Somatization Disorder

Background 1. Definition: o Chronic, fluctuating disorder beginning before age 30 years and presenting as multiple physical complaints without adequate medical explanation o See diagnostic criteria

Pathophysiology 1. 4 psychological mechanisms5 o Mechanisms tend to be independent o May demonstrate single mechanism or any combination . Amplification of Body Sensations  Preoccupation with normal physical sensations that become disturbing and provide patient "confirmatory" evidence of pathology . Identified patient  Family unit forms rules of function around a single member in the context of illness, producing a patient that insists on being ill to fill that role . The "Need to Be Sick"  Psychic stress manifests as physical illness in a patient who may lack the vocabulary to express their distress  Complaints of physical illness wax and wane in response to stressful life circumstances  The "sick" role provides relief from stressful inter-personal expectations and promotes secondary gain (sympathy, attention, and sometimes money) . Dissociation  Dissociative symptoms, including out of body experiences, flashbacks, and depersonalization, are reported more commonly among somatization patients 2. Incidence, prevalence: o 1-year prevalence 0.2-2 % 3. Risk factors: o Predominately seen in females 10:11,2 o Family history of: . Antisocial Personality Disorder . Substance-Related Disorder . Somatization Disorder o Other comorbid mental/personality/mood disorders:1,10 . Depressive disorder . Anxiety disorder . Drug/alcohol dependence o Anger management issues, specifically anger repression8 o Childhood emotional and physical abuse (but not sexual abuse)9 o Decreased family cohesiveness9

Somatization Disorder Page 1 of 5 1.21.09 4. Morbidity / mortality: o No increased mortality than normal populations2 o Use 9 times the resources as an average medical patient2

Diagnostics 1. Three key features: o Multiple organ systems involved o Early onset, chronic course without physical signs/ structural abnormalities o Absence of laboratory abnormalities 2. History o Numerous physicians2 o Multiple hospitalizations2 o Multiple surgeries2 o Stories often lack detail and are inconsistent o Symptoms often colorfully described and exaggerated o Symptoms often out of proportion to the patient's healthy appearance5 o Childhood emotional or physical abuse (not sexual abuse)9 3. Physical exam o Surgical scars from prior exploratory surgeries 4. Diagnostic testing o Laboratory evaluation: Usually negative. No laboratory evidence to support patient complaints o Diagnostic imaging: None 5. Other tools o Physical Symptom Checklist6 . 55 questions covering symptoms from most organ systems including 3 female specific questions (irregular, painful or excessive menses), and 1 male specific question (impotence), graded on 4-point Likert scale o Screening for Somatoform Symptoms10 . 46 questions based on DSM-IV criteria o Tools such as these may be confounded by comorbid conditions7,9 6. Diagnostic criteria (SOR:A) o History of many physical complaints beginning before age 30 years that occur over a period of several years (Criterion A) o Symptoms result in seeking multiple treatments, and significant impairment in social, occupational, or other important areas of functioning o Multiple somatic complaints that cannot be explained by a general medical condition, or occur in excess of any identified medical illness (Criterion C) o All of the following criteria must be present at some point during the course of illness: . Four pain symptoms; pain related to at least 4 different sites (head, abdomen, back, joints, extremities, chest, rectum) or functions (menstruation, sexual intercourse, urination) (Criterion B1) . Two gastrointestinal tract symptoms, other than pain (Criterion B2)  Nausea (more common)  Abdominal bloating (more common)  Vomiting (less common)  Diarrhea (less common)

Somatization Disorder Page 2 of 5 1.21.09  Food intolerance (less common) . One sexual/ reproductive symptom, other than pain (Criterion B3)  Irregular menses  Menorrhagia  Vomiting throughout pregnancy  Erectile or ejaculatory dysfunction  Sexual indifference . One pseudoneurologic symptom, other than pain (Criterion B4)  Impaired coordination or balance  Paralysis or localized weakness  Difficulty swallowing or lump in throat  Aphonia  Urinary retention  Hallucinations  Loss of touch or pain sensation  Double vision  Blindness  Deafness  Seizures  Amnesia  Loss of consciousness other than fainting o Unexplained symptoms in Somatization Disorder are NOT intentionally feigned or produced

Differential Diagnosis 1. Hypochondriasis 2. Malingering 3. Factitious Disorder 4. Mood Disorder 5. Conversion Disorder 6. Body Dysmorphic Disorder 7. Schizophrenia 8. Systemic Lupus Erythematosis 9. Hyperparathyroidism 10. Multiple Sclerosis 11. Acute intermittent porphyria 12. Hemochromatosis 13. Lyme disease 14. Chronic parasitic disease

Therapeutics 1. Acute treatment (SOR:B) o Proper evaluation of symptoms . Look for an underlying medical condition to explain symptoms5 o Evaluate for common mental/personality disorders as these may be comorbid . Especially anxiety and depression o Avoid inferring that "it is all in your head." o Acknowledge suffering despite negative exam and testing6

Somatization Disorder Page 3 of 5 1.21.09 o Express the new diagnosis from the perspective that there is much that isn't known about these conditions and that as the physician you will be an active participant in their care6 2. Long-term care (SOR:A) o Be sure to properly work up new symptoms, as patients with somatization disorder are still susceptible to general medical conditions5 o Be careful not to over investigate as this may produce iatrogenic somatization o Therapy 4 . Cognitive-behavioral therapy improves physical symptoms and provides small improvements in psychological distress . Group therapy effective in as few as 5 sessions  Benefits lasted for up to 12 months4 . Physchopharmacotherapy for comorbid disorders6 . TCAs significantly reduce pain symptoms

Follow-Up 1. Return to office o Regular visits encouraged to avoid new symptom development o 15 minutes once a month 2. Refer to specialist o Psychotherapist o Group therapy 3. Admit to hospital o If patient is at risk for harm to themselves or others

Prognosis (SOR:A) 1. Poor prognosis o Somatization disorder has a chronic, but fluctuating course regardless of treatment 2. Patients will likely visit a healthcare professional at least once a year for somatic complaints

Prevention (SOR:B) 1. Stress reduction in order to avoid/prolong recurrence6

Patient Education 1. http://www.nlm.nih.gov/medlineplus/ency/article/000955.htm 2. http://www.emedicine.com/ped/topic3015.htm

References 1. First, M. DSM IV-TR. American Psychiatric Association. Washington, DC. 2000. 2. Smith GR, Monson RA, Ray DC. Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization. Arch Intern Med 1986;146:69-72.

Somatization Disorder Page 4 of 5 1.21.09 3. Kroenke K, Spitzer RL, Williams JB, Linzer M, Hahn SR, deGruy FV 3d, et al. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Family Med 1994; 9:774-9. 4. Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000 Jul-Aug;69(4):205-15. 5. Servan-Schreiber D, Kolb N, Tabas G. Somatizing Patients: Part I. Practical Diagnosis. Am Fam Phys 2000; 61:1073-8. http://www.aafp.org/afp/20000215/1073.html 6. Servan-Schreiber D, Kolb N, Tabas G. Somatizing Patients: Part II. Practical Management. Am Fam Phys 2000; 61:1073-8. http://www.aafp.org/afp/20000301/1423.html 7. de Waal MW, Arnold IA, Spinhoven P, Eekhof JA, Assendelft WJ, van Hemert AM. The role of comorbidity in the detection of psychiatric disorders with checklists for mental and physical symptoms in primary care. Soc Psychiatry Psychiatr Epidemiol. 2008 Jul 19. 8. Koh KB, Kim DK, Kim SY, Park JK, Han M. The relation between anger management style, mood and somatic symptoms in anxiety disorders and somatoform disorders. Psychiatry Res. 2008 Sep 30;160(3):372-9. 9. Brown RJ, Schrag A, Trimble MR. Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder.Am J Psychiatry. 2005 May;162(5):899-905. 10. Henningsen P, Jakobsen T, Schiltenwolf M, Weiss MG. Somatization revisited: diagnosis and perceived causes of common mental disorders. J Nerv Ment Dis. 2005 Feb;193(2):85-92.

Evidence-Based Inquiries 1. What is the best treatment for adult somatization disorder?

Author: Anthony Dambro, MD, Penn State Hershey Medical Center, PA

Editor: Robert Marshall, MD, MPH, Capt MC USN, Puget Sound Family Medicine Residence, Naval Hospital, Bremerton, WA

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