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 somatization disorder (involving multisystem physical symptoms), undifferentiated somatoform disorder (fewer symp- toms than somatization disorder), conversion disorder (voluntary motor or sensory function symptoms), pain disorder (pain with strong psychological involvement), hypochondriasis (fear of having a life-threatening illness or condition), body dysmorphic disorder (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 mental health 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 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2007 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE 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, disease- 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, factitious disorder 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 Headaches explained by a general medical condition, Chest pain another mental disorder, or the effects of a Dizziness substance; (2) are not the result of factitious disorder or malingering; 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 chronic pain 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