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)
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
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
Risk factors
- female sex
- fewer years of education
- ethnic minority status
- low socioeconomic status
The DSM-IV-TR diagnostic criteria are:
- A history of somatic complaints over several years, starting prior to the age of 30.
- At least four different sites of pain on the body, AND at least two gastrointestinal problems, AND one sexual dysfunction, AND one pseudoneurological symptom.
- 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.
- Complaints are not feigned as in malingering or factitious disorder
Diagnostic Features Suggesting Somatization
- Multiple symptoms, often occurring in different organ systems (KEY FEATURE)
- Symptoms that are vague or that exceed objective findings
- Chronic course (KEY FEATURE)
- Presence of a psychiatric disorder
- History of extensive diagnostic testing
- Rejection of previous physicians
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
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.
- Patients with somatization sometimes have comorbid depressive, anxiety, and personality disorders. Somatization frequently resolves when these psychiatric syndromes are appropriately treated.
- 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.
- Often a misdiagnosis for an insidious illness so rule out all organic illnesses (eg MS, SLE, etc see ddx)
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:
- scheduling regular visits,
- acknowledging symptoms,
- communicating with other clinicians,
- assessing and treating diagnosable medical and psychiatric disorders,
- limiting tests and referrals,
- reassuring the patient that grave medical diseases have been ruled out
- making functional improvement the goal of treatment
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).
- 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
- If Tx with meds: initial with fluoxetine 20 mg per day or another SSRI in AM, titrating the dose Q4Wk prn and as tolerated
- Avoid opioids
- 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
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.
References:
- DSM5
- TN2013
- UpToDate Dec 22, 2014
- http://www.aafp.org/afp/2007/1101/p1333.html
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:
- Disproportionate & persistent thoughts about the seriousness of one’s symptoms
- Persistenly high level of anxiety about health or symptoms
- xs time & energy devoted to these symptoms or health concerns
- Symptomatic ≥ 6months = persistent with marked impairment
Illness Anxiety Disorder (DSM5): Care-seeking type or care-avoidant type
- Preoccupation with having or acquiring a serious illness
- 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.
- There is a high level of anxiety about health, and the individual is easily alarmed about personal health status
- The individual performs xs health-related behaviours (repeatedly checks body for signs of illness) or exhibits maladaptive avoidance (avoid MD appt & hospital)
- Illness preoccupation has been present for >6mo, but the specific illness that is feared may change over that period of time
- The illness-related preoccupation is not better explained by another mental disorer.
Conversion disorder (DSM5)
- ≥1 symptoms of altered voluntary motor or sensory function
- Clinical findings incompatible between the symptom and recognized neurological or medical conditions
- The deficit is not better explained by another medical or mental disorder
- The symptom or deficit causes clinically sig distress or impairment in social, occupational, or other areas of functioning and warrant medical evaluation.
Factitious Disorder (DSM5); Factitious Disorder IMposed on Another (if pt presents another victim)
- Falsification of physical or psychological s/sx or induction of injury/dz assoicated with identified deception
- The individual presents him/herself to others as ill, impaired, or injured
- The deceptive behavior is evident even in the absence of obvious external rewards
- The behaviour is not better explained by another mental disorder, eg. delusional disorder or another psychotic disorder.
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