SOMATIC SYMPTOM (SOMATIZATION) DISORDER

William G. Elder, PhD

 BASICS

DESCRIPTION

•  A pattern of one or more somatic symptoms recurring or persisting for >6 months that are distressing or result in significant disruption of daily life

•  Conceptualization and diagnostic criteria for somatic symptom presentations were significantly modified with the advent of DSM-5. Somatic symptom disorder (SSD) is similar in many aspects to the former somatization disorder, which required presentation with multiple physical complaints, no longer based on symptoms counts; current diagnosis is based on the way the patient presents and perceives his or her symptoms.

•  SSD now includes most presentations that would formerly be considered hypochondriasis. Hypochondriasis has been replaced by illness anxiety disorders, which is diagnosed when the patient presents with significant preoccupation with having a serious illness in the absence of illness-related somatic complaints.

•  Somatization increases disability independent of comorbidity and individuals with SSD have health-related functioning that is two standard deviations below the mean.

•  Symptoms may be specific (e.g., localized pain) or relatively nonspecific (e.g., fatigue).

•  Symptoms sometimes may represent normal bodily sensations or discomfort that does not signify serious disease.

•  Suffering is authentic. Symptoms are not intentionally produced or feigned.

EPIDEMIOLOGY

Incidence

•  Usually, first symptoms appear in adolescence.

•  Predominant sex: female > male (10:1)

•  Type and frequency of somatic complaints may differ among cultures, so symptom reviews should be adjusted based on culture. More frequent in cultures without Western/empirical explanatory models.

Prevalence

•  Expected 2% among women and <0.2% among men

•  Somatization seen in up to 29% of patients presenting to primary care offices

•  Somatic concerns may increase, but other features of the presentation decrease such that prevalence declines after age 65 years.

ETIOLOGY AND PATHOPHYSIOLOGY

Patients with SSD demonstrate different patterns of heart rate variability. Although this cannot be used to clinically, it does point to the differences in psychophysiology of SSD.

Genetics

Consanguinity studies and single nucleotide polymorphism genotyping indicate that both genetic and environmental factors contribute to the risk of SSD.

RISK FACTORS

•  Child abuse, particularly sexual abuse, has been shown to be a risk factor for somatization.

•  Symptoms begin or worsen after losses (e.g., job, close relative, or friend).

•  Greater intensity of symptoms often occurs with stress.

COMMONLY ASSOCIATED CONDITIONS

Comorbid with other psychiatric conditions is yet to be determined but is likely to be 20–50% with anxiety, depression, or personality disorders.

 DIAGNOSIS

•  Determining that a somatic symptom is medically unexplained is unreliable, and it is inappropriate to diagnose a mental disorder solely because a medical diagnosis is not demonstrated. Rely on symptoms and presentation rather than ruling out medical causes in making the SSD diagnosis.

•  Illness anxiety and somatic distress are independent but often co-occur.

HISTORY

•  One or more somatic complaints, with sometimes a grossly positive review of symptoms

•  SSD involves patient excessive thoughts, feelings, or behaviors associated with symptoms or associated health concerns manifested by at least one of the following:

–  Disproportionate and persistent thoughts about the seriousness of the symptoms

–  Persistent high level of anxiety about health or symptoms

–  Excessive time or energy devoted to symptoms or health concerns

•  Diagnoses no longer rely on symptom counts, but common symptoms include:

–  Pain symptoms related to different sites such as head, abdomen, back, joints, extremities, chest, or rectum, or related to body functions such as menstruation, sexual intercourse, or urination

–  GI symptoms such as nausea, bloating, vomiting (not during pregnancy), diarrhea, intolerance of several foods

–  Sexual symptoms such as indifference to sex, difficulties with erection or ejaculation, irregular menses, excessive menstrual bleeding, or vomiting throughout all 9 months of pregnancy

–  Pseudoneurologic symptoms such as impaired balance or coordination, weak or paralyzed muscles, lump in throat or trouble swallowing, loss of voice, retention of urine, hallucinations, numbness (to touch or pain), double vision, blindness, deafness, seizures, amnesia or other dissociative symptoms, loss of consciousness (other than with fainting); none of these is limited to pain.

•  Patients with SSD frequently use alternative treatments, which should be explored for their effects on health and physical functioning.

PHYSICAL EXAM

Physical exam remarkable for absence of objective findings to explain the many subjective complaints

DIFFERENTIAL DIAGNOSIS

•  Other psychiatric illnesses must be ruled out:

–  Depressive disorders

–  Anxiety disorders

–  Schizophrenia

–  Other somatic disorders: illness anxiety disorder, conversion disorder

–  Factitious disorder

–  Body dysmorphic disorder

•  Malingering

•  General medical conditions, with vague, multiple, confusing symptoms, must be ruled out.

–  Systemic lupus erythematosus

–  Hyperparathyroidism

–  Hyper- or hypothyroidism

–  Lyme disease

–  Porphyria

DIAGNOSTIC TESTS & INTERPRETATION

Several screening tools are available that help to identify symptoms as somatic:

•  Patient Health Questionnaire (PHQ)-15 (screens and monitors symptoms) (1)[B]

•  Minnesota Multiphasic Personality Inventory (MMPI) (identifies somatization) (2)[B]

Initial Tests (lab, imaging)

•  Laboratory test results do not support the subjective complaints.

•  Imaging studies do not support the subjective complaints.

Test Interpretation

None are identified.

 TREATMENT

GENERAL MEASURES

•  The goal of treatment is to help the person learn to control the symptoms (3)[B].

•  A supportive relationship with a sympathetic health care provider is the most important aspect of treatment:

–  Regular scheduled appointments should be maintained to review symptoms and the person’s coping mechanisms (at least 15 minutes once a month).

–  Acknowledge and explain test results.

•  The involvement of a single provider is important because a history of seeking medical attention and “doctor shopping” is common.

•  Antidepressant or antianxiety medication and referral to a support group or mental health provider can help patients who are willing to participate in their treatment.

•  Patients usually receive the most benefit from primary care providers who accept the limitations of treatment, listen to their patient’s concerns, and provide reassurance.

•  It is not helpful to tell patients that their symptoms are imaginary.

MEDICATION

Antidepressants (e.g., SSRIs) help to treat comorbid depression and anxiety (4)[C].

ISSUES FOR REFERRAL

•  Discourage referrals to specialists for further investigation of somatic complaints.

•  Referrals to support groups or to a mental health provider may be helpful.

ADDITIONAL THERAPIES

Treatments have not been evaluated for this recently reformulated disorder. However, there are numerous studies with positive outcomes for patients with various forms of somatization or medically unexplained symptoms.

•  Treatment typically includes long-term therapy, which has been shown to decrease the severity of symptoms.

•  Individual or group cognitive-behavioral therapy addressing health anxiety, health beliefs, and health behaviors has been shown to be the most efficacious treatment for somatoform disorders. Cognitive processes modified in therapy include patient tendencies to ruminate and catastrophize (5,6)[A].

 ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patients should have regularly scheduled follow-up with a primary care doctor, psychiatrist, and/or therapist.

PATIENT EDUCATION

Encourage interventions that decrease stressful elements of the patient’s life:

•  Psychoeducational advice

•  Increase in exercise

•  Pleasurable private time

PROGNOSIS

•  Chronic course, fluctuating in severity

•  Full remission is rare.

•  Individuals with this disorder do not experience any significant difference in mortality rate or significant physical illness.

•  Patients with this diagnosis do experience substantially greater functional disability and role impairment than nonsomatizing patients (7).

COMPLICATIONS

•  May result from invasive testing and from multiple evaluations that are performed while looking for the cause of the symptoms

•  A dependency on pain relievers or sedatives may develop.

REFERENCES

1.  Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002;64(2):258–266.

2.  Wetzel RD, Brim J, Guze SB, et al. MMPI screening scales for somatization disorder. Psychol Rep. 1999;85(1):341–348.

3.  Heijmans M, Olde Hartman TC, van Weel-Baumgarten E, et al. Experts’ opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials. Fam Pract. 2011;28(4):444–455.

4.  Somashekar B, Jainer A, Wuntakal B. Psychopharmacotherapy of somatic symptoms disorders. Int Rev Psychiatry. 2013;25(1):107–115.

5.  Herzog A, Voigt K, Meyer B, et al. Psychological and interactional characteristics of patients with somatoform disorders: validation of the Somatic Symptoms Experiences Questionnaire (SSEQ) in a clinical psychosomatic population. J Psychosom Res. 2015;78(6):553–562.

6.  Moreno S, Gili M, Magallón R, et al. Effectiveness of group versus individual cognitive-behavioral therapy in patients with abridged somatization disorder: a randomized controlled trial. Psychosom Med. 2013;75(6):600–608.

7.  Momsen AM, Jensen OK, Nielsen CV, et al. Multiple somatic symptoms in employees participating in a randomized controlled trial associated with sickness absence because of nonspecific low back pain. Spine J. 2014;14(12):2868–2876.

ADDITIONAL READING

•  Elder WG Jr, King M, Dassow P, et al. Managing lower back pain: you may be doing too much. J Fam Pract. 2009;58(4):180–186.

•  Sharma MP, Manjula M. Behavioural and psychological management of somatic symptom disorders: an overview. Int Rev Psychiatry. 2013;25(1):116–124.

 CODES

ICD10

•  F45.9 Somatoform disorder, unspecified

•  F45.20 Hypochondriacal disorder, unspecified

•  F45.22 Body dysmorphic disorder

CLINICAL PEARLS

•  With the advent of DSM-5, diagnosis is now based on a pattern of symptoms rather than an absence of medical explanation.

•  A clue is accumulation of several diagnoses with >13 letters (e.g., chronic fatigue syndrome, fibromyalgia syndrome, reflex sympathetic dystrophy, temporomandibular joint syndrome, carpal tunnel syndrome, mitral valve prolapse).

•  Inability of more than three physicians to make a meaningful diagnosis suggests somatization.

•  Acknowledge the patient’s pain, suffering, and disability.

•  Do not tell patients the symptoms are “all in their head.”

•  Emphasize that this is not a rare disorder.

•  Discuss the limitations of treatment while providing reassurance that there are interventions that will lessen suffering and reduce symptoms.