Patients who somatize psychosocial distress commonly present in medical clinical settings. Approximately 25% of patients in primary care demonstrate some degree of somatization, and at least 10% of medical or surgical patients have no evidence of a disease process. Somatizing patients use a disproportionately large amount of medical services and frustrate their physicians, who often do not recognize the true nature of these patients’ underlying problems. Somatizing patients rarely seek help from psychiatrists at their own initiative, and they may resent any implication that their physical distress is related to psychological problems. Despite the psychogenic etiology of their illnesses, these patients continue to seek medical care in nonpsychiatric settings where their somatization is often unrecognized.
Somatization is not an either-or proposition. Rather, many patients have some evidence of biological disease but overrespond to their symptoms or believe themselves to be more disabled than objective evidence would indicate. Medical or surgical patients who have concurrent anxiety or depressive disorders use medical services at a rate two to three times greater than that of persons with the same diseases who do not have a comorbid psychiatric disorder.
Despite the illusion that somatoform disorders are specific entities, as is implied by the use of specific diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the symptoms most of these patients experience fail to meet the diagnostic criteria of the formal somatoform disorders. Further, over time, patients’ symptoms tend to be fluid, and patients may be best described as having one disorder at one time and another disorder at some other time. Somatization is caused or facilitated by numerous interrelated factors (Table 22–1), and for an individual patient a particular symptom may have multiple etiologies. In other words, these disorders are heterogeneous both in clinical presentation and in etiology.
Table 22–1. Causes of Somatization
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Table 22–1. Causes of Somatization
Illness allows a socially isolated person access to an auxiliary social support system.
The sick role can be used as a rationalization of failures in occupation, social, or sexual roles.
Illness can be a means of obtaining nurturance.
Illness can be used as a source of power to manipulate other people or social situations.
Somatic symptoms may be used as a communication or as a cry for help.
The somatic symptoms of certain psychological disorders (e. g., major depression and panic disorder) may be incorrectly attributed to physical disease.
Because physical illness is less stigmatizing than psychiatric illness, many patients prefer to attribute psychological symptoms to physical causes.
Some individuals may be hypersensitive to somatic symptoms and amplify them. Such hypersensitivity is often related to concurrent emotions such as depression and anxiety.
Somatic symptoms can represent behavior learned in childhood, in that some parenting styles may emphasize attention to illness.
The sick role can provide incentives such as disability payments, the avoidance of social responsibilities, and solutions to intrapsychic conflicts.
Trauma, particularly childhood physical or sexual abuse, appears to predispose individuals to the use of somatic symptoms as a communication of psychosocial distress.
Physicians can inadvertently reinforce the concept of physical disease by symptomatic treatment or through so-called fashionable diagnoses, such as multiple chemical sensitivities or reactive hypoglycemia.
Somatoform disorders are generally multidetermined, and because they represent final common symptomatic pathways of many etiologic factors, each patient must be evaluated carefully so that an individualized treatment plan can be developed.
Barsky AJ, Ettner SL, Horsky J, et al.: Resource utilization of patients with hypochondriacal health anxiety and somatization. Med Care
Ford C: Somatization and fashionable diagnoses: Illness as a way of life. Scand J Work Environ Health 1997;3(23 suppl):7–16.
DSM-IV-TR Diagnostic Criteria
One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.
Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.
The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).
The symptoms or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience.
The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.
The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.
Specify type of symptom or deficit:
- With motor symptom or deficit. This subtype includes such symptoms as (impaired coordination or balance, paralysis, or localized weakness, difficulty swallowing or “lump in throat,” aphonia, and urinary retention).
- With sensory symptom or deficit. This subtype includes such symptoms as (loss of touch or pain sensation, double vision, blindness, deafness, and hallucinations).
- With seizures or convulsions. This subtype includes such symptoms as seizures or convulsions with voluntary motor or sensory components.
- With mixed presentation. This subtype is used if symptoms of more than one category are evident.
(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text Revision. Washington DC: American Psychiatric Association, 2000.)
Conversion disorder previously known as hysteria or hysterical conversion reaction is an ancient medical diagnosis: described in both the Egyptian and Greek medical literature. Although often thought to have disappeared with the Victorian age, these disorders continue to the present but often with more subtlety and sophisticated mimicry than characterized by the dramatic symptoms of the past.