Somatoform Disorders and Unexplained Physical Symptoms Bart Sheehan

HISTORY

Mysterious physical symptoms of uncertain origin have been noted as long as medical matters have been written about. Early explanations of mysterious symptoms involved the abnormal movement or function of the womb, hence the origin of the term hysteria from the Greek word hysterikos. Such explanations may now seem absurd, but were influential till at least the seventeenth century, when Syden-ham first wrote of hypochondriasis (a male condition) and hysteria (a female equivalent). Sydenham described the two conditions as alike ‘as one egg is to another’. He recognized that psychological disturbance was primary, that symptoms were changeable and that these conditions cause great diagnostic difficulty. Over the next 200 years, acceptance of a psychological origin for some ill-defined physical symptoms grew, along with the concept of a group of psychological illnesses called neuroses.

Interest in these ill-defined symptoms really accelerated with the popularization of Sigmund Freud’s early ideas about unconscious conflicts and psychological disturbance. Freud was struck by Char-cot’s demonstrations in Paris of hysterical physical symptoms. He developed the idea that unconscious conflicts were manifest as physical symptoms, as a form of defence mechanism. After the First World War, no-one who had seen the victims of ‘shell-shock’ could doubt the ability of psychological trauma to cause physical symptoms.

Proponents of psychoanalytic ideas developed terms like somati-zation and psychosomatic illnesses. As the influence of these ideas eventually waned after the Second World War, clinicians became less focused on aetiology and more on careful description of patients with persistent troublesome physical symptoms. By 1980, when DSM-III was published, the term hysteria was dropped. Somatization disorder, in which multiple physical symptoms persist over years, with no organic explanation, and hypochondriasis, in which patients dread a particular disease and cannot be reassured despite investigation, became the prototypical somatoform disorders. Thus, Sydenham’s observations from 300 years previously were confirmed in modern medicine.

MODERN TERMINOLOGY

Both DSM-IV and ICD-10 have categories of somatoform disorders. Both include core somatization disorder and hypochondriacal disorder, and a handful of other disorders like conversion disorder and body dysmorphic disorder (DSM-IV), Somatoform autonomic disorder (ICD-10) and persistent pain disorders (both classifications).

Clinicians dealing with older patients are likely to mainly encounter less differentiated admixtures of unexplained symptoms and hypochondriacal beliefs. The diagnostic categories in DSM-IV are unlikely to be especially helpful when faced with a persistently complaining patient who is likely also to have at least one organic illness. The term ‘medically unexplained symptoms’ is sometimes used to cover the wider range of patient presentations. This term avoids diagnostic confusion and can sometimes be useful in the presence of real physical illness.

CLINICAL PRESENTATIONS

Case 1

Mr W is a 76-year-old man admitted with worsening depression to a psychiatric ward. In the last two weeks he has become increasing preoccupied with his bowels, plaguing his primary care doctor for consultations. He is now convinced that his bowels have stopped working due to ‘a blockage … cancer or something’. He is reluctant to eat or drink and feels that any treatment is futile. Examination and investigation shows mild constipation but no evidence of any other organic lesion. Reassurance is ineffective. He eventually requires intravenous rehydration and ECT. He begins to improve after about a week, initially saying ‘I am not so sure’, then later ‘I suppose I was worrying too much’. He regains much of the weight he had lost and is discharged home after seven weeks in hospital.

A case of severe depressive disorder with psychotic features (hypochondriacal and nihilistic delusions). Rapid improvement in physical complaints noted with definitive treatment of underlying psychiatric disorder.

Case 2

Mrs K is a 64-year-old woman who is referred to psychiatric services for the fifth time in her life. She is well known to primary care as a frequent attender and for the last three years has seen her general practitioner at least once a week. She complains of multiple symptoms including pain in the head, back and limbs, abdominal discomfort, bloating and frequency of bowel motions, blurred vision, dry mouth, urinary frequency, some shortness of breath and chest pain, and is ‘unable to settle at night’. She has had multiple referrals to secondary care over 40 years. Investigations by gynaecology, general surgery, cardiology and gastroenterology have been negative but did not help. She does not feel taken seriously and is ‘fed up with doctors … the whole time they just try to get rid of me’. She has mild depression but is very reluctant to see a psychiatrist or counsellor. The psychiatrist writes ‘No sign of formal mental illness’ and discharges the patient back to the general practitioner.

A probable case of somatization disorder. Psychiatry is unhelpful here, maintaining the disorder by rejecting the validity of the complaint and offering nothing helpful to the GP.

Case 3

Mrs T, a 76-year-old widow, presents to her GP with abdominal pain. This has come on in the last three weeks. There are no findings on examination and she has no significant medical or surgical history. Her husband died about six years ago. She becomes tearful during the consultation and says she is ‘desperately worried’ that the marriage of her only daughter is in trouble. This daughter is her main social support. She thinks she may not see her grandchildren again for some time. She agrees that stress makes the pain worse, and agrees that the family situation is stressful. She comes back to see the GP after two weeks. The pain has lessened, though she is still worried. She has told her daughter of her worry, and been reassured that she will not lose contact with any family members.

Illustrates how mild physical symptoms may follow psychological distress, and how watchful waiting and a sympathetic approach may be associated with improvement and no unnecessary referrals.

EPIDEMIOLOGY

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