Somatoform Disorders OLIVER OYAMA, PhD, MHS, PA-C; CATHERINE PALTOO, MD, MS; and JULIAN GREENGOLD, MD Morton Plant Mease/University of South Florida, Clearwater, Florida

The somatoform disorders are a group of psychiatric disorders that cause unexplained physical symptoms. They include disorder (involving multisystem physical symptoms), undifferentiated somatoform disorder (fewer symp- toms than ), (voluntary motor or sensory function symptoms), (pain with strong psychological involvement), (fear of having a life-threatening illness or condition), (preoccupation with a real or imagined physical defect), and somatoform disorder not other- wise specified (used when criteria are not clearly met for one of the other somatoform disorders). These disorders should be considered early in the evaluation of patients with unexplained symptoms to prevent unnecessary interventions and testing. Treatment success can be enhanced by discussing the possibility of a somatoform disorder with the patient early in the evaluation process, limiting unnecessary diagnostic and medical treatments, focusing on the management of the disorder rather than its cure, using appropriate medications and psychotherapy for comorbidities, maintaining a psy- choeducational and collaborative relationship with patients, and referring patients to professionals when appropriate. (Am Fam Physician 2007;76:1333-8. Copyright © 2007 American Academy of Family Physicians.) ▲ Patient information: he somatoform disorders are a negative emotions toward the physician or A handout on somato- group of psychiatric disorders office staff; unrealistic expectations; and, form disorder is available at http://familydoctor. in which patients present with occasionally, resistance to or noncompliance org/162.xml. a myriad of clinically significant with diagnostic or treatment efforts. These butT unexplained physical symptoms. They behaviors may result in more frequent office include somatization disorder, undifferenti- visits, unnecessary laboratory or imaging ated somatoform disorder, hypochondriasis, tests, or costly and potentially dangerous conversion disorder, pain disorder, body dys- invasive procedures.5-7 morphic disorder, and somatoform disorder Little is known about the causes of the not otherwise specified.1 These disorders somatoform disorders. Limited epidemio- often cause significant emotional distress logic data suggest familial aggregation for for patients and are a challenge to family some of the disorders.1 These data also indi- physicians. cate comorbidities with other mental health Up to 50 percent of primary care patients disorders, such as mood disorders, anxiety present with physical symptoms that cannot disorders, personality disorders, eating dis- be explained by a general medical condi- orders, and psychotic disorders.1,3 tion. Some of these patients meet criteria for somatoform disorders.2,3 Although most Diagnosis do not meet the strict psychiatric diagnostic The challenge in working with somato- criteria for one of the somatoform disorders, form disorders in the primary care setting they can be referred to as having “somatic is to simultaneously exclude medical causes preoccupation,”4 a subthreshold presentation for physical symptoms while considering of somatoform disorders that can also cause a mental health diagnosis. The diagnosis patients distress and require intervention. of a somatoform disorder should be con- The unexplained symptoms of somato- sidered early in the process of evaluating form disorders often lead to general health a patient with unexplained physical symp- anxiety; frequent or recurrent and excessive toms. Appropriate nonpsychiatric medical preoccupation with unexplained physical conditions should be considered, but over- symptoms; inaccurate or exaggerated beliefs evaluation and unnecessary testing should about somatic symptoms; difficult encoun- be avoided. There are no specific physical ters with the health care system; dispropor- examination findings or laboratory data that tionate disability; displays of strong, often are helpful in confirming these disorders; it

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Evidence Clinical recommendation rating References Comments

Fostering a strong physician-patient relationship is C 27-30 Recommendations from clinical integral to managing somatoform disorders. practice settings Cognitive behavior therapy is effective in treating B 19-22 Consistent findings from patients with somatoform disorders. randomized controlled trials Psychiatric consultation helps improve the effects of B 23, 24, 26 Consistent findings from somatoform disorders. randomized controlled trials

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, - oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1262 or http://www.aafp.org/afpsort.xml. often is the lack of any physical or laboratory findings to desires to take on the role of being sick), whereas malinger- explain the patient’s excessive preoccupation with somatic ing involves the purposeful feigning of physical symptoms symptoms that initially prompts the physician to consider for external gain (e.g., financial or legal benefit, avoidance the diagnosis. of undesirable situations). In somatoform disorders, there Two related disorders, and malin- are no obvious gains or incentives for the patient, and the gering, must be excluded before diagnosing a somatoform physical symptoms are not willfully adopted or feigned; disorder. In factitious disorder, patients adopt physical rather, anxiety and fear facilitate the initiation, exacerba- symptoms for unconscious internal gain (i.e., the patient tion, and maintenance of these disorders. Clinical diagnostic tools have been used to assist in the diagnosis of somatoform Patient Health Questionnaire: disorders.8 One screening tool for psychi- Screening for Somatoform Disorders atric disorders that is used in primary care settings is the Patient Health Question- During the past four weeks, how much have you been bothered naire (PHQ).9 The somatoform screening by any of the following problems? questions on the PHQ include 13 physical symptoms (Figure 1).9 If a patient reports Not at all A little A lot being bothered “a lot” by at least three of Stomach pain the symptoms without an adequate medical Back pain explanation, the possibility of a somatoform disorder should be considered. Pain in your arms, legs, or joints (knees, hips, etc.) Characteristics Menstrual cramps or other problems with your periods There are three required clinical criteria com- Pain or problems during sexual mon to each of the somatoform disorders: intercourse The physical symptoms (1) cannot be fully explained by a general medical condition, another , or the effects of a Dizziness substance; (2) are not the result of factitious disorder or ; and (3) cause sig- Fainting spells nificant impairment in social, occupational, Feeling your heart pound or race or other functioning. The additional charac- Shortness of breath teristics of each disorder are discussed briefly Constipation, loose bowels, or diarrhea in the following and are listed in Table 1.1 Nausea, gas, or indigestion somatization disorder note: If a patient reports being bothered “a lot” by at least three of the symptoms with- Patients with somatization disorder (also out an adequate medical explanation, a somatoform disorder should be considered. known as Briquet’s syndrome) present with unexplained physical symptoms beginning Figure 1. Patient Health Questionnaire: Screening for Somatoform before 30 years of age, lasting several years, Disorders. and including at least two gastrointesti- Information from reference 9. nal complaints, four pain symptoms, one

1334 American Family Physician www.aafp.org/afp Volume 76, Number 9 ◆ November 1, 2007 Table 1. Characteristics of Somatoform Disorders

Disorder Essential characteristics pseudoneurologic problem, and one sexual Somatization disorder Unexplained physical symptoms manifested before age 30 symptom (Table 2).1 For example, a patient Symptoms last for several years might have chronic abdominal complaints Symptoms include two gastrointestinal, (e.g., abdominal cramping, diarrhea) that four pain, one pseudoneurologic, and have been thoroughly evaluated but have no one sexual identified cause, as well as a history of other Undifferentiated somatoform ≥ Six months’ history unexplained somatic symptoms such as anor- disorder One or more unexplained physical gasmia, ringing in the ears, and symptoms in the shoulder, neck, low back, and legs. Conversion disorder Single unexplained symptom involving Patients with this disorder often have made voluntary or sensory functioning frequent clinical visits, had multiple imaging Pain disorder Pain symptom is predominant focus and laboratory tests, and had numerous refer- Psychological factors play the primary rals made to work up their diverse symptoms. role in the perception, onset, severity, exacerbation, or maintenance of pain Somatization disorder appears to be more Hypochondriasis Fixation on the fear of having a life- common in women than men, with a life- threatening medical condition time prevalence of 0.2 to 2 percent in women Body dysmorphic disorder Preoccupation with a real or imagined compared with less than 0.2 percent in physical defect men. Subthreshold somatization disorder Somatoform disorder not Misinterpretation or of may have a prevalence up to 100 times otherwise specified unexplained physical symptoms greater. Familial patterns exist, with a 10 to Patient does not meet full criteria for any 20 percent incidence in first-degree female of the other somatoform disorders relatives.1 No definitive cause has been iden- tified for somatization disorder, although Information from reference 1. the familial patterns suggest genetic or envi- ronmental contributions. undifferentiated somatoform disorder Table 2. Selected Symptoms of Somatization Disorder The diagnosis of undifferentiated somato- form disorder is a less-specific version of Gastrointestinal (two) Pseudoneurologic (one) somatization disorder that requires only a Bloating six-month or longer history of one or more Diarrhea Aphonia unexplained physical complaints in addi- Food intolerance Blindness tion to the other requisite clinical crite- Nausea Difficulty swallowing ria. Chronic that cannot be fully Vomiting Double vision explained by a known medical condition is Pain (four) Impaired coordination a typical symptom. The highest incidence of Abdominal Loss of consciousness complaints occurs in young women of low Back Paralysis socioeconomic status, but symptoms are not Chest Paresthesias limited to any group.1 Urinary retention conversion disorder Dysuria Sexual (one) Extremity Ejaculatory dysfunction Conversion disorder involves a single symp- Head tom related to voluntary motor or sen- Joint Hyperemesis of pregnancy sory functioning suggesting a neurologic Rectal Irregular menses condition and referred to as pseudoneuro- Menorrhagia logic. Conversion symptoms typically do not Sexual indifference conform to known anatomic pathways or physiologic mechanisms, but instead they note: Numbers in parenthesis refer to the number of symptoms in each category more commonly fit a lay view of physiol- required for the diagnosis of somatization disorder (in addition to other criteria). ogy (e.g., a hemiparesis that does not fol- Information from reference 1. low known corticospinal-tract pathways or

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without changes in would reveal it, avoids all social situations in which it may Clinically significant depres- reflexes or muscle be seen by others, and feels others are judging her because sive disorder, anxiety tone), a clue to this of it. The disorder occurs equally in men and women.10 disorder, personality disor- disorder. Patients der, and substance may present in a somatoform disorder not otherwise specified disorder often coexist with dramatic fashion or Somatoform disorder not otherwise specified is a psychi- somatoform disorders. show a lack of con- atric diagnosis used for conditions that do not meet the cern for their symp- full criteria for the other somatoform disorders, but have tom. Onset rarely physical symptoms that are misinterpreted or exagger- occurs before age 10 or after 35 years of age. Conversion ated with resultant impairment. A variety of conditions disorder is reported to be more common in rural popula- come under this diagnosis, including pseudocyesis, the tions, persons of lower socioeconomic status, and those mistaken belief of being pregnant based on actual signs of with minimal medical or psychological knowledge.1 pregnancy (e.g., expanding abdomen without eversion of the umbilicus, oligomenorrhea, amenorrhea, feeling fetal pain disorder movement, nausea, breast changes, labor pains). Pain disorder is fairly common. Although the pain is associated with psychological factors at its onset Treatment (e.g., unexplained chronic that began after a Patients who experience unexplained physical symptoms significant stressful life event), its onset, severity, exacer- often strongly maintain the belief that their symptoms bation, or maintenance may also be associated with a gen- have a physical cause despite evidence to the contrary. eral medical condition. Pain is the focus of the disorder, These beliefs are based on false interpretation of symp- but psychological factors are believed to play the primary toms.11 Additionally, patients may minimize the involve- role in the perception of pain. Patients with pain disorder ment of psychiatric factors in the initiation, maintenance, use the health care system frequently, make substantial or exacerbation of their physical symptoms. use of medication, and have relational problems in mar- riage, work, or family. Pain may lead to inactivity and discussing the diagnosis social isolation, and it is often associated with comorbid The initial steps in treating somatoform disorders are to , anxiety, or a substance-related disorder. consider and discuss the possibility of the disorder with the patient early in the work-up and, after ruling out hypochondriasis organic pathology as the primary etiology for the symp- Patients with hypochondriasis misinterpret physical toms, to confirm the psychiatric diagnosis. A psychiatric symptoms and fixate on the fear of having a life- diagnosis should be made only when all criteria are met. threatening medical condition. These patients must have Discussing the diagnosis requires forethought and a nondelusional preoccupation with their symptom or practice.12 The delivery of the diagnosis may be the symptoms for at least six months before the diagnosis most important treatment step. The physician must first can be made. Prevalence is 2 to 7 percent in the primary build a therapeutic alliance with the patient. This can care outpatient setting, and there do not appear to be be partially achieved by acknowledging the patient’s dis- consistent differences with respect to age, sex, or cul- comfort with his or her unexplained physical symptoms tural factors.1 The predominant characteristic is the fear and maintaining a high degree of empathy toward the patients exhibit when discussing their symptoms (e.g., an patient during all encounters. exaggerated fear of having acquired human immunode- The physician should review with the patient the diag- ficiency virus despite reassurance to the contrary). This nostic criteria for the suspected somatoform disorder, fear is pathognomonic for hypochondriasis. explaining the disorder as for any medical condition, with information regarding etiology, epidemiology, and body dysmorphic disorder treatment. It should also be explained that the goal of Body dysmorphic disorder involves a debilitating preoc- treatment for somatoform disorders is management cupation with a physical defect, real or imagined. In the rather than cure. case of a real physical imperfection, the defect is usually slight but the patient’s concern is excessive. For example, therapy a woman with a small, flat keloid on the shoulder may be Once the diagnosis is made and the patient accepts the so self-conscious of it that she never wears clothing that diagnosis and treatment goals, the physician may treat

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referral Table 3. Practice Management Strategies Collaboration with a mental health profes- for Somatoform Disorders sional can be helpful in making the initial diagnosis of a somatoform disorder, con- Accept that patients can have distressing, real physical symptoms and firming a comorbid diagnosis, and provid- medical conditions with coexisting psychiatric disturbance without ing treatment.23 The family physician is in malingering or feigning symptoms the best position to make the initial diag- Consider and discuss the possibility of somatoform disorders with the patient early in the work-up, if suspected, and make a psychiatric nosis of somatoform disorder, being most diagnosis only when all criteria are met knowledgeable of the specific presentation Once the diagnosis is confirmed, provide patient education on the of general medical conditions; however, col- individual disorder using empathy and avoiding confrontation laboration with a psychiatrist or other men- Avoid unnecessary medical tests and specialty referrals, and be cautious tal health professional may help with the when pursuing new symptoms with new tests and referrals subtleties between these disorders and their Focus treatment on function, not symptom, and on management of the psychiatric comorbidities, the severity of disorder, not cure disorders, and the time demands in caring Address lifestyle modifications and reduction, and include the for these patients. Results of a recent, small patient’s family if appropriate and possible randomized controlled trial conducted in Treat comorbid psychiatric disorders with appropriate interventions the Netherlands, which combined cogni- Use medications sparingly and always for an identified cause tive behavior therapy provided by general Schedule regular, brief follow-up office visits with the patient (five minutes each month may be sufficient) to provide attention and practitioners with psychiatric consultation, reassurance while limiting frequent telephone calls and “urgent” visits suggest improvements in symptom severity, Collaborate with mental health professionals as necessary to assist with social functioning, and health care use when the initial diagnosis or to provide treatment multiple interventions are employed.24

Information from references 27 through 30. follow-up A schedule of regular, brief follow-up office visits with the physician is an important any psychiatric comorbidities. Psychiatric disorders rarely aspect of treatment.13 This maintains the therapeutic alli- exist in isolation, and somatoform disorders are no ance with the physician, provides a climate of openness exception. Clinically significant depressive disorder, anxi- and willingness to help,25 allows the patient an outlet for ety disorder, , and dis- worry about illness and the opportunity to be reassured order often coexist with somatoform disorders and should repeatedly that the symptoms are not signs of a physical be treated concurrently using appropriate modalities.13 disorder, and allows the physician to confront problems Studies supporting the effectiveness of pharmaco- or issues proactively. Scheduled visits may also prevent fre- logic interventions targeting specific somatoform dis- quent and unnecessary between-visit contacts and reduce orders are limited. are commonly used excessive health care use.26 to treat depressive or anxiety disorders and may be part The practical management strategies described here of the approach to treating the comorbidities of somato- and elsewhere are summarized in Table 3.27-30 Follow- form disorders. Antidepressants such as fluvoxamine ing these strategies will assist physicians in managing (Luvox, brand not available) for treating body dysmor- some of the most challenging clinical encounters in phic disorder, and St. John’s wort for treating somatiza- family medicine. tion and undifferentiated somatoform disorders have been proposed.14,15 The authors thank Elizabeth Lawrence, MD, for reviewing the manuscript. Cognitive behavior therapy has been found to be an effective treatment of somatoform disorders.16-21 It The Authors focuses on cognitive distortions, unrealistic beliefs, OLIVER OYAMA, PhD, MHS, PA-C, is an associate director of the Morton worry, and behaviors that promulgate health anxiety Plant Mease/University of South Florida Family Medicine Residency and somatic symptoms. Benefits of cognitive behav- Program, Clearwater, and an affiliate assistant professor in the Department ior therapy include reduced frequency and intensity of Family Medicine at the University of South Florida, Tampa. He received his doctoral degree in from Indiana University, of symptoms and cost of care, and improved patient Bloomington, and his master’s degree in health sciences and a physician functioning.22 assistant certification from Duke University, Durham, N.C.

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CATHERINE PALTOO, MD, MS, is in private practice in Tampa, and was one Clark DM, eds. Cognitive Behavior Therapy for Psychiatric Problems: A of the chief residents of the Morton Plant Mease/University of South Florida Practical Guide. New York, N.Y.: Oxford University Press, 1989:235-76. Family Medicine Residency Program. She received her master’s degree in 12. McCahill ME. Somatoform and related disorders: delivery of diagnosis clinical psychology from Fort Hays State University, Hays, Kan., and her as first step. Am Fam Physician 1995;52:193-204. medical degree from the University of Kansas School of Medicine, Wichita. 13. Servan-Schreiber D, Kolb NR, Tabas G. Somatizing patients: Part I. Practical diagnosis. Am Fam Physician 2000;61:1073-8. JULIAN GREENGOLD, MD, is an assistant director of the Morton Plant 14. Phillips KA, Siniscalchi JM, McElroy SL. Depression, anxiety, anger, and Mease/University of South Florida Family Medicine Residency Program, somatic symptoms in patients with body dysmorphic disorder. Psychiatr the director of continuing medical education for the Morton Plant Mease Q 2004;75:309-20. Health System, and an affiliate associate professor in the Department of 15. Muller T, Mannel M, Murck H, Rahlfs VW. Treatment of somatoform Family Medicine at the University of South Florida. He received his medi- disorders with St. John’s wort: a randomized, double-blind and pla- cal degree from St. Louis (Mo.) University and completed his postgraduate cebo-controlled trial. Psychosom Med 2004;66:538-47. training at Waterbury Hospital/Yale University, Waterbury, Conn. 16. Burton C. Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). Br J Address correspondence to Oliver Oyama, PhD, MHS, PA-C, Morton Gen Pract 2003;53:231-9. Plant Mease/USF Family Medicine Residency Program, 807 N. Myrtle 17. McLeod CC, Budd MA. Treatment of somatization in primary care: Ave., Clearwater, FL 33755 (e-mail: [email protected]). evaluation of the Personal Health Improvement Program. HMO Pract Reprints are not available from the authors. 1997;11:88-94. Author disclosure: Nothing to disclose. 18. McLeod CC, Budd MA, McClelland DC. Treatment of somatization in primary care. Gen Hosp 1997;19:251-8. 19. Speckens AE, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooij- mans HG. Cognitive behavioural therapy for medically unexplained physi- REFERENCES cal symptoms: a randomised controlled trial. BMJ 1995;311:1328-32. 20. Warwick HM, Clark DM, Cobb AM, Salkovskis PM. A controlled trial 1. American Psychiatric Association. Diagnostic and Statistical Manual of of cognitive-behavioural treatment of hypochondriasis. Br J Psychiatry Mental Disorders. 4th ed. rev. Washington, D.C.: American Psychiatric 1996;169:189-95. Association, 2000. 21. Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: 2. Barsky AJ, Borus JF. Somatization and medicalization in the era of man- a randomized controlled trial. JAMA 2004;291:1464-70. aged care. JAMA 1995;274:1931-4. 22. Allen LA, Woolfolk RL, Escobar JI, Gara MA, Hamer RM. Cognitive- 3. de Waal MW, Arnold IA, Eekhof JA, van Hemert AM. Somatoform behavioral therapy for somatization disorder: a randomized controlled disorders in general practice: prevalence, functional impairment and trial. Arch Intern Med 2006;166:1512-8. comorbidity with anxiety and depressive disorders. Br J Psychiatry 23. Smith GR Jr, Monson RA, Ray DC. Psychiatric consultation in soma- 2004;184:470-6. tization disorder. A randomized controlled study. N Engl J Med 4. Righter EL, Sansone RA. Managing somatic preoccupation. Am Fam 1986;314:1407-13. Physician 1999;59:3113-20. 24. van der Feltz-Cornelis CM, van Oppen P, Ader HJ, van Dyck R. Ran- 5. Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utiliza- domised controlled trial of a collaborative care model with psychiatric tion and costs independent of psychiatric and medical comorbidity. consultation for persistent medically unexplained symptoms in general Arch Gen Psychiatry 2005;62:903-10. practice. Psychother Psychosom 2006;75:282-9. 6. Hiller W, Fichter MM, Rief W. A controlled treatment study of somato- 25. Margo KL, Margo GM. The problem of somatization in family practice. form disorders including analysis of healthcare utilization and cost- Am Fam Physician 1994;49:1873-9. effectiveness. J Psychosom Res 2003;54:369-80. 26. Smith GR Jr, Rost K, Kashner TM. A trial of the effect of a standardized 7. Barsky AJ, Ettner SL, Horsky J, Bates DW. Resource utilization of psychiatric consultation on health outcomes and costs in somatizing patients with hypochondriacal health anxiety and somatization. Med patients. Arch Gen Psychiatry 1995;52:238-43. Care 2001;39:705-15. 27. Goldberg RJ, Novack DH, Gask L. The recognition and management of somatization. What is needed in primary care training. Psychosomatics 8. Chaturvedi SK, Desai G, Shaligram D. Somatoform disorders, somatiza- 1992;33:55-61. tion and abnormal illness behaviour. Int Rev Psychiatry 2006;18:75-80. 28. Walker EA, Unutzer J, Katon WJ. Understanding and caring for the 9. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV III, Hahn SR, distressed patient with multiple medically unexplained symptoms. J Am et al. Utility of a new procedure for diagnosing mental disorders in Board Fam Pract 1998;11:347-56. primary care. The PRIME-MD 1000 study. JAMA 1994;272:1749-56. 29. Gillette RD. Caring for frequent-visit patients. Fam Pract Manag 10. Castle DJ, Rossell S, Kyrios M. Body dysmorphic disorder. Psychiatr Clin 2003;10:57-62. North Am 2006;29:521-38. 30. Gillette RD. “Problem patients”: a fresh look at an old vexation. Fam 11. Salkovskis PM. Somatic problems. In: Hawton K, Salkovskis PM, Kirk J, Pract Manag 2000;7:57-62.

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