Somatoform disorders involve unexplained physical symptoms that bring significant distress and functional impairment. They present one of the more common and most difficult problems in primary care. They are seldom "cured" and should be approached as a chronic disease. Recognition, a patient-centered approach, and specific treatments may help alleviate symptoms and distress. Factitious disorder and malingering, although not true somatoform disorders, are addressed separately in this chapter because of their similarity in the form of medically unexplained symptoms.
Features that characterize the spectrum of somatoform disorders include the following:
- Physical symptoms or irrational anxiety about illness or appearance, for which biomedical findings are not consistent with a general medical condition. Somatoform disorders have specific courses, symptoms, and complaints (Table 55-1).
- Symptoms develop with or are worsened by psychological stress, and are not intentional.
- Extensive utilization of medical care. Paradoxically, treatment and attempts to reassure patients can be counterproductive.
- Feelings of frustration on the part of the physician. Patients are often seen as "difficult patients."
Table 55-1. Somatoform Disorders, Factitious Disorder, and Malingering. |Favorite Table|Download (.pdf)
Table 55-1. Somatoform Disorders, Factitious Disorder, and Malingering.
|Symptoms Volitional?||Symptom Presentation||Type of Symptoms||Symptom Duration||Treatment Modalities|
|Somatization disorder||no||Sees self as sickly; frequent medical care Begins before age 30|
Multiple systems or functions:
Four sites/functions producing pain
Two GI symptoms other than pain
One sexual symptom other than pain
One pseudoneurologic symptom
|Chronic, recurring, and/or stable||Frequent visits, therapeutic relationship with provider, active listening, avoidance of excessive or invasive treatments, focus on management vs cure, consider CAM modalities|
|Undifferentiated somatoform disorder||no||Same as somatization disorder except symp- tom number insuffi- cient to meet criteria||Some of above symptoms and/or vague somato- form complaints such as fatigue for at least 6 mo||>6 mo||Same as above|
|Conversion disorder||no||Onset after acute stress||Pseudoneurologic symptom or symptom complex such as stroke-like weakness, sensory loss, or pseudoseizure||Sudden onset; short duration|
Reassurance that symptom will resolve over days
Avoid labeling as mental illness
|Pain disorder||no||Preoccupation with pain; examination out-of- proportion with disease or injury||Pain insufficiently explained by any organic cause; frequently associated with disability, relationship disruptions, depression, anxiety||Sudden onset; worsens with time||Focus on functionality, symptom management, and non-narcotic therapy|
|Hypochondriasis||no||Fearful of disease; preoccupied with symptoms; not reassured||Multiple symptoms over time; misinterpretation of normal sensations, may have unusual health and prevention behaviors||Long history, worsens after actual illness||SSRI may be beneficial, otherwise similar to somatization|
|Body dysmorphic disorder||no||Excessive concern about imagined defect in appearance||Specific complaints of defect (other than obesity); behaviors to hide or avoid public exposure of "defect"||Usually several years||SSRI may be beneficial, otherwise similar to somatization|
|Factitious disorder with physical symptoms||Yes—motivation primary gain: sick role, attention||Unexplained fever, bleeding, injuries||Nonhealing and unremit- ting; tend to receive multiple procedure/ operations over time; falsify ...|
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