Somatic Symptom Disorders
Anna Lopatin Dickerman
Philip R. Muskin
INTRODUCTION
Somatic symptom disorders are a group of psychiatric illnesses in which patients experience bodily symptoms along with associated abnormal thoughts, feelings, and behaviors that cause clinically significant distress and functional impairment. Patients with somatic symptom disorders tend to initially present in medical or neurologic settings. The disorders account for medical and psychiatric morbidity among patients, as well as increased costs due to greater chronicity of symptoms, health care use, and higher rates of disability. Patients with somatic symptom disorders can be among the most challenging for both psychiatric and nonpsychiatric clinicians alike, as their presentation initially appears “real.” Evidence-based treatments exist for these illnesses, and timely recognition and appropriate referral may significantly improve outcomes. Therefore, it behooves all clinicians—and in particular neurologists, who often encounter these patients before psychiatrists—to be familiar with these complex conditions. Patients with somatic symptom disorders can present with almost any neurologic complaint, including (but not limited to) headache, sensorimotor loss, problems with gait, tremor and other movement disturbances, cognitive complaints, ocular symptoms, and urogenital symptoms. This chapter provides an overview of the different types of somatic symptom disorders, their epidemiology and pathophysiology, and treatment strategies.
SOMATIC SYMPTOM DISORDERS IN DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5TH EDITION
The somatic symptom disorders have undergone significant diagnostic criteria revision in Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) (Table 151.1).
There were several problematic issues with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria for somatic symptom disorders (formerly referred to as somatoform disorders). Clinicians underdiagnosed these illnesses because of confusion about terminology. The DSM-IV diagnostic criteria were particularly challenging for nonpsychiatric clinicians, who are often the first to encounter these patients. Furthermore, the hallmark of somatoform disorders in DSM-IV was the absence of a medical explanation for the somatic symptoms. This resulted in a problematic mind-body dualism that does not conform well to actual clinical experience. Conditions that are medically “unexplained” are not necessarily psychogenic in origin, that is, fibromyalgia and chronic fatigue syndrome are not considered psychiatric illnesses. Having a medically unexplained symptom is insufficient to make a psychiatric diagnosis; conversely, it is possible to have a documented medical condition and still have an abnormal psychological response to the physical symptoms. Patients with somatic symptom disorders may or may not have a comorbid diagnosed medical condition. The distinctive characteristic of these disorders has been shifted away from the somatic symptoms or their underlying etiology per se and focused on the maladaptive way in which the patient presents and interprets symptoms.
The terminology of somatic symptom disorders in DSM-5 reduces the number of disorders and subcategories to minimize problematic overlap and diagnostic confusion. Somatic symptom disorders are defined on the basis of positive psychiatric symptoms rather than the absence of medical explanation for symptoms. Diagnosis no longer requires an exhaustive workup necessitating that the clinician rule out any physiologically based medical condition. The notable exceptions to this new rule are conversion disorder (functional neurologic symptom disorder) and pseudocyesis. DSM-5 also eliminates the use of arbitrarily high symptom requirements that existed in DSM-IV diagnostic criteria for somatoform disorders. A large body of research has shown that the relationship between somatic symptoms and psychopathology exists along a spectrum that was not adequately reflected by these symptom count prerequisites.
The DSM-IV diagnosis of body dysmorphic disorder has been moved to the chapter on obsessive-compulsive disorder and related illnesses in DSM-5, as there is a large body of research establishing pathophysiologic connections between obsessive-compulsive illness and body dysmorphia. Body dysmorphic disorder is thus no longer considered a somatic symptom disorder. This research has considerable treatment implications. Somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder (all diagnoses in DSM-IV) have been removed and incorporated into two central diagnoses in DSM-5: somatic symptom disorder
and illness anxiety disorder. Factitious disorder is now considered a somatic symptom disorder in DSM-5, as these patients often present with somatic symptoms in general medical settings. Psychological factors affecting other medical conditions is now a psychiatric diagnosis in DSM-5. The diagnosis is quite prevalent in medical and surgical patients. The revised DSM-5 criteria should result in a reduction of the stigmatization of patients and to an improvement of diagnostic accuracy across various medical disciplines.
and illness anxiety disorder. Factitious disorder is now considered a somatic symptom disorder in DSM-5, as these patients often present with somatic symptoms in general medical settings. Psychological factors affecting other medical conditions is now a psychiatric diagnosis in DSM-5. The diagnosis is quite prevalent in medical and surgical patients. The revised DSM-5 criteria should result in a reduction of the stigmatization of patients and to an improvement of diagnostic accuracy across various medical disciplines.
TABLE 151.1 DSM-IV Somatoform Disorders and New DSM-5 Somatic Symptom Disorders | ||||||||||||||||||
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TABLE 151.2 Clinical Characteristics of DSM-5 Somatic Symptom Disorders | ||||||||||
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Table 151.2 summarizes the hallmark features of the DSM-5 somatic symptom disorders.
SOMATIC SYMPTOM DISORDER
Somatic symptom disorder (somatization disorder in DSM-IV) is defined as an illness in which patients experience at least 6 months of one or more distressing somatic symptoms in addition to maladaptive thoughts, feelings, and behaviors related to these symptoms. This may include disproportionate or persistent thoughts about symptoms, an abnormally high level of anxiety about symptoms, and/or excessive time and energy devoted to the symptoms.
SAMPLE CASE
A 50-year-old woman complains of constant back pain. She is reluctant to take any narcotic analgesics for fear of addiction. Magnetic resonance imaging (MRI) of her back is not diagnostic. She continues to go to work daily but finds herself so exhausted at the end of the day from her pain that she goes to bed immediately when she returns home, unable to participate in any of the family’s activities. Each time she improves and the neurologist recommends she return in 6 months, her pain increases and she seeks out a new physician.
EPIDEMIOLOGY
The prevalence of somatic symptom disorder is approximately 5% to 7% in the general adult population. Females report distressing somatic symptoms more frequently than males. Initial symptoms can begin at any age and usually appear by early adulthood.
Certain demographic factors are associated with a more severe clinical course, including female gender and older age. In elderly individuals, somatic symptom disorder is more likely to go unrecognized because of comorbid medical illness. The physical complaints of older patients may also be misattributed to “normal aging” or “understandable” concern.
Somatic symptom disorder occurs more frequently in individuals with lower educational/socioeconomic status. They have more severe illness and worse outcomes. Demographic factors that adversely affect clinical course include unemployment, history of childhood physical or sexual abuse or other adversity, medical and psychiatric comorbidity, and external factors that reinforce the illness (e.g., disability payments).
PATHOPHYSIOLOGY AND ETIOLOGY
As is the case for most psychiatric illnesses, there are biologic, psychological, and social factors that contribute to the development of somatic symptom disorder. Biologic risk factors include genetic vulnerability to increased sensitivity to pain and other physical sensations. There is also an emerging literature to suggest a potential role for psychoneuroimmune mechanisms of somatic symptom amplification. Proinflammatory cytokines are known to be involved in the production of illness behavior; chronic activation or sensitization of this system may result in nonspecific somatic symptoms and chronic pain. Some have hypothesized that immunologic mechanisms in the setting of infectious triggers may contribute to the development of somatic symptom disorders. Functional neuroimaging studies have demonstrated aberrant cortical and limbic activity that may impact conscious processing of mild or chronically painful stimuli.
Psychosocial risk factors for somatic symptom disorder include early childhood trauma such as physical, sexual, or emotional abuse and/or neglect. Social learning mechanisms such as the attention gained from physical illness or lack of reinforcement of nonsomatic (emotional) expressions of distress may also contribute to the occurrence of somatic symptom disorder. Intrinsic temperamental factors may correlate with a higher risk of developing somatic symptom disorder, including alexithymia (difficulty identifying inner emotional states) and neuroticism (high levels of negative affect). Difficulties in communication—from intellectual, emotional, or social limitations—can predispose to bodily expression of distress.
DIFFERENTIAL DIAGNOSIS AND COMORBIDITY
Patients with psychiatric illness often present with somatic symptoms. Patients with major depressive disorder may experience prominent fatigue, whereas patients with anxiety disorders may experience tachycardia or abdominal pain. Usually the cardinal feature of these other illnesses is a pronounced mood disturbance accompanied by numerous other physical and mental symptoms, whereas the distress in somatic symptom disorders emanates predominantly from the physical symptoms themselves. Mood and anxiety disorders frequently co-occur with somatic symptom disorders. Depressive disorders are common in patients with somatic symptom disorder, particularly in the elderly. Patients with somatic symptom disorder are at risk to develop secondary substance use disorders.
Medical comorbidity is common among patients with somatic symptom disorder, which may further complicate the diagnosis. Iatrogenic creation of symptoms may be subsequently mislabeled as psychogenic. Common complications of somatic symptom disorder include iatrogenic harm from invasive procedures or dependence on habit-forming substances such as opiates. Greater medical and psychiatric comorbidity is typically associated with greater severity of illness, degree of distress, and functional impairment.
Cultural factors are crucial when considering the diagnosis of somatic symptom disorder; many culture-bound syndromes present with prominent physical symptoms. Differences in medical care across cultures can also affect the presentation and course of somatic symptom disorders. The ways in which individuals recognize and respond to bodily sensations is influenced by numerous interacting factors that occur within a given social and cultural context, which affects the way in which the patient perceives illness and seeks medical attention.
TREATMENT
Somatic symptom disorder is difficult to treat, and the literature does not suggest a single superior treatment approach. It is recommended that the patient form a stable relationship with a primary care physician who regularly and reliably follows up on a predeter-mined scheduled basis. When talking to the patient with suspected somatic symptom disorder, a thorough/empathic approach will put the patient at ease and facilitate successful psychiatric referral and follow-up. Objectively corroborated problems should be judiciously investigated; however, unnecessary exhaustive diagnostic testing should be avoided, as this may inadvertently reinforce the development of new somatic symptoms or even cause iatrogenic harm. The therapeutic focus shifts from “cure” toward symptom management. In the case of somatic symptom disorder with predominant pain, use of addictive substances should be avoided.
Early psychiatric intervention is likely to improve outcomes for patients with somatic symptom disorder; greater chronicity of undiagnosed somatization is correlated with worse outcomes and makes subsequent mental health treatment more challenging. An interdisciplinary “team” approach to the patient is crucial; close collaboration between the mental health practitioner and the medical care provider can help minimize errors of diagnostic omission in either domain. Frequent communication between treatment disciplines helps maximize consistency and reduce the likelihood of the patient feeling dismissed or abandoned.
When discussing a suspected diagnosis of somatic symptom disorder with a patient, the clinician may emphasize that stress can generate physical symptoms without the patient’s awareness. Providing education about the illness and giving patients a list of psychiatric diagnostic criteria is helpful in legitimizing and validating their complaints by giving them a “genuine” diagnosis. Developing a relationship with the patient’s family may also be helpful for understanding and managing the greater social context in which somatic symptoms tend to occur.
Various treatments are successful for somatic symptom disorders. Psychotherapy is the mainstay of treatment for somatizing patients; such approaches include cognitive behavioral therapy [Level 1]1,2 and psychodynamic psychotherapy [Level 1].3
Data suggests that pharmacotherapy can be helpful in the management of somatic symptom disorder. Serotonergic antidepressants are moderately effective in reducing intensity of functional somatic symptoms. Medications are helpful in treating the comorbid depressive and anxiety disorders. Agents commonly used for neuropathic pain such as mixed noradrenergic/serotonergic antidepressants, tricyclic antidepressants, and certain anticonvulsants may be helpful. The mechanism of action for these agents remains to be fully elucidated, but recent research findings suggest potential modulation of the psychoneuroimmune pathophysiology described earlier.
When treating patients with somatic symptom disorder, consider the reinforcing role of secondary gain in maintaining symptoms. Although patients with somatic symptom clearly suffer, they may also obtain relief from certain societal, personal, and professional responsibilities as a result of their illness. Any successful treatment of somatic symptom disorder will seek as much as possible to eradicate these reinforcing agents and help reduce the possibility of further iatrogenic harm.
ILLNESS ANXIETY DISORDER
Illness anxiety disorder, formerly termed hypochondriasis, is characterized by a preoccupation with having or acquiring a serious medical illness that leads to clinically significant distress and dysfunction in social and/or occupational function. In this condition, bodily complaints and symptoms are often absent or mild. The hallmark of illness anxiety disorder is distress and preoccupation related to the individual’s anxiety about the meaning or significance of the somatic complaint rather than the actual symptoms. Patients with illness anxiety disorder have a high level of health anxiety, disproportionate to their actual physical illness or risk of illness. They may engage in excessive health-related behaviors, including frequently checking their body or researching diseases on the Internet. Medical reassurance or negative diagnostic tests are unlikely to alleviate these patients’ excessive concerns.
SAMPLE CASE
A 35-year-old woman finds what she thinks is a lump in her breast. She has a strong family history of breast cancer. She requests an “emergency appointment” with a surgeon who tells her that she does not feel a mass. Imaging of the woman’s breast shows no pathology. The woman continues to fear she has breast cancer, examining her breast repeatedly and calling her gynecologist’s office weekly regarding her concerns that she might have breast cancer.
EPIDEMIOLOGY
Estimates of the prevalence of illness anxiety disorder are based on epidemiologic studies on the DSM-IV diagnosis of hypochondriasis. These community surveys and population-based samples demonstrate a 1- to 2-year prevalence of health anxiety and/or disease
conviction ranging from 1.3% to 10%. In ambulatory medical populations, the 6-month/1-year prevalence rates are between 3% and 8%. Illness anxiety is equally prevalent in males and females.
conviction ranging from 1.3% to 10%. In ambulatory medical populations, the 6-month/1-year prevalence rates are between 3% and 8%. Illness anxiety is equally prevalent in males and females.
Illness anxiety disorder is a chronic/relapsing condition that begins in early to middle adulthood. In the general population, health-related anxiety increases with age, often focusing on cognitive deficits. In medical settings, no significant age differences have been found between those with low and those with high levels of illness anxiety.
PATHOPHYSIOLOGY AND ETIOLOGY
There are biologic and psychosocial components to the development of illness anxiety disorder. A history of childhood abuse/neglect or serious childhood illness is a risk factor for the development of illness anxiety disorder in adulthood. Major life stressors or illnesses are factors that may trigger the development of illness anxiety disorder.
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