Somatization – AAFP2007

Somatization

• Definition: Patients with somatization disorder experience their emotional distress or difficult life situation through physical symptoms, where no physiologic explanation can be found
• A syndrome of physical symptoms that are distressing (cause impairment in functioning) and may not be fully explained by a known medical condition after appropriate investigation
• symptoms may be exacerbated by anxiety, depression, and interpersonal conflicts, and it is common for somatization, depression, and anxiety to all occur together
• Symptoms are produced unconsciously and are not the result of malingering or factitious disorder
• 1º Gain: somatic symptom represents a symbolic resolution of an unconscious psychological conflict; serves to reduce anxiety and conflict; no external incentive
• 2º Gain: the sick role or external benefits obtained or unpleasant duties avoided (work)
• Often a misdiagnosis for an insidious illness so rule out all organic illnesses (eg MS)

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Factitious disorder and malingering, must be excluded before diagnosing a somatoform disorder.

• Malingering – intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by 2º gain.
• Factitious – intential production of phsyical/psych s/sx to assume the “sick role” – other 2º gain absent

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 CLINICAL PRESENTATION

The essential feature of somatization is a history of physical symptoms that the patient attributes to a nonpsychiatric disease The symptoms may be unexplained. Somatizing patients present with a wide array of symptoms:

• Pain: headache, back pain, dysuria, joint pain, diffuse pain, and extremity pain
• GI:  nausea, vomiting, abdominal pain, bloating, gas, and diarrhea
• C/V: chest pain, dizziness, shortness of breath, and palpitations
• Neuro: fainting, pseudoseizures, amnesia, muscle weakness, dysphagia, double or blurred vision, difficulty walking, difficulty urinating, deafness, and hoarseness or aphonia
• GU: dyspareunia, dysmenorrhea, and burning in sex organs

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Risk factors

1. female sex
2. fewer years of education
3. ethnic minority status
4. low socioeconomic status

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 The DSM-IV-TR diagnostic criteria are:

1.  A history of somatic complaints over several years, starting prior to the age of 30.
2.  At least four different sites of pain on the body, AND at least two gastrointestinal problems, AND one sexual dysfunction, AND one pseudoneurological symptom.
3. Such symptoms cannot be fully explained by a general medical condition or substance use OR, when there is an associated medical condition, the impairments due to the somatic symptoms are more severe than generally expected.
4. Complaints are not feigned as in malingering or factitious disorder

Diagnostic Features Suggesting Somatization

1. Multiple symptoms, often occurring in different organ systems (KEY FEATURE)
2. Symptoms that are vague or that exceed objective findings
3. Chronic course (KEY FEATURE)
4. Presence of a psychiatric disorder
5. History of extensive diagnostic testing
6. Rejection of previous physicians

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1 In patients with recurrent physical symptoms, diagnose somatization only after an adequate work-up to rule out any medical or psychiatric condition (e.g., depression).

DDX:

• ψ:  depression, panic disorder, and substance use disorder.
• Medical conditions that may be confused with somatization disorder include
  • MS, SLE, acute intermittent porphyria, and hemochromatosis.
• Rule out other organic causes:  GI/ GU / Neuro / MSK / C/V causes of the S/Sx

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2 Do not assume that somatization is the cause of new or ongoing symptoms in patients previously diagnosed as somatizers. Periodically reassess the need to extend/repeat the work-up in these patients.

1. Patients with somatization sometimes have comorbid depressive, anxiety, and personality disorders. Somatization frequently resolves when these psychiatric syndromes are appropriately treated.
2. Patients with prominent somatic symptoms should receive a history and physical examination. Ancillary laboratory testing should be judicious, and ordered only when specific diagnoses are suspected.
3. Often a misdiagnosis for an insidious illness so rule out all organic illnesses (eg MS, SLE, etc see ddx)

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3 Acknowledge the illness experience of patients who somatize, and strive to find common ground with them concerning their diagnosis and management, including investigations. This is usually a long-term project, and should be planned as such.

Principles for managing somatization:

1. scheduling regular visits,
2. acknowledging symptoms,
3. communicating with other clinicians,
4. assessing and treating diagnosable medical and psychiatric disorders,
5. limiting tests and referrals,
6. reassuring the patient that grave medical diseases have been ruled out
7. making functional improvement the goal of treatment

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4 In patients who somatize, inquire about the use of and suggest therapies that may provide symptomatic relief, and/or help them cope with their symptoms (e.g., with biofeedback, acupuncture, or naturopathy).

1. Psychotherapy to treat somatization, especially cognitive behavioral therapy
   • Clearly explain the structure of the treatment plan
   • Teach meaningful skills relevant to daily life
   • Training in these skills should continue until they are mastered in the therapist’s office
   • Patients need to practice these skills outside of the office
   • Clinicians should attribute improvement to the patient’s increased skills
2.  If Tx with meds: initial with fluoxetine 20 mg per day or another SSRI in AM, titrating the dose Q4Wk prn and as tolerated
3. Avoid opioids
4. A one-time psychiatric referral as an effective intervention for patients with somatization to clarify the diagnosis and its nonlethal nature, and make specific recommendations for management, such as limiting tests.
   • Tell patients that their symptoms are taken seriously
   • Avoid describing symptoms as entirely psychogenic (“all in your head”)
   • Avoid further referrals and laboratory tests unless there is a clear indication of a general medical disorder
   • Schedule regular visits
   • Perform a physical exam at each visit

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Prognosis

Somatization follows a chronic and fluctuating course. Short-term studies show that 50 percent or more of patients improve and no longer meet criteria for a specific type of disorder, but this is not the same thing as complete and permanent resolution of all medically unexplained symptoms.

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 References:

• DSM5
• TN2013
• UpToDate Dec 22, 2014
• http://www.aafp.org/afp/2007/1101/p1333.html

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Somatic Symptom Disorder (DSM5)

• ≥1 somatic symptoms that are distressing or result in significant disruption of daily life
• xs thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by ≥1:
  1. Disproportionate & persistent thoughts about the seriousness of one’s symptoms
  2. Persistenly high level of anxiety about health or symptoms
  3. xs time & energy devoted to these symptoms or health concerns
• Symptomatic ≥ 6months = persistent with marked impairment

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 Illness Anxiety Disorder (DSM5): Care-seeking type or care-avoidant type

1. Preoccupation with having or acquiring a serious illness
2. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly xs or disproportionate.
3. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status
4. The individual performs xs health-related behaviours (repeatedly checks body for signs of illness) or exhibits maladaptive avoidance (avoid MD appt & hospital)
5. Illness preoccupation has been present for >6mo, but the specific illness that is feared may change over that period of time
6. The illness-related preoccupation is not better explained by another mental disorer.

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 Conversion disorder (DSM5)

1. ≥1 symptoms of altered voluntary motor or sensory function
2. Clinical findings incompatible between the symptom and recognized neurological or medical conditions
3. The deficit is not better explained by another medical or mental disorder
4. The symptom or deficit causes clinically sig distress or impairment in social, occupational, or other areas of functioning and warrant medical evaluation.

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 Factitious Disorder (DSM5); Factitious Disorder IMposed on Another (if pt presents another victim)

1. Falsification of physical or psychological s/sx or induction of injury/dz assoicated with identified deception
2. The individual presents him/herself to others as ill, impaired, or injured
3. The deceptive behavior is evident even in the absence of obvious external rewards
4. The behaviour is not better explained by another mental disorder, eg. delusional disorder or another psychotic disorder.