Somatoform Disorders: Introduction
Patients who somatize psychosocial distress commonly present in medical clinical settings. Approximately 25% of patients in primary care demonstrate some degree of somatization, and at least 10% of medical or surgical patients have no evidence of a disease process. Somatizing patients use a disproportionately large amount of medical services and frustrate their physicians, who often do not recognize the true nature of these patients’ underlying problems. Somatizing patients rarely seek help from psychiatrists at their own initiative, and they may resent any implication that their physical distress is related to psychological problems. Despite the psychogenic etiology of their illnesses, these patients continue to seek medical care in nonpsychiatric settings where their somatization is often unrecognized.
Somatization is not an either-or proposition. Rather, many patients have some evidence of biological disease but overrespond to their symptoms or believe themselves to be more disabled than objective evidence would indicate. Medical or surgical patients who have concurrent anxiety or depressive disorders use medical services at a rate two to three times greater than that of persons with the same diseases who do not have a comorbid psychiatric disorder.
Despite the illusion that somatoform disorders are specific entities, as is implied by the use of specific diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the symptoms most of these patients experience fail to meet the diagnostic criteria of the formal somatoform disorders. Further, over time, patients’ symptoms tend to be fluid, and patients may be best described as having one disorder at one time and another disorder at some other time. Somatization is caused or facilitated by numerous interrelated factors (Table 22–1), and for an individual patient a particular symptom may have multiple etiologies. In other words, these disorders are heterogeneous both in clinical presentation and in etiology.
Illness allows a socially isolated person access to an auxiliary social support system. |
The sick role can be used as a rationalization of failures in occupation, social, or sexual roles. |
Illness can be a means of obtaining nurturance. |
Illness can be used as a source of power to manipulate other people or social situations. |
Somatic symptoms may be used as a communication or as a cry for help. |
The somatic symptoms of certain psychological disorders (e. g., major depression and panic disorder) may be incorrectly attributed to physical disease. |
Because physical illness is less stigmatizing than psychiatric illness, many patients prefer to attribute psychological symptoms to physical causes. |
Some individuals may be hypersensitive to somatic symptoms and amplify them. Such hypersensitivity is often related to concurrent emotions such as depression and anxiety. |
Somatic symptoms can represent behavior learned in childhood, in that some parenting styles may emphasize attention to illness. |
The sick role can provide incentives such as disability payments, the avoidance of social responsibilities, and solutions to intrapsychic conflicts. |
Trauma, particularly childhood physical or sexual abuse, appears to predispose individuals to the use of somatic symptoms as a communication of psychosocial distress. |
Physicians can inadvertently reinforce the concept of physical disease by symptomatic treatment or through so-called fashionable diagnoses, such as multiple chemical sensitivities or reactive hypoglycemia. |
Somatoform disorders are generally multidetermined, and because they represent final common symptomatic pathways of many etiologic factors, each patient must be evaluated carefully so that an individualized treatment plan can be developed.
Conversion Disorder
DSM-IV-TR Diagnostic Criteria
One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
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.
The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
The symptoms 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.
The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
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.
Specify type of symptom or deficit:
- With motor symptom or deficit. This subtype includes such symptoms as (impaired coordination or balance, paralysis, or localized weakness, difficulty swallowing or “lump in throat,” aphonia, and urinary retention).
- With sensory symptom or deficit. This subtype includes such symptoms as (loss of touch or pain sensation, double vision, blindness, deafness, and hallucinations).
- With seizures or convulsions. This subtype includes such symptoms as seizures or convulsions with voluntary motor or sensory components.
- With mixed presentation. This subtype is used if symptoms of more than one category are evident.
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)
Conversion disorder previously known as hysteria or hysterical conversion reaction is an ancient medical diagnosis: described in both the Egyptian and Greek medical literature. Although often thought to have disappeared with the Victorian age, these disorders continue to the present but often with more subtlety and sophisticated mimicry than characterized by the dramatic symptoms of the past.
The reported incidence of conversion symptoms varies widely depending on the populations studied. The lifetime incidence of conversion disorder in women is approximately 33%; however, most of these symptoms remit spontaneously, and the incidence in tertiary-care settings is considerably lower. The incidence in men is unknown. Patients with conversion symptoms comprise 1–3% of patients seen by neurologists. Conversion is diagnosed in 5–10% of hospitalized medical or surgical patients who are referred for psychiatric consultation. Conversion symptoms occur in all age ranges from early childhood to advanced age. The disorder occurs with an approximately equal frequency in prepubertal boys and girls, but it is diagnosed much more frequently in adult women than in men.
Conversion symptoms appear to occur more frequently in people of lower intelligence, in those with less education or less social sophistication, and in those with any condition or situation in which verbal communication may be impeded.
Some authors have viewed conversion as more of a symptom than a diagnosis, with the implication that another underlying psychiatric disorder is usually present. It is likely that conversion is heterogeneous and that for some patients there is more than one cause. Among proposed etiologies are suggestions that the symptoms resolve an intrapsychic conflict expressed symbolically through a somatic symptom. For example, a person with a conflict over anger may experience paralysis of a right arm. Interpersonal issues have also been implicated. That is, the symptom may manipulate the behavior of other persons and elicit attention, sympathy, and nurturance.
Conversion often follows a traumatic event and may be a psychological mechanism evoked to cope with acute stress. Conversion symptoms are frequently found in patients receiving treatment on neurologic services and in patients with cerebral dysfunction. It seems likely that underlying neurologic dysfunction facilitates the emergence of conversion symptoms, perhaps as a result of impairment in the patient’s ability to articulate distress. Conversion may also be viewed as a learned behavior. For example, a person who has genuine epileptic convulsions may learn that seizures have a profound effect on others and may develop pseudoseizures. In this case, the individual may have both genuine epileptic seizures and pseudoseizures, and distinguishing between the two may be difficult.
Current theories about the etiology of conversion emphasize the role of communication. People who have difficulty in verbally articulating psychosocial distress, for any reason, may use conversion symptoms as a way of communicating their distress.
According to one nonreplicated Scandinavian study, relatives of patients with conversion disorder were at much higher risk for conversion symptoms. Polygenic transmission was proposed.
A conversion symptom, by definition, mimics dysfunction in the voluntary motor or sensory system. Common symptoms include pseudoseizures, vocal cord dysfunction (e. g., aphonia), blindness, tunnel vision, deafness, and a variety of anesthesias and paralyses. On careful clinical examination and with the aid of laboratory investigations, these symptoms prove to be nonphysiologic. A clinical example is the presence of normal deep tendon reflexes in a person with a “paralyzed” arm.
Contrary to popular belief, patients with conversion disorder may be depressed or anxious about the symptom. Some phenomena that have traditionally been associated with conversion, such as symbolism, la belle indifference (an inappropriate lack of concern for the disability), and histrionic personality, do not reliably differentiate conversion from physical disease.
Psychological tests often demonstrate comorbid psychiatric illness associated with tendencies to deny or repress psychological distress. A characteristic finding on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) is the presence of the “conversion V,” in which the hypochondriasis and hysteria scales are elevated above the depression scale, forming a “V” in the profile. However, such a finding is not pathognomonic for conversion.
Most conversion symptoms are, by definition, pseudoneurologic. Laboratory examinations, such as nerve conduction speed, electromyograms, and visual and auditory evoked potentials, demonstrate that the sensory and nervous system is intact despite the clinical symptoms. Simultaneous electromyographic and video recording of a patient with pseudoseizures can be diagnostic when the patient has epileptic-like movements while the simultaneous electroencephalogram (EEG) tracing demonstrates normal electrical activity in the brain.
Consistent with observations that conversion symptoms are more likely to involve the non-dominant side of the body is the finding that the majority of conversion disorder patients have unilateral right hemisphere structural or physiological abnormalities demonstrated by neuroimaging. Functional neuroimaging has demonstrated decreased activity in cortex and subcortical circuits reflecting cerebral representation of peripheral symptoms (e. g., decreased activation of visual cortex during “hysterical” blindness). These decreases have been frequently shown to be associated with concurrent activation in limbic regions such as the cingulate or orbitofrontal cortex. In general, there appears to be similarity of functional neuroimaging findings of conversion disorder and hypnosis.
Most conversion symptoms remit quickly, often spontaneously. They are frequently transient reactions to acute psychosocial stressors. Prolonged symptoms are generally associated with environmental reinforcers (e. g., the symptom provides a solution to a chronic family conflict and/or disability payments). Conversion symptoms, either similar to the original symptoms or a new symptom, may occur with recurrence of stressors. This is particularly true with pseudoseizures.
The differential diagnosis of conversion disorder always involves the possibility of physical disease. Even when conversion is obvious, the patient may have underlying neurologic or other disease that he or she has unconsciously amplified or elaborated. Table 22–2 lists conditions that often cause errors in diagnosis.
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Malingering must also be considered. The primary difference between malingering and conversion is that the degree of conscious motivation is higher in malingering. Systematic studies of conversion disorder suggest that it is often accompanied by other psychiatric disorders. Depression is common; and schizophrenia has also been reported, though rarely. Patients with conversion disorder may be responding to overwhelming environmental stressors that they cannot articulate, such as concurrent sexual or physical abuse or the feeling of being overwhelmed with responsibilities. Dissociative syndromes are also often associated with conversion, particularly pseudoseizures (which are regarded by some clinicians to be dissociative episodes). Some clinicians have proposed that dissociative disorders and conversion disorders involve the same mechanisms: dissociation reflects mental symptoms and conversion represents somatic symptoms. Conversion is grouped with the dissociative disorders in International Classification of Disease, tenth edition (ICD-10).
The treatment of conversion disorder is often multimodal and varies according to the acuteness of the symptom. If the symptom is acute, symptom relief often occurs spontaneously or with suggestive techniques. If the symptom is chronic, it is often being reinforced by factors in the patient’s environment; therefore, behavioral modification techniques are necessary.
There are no specific psychopharmacologic interventions for conversion disorder. However, when comorbid conditions are identified (e. g., depression), these conditions must be treated with the appropriate medications (see Chapter 18 and 19).
Acute conversion symptoms may, on occasion, respond to insight-oriented psychotherapy techniques. On the whole, insight-oriented therapies have not been effective for chronic conversion symptoms, which generally require behavioral modification for symptom relief. Behavioral therapy can be offered in the context of physical or speech therapy and this offers the patient a face-saving mechanism by which the patient can gradually discard their symptoms. Patients also receive positive reinforcement for symptomatic improvement and are ignored, to avoid reinforcement, at times of symptom expression.
Hypnosis and Amobarbital Interviews: An acute conversion symptom may remit with suggestions through hypnosis or by the use of an Amytal (or lorazepam) interview that creates an altered state of consciousness. Such techniques may be useful in determining underlying psychological stressors, but caution must be exercised so that patients do not incorporate the interviewer’s suggestions as a part of their own history.
When the conversion symptom represents “a cry for help” because of environmental pressures, it may be necessary to manipulate these stressors in order to produce symptomatic relief. For example, the pseudoseizures of a teenage girl might be a cry for help because she is involved in an incestuous relationship with her stepfather. Obviously, symptom relief will require attention to the sexual abuse.
When identified, comorbid disorders must be treated concurrently. Conversion symptoms may respond, for example, to treatment for an underlying depression.
Remission, with treatment of a conversion symptom, does not rule out the possibility that the patient has an underlying physical disease to which he or she was reacting with exaggeration or elaboration. Thus each patient must receive a careful medical evaluation. Conversely, a failure to consider conversion disorder and to continue to provide treatment as though the patient has a physical disease reinforces the symptom and can lead to permanent invalidism.
Most conversion symptoms remit quickly, those which persist are often associated with environmental reinforcers and are more resistant to treatment. Factors associated with a good prognosis are symptoms precipitated by stressful events, preceded by good premorbid psychological health, the absence of comorbid neurologic or psychiatric disorders.
In the past, an underlying neurologic disease would later emerge in about 25% of patients. However, at the present, with more sophisticated neurologic diagnostic tests, the subsequent emergence of previously undetected neurologic disease is uncommon.
Somatization Disorder & Undifferentiated Somatoform Disorder
DSM-IV-TR Diagnostic Criteria
Somatization Disorder
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.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:
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)
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)
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)
one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis 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 other than fainting)
Either (1) or (2):
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)
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
The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).
DSM-IV-TR Diagnostic Criteria
Undifferentiated Somatoform Disorder
One or more physical complaints (e. g., fatigue, loss of appetite, gastrointestinal complaints).
Either (1) or (2):
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)
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
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The duration of the disturbance is at least 6 months.
The disturbance is not better accounted for by another mental disorder (e. g., another somatoform disorder, sexual dysfunction, mood disorder, anxiety disorder, sleep disorder, or psychotic disorder).
The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)
