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Somatoform Disorders

I. Introduction

A. Somatization

1. Definition: The tendency to experience and communicate somatic distress that has no organic basis in response to psychosocial stress, to attribute this distress to physical illness, and to seek medical help for these symptoms.

OR

A disturbance in the way physical experiences are perceived, organized, attributed and/or expressed somatization disorder, hysteria, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, body dismorphic disorder.

2. The scope of the problem:

a. Most people report numerous physical symptoms that do not lead them to seek care

b. There is a large overlap between psychosocial and physical concerns in patient presentations to 

c. Somatization accounts for a disproportionate number of users of medical care, labs, procedures, visit rates, hospital stays, and

3. Biologic theories of somatization:

a. The wandering womb

b. Psychodynamic defense

c. Social communication

d. Abnormal illness behavior

e. Learned behavior-modeling

f. Culture

g. Brain disorder

4. All disorders share the feature of the over-importance of physical symptoms and illness in a patient's life, and often lead to the patient feeling misunderstood by health care professionals with consequent breakdowns in the physician-patient relationship; as well as increasing attempts to be legitimized in the quest for care

B. DSM -IV Somatoform Disorders

1. Somatization Disorder

2. Undifferentiated Somatoform Disorder

3. Conversion Disorder

4. Pain Disorder

5. Hypochondriasis

6. Body Dysmorphic Disorder

7. Somatoform Disorder Not Otherwise Specified

II. Somatization disorder AKA Hysteria, Multisymptomatic hysteria.

Briquet's disease A chronic disorder characterized by multiple, clinically significant somatic complaints that results in impairment of function and/or frequent use of 

A. History:

B. DSM-IV Criteria:

1. History of many physical complaints beginning before age 30, occurs over several years, and results in treatment seeking or significant impairment in social, occupational, or other important area of functioning.

2. Each of the following criteria have been met at some time during the illness:

a. Four pain symptoms: each in a different area of the body or function

b. Two gastrointestinal symptoms (not including pain)

c. One sexual symptom other than pain

d. One pseudoneurological symptom

3. Either:

a. Symptoms above are not caused by a known medical condition or substance after appropriate investigation b. If there is a medical condition, the complaints or impairment are grossly in excess of expected

4. The symptoms are not intentionally produced or feigned

C. Clinical Features: "I Suffer"

1. Presentation of history:

a. The major goal is to communicate distress through a recitation of symptoms.

b. The history is often colorful and dramatic with little specific information, it is chaotic and inconsistent from vsit to visit.

c. Patients have difficulty distinguishing between motional and somatic feelings

d. Patient's see themselves as seriously ill

2. Relationship with physicians:

a. Patients may see multiple treaters simultaneously, including alternative health providers

b. Relationships with treaters are often strained and end in mutual frustration and dissatisfaction

c. Patients are at risk for iatrogenic complications

3. Course:

a. Onset: can start in adolescence, diagnostic criteria usually met by age 25

b. Chronic and fluctuating, rarely remits completely

c. Episodes last 6-9 months, often episode will be triggered by psychosocial stress.

d. Diagnosis is unstable over time

D. Epidemiology:

1. Women: 0.2-2% lifetime prevalence in community surveys, prevalence lower when non-MD's do interviews

2. Men: 0.2, varies by culture

3. Culture may impact symptom presentation also

E. Psychiatric co-morbidity:

1. Axis I: Mood disorders, anxiety disorders, substance abuse, post-traumatic stress disorder

2. Axis II: Personality disorder in 72%: Histrionic, borderline, antisocial personality disorders

3. Family history:

a. 10-20% of first degree female relatives of female patients with somatization disorder develop it themselves

b. Male relatives of female patients with somatization disorder are more likely to have to antisocial personality disorder and substance abuse

c. Adoption studies

D. Differential diagnosis:

1. Medical conditions: conditions with variable and fluctuating courses, ex. acute intermittent porphyria, multiple sclerosis, systemic lupus erythematosus, endocrine disorders, chronic infections, etc.

2. Clues to somatization disorder vs. medical disorder

3. Psychiatric conditions

4. Somatization disorder vs. other somatoform disorders: Do not diagnose another somatoform disorder if it only occurs in the context of somatization disorder

E. Treatment:

1. Goal: Care not cure

2. Best treatment occurs in a long term relationship with an empathic primary care provider

3. Psychiatric consultation decreases health care costs and utilization

4. Goal of psychiatric consultation is to provide a framework for provider

a. Don't fight the sick role

b. Regularly schedule appointments of set length

c. Provider sets the agenda

d. Prevent iatrogenesis

e. Work-ups limited to objective findings, not complaints

f. Do no more and no less for patient

g. Set limits outside of visit time

h. Introduce psychosocial issues slowly, use stress or mind-body language

5. Psychiatric referral:

a. Treat and manage comorbid psychiatric disorders

b. Psychotherapy: individual, cognitive-behavioral, group

III. Undifferentiated Somatoform Disorder AKA Somatization Syndrome

Subthreshold somatization disorder

A. DSM-IV Criteria:

1. One or more physical complaints that persist for 6 months or longer (fatigue, loss of appetite, gastrointestinal complaints, etc.)

2. Either:

a. The symptoms cannot be fully explained by a known medical condition or substance after appropriate evaluation

b. The complaints or impairments are grossly in excess of what would be expected on the basis of the existing medical condition

3. The symptoms cause significant distress or impairment in social, occupational or other important areas of functioning

4. The symptoms are not intentionally produced or feigned

B. Clinical features:

1. Presentation similar to somatization disorder, may be more culturally based (idiom of distress, stigma avoidance)

2. Course is variable

3. Eventual diagnosis of a general medical disorder more common than in somatization disorder

C. Epidemiology:

1. Most common in young women of low socioeconomic status

2. More frequent in women

3. 30 times more frequent than somatization disorder

4. Lifetime prevalence 4-11%

5. Multisomatoform disorder

D. Differential Diagnosis:

1. Same medical disorders as somatization disorder

2. Psychiatric disorders: Somatization D/O, Somatoform D/O NOS, Major Depression, Anxiety, Malingering

E. Treatment:

• Similar to somatization disorder
• May be more responsive to psychiatric referral on the basis of difficulty dealing with the presumptive illness

IV. Conversion Disorder AKA Hysteria, Conversion Reaction. Hysterical Psychoneurosis, Conversion Type

Presence of symptoms or deficits affecting a voluntary motor or sensory function that suggests a neurologic condition which is not explained by the medical findings

A. History:

1. Described since 1900 BC

2. Briquet: modem concept conversion disorder

3. Charcot, Freud

4. Current: Gradual decrease in importance of unconscious processes in diagnostic criteria

B. DSM-IV Criteria:

1. One or more symptoms or deficits affecting a voluntary motor or sensory function that suggests a neurological or general medical condition

2. The symptom initiation or exacerbation is preceded by psychological conflicts or stresses

3. The symptom, after appropriate investigation, cannot be fully explained by a general medical condition, substance, or culturally sanctioned experience.

4. The symptom causes significant distress or impairment and is not feigned.

5. The symptom is not limited to pain or sexual dysfunction and does not occur only in the course of somatization disorder. 6. Should be coded with type of deficit

C. Clinical Features: "I Can't"

1. Patients:

a. Naive 

b. La belle indifference 

c. Suggestible 

d. More likely if prior conversion symptoms or dissociative symptoms 

e. One-third have concurrent neurological illness

2. Symptoms:

a. Usually psuedoneurological 

b. Symptoms conform to patients beliefs rather than known anatomical pathways 

c. Symptoms are inconsistent with exams 

d. May resemble patients own symptoms, ex. pseudoseizures in epileptic 

e. Rarely cause physical disability 

f. More common following extreme stress

3. Etiology:

a. Dynamic hypothesis: solution to unconscious conflict 

b. Secondary gain 

c. Biological factors

4. Course:

a. Rare <10yrs. or >35yrs, over 35 yrs. greater likelihood occult neurological condition 

b. Usually remits in 2 weeks if hospitalized 

c. Recurrence in 20 -25% within a year 

d. 20% develop somatization disorder within 4 years

D. Epidemiology:

1. Most common somatoform disorder

a. 25% of women outpatients report 1 lifetime conversion symptom, some figures 33 % prevalence

b. 11-300/100,000 annual incidence in the general population

2. Increased in rural, low socioeconomic, developing regions

3. Gender: 2-10:1, women >men

E. Psychiatric co-morbidity:

1. Axis I: Depression, somatization disorder

2. Axis II: Histrionic, passive-dependent, passive-aggressive personality disorder, antisocial (men)

3. Family: Conversion more likely in family members

F. Differential diagnosis:

1. Neurologic disease found later in 1/5 to 1/2 patients

2. Most likely neurological disorders are multiple sclerosis, myasthenia gravis, seizures, dystonias

3. Other somatoform disorders

G. Treatment:

1. Good prognosis:

a. Acute onset

b. Clear stress

c. Short time between symptom onset and treatment

d. Rapid improvement in hospital

e. Above average intelligence

f. Paralysis, aphonia, blindness

2. Poor prognosis:

a. Tremor, seizures

3. Use suggestion

4. Provide physical therapy

5. No need to confront

6. Indirectly examine and relieve stress

7. Psychotherapy

V. Pain Disorder AKA Psychogenic Pain Disorder. Somatoform Pain Disorder

Pain as the predominant focus of clinical attention

A. History: Movement away from etiology to descriptive

1. DSM-IV: Includes subtype pain associated with a medical disorder that is NOT a mental disorder

B. DSM-IV Criteria:

1. Pain in one or more anatomical sites as the focus of attention

2. Pain causes significant distress or impairment in social, occupational or other areas of functioning

3. Psychological factors have a role in the onset, severity, exacerbation or maintenance of the pain

4. Not intentionally produced

5. Not due to mood, anxiety, psychotic disorder or dyspareunia.

6. Subtypes and Specifiers:

a. 307.80 Pain disorder associated with psychological factors

b. 307.89 Pain disorder associated with both psychological factors and a general medical condition

c. Pain disorder associated with a general medical condition

C. Clinical Features: "I Hurt"

1. Sites

2. Pain as the main life focus

3. Complications:

a. Iatrogenic substance abuse (opioid/benzodiazepine)

b. Fractured relationships

c. Depression: 30-50% with chronic pain

d. Anxiety: acute pain

e. Insomnia

f. Disability

4. Etiology is multifactorial

D. Epidemiology

1. Prevalence unknown, but high

2. Peak incidence in third and fourth decade

3. Women complain of more headaches than men

4. Family: Increased depression, alcohol abuse, and pain disorders

E. Course:

1. Very variable, often persists for years

2. Good prognosis associated with:

a. Continued work

b. Not allowing pain to become life focus

F. Differential diagnosis:

1. Psychiatric: malingering, factitious disorder

G. Treatment:

1. Shift focus from removal of pain to living with pain

2. Multimodal treatment is best: combination physical therapy, and family, group and cognitive-behavioral therapy

3. Avoid iatrogenesis

4. Treat psychiatric illnesses as they arise

VI. Hypochondriasis

A preoccupation with fears of having or the belief that one has a serious illness that does not respond to reassurance after appropriate medical assessment

A. History: Described as a modern disease in the 1920's

B. DSM-IV Criteria:

1. Preoccupation with fears of having, or the idea that one has a serious disease based on one's misinterpretation of bodily symptoms

2. Preoccupation persists despite appropriate medical evaluation and reassurance

3. The belief is not of delusional intensity (if so, dx delusional disorder, somatic type)

4. Preoccupation causes significant distress or impairment and lasts at least 6 months

5. Not accounted for by another mental disorder

C. Clinical features: "I'm Sick"

1. Symptoms:

a. Disorder of belief -preoccupation can be about almost any symptom

b. Symptoms presented in excruciating detail

c. Can be single or multisystem or disease

d. "Medical student disease"

2. Doctor-patient relationship:

a. Doctor-shopping

b. Mutual frustration

c. Risk of too much and too little

d. Resistance to psychiatric referral

3. Course

4. Etiology

a. Amplification

b. Psychodynamic

c. Learning theory

d. Variant form of psychiatric disorder

D. Epidemiology:

1.3-13 % general population

2.4-9% of general medical practice

3. Genders equal

E. Differential diagnosis:

1. Medical conditions

2. Transient response to medical illness

3. Axis I: Depression, anxiety disorders, specific disease phobia, obsessive-compulsive disorder, somatoform disorders psychotic disorders, body dysmorphic disorder

F. Treatment:

1. Good prognosis

a. Acute onset

b. General medical co-morbidity

c. Absence of a personality disorder

d. No secondary gain

e. High SES

2. Treat accompanying psychiatric conditions

3. Regular contact with a caring medical physician

4. Work-ups based on objective findings

5. Cognitive-educational group treatments 6. SSRI

VII. Body Dysmorphic Disorder AKA Dysmorphobia

Disease of imagined ugliness

A. History: Krapelin-compulsive neurosis, Janet-obsession of shame

B. DSM-IV Criteria:

1. Preoccupation with an imagined defect in appearance, or a markedly excessive preoccupation if a slight anomaly is present.

2. The preoccupation causes significant distress or impairment

3. Not accounted for by another mental disorder

C. Clinical features: "I'm Ugly"

1. Complaints are often of facial deformity (asymmetry, size of nose, etc.), can be anything

2. Patient behaviors:

a. May feel too ashamed to present for treatment or to describe anomaly.

b. Frequent checking and grooming

3. Complications:

a. Social isolation

b. Imagined mockery

c. Function below capacity

d. Iatrogenic complications

4. Course:

a. Onset in adolescence

b. Chronic, picked up mean age 30

c. Presentation can be culture specific

5. Etiology

a. Psychodynamic

b. Shared with OCD

D. Epidemiology:

1. Male = female

2. 2% university plastic surgery clinic

3. Co-morbidity:

4. Relationship to delusional disorder, somatic type

E. Treatment:

1. Prevent iatrogenesis

2. SSRI

3. Antipsychotics for delusional disorder

VIII. Somatoform Disorder Not Otherwise Specified

Residual category for disorders where physical symptoms are the focus of treatment but do not meet criteria for another somatoform disorder.

A. Examples:

1. Pseudocyesis

2. Non-psychotic hypochondriasis lasting less than 6 months

3. Unexplained physical complaints lasting less than 6 months