Somatoform Disorders


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Related to Somatoform Disorders: Dissociative disorders

Somatoform Disorders

 

Definition

The somatoform disorders are a group of mental disturbances placed in a common category on the basis of their external symptoms. These disorders are characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder. In order to meet the criteria for a somatoform disorder, the physical symptoms must be serious enough to interfere with the patient's employment or relationships, and must be symptoms that are not under the patient's voluntary control.
It is helpful to understand that the present classification of these disorders reflects recent historical changes in the practice of medicine and psychiatry. When psychiatry first became a separate branch of medicine at the end of the nineteenth century, the term hysteria was commonly used to describe mental disorders characterized by altered states of consciousness (for example, sleepwalking or trance states) or physical symptoms (for example, a "paralyzed" arm or leg with no neurologic cause) that could not be fully explained by a medical disease. The term dissociation was used for the psychological mechanism that allows the mind to split off uncomfortable feelings, memories, or ideas so that they are lost to conscious recall. Sigmund Freud and other pioneering psychoanalysts thought that the hysterical patient's symptoms resulted from dissociated thoughts or memories reemerging through bodily functions or trance states. Prior to the categorization all mental disorders that were considered to be forms of hysteria were grouped together on the basis of this theory about their cause. Since 1980, however, the somatoform disorders and the so-called dissociative disorders have been placed in separate categories on the basis of their chief symptoms. In general, the somatoform disorders are characterized by disturbances in the patient's physical sensations or ability to move the limbs or walk, while the dissociative disorders are marked by disturbances in the patient's sense of identity or memory.

Description

As a group, the somatoform disorders are difficult to recognize and treat because patients often have long histories of medical or surgical treatment with several different doctors. In addition, the physical symptoms are not under the patient's conscious control, so that he or she is not intentionally trying to confuse the doctor or complicate the process of diagnosis. Somatoform disorders are, however, a significant problem for the health care system because patients with these disturbances overuse medical services and resources.

Somatization disorder (briquet's syndrome)

Somatization disorder was formerly called Briquet's syndrome, after the French physician who first recognized it. The distinguishing characteristic of this disorder is a group or pattern of symptoms in several different organ systems of the patient's body that cannot be accounted for by medical illness. The criteria for this disorder require four symptoms of pain, two symptoms in the digestive tract, one symptom involving the sexual organs, and one symptom related to the nervous system. Somatization disorder usually begins before the age of 30. It is estimated that 0.2% of the United States population will develop this disorder in the course of their lives. Another researcher estimates that 1% of all women in the United States have symptoms of this disorder. The female-to-male ratio is estimated to range between 5:1 and 20:1.
Somatization disorder is considered to be a chronic disturbance that tends to persist throughout the patient's life. It is also likely to run in families. Some psychiatrists think that the high female-to-male ratio in this disorder reflects the cultural pressures on women in North American society and the social "permission" given to women to be physically weak or sickly.

Conversion disorder

Conversion disorder is a condition in which the patient's senses or ability to walk or move are impaired without a recognized medical or neurological disease or cause and in which psychological factors (such as stress or trauma) are judged to be temporarily related to onset or exacerbation. The disorder gets its name from the notion that the patient is converting a psychological conflict or problem into an inability to move specific parts of the body or to use the senses normally. An example of a conversion reaction would be a patient who loses his or her voice in a situation in which he or she is afraid to speak. The symptom simultaneously contains the anxiety and serves to get the patient out of the threatening situation. The resolution of the emotion that underlies the physical symptom is called the patient's primary gain, and the change in the patient's social, occupational, or family situation that results from the symptom is called a secondary gain. Doctors sometimes use these terms when they discuss the aftereffects of conversion disorder or of other somatoform disorders on the patient's emotional adjustment and lifestyle.
The specific physical symptoms of conversion disorder may include a loss of balance or paralysis of an arm or leg; the inability to swallow or speak; the loss of touch or pain sensation; going blind or deaf; seeing double; or having hallucinations, seizures, or convulsions.
Unlike somatization disorder, conversion disorder may begin at any age, and it does not appear to run in families. It is estimated that as many as 34% of the population experiences conversion symptoms over a lifetime, but that the disorder is more likely to occur among less educated or sophisticated people. Conversion disorder is not usually a chronic disturbance; 90% of patients recover within a month, and most do not have recurrences. The female-to-male ratio is between 2:1 and 5:1. Male patients are likely to develop conversion disorders in occupational settings or military service.

Pain disorder

Pain disorder is marked by the presence of severe pain as the focus of the patient's concern. This category of somatoform disorder covers a range of patients with a variety of ailments, including chronic headaches, back problems, arthritis, muscle aches and cramps, or pelvic pain. In some cases the patient's pain appears to be largely due to psychological factors, but in other cases the pain is derived from a medical condition as well as the patient's psychology.
Pain disorder is relatively common in the general population, partly because of the frequency of work-related injuries in the United States. This disorder appears to be more common in older adults, and the sex ratio is nearly equal, with a female-to-male ratio of 2:1.

Hypochondriasis

Hypochondriasis is a somatoform disorder marked by excessive fear of or preoccupation with having a serious illness that persists in spite of medical testing and reassurance. It was formerly called hypochondriacal neurosis.
Although hypochondriasis is usually considered a disorder of young adults, it is now increasingly recognized in children and adolescents. It may also develop in elderly people without previous histories of health-related fears. The disorder accounts for about 5% of psychiatric patients, and is equally common in men and women. Hypochondriasis may persist over a number of years but usually occurs as a series of episodes rather than continuous treatment-seeking. The flare-ups of the disorder are often correlated with stressful events in the patient's life.

Body dysmorphic disorder

Body dysmorphic disorder is a new category of somatoform disorders. It is defined as a preoccupation with an imagined or exaggerated defect in appearance. Most cases involve features on the patient's face or head, but other body parts—especially those associated with sexual attractiveness, such as the breasts or genitals—may also be the focus of concern.
Body dysmorphic disorder is regarded as a chronic condition that usually begins in the patient's late teens and fluctuates over the course of time. It was initially considered to be a relatively unusual disorder, but may be more common than was formerly thought. It appears to affect men and women with equal frequency. Patients with body dysmorphic disorder frequently have histories of seeking or obtaining plastic surgery or other procedures to repair or treat the supposed defect. Some may even meet the criteria for a delusional disorder of the somatic type.

Somatoform disorders in children and adolescents

The most common somatoform disorders in children and adolescents are conversion disorders, although body dysmorphic disorders are being reported more frequently. Conversion reactions in this age group usually reflect stress in the family or problems with school rather than long-term psychiatric disturbances. Some psychiatrists speculate that adolescents with conversion disorders frequently have overprotective or overinvolved parents with a subconscious need to see their child as sick; in many cases the son or daughter's symptoms become the center of family attention. The rise in body dysmorphic disorders in adolescents is thought to reflect the increased influence of media preoccupation with physical perfection.

Causes and symptoms

Because groups the somatoform disorders are categorized on the basis of symptom patterns, their causes as presently understood include several different factors.

Family stress

Family stress is believed to be one of the most common causes of somatoform disorders in children and adolescents. Conversion disorders in this age group may also be connected with physical or sexual abuse within the family of origin.

Parental modeling

Somatization disorder and hypochondriasis may result in part from the patient's unconscious reflection or imitation of parental behaviors. This "copycat" behavior is particularly likely if the patient's parent derived considerable secondary gain from his or her symptoms.

Cultural influences

Cultural influences appear to affect the gender ratios and body locations of somatoform disorders, as well as their frequency in a specific population. Some cultures (for example, Greek and Puerto Rican) report higher rates of somatization disorder among men than is the case for the United States. In addition, researchers found lower levels of somatization disorder among people with higher levels of education. People in Asia and Africa are more likely to report certain types of physical sensations (for example, burning hands or feet, or the feeling of ants crawling under the skin) than are Westerners.

Biological factors

Genetic or biological factors may also play a role. For example, people who suffer from somatization disorder may also differ in how they perceive and process pain.

Diagnosis

Accurate diagnosis of somatoform disorders is important to prevent unnecessary surgery, laboratory tests, or other treatments or procedures. Because somatoform disorders are associated with physical symptoms, patients are often diagnosed by primary care physicians as well as by psychiatrists. In many cases the diagnosis is made in a general medical clinic. Children and adolescents with somatoform disorders are most likely to be diagnosed by pediatricians. Diagnosis of somatoform disorders requires a thorough physical workup to exclude medical and neurological conditions, or to assess their severity in patients with pain disorder. A detailed examination is especially necessary when conversion disorder is a possible diagnosis, because some neurological conditions—including multiple sclerosis and myasthenia gravis—have on occasion been misdiagnosed as conversion disorder. Some patients who receive a diagnosis of somatoform disorder ultimately go on to develop neurologic disorders.
In addition to ruling out medical causes for the patient's symptoms, a doctor who is evaluating a patient for a somatization disorder will consider the possibility of other psychiatric diagnoses or of overlapping psychiatric disorders. Somatoform disorders often coexist with personality disorders because of the chicken-and-egg relationship between physical illness and certain types of character structure or personality traits. At one time, the influence of Freud's theory of hysteria led doctors to assume that the patient's hidden emotional needs "cause" the illness. But in many instances, the patient's personality may have changed over time due to the stresses of adjusting to a chronic disease. This gradual transformation is particularly likely in patients with pain disorder. Patients with somatization disorder often develop panic attacks or agoraphobia together with their physical symptoms. In addition to anxiety or personality disorders, the doctor will usually consider major depression as a possible diagnosis when evaluating a patient with symptoms of a somatoform disorder. Pain disorders may be associated with depression, and body dismorphic disorder may be associated with obsessive-compulsive disease.

Treatment

Relationship with primary care practitioner

Because patients with somatoform disorders often have lengthy medical histories, a long-term relationship with a trusted primary care practitioner (PCP) is a safeguard against unnecessary treatments as well as a comfort to the patient. Many PCPs prefer to schedule brief appointments on a regular basis with the patient and keep referrals to specialists to a minimum. This practice also allows them to monitor the patient for any new physical symptoms or diseases. However, some PCPs work with a psychiatric consultant.

Medications

Patients with somatoform disorders are sometimes given antianxiety drugs or antidepressant drugs if they have been diagnosed with a coexisting mood or anxiety disorder. In general, however, it is considered better practice to avoid prescribing medications for these patients since they are likely to become psychologically dependent on them. However, body dysmorphic disorder as been successfully treated with selective serotonin reuptake inhibitors (SSRI) antidepressants.

Psychotherapy

Patients with somatoform disorders are not considered good candidates for psychoanalysis and other forms of insight-oriented psychotherapy. They can benefit, however, from supportive approaches to treatment that are aimed at symptom reduction and stabilization of the patient's personality. Some patients with pain disorder benefit from group therapy or support groups, particularly if their social network has been limited by their pain symptoms. Cognitive-behavioral therapy is also used sometimes to treat pain disorder.
Family therapy is usually recommended for children or adolescents with somatoform disorders, particularly if the parents seem to be using the child as a focus to divert attention from other difficulties. Working with families of chronic pain patients also helps avoid reinforcing dependency within the family setting.
Hypnosis is a technique that is sometimes used as part of a general psychotherapeutic approach to conversion disorder because it may allow patients to recover memories or thoughts connected with the onset of the physical symptoms.

Alternative treatment

Patients with somatization disorder or pain disorder may be helped by a variety of alternative therapies including acupuncture, hydrotherapy, therapeutic massage, meditation, botanical medicine, and homeopathic treatment. Relief of symptoms, including pain, can occur on the physical level, as well as on the mental, emotional, and spiritual levels.

Prognosis

The prognosis for somatoform disorders depends, as a rule, on the patient's age and whether the disorder is chronic or episodic. In general, somatization disorder and body dysmorphic disorder rarely resolve completely. Hypochondriasis and pain disorder may resolve if there are significant improvements in the patient's overall health and life circumstances, and people with both disorders may go through periods when symptoms become less severe (remissions) or become worse (exacerbations). Conversion disorder tends to be rapidly resolved, but may recur in about 25% of all cases.

Prevention

Generalizations regarding prevention of somatoform disorders are difficult because these syndromes affect different age groups, vary in their symptom patterns and persistence, and result from different problems of adjustment to the surrounding culture. In theory, allowing expression of emotional pain in children, rather than regarding it as "weak," might reduce the secondary gain of physical symptoms that draw the care or attention of parents.

Resources

Books

Eisendrath, Stuart J. "Psychiatric Disorders." In Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.

Key terms

Briquet's syndrome — Another name for somatization disorder.
Conversion disorder — A somatoform disorder characterized by the transformation of a psychological feeling or impulse into a physical symptom. Conversion disorder was previously called hysterical neurosis, conversion type.
Dissociation — A psychological mechanism in which the mind splits off certain aspects of a traumatic event from conscious awareness. Dissociation can affect the patient's memory, sense of reality, and sense of identity.
Hysteria — The earliest term for a psychoneurotic disturbance marked by emotional outbursts and/or disturbances of movement and sense perception. Some forms of hysteria are now classified as somatoform disorders and others are grouped with the dissociative disorders.
Hysterical neurosis — An older term for conversion disorder or dissociative disorder.
Primary gain — The immediate relief from guilt, anxiety, or other unpleasant feelings that a patient derives from a symptom.
Repression — A unconscious psychological mechanism in which painful or unacceptable ideas, memories, or feelings are removed from conscious awareness or recall.
Secondary gain — The social, occupational, or interpersonal advantages that a patient derives from symptoms. A patient's being relieved of his or her share of household chores by other family members would be an example of secondary gain.
Somatoform disorder — A category of psychiatric disorder characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.

somatoform

 [so-mat´-o-form]
denoting physical symptoms that can not be attributed to organic disease and appear to be of psychic origin.
somatoform disorders a group of mental disorders in which physical symptoms suggest the presence of a medical disorder but are not fully explained by a general medical condition, the direct effects of a psychoactive substance, or another mental disorder. Symptoms are not under voluntary control, unlike those occurring in factitious disorders. The category includes: body dysmorphic disorder, conversion disorder, hypochondriasis, pain disorder, somatization disorder, and undifferentiated somatoform disorder.
somatoform pain disorder pain disorder.
undifferentiated somatoform disorder one or more persistent physical complaints, not intentionally produced or feigned, that can not be fully explained by a general medical condition or the direct effects of a substance; this category is the group of persisting disorders that do not completely satisfy the criteria for other somatoform disorders.
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This tension between the legal analysis of somatoform disorders and medical understanding of the conditions is perhaps best demonstrated within the disability determination context.
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As Ze 185 has already been proven to be of benefit in anxiety and as a herbal tranquilising agent, this double blind study was designed to determine the value of the product in somatoform disorders and the relative efficacy of including butterbur in the formulation.
These findings led the researchers to conclude that muscle dysmorphia aligns more closely with disorders on the obsessive compulsive disorder continuum than with somatoform disorders, which is also the case for body dysmorphic disorder.
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Somatoform disorders in general practice: prevalence, functional impairment and co-morbidity with anxiety and depressive disorders.
9) In the current taxonomies DSM-IV and International Statistical Classification of Diseases, 10th revision (ICD-10), functional symptoms can be classified as manifestations of somatoform disorders (physical symptoms which suggest a general medical condition).
9,34,47) We are not aware of any published studies that have included somatoform disorders in investigations of psychiatric disorders in relatives of persons with autism.
Also, bearing in mind that no non-adherent patients were diagnosed with anxiety-based disorders (see Table 6), one can then confidently rule out that any of them suffered from somatoform disorders.
6 3 8 Abuse, neglect (focus on victim) 7 7 7 Abuse, neglect (focus on perpetrator) 2 1 3 Other situationally precipitated problems 18 13 22 Other Mental Disorders Mood disorders 22 20 25 Anxiety disorders 14 16 13 Adjustment disorders 7 6 8 Personality disorders 7 6 7 Impulse control disorders NEC 6 6 7 Sleep disorders 4 4 4 Eating disorders 3 3 3 Other mental disorder(s) 3 4 2 Mental disorders due to a general medical condition 2 2 3 Schizophrenia and other psychotic disorders 2 2 3 Dissociative disorders 2 3 1 Somatoform disorders 1 2 1 Delirium, dementias 1 2 1 Factitious disorders 1 2 <1 Sexual and gender identity disorders <1 1 0 (1) Respondents were asked to mark all that apply.
Research: Researchers treated 184 patients diagnosed with somatoform disorders (physical symptoms that seem as if they are part of a general medical condition, however no general medical condition, other mental disorder, or substance is present), but without major depression.
Key Words: cardiopathia fantastica, factitious disorder, Munchausen syndrome, somatoform disorders