Somatoform and conversion disorders in older adults

Definition. Physical symptoms not fully explained by a medical condition, accompanied by excessive thoughts, feelings and behaviours about the symptoms, causing distress and impairment. DSM-5 renamed this group "Somatic Symptom and Related Disorders".

Spectrum. Somatic symptom disorder, illness anxiety disorder (formerly hypochondriasis), conversion disorder (functional neurological symptom disorder), factitious disorder, and psychological factors affecting a medical condition.

The key geriatric rule. New-onset somatoform disorder after 60 years is rare. A first presentation in old age must trigger a search for occult organic disease, depression, anxiety, or early dementia. Depression is the commonest cause of medically unexplained somatic complaints in the elderly ("masked depression").

Clinical features. Multiple, shifting complaints — pain, fatigue, dizziness, gastrointestinal symptoms; repeated consultations and investigations; doctor-shopping; poor response to reassurance. Conversion presents with functional weakness, non-epileptic attacks, gait disorder (astasia–abasia), or aphonia; Hoover's sign is a positive rule-in sign.

Assessment. Proportionate but time-limited investigation; screen for depression (GDS-15), anxiety, and cognition (MoCA); complete medication review; explore bereavement, loneliness, elder abuse and role loss. Diagnose functional disorder on positive clinical signs, not by exclusion alone.

Management. One named coordinating physician; regular scheduled (not symptom-triggered) appointments; avoid repeat investigations and iatrogenic harm; validate that the symptoms are real. CBT is first-line; treat comorbid depression/anxiety with SSRIs; graded physiotherapy for functional neurological disorder. Avoid benzodiazepines and opioids.

ICD-11 and FND practice (2023–2025). ICD-11 has replaced the somatoform group with Bodily Distress Disorder, graded mild / moderate / severe. Functional Neurological Disorder is now a rule-in diagnosis made on positive clinical signs, no longer a diagnosis of exclusion. Current evidence and UK/NICE-aligned FND guidance support specialist physiotherapy plus CBT as core treatment, with clear explanation of the diagnosis itself being therapeutic. If asked for 15 marks, add: detailed DSM-5 versus ICD-11 criteria comparison; epidemiology in Indian primary care; the biopsychosocial model with predisposing / precipitating / perpetuating factors; a table of positive rule-in signs for FND (Hoover's, hip-abductor, tremor entrainment, give-way weakness); prognosis and predictors of poor outcome; and the role of liaison psychiatry services.