Managing the Somatoform Disorders a Fascinating Group of Conditions That Have Recently Emerged from a Period of Relative Disregard and Neglect

MAIN TOPIC

Managing the somatoform disorders A fascinating group of conditions that have recently emerged from a period of relative disregard and neglect.

The somatoform disorders are charac- The differentiation between physical ill- terised by the presence of physical symp- ness and psychogenic symptoms, while toms in the absence of a diagnosable being problematic philosophically because medical illness to account fully for them. of its inherently dualistic orientation, The symptoms are presumed to be psy- remains limited by currently available sci- chologically based, outside the patient’s entific evidence. The somatoform disor- conscious control, and should be severe ders have achieved a degree of legitimacy enough to cause significant distress, or by their inclusion in current psychiatric impair interpersonal, social and occupa- disease classifications. This is not without PETER SMITH tional functioning. Patients presenting problems, demonstrated by the unfortu- MB ChB, FCPsych (SA) with somatoform symptoms are seen in a nate attachment of stigma and other social Consultant variety of medical settings and are often a disadvantages that psychiatric diagnoses Psychiatrist source of frustration because of their often attract (somatisers are not very pop- Valkenberg Hospital incessant visits and resistance to reassur- ular people!). Cape Town ance. Despite their relatively small num- Lecturer bers they are liable to consume a dispro- Department of portionately large share of the available Psychiatry The somatoform disor - University of Cape health resources because of excessive con- Town sultations, special investigations and treat- ders have achieved a ment. This imposes an important respon- degree of legitimacy by Peter Smith has an sibility on doctors, particularly at primar y interest in cultural care level, to identify and manage th e s e their inclusion in current psychiatry and psychiatric ethics. He man- pa tients appropria tely and timeously. psychiatric disease clas - ages the outpatient These are a fascinating group of condi- s i f i c a t i o n s . service of Valkenberg Hospital. tions that have recently emerged from a period of relative disregard and neglect. Interest has been aroused by research CLASSIFICATION findings in fields such as psychoneuroim- The fourth edition of the Diagnostic and munology, invoking a reconceptualisation Statistical Manual of Mental Disorders of conventional notions of health and dis- (DSM-IV), the American Psychiatric ease, and a re-exploration of the mind- Association’s catalogue of mental disor- body divide. ders, designates five specific somatoform Historically, the status of these disorders disorders. has often been controversial and illustrates • somatisation disorder the powerful role of historical epoch and culture in shaping the expression of emo- • conversion disorder tional distress. The current preoccupation • hypochondriasis with health and the perfect appearance, • body dysmorphic disorder and the arrival of indeterminate condi- • pain disorder. tions such as chronic fatigue syndrome There are also two residual categories, and Gulf War syndrome, illustrate this. namely undifferentiated somatoform dis-

156 C M E M a r ch 2003 Vol.21 No.3 MAIN TOPIC order and somatoform disorder not men, may be a manifestation of (in contrast to the histrionic style otherwise specified, to accommo- childhood sexual abuse. They may seen in somatisation disorder), and date symptoms that do not meet also be the presenting problem in defy the reassurances offered by the criteria for the specific somato- the index patient in a dysfunctional negative examinations and special form disorder diagnoses. family, often distracting the family investigations. Men and women and the treating doctor from more are affected in equal numbers and Somatisation disorder is charac- significant problems such as there may be a strong family histo- terised by a variety of symptoms in domestic violence, sexual abuse or ry of hypochondriasis. Patients’ ill- multiple organ systems, usually a alcoholism. It is important to ness concerns result in significant combination of pain, gastrointesti- remember that conversion symp- distress to themselves, their loved nal, sexual and pseudoneurological toms can occur in patients with ones, and (not least) their treating symptoms. It differs from the established neurological disease doctors. other somatoform disorders by this (i.e. pseudoseizures in an epilep- multiplicity of complaints and the Body dysmorphic disorder is tic). Similarly, a significant num- multiple organ systems involved. characterised by a preoccupation ber of patients diagnosed with con- The disorder is chronic, with onset with an imagined anatomical version symptoms will eventually before 30 years of age, and is asso- defect (e.g. a large nose) or an receive an actual disease diagnosis. ciated with significant psychologi- exaggerated distortion of a minor Bias towards women within med- cal distress, psychosocial dysfunc- defect in physical appearance (e.g. ical systems and towards patients tion and excessive help-seeking mild acne). Despite its apparent from diverse cultural or deprived behaviour. Patients often have triviality, the condition may be backgrounds needs to be guarded poor social support and generally severely stressful for patients, who against to prevent premature diag- require social grants. There is a may be virtually incapacitated by nosis of conversion disorders in the strong association with co-morbid social avoidance and emotional dis- presence of actual disease. psychiatric problems including tress. Cultural shaping may play a depression, cluster-B personality significant role in the generation of disorder (histrionic and border- It may be necessary these concerns by the high premi- line), and eating disorders. There um placed on physical appearance may be a history of childhood sex- to clarify the limits in some societies. Patients are ual abuse and complex post-trau- of the interventions inclined to avoid mirrors or scruti- matic stress disorder (PTSD). The on offer, and ny through social exchanges and management of these patients is will often procure repeated plastic often complicated by difficulties in appointments may surgical procedures. There seems the doctor-patient relationship, have to be sched - to be a correlation with obsessive- repeated acting-out behaviours compulsive disorder in terms of such as parasuicide and deliberate uled strictly. some of the clinical features and self-harm, and substance abuse. the underlying biological substrate, which is supported by a shared Conversion disorder is defined Hypochondriasis, the common- response to certain anti-obsessional by the presence of one or more est of the somatoform disorders, is psychotropic drugs. neurological symptoms (e.g. paral- defined by the presence of a pre- Pain disorder is similar to a con- ysis, blindness, seizures, or numb- occupation with fears of having a version disorder in which pain is ness) that cannot be accounted for serious disease based upon the the presenting complaint. The by a diagnosable neurological or misinterpretation of one or more underlying cause must be at least medical disorder. Physical exami- physical symptoms. Hypochon- partially psychogenic, and the con- nation may reveal unanatomical driacs are less concerned with their dition should be accompanied by a physical signs, and special investi- symptoms per se than they are with degree of emotional and functional gation results are usually negative. what their symptoms signify. They impairment. There may be an The relationship between the phys- often display an obsessive preoccu- associated physical condition, but ical symptom and the underlying pation with their bodies and har- the pain is out of proportion to its psychological conflict may be strik- bour the conviction that they are extent or severity.Pain disorder is ingly clear (e.g. paralysis in a sol- afflicted with a serious disease. diagnosed twice as frequently in dier facing battle). Conversion They visit their doctors repeatedly, women as in men, and there may symptoms, which are significantly present their complaints in a be a positive family history. Many more common in women than detailed and ruminative manner

C M E M a r ch 2003 Vol.21 No.3 157 MAIN TOPIC

chronic pain specialists find the It is useful to organise the assess- These assessments will determine notion of somatoform pain prob- ment and management approach the choice of a definitive trea t- lematical. There are inherent diffi- around a series of discrete steps. ment strategy for the individual culties in trying to discriminate patient. The initial evaluation of somatic physically based pain from psy- symptoms should always be direct- A central feature of that definitive chogenic pain, and the somatising ed at excluding an underlying treatment strategy is the doctor- aspect of the diagnosis may lead to physical illness . It may be diffi- patient relationship . It has been a tendency to underestimate the cult to determine how far to pro- demonstrated repeatedly that the patient’s subjective pain experi- ceed in the face of negative results, most helpful intervention for many ence. The stigmatising effect of especially when patients refuse to patients with somatoform disorders acquiring a psychiatric diagnosis be reassured by these. The nag- is a stable, ongoing relationship may also be uncomfortable for ging possibility that an occult med- with a caring, reassuring and sup- patients. ical condition could emerge later portive doctor who can empatheti- may engender doubt and anxiety. cally understand and validate their physical and emotional distress. Despite its apparent When it becomes apparent that the The ideal doctor would have great physical symptoms are psychogenic triviality, the condi - skills not only at mediating in origin, a complete psychiatric patients’ inner conflicts, but also in tion may be severely assessment is required. A specific dealing with his ‘own stuff’. He somatoform disorder diagnosis is stressful for should be undogmatic, open-mind- made according to a standard sys- ed and able to cope with uncer- patients, who may tem of classification, for example, tainty when confronted with a con- be virtually incapac - the DSM-IV, including an assess- dition where the physical and psy- ment of the duration, severity and itated by social chological bases are unclear. psychosocial impact of the symp- Conflicts between empathy and avoidance and emo - toms. Somatic symptoms may apathy, underinvolvement and tional distress. accompany a range of psychiatric overinvolvement, undertreatment disorders, including depression, and overtreatment, and a range of anxiety disorders, schizophrenia, other emotional responses includ- and substance use disorders (which ing frustration, anger, resentment MANAGEMENT masquerade as vague physical and despair may need to be man- symptoms for which patients The management of the somato- aged appropriately, for example in repeatedly seek medical attention). form disorders is widely regarded doctor support groups. Patients The identification of co-morbid as complex and challenging, and is often make unreasonable demands psychiatric conditions may have often shrouded in a pall of pes- with regard to the frequency and very important treatment and simism and despair. This view is extent of treatment. It may be prognostic implications. justified to some extent by the fre- necessary to clarify the limits of the quent chronicity and tenacity of A crucial next step is the formula- interventions on offer, and somatoform symptoms. However, tion of a biopsychosocial under - appointments may have to be this should not obscure the fact standing of the patient and his/her scheduled strictly. that some fairly straightforward symptoms. This would address Because of the invariable impact interventions can offer dramatic matters such as familial and tem- on social functioning, it may be results, particularly if offered peramental vulnerabilities; the useful to offer couple or family timeously, before the symptoms symbolic meaning the patient interventions, and the assistance of and accompanying pathological ill- ascribes to the symptoms and how a social worker and other members ness behaviours become this connects with formative and of a multidisciplinary team (i.e. entrenched. Many of these inter- current life experiences; the influ- psychologists and occupational ventions can be (and often have to ence of stressful life circumstances; therapists) could prove helpful. be) administered at the primary the role of learning, especially as it care level. Specialist assessment applies to the reinforcement of Psychopharmacological treatments may be necessary in complex pathological illness behaviour; and are used most commonly in cases, especially in the presence of the broader overarching influence patients who have co-morbid psy- co-morbid psychiatric disorders or of the social and cultural context. chiatric conditions, and the soma- substance abuse. toform symptoms may resolve with

158 C M E M a r ch 2003 Vol.21 No.3 MAIN TOPIC

successful treatment. The selective ly consume a large portion of the serotonin reuptake inhibitors available health resources. They (SSRIs) have shown some success, resist reassurance and are often in IN A NUTSHELL especially in somatoform disorders conflict with their doctors, with Somatomform disorders are char- characterised by obsessional fea- invariable professional, ethical and acterised by physical symptoms in the absence of a diagnosable tures, such as hypochondriasis and legal implications. Prompt manage- medical condition. body dysmorphic disorder. ment promises the best outcome. This imposes an important respon- Somatoform disorders are classi- Cognitive behaviour therapy, fied in the DSM-IV into five specif- sibility on primary care practition- which can be delivered in individ- ic types: somatisation disorder, ers to screen and manage these conversion disorder, hypochon- ual or group settings, has also patients appropriately. driasis, body dysmorphic disor- shown a range of benefits with der, pain disorder. regard to symptom reduction and Conceptually, these disorders oper- Somatisation disorder exhibits a enhancing overall sense of well- ate in the exciting and burgeoning combination of multiple organ being. field of psychosomatic medicine in symptoms, involving pain, gas- which fascinating research findings trointestinal, sexual and It is not unusual for legal and ethi- are emerging.They invite a re- pseudoneurological symptoms. cal issues to arise in the manage- exploration of the boundaries of Conversion disorder is defined by ment of these patients, given the mind-body medicine, and a recon- the presence of one or more range of difficulties already men- sideration of the social and cultural neurological symptoms, e.g. tioned. The legal matters usually determinants of health and disease. blindness, paralysis, seizures or revolve around confidentiality and numbness. access to patient information. Hypochondriasis is defined by the Ethical issues may arise in the con- presence of a preoccupation with text of emotional conflict between fears of having a serious disease. the doctor and the patient or by Physical symptoms are misinter- desperation and frustration often preted. experienced by both. This may FURTHER READING Body dysmorphic disorder is take many forms, for example the Balint M. The Doctor, his Patient, and characterised by a preoccupation temptation to administer treatment the Illness. New York: International with an imagined anatomical defect such as a large nose, or an without full disclosure of its pur- Universities Press, 1957. Cantor C. Phantom Illness — exaggeration of a minor appear- pose or mode of action (i.e. a Shattering the Myth of Hypochondria. ance defect. placebo), deliberately overtreating New York: Houghton Mifflin Pain disorder is similar to conver- a trivial condition and exposing the Company, 1996. sion disorder, with pain being the patient to iatrogenic hazards, and Kaplan H, Sadock, B. Synopsis of presenting complaint. colluding in other ways with Psychiatry, 8th Ed. Baltimore, Md: Williams & Wilkins, 1998. Management should be prompt, patients’ pathological illness behav- Kleinman A. The Illness Narratives: with a thorough assessment, ini- iours for perverse gain. These are Suffering, Healing and the Human tially directed at excluding an common pitfalls that ought to be Condition. New York: Basic Books, underlying physical illness. guarded against by constant vigi- 1988. A complete psychiatric assess- lance and the highest ethical stan- Lipowski Z. Somatization — the con- ment may be required, and iden- dards at all times. cept and its clinical application. Am J tification of co-morbid psychiatric 145: Psychiatry 1988, 1358. conditions may have significant implications regarding treatment CONCLUSION and prognosis. Patients who somatise their emo- The doctor-patient relationship tional difficulties are seen in many may suffer or be severely medical settings. They are relatively strained. small in number, but can potential- Psychopharmacological treatments and/or cognitive behaviour therapy may be indicated.

160 C M E M a r ch 2003 Vol.21 No.3