Somatic symptom and related disorders
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has recategorized “somatoform disorders” as somatic symptom and related disorders. The term somatoform disorder is still recognized, however, by the WHO International Classification of Diseases, 10th Revision (ICD-10). (In ICD-11, which is now in development and is scheduled for approval by January 2022, this designation may be replaced with the term bodily distress disorder.) The term “somatization” is a more general description of the syndrome of symptoms that suggest physical illness or injury in the absence of objective findings or a known physiological mechanism. These symptoms may be result from anxiety, depression, or interpersonal conflicts.
The syndrome is not uncommon; the prevalence in the general population is approximately 6%. Risk factors associated with somatization include female sex, lower socioeconomic or educational level, and ethnic minority status. Somatization is a known problem among outpatient clinics, emergency department visits, and admittances to hospitals because each case requires investigation to rule out underlying disease. However, the disorder has significant ramifications for the individual affected because it can cause impaired functioning and disability. The most common presentation includes pain (eg, headache, back pain), gastrointestinal complaints, cardiopulmonary symptoms, and various neurological symptoms. The manifestation can involve any system; ophthalmologists should be aware of this syndrome because patients may present with ophthalmic-related symptoms such as blurred or double vision.
Entities under the DSM-5 designation of somatic symptom and related disorders include conversion disorder, illness anxiety disorder, and factitious disorder.
Conversion disorder is characterized by temporary and involuntary loss or alteration of physical functioning caused by psychosocial stress. Symptoms are typically neurologic and may include functional vision loss. Psychotherapy is the primary treatment. Diagnosis may be difficult because of the subjective nature of the symptoms.
Illness anxiety disorder Formerly called hypochondriasis, illness anxiety disorder is a preoccupation with the fear of having or developing a serious disease. Physical examination fails to support the patient’s belief, and reassurance by the examining physician often fails to allay the fear. A subcategory of this entity relevant to ophthalmologists is body dysmorphic disorder, in which the patient believes that his or her body is deformed, even though there is no physical defect, or the patient has an exaggerated concern about a mild physical anomaly. Ophthalmologists performing reconstructive and cosmetic surgery should be aware of this disorder because surgical repair of the “defect” is rarely successful in the patient’s mind.
Factitious disorder and malingering
Factitious disorder (previously known as Munchausen syndrome) is characterized by the willful production, feigning, or exaggeration of physical or psychological signs or symptoms in the absence of external causes. Treatment requires discovery of the true nature of the physical illness, a carefully planned confrontation, and psychotherapy. Prognosis for recovery is guarded. Self-inflicted chronic conjunctivitis, keratitis, and even scleritis are the usual ophthalmic presentations of factitious disease. Although related, malingering is not classified as a mental illness because it involves the fabrication of symptoms for secondary personal gain (eg, money, drugs); malingering should be considered when symptoms and findings do not make sense. Ophthalmologists should be familiar with techniques for detecting malingerers because patients are occasionally encountered in practice settings. See BCSC Section 5, Neuro-Ophthalmology, for a description of some of these techniques.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) occurs after an individual has been exposed to a traumatic event associated with intense fear. When exposed to reminders of the event, the patient then persistently re-experiences the event through intrusive recollections, nightmares, flashbacks, or distress. The lifetime prevalence of PTSD is variable but has been reported at rates as high as 12% in the general population of North America and significantly lower rates (approximately 1%) in other countries. This difference is poorly understood. Combat soldiers and victims of assault are at particular risk. Treatment usually includes cognitive behavioral therapy, psychotherapy, and antidepressants.
Personality disorders, which affect approximately 6% of the global population, merit discussion here because they may be associated with substance abuse and poor adherence to treatment. These disorders are diagnosed when personality traits become so inflexible and maladaptive that they create significant occupational and/or interpersonal dysfunction. Patients usually have little or no insight into their disorder. DSM-5 categorizes these disorders into 3 types:
Cluster A personality disorders include paranoid, schizotypal, and schizoid disorders.
Cluster B personality disorders include antisocial, borderline, histrionic, and narcissistic personality disorders. Patients with these disorders may display dramatic or irrational behavior and may have a tendency for disruptive behavior in clinical settings.
Cluster C personality disorders include avoidant, dependent, and obsessive-compulsive personality disorders.
Psychotherapy is generally the treatment of choice for all of these entities. There are no medications indicated specifically for personality disorders, although psychotropic agents may be helpful in treating coexisting mental health disorders (eg, depression or substance abuse).
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.