Somatoform Disorders

 It is estimated that in up to 20% of primary care physician visits, some of the patient's symptoms cannot be explained by or attributed to an underlying biologic disease. In these situations, the physician must clearly keep in mind that illness is a subjective experience of distress, which might be experienced by the patient in the absence of a discoverable disease process. When a patient continues to present with symptoms over time without evidence of disease, the diagnosis of a somatoform disorder should be considered.

The term somatoform disorder refers to a number of Diagnostic and Statistical Manual of Mental Disorders (DSM) IV-TR syndromes that are all remarkable for the absence of objective findings to fully explain the patient's subjective complaints. These patients are often high utilizers of outpatient and inpatient services. They tend to “doctor shop” and frequently request further testing and treatment despite the lack of abnormalities found on prior evaluations. Somatoform disorder patients have healthcare costs that are nine times the United States per capita average.

The estimated prevalence rate of somatoform disorders is 3% to 4% among primary care patients. Somatoform disorder often begins in adolescence and usually before age 25 years. The diagnosis is rarely made in men in the United States, but is reported with higher frequency in men in some other cultures. Patients with somatoform disorders often report multiple symptoms, described in meticulous detail, often supported by lists or daily logs. Somatoform disorders tend to have a chronic course, with remissions and exacerbations that significantly impair daily functioning.

Etiology

The exact cause of these disorders is unknown. Both genetic and environmental factors contribute to the risk of somatization disorder. Female relatives of somatization disorder patients have 10% prevalence of somatization disorder, whereas male relatives have higher rates of substance-related disorders and antisocial personality disorder. Patients with somatoform disorders frequently give a history of childhood sexual and physical abuse and often have a history of growing up in a socially dysfunctional family. Commonly, a parent or other family member suffered from a disabling illness or an anxiety disorder. Symptoms often begin or increase after social, psychological, or physical stressors.

Clinical Manifestations

The history and physical examination should search for objective findings to explain the patient's presenting symptoms. The results of all prior positive and negative evaluations should be uncovered and reviewed before ordering repeat evaluations or treatments. It sometimes is helpful to ask the patient what they feel is the underlying problem; however, they typically will ascribe their symptoms to an underlying physical ailment, rather than having insight into their underlying psychiatric diagnosis. Providing brief emotional support and a physical examination focused on the patient's complaints may help the patient feel that their needs for care are met. Establishing a consistent, supportive physician-patient relationship may build patient confidence in the physician's reassurances that no underlying physical problem is causing their symptoms, allowing the patient to avoid unnecessary and potentially unsafe diagnostic tests and therapies.

The patient's belief that he or she is suffering from a serious disease is common to all of the somatic distress syndromes. Somatization disorder, hypochondriasis, and conversion disorders are discussed below. Chronic pain disorder is discussed in another chapter (Chapter E30). Additional somatoform disorders include body dysmorphic disorder, which refers to preoccupation with an imagined or exaggerated defect in physical appearance, and undifferentiated somatoform disorder, which is a term applied to patients with 6 months of at least one physical symptom unexplained by a physical disorder but who do not fully meet the specific diagnostic criteria for somatization disorder. Although some of these disorders have a predominant feature, in general, the syndromes have more similarities than differences.

Somatization disorder is characterized by multiple physical complaints in multiple body systems over several years that cannot be explained fully by a physical disorder and are not intentionally produced or feigned. Often, patients are dramatic and emotional when recounting their symptoms. These patients usually have a grossly positive review of symptoms. Inability of more than three doctors to make a diagnosis strongly suggests the disorder. Specific diagnostic criteria are listed in Table E19.1.

Hypochondriasis patients have a recurring, persistent belief that they are, or will become, afflicted with a serious disease. The patient usually has a focus of somatic distress in a particular location that serves as the nidus for the hypochondriacal fears. The particular bodily distress focus often will rotate among the organ systems. Serious organic disease should be excluded before making this diagnosis. The DSM IV-TR criteria for the diagnosis require that symptoms have lasted for 6 months.

Conversion disorder presents with symptoms that simulate a neurological disorder, such as anesthetic limbs; loss of motor function; aphonia; visual disturbance, including blindness; and behavior suggesting seizures. Symptoms have a sudden onset and usually are precipitated by a threatening social or interpersonal occurrence. A common malady in this category is that of pseudoseizures. In some instances, the conversion of psychic conflict into physical symptoms may have symbolic meaning (e.g., blindness after witnessing a traumatic event). A pre-existing personality disorder usually is present. A careful medical and neurological examination is necessary to verify the absence of a disease process.

Conversion disorder must be differentiated from factitious disorder and malingering. In factitious disorder, the patient consciously and voluntarily produces physical symptoms, psychological symptoms, or both. The full-blown form is known as Munchausen's syndrome. Many of these patients are associated with the health care field and are adept at simulating illnesses (e.g., hypoglycemia as a result of surreptitious insulin use). The confusing nature of these patients' symptoms leads to emergency department visits, hospitalizations, and even multiple surgeries. The motivations behind such behavior are not usually obvious to the physician, and the patient does not reveal them. However, the patient universally assumes a sick role to gain respite from life predicaments that he or she is unable to resolve. Usually an underlying personality disorder exists, often a borderline personality disorder. In malingering, the fabrication of symptoms derives from a desire for some secondary gain, such as a narcotic medication or disability reimbursement.

A variant of factitious disorder is Munchausen's syndrome by proxy, where a sick role is constructed by care-giving persons for someone in their care, and the dependent one assumes the sick role. This is most commonly seen in a mother-child relationship. The child is an unwitting accomplice participating in a folie à deux. The perpetrator repeatedly presents a child for medical care. Genuine illness is absent, but in some circumstances the perpetuator produces physiologic dysfunction by administering substances or inflicting injury.

Diagnosis

Diagnosis of somatoform disorders is based on history after excluding physical disorders and concurrent psychiatric disorders. By definition of the somatoform disorders, laboratory tests and imaging study results do not support a physical explanation for the patient's symptoms. However, in patients with suggestive symptoms or physical findings, systemic medical conditions with vague, multiple, confusing manifestations (e.g., systemic lupus erythematosus, thyroid disorders, Lyme disease) should be ruled out. In addition, because patients with somatoform disorders may develop concurrent physical disorders, appropriate tests should be performed when symptoms change significantly or when objective signs develop.

Standardized psychological screening tests such as the Minnesota Multiphasic Personality Inventory and the Patient Health Questionnaire 15 can help clinicians identify somatization disorder. Patients with somatoform disorders have a higher incidence of major depression and anxiety disorders than seen in the population as a whole. Conversely, the belief that one is suffering from a serious physical illness can be a part of a depressive disorder and is commonly seen in panic disorder or other anxiety states. This preoccupation with the body also can result from a form of delusion in schizophrenia. Patients with somatoform disorders with these comorbid psychiatric conditions will experience some relief of symptoms when treated with appropriate medications; however, they might not experience a change in their fixed beliefs regarding their bodily symptoms.

Treatment

Because patients with somatoform disorder have no specific biologic abnormality to treat, the physician must manage a patient with considerable persistent distress that often produces marked social and occupational dysfunction. Unfortunately, the absence of disease indicators after diagnostic testing does not usually provide sustained relief of the patient's symptoms. Patients can become frustrated and angered by suggestions that their symptoms are psychologically based. However, if psychological factors are not addressed, the patient might seek out more and more specialists and tests, and some patients eventually choose other forms of therapy in the area of alternative medicine. Clinicians should accept that the patient's distress is real. Patient education within the context of a strong patient-physician therapeutic relationship frequently will enable the patient to make connections between his or her life predicaments, dysfunctional behavior patterns, and the bodily distress for which she or he has consulted the doctor.

Elements of successful treatment include involvement of a single physician who has developed a good rapport, which helps reduce “doctor shopping” and unnecessary diagnostic or therapeutic interventions, cognitive-behavioral psychotherapy that emphasizes patient self-management of the disorder, and behavior modification in which access to the physician is regulated and adjusted to provide a sustained and predictable level of support that is not contingent on the patient's symptoms. Therefore, some experts recommend frequently scheduled brief appointments at regular intervals. However, the physician must avoid becoming an unwitting facilitator of continued illness by not allowing these visits to result in additional diagnostic adventures, ineffective medications, or repeated hospitalizations. Some patients benefit from group therapy with other individuals who have similar problems because it allows them to ventilate, discuss/learn coping strategies, and practice interpersonal skills. Referrals to specialists for further investigation of somatic complaints unsubstantiated by associated physical findings should be discouraged.

For patients with somatization disorder, a comprehensive program that addresses issues of exercise, appropriate nutrition, and sleep hygiene measures is helpful. A graded exercise program has been shown to be therapeutic. The patient often is benefited by joint interviews with involved family members who can be enlisted as allies in the recovery process of the patient. There is some limited literature suggesting that treatment with antidepressants may help reduce psychological distress, anxiety, and obsessive focus on multiple somatic symptoms. The patient must be informed that incremental improvement is the goal and that no single therapeutic intervention will alleviate the condition.

Treatment of conversion disorder necessitates a collaboration of psychiatry with medicine and neurology. The pseudoneurologic symptoms usually remit in a relatively short period of time with appropriate diagnosis and supportive and insight oriented psychotherapy. When the acute symptoms subside, the underlying anxious diathesis of the patient must be addressed. Pharmacologic treatment of accompanying anxiety disorder syndromes and depressive disorders is important.

Psychiatric consultation is essential when factitious disorder is suspected. Such a consultation might reveal the nature of the patient's social or psychological predicament, or both, and the person then can be confronted with diagnosis and offered treatment. Some experts recommend using a face-saving method of announcing the diagnosis, such as labeling the disorder as a cry for help and providing psychiatric interventions as one of two treatment options. Unfortunately, these patients frequently flee the hospital or outpatient setting after confrontation and often reappear in other medical care facilities.

Complications

Patients with somatoform disorders have significant morbidity, but the condition does not cause any increases in mortality or illness rates. They can experience complications from multiple unnecessary invasive tests or treatments directed at their symptoms. For example, some patients develop dependency on sedatives or analgesics that were prescribed to empirically control chronic symptoms, which instead tend to fluctuate in severity in relation to social stressors rather than any underlying biologic changes. Unfortunately, full remission of symptoms is rare. Patients with somatoform disorders may become socially withdrawn, and a minority will become completely incapacitated.