# Lecture 8: Somatic Symptom and Eating Disorders ## Unit 2.6: Psychiatry --- ## Learning Objectives By the end of this lecture, students will be able to: 1. Describe somatic symptom disorder and its diagnostic criteria 2. Explain illness anxiety disorder and conversion disorder 3. Describe factitious disorder and malingering 4. Explain the diagnostic criteria for anorexia nervosa 5. Describe bulimia nervosa and binge eating disorder 6. Explain the medical complications and treatment of eating disorders --- ## Lecture Outline ### I. Somatic Symptom Disorder Somatic symptom disorder is characterized by one or more somatic symptoms that are distressing or result in significant disruption of daily life, along with excessive thoughts, feelings, or behaviors related to the somatic symptoms. The key diagnostic shift in DSM-5 emphasizes the excessive psychological response to symptoms rather than the absence of medical explanation. This change recognizes that patients with legitimate medical conditions can simultaneously have disproportionate psychological distress about those symptoms. The diagnostic criteria require one or more somatic symptoms that are distressing or disruptive, plus excessive thoughts, feelings, or behaviors manifested by at least one of three phenomena: disproportionate and persistent thoughts about the seriousness of symptoms, persistently high level of anxiety about health or symptoms, or excessive time and energy devoted to these symptoms or health concerns. The state of being symptomatic must persist for more than six months, though the specific symptom may change over time. Specifiers describe particular presentations. With predominant pain specifies that pain symptoms dominate the presentation, replacing the former diagnosis of pain disorder. Persistent indicates severe symptoms and marked impairment lasting more than six months. Severity is rated as mild with one criterion, moderate with two or more, or severe with two or more plus multiple somatic complaints or one very severe somatic symptom. The clinical approach to somatic symptom disorder emphasizes validation and collaborative care. Patients genuinely suffer and should not be dismissed or told their symptoms are imaginary. Regular scheduled appointments provide reassurance without reinforcing illness behavior through only seeing the patient during crises. Careful physical examination at each visit reassures while avoiding unnecessary tests. Gradual focus on function rather than symptom elimination promotes rehabilitation. Treatment of comorbid depression and anxiety is often beneficial. Panel A displays the DSM-5 diagnostic criteria emphasizing both somatic symptoms and excessive psychological response, with the three manifestations (disproportionate thoughts, health anxiety, excessive time/energy) shown as required elements. Panel B illustrates the shift from DSM-IV to DSM-5: removal of requirement that symptoms be medically unexplained, focus on psychological response rather than symptom origin, recognition that medical illness and excessive response can coexist. Panel C shows specifiers: with predominant pain (replacing pain disorder), persistent (greater than 6 months, marked impairment), and severity levels (mild: 1 criterion, moderate: 2+, severe: 2+ with multiple or severe symptoms). Panel D presents the clinical approach framework: validation (genuine suffering), scheduled visits (not only during crises), examination (reassurance without excess testing), function focus (not just symptom elimination), comorbidity treatment (depression, anxiety). --- ### II. Illness Anxiety Disorder Illness anxiety disorder, previously termed hypochondriasis, is characterized by preoccupation with having or acquiring a serious illness. Somatic symptoms are not present or are only mild in intensity. There is high level of anxiety about health, and the individual is easily alarmed about personal health status. The individual performs excessive health-related behaviors such as repeatedly checking the body for signs of illness, or exhibits maladaptive avoidance such as avoiding doctor appointments and hospitals. The illness preoccupation has been present for at least six months, though the specific illness feared may change. The key distinction from somatic symptom disorder is the presence or absence of somatic symptoms. In illness anxiety disorder, symptoms are absent or only mild, and the focus is on the idea of being ill. In somatic symptom disorder, actual symptoms are present and cause distress. Both involve excessive concern about health, but the phenomenology differs fundamentally in whether symptoms or the disease idea predominates. Illness anxiety disorder is divided into care-seeking type and care-avoidant type. The care-seeking type involves frequent medical visits, diagnostic testing, and requests for reassurance from physicians. The care-avoidant type involves avoidance of the medical system, hospitals, and reminders of illness due to anxiety that medical attention might confirm feared diagnoses. The prevalence is approximately one to two percent, and the disorder often runs a chronic, relapsing course. Onset can occur at any age but often begins in early adulthood. Comorbidity with anxiety disorders and depression is common. Treatment approaches include cognitive-behavioral therapy focusing on health anxiety, reduction of excessive health-related behaviors, stress management, and sometimes SSRIs for associated anxiety and depression. Panel A presents illness anxiety disorder diagnostic criteria: preoccupation with having or acquiring serious illness, absent or mild somatic symptoms, high health anxiety, excessive health behaviors or maladaptive avoidance, duration of at least 6 months. Panel B contrasts illness anxiety disorder with somatic symptom disorder: illness anxiety (minimal symptoms, fear of disease idea, preoccupied with diagnosis) versus somatic symptom disorder (actual symptoms present, distressed by symptoms themselves, excessive response to symptoms). Panel C shows the two subtypes: care-seeking (frequent visits, testing, reassurance-seeking shown as person in medical setting) versus care-avoidant (avoids hospitals, doctors, reminders of illness shown as person turning away from medical setting). Panel D displays treatment approaches: CBT for health anxiety, reduction of excessive health behaviors, stress management, and SSRIs for comorbid anxiety/depression. --- ### III. Conversion Disorder and Factitious Disorder Conversion disorder, also termed functional neurological symptom disorder, presents with one or more symptoms of altered voluntary motor or sensory function. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. The symptom is not better explained by another medical or mental disorder. Symptoms cause clinically significant distress or impairment. Specifiers include weakness or paralysis, abnormal movement, swallowing symptoms, speech symptom, attacks or seizures, anesthesia or sensory loss, and special sensory symptom. The clinical findings demonstrating incompatibility are essential for diagnosis and include positive neurological signs indicating functional rather than structural etiology. Hoover's sign tests for functional weakness: the patient is asked to extend the weak hip against resistance while the examiner feels for downward pressure from the supposedly weak leg when the opposite leg is raised. Variable examination findings that change with attention and distraction suggest functional rather than fixed neurological deficits. Normal findings on diagnostic testing when abnormalities would be expected with true neurological disease provide additional evidence. Factitious disorder involves falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents themselves to others as ill, impaired, or injured. The deceptive behavior is evident even in the absence of obvious external rewards. The behavior is not better explained by another mental disorder such as delusional disorder. Factitious disorder imposed on self refers to fabrication of one's own illness. Factitious disorder imposed on another, previously termed Munchausen syndrome by proxy, involves fabricating or inducing illness in another person under the individual's care. Malingering is not a mental disorder but rather the intentional production of false or exaggerated symptoms motivated by external incentives such as avoiding work or military duty, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Unlike factitious disorder, the motivation is external gain rather than assuming the sick role. Malingering should be suspected when there is marked discrepancy between claimed disability and objective findings, when medicolegal context is present, when the patient is uncooperative with evaluation, or when antisocial personality disorder is present. Panel A presents conversion disorder diagnostic framework: symptoms of altered motor or sensory function, clinical evidence of incompatibility with neurological disease, not explained by other disorder, causes distress or impairment, with specifiers (weakness, movement, swallowing, speech, seizures, sensory loss). Panel B illustrates positive neurological signs: Hoover's sign (downward pressure on weak hip when raising opposite leg), variable examination (changes with attention and distraction), normal testing (when abnormalities expected). Panel C displays factitious disorder components: falsification or induction of symptoms, identified deception, presents as ill, no obvious external reward, with imposed on self versus imposed on another (Munchausen by proxy). Panel D compares factitious disorder versus malingering: both involve intentional symptom production, but factitious is motivated by sick role assumption while malingering is motivated by external gain (avoiding duty, obtaining compensation, evading prosecution, obtaining drugs). --- ### IV. Anorexia Nervosa Overview Anorexia nervosa is characterized by three diagnostic criteria: restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health; intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain even though at significantly low weight; and disturbance in the way one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. The two subtypes reflect different behavioral patterns. The restricting type describes presentations during the last three months in which the individual has not engaged in recurrent episodes of binge eating or purging behavior. Weight loss is accomplished primarily through dieting, fasting, or excessive exercise. The binge-eating/purging type applies when the individual has engaged in recurrent episodes of binge eating or purging behavior during the last three months. This may occur even when the individual is at significantly low weight. Epidemiology reveals a lifetime prevalence of approximately 0.5 to 1 percent in women and approximately 0.1 percent in men. Peak onset occurs in adolescence. Anorexia nervosa has the highest mortality rate of any psychiatric disorder, with estimates of five to ten percent for those hospitalized and twelve-year mortality rates approaching twenty percent in some studies. Death results from medical complications or suicide. Risk factors include female sex, adolescence, perfectionism, family history of eating disorders, and certain activities emphasizing thinness such as ballet and modeling. The psychological features of anorexia nervosa extend beyond the diagnostic criteria. Body image disturbance involves experiencing one's body as larger than it objectively is. Perfectionism and rigidity often characterize thinking patterns. Achievement orientation may drive relentless pursuit of weight loss goals. Alexithymia, difficulty identifying and expressing emotions, is common. Anxiety and obsessional features frequently co-occur. Depression may be secondary to starvation or a primary comorbidity. Panel A presents the three diagnostic criteria as interconnected elements: restricted intake leading to low weight, intense fear of gaining weight or behavior interfering with weight gain, and disturbance in body weight/shape experience with undue influence on self-evaluation or denial of seriousness. Panel B contrasts the two subtypes: restricting type (no binge/purge in past 3 months, weight loss via dieting, fasting, exercise) versus binge-eating/purging type (recurrent binge or purge episodes even at low weight). Panel C displays epidemiology: 0.5-1% women, 0.1% men, peak onset adolescence, highest psychiatric mortality (5-10% hospitalized, up to 20% at 12 years), death from complications or suicide. Panel D shows psychological features: body image disturbance (perceive larger), perfectionism and rigidity, achievement orientation, alexithymia (difficulty with emotions), comorbid anxiety/OCD features, depression. --- ### V. Medical Complications of Anorexia Nervosa Cardiovascular complications result from malnutrition and electrolyte abnormalities. Bradycardia is common and may be severe. Hypotension occurs due to volume depletion. Orthostatic changes reflect impaired autonomic function. QT prolongation predisposes to arrhythmias. Mitral valve prolapse may develop with weight loss. Heart failure can occur during refeeding if fluid shifts are not carefully managed. Metabolic and endocrine abnormalities are widespread. Hypothermia reflects decreased metabolic rate. Amenorrhea results from hypothalamic suppression of the reproductive axis, though it is no longer required for diagnosis. Bone loss occurs due to estrogen deficiency and malnutrition, with osteopenia and osteoporosis developing even in young patients. Low T3 syndrome reflects the body's effort to conserve energy. Hypoglycemia may occur with severe restriction. Gastrointestinal complications include delayed gastric emptying contributing to early satiety and fullness complaints, constipation due to decreased gut motility, and elevated liver enzymes. In the binge-eating/purging subtype, additional complications include esophageal tears, dental erosion from vomiting, and parotid gland enlargement. Laboratory findings reflect the multisystem involvement. Electrolyte abnormalities include hypokalemia from vomiting or laxative use and hyponatremia. Hypophosphatemia is particularly concerning during refeeding and can cause refeeding syndrome with cardiac and neurological complications. Complete blood count often reveals leukopenia and anemia. Metabolic panel may show elevated BUN due to dehydration. ECG may show bradycardia and prolonged QT interval. Panel A displays cardiovascular complications with heart diagram: bradycardia (slow rate), hypotension (low BP), orthostatic changes (drop with standing), QT prolongation (arrhythmia risk on ECG strip), MVP (valve changes), and refeeding heart failure risk. Panel B shows metabolic and endocrine abnormalities: hypothermia (temperature icon), amenorrhea (reproductive axis suppression), bone loss (osteoporosis developing even in young patients), low T3 syndrome (metabolic conservation), hypoglycemia. Panel C illustrates GI complications: delayed gastric emptying and constipation (both subtypes), plus esophageal tears, dental erosion, and parotid enlargement (binge/purge subtype only). Panel D presents laboratory findings organized by system: electrolytes (low K from purging, low Na, low phosphorus especially concerning in refeeding), CBC (low WBC, anemia), BUN elevated, ECG (bradycardia, long QT). --- ### VI. Anorexia Nervosa Treatment Medical stabilization is the immediate priority for patients who are severely underweight or medically unstable. Hospitalization criteria include heart rate below forty beats per minute, blood pressure below 80/50, severe electrolyte abnormalities, temperature below 97 degrees Fahrenheit, weight below seventy percent of ideal body weight, or acute medical complications. Careful monitoring during refeeding is essential due to refeeding syndrome risk. Refeeding syndrome occurs when malnourished patients are refed too rapidly. The shift from catabolism to anabolism increases cellular uptake of phosphorus, potassium, and magnesium, causing dangerous drops in serum levels. Hypophosphatemia can cause cardiac arrhythmias, respiratory failure, and neurological dysfunction. Prevention involves starting with lower caloric intake, typically 1200-1400 calories initially, with gradual increases and close monitoring of electrolytes with aggressive supplementation. Nutritional rehabilitation aims to restore healthy weight through structured meal plans with supervision, gradual caloric increases as tolerance develops, typically gaining one to two pounds per week in inpatient settings, and addressing fears about weight gain through psychological support. Target weight is typically determined using BMI references for age and sex, often aiming for BMI above 19-20. Psychotherapy is essential once medical stability permits engagement. Family-based treatment, also known as the Maudsley approach, is the first-line treatment for adolescents and involves empowering parents to take control of refeeding, then gradually returning control to the adolescent. Cognitive-behavioral therapy for adults addresses distorted cognitions about weight and shape, along with behavioral strategies for normalized eating. Pharmacotherapy plays a limited role: no medications are FDA-approved for anorexia nervosa, though SSRIs may help with comorbid depression and anxiety after weight restoration, and olanzapine has some evidence for aiding weight gain. Panel A presents hospitalization criteria: HR less than 40, BP less than 80/50, severe electrolyte abnormalities, temperature less than 97°F, weight less than 70% IBW, acute medical complications. Panel B illustrates refeeding syndrome: rapid refeeding → shift to anabolism → intracellular shift of phosphorus, potassium, magnesium → serum depletion → cardiac/respiratory/neurological complications; prevention through slow start (1200-1400 kcal), gradual increase, electrolyte monitoring and supplementation. Panel C displays nutritional rehabilitation: structured meals with supervision, gradual caloric increases, target 1-2 lb/week gain inpatient, target BMI above 19-20. Panel D shows treatment modalities: FBT/Maudsley for adolescents (parents control then gradual transfer), CBT for adults (cognitions and behaviors), limited pharmacotherapy (no FDA-approved, SSRIs for comorbidity after weight restoration, olanzapine for weight gain). --- ### VII. Bulimia Nervosa Bulimia nervosa is characterized by recurrent episodes of binge eating, defined as eating in a discrete period of time an amount of food that is definitely larger than what most individuals would eat under similar circumstances, accompanied by a sense of lack of control over eating during the episode. Recurrent inappropriate compensatory behaviors follow the binge eating, aimed at preventing weight gain. These include self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, and excessive exercise. The binge eating and compensatory behaviors must occur at least once a week for three months. An essential criterion is that self-evaluation is unduly influenced by body shape and weight. Unlike anorexia nervosa, body weight is typically at or above normal range. The disturbance does not occur exclusively during episodes of anorexia nervosa, meaning that if a patient at low weight is bingeing and purging, the diagnosis is anorexia nervosa, binge-eating/purging type rather than bulimia nervosa. Medical complications differ somewhat from those of anorexia nervosa due to the different behaviors involved. Self-induced vomiting causes dental enamel erosion, parotid gland hypertrophy producing a characteristic chipmunk appearance, esophageal tears, and Mallory-Weiss syndrome. Electrolyte abnormalities, particularly hypokalemia and metabolic alkalosis, result from vomiting. Laxative abuse causes fluid shifts, electrolyte disturbances, and dependence with rebound constipation. Russell's sign consists of calluses on the knuckles from inducing vomiting. Treatment for bulimia nervosa differs from anorexia nervosa in the role of pharmacotherapy. Cognitive-behavioral therapy specifically adapted for bulimia nervosa, termed CBT-E or enhanced CBT, is the first-line treatment and focuses on breaking the binge-purge cycle, normalizing eating patterns, and addressing cognitive distortions about weight and shape. Fluoxetine is FDA-approved at 60 mg daily and is more effective than placebo for reducing binge and purge episodes. Interpersonal psychotherapy is an effective alternative. Nutritional counseling supports regularized eating patterns. Panel A presents bulimia nervosa diagnostic criteria: binge eating (large amount, lack of control), compensatory behaviors (vomiting, laxatives, diuretics, fasting, exercise), frequency at least weekly for 3 months, self-evaluation influenced by shape/weight, not occurring exclusively during AN. Panel B shows medical complications specific to bulimia: dental erosion (teeth diagram), parotid hypertrophy (face showing chipmunk appearance), esophageal tears, Russell's sign (knuckle calluses), electrolyte abnormalities (hypokalemia, metabolic alkalosis from vomiting), laxative dependence and rebound constipation. Panel C contrasts BN versus AN: BN typically normal or above normal weight while AN at significantly low weight, both have compensatory behaviors, diagnosis is AN binge/purge if low weight. Panel D displays treatment: CBT-E first-line (breaking cycle, normalizing eating, addressing cognitions), fluoxetine 60mg FDA-approved, IPT as alternative, nutritional counseling. --- ### VIII. Binge Eating Disorder Binge eating disorder is characterized by recurrent episodes of binge eating, with binge episodes associated with three or more of five behavioral features: eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts when not physically hungry, eating alone because of embarrassment about how much one is eating, and feeling disgusted, depressed, or very guilty afterward. Marked distress regarding binge eating is present, and the binge eating occurs at least once a week for three months. The critical distinction from bulimia nervosa is the absence of regular compensatory behaviors. Individuals with binge eating disorder do not regularly engage in purging, excessive exercise, or fasting to prevent weight gain following binges. As a result, the disorder is commonly associated with overweight and obesity, though individuals can be at any weight. Binge eating disorder is the most common eating disorder, with lifetime prevalence of approximately 2-3 percent. Unlike anorexia and bulimia nervosa, the sex ratio is more balanced, with approximately 40 percent of cases in males. Onset is typically later than other eating disorders, often in late adolescence or early adulthood. Comorbidity with obesity-related medical conditions is common, as is comorbidity with mood and anxiety disorders. Treatment addresses both the eating pathology and any comorbid obesity. Cognitive-behavioral therapy adapted for binge eating disorder is first-line and focuses on identifying triggers, developing alternative coping strategies, and addressing cognitive distortions. Interpersonal psychotherapy is an effective alternative. Lisdexamfetamine is FDA-approved for moderate to severe binge eating disorder and reduces binge eating frequency. SSRIs and topiramate have some evidence but are not FDA-approved for this indication. Behavioral weight loss programs may be combined with psychological treatment. Panel A presents binge eating disorder diagnostic criteria: binge episodes with at least 3 of 5 features (eating rapidly, eating until uncomfortable, eating when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterward), marked distress, weekly for 3 months, no regular compensatory behaviors. Panel B contrasts BED with bulimia nervosa: both have binge eating, BN has regular compensatory behaviors while BED does not, BED commonly but not always associated with overweight. Panel C displays epidemiology: 2-3% prevalence (most common eating disorder), more balanced sex ratio (40% male), later onset (late adolescence/adulthood), comorbid with obesity-related conditions and mood/anxiety disorders. Panel D shows treatment: CBT adapted for BED (triggers, coping, cognitions), IPT alternative, lisdexamfetamine FDA-approved for moderate-severe, behavioral weight loss programs as adjunct. --- ### IX. Other Eating and Related Disorders Avoidant/restrictive food intake disorder features eating or feeding disturbance manifested by persistent failure to meet nutritional or energy needs associated with significant weight loss or failure to achieve expected weight gain, nutritional deficiency, dependence on enteral feeding or oral supplements, or marked interference with psychosocial functioning. The disturbance is not explained by lack of available food or cultural practice and does not occur exclusively during anorexia or bulimia nervosa. There is no evidence of body image disturbance characteristic of anorexia nervosa. ARFID often begins in childhood and may involve sensory sensitivity to textures, lack of interest in eating, or fear of aversive consequences such as choking or vomiting. Pica involves persistent eating of non-nutritive, nonfood substances over a period of at least one month. The eating behavior is inappropriate for the developmental level and not part of a culturally supported practice. Common substances include dirt, clay, starch, ice, paper, and hair. The disorder can occur in children, during pregnancy, or in individuals with intellectual disability. Medical complications include gastrointestinal obstruction, toxicity from ingested substances, and parasitic infection. Rumination disorder involves repeated regurgitation of food over a period of at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out. The behavior is not attributable to a gastrointestinal or other medical condition and does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, BED, or ARFID. When occurring with another mental disorder or intellectual disability, the behavior is sufficiently severe to warrant clinical attention. Orthorexia, while not a DSM-5 diagnosis, describes an unhealthy obsession with healthy eating that leads to impaired functioning or nutritional deficiency. Individuals become consumed with food quality, elimination of food groups perceived as unhealthy, and rigid adherence to dietary rules. When severe, the pattern may meet criteria for anorexia nervosa or ARFID. The construct remains controversial and research continues regarding its validity and relationship to established eating disorders. Panel A presents ARFID diagnostic criteria: eating disturbance leading to failure to meet nutritional needs (weight loss/poor gain, nutritional deficiency, dependence on supplements/tube feeds, or psychosocial interference), not explained by food availability or culture, not during AN/BN, no body image disturbance, with common presentations (sensory sensitivity, lack of interest, fear of aversive consequences). Panel B displays pica characteristics: eating non-nutritive substances for at least 1 month, inappropriate for developmental level, not cultural practice, common substances (dirt, clay, starch, ice, paper, hair), complications (obstruction, toxicity, parasites). Panel C shows rumination disorder: repeated regurgitation for at least 1 month, may re-chew, re-swallow, or spit, not due to GI condition, not during other eating disorders. Panel D presents orthorexia concept: obsession with healthy eating, elimination of food groups, rigid dietary rules, functional impairment or nutritional deficiency, may meet criteria for AN or ARFID when severe, not a DSM-5 diagnosis. --- ### X. Special Considerations in Eating and Somatic Symptom Disorders Comorbidity is common across both diagnostic categories. Eating disorders frequently co-occur with depression, anxiety disorders, OCD, and substance use disorders. Somatic symptom disorders commonly co-occur with depression and anxiety. Personality disorders, particularly borderline and avoidant, occur at elevated rates in eating disorder populations. Addressing comorbid conditions is essential for comprehensive treatment, though establishing medical stability and adequate nutrition takes priority in eating disorders. Assessment tools facilitate diagnosis and treatment monitoring. The Eating Disorder Examination is a structured interview considered the gold standard for eating disorder assessment. The EDE-Q is a self-report questionnaire based on the interview. The PHQ-15 assesses somatic symptom burden. The Illness Attitude Scales assess health anxiety. Serial monitoring helps track symptom change and treatment response. Cultural considerations affect both presentation and diagnosis. Ideals of body size and shape vary across cultures. Fat phobia may be less prominent in some cultural presentations of anorexia nervosa. Somatic presentations of distress are more common in some cultures than psychological presentations. Dietary practices influenced by religion or culture must be distinguished from eating disorder restriction. Prognosis varies by disorder and individual factors. Anorexia nervosa has the highest mortality of psychiatric disorders but many patients recover, with approximately half achieving full recovery, one-quarter achieving partial recovery, and one-quarter having chronic courses. Bulimia nervosa has somewhat better outcomes, with higher recovery rates. Binge eating disorder often responds well to treatment but recurrence is common. Somatic symptom disorders tend toward chronic courses, though symptoms may wax and wane. Early intervention and treatment engagement improve outcomes across conditions. Panel A displays comorbidity patterns: eating disorders with depression, anxiety, OCD, substance use, and personality disorders (especially borderline, avoidant); somatic symptom disorders with depression and anxiety; importance of addressing comorbidities while prioritizing medical stability. Panel B presents assessment tools: EDE structured interview (gold standard for eating disorders), EDE-Q self-report, PHQ-15 for somatic symptoms, Illness Attitude Scales for health anxiety, with serial monitoring for treatment response. Panel C shows cultural considerations: variable body ideals, fat phobia may be less prominent in some AN presentations, somatic presentations of distress more common in some cultures, religious/cultural dietary practices distinguished from restriction. Panel D illustrates prognosis: AN (highest mortality, ~50% full recovery, 25% partial, 25% chronic), BN (higher recovery rates), BED (responds to treatment, recurrence common), somatic disorders (chronic with fluctuation), with early intervention improving outcomes across conditions. --- ## Summary - Somatic symptom disorder emphasizes excessive psychological response to symptoms rather than unexplained symptoms; treatment focuses on validation, scheduled visits, function, and comorbidity - Illness anxiety disorder features preoccupation with having serious illness despite absent or mild symptoms; subtypes are care-seeking and care-avoidant - Conversion disorder requires symptoms incompatible with neurological disease, diagnosed with positive signs like Hoover's sign rather than just exclusion - Factitious disorder involves falsification of symptoms for assuming sick role; malingering is symptom production for external gain and is not a mental disorder - Anorexia nervosa features restriction leading to low weight, fear of gaining weight, and body image disturbance; subtypes are restricting and binge-eating/purging - Anorexia nervosa has highest psychiatric mortality; medical complications span cardiovascular, metabolic, endocrine, and GI systems - Refeeding syndrome risk requires careful, gradual nutritional rehabilitation with electrolyte monitoring - Family-based treatment is first-line for adolescent anorexia; CBT is primary for adults; no medications are FDA-approved for AN - Bulimia nervosa features binge eating with compensatory behaviors; fluoxetine 60mg is FDA-approved in addition to CBT - Binge eating disorder is the most common eating disorder, features binge eating without compensatory behaviors, and has lisdexamfetamine FDA-approved for moderate-severe cases --- ## Key Terms | Term | Definition | |------|------------| | Somatic symptom disorder | Disorder featuring distressing somatic symptoms with excessive thoughts, feelings, or behaviors related to those symptoms | | Illness anxiety disorder | Preoccupation with having or acquiring serious illness despite absent or mild somatic symptoms | | Conversion disorder | Neurological symptoms incompatible with recognized neurological conditions, also termed functional neurological symptom disorder | | Factitious disorder | Falsification or induction of symptoms with identified deception, motivated by assuming the sick role | | Anorexia nervosa | Eating disorder characterized by restriction leading to low weight, fear of weight gain, and body image disturbance | | Refeeding syndrome | Dangerous electrolyte shifts, particularly hypophosphatemia, occurring when malnourished patients are refed too rapidly | | Bulimia nervosa | Eating disorder characterized by binge eating followed by compensatory behaviors, at normal or above normal weight | | Binge eating disorder | Recurrent binge eating episodes without regular compensatory behaviors | --- *This content is subject to the [MIT License](https://opensource.org/licenses/MIT). © 2024–2026 Hibbert School of Medicine.*