Somatoform disorders is the umbrella term developed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) in 1980 to describe a group of conditions characterized by the presence of physical symptoms without evidence of a physiologic cause. DSM-IV divides these conditions into six separate psychiatric disorders.
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 fourth edition of DSM in 1980, 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.
Somatization disorder
Somatization disorder was formerly called Briquet's syndrome, after the French physician who first recognized it. Z. J. Lipowski defined somatization in the American Journal of Psychiatry as "the tendency to experience and communicate somatic distress and symptoms not accounted for by pathologic findings, to attribute them to physical illness and to seek medical help for them."
Somatization disorder typically begins before the age of 30. It is estimated that worldwide, between 0.2% and 2% of the population will develop this disorder in their lifetime. In the United States, it is nearly twice as common in women, but in other cultures, it is believed to be more widespread in men. Some psychiatrists think that the high female-to-male ratio in this disorder in North America reflects the cultural pressures on women and the social expectation that women are generally physically weak or sickly. It is also likely to run in families. As many as 20% of the mothers, sisters, or daughters of somatization disorder patients have the same illness. Their male first-degree relatives are more apt to have anti-social personality disorder or addiction problems. When asked to self-assess health, somatization disorder patients usually rate their well-being as worse than people suffering from actual long-term illness do. Physical complaints normally develop or increase during times of stress, and though these people look for help frequently, it is highly unusual for them to find relief.
Undifferentiated somatoform disorder
Undifferentiated somatoform disorder is generally less specific than somatization disorder, and requires only the presence of one symptom to be consistently present. But patients suffering from undifferentiated somatoform disorder often complain of fatigue, loss of appetite, or difficulty swallowing. Symptoms commonly develop when the person is under stress or is depressed, and to meet DSM-IV criteria, must have no physical basis and remain for more than six months.
Conversion disorder
In conversion disorders, people typically report a loss or change in the function of some part of their body that does not correlate with what medical science knows today of anatomy or physiology. Symptoms are often neurological in nature, such as seizures that are not seen on EEG, or an inability to move an arm or leg, or walk. 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 somato-form disorders on the patient's emotional adjustment and lifestyle.
Unlike somatization disorder, the symptoms of conversion disorder typically occur in adolescence or early adulthood, when the person is under extreme stress. It does not appear to run in families. It is estimated that as many as one in four people admitted to a general hospital have experienced conversion symptoms, but that the disorder is more likely to occur among less educated or sophisticated people. Females are at least twice as likely to develop conversion disorder symptoms, and men are more likely to develop such symptoms in occupational settings or military service.
Pain disorder
Pain disorder is marked by the experience of severe pain in the absence of physical cause for the pain, or markedly unwarranted complaint of pain from an actual illness. DSM-IV requirements include duration of a minimum of six months, a curtailing of normal activities such as work or school, and relationship problems. Prescription drug dependency often accompanies somatoform pain disorder, but drug-seeking does not cause it. Somatoform pain disorder is not deliberately put on. 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.
Pain disorder is frequently accompanied by what are termed the Five D's. These are:
depressed mood
disturbed sleep pattern
dysfunction in social situations
decreased activity level
decreased physical activity
Because pain is such an individual experience, the incidence of somatoform pain disorder is unclear. It is known that between 10–15% of all of the population that suffer from back pain eventually become work-disabled. What percent of these people suffer from somatoform pain disorder is unclear.
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. Patients typically are abnormally attentive to normal bodily functions such as heartbeat or perspiring. DSM-IV criteria include the presence of unrealistic fears or beliefs for at least six months. During any six month period, between 4% and 6% of the population suffers from hypochondria. Episodes can last anywhere from months to years, and it is a persistent, relapsing condition. Chronic stress is believed to play a large role in its occurrence.
Body dysmorphic disorder
Body dysmorphic disorder is a new category in DSM-IV. 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. Patients with this disorder are often found in plastic surgery clinics. They frequently have histories of seeking or obtaining plastic surgery or other procedures to repair or treat supposed defects, but it seldom if ever provides them with long-term relief.
Though the average age of body dysmorphic disorder patients is thirty, it 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 it is now estimated that two percent of those seeking plastic surgery may be dysmorphic disorder patients. It appears to affect men and women with equal frequency. Some may even meet the criteria for a delusional disorder of the somatic type.
Somatoform disorders in children and adolescents
In children and adolescents, the most common somatoform disorder is conversion disorder, though 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 over-involved 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 incidence of body dysmorphic disorder in adolescents is thought to reflect the increased influence of media preoccupation with physical perfection.
Causes and symptoms
In somatoform disorders, the patient's reported symptoms are considered to be the unconscious manifestation of very real emotional suffering. In classic psychoanalytic theories, unconscious conflicts are the result of painful early-life events that are re-awakened in adult life by similar stressors. Because the person is unable to express the re-awakened emotion because of fear or guilt, their emotions are repressed and changed into physical symptoms.
Because DSM-IV groups the somatoform disorders into their present category 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. But it is equally important for physicians and all healthcare staff to carefully evaluate the person to assure that an actual physical cause for the somatoform-appearing symptom is not being missed. Diagnosis of somatoform disorders requires a thorough physical workup. Pain disorder patients have, on occasion, later been discovered to actually have cancer, and a detailed examination is especially necessary when conversion disorder is a possible diagnosis, because some neurological conditions, including multiple sclerosis and myasthenia gravis, have 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 dysmorphic disorder may be associated with obsessive-compulsive disorder.
Psychiatric therapies
Patients with somatoform disorders are not considered good candidates for psychoanalysis or other forms of insight-oriented psychotherapy. They can benefit, however, from supportive approaches 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.
Medications
Patients with somatoform disorders are sometimes given anti-anxiety drugs or antidepressant drugs if they have been diagnosed with a coexisting mood or anxiety disorder. In general, though, it is considered better practice to avoid prescribing medications for these patients since they run the risk of becoming psychologically dependent on them.
Hypnosis is a time-honored technique used since Freud's time as part of a general psychotherapeutic approach to conversion disorder. It may allow patients to recover memories or thoughts connected with the onset of the physical symptoms.
Alternative treatment
Patients with somatization or pain disorders may be helped by a variety of alternative therapies including acupuncture, hydrotherapy, therapeutic massage, yoga, meditation, botanical medicine, and homeopathic treatment. These are often available through both pain and stress reduction clinics that many general hospitals now have.
Prognosis
Somatization disorder is considered to be a chronic disturbance that tends to persist throughout the patient's life, but a recent three year follow-up study reported in Caring For The Mind: The Comprehensive Guide to Mental Health showed that a consistent approach using education and reassurance resulted in noticeable improvement.
The prognosis for conversion disorder is considered to be good. Ninety percent of patients recover within a month, and only one in five will ever have a recurrence.
People suffering from hypochondriasis have a more optimistic outlook if treatment is initiated early, before they have gotten themselves into a cycle of medical tests and procedures. There has been very little research regarding the effectiveness of treatment in body dysmorphic disorder.
Health care team roles
In many cases a somatoform disorder diagnosis is made in a general medical clinic by a primary care practitioner, rather than by a psychiatrist. Children and adolescents with somatoform disorders are most likely to be diagnosed by their primary care physician, or pediatrician.
Primary care practitioner (PCP)
A PCP is typically a licensed medical doctor. Because somatoform disorders are associated with physical symptoms, patients are much more apt to be seen by primary care physicians. Their lengthy medical histories make a long-term relationship with a trusted PCP a safeguard against unnecessary treatments as well as being 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.
Psychiatrist
Psychiatrists are licensed medical doctors that have undergone a three year psychiatric residency. They are often the providers of both education and support for patients with somatoform disorders.
Registered nurse (RN), psychiatric nurse, or licensed practical nurse (LPN)
Both RNs and LPNs must complete a prescribed course in nursing and pass a state examination. RNs typically
have a degree in nursing, and psychiatric nurses have additional training specific to psychiatry. Both RNs and LPNs are often the people who deal the most with patients with somatoform disorders in general hospitals, clinics and on psychiatric units. An open mind and nonjudgmental attitude toward the patient and careful, detailed observation of symptoms can be highly useful. The provision of education about the nature of these illnesses will typically come from both physicians and nurses.
Clinical laboratory scientist
Clinical laboratory scientists have specialized training and must pass a state examination. They draw blood samples or test urine or other specimens that are ordered by the physician to help in making a correct diagnosis.
Radiologic technologist
Radiologic technologists have specialized training and must pass a state examination. They take x-rays or other imaging such as MRIs or CT scans that are ordered by the physician to help in making a correct diagnosis.
Social workers
Social workers are usually either certified (CSW) or licensed clinical social workers (LCSW). A two-year graduate program degree and specialized training including supervised clinical work in working with the mentally ill, and state licensure are typical requirements. Social workers often conduct supportive groups or programs that help people vent feelings or work on ways to better be able to cope.
Specialized therapists
Stress reduction therapists are a good example of this category. They are not necessarily licensed in all states, but typically have a degree in one of the human service fields such as social work, psychology or nursing. They are often certified in a specific stress reduction program such as the now-nationwide one that was developed at University of Massachusetts Medical Center by Dr. Jon Kabat-Zinn. Most of these stress reduction programs incorporate standard supportive group therapy techniques with alternative medicine areas such as yoga and meditation.
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 a weakness, might reduce the secondary gain of physical symptoms that draw the care or attention of parents.
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.
CT scan—Computerized Tomography Scanning. A diagnostic technique in which the combined use of a computer and x-rays passed through the body at different angles produces clear, cross-sectional images.
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.
MRI—Magnetic Resonance Imaging. A diagnostic technique that provides very clear cross-sectional images of organs and structures in the human body without x-rays or other radiation.
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.
Stressor—Any interference that disturbs a person's healthy mental and physical well-being.
BOOKS
Clark, R. Barkley. "Psychosocial Aspects of Pediatrics and Psychiatric Disorders." In Current Pediatric Diagnosis and Treatment, edited by William W. Hay Jr., et al. Stamford, CT: Appleton & Lange, 1997.
Eisendrath, Stuart J. "Psychiatric Disorders." In Current Medical Diagnosis & Treatment 1998, edited by Lawrence M. Tierney Jr., et al. Stamford, CT: Appleton & Lange, 1997.
Kaplan, David W., and Kathleen A. Mammel. "Adolescence." In Current Pediatric Diagnosis & Treatment, edited by William W. Hay Jr., et al. Stamford, CT: Appleton & Lange, 1997.
Hales, Dianne, and Hales, Robert E., M.D. Caring For The Mind, The Comprehensive Guide to Mental Health New York: Bantam Books, 1996.
Stone, Timothy E., and Romaine Hain. "Somatoform Disorders." In Current Diagnosis 9, edited by Rex B. Conn, et al. Philadelphia: W.B. Saunders Company, 1997.
