Somatoform Disorders

Somatoform Disorders

1. Somatization disorder

Somatization disorder is the generation of recurrent physical symptoms-referred to as ‘somatic symptoms' (a somatic syndrome is also described in depression, and also termed biological symptoms of depression. It is not the same as somatic symptoms discussed here).

Somatization here is associated with a demand for medical investigations in case the symptoms are harbingers of an underlying physical illness.

The diagnostic features of Somatization disorder include:

• v Two years or more of a range of variable symptoms which are recurrent and cannot be explained by detectable physical disorder.
• v Preoccupation with the symptoms causes distress and lead to the patient demanding three or more sets of investigations or specialist referral, but, despite this, the patient still refuses to be reassured that nothing is medically wrong
• v At least six of the symptoms listed are present

Body system

Symptoms

Gastrointestinal

Abdominal pain

Nausea

Bloatedness

Bad taste in mouth

Food vomited or regurgitated

Frequent/loose motion

Cardiovascular

Breathlessness without exertion

Chest pain

Genitourinary

Dysuria or frequency of micturation

Unpleasant genital sensation

Increased or changed vaginal discharge

Neurological

Joint/limb pain

Numbness/tingling

Skin

Discoloration

Rash

2. Hypochondrical disorder

For a diagnosis of Hypochondrical disorder there must be present:

• 1. A persistent belief lasting six month or more that the individual has one or two serious physical diseases, one of which must be named (e.g. cancer)
• 2. Evidence of distress or impairment in functioning caused by the belief or by the symptoms associated with the ‘disease', leading to seeking of medical attention
• 3. Persistent refusal to accept medical reassurance as the lack of a physical cause for the symptoms, for more than brief periods.

Dysmorphophobia (body dysmorphic disorder) is a related condition involving a persistent belief of deformity or disfigurement, again causing distress and producing a demand for medical input.

3. Somatoform autonomic dysfunction

Here, although the patient attributes their symptoms to a disorder of the cardiovascular, gastrointestinal, respiratory, or genitourinary system, there is no evidence of true pathological changes affecting the relevant organ system. There must be two symptoms typical of autonomic arousal (palpitation, sweating, flushing, dry mouth, or abdominal churning) and a further non-specific symptoms referred to the relevant organ system (e.g. chest pain)

4. Persistent somatoform pain disorder

Here the somatic symptoms are confined to pain, which may occur in various diverse regions of the body and which must be severe and distressing for at least six months.

Aetiology of somatoform disorder:

The aetiology is poorly misunderstood, although episodes often follow the appearance of a stress (remember the 3Ps!). In case of somatoform pain disorder, the stressor typically involves pain (e.g. unexpected physical trauma).

Somatization disorder may have some genetic component in that up to one-fifth of sufferers' female. First-degree relatives also have higher rates. Theories of a biological aetiology include the suggestion that physical symptoms result from a failure to regulate cytokines (e.g. interleukins)

There is close association with personality disorders or dysfunctional personality traits

Psychological models consider the symptoms to be produced as a surrogate form of communication.

Patient with Hypochodriasis may simply have a lower threshold for identifying illness or may subconsciously covet the gain to be had from adopting the sick role.

Epidemiology

A somatization disorder has a lifetime prevalence of about 0.5%. There are no data on the lifetime prevalence of Hypochondriasis or somatoform pain disorder, but both disorders are common and present recurrently to physicians.

Somatization disorder usually starts before the age of 30 (in some classification this is essential). The onset of Hypochodriasis, by contrast, may be at any age, although the peak incidence is between 20 and 30. The age of onset for somatoform pain disorder most likely between 30 and 40.

Somatization disorder tends to be linked with low socioeconomic, low education individuals. Hypochodriasis is equally common in all groups.

 Course & prognosis

Comorbidity with other psychiatric disorders and personality disorder is extremely common and complicate the clinical picture.

Both Somatization disorder and Hypochodriasis tend to have a chronic episodic course, often precipitated by stress. The episode may go for many month s before remission. Hypochondriasis is more likely than Somatization disorder to have a full remission (better prognosis).

Good prognostic factors for somatoform disorders are:

• Absence of personality disorder
• early diagnosis (least amount of medical interventions)
• Diagnosed medical problem
• Presence of treatable psychiatric disorder such as depression or anxiety.

 Treatment

• One doctor: patent seek variety of doctors in different specialties. It is desirable for one doctor (family physician, or general medical physician) to take charge, evaluate the emergence of new symptoms by as fewer tests as possible and be aware that referral to specialist can be counterproductive.
• Medication: helpful when clear symptoms of treatable psychiatric disorder such as anxiety or depression are present. SSRI are worth trying, esp. in hypochondriasis.
• Psychotherapy: CBT is gaining popularity and the evidence are gathering for its effectiveness. Supportive therapy is extremely important, especially by the responsible physician. It may prove valuable and should aim to help the patient to deal with the symptoms (rather than trying to convince them that the symptoms are ‘all in the mind'.

Reference:

1. Boyle D, Davies S. Psychiatry, Mosby's crash course 2002.

2. Steple D. Oxford 2.Handbook of Psychiatry, Oxford University Press, 2006