Somatic Symptom Disorders

Essentials of Diagnosis

• Prominent physical symptoms may involve one or more organ systems and are associated with distress and/or impairment

• Sometimes able to correlate symptom development with psychosocial stresses

• Combination of biogenetic and developmental patterns

General Considerations

• This diagnostic grouping includes conversion disorder, hypochondriasis, and somatic symptom disorder

• Vulnerability in an organ system and exposure to family members with somatization problems are thought to interact in the development of symptoms

Demographics

• Conversion disorder is more common in lower socioeconomic classes and certain cultures

• Somatic symptom disorder usually occurs before age 30 and is ten times more common in women

Symptoms and Signs

• A precipitating emotional event often precedes somatic symptoms

• Conversion disorder

  • Psychic conflict is converted into physical neurologic symptoms

  • The somatic symptom is often paralysis

  • The dysfunction may have symbolic meaning (eg, arm paralysis in marked anger so the individual cannot use the arm to strike someone)

• Somatic symptom disorder

  • Multiple physical complaints are referable to several organ systems

  • Anxiety, panic disorder, and depression are often present

  • Preoccupation with medical and surgical issues often precludes other life activities

  • Patients have often undergone multiple surgeries and have evidence of long-standing symptoms

  • Multiple symptoms that frequently change and have eluded diagnosis by three or more physicians support this diagnosis

Differential Diagnosis

• Depression must be considered in any patient with a condition judged to be somatoform

• Factitious disorders, which differ from this grouping in that symptom production is intentional

• Intoxication states

Diagnostic Procedures

• In conversion disorder with pseudoseizures, video-electroencephalography may be necessary to rule out epilepsy

• Since all somatic disorders are diagnoses of exclusion, a workup sufficient to rule out physical illness is required

Medications

• Medications should not be prescribed in place of frequent appointments

Therapeutic Procedures

• Behavioral therapy

  • Biofeedback can be helpful in training patients to recognize symptoms and learn countermaneuvers that provide relief

• Psychotherapy

  • Psychological intervention by the primary clinician should focus on pragmatic changes

  • Analytic approaches focused on exploration of early experiences often fail, since patients do not relate these to their current distress

  • Cognitive-behavioral therapy has been shown to be an effective treatment for somatoform disorders by reducing physical symptoms, psychological distress and disability

  • Group therapy sometimes allows ventilation, improves coping, and focuses on interpersonal adjustment

  • Conversion disorder is sometimes helped by hypnosis or amobarbital interviews

• Social therapeutic procedures

  • Family members should attend appointments to learn how best to live with the patient

  • Peer support groups can encourage patients to accept and live with their problem

  • Communication with employers may be necessary to encourage long-term interest in the employee/patient

Follow-Up

• Regular appointments are helpful. These should be brief and not contingent on symptoms

• Care should be consolidated under a primary clinician, with consultants for evaluation only

• Ongoing reevaluation is important

• Somatic symptom disorders may coexist with physical illness, which can be overlooked

Prognosis

• Intervention is most successful when instituted before chronicity develops