Organ system
Frequent symptoms
Heart
Chest pains, paroxysmal tachycardias
Blood pressure
Hypertension and hypotension regulation disorders, syncope
Upper gastrointestinal tract
Nausea, feeling of repletion, meteorism
Lower gastrointestinal tract
Pain, diarrhoea, obstipation
Respiration
Hyperventilation with paresthesias
Motor apparatus
Back pain
Urogenital system
Urination problems, menstruation problems
Nervous system
Dizziness, convulsions, paralysis
General symptoms
Reduced performance capacity, insomnias
Most of the complaints listed in Table 11.1 are ascribed to certain diagnoses. It is thus suggested that the disease is physical. Accordingly, therapeutic success with medication, operation and other primarily somatic-oriented therapeutic procedures is low. Table 11.2 presents an overview of the diagnoses found in a wide variety of specialties, and in which somatization is usually present.
Table 11.2
Diagnosis in various specialties
Speciality | Diagnoses |
|---|---|
Allergology | Allergy to foods |
Cardiology | Non-cardiac chest pains Mitral valve prolapse |
Dentistry | Complaints with mandibular joint Atypical facial pain |
General practice | Tinnitus Dizziness Globus syndrome |
Gynaecology | Premenstrual syndrome Chronic lower abdominal pain |
Occupational medicine | Multiple chemical sensitivity (MCS) Chronic fatigue syndrome (CFS) Sick building syndromea |
Orthopaedics | Prolapsed disc |
Pneumology | Dyspnea Hyperventilation |
Rehabilitation medicine | Whiplash |
Rheumatology | Fibromyalgia |
Military medicine | Gulf War syndromeb |
Diagnostic Categories
Somatoform Disorders (ICD-10: F 45)
The following subclassification has proven helpful in practice :
Undifferentiated somatoform disorder (ICD-10: F 45.1): Multiple somatoform symptoms for at least 6 months.
Somatoform autonomic dysfunction of the vegetatively supplied organ systems like the heart, gastrointestinal tract, respiration and urogenital system (ICD-10: F 45.3) (Table 11.1).
Persistent somatoform pain disorders (ICD-10: F 45.4)
Hypochondriacal disorders (ICD-10: F 45.2): The patient is excessively occupied over long periods with the possibility of suffering from one or more serious, progressive physical diseases. Everyday physical sensations are misinterpreted as threatening and stressful.
In body dysmorphic disorders, the body is interpreted as being deformed. This is usually accompanied by a desire for cosmetic surgery.
Dissociative Disorders (ICD-10: F 44)
Dissociation means literally ‘splitting of the consciousness’. Examples are feelings of alienation, like depersonalization and derealization, loss of memory and escapism, semiconsciousness and non-epileptic convulsions.
These phenomena occur frequently in connection with severe emotional traumata, especially after experiences of violence and sexual abuse. No verbal working out of the event is possible. The traumatic experience is split off and finds expression as fear, states of vegetative tension and in the symptoms described under ‘posttraumatic stress disorders’.
Differential Diagnosis
Somatoform symptoms may also be part of an anxiety disorder or depression. Feelings of anxiety or depressive symptoms are not experienced consciously, but are expressed at the physical level. We also speak here of affect equivalent. See Fig. 11.1 for the overlapping of somatization, anxiety and depression.
Fig. 11.1
Overlapping of somatization, anxiety and depression
Outlook on DSM-V and ICD-11
The concept of ‘medically unexplained systems’ fosters the dualism of mind and body. The patient’s symptoms are seen either as organic (‘medically explained’) or ‘medically unexplained’ which may be taken to imply a psychosocial cause. This is still enshrined in the classification of diseases (ICD, DSM) despite the fact that we know that illness is determined by a mixture of biological, psychological and social factors. To overcome this issue of dualism, there is a need to describe relevant factors on all three dimensions (biological, psychological and social) contributing to the distress and suffering of patients with often multiple somatic symptoms.
The next editions of the diagnostic classification systems DSM-V and ICD-11 are in preparation. Intense discussions are currently being held about the future of the category of ‘somatoform disorders’. Critics of the current classification point out that, among other issues, the division into organ-medical and psychological conditions is questionable, the current description of the definition is not culturally sensitive, a number of disorders within the category of somatoform disorders are unreliable, and that the diagnostic criteria of somatization disorder are too narrow .
A result of this criticism is a push for a positive definition of somatoform disorders, including illness perception and illness attribution, illness behaviour, health-related anxiety, emotional distress, disability, quality of life, doctor–patient interaction and health care utilisation. The current proposals by the DSM-V working group suggest that these disorders might be subsumed in the future under the diagnostic label of ‘Complex Somatic Symptom Disorders’ (CSSD). The following preliminary criteria have been specified for CSSD:
To meet criteria for CSSD, criteria A, B and C must be met:
1.
Somatic symptoms: One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
2.
Excessive thoughts, feelings and behaviours related to these somatic symptoms or associated health concerns: At least two of the following are required to meet this criterion:
a.
High level of health-related anxiety.
b.
Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.
c.
Excessive time and energy devoted to these symptoms or health concerns.
3.
Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).
Frequency and Course
The 12-month prevalence of somatoform disorders in the European adult population is 6.3 % (Wittchen et al. 2011). After anxiety and affective disorders, they are ranked third in terms of frequency of occurrence. Somatoform disorder is diagnosed much more frequently in women than in men.
An American study (Kroenke and Mangelsdorff 1989) examined the proportion of physical diseases for the ten most frequent complaints over a 3-year period. An organic cause was identified in only 16 % of 1,000 patients. Functional somatic symptoms/somatization was probable in a large number of the remaining patients (Fig. 11.2).
Fig. 11.2
Physical complaints in a 3-year-course
Onset
Every person reacts to emotional stress with physical symptoms, such as sweating, insomnia, palpitations, diarrhoea etc. MUS-patients either do not perceive the emotional stress, or there is inhibition in expressing emotions. The attention is focused instead on the accompanying physical symptoms, which undergo negative assessment and potentiation and are no longer associated with the eliciting feelings. Complaining of the physical pain replaces the expression of unpleasant feelings.
In a vicious circle, the physical symptoms increase the fear, which in turn results in greater physical symptoms (Fig. 11.3).
Fig. 11.3
Vicious circle
The following psychosocial factors promote somatization :
Traumatization in childhood
Negative bonding experience
Model learning from parental models, who experience similar complaints
Tendency to emotional and physical overtaxing
Low self-esteem, easily insulted and hurt
Strengthening of the role of illness with increased attention and support of the environment
Relief from social or family demands and responsibilities as a result of the complaints
Practice
Recognition
Signs of somatoform disorders may be :
The symptoms do not follow anatomic or physiological patterns
The report of the symptoms is diffuse
Complaints are accepted without emotion on the one hand, described in dramatic images and inadequate effects on the other
The patient appears lamenting, demanding clinging
There are other complaints which cannot be adequately explained organically
Frequent change of doctor (doctor shopping)
Current stress, such as at work, or in the family.
Practical Tip: ‘Pain History’
What relieves the pain?
What aggravates the pain?
What does a typical day with pain look like?
Is there a change in pain level during the day?
When did the pain first occur?
What kind of experiences with respect to pain are there in the family and personal history?
Basic Therapeutic Attitude
The objective of treatment in psychosomatic primary care is to establish an empathic and trusting doctor–patient relationship, in which the patient feels that he is being taken seriously in his complaints and his view of the illness. After an organic disease has been ruled out, other explanation models can then be discussed and, if necessary, the patient motivated to accept further psychotherapeutic treatment. Treatment goal is relief of complaints, not cure. Regular appointments, e.g. every 14 days, is recommended.
The following belong to a basic therapeutic attitude:
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