Unexplained Physical Symptoms—Somatoform Disorders
Robert M. McCarron DO
Glen L. Xiong MD
Mark C. Henderson MD, FACP
A 32-year-old man with no previous medical history presents to an urgent care clinic complaining of “gas in the stomach,” shortness of breath, and squeezing back pain that prevents him from working. Other symptoms include a “jumping sensation in the legs” and “poor circulation in the hands and feet.” He is unsure about what condition he might have. He is so concerned about his health that he has been sleeping in his car near the hospital for the past few days. He has seen numerous doctors over the past 6 months and, after an extensive medical work-up, has been told there are no obvious medical problems.
CLINICAL HIGHLIGHTS
Unexplained physical symptoms (UPS) are commonly encountered in the outpatient setting and often require a long-term treatment plan.
Unlike malingering and factitious disorders, patients who have somatoform disorders do not intentionally feign physical symptoms.
Psychiatric disorders, such as depression and anxiety, frequently coexist with somatoform disorders. We suggest using the AMPS screening tool (inquiring about anxiety, mood, psychotic, and substance use disorders) when assessing the psychiatric review of systems. The prognosis of someone with a somatoform disorder will usually improve when comorbid psychiatric illness is promptly identified and treated.
Although most patients with UPS may benefit from psychiatric consultation, they often initially refuse to see a psychiatrist. Therefore, primary care practitioners play a key role in the treatment of somatoform disorders.
Clinical Significance
Patients and primary care practitioners alike often become frustrated with troublesome symptoms that are unexplainable after repeated assessments and unresponsive to multiple treatment regimens. Unexplained physical complaints (UPS) consist of somatic complaints that cannot be satisfactorily explained after a complete general medical work-up. Although UPS may ultimately have general medical and psychiatric etiologies, the focus of this chapter is to help practitioners accurately diagnose and effectively manage patients who have UPS due to psychiatric pathology.
Primary care practitioners encounter unexplained and perplexing complaints in up to 40% of their patients (1, 2). Medical explanations for common physical complaints such as malaise, fatigue, abdominal discomfort, and dizziness are only found 15% to 20% of the time (3). Although it is difficult to reliably determine the prevalence of UPS (loosely termed somatization) due to wide-ranging definitions, most studies estimate a prevalence of 16% to 20% in primary care settings (4).
The common occurrence of UPS, whether from general medical or psychopathologic causes, carries a large financial burden. A retrospective review of over 13,000 psychiatric consultations found that somatization resulted in more disability and unemployment than any other psychiatric illness (5). Moreover, patients with somatization in the primary care setting have more than twice the outpatient utilization and overall medical care costs when compared with patients without somatization. The direct costs related to the management of UPS approach 10% of medical expenditures or over $100 billion annually in the U.S. (6).
Diagnosis
Although the word somatization is often used to describe physical complaints that cannot be completely explained by a physical examination and corresponding diagnostic work-up, a more precise nomenclature should be used. We use the term UPS to capture the general Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) diagnostic category of somatoform disorders (7). With a focus on the need to “exclude occult general medical conditions or substance-induced etiologies for the bodily symptoms,” the DSM-IV-TR includes seven diagnoses under the category of somatoform disorders: somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder not otherwise specified.
In order to meet the criteria for any of the somatoform disorders, one must have significant social or occupational dysfunction that is directly related to psychopathology. Also, unlike those with malingering or factitious disorder, patients with somatoform disorders unconsciously somatize as a coping mechanism and do not intentionally produce their symptoms (Table 8.1).
Alternatives to the DSM-IV-TR nomenclature have been proposed because of the perceived rigid and imprecise diagnostic criteria, frequent overlap between the somatoform disorders, and resultant impractical and confusing application to clinical practice. For example, in order to establish a DSM-IV-TR diagnosis of somatization disorder, one must manifest four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurologic symptom during the course of
the illness. This somewhat arbitrary combination of symptoms is not usually relevant to commonly encountered somatization in the primary care setting. Whether a patient has all of the required symptoms or just a few UPS may not change management strategies. Furthermore, people with a diagnosis of somatization disorder must have had multiple somatic complaints before the age of 30. This information is difficult to obtain as studies have shown that patients beyond the age of 30 often cannot reliably recall their medical history with sufficient detail (8).
the illness. This somewhat arbitrary combination of symptoms is not usually relevant to commonly encountered somatization in the primary care setting. Whether a patient has all of the required symptoms or just a few UPS may not change management strategies. Furthermore, people with a diagnosis of somatization disorder must have had multiple somatic complaints before the age of 30. This information is difficult to obtain as studies have shown that patients beyond the age of 30 often cannot reliably recall their medical history with sufficient detail (8).
Table 8.1 Somatoform Disorders: Diagnostic Criteria | ||||||||||||||||||||
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The wide clinical spectrum of somatization has prompted some medical specialties to develop their own system to identify unexplained physical symptoms. Some common examples include chronic fatigue syndrome, irritable bowel syndrome, and fibromyalgia. These three disorders all have controversial and elusive etiologies and therefore are challenging to manage. Although several non-DSM-IV-TR somatoform disorder diagnostic alternatives exist, it is both accurate and practical to classify most primary care somatizing patients as having undifferentiated somatoform disorder. Generally speaking, this may be more of a technical point as the long-term treatment plan is similar for most of the somatoform disorders.
PATIENT ASSESSMENT
Other than completing a thorough history and physical examination with indicated laboratory or radiographic tests, there are no specific diagnostic protocols for patients who have a somatoform disorder. Collateral history from other health care providers as well as family members is important to review, because this will help confirm a diagnosis and possibly reduce redundant and unnecessary medical evaluations.
Differential Diagnosis
The differential diagnosis for UPS seen in the primary care setting is extensive. It is important to keep in mind that “unexplainable” physical symptoms may be due to (1) a medical condition that has not yet been diagnosed (e.g., hypothyroidism, celiac sprue, multiple sclerosis, or vascular claudication); (2) a psychiatric condition such as malingering, factitious disorder, or one of the somatoform disorders; and (3) a medical condition that is present but not yet known to the medical community at large. Lyme disease is an example of the latter. Before Lyme disease was discovered, patients were presenting with arthritis, myalgias, cardiac problems, depression, and fatigue, with no known precipitant or cause. It is beyond the scope of this book to explore an all-inclusive differential diagnosis for somatization, but it is noteworthy to stress the importance of doing a complete diagnostic work-up to rule out potential medical causes while considering each somatoform disorder to be “a diagnosis of exclusion” (Figure 8.1).
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