In patients with somatoform disorders, emotional distress or difficult life situations are experienced as physical symptoms. Patients who somatize present with persistent physical complaints for which a physiologic explanation cannot be found. Failure to recognize this condition and manage it appropriately may lead to frustrating, costly and potentially dangerous interventions that generally fail to identify occult disease and do not reduce suffering.
Somatization is common.1,2 In one study, no organic cause was found in more than 80 percent of primary care visits scheduled for evaluation of common symptoms such as dizziness, chest pain or fatigue.3 In addition, somatizing patients use inordinate amounts of health care resources. One study4 estimated that patients with somatization disorder (the most severe form of the condition) generated medical costs nine times greater than those of the average medical patient. Despite substantial amounts of medical attention, somatizing patients report high levels of disability and suffering.5 Finally, physicians report that somatizing patients are frustrating to treat.6 Physicians lack a sense of effectiveness when multiple complaints do not fit into usual diagnostic categories or patients do not fit into a typical office schedule.
Traditional medical training is focused on the identification and treatment of organic disorders and leaves most physicians ill prepared for recognizing and managing patients who somatize. This first part of a two-part article provides an approach to diagnosing and understanding the process of somatization that may lead to more effective and satisfying relationships with these often-difficult patients.
Diagnosis of Somatization
Somatization is too often a diagnosis of exclusion. This is a costly and frustrating approach in patients with multiple and chronic complaints. It is much more effective to pursue a positive diagnosis of somatization when the patient presents with typical features. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)7 defines several different somatoform disorders. However, somatization is not a specific disease but rather a process with a spectrum of expression.8–10 Once the process of somatization is identified, management of the different somatoform disorders is based on similar principles.
The low end of the somatization spectrum includes stress-related exaggeration of common symptoms, such as headache, lightheadedness or low back pain in the context of, for example, a divorce, new family member or new job. At the high end, it includes unrelenting problems that can leave patients completely disabled and withdrawn from most aspects of personal and occupational functioning. The primary care physician's emotional response to a patient can serve as an early cue to pursue a somatization 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, or a sense of being overwhelmed by a patient who has had numerous evaluations by other physicians, may be a signal to the clinician to consider somatization in the differential diagnosis early in the patient's evaluation. In addition, identifying the physician's emotional reaction to somatizing patients may help prevent deterioration of the physician-patient relationship.
Because the features of somatoform disorders are so variable, establishing specific diagnostic criteria, such as those listed in DSM-IV, can be difficult and may not be very useful. Clinical experience and existing research on diagnostic criteria for the more severe forms of somatization suggest that only two features are necessary to establish a positive diagnosis of somatization in patients in primary care settings: (1) several (more than three) vague or exaggerated symptoms in, often, different organ systems, and (2) a chronic course (i.e., a history of such symptoms for more than two years).9
Table 1 lists many of the symptoms and syndromes affecting patients with somatoform disorders. Most of these symptoms also occur in patients with organic pathology. As isolated symptoms, they would require a full medical work-up. However, somatizing patients have too many symptoms, in too many organ systems, that last too long. The intensity of the symptoms often strikes the physician as being out of proportion to the healthy appearance of the patient. The syndromes listed in Table 1 may be legitimate in many patients but are typically impossible to verify in somatizing patients.
|Bloating and excessive gas|
|Diffuse pain (i.e.,“I hurt all over.”)|
|Pain in extremities|
|Pain during urination|
|Shortness of breath at rest|
|Loss of voice|
|Double or blurred vision|
|Reproductive organ symptoms|
|Burning sensations in sexual organs|
|Irregular menstrual cycles|
|Excessive menstrual bleeding|
|Vomiting throughout pregnancy|
|Vague “food allergies”|
|Atypical chest pain|
|Temporomandibular joint syndrome|
|Chronic fatigue syndrome|
|Vague “vitamin deficiency”|
|Multiple chemical sensitivity|
Psychiatric and psychosocial disorders have a strong association with somatoform disorders. Finding evidence of a psychiatric condition does not rule somatization in or out; rather, it can be a clue to diagnosis. There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea.9,11–14 In one large family practice sample,15 multiple somatic complaints provided the best indicator of depression.
Second, patients with somatization disorder commonly have coexisting depression (up to 60 percent), anxiety disorders such as panic or obsessive-compulsive disorder (up to 50 percent), personality disorders (up to 60 percent)9,16 or a substance abuse disorder.17 In fact, the risk for a psychiatric disorder in a primary care patient increases linearly with the number of physical complaints.9
Table 2 summarizes the typical diagnostic features of somatization. Perhaps the greatest challenge in making the diagnosis is that the presence of somatization does not exclude the presence of an organic medical condition. Therefore, medical conditions must constantly be considered, even in patients with somatization. Patients with chronic debilitating medical conditions often have features similar to those associated with somatoform disorders. However, when the symptoms appear to be in excess of the medical condition and other features of somatization are present, the physician's approach should be adjusted to address somatization in addition to appropriate work-up and treatment of the medical condition. At this point, a colleague's second opinion may be helpful in confirming the diagnosis of somatization and its relationship to the existing organic pathology.
|Multiple symptoms, often occurring in different organ systems|
|Symptoms that are vague or that exceed objective findings|
|Presence of a psychiatric disorder|
|History of extensive diagnostic testing|
|Rejection of previous physicians|
To optimize care and limit frustration for patients and physicians, the investigation of patients with multiple vague somatic complaints should follow a standard process (Table 3). After performing an initial medical evaluation, reviewing medical records and evaluating the patient for common psychiatric conditions, the presence of the typical features of somatization (Table 2) may be sufficient to allow a firm diagnosis of somatization. Although achieving this diagnosis may require more than a single office visit, over the long run this systematic process will prevent many unnecessary acute office visits, evaluations in the emergency department, telephone calls and frustrating arguments.
|Step 1. Evaluate for organic medical conditions.|
|Step 2. Evaluate for psychiatric conditions associated with somatic complaints (depression, anxiety disorders, substance abuse/dependence).|
|Step 3. Pursue a positive diagnosis of somatization.|
No one fully understands the pathophysiology of somatization. However, four psychologic mechanisms are frequently discussed. Understanding them can help physicians develop empathy with patients and direct care more effectively. The mechanisms tend to be independent, and individual patients may show evidence of a single mechanism or any combination of the four mechanisms.
AMPLIFICATION OF BODY SENSATIONS
Worries about physical disease can focus the patient's attention on common variations in bodily sensations to the degree that they become disturbing and unpleasant. At the least, they provide the patient with “confirmatory evidence” for the suspected presence of pathology. The perception of such altered sensations then seems to exacerbate the patient's concerns, which further increases anxiety and amplifies the sensations. This mechanism is well established in the pathophysiology of panic attacks and has also been documented in the pathophysiology of somatization.22,23
THE IDENTIFIED PATIENT
When a family system is under stress, identifying one person as a patient may provide a focus that stabilizes the family system and alleviates feelings of anxiety within the family. Members know how to interact with each other in the context of the illness. The patterns of behavior may become recurrent, and family rules about how each member should act are formed. The patterns may become dysfunctional when one member takes on the role of being weak and defective. The physician may reinforce this troublesome dynamic by focusing medical attention on the somatizing patient's disability and illness. The family system often has a powerful tendency to resist change, even though changes, such as the improved health or function of the identified patient, may be desired.
THE ‘NEED TO BE SICK’
Viewed from an individual perspective, the somatizing patient seems to seek the sick role, which affords relief from stressful or impossible interpersonal expectations (“primary gain”) and, in most societies, provides attention, caring and sometimes even monetary reward (“secondary gain”). This is not malingering (consciously “faking” the symptoms), because the patient is not aware of the process through which the symptoms arise, cannot will them away and genuinely suffers from the symptoms. The physician should remember this subconscious need when experiencing the urge to try yet another empiric treatment. In the words of Barsky, “There is no pill that can cure, and no surgery that can excise, the need to be sick.”26
Dissociation corresponds to the mind's ability, as displayed in hypnosis, to have complete and detailed sensory experiences in the absence of actual sensory stimulation. For example, in a hypnotic state, a person may report that a hand is “freezing,” “burning” or “anesthetized,” depending on the suggestions made by the therapist. The subjective experiences are “real” to the extent that the person behaves as if the hand were actually in that state (for example, they may allow the “anesthetized” hand to be pierced by a needle without flinching). Neuroimaging studies of dissociative experiences such as dreams and flashbacks (experiencing a past event as if it were recurring in the present) suggest that the same sensory areas of the central nervous system that are activated by external events may also be activated by such internal experiences.27,28
Patients with somatization report having dissociative symptoms much more commonly than patients with other psychiatric conditions.29 Examples of such symptoms include flashbacks, out-of-body experiences (observing one's body from the outside, as if by a third person) and depersonalization (feeling as if one is not oneself). It is therefore likely that some somatized symptoms also result from dissociation (activation of somatic representations of pain or of other physical sensations in the central nervous system in the absence of actual physical stimulation). The phenomenon may be analogous to phantom limb pain: although there is no observable tissue damage in the area of the reported pain, the central nervous system behaves “as if ” tissue damage were present.
Somatization is the experience of physical symptoms in relation to emotional distress. It is common, costly and frustrating to patients as well as to physicians, who are trained to focus on organic etiologies. Our simple and effective approach to making a positive diagnosis of somatization in primary care settings relies on only two essential criteria: (1) several nonspecific symptoms in different organ systems and (2) a chronic course. Mechanisms commonly thought to explain somatization in primary care patients include amplification of normal body sensations, the expression of emotional distress constrained by cultural and familial rules, and dissociation. Understanding these mechanisms facilitates the development of empathy, which is essential to an effective physician-patient relationship.