Neurologists routinely assess patients with symptoms for which medical causes are unknown, and psychiatric illness is ultimately suspected. Among first-time referrals for neurologic consultation, Fink et al. (21) documented at least one medically unexplained symptom in 63% of male and 59% of female patients. More than one third of these patients fulfilled International Classification of Diseases 10th Revision (ICD-10) criteria for somatoform disorder. Similarly high prevalence rates were documented according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. In primary and secondary care settings, symptoms not adequately explained by a known medical condition account for 25% to 50% of clinical presentations. Advancing age adds yet another dimension of complexity to the evaluation of medically unexplained symptoms; dynamic changes in physical, neurochemical, metabolic, emotional, and behavioral functioning may be virtually inseparable.
Late-life psychiatric disorders are a common and complex source of excess functional disability. The prevalence of severe depressive symptoms in individuals aged 65 to 79 years is approximately 15%. More than 20% of persons aged 80 years and older have similarly severe manifestations of depression (50). In a collaborative study conducted under the auspices of the World Health Organization (WHO), somatization was deemed common across cultures and associated with “significant (health) problems and disability” (26). Health anxiety and related psychiatric concomitants in older adults are associated with considerable adversity, including increased medical utilization, longer duration of inpatient hospitalization, diminished quality of life, and decline in functional independence. Somatic symptoms also predict poorer outcomes on older patients’ ratings of overall health, quality of life, restrictions in physical and social activity independent of depression, and physical health status. Among patients presenting in primary care settings, Smith (66) found a ninefold increase in health care utilization expenditures among older patients with concomitant somatization. Costs to patients, as well as to their families, are likely inestimable.
This chapter begins with an overview of classification schemes used in the differential diagnosis of somatoform disorders followed by a brief epidemiology review. Biologic, psychological, and psychosocial mechanisms are then discussed as inseparable sources of somatization in older adults. Theoretical bases of unconscious symptom production are described and further exemplified in discussions of psychogenic nonepileptic seizures (PNES), tremor, and gait disturbance. A discussion of common treatment barriers and therapeutic approaches of benefit to older adults concludes this chapter.
CLASSIFICATION SCHEMES
The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) first introduced somatoform disorders as a provisional diagnostic category in 1980. The subsequent and current edition, DSM-IV, replaced the concept of neurosis with multiple new diagnoses that could not be explained by a general medical condition or clearly associated with depression or anxiety. Specifically, DSM-IV omitted “organic” rule-out differentials in recognition of both known and highly suspected biologic substrates of primary psychiatric disorders (67). The phrase “due to a general medical disorder” appears in its place. The classification “Mental Disorders Due to a General Medical Condition” is also new to this edition. Such revisions were intended to underscore the physical versus mental distinction as an anachronistic perspective in modern medicine. The fifth edition of this classification is due to be published in 2012. One of the most widely debated revisions is the diagnostic category of somatization disorders. Major criticisms and proposed solutions to related shortcomings of DSM-IV follow a brief description of the existing framework.
Within the diagnostic classification of somatoform disorders, the DSM-IV delineates seven categorical entities: Conversion Disorder, Hypochondriasis, Somatization Disorder, Pain Disorder, Undifferentiated Somatoform Disorder, Body Dysmorphic Disorder, and Somatoform Disorder Not Otherwise Specified. The unifying trait of disorders falling within the somatoform classification is that patients present for evaluation of somatic complaints for which a physical cause is not the primary etiology. By definition, a physiologic cause has either been ruled out or is independently unable to explain symptom severity, frequency, and/or associated degree of functional disability.
Table 32-1.Diagnostic Criteria for Conversion Disorder
A.
One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurologic or other general medical condition.
B.
Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.
C.
The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
D.
The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.
E.
The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
F.
The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC; 1994, with permission.
The defining feature of somatization is that covert psychological factors are presumed to play a major role in symptom production. Importantly, this role is not feigned or otherwise consciously produced. Such symptoms fall within the distinct categories of Factitious Disorders or Malingering, which will not be addressed in this chapter. DSM-IV criteria for somatoform disorders most commonly seen in older adults are presented in Tables 32-1, 32-2, 32-3 and 32-4.
Table 32-2.Diagnostic Criteria for Hypochondriasis
A.
Preoccupation with fears of having, or the idea that one has, a serious disease based on the person’s misinterpretation of bodily symptoms.
B.
The preoccupation persists despite appropriate medical evaluation and reassurance.
C.
The belief in criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder).
D.
The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E.
The duration of the disturbance is at least 6 months.
F.
The preoccupation is not better accounted for by generalized anxiety or another somatoform disorder.
From American Psychiatric Association. Diagnostic and Statistical Manula of Mental Disorders. 4th ed. Washington, DC; 1994, with permission.
Table 32-3.Diagnostic Criteria for Pain Disorder
A.
Pain in one or more anatomic sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
B.
The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C.
Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
D.
The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
E.
The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC; 1994, with permission.
DSM-IV is under considerable scrutiny regarding its restrictive classification of unexplained medical illness, as well as falling short in its attempt to improve understanding of these disorders, facilitate research, and enhance clinical care (11,45,70). It has been argued that the empirical foundation for the current classification is limited, as is its discriminative validity in separating somatization from mood and anxiety disorders. Many patients seen in primary care settings do not meet the symptom threshold required for major diagnostic classification, yet clearly present with excess symptom production and functional impairment (29). In one study of 191 consecutive patients seen in family practice settings, the majority of patients either met criteria for somatization disorder not otherwise specified (NOS) or undifferentiated somatization disorder (29.93% and 27.3%, respectively). The prevalence of major DSM-IV somatoform diagnoses, in contrast, was relatively small and ranged between 1.0% and 8.1% (20). Thus, although somatization as a symptom is common, relatively few patients actually meet diagnostic criteria for major classification. In addition, patients may be diagnosed with an Axis I psychiatric disorder and Axis III medical condition when both diagnoses refer to the same presentation. As described by Strassnig et al. (70), “the current system—with the ‘medical’ and ‘psychiatric’ specialties investigating essentially the same phenomena from different perspectives not only clearly reflects a persisting ‘mind-body’ distinction, but also at worst creates oxymoronic diagnostic labeling of patients.”
Table 32-4.Diagnostic Criteria for Somatization Disorder
A.
A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning
B.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:
1.
Four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
2.
Two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
3.
One sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
4.
One pseudoneurologic symptom: a history of at least one symptom or deficit suggesting a neurologic or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures, dissociative symptoms such as amnesia, or loss of consciousness rather than fainting)
After appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
2.
When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings
D.
The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering)
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC; 1994, with permission.
In anticipation of DSM-V publication, debates regarding revisions of existing classification schemes have increasingly escalated. Initiatives intended to summarize existing knowledge and bring together diverging classification proposals on somatoform disorders include the Conceptual Issues in Somatoform and Similar Disorders (CISSD) project, expert meetings of the American Psychiatric Association (APA), and the WHO on Somatic Presentation on Psychiatric Disorders. Among many proposals are those advocating for abridged diagnostic criteria intended to simplify diagnostic classification as multisymptomatic or monosymptomatic somatization, with pain disorder assigned to the latter classification. Others advocate for abolition of the somatization category all together and, in its place, would position somatic symptoms on Axis III as functional somatic symptoms and syndromes. In this framework, hypochondriasis would be renamed as “health anxiety disorder” subsumed within the anxiety disorders spectrum, and only dissociative and conversion symptoms would remain on Axis I. Ultimately, a consensus has emerged regarding the need for improvement of the existing classification scheme. The extent to which DSM-V will facilitate better understanding of psychological distress and its relationship to physical illness, in addition to its ability to advance clinical care and research in older adults, will undoubtedly be key measures of success within our rapidly aging population.
EPIDEMIOLOGY
As highlighted in the foregoing discussion, estimates regarding the overall prevalence of somatoform disorders vary widely due to differences in diagnostic criteria, as well as sample characteristics, and even to discrepancies in determining what is considered a medical disease and what is not. In primary care settings, the prevalence of somatoform disorders was estimated to be between 22% and 58% (20). Community surveys have shown an “exaggerated concern about health” in approximately 10% of older adults (9). Somatization is recognized not only as the presence of somatic symptoms without a known or sole physiologic cause, but it also entails complaints made to a health professional, taking medications, or making significant lifestyle alterations due to symptom burden (54).
Current literature provides conflicting information regarding demographic characteristics of late-life somatization; whereas some researchers report that gender, education, age, depression, socioeconomic status, and social activity covary with somatization symptoms, other studies show no relationship with gender, ethnicity, situational stress, recent bereavement, retirement, or physical disability (4,48). In terms of age-related factors, Pribor et al. (54) found no age-related differences in symptom frequency, number of surgeries, medical hospitalizations, or psychiatric hospitalizations in their study of 353 women meeting DSM-IV criteria for somatization disorder. Only 10% of their sample, however, was over the age of 65. Sheehan and Banerjee (64) underscore the difficulty of estimating the prevalence of late-life somatization in this population due to discrepancies in defining clinical populations, sampling procedures, and diversity of measurement instruments.
MECHANISMS OF SOMATIZATION IN OLDER ADULTS
BIOLOGIC FOUNDATIONS
Neurologic, genetic, and biochemical links to somatization and other psychiatric conditions are advancing at a rapid pace. A recent Medline search yielded 9,284 articles identified with the keywords “psychiatric” and “imaging or neuroimaging” or “genetic or genomic.” Approximately 60% of these articles (i.e., 5,672) were published since the year 2000.
Functional neuroimaging studies have documented metabolic correlates of conversion symptoms, including selective decreases in frontal and subcortical circuits subserving motor control in patients with hysterical paralysis, metabolic decreases in somatosensory cortices in patients with medically unexplained anesthesia, and decreases in visual cortex in patients with psychogenic blindness [see review by Vuilleumier (72)]. In one such study, Vuilleumier et al. (73) assessed functional unilateral sensorimotor loss via single photon emission computed tomography (SPECT) in seven patients with actively symptomatic hemiplegia. Imaging studies were repeated 2 to 4 months after deficit resolution. Results showed consistent hyperperfusion in thalamus and basal ganglia in the contralateral hemisphere, which are findings consistent with known pathophysiology of the organic equivalent. Moreover, perfusion abnormalities were absent at follow-up, when symptoms associated with unilateral hemiparesis had fully abated (73). Such parallel changes in cerebral perfusion suggest shared neuroanatomic pathways between symptoms of organic and functional origin. Similar techniques have greatly enhanced our understanding of structural and functional correlates of major depression, anxiety, and thought disorders at various ages and levels of chronicity [see reviews by Moresco et al. (49) and Parsey and Mann (51)].
Genetic predispositions for somatization symptoms have also been identified. Up to half of the stable variance in self-report of somatization symptoms was attributed to genetic factors in the absence of familialenvironmental effects in the “Virginia 30,000” twinfamily sample (36). More recently, Saito et al. (62) reviewed studies of familial aggregation, twins, candidate gene association, and pharmacogenomics in an attempt to understand genetic underpinnings of irritable bowel syndrome (IBS). Overall, modest support for a genetic basis of IBS was derived from familial and twin studies, with stronger associations found for pharmacogenomic factors. Bienvenu et al. (8) found a higher incidence of somatoform disorders in family members of people with hypochondriasis or other “obsessive-compulsive spectrum disorders” compared to first-degree relatives of case-control probands. Major confounding factors in familial association studies include exposure to similar environments and reporting bias due to increased familial awareness of target symptoms. The potential for genomic advances to better our understanding of the role of genetics in the pathophysiology and clinical manifestation of psychogenic disorders is considerable. However, the literature continues to support, particularly with regard to treatment initiatives, the importance of psychological and psychosocial dynamics that underlie and promote emotional distress in older adults.
PSYCHOLOGICAL FOUNDATIONS
Illness is an inextricable part of aging; excess functional disability is not. Thus, adequate assessment and treatment of somatization spectrum disorders require fundamental knowledge of psychological mechanisms within the broader perspective of illness behavior.
A growing body of research has emerged regarding “abnormal illness behavior,” a term that encompasses a variety of symptom presentations in which excessive concern about illness predominates and extensive evaluation and medical treatment is sought (53). Although this term applies to complaints associated with well-defined medical conditions, it has primarily been ascribed to disorders or symptoms not explained by primary medical conditions. As further described by Kirmayer and Looper (38), illness behavior reflects important dimensions of somatization that include sociocultural perspectives, developmental processes, and physiologic mechanisms. Specific psychological dimensions of illness behavior entail cognitive, perceptual, and behavioral aspects of a patient’s response to symptoms or disease expressed as heightened somatic sensitivity, symptom attribution, catastrophizing, and denial.
A majority of patients with medically unexplained symptoms exhibits high sensitivity to somatic symptoms, including increased intensity and duration of pain or other bodily sensations, higher levels of subjective stress, and sheer number of symptoms relative to healthy and patient controls. Somatizing patients also show a greater tendency to attribute common physical symptoms to major illness and to more serious pathology. Such symptoms are then further amplified via catastrophic thoughts and rumination.
Catastrophizing refers to the generation of unrealistic and excessive fears regarding health status and outcome, such as when the individual maintains a focus on low-incident side effects or adverse events leading to disastrous, although improbable, outcomes. Relatedly, somatizing patients excessively worry about symptoms or conditions in a pathologic manner that induces negative affect, anxiety, and heightened autonomic arousal. Hypervigilance to signs and sensations may occur in a manner that promotes “somatosensory amplification,” which, in turn, is reinforced through a confirmatory bias that maintains this closed-loop system. A major advantage of cognitive-behavioral models of somatization is that they facilitate interventions specifically targeting dysfunctional and unrealistic thoughts and beliefs.
At the other extreme of the cognitive continuum are forms of unconscious symptom production associated with minimization of illness, or denial, long considered the primary mechanism underlying conversion disorders. Based on the early works of Briquet, Charcot, Freud, Breuer, and Janet, somatization is understood to reflect painful psychological turmoil translated into a more acceptable and concrete (i.e., physical) form.
“… In hysteria the unbearable idea is rendered innocuous by the quantity of excitation attached to it being transmitted into some bodily form of expression … conversion may be either total or partial, and it proceeds along the line of the motor or sensory innervation that is more or less intimately related to the traumatic experience.” Freud (22)
Sadavoy (61) provides a useful theoretical understanding of psychiatric disorders in the context of developmental changes in late life. According to this conceptualization, as impulse and action-oriented defenses diminish with normal aging, other responses to affective states become increasingly evident. Expression of these inner states, in turn, often mimics symptoms associated with Axis I disorders. The expression of distress is further tied to unique personality traits, characterologic adjustment, and external stressors. A list of stress reactions commonly occurring in late life is presented in Table 32-5. Thus, personality structure and both internal and external stressors are considered to mediate excess symptom production in older adults.
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Medically Unexplained Symptoms in Older Adults
