Somatoform Disorders


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


aUnspecific symptoms like headache, nausea and rash on staying in buildings for longer periods

bMarked fatigue, skin rash, impaired sense of smell etc. in English and American soldiers who participated in the 1990 Gulf War



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.



A271970_1_En_11_Fig1_HTML.gif


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).



A271970_1_En_11_Fig2_HTML.gif


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).



A271970_1_En_11_Fig3_HTML.gif


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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Jun 17, 2017 | Posted by in PSYCHOLOGY | Comments Off on Somatoform Disorders

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