CHAPTER 127

Somatoform Disorders

Somatoform disorders include several mental health disorders. In some, people report physical symptoms or concerns that suggest but are not fully explained by a physical disorder. In one, people are preoccupied with a slight or nonexistent defect in appearance. These symptoms or concerns are considered disorders if they cause significant distress or interfere with daily functioning.

Somatoform disorder refers to what many people used to call a psychosomatic disorder. In somatoform disorders, the physical symptoms cannot be fully explained by any underlying physical disorder. People with a somatoform disorder are not faking. They sincerely believe that they have a serious physical problem.

The somatoform disorders include body dysmorphic disorder, conversion disorder, hypochondriasis, somatization disorder, and pain disorder (see page 640). Children are also affected (see page 1872). Treatment varies according to which somatoform disorder a person has.

Munchausen Syndrome: Faking Illness for Attention

Munchausen syndrome is not a somatoform disorder, but its features are somewhat similar. That is, mental health problems underlie physical symptoms. The key difference is that people with Munchausen syndrome consciously fake the symptoms of a physical disorder. They repeatedly fabricate illnesses and often wander from hospital to hospital for treatment.

However, Munchausen syndrome is more complex than simple dishonest fabrication and simulation of symptoms. The disorder is associated with severe emotional problems. People with the disorder are usually quite intelligent and resourceful. They not only know how to mimic diseases but also have sophisticated knowledge of medical practices. They can manipulate their care so that they are hospitalized and subjected to intense testing and treatment, including major operations. Their deceits are conscious, but their motivation and quest for attention are largely unconscious.

Munchausen by proxy is a bizarre variant of Munchausen syndrome. In it, a caregiver (often a parent) intentionally produces or feigns symptoms in someone in their care (often a child). The caregiver falsifies the child’s medical history and may injure the child with drugs or add blood or bacterial contaminants to urine specimens. All is done in an effort to fake disease. The motivation for such behavior appears to be a psychologic need to experience the role of a sick person through a substitute (proxy). People with this disorder also have a pathologic need for attention and an intense relationship with the child.

Body Dysmorphic Disorder

In body dysmorphic disorder, a preoccupation with a nonexistent or slight defect in appearance results in significant distress or impaired functioning.

People typically spend hours a day worrying about their perceived defect, which may involve any body part.

Doctors diagnose the disorder when concerns about appearance cause significant distress or interfere with functioning.

Certain antidepressants and cognitive-behavioral therapy may help.

People with body dysmorphic disorder believe they have a flaw or defect in their physical appearance that in reality is nonexistent or slight. The disorder usually begins during adolescence. It is believed to occur in men and women about equally or somewhat more frequently in women.

Did You Know…

People may be so concerned about a nonexistent or slight defect in their appearance that they avoid going out in public.

Symptoms

Symptoms may develop gradually or abruptly, vary in intensity, and tend to persist unless appropriately treated. Concerns commonly involve the face or head but may involve any body part or several parts and may change from one body part to another. For example, people may be concerned about hair thinning, acne, wrinkles, scars, color of complexion, or excessive facial or body hair. Or people may focus on the shape or size of a body part, such as the nose, eyes, ears, mouth, breasts, legs, or buttocks. Some men with normal or even athletic builds think that they are puny and obsessively try to gain weight and muscle; this is called muscle dysmorphia.

Most people with body dysmorphic disorder have difficulty controlling their preoccupation and spend hours each day worrying about their perceived defect. Many people check themselves often in mirrors, others avoid mirrors, and still others alternate between the two behaviors. Many people compulsively and excessively groom themselves, pick at their skin, seek reassurance, and change their clothes. Most try to camouflage their nonexistent or slight defect—for example, by growing a beard to hide perceived scars or by wearing a hat to cover slightly thinning hair. Many have cosmetic medical (most often, dermatologic), dental, or surgical treatment, sometimes repeatedly, to correct their perceived defect. Such treatment is usually unsuccessful and may intensify their preoccupation. Men with muscle dysmorphia may take anabolic steroids such as testosterone.

Because people with body dysmorphic disorder feel self-conscious about their appearance, they may avoid going out in public, including going to work, school, and social events. Some with severe symptoms leave their homes only at night, and others not at all. This behavior can result in social isolation. Distress and dysfunction caused by the disorder can lead to repeated hospitalization and suicidal behavior.

Diagnosis and Treatment

Because many people with body dysmorphic disorder are too embarrassed and ashamed to reveal their symptoms, the disorder may go undiagnosed for years. It is distinguished from normal concerns about appearance because the preoccupations are time-consuming and cause significant distress or impair functioning.

Treatment with serotonin reuptake inhibitors, a class of antidepressants, is often effective. Cognitive-behavioral therapy that specifically focuses on this disorder may also lessen symptoms.

Conversion Disorder

In conversion disorder, physical symptoms that resemble those of a neurologic disorder develop. The symptoms are triggered by mental factors such as conflicts or other stresses.

An arm or leg may be paralyzed, or people may lose their sense of touch, sight, or hearing.

Many physical examinations and tests are usually done to make sure symptoms do not result from a physical disorder.

Reassurance from a supportive, trusted doctor is important; hypnosis and cognitive-behavioral therapy may also help.

Conversion disorder, once referred to as hysteria, is thought to be caused by mental factors, such as stress and conflict, which people with this disorder experience as (convert into) physical symptoms. Although conversion disorder tends to develop during late childhood to early adulthood, it may appear at any age. The disorder appears to be more common among women.

Symptoms

The symptoms—such as paralysis of an arm or leg or loss of sensation in a part of the body—suggest nervous system dysfunction. Other symptoms may include seizures and loss of one of the special senses, such as vision or hearing.

Often, symptoms begin after some distressing social or psychologic event.

People may have only one episode in their lifetime or episodes that occur sporadically. Usually, the episodes are brief. Most people with conversion symptoms who are hospitalized improve within 2 weeks. However, in 20 to 25% of people, symptoms recur within a year and, for some people, become chronic.

Diagnosis

The diagnosis tends to be initially difficult for a doctor to make because people believe that the symptoms stem from a physical problem and may resist being seen by a psychiatrist or other mental health practitioner. Also, doctors take great care to be certain no physical disorder is causing the symptoms. Thus, the diagnosis is usually considered only after extensive physical examinations and tests fail to detect a physical disorder that can fully account for the symptoms.

Mind and Body

How the mind and body interact to influence health has long been discussed. The term psychosomatic expresses this interaction. Paired with disorder, the term was once used to refer to physical symptoms that appear to be caused or worsened by mental factors, rather than by a physical disorder. Now, the term somatoform disorders is used to refer to these disorders. The term does not imply that physical symptoms are imagined or are being faked (as in Munchausen syndrome). People with a psychosomatic disorder actually experience the symptoms.

The mind and body interact in many other ways.

Social and mental stress can aggravate many physical disorders, including diabetes mellitus, coronary artery disease, and asthma. Such stress can trigger, worsen, or prolong physical symptoms.

Stress can cause physical symptoms even when no physical disorder is present. Sometimes physical symptoms result from the body’s automatic response to emotional stress, as when heart rate and blood pressure increase in response to fear.

Sometimes a physical symptom appears to be a metaphor for an emotional experience, as when people with a “broken heart” have chest pain. Or a physical symptom may reflect identification with another person’s pain. For example, people may have chest pain after a family member or friend has had a heart attack.

Physical symptoms can evolve from stress or mental symptoms in anyone, including people who do not have a serious underlying mental health disorder. Such physical symptoms are often mild and transient. They can be difficult for a doctor to diagnose, and various diagnostic tests may be required to eliminate the possibility of an underlying physical disorder.

Mental factors can also influence the course of a disorder. For example, people with high blood pressure may deny having it or deny its seriousness. Denial is a defense mechanism that helps reduce anxiety. However, denial may prevent people from following their treatment plan. For example, they may not take their prescribed drugs, thus worsening their disorder.

Conversely, a physical disorder can influence or lead to a mental condition. For example, people with a life-threatening, recurring, or chronic physical disorder may become depressed. The depression, in turn, may worsen the effects of the physical disorder.

Treatment

A supportive, trustful doctor-patient relationship is essential. The most helpful approach may involve collaboration of a primary care doctor with a psychiatrist and a doctor from another field, such as a neurologist or internist. As the doctor evaluates a possible physical disorder and reassures the person that the symptoms do not indicate a serious underlying disease, the person may begin to feel better, and the symptoms may fade.

The following treatments may help:

Hypnosis may help by enabling people to control how stress and other mental states affect their bodily functions.

Narcoanalysis is a rarely used procedure similar to hypnosis except that people are given a sedative to make them drowsy.

Psychotherapy, including cognitive-behavioral therapy, is effective for some people.

Any coexisting psychiatric disorders (such as depression) should be treated.

Hypochondriasis

In hypochondriasis, people are preoccupied with the fear of having a serious disease or are preoccupied with the belief that they actually have a disease. These feelings are usually based on a misinterpretation of normal bodily sensations or minor physical symptoms.

People believe that signs of normal body functions, such as a grumbling in the intestines or sweating, indicate a serious physical disorder.

Even though a thorough medical evaluation determines that no physical or other mental disorder can account for the symptoms, people remain preoccupied with their concerns.

A supportive, trustful relationship with a doctor may help, but referral to a psychiatrist is often needed.

Hypochondriasis begins most commonly during early adulthood and appears to affect both sexes equally.

Symptoms

People misinterpret normal bodily functions or minor physical symptoms that are not related to any abnormality or disorder. These symptoms may include abdominal bloating, rumbling in the abdomen, awareness of the heartbeat, sweating, pain, and fatigue. People may describe their symptoms in minute detail. They think that the symptoms indicate a serious physical disorder. For example, they may think headaches indicate a brain tumor. The symptoms cause them great distress. As people become increasingly concerned with health issues, personal relationships and work performance often suffer.

Examination and reassurance by a doctor do not relieve the concerns of people with hypochondriasis. They tend to believe that the doctor has somehow failed to find the underlying disorder.

Some people with hypochondriasis also have depression or anxiety.

Hypochondriasis often persists, lasting years. In some people, it comes and goes. Some people recover completely.

Diagnosis

Hypochondriasis is suspected when healthy people with minor symptoms are preoccupied with the significance of the symptoms and do not respond to reassurance after a thorough medical evaluation.

The diagnosis of hypochondriasis is confirmed if the situation persists for at least 6 months despite a medical evaluation and a doctor’s reassurance and if the symptoms cannot be attributed to depression or another mental health disorder.

Treatment

Treatment can be difficult because people with hypochondriasis believe that something inside the body is seriously wrong. Reassurance does not relieve these concerns. However, a supportive, trustful relationship with a caring doctor is beneficial, especially if regular visits are scheduled. If symptoms are not adequately relieved, people may benefit from referral to a psychiatrist or another mental health practitioner for further evaluation and treatment, with continuing care by the primary doctor.

Treatment with serotonin reuptake inhibitors, a class of antidepressants, may be effective. Cognitive-behavioral therapy may also relieve symptoms.

Somatization Disorder

Somatization disorder is a chronic, severe disorder characterized by many recurring physical symptoms that cannot be fully explained by a physical disorder. These symptoms include some combination of pain and digestive, sexual, and neurologic symptoms.

People typically have many symptoms (such as headache, nausea, diarrhea, constipation, and fatigue) over a period of several years.

They seek treatment for their physical complaints, and many physical examinations and tests may be done to make sure symptoms do not result from a physical disorder.

Having a supportive, trustful relationship with a doctor can be very helpful; cognitive-behavioral therapy can also help.

Somatization disorder often runs in families and occurs predominantly in women. Male relatives of women with the disorder tend to have a high incidence of antisocial personality (see page 881) and substance-related disorders. Many people with somatization disorder also have symptoms of depression and anxiety, a personality disorder, and excessive dependence on others (see page 882).

Did You Know…

People with a somatization disorder are not faking their symptoms.

The physical symptoms in somatization disorders may reflect a plea for help and attention and a desire to be cared for. The symptoms may also have other purposes, such as enabling people to avoid the responsibilities of adulthood. However, symptoms are not intentionally produced or feigned. The symptoms tend to be uncomfortable and prevent people from engaging in many enjoyable pursuits.

Symptoms

Symptoms first appear during adolescence or early adulthood (before age 30). People have many physical complaints, which they may describe as “unbearable,” “beyond description,” or “the worst imaginable.”

Any part of the body may be affected. Specific symptoms and their frequency vary among different cultures. Typical symptoms include headaches, nausea and vomiting, abdominal pain, diarrhea or constipation, painful menstrual periods, fatigue, fainting, pain during intercourse, and loss of sexual desire. Men frequently complain of erectile or other sexual dysfunction. Anxiety and depression also occur.

People with somatization disorder demand help and emotional support and may become angry when they feel their needs are not being met. Often dissatisfied with their medical care, they may go from doctor to doctor, seeking medical tests and treatment.

Diagnosis

People with somatization disorder are not aware that their basic problem is psychologic, so they press their doctors for diagnostic tests and treatments. Doctors usually conduct many physical examinations and tests to determine whether a physical disorder adequately explains the symptoms. Referrals to specialists for consultations are common, even for people who have developed a reasonably satisfactory relationship with one doctor.

Once a doctor determines that the problem is psychologic, somatization disorder can be distinguished from similar mental health disorders by its many symptoms and their tendency to persist over a period of years.

Prognosis

Somatization disorder tends to fluctuate in severity but may persist throughout life. Symptoms are rarely completely relieved for any length of time. Some people become more depressed after many years. Suicide is a risk.

Treatment

Treatment is difficult. Psychotherapy, particularly cognitive-behavioral therapy, may help. Drugs may lessen symptoms of coexisting mental disorders such as depression.

Usually, people with this disorder are best helped by a supportive, trustful relationship with a doctor who coordinates their health care, offers symptomatic relief, sees them regularly, and protects them from unnecessary diagnostic or therapeutic procedures. However, the doctor must remain alert to the possibility that these people may develop an actual physical disorder that requires evaluation and treatment.