Somatoform Disorders
Lucy A. Epstein
Theodore A. Stern
Patients often present to the emergency department (ED) with physical symptoms that suggest disease in a variety of organ systems. Although true medical conditions, such as multiple sclerosis (MS) or systemic lupus erythematosus (SLE), may be the source of these varied complaints, the correct diagnosis may be a somatoform disorder. The somatoform disorders have in common the unconscious production of physical symptoms for which no organic basis is found. Symptoms can be quite disabling; many somatizing patients have lower overall functioning than those patients with chronic medical illness (1,2). Somatizing patients account for up to one third of all cases seen in hospital outpatient clinics (3,4), and they have twice the medical care utilization (and cost) of their nonsomatizing counterparts (5). The etiology of somatoform disorders is multifactorial, including biologic, psychological, and social factors (6, 7, 8, 9, 10, 11, 12, 13, 14). Discussion in the literature is ongoing regarding the classification and terminology of these disorders (e.g., the use of the terms medically unexplained symptoms, functional symptoms, and somatization). Alternatives to the current classification scheme have been proposed (7).
Psychiatrists are likely to encounter patients with somatoform disorders in the emergency setting for several reasons: They are common, they comprise physical symptoms that mandate a full medical evaluation, and they are often associated with psychiatric illness (most often depression and anxiety) (2,15, 16, 17, 18, 19, 20). Because somatoform disorders are diagnoses of exclusion, they can be difficult to evaluate and manage in the time-limited setting of the ED (21). Misdiagnosis is also possible; for example, up to 15% of patients diagnosed with conversion disorder are later found to have a neurologic illness (22,23). However, a systematic review demonstrated that improvements in study quality have helped reduce this percentage in recent years (24). In the ED, treatment is focused on ruling out life-threatening causes of symptoms, encouraging a treatment alliance with a primary provider, and promoting improvement in function.
PRESENTING CLINICAL FEATURES
Several subtypes of somatoform disorders are recognized by psychiatrists and are included in the Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV) (25). Somatization disorder, one of the most persistent of these conditions, involves recurrent symptoms in at least four organ systems: gastrointestinal (e.g., abdominal cramping), genitourinary (e.g., dysuria), neurologic (e.g., unexplained headache), and pain (e.g., pain in the absence of corroborating neurologic signs).
CASE
A 30-year-old woman recurrently presents to the ED reporting a “diffusely positive” review of systems. The ED staff says they are no longer sure “how much of this is psychological,” but they are concerned about missing an obscure etiology of her symptoms. A review of the medical record reveals multiple visits for headache, abdominal pain, and vague somatic complaints over the preceding years; no obvious physical cause had ever been identified. The psychiatrist recommends that they proceed with full medical evaluation in the ED and establish consistent follow-up with her primary care provider.
According to diagnostic criteria, symptoms of somatization disorder must occur before the age of 30 and will have persisted for several years (25). This disorder occurs more commonly in women than men (26, 27, 28) and can co-occur with numerous psychiatric conditions (such as major depression, substance dependence, and axis II disorders). Patients may also have a history of trauma or abuse. The involvement of numerous organ systems can force ED clinicians to generate an overly broad differential diagnosis, complicating the task of ruling out life-threatening medical conditions. Not all patients with somatization disorder present with the full symptom complex outlined by DSM-IV; some have forme fruste features and qualify for a diagnosis of undifferentiated somatoform disorder.
Another subset of somatoform disorders is somatoform pain disorder. In this condition, the patient has persistent pain that is the focus of clinical attention (25). The pain has no clear organic basis, or, if it does, the experience of pain is out of proportion to what would typically be expected (21). Patients describe the pain as severe and disabling, which results in significant loss of function. Its onset may be traced to a clear psychosocial stressor or loss. Women are affected more commonly than men, and patients may have co-occurring major depression. As with other somatoform disorders, it remains a diagnosis of exclusion; it is essential to rule out other conditions that present with pain (e.g., reflex sympathetic dystrophy). The ED psychiatrist should be particularly adept at delineating indicated uses for narcotics from use of narcotics for secondary gain. This may mean that the ED might set a policy that states that narcotics will not be prescribed to any nonadmitted patient.
A patient with conversion disorder typically presents with acute physical symptoms (most often neurologic) in the setting of psychological stress (25); consultation by both psychiatry and neurology is often advisable.
CASE
A 19-year-old patient is brought into the emergency room in a wheelchair by her concerned parents. She reports that her left leg suddenly became weak and that she can no longer walk. When asked when these symptoms started, she states that it may have been soon after her parents announced they were getting a divorce. Although she has adequate strength in the limb on exam and imaging results are normal, the patient still states (rather blandly) that she feels she can’t move her leg.
Symptoms often do not correspond to known neuroanatomic structures and may appear, and resolve, abruptly. Patients may demonstrate a striking lack of alarm at their symptoms (la belle indifference). Conversion symptoms may also be superimposed on known medical illnesses (such as the appearance of pseudoseizures in the setting of a known seizure disorder) (29). Functional brain imaging studies have implicated the anterior cingulate gyrus, orbitofrontal cortex, striatum, thalamus, and the primary sensorimotor cortex (30,31). Of note, several medical conditions, such as MS, can present with a similar array of disparate and perplexing symptoms. It may take several years and recurrent presentations before the correct diagnosis is made.
Hypochondriasis involves a preoccupation with the persistent belief that one has a serious medical illness, despite repeated evaluations and reassurances to the contrary (25). Afflicted patients do not create symptoms, but rather they misattribute trivial symptoms to serious causes. They intensely fear disease and are preoccupied by bodily symptoms. Some authors have argued that hypochondriasis is an anxiety disorder with somatic features, as opposed to a somatoform disorder (7
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