Somatization Disorder and Related Disorders
Per Fink
Introduction
The essential feature of somatization disorder and related disorders is that the patient presents multiple, medically unexplained symptoms or functional somatic symptoms. These physical complaints are not consistent with the clinical picture of known, verifiable, conventionally defined diseases, and are unsupported by clinical or paraclinical findings. The phenomenon of medically unexplained symptoms cannot simply be classified into one or a few diagnostic categories, but must be regarded as an expression of a basic mechanism by which people may respond to stressors as in the cases of depression and anxiety.(1, 2 and 3) Somatization disorder and related disorders must thus be considered to possess a spectrum of severity.(3,4) In this chapter, the focus will be on the chronic and multisymptomatic forms.
The somatization disorder diagnosis has its origin in the concept of hysteria. It was introduced in DSM-III in 1980 and was based on the criteria for ‘Briquet’s syndrome’, a syndrome described in the early 1960s by Perley and Guze.(5) They listed 59 physical and psychological symptoms distributed in 10 groups: 25 of the symptoms from nine groups were required to qualify for the diagnosis of somatization disorder. All psychological symptoms were eliminated in the DSM-III modification to avoid overlapping with other diagnoses.
The diagnostic criteria for DSM somatization disorder varied until the introduction of the current DSM-IV. The diagnosis was included in ICD-10 in 1992, but the ICD-10 criteria list different
symptoms, and require a different number of symptoms compared with the corresponding DSM criteria.
symptoms, and require a different number of symptoms compared with the corresponding DSM criteria.
The somatization disorder diagnosis has been criticized for being too rigid for clinical use. Only the most severe cases with a specific predefined symptom profile fulfil the diagnostic criteria, and the majority of those with multiple symptoms fall into one of the residual categories of ‘undifferentiated’ or ‘not otherwise specified’ somatoform disorders.(6)
To increase the sensitivity, Escobar et al.(7) introduced an abridged somatization index. This required 4 symptoms for males and 6 symptoms for females out of the 37 somatic symptoms listed in the DSM-III, compared with 12 and 14 symptoms respectively for the full DSM-III somatization disorder diagnosis. Kroenke et al.(8) have suggested a diagnosis of ‘multisomatoform disorder’, defined as three or more medically unexplained physical symptoms from a 15-symptom checklist along with at least a 2-year history of medically unexplained symptoms.
However, these abridged versions share the same basic problem as the original ones, namely that the chosen number of symptoms to qualify for the individual diagnoses is arbitrary and not empirically based. Recently a new empirically based construct was introduced, and this may have solved the problem. This new ‘bodily distress disorder’ diagnosis is based on positive criteria and not solely on the exclusion of all organic possibilities.(3) (Table 5.2.3.1)
This chapter will not differentiate between the different subcategories of somatoform and related disorders that are present along with somatic symptoms.
Table 5.2.3.1 Symptoms of and diagnostic criteria for bodily distress disorder | |||||||||||||||||||||||||||
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Clinical features
Physical symptoms and complaints
Patients with somatization and related disorders may complain of any medically unexplained non-verifiable subjective physical symptoms, and the symptoms may refer to any part or system of the body.
Complaints can be divided into:
Subjective symptoms, which are sensations and other complaints that cannot be verified by another individual or by general methods of examination (e.g. pains and paraesthesia).
Objective symptoms, which are complaints that can be verified if present at the time of examination (e.g. haematuria, icterus, etc.).
Findings can be divided into:
Provoked findings, i.e. symptoms or signs (such as soreness resulting from pressure or sensory impairment), which the patient is unaware of until these are provoked during the physical examination
Certain findings, which include objective symptoms that are verified and phenomena unnoticed by the patient but found during the physical examination (such as an abdominal tumor)
The symptom complaints in patients with somatization disorder and related disorders are dominated by subjective symptoms and provoked findings, whereas objective symptoms and positive certain findings and paraclinical findings are unusual.
Subjective symptoms may be considered to be psychological phenomena arising from personal experiences, which others cannot judge or measure, despite the fact that these symptoms could be fully explained by the presence of organic pathology. This means that there are considerable inter-individual, cultural, and historical variations in the symptom presentation, which are determined by the patient’s life experience and sociocultural background, and the setting in which the patient is seen also plays a role.(9) However, the patients may also present verifiable symptoms and signs due to a physical disease or defect, which they exaggerate and incorporate into their illness. Incidental inborn errors or degenerative changes, which are asymptomatic in most individuals, may tenuously be assigned clinical importance by the doctor or the patient. For instance, degenerative changes in the spinal column are seen in most individuals when they become older, and most do not have any pain, but a patient’s backache may be attributed to those changes. Furthermore, over time, the patient with a chronic condition is likely to have undergone multiple tests, invasive procedures, operations, and received medications for treatment or diagnostic purposes, and this may cause not only iatrogenic harm but also physical complications.(10) Finally, the patient may have a concurrent physical disease. The presented symptoms may thus be a difficult mixture of complaints of both organic and non-organic origin.(11)
The patients typically complain of multiple physical symptoms, but the number of symptoms reported by the patients vary considerably from one patient to another and over time in the same individual. The patients may complain of multiple, medically unexplained symptoms in numerous bodily systems at presentation, but sometimes the complaints are concentrated on one
symptom pattern at one time (e.g. a gastrointestinal illness) and on a different symptom pattern at another (e.g. a cardiopulmonary illness).(11) This single-organ illness picture may be due to physicians being inclined to focus their attention and investigation on the organ of their own specialty—especially in a multisymptomatic, complex patient, i.e. a gastroenterologist will focus on gastrointestinal symptoms and may ignore musculoskeletal symptoms. A new set of symptoms from another organ system may come to attention when diagnoses and treatment options have been ruled out for the current complaint. Iatrogenic factors may thus contribute significantly to the presented symptom pattern and changes in symptom pattern. Patients with somatization disorder are often inconsistent historians. They may supply incorrect information about previous episodes of their illness, minimizing or ignoring earlier instances of illness and exclusively focusing on the current symptom pattern. This may be because the patients find it difficult to account for their complicated medical history, or because they do not want to confuse the doctor with what they believe is irrelevant information. Therefore, the full clinical picture often only becomes evident after a full medical history has been obtained and the patient has been followed for some time.
symptom pattern at one time (e.g. a gastrointestinal illness) and on a different symptom pattern at another (e.g. a cardiopulmonary illness).(11) This single-organ illness picture may be due to physicians being inclined to focus their attention and investigation on the organ of their own specialty—especially in a multisymptomatic, complex patient, i.e. a gastroenterologist will focus on gastrointestinal symptoms and may ignore musculoskeletal symptoms. A new set of symptoms from another organ system may come to attention when diagnoses and treatment options have been ruled out for the current complaint. Iatrogenic factors may thus contribute significantly to the presented symptom pattern and changes in symptom pattern. Patients with somatization disorder are often inconsistent historians. They may supply incorrect information about previous episodes of their illness, minimizing or ignoring earlier instances of illness and exclusively focusing on the current symptom pattern. This may be because the patients find it difficult to account for their complicated medical history, or because they do not want to confuse the doctor with what they believe is irrelevant information. Therefore, the full clinical picture often only becomes evident after a full medical history has been obtained and the patient has been followed for some time.
Symptoms and findings are not idiosyncratic but need clarification or specification before becoming meaningful clinically. For instance, a patient complains of chest pain. There are multiple causes for chest pain, so for the doctor this is not very informative. A clarification or specification is needed. A retrosternal-localized pain of a pressing nature offers the doctor a very different diagnostic association than a chest pain that is described as being stabbing and located in the left side of the chest. In somatization disorder and related disorders, the patient usually presents a vague illness picture with symptoms of non-specific character and of low diagnostic value, i.e. symptoms that are common in the general population and which are found in many different mental and physical disorders (symptoms like fatigue, nausea, headache, dizziness).
Table 5.2.3.2 Characteristic differences in symptom description and other characteristics of well-defined somatic and related disorders including functional somatic syndromes | |||||||||||||||||||||||||||||||||||||||||||||
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The presentation of medically unexplained symptoms is atypical, that is to say the symptoms lie outside what is usual in an authentic physical disease.(11) However, the patients may have ‘learned’ the typical symptom presentation from different sources. For example, a patient with atypical asthma-like attacks shared a room with a patient with genuine asthma during her third hospital stay; subsequently, her attacks took on a more ‘authentic’ appearance.(11)
Descriptions of symptoms are usually vague, imprecise, and inconsistent, and the patients often have difficulties giving further details about their illness and symptoms, i.e. describing the quality, intensity, and chronology. The symptoms are described as being of maximum intensity all the time, but if the patients keep a diary of symptoms or if information is gathered from other sources like relatives or the family physician, a considerable variation in the symptom intensity from day to day or from year to year often surfaces. The patients may have difficulties in the chronology of symptoms, mixing current and past symptoms and illness episodes in a disorganized and confusing manner. It is difficult for the patients to identify relieving factors or behaviour and to identify triggering events or things that make them worse, or these are multiple, or vague and unspecific. This is in contrast to patients with physical disease, who usually describe their symptoms in a consistent and precise manner (Table 5.2.3.2).
Typically, there is a marked discrepancy between a patient’s subjective complaints and reports on his or her functioning when this is compared with the way the patient is observed to act, move
and perform during the examination, or compared with information from other sources like family. For instance, the patient moves and sits completely freely despite complaining of severe back pain or gives detailed information despite complaints of severe memory impairment.
and perform during the examination, or compared with information from other sources like family. For instance, the patient moves and sits completely freely despite complaining of severe back pain or gives detailed information despite complaints of severe memory impairment.
There may be emotional discrepancy in which the patient shows a lack of concern about the nature and implications of the symptoms despite presenting severe symptoms that are threatening the patient’s future functioning and quality of life. Other patients may in turn be very affected and emotional in their description of the symptoms and illness, describing in a colourful, dramatic, and strikingly graphic manner.
The patient’s centre of attention is typically on the suffering, on the psychosocial consequences, and the restrictions that the symptoms impose on their life. On the contrary, patients with well-defined physical disease are concerned or worried about the implication of their disease for their future health, i.e. will they recover or will they die from the disease. This emotional or psychosocial communication among patients with somatization disorder may put pressure on the doctor to do something.
Patients with somatization disorder and related disorders usually attribute their symptoms to a physical disease, and in some cases they persistently may refuse to accept medical reassurance despite appropriate medical evaluations. The ICD-10 criteria for somatoform disorders include this refusal to accept medical reassurance, but recent research indicates that many patients are unsure what is wrong with them, and they do not necessarily refuse non-medical explanations if they are presented in a meaningful and understandable way.(12) Although the patients may recognize that their physical symptoms are caused by, e.g. stressful events, this does not make the symptoms disappear, and they still need treatment. The weight of the symptom (refusing to accept medical reassurance) in the medical literature therefore seems out of proportion. However, in the most severe cases, patients may be involved in patient organizations fighting for their illness to be recognized as an ‘authentic’ physical disease or fighting for a particular causality of their illness as, e.g. whiplash-associated disorder or hypersensitivity to electricity or chemicals (multiple chemical sensitivity). The patients may also fight for disability pension or financial compensation. This is often more a question of getting their illness recognized than receiving financial compensation. Some patients may be preoccupied with the idea that they have been mistreated or neglected by doctors, and this group will often become involved in conflicts with doctors and in legal disputes.
In some cases, there is a sudden onset of the disorder in connection with a medical condition or a trauma in a previously normal and healthy individual. It could be a whiplash trauma, a fracture, an infection, or an acute intoxication. The symptoms persist despite the original disease being cured according to a biomedical or a surgical judgement. Instead, the illness worsens and more symptoms may emerge. Our knowledge about such disorders with abrupt onset is sparse.
Psychological symptoms and comorbidity
At examination, the patients may deny emotional symptoms or conflicts, and when they do report them, they often blame them on their physical affliction. Patients may also be reluctant to display emotional difficulties because of bad experiences of doing so. They may have experienced that doctors did not believe them or accused them of making up their symptoms and have consequently felt that their physical problems are not taken seriously. However, sooner or later, most patients will exhibit emotional difficulties, and if the patients feel understood by the physician, emotional problems may as well be presented. Patients may present many different types of emotional symptoms, often unspecific, but prominent anxiety and depressive symptoms are prevalent. Although the symptoms may be as marked as in affective and anxiety disorders, they are usually more transient, changing from one day to another and especially related to specific events. At times, the psychological symptoms may fulfil the criteria for a mood or anxiety disorder; but it is characteristic that the illness picture shows variations in both bodily and emotional symptoms.
Suicidal attempts are unusual but may occur especially among severe cases, but suicide is rare. Substance abuse is frequent, whether or not this is iatrogenic sanctioned.
The way the patients present themselves is inextricably linked to personal style and possible personality disorder. As a broad spectrum of personality disorders or traits(13) is associated with somatization disorder, the presenting style varies greatly from one patient to another. Characteristically, three broad patterns of personality style may be found in these patients, especially in chronic cases: dramatic-emotional type, paranoid-hostile type, and passive-aggressive-dependent type. The same patient may show all three patterns. In less severe cases it is often observed clinically that the patients have previously been very active and hard working, have conformed socially, and had a strong social network with many responsibilities. The patients often display perfectionist traits and prefer to be in control of a situation.
Illness behaviour
Typically, patients with somatization disorder persistently exhibit consulting behaviour which results in an excessive use of medical services and alternative therapies. In chronic cases, they have often been subject to a large number of futile examinations, surgery, and medical/surgical attempts at treatment.(10,14,15) However, some patients realize quite early in the illness course that the doctors cannot help them, or they are well managed by their family physician, so they do not necessarily display this consultation behaviour.
Due to negative results of medical check-up and treatment attempts and the patients’ persistent belief that they must have a physical disease, the patients may consult different physicians. The patients may have been, or may feel, mistreated or neglected by doctors and therefore want to get a second opinion, or they want to find a doctor who can help them. Sometimes this behaviour, together with the patients’ personality, can result in disagreement and a mutual hostility between the patients and their doctors.
Furthermore, the different illness patterns at different times, combined with the patients’ seductive, demanding personality style, may result in disagreements between the different health care professionals involved in their care, which may complicate their care.
In chronic cases, all aspects of the patients’ social and family life may be centered around their illness, so that the whole of their family life is adjusted to the patients’ demands (‘illness as a way of living’).(16)
Classification
The diagnostic criteria for somatization disorder and related disorders have varied, with different permutations of the diagnostic terminology reflecting difficulties in classification and in establishing valid criteria. The distinction between the individual somatoform disorders is unclear, which means that the majority of patients will exhibit clinical characteristics from different diagnostic categories.(6)
Except for hypochondriasis or health anxiety, the somatoform disorder categories are primarily based on the number or specificity of bodily symptoms and on the duration of illness.(17) The disorders can be divided into acute and chronic forms, into a multisymptomatic form, and into a form in which the patients only present few symptoms or symptoms mainly referring to a single organ system. The somatization disorder diagnosis includes the most chronic multisymptomatic cases lasting for 2 years or more.
The ICD-10 criteria require the following:
1 at least 2 years of multiple and variable physical symptoms for which no adequate physical explanation has been found;
2 persistent refusal to accept the advice or reassurance of several doctors that there is no physical explanation for the symptoms;
3 some degree of impairment of social and family functioning attributable to the nature of the symptoms and resulting behaviour.
The ICD-10 criteria require ‘multiple physical symptoms’ to include at least 6 out of 14 predefined symptoms, involving at least 2 of the following: gastrointestinal, cardiovascular, urogenital, or skin or pain symptoms. In contrast, the DSM-IV criteria demand four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom that are not fully explained by a medical condition. No specific symptoms are listed, but examples are given. Consequently, there is only poor to moderate agreement between the DSM-IV and ICD-10 diagnostic criteria.(16) Cases lasting less than 2 years are classified as undifferentiated somatization disorder. In ICD-10, multiple symptoms are required, which is not the case in DSM-IV.
Functional or somatoform diagnoses defined mainly by the number or specificity of bodily symptoms include, besides somatization disorder (F45.0 and 300.81), undifferentiated SD (F45.1 and 300.81), persistent somatoform pain disorder (F45.4 and 307.80), and somatoform disorder unspecified/NOS (F45.9 and 300.82). In ICD-10, this also includes somatoform autonomic dysfunction.(3, 4 and 5) There may be reasons for also including neurasthenia (F48.0) into the group. The somatoform disorder concept has never been accepted among non-psychiatrists, which has led to the introduction of many different functional somatic syndromes, e.g. chronic fatigue syndrome (CFS), fibromyalgia, irritable bowel syndrome (IBS), and chronic benign pain syndrome, and new syndromes are intermittently introduced.(18)
The newly introduced diagnosis of bodily distress syndrome or disorder may be a solution to this classification problem, although it has not yet been sufficiently tested in daily clinical practice.(3) The suggested diagnosis is based on an analysis of a large sample of patients from different medical settings, and it seems to encompass the various functional syndromes advanced by different medical specialties as well as somatization disorder and related diagnoses of the psychiatric classification. The disorder may have different manifestations, i.e. GI, MS, or CP syndromes as shown in Table 5.2.3.1.
Diagnosis
A somatization disorder should be suspected in any individual with a vague or complicated medical history or unaccountable non-responsiveness to therapy. Patients with somatization disorder may not have or may deny emotional symptoms or conflicts, so the absence of significant emotional symptoms at the general psychiatric interview and history taking will not exclude the diagnosis. But the presence of a previous or current emotional disturbance does support the diagnosis, as do previous episodes of medically unexplained bodily symptoms. Taken at face value, the physical symptoms are only of modest diagnostic importance, whereas unspecific or atypical symptoms in several bodily systems, or a very unusual presentation, speak in favour of the diagnosis. Multiple fluctuating symptoms of obscure origin, and their onset before the age of 30, strongly support the diagnosis. The diagnostic criteria displayed in Table 5.2.3.1 may be used, or the criteria listed in the DSM-IV or ICD-10 diagnostic criteria for somatoform disorders may be used.
Differential diagnosis
Mental and somatoform disorders
In malingering, the patient feigns illness with a conscious motivation to avoid responsibility or to gain an advantage. In factitious disorder, the symptoms are intentionally produced and the patient may self-inflict or induce diseases and lesions. In contrast to malingering, there is no external incentive for producing the symptom(s), and the motive is unconscious and only understandable in a psychopathological context.(19,20) In somatoform disorders, both the symptom-producing behaviour and the motive are believed to be unconscious. However, factitious or malingering symptoms, mixed with other non-intentional symptoms, may occur in somatization disorder and related disorders.(11)
Hypochondriasis or health anxiety is mainly defined in cognitive terms with the emphasis on a preoccupation with physical appearance or the fears of harbouring or developing a serious physical disease. The other categories of somatoform disorders put more emphasis on bodily symptoms. In dissociative or conversion disorder the patients usually present fewer symptoms, but these are almost exclusively pseudoneurological symptoms. The onset is sudden, and closely associated in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. The symptoms are transient and often remit suddenly after a few days, although they may persist for longer, but seldom for more than a few months. Episodes of dissociative or conversion disorders frequently occur in patients with other somatoform disorders.
In pain disorder, the predominating complaints are of medically unexplained pain in one or more anatomical sites. Various aches and pains are common in somatization disorder but are more fluctuating and not so dominating in the clinical presentation since they merge with other complaints.
In ICD-10 somatoform autonomic dysfunction, the patients complain of symptoms associated with a specific system or organ
that is largely or completely under autonomic innervation and control. For example, the patient refers the symptoms to the heart and cardiovascular system, the gastrointestinal tract, respiratory system, genitourinary system, etc.
that is largely or completely under autonomic innervation and control. For example, the patient refers the symptoms to the heart and cardiovascular system, the gastrointestinal tract, respiratory system, genitourinary system, etc.
In most other mental disorders physical symptoms are prominent; it is the rule, rather than the exception, that patients with mental disorders consult their family physician because of physical and not emotional symptoms.(2,21) The symptoms may be misinterpreted by the patient and the doctor as being caused by a physical disease. However, in these cases of ‘presenting’ or ‘facultative’ somatizing, the patient will accept the diagnosis of a psychiatric disorder when it is established and will accept that the symptoms are attributable to a psychic rather than a physical affliction.(2)
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