Somatization disorder

Overview

Somatization, or the physical manifestation of psychological anguish, affects a high number of primary care patients. It is linked to significant distress and disability, as well as increased health-care consumption. Some somatizing individuals have a history of several unexplained complaints (somatization disorder), while others are overly concerned about serious disease (hypochondriasis), and still others have mental problems that manifest as somatic symptoms (depression and anxiety).

Somatizing patients, in general, exhibit atypical sickness behavior (e.g., failure to react to therapy, excessive consumption of care) as well as psychological distress (eg, depressive symptoms, psychosocial stressors). Recognition necessitates a keen eye for distinguishing characteristics as well as a deft interview style. The first step toward effective management is to legitimize symptoms. Restraint should be exercised while completing workups on somatizing individuals and giving diagnoses.

Treatment objectives should be defined, and frequent appointments should be organized. In addition, behaviors that endanger the physician-patient relationship must be addressed. When depression and anxiety are present, they should be addressed. There have been descriptions of pharmacologic and psychosocial therapies for somatizing patients, but none have been demonstrated to be effective.

 

Somatic symptom disorder definition

Somatic symptom disorder (SSD), according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), is defined as one or more physical symptoms accompanied by an excessive amount of time, energy, emotion, and/or behavior related to the symptom, resulting in significant distress and/or dysfunction. A medical issue may or may not explain physical symptoms.

Previous editions of the Diagnostic and Statistical Manual of Mental Disorders did not allow for the diagnosis of somatic symptom disorder unless the symptoms could not be explained clinically. Furthermore, prior versions did not include the criteria that specific psychobehavioral elements be present in order to make a diagnosis of somatic symptom disorder.

Somatization disorder, undifferentiated somatoform disorder, hypochondriasis, and pain disorder were also dropped from the DSM-5. Based on these adjustments, many people who previously fit the criteria for one of these disorders now satisfy the criteria for SSD. 

 

Etiology

Somatic symptom disorder (SSD) is characterized by heightened awareness of diverse physiological sensations mixed with a propensity to interpret these experiences as signs of medical disease. While the cause of SSD remains unknown, research have looked into risk factors such as childhood neglect, sexual abuse, a chaotic lifestyle, and a history of alcohol and substance misuse.

Severe somatization has also been linked to axis II personality disorders, namely avoidant, paranoid, self-defeating, and obsessive-compulsive disorder. Unemployment and reduced occupational functioning have also been linked to psychosocial pressures.

 

Epidemiology

Somatic symptom disorder (SSD) is believed to affect 5% to 7% of the general population, with a larger female representation (female-to-male ratio 10:1), and can arise in infancy, adolescence, or maturity. The prevalence rises to almost 17% of the primary care patient group. Certain patient groups with functional diseases, such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, are likely to have a greater prevalence.

 

Pathophysiology

Somatic symptom disorder (SSD) has no established pathophysiology. In individuals with SSD, autonomic arousal from endogenous noradrenergic substances may produce tachycardia, gastric hypermotility, heightened alertness, muscle tension, and discomfort associated with muscular hyperactivity. There might be a hereditary component as well. A study of monozygotic and dizygotic twins found that genetic variables contributed 7% to 21% of somatic symptoms, with the remainder owing to environmental factors. In another investigation, some single nucleotide polymorphisms were linked to somatic symptoms.

 

Clinical manifestations

Three requirements fulfill the diagnostic criteria for somatic syndrome disorders (SSDs) according to the American Psychiatric Association's 2013 DSM-5:

• Somatic symptom(s) causing severe anguish or disturbance in everyday activities
• One or more thoughts, feelings, and/or actions connected to the somatic symptom(s) that are persistent, excessive, associated with a high degree of anxiety, and require an excessive amount of time and energy.
• Symptoms that continue longer than 6 months

 

A vague and often inconsistent history of current illness, symptoms that are rarely alleviated with medical interventions, patient attribution of normal sensations as medical illness, avoidance of physical activity, high sensitivity to medication adverse effects, and medical care from multiple providers for the same complaints may all point to the presence of SSD.

To investigate physical reasons of somatic symptoms, a complete history, a full evaluation of systems (not only at the area of the symptom), and a comprehensive physical exam are necessary. Given the prevalence of concomitant psychiatric disorder, a mental state assessment should be undertaken, with emphasis paid to appearance, mood, affect, attention, memory, concentration, orientation, the existence of hallucinations or delusions, and suicidal or homicidal intent.

Finally, the physical examination may establish a baseline for future monitoring, reassure patients that their concerns are being addressed, and aid in validating the primary care provider's worry that the patient does not have a physical medical disease. If a disease is present, the exam may reveal its severity.

 

Diagnosis of somatic syndrome disorder

Limited laboratory testing is advised since individuals with somatic syndrome disorder (SSD) are likely to have had a thorough past workup. Excessive testing raises the possibility of false-positive results, which might lead to extra interventional procedures, dangers, and expenses. While some practitioners request tests to reassure patients, research show that such diagnostic testing does not relieve SSD symptoms.

A meta-analysis conducted by Rolfe and colleagues compared diagnostic testing to a non-testing control condition and found that remission of somatic symptoms and reduction of sickness worry and anxiety were equivalent in both groups. In the group that got diagnostic testing, there was only a little decrease in following visits.

Specific examinations, such as thyroid function tests, urine drug screens, restricted blood studies (i.e., alcohol level), and limited radiographic imaging, may be conducted to rule out somatization owing to medical issues.

 

Treatment 

The primary goal is to assist the patient in coping with physical symptoms, including health anxiety and maladaptive behaviors, rather than to eliminate the symptoms. Patients may be resistant to the notion that their physical symptoms are compounded by worry or severe emotional difficulties, so proceed with caution.

The primary care physician should plan regular appointments to reassure the patient that his or her symptoms do not indicate a life-threatening or debilitating medical condition. Diagnostic tests and invasive surgical therapy are not advised. Sedative drugs, such as benzodiazepines and narcotic analgesics, are not recommended. Early mental therapy is advised.

Cognitive-behavioral therapy has been linked to significant improvements in patient-reported functioning and somatic symptoms, a reduction in health-care expenses, and a reduction in depressed symptoms, according to research. Pharmacologic interventions should be restricted, however antidepressants can be used to address mental comorbidities (anxiety, depressive symptoms, obsessive-compulsive disorder).

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have demonstrated effectiveness in improving SSD when compared to placebo. However, because individuals with SSD may have a low threshold for experiencing side effects, drugs should be started at the lowest possible dose and gradually raised to produce a therapeutic impact. 

 

Psychosocial interventions

Patients may be resistant to proposals for individual or group psychotherapy because they perceive their sickness as a medical problem. Patients who embrace psychotherapy may be able to lessen their need of health care. Psychosocial therapies aimed at sustaining social and occupational function in the face of persistent medical complaints may be beneficial. Somatic symptom problems have been related to emotional processing deficits, which may lead to the development of medically unexplained physical ailments. As a result, emotion processing may become a significant focus for psychotherapy methods to treating somatic symptom problems.

Cognitive-behavioral therapy has been found in studies to lessen depression symptoms in persons with somatic disorders. This sort of therapy is very useful for people who meet the criteria for a depressive condition. Cognitive-behavioral treatment outperformed control conditions, with much higher results in groups limited to patients with major depression.

 

Differential Diagnosis

Somatic syndrome disorder (SSD) symptoms are widespread and non-specific, making diagnosis and therapy challenging. Adjustment disorder, body dysmorphic disorder, obsessive-compulsive disorder, and sickness anxiety disorder may all exhibit excessive and exaggerated emotional and behavioral reactions. Other functional diseases with unknown origin, such as fibromyalgia and irritable bowel syndrome, do not usually present with excessive thoughts, feelings, or maladaptive behavior.

 

Prognosis

Longitudinal investigations reveal significant chronicity, with up to 90% of somatic syndrome disorder (SSD) patients lasting more than 5 years. Therapeutic treatments only have small-to-moderate impact sizes, according to systematic reviews and meta-analyses. Chronic limitations in general function, substantial psychological handicap, and a reduction in quality of life are all common.

 

Complications

Alcohol and drug misuse are common occurrences, and are sometimes used to relieve symptoms, raising the risk of dependence on controlled drugs. Iatrogenic consequences may occur if the clinician chooses to undertake invasive diagnostic techniques or surgical treatments.

 

Somatic Symptom Disorders Follow-up

Somatic symptom diseases seldom necessitate hospitalization. If a patient seems suicidal or requires detoxification from concomitant drug use, consider inpatient treatment. Inpatient treatment may also be required for individuals whose somatic symptom condition is incapacitating (ie, conversion disorder with motor symptoms of such severity to impair ambulation). The following are the principles of inpatient care for somatization disorder:

• Rapid medical evaluation to rule out any medical causes of the patient's symptoms
• Assessment for psychiatric comorbidity and start of treatment for the concomitant psychiatric disease
• Education of the patient and family on the somatic symptom problem
• A return to full normal functioning is expected, with rehabilitation if necessary to regain function.
• If one does not already exist, a primary care physician who is knowledgeable with the management of somatic symptom problems should be established.
• A thorough discharge plan that includes primary care and, if necessary, mental follow-up.

 

Related Disorders

Illness anxiety disorder

Illness anxiety disorder (formerly known as hypochondriasis, a word altered in the DSM-5 owing to its derogatory connotation) is a mental disease characterized by excessive concern about having or developing a dangerous undetected medical condition. Ailment anxiety disorder (IAD) is characterized by continuous worry or dread of developing or having a significant medical illness that has a negative impact on one's everyday life.

Despite normal physical exams and laboratory testing findings, this dread continues. IAD patients pay undue attention to typical physiological sensations (such as digestion or sweating) and misunderstand these feelings as symptoms of serious illness. IAD is often a long-term condition.

Illness anxiety disorder is a newer diagnosis, appearing in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in 2013. The frequency of IAD is mainly unclear due to the novelty of this diagnosis. The prevalence of IAD is assessed by the prevalence of hypochondriasis diagnoses in DSM-III and DSM-IV. Among hypochondriac individuals who had previously been diagnosed

The prevalence of IAD varies depending on the research site (e.g., medical clinical setting vs. community). The estimated frequency of IAD in the medical outpatient setting is around 0.75 percent, while it is roughly 0.1 percent in the general population. IAD is frequent among teenagers, regardless of gender, and it often increases with age. IAD is more frequent in the jobless and the less educated.

People suffering with sickness anxiety disorder frequently seek first assistance from their primary care physician rather than a mental health care practitioner. Primary care physicians are often the first to speculate on an IAD diagnosis when, after a normal physical examination, laboratory studies, and repeated reassurance, patients continue to have a significant debilitating concern and worry about an underlying dangerous medical condition. These individuals frequently do not have somatic symptoms. If somatic symptoms exist, they are only modest. If they have another medical problem, their obsession with their health is plainly excessive and disproportionate to the severity of the disease.

Patients with Illness anxiety disorder are frequently unsatisfied with unfavorable evaluations and seek treatment from several providers for the same medical condition. They believe that their prior physicians were either inept or did not pay attention to detail, causing them to overlook a major medical problem with disastrous repercussions. Patients may also disclose that they often examine their bodies for skin blemishes, hair loss, or physical abnormalities. They may also obsess with death and incapacity. They are so focused with their body-checking practices and health worries that their social and vocational functioning may suffer.

 

Factitious disorder

Munchausen syndrome, also known as factitious disorder imposed on self, is a syndrome in which patients actively generate, simulate, or exaggerate medical or psychological problems for main advantage. These patients are simply driven by internal advantages, such as a desire for attention, coping with stress, or satisfaction in perplexing healthcare professionals. Patients suffering from factitious condition might endanger themselves by having a slew of unneeded operations or inducing symptoms.

Furthermore, they frequently overuse scarce healthcare resources. The condition's inherent deceit presents a considerable problem for healthcare practitioners in making a diagnosis. Evidence-based recommendations for the management of these individuals are restricted due to a paucity of willing participants in large-scale randomized therapy studies. The majority of current recommendations are based on expert opinion, case studies, and systematic reviews. According to this information, therapeutic choices are limited, and the prognosis for these individuals is often bad.

The incidence of factitious disorder in the general population is difficult to measure and varies greatly between research. Because of the disorder's covert character, it is likely underdiagnosed; also, there is no set threshold for the amount of deceit necessary to make a diagnosis.

 

Conversion disorder 

Conversion disorder, also known as functional neurological symptom disorder (FND), is a mental illness characterized by sensory or motor dysfunction. These signs and symptoms do not correspond to any recognized neurologic illness or other medical condition. Despite the fact that conversion disorder has no biological foundation, the symptoms have a major influence on a patient's capacity to operate. Furthermore, the symptoms cannot be controlled at will and are not thought to be exaggerated on purpose by the patient.

Conversion disorder can be caused by a combination of psychological, social, and biological causes. Symptoms of conversion disorder are frequently preceded by a trauma, a negative life experience, or an acute/chronic stressor. Many people with conversion disorder have a history of emotional and sexual abuse as children.

Poor coping skills and internal psychological problems are two more psychological elements that contribute to conversion disorder. Patients with conversion disorder are more likely than patients with recognized neurologic diseases to have specific mental illnesses (depression, anxiety, and personality disorders).

They are also more likely to have a history of various somatic complaints with no apparent explanation, such as widespread tiredness, weakness, or discomfort. Physical damage or genuine neurologic disease (such as a stroke or migraine) might "prompt" conversion disorder symptoms. Patients with less education, poorer socioeconomic level, and those living in developing or rural areas are more prone to acquire conversion disorder.

Obtaining an accurate history is critical in conversion disorder. It is critical to make the patient feel at ease and urge them to relate not only their symptoms but also their narrative. At the initial appointment, one way to consider is making a list of the patient's symptoms; ask the patient to identify all symptoms that they have been having recently. This is an important first step since it allows you to capture any modest changes in symptoms during the illness and check if the patient has various somatic symptoms.

It is critical to request a list of symptoms for which the patient has previously received therapy, as well as suspected neurologic disorders. The doctor should concentrate on acquiring information such as the time frame of symptoms and the setting. It is critical to enquire about recent events or stresses in the patient's life and complete a psychiatric history without disclosing the probable illness. A mental component should be included in the family history.

The doctor may wait until the conclusion of the interview to inquire about the patient's mental history. What was the patient's diagnosis and how were they treated if they had previously had similar symptoms? Even in the absence of a previous diagnosis, patients with a history of conversion disorder are more likely to have recurring episodes.

These inquiries can also assist shed insight on the patient's perception of other physicians, as well as which specialists they've visited and what work-up they've had. Involving the patient in the process is critical for developing rapport; ask them what they think is going on. Instead than focusing on what the patient is unable to perform at the time of the interview, ask them to explain the last time they were symptom-free and a typical day for them.

 

Conclusion 

Somatic syndrome disorders (SSDs) have broad and simple diagnostic criteria. Based on DSM-V criteria, a patient may be diagnosed with SSD if they have a medical disease that produces excessive concern. Furthermore, these criteria are subjective and inaccurate, and they may lead the provider to conduct an insufficient diagnostic workup, perhaps ignoring underlying medical or psychological problems.

The previous concern with the DSM-IV criteria was that they were overly restrictive and stringent; for example, to meet DSM-IV criteria for somatoform disorder, one would have to report four distinct pain symptoms, two gastrointestinal symptoms, one sexual or reproductive symptom other than pain, and one pseudoneurological complaint.

However, in order to develop criteria that are more often used in clinical settings, the DSM-V work group may have selected parameters with high sensitivity but poor specificity, catching just 7% of healthy persons. modifications to decrease false-positive overdiagnosis To begin, for individuals suffering from a medical condition, the reaction must be defined as "maladaptive," "extreme," "invasive," "impairing," and "grossly in excess" of the predicted reaction.

These exact terms may help to prevent misdiagnosis in people who are adaptively vigilant about their health issues. In people who have no recognized medical ailment, proper and recurrent medical workups at appropriate intervals would be required to detect medical disorders that may manifest over time. The third proposed criterion is to rule out mental diseases, notably panic, generalized anxiety, and depression, because these disorders might appear physically.

Some physicians find patients with SSD difficult to handle and frequently describe them in negative ways; the mistaken prejudice being that physical problems are regarded legitimate, but people with SSD are wrongfully accused of fabricating their symptoms. As a growing number of patients in primary care with medically unexplained symptoms are diagnosed with SSD, there is a need to educate and teach clinicians on SSD, its relevance, and how to appropriately manage these patients.