Patient professional reference
This is a chronic condition in which there are numerous physical complaints. These complaints can last for years and result in substantial impairment.
In the International Classification of Diseases 10th edition (ICD-10), somatisation is defined as multiple, recurrent and frequently changing physical symptoms usually present for several years, (at least two years) before the patient is referred to a psychiatrist. More latterly, the term 'unexplained somatic complaints' was introduced to describe patients presenting with any physical symptom and frequent medical visits in spite of negative investigations. This term is thought to be more acceptable to patients and has fewer aetiological implications.
In the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-5), the condition has been renamed somatic symptom disorder (SSD). There are significant departures from the DSM-IV categorisation which identified somatisation disorder, hypochondriasis, pain disorder,and undifferentiated somatoform disorder. All these are now included under the heading of SSD. Another innovation is that the symptoms need no longer to be medically unexplained but may or may not be associated with another medical condition. Thus, patients who had organic comorbidities such as heart disease, osteoarthritis or cancer - who were previously excluded under DSM-IV - can now be included in the diagnosis of SSD and be considered for appropriate treatment.
The DSM-IV diagnosis of somatisation disorder requiring a specific number of complaints from four symptom groups is no longer a requirement in the DSM-5 diagnosis of SSD. Recent literature has used the terms somatisation disorder, somatic symptom disorder, functional somatic syndromes and somatisation syndromes more or less interchangeably. Much of the evidence base relating to somatisation disorder is, however, also relevant to SSD and has been quoted where appropriate.
SSD can be associated with a great deal of stigma; there is a risk that patients may be dismissed by their physicians as having problems that are 'all in their head'.
However, as researchers study the connections between the brain, the digestive system and the immune system, SSD is becoming better understood. It should not be seen as a 'malingering' condition that the patient can control.
- Recent research has shown higher percentages of this disorder in people with irritable bowel syndrome and in chronic pain patients[2, 3].
- A high proportion of patients with post-traumatic stress disorder also have somatisation.
- Antisocial personality disorder is associated with a risk for SSD.
- The somatising patient seems to seek the sick role, which affords relief from stressful or impossible interpersonal expectations ('primary gain'):
- In most societies this provides attention, caring and sometimes even monetary reward ('secondary gain').
- This is not malingering, because the patient is not aware of the process through which the symptoms arise, cannot will them away and genuinely experiences the symptoms.
- Several studies have suggested an association between somatisation and a history of sexual or physical abuse in a significant proportion of patients.
- One study reported that patients with somatisation syndromes were often associated with the interpersonal representation of the unmet need for closeness with others.
- Another study suggested that neuroendocrine genes may be implicated.
- Information concerning the epidemiology of SSD as strictly defined by DSM-5 is hard to come by, as the umbrella term encompasses several different disorders. Such information as does exist in the literature chiefly relates to the individual disorders identified in DSM-IV.
- Epidemiological studies generally quote a prevalence of 0.1-0.2% for the general population and one general practice study reported a prevalence rate of somatoform disorders of 16.1% increasing to 21.9% when disorders with mild impairment were included.
- The disorder usually begins before the age of 30 years and occurs more often in women than in men[11, 12].
DSM-5 has reformulated the criteria to rely less on strict patterns of somatic symptoms and more on the degree to which a patient's thoughts, feelings and behaviours about their symptoms are disproportionate or excessive. The symptoms are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication. A lifelong history of 'sickliness' is often present:
- DSM-5 acknowledges that patients may have a combination of symptoms for which an organic cause can be found and symptoms for which there is no underlying physical explanation.
- Stress often worsens the symptoms.
Some of the numerous symptoms that can occur with somatisation disorder include:
- Shortness of breath.
- Chest pain.
- Abdominal pain.
- Difficulty with swallowing.
- Pain in the legs or the arms.
- Back pain.
- Joint pain.
- Vision changes.
- Paralysis or muscle weakness.
- Pain during urination.
- Low libido.
- Dysmenorrhoea, irregular menstruation and menorrhagia.
Making a diagnosis
- A thorough physical examination and diagnostic tests are performed to rule out physical causes - which tests are done are determined by the symptoms present.
- A psychological evaluation should also be performed to rule out related disorders:
- However, finding evidence of a psychiatric condition does not rule somatisation in or out.
- It can be a clue to the diagnosis.
- There is considerable evidence that patients with common psychiatric conditions, such as depression and anxiety disorders, may present with nonspecific symptoms (including fatigue, aches and pains, palpitations, dizziness and nausea) to primary care physicians.
Somatisation is often a diagnosis of exclusion; however, it is much more effective to pursue a positive diagnosis of somatisation when the patient presents with typical features:
- There may be multiple symptoms, often occurring in different organ systems.
- Symptoms that are vague or that exceed objective findings.
- Chronic course.
- Presence of a psychiatric disorder.
- History of extensive diagnostic testing.
- Rejection of previous physicians.
The general practitioner's emotional response to a patient can serve as an early cue to pursue a somatisation diagnosis:
- A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person.
- A sense of being overwhelmed by a patient who has had numerous evaluations by other physicians.
These can be a signal to the clinician to consider somatisation in the differential diagnosis early in the patient's evaluation.
Doctors' explanations of their symptoms are often at odds with these patients' own thinking and clinicians should take time to ensure their explanations are 'tangible, exculpating and involving'. Empowering explanations have been shown to improve these patients' well-being.
The first occasion that the diagnosis is discussed (after the initial investigations have failed to show any organic pathology) is a key moment in the physician-patient relationship. The challenge is to describe the condition to the patient in a manner that avoids any implication of a psychosomatic illness. One journal suggests the following:
'The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, you do have a serious and impairing medical condition, which I see often but which is not completely understood. Although no treatment is available that can cure it completely, there are a number of interventions that can help you deal with the symptoms better than you have so far'.
Once other causes have been ruled out and a diagnosis of SSD secured, the goal of treatment is to help the person learn to control the symptoms:
- There is often an underlying mood disorder which can respond to antidepressants.
- Unfortunately, those with this disorder rarely admit that it can be caused, at least in part, by mental health problems and may refuse psychiatric treatment.
It is important to ask open-ended questions. The BATHE technique provides a framework for exploration of psychosocial stressors in less than five minutes:
- Background: 'What is going on in your life?'
- Affect: 'How do you feel about it?'
- Trouble: 'What troubles you the most about that situation?'
- Handle: 'What helps you handle that?'
- Empathy: 'This is a tough situation to be in. Your reaction makes sense to me.'
It is sensible to avoid setting unrealistic goals:
- In severe cases of SSD, symptoms are unlikely to resolve completely. Therefore, avoid making the goal of the treatment plan to relieve the patient's illness. The physician and patient will soon become frustrated and tempted to engage in a new flurry of diagnostic tests and invasive procedures.
- Attempts to 'take away the symptom' may cause the patient to substitute another symptom as a result of the need-to-be-sick phenomenon.
A better goal is to help the patient succeed in coping with the symptoms. Treatment is successful if it keeps the patient out of the hospital.
- The whole primary care health team should be aware of the diagnosis and management plan. This will make the approach to management consistent across the practice.
- Interventions directed at reducing specific sources of stress are most helpful; these may include advice about dealing with marital conflict.
- Some physical exercise is important, as it prevents loss of fitness, enhances self-esteem and provides an opportunity for patients to take a break from oppressive duties or unpleasant situations. One study reported a reduction in symptoms with low-grade short bouts of exercise.
- The importance of pleasurable private time should be emphasised. This may include yoga classes or meditation, bowling or nature walks, which, under the general title of 'stress management', can be presented as necessary medical treatments.
Some patients may request tests repeatedly but they should be reminded that they will be followed with frequent and regular visits so that any problems will be identified early. Sometimes requesting investigations becomes a 'negotiating' process designed to give the patient some control over what test is performed and to enhance the trust level between the physician and patient.
Approaches derived from cognitive behavioural therapy have been shown to reduce the intensity and frequency of somatic complaints and to improve functioning in many somatising patients:
- This type of treatment starts with the mutual agreement that whatever the patient has been thinking and doing about the condition has not been successful.
- It then begins to challenge the patient's beliefs and maladaptive behaviours in a caring manner.
- Short course intervention therapy (8-16 sessions) specifically for treatment of somatising patients has been shown to be remarkably effective in improving function and reducing distress.
- The sessions combine general advice such as stress management, problem solving and training in social skills, with specific interventions targeted at the amplification and need-to-be-sick features of somatisation.
Mindfulness therapy is a feasible and acceptable treatment.
There are psychiatric disorders associated with somatisation, specifically anxiety and depression. These respond well to treatment but, especially with antidepressants, it is important to start with low doses and to increase them progressively to avoid side-effects that may be present at the beginning of treatment and which might discourage the patient from continuing. One study reported the successful use of duloxetine.
- Complications may result from invasive testing and from multiple evaluations that are performed while looking for the cause of the symptoms.
- A dependency on pain relievers or sedatives may develop.
- A poor relationship with the healthcare provider seems to worsen the condition, as does evaluation by many providers.
Further reading and references
Zimmermann T, Puschmann E, Ebersbach M, et al; Effectiveness of a primary care based complex intervention to promote self-management in patients presenting psychiatric symptoms: study protocol of a cluster-randomized controlled trial. BMC Psychiatry. 2014 Jan 314(1):2.
de Greck M, Bolter AF, Lehmann L, et al; Changes in brain activity of somatoform disorder patients during emotional empathy after multimodal psychodynamic psychotherapy. Front Hum Neurosci. 20137:410. doi: 10.3389/fnhum.2013.00410. eCollection 2013.
Al Busaidi ZQ; The Concept of Somatisation: A Cross-cultural perspective. Sultan Qaboos Univ Med J. 2010 Aug10(2):180-6. Epub 2010 Jul 19.
MacLean EW, Palsson OS, Turner MJ, et al; Development and validation of new disease-specific measures of somatization and comorbidity in IBS. J Psychosom Res. 2012 Nov73(5):351-5. doi: 10.1016/j.jpsychores.2012.08.007. Epub 2012 Aug 31.
Pawl R; "When the pain won't wane it's mainly in the brain". Surg Neurol Int. 2013 Jun 134(Suppl 5):S330-3. doi: 10.4103/2152-7806.113442. Print 2013.
Andersen TE, Elklit A, Brink O; PTSD Symptoms Mediate the Effect of Attachment on Pain and Somatisation after Whiplash Injury. Clin Pract Epidemiol Ment Health. 2013 May 179:75-83. doi: 10.2174/1745017901309010075. Print 2013.
Sansone RA, Tahir NA, Buckner VR, et al; The relationship between borderline personality symptomatology and somatic preoccupation among internal medicine outpatients. Prim Care Companion J Clin Psychiatry. 200810(4):286-90.
Moran JR, Gross AF, Stern TA; Staying against advice: refusal to leave the hospital. Prim Care Companion J Clin Psychiatry. 201012(6). pii: PCC.10f01046. doi: 10.4088/PCC.10f01046whi.
Spitzer C, Barnow S, Gau K, et al; Childhood maltreatment in patients with somatization disorder. Aust N Z J Psychiatry. 2008 Apr42(4):335-41. doi: 10.1080/00048670701881538.
Landa A, Bossis AP, Boylan LS, et al; Beyond the unexplainable pain: relational world of patients with somatization syndromes. J Nerv Ment Dis. 2012 May200(5):413-22. doi: 10.1097/NMD.0b013e3182532326.
Holliday KL, Macfarlane GJ, Nicholl BI, et al; Genetic variation in neuroendocrine genes associates with somatic symptoms in the general population: results from the EPIFUND study. J Psychosom Res. 2010 May68(5):469-74. doi: 10.1016/j.jpsychores.2010.01.024.
de Waal MW, Arnold IA, Eekhof JA, et al; Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry. 2004 Jun184:470-6.
Kallivayalil RA, Punnoose VP; Understanding and managing somatoform disorders: Making sense of non-sense. Indian J Psychiatry. 2010 Jan52(Suppl 1):S240-5. doi: 10.4103/0019-5545.69239.
Shidhaye R, Mendenhall E, Sumathipala K, et al; Association of somatoform disorders with anxiety and depression in women in low and middle income countries: a systematic review. Int Rev Psychiatry. 2013 Feb25(1):65-76. doi: 10.3109/09540261.2012.748651.
Somatic Symptom Disorder; American Psychiatric Association, 2013
Servan-Schreiber D, Tabas G, Kolb R; Somatizing patients: part II. Practical management. Am Fam Physician. 2000 Mar 161(5):1423-8, 1431-2.
Leiblum SR, Schnall E, Seehuus M, et al; To BATHE or not to BATHE: patient satisfaction with visits to their family physician. Fam Med. 2008 Jun40(6):407-11.
Schaefert R, Hausteiner-Wiehle C, Hauser W, et al; Non-specific, functional, and somatoform bodily complaints. Dtsch Arztebl Int. 2012 Nov109(47):803-13. doi: 10.3238/arztebl.2012.0803. Epub 2012 Nov 23.
Jackson JL, George S, Hinchey S; Medically unexplained physical symptoms. J Gen Intern Med. 2009 Apr24(4):540-2. doi: 10.1007/s11606-009-0932-x.
Edwards TM, Stern A, Clarke DD, et al; The treatment of patients with medically unexplained symptoms in primary care: a review of the literature. Ment Health Fam Med. 2010 Dec7(4):209-21.
Fjorback LO, Arendt M, Ornbol E, et al; Mindfulness therapy for somatization disorder and functional somatic syndromes: randomized trial with one-year follow-up. J Psychosom Res. 2013 Jan74(1):31-40. doi: 10.1016/j.jpsychores.2012.09.006. Epub 2012 Oct 1.
Somashekar B, Jainer A, Wuntakal B; Psychopharmacotherapy of somatic symptoms disorders. Int Rev Psychiatry. 2013 Feb25(1):107-15. doi: 10.3109/09540261.2012.729758.
Garcia Martin I, Miranda Vicario EM, Soutullo CA; Duloxetine in the treatment of adolescents with somatoform disorders: a report of two cases. Actas Esp Psiquiatr. 2012 May-Jun40(3):165-8. Epub 2012 May 1.
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