them, and treated.
Read This First
The Central Fact of This Section
The central fact of this section comes first. The symptoms in these conditions are real, and they are involuntary. They are not fabricated, and the person is not pretending. A person with functional weakness cannot move the limb. A person with functional seizure-like episodes is not performing them. This is a statement about the condition. It is not a courtesy extended to the people who have it. Second, a psychological diagnosis never removes the obligation to investigate and monitor for medical disease. New or changing physical symptoms need medical assessment, whatever else a person has been diagnosed with. This material is educational. It is not a basis for interpreting anyone's physical symptoms, including your own. And on language. This section avoids words like hysterical, somatizer, and attention-seeking, because of the harm they have done.
The Family
Bodily Symptoms at the Center
The conditions in this chapter share one feature. Bodily symptoms, or bodily concerns, sit at the center of the presentation. And the distress and disability are out of proportion to what physical examination and investigation explain. These conditions sit at the interface between medical and psychological services. That is the source of most of the difficulty. The person presents to medicine, the formulation draws on psychology, and neither service alone accounts for the whole picture. Somatic symptom disorder and functional neurological disorder are developed here. Illness anxiety comes in section three. Psychological factors affecting other medical conditions come in section four. And factitious disorder, where symptoms are produced intentionally, is named here only to mark a boundary. It belongs to chapter twenty-three. Everything else in this family involves symptoms the person is not producing deliberately. That line is the most consequential one in the chapter.
History
Why "Hysteria" Was Abandoned
For most of the history of medicine, much of this territory was described under one word. Hysteria. The word comes from the Greek for uterus. And for most of its existence, it carried a claim that these presentations arose from women's bodies, or women's character. The harm was substantial, and it is not a historical curiosity. Women with physical symptoms were routinely described as suggestible, attention-seeking, or unstable. Presentations were dismissed rather than investigated. Treatments were applied with no rationale, and some caused injury. And conditions later shown to be clearly organic were attributed to hysteria in the meantime. The word was abandoned because it had become an insult, carried an unsupported claim about cause, and was applied too broadly to mean anything. Two features of the modern field are direct responses to that history. The insistence that the symptoms are real. And the insistence that diagnosis rests on positive features, not on failing to find something else.
The Reclassification
A Real Fix That Created a New Risk
The current edition of the most widely used classification system changed how these conditions are defined. The reasoning and the criticism both deserve a fair statement. Previously, symptoms had to be medically unexplained. Now, the diagnosis rests on positive psychological features, the thoughts, feelings, and behaviors around the symptoms. The rationale was that unexplained depended on the state of medical knowledge, and on how thoroughly someone had been investigated. The criticism is that a person with a well-explained illness can now receive the diagnosis, which widens it considerably. Previously, a set count of symptoms across body systems was required. Now, one or more distressing symptoms is enough, with the emphasis on the response to them. Symptom counts were arbitrary. But the threshold is now a judgment about proportion, which is harder to apply consistently. And the old approach implicitly separated real from unreal illness. The new one explicitly declines that separation, treating psychological and physical processes as interacting. Critics accept that principle, but argue the implementation risks the opposite error. Attaching a psychological diagnosis to people who are physically ill. The honest summary is that the change fixed a real problem, and created a different one.
Somatic Symptom Disorder
The Response to Symptoms, Not Their Origin
Somatic symptom disorder involves one or more distressing bodily symptoms that disrupt daily life. They come with excessive thoughts, feelings, or behaviors related to those symptoms. And the symptomatic state persists over a period of months. Here is the point most often missed. A diagnosed medical condition does not exclude this diagnosis. A person with confirmed heart disease, a confirmed autoimmune condition, or confirmed cancer can also meet this description. The medical condition is not an argument against it. What the diagnosis adds is a description of the person's response to their symptoms. The preoccupation, the anxiety, and the time and energy consumed. It applies where that response is itself producing distress and disability, beyond what the condition accounts for. So the two are not competing explanations for the same thing. One describes the illness, the other describes the response to it.
3 Features
Proportion, Not the Presence of Concern
At least one of three features must be present. Each is distinguished from an appropriate response to illness. The first is disproportionate, persistent thoughts about how serious the symptoms are. A conviction that persists even after assessment. An appropriate response updates on new information. This one does not, and it continues after the question has been addressed. The second is persistently high anxiety about health. Anxiety present much of the time, not only at moments of genuine uncertainty. Anxiety while waiting for a result is appropriate. Anxiety that stays the same whatever the results show is the feature described here. The third is excessive time and energy devoted to the symptoms. Much of the day spent monitoring, researching, consulting, or arranging life around them. Managing a serious illness genuinely takes time. The judgment is whether the time is proportionate to what management actually requires. Notice what all three keep returning to. Proportion relative to the person's actual situation, not the presence of concern.
The Controversy
Who Decides What Is Disproportionate?
That word, disproportionate, is exactly where the diagnosis is most controversial. Here is the criticism at full strength. Proportion is a clinician's judgment about how worried a person ought to be. And that judgment can go wrong in a predictable direction. A person who is seriously ill, or whose illness has not yet been identified, may reasonably show all three features. Those most likely to be misjudged are people whose concerns have already been dismissed. Disproportionately women, and groups whose reports are taken less seriously. Applying a psychological diagnosis to such a person compounds the original failure, and can close off further investigation. The response from the diagnosis's authors is that it is not meant to be made on worry alone. They argue it identifies people with real distress and disability, who previously had no diagnosis, and therefore no treatment pathway. And the old rule had its own documented harms. What remains unsettled is whether the safeguard holds in ordinary practice, under time pressure, with people whose accounts are already discounted. This is a genuine and current disagreement. This course does not resolve it.
Functional Neurological Disorder
Diagnosed on Positive Findings
Functional neurological symptom disorder involves altered voluntary motor or sensory function. Clinical examination shows the symptom is incompatible with recognized neurological or medical conditions. And it causes significant distress or impairment. Presentations include abnormal movement, weakness or altered walking, altered sensation, vision, or hearing, and altered speech. They also include seizure-like episodes without the electrical activity of epileptic seizures. The older term pseudoseizures is avoided, because the prefix implies falsity. Now the most important idea after involuntariness. The positive-diagnosis principle. The diagnosis rests on characteristic findings that are present, and that a trained examiner can identify. Not on the absence of findings of something else. Those findings show internal inconsistency. Function is affected in one context and present in another, in a pattern that does not match how the nervous system is organized. A diagnosis by exclusion is never secure, and gives the person nothing but a negative. A positive diagnosis can be made confidently, explained, and made early. No examination signs are described here. They belong to trained clinicians, and describing them would be neither useful nor safe.
Figure 14.1.5
The Intentionality Spectrum
This figure places each category on a spectrum of intention. In the left column are the presentations that are not produced deliberately. Somatic symptom disorder and functional neurological disorder. Everything in this chapter sits there. In the middle are symptoms produced deliberately, with no obvious external reward. That is factitious disorder, covered in chapter twenty-three. On the right are symptoms produced deliberately, for an identifiable external incentive, such as a benefit payment. That is malingering, which is a behavior, not a mental disorder. Two questions separate the columns. Is the symptom produced deliberately? And is there an identifiable external incentive? Notice what the questions are not about. Not severity, not plausibility, and not how unusual the presentation looks. A severe or unusual presentation is not thereby a deliberate one. That is the single most misunderstood point in this whole area.
Mechanism
Why Inconsistency Is Not Pretending
So why does the inconsistency in a functional presentation not mean the person is pretending? Inconsistency is intuitively read as evidence of pretending. The current account explains why it is exactly what this condition should produce. Voluntary movement normally runs largely automatically once it starts. Paying close attention to a movement changes how it is executed. That is why ordinary skilled actions become clumsy when we watch ourselves doing them. The proposal is that in these conditions, the relationship between attention, expectation, and motor control is disrupted. An expectation about the body shapes what the motor system produces. Brain imaging has found differences in regions associated with the sense of agency. That is an association, not an established mechanism. Two useful consequences follow. The inconsistency is predicted. Function returns when attention is elsewhere, and fails when it is directed at the movement. And the person can be given a coherent account. A problem with how the nervous system is functioning. Not damage, and not fabrication. What keeps the cycle going are perpetuating factors. Illness beliefs, symptom focusing, and others' responses, including repeated investigation. Those are the treatment targets.
Assessment and Communication
Parallel, Not Sequential
The intuitive approach to assessment is sequential. Investigate medically, exclude everything, and only then refer for psychological assessment. That fails for three reasons. It takes years. And it teaches the person that psychology is what is left when medicine has given up. It also turns the diagnosis into one of exclusion. The parallel model conducts medical assessment and psychological formulation alongside each other from the outset, and tells the person both are happening. It also avoids a poor explanation. We have ruled everything else out. That only explains what the symptom is not, and invites yet more investigation. How the diagnosis is explained affects whether it is accepted, so the explanation is part of treatment. First, name the condition. Second, say how it was diagnosed. Positive findings were present, not simply absent results. Third, explain the mechanism in terms of function rather than damage, which is why scans looking for damage were normal. Fourth, say explicitly that the symptoms are real and involuntary. People often arrive expecting to be told they are imagining it. And fifth, say it can improve, and leave the door open. The diagnosis will be revisited if the picture changes.
Treatment
Principles, Not Protocols
Treatment is described here at the level of principle only. None of it is a protocol, and none of it should be attempted independently. Education is a treatment in its own right. A coherent account of what the symptoms are reduces the fear that sustains attention to them. Specialist physiotherapy has the best evidence for functional motor presentations. It works with the difference between automatic and attended movement, and it is clinician-led. Cognitive-behavioral approaches target the perpetuating factors. Symptom focusing, illness beliefs, and avoidance. Treating co-occurring anxiety or depression is often among the most effective steps available, because those conditions have well-established treatments. The general finding is that outcome depends heavily on whether the person accepts and engages with the formulation. A person who leaves believing they were told it is all in their head will not engage. And they will be right not to trust the explanation they were given. Coordinated care matters too. One clinician should hold the overall plan, with medical and psychological care running in parallel, not in sequence.
2 Composite Cases
Both Diagnoses Apply - and a Positive Explanation
Two composite cases, constructed for instruction, pull this together. They describe no real people. Helena is fifty-eight. She has a confirmed heart condition, well controlled and stable on review. Yet she checks her pulse many times a day, has attended emergency services eleven times, and has organized her life around her heart. Both diagnoses apply. Her heart condition is real and needs treatment, and all three somatic symptom features are present too. Concluding her behavior needs no attention would leave her life shrunk to the size of her illness. Concluding her symptoms need no assessment would be dangerous. Omar is thirty-three. He developed weakness in his right leg, and has not worked in four months. His scans were normal. He was told nothing was found, and that he should be reassured. He was not, because he still could not use his leg. A neurologist then made a positive diagnosis, from findings that were present. He was told its name, that it is real and not something he is doing, and that it can improve. Nothing was found gave him no account, and no treatment. The positive explanation gave him both.
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