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 psychi- atric 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