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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.

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.

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

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.

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.

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.