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Somatization

Somatization refers to a group of disorders in which psychological distress is represented in the form of physical or somatic symptoms. Diagnosis of somatization is now replaced by somatic symptom disorder as per the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, Text Revision (DSM-V).


Presentation

Somatic symptom disorder is characterized by symptoms that considerably affect daily activities and the patient may have significant thoughts about the symptoms. The symptoms are often exaggerated in seriousness and are accompanied by high levels of anxiety. None of the symptoms are accompanied by a diagnosis of any medical illness. In general, patients with this disorder appear normal but are preoccupied by the somatic complaints. Most of their thoughts are limited to the issues surrounding the physical symptoms. Patients are often mildly depressed but do not have any hallucinations or delusions. Memory and concentration remains within normal range.

Some of the common symptoms include

Pain or difficulty while swallowing, difficulty to speak, and urine retention are also noted in some.

Regurgitation
  • Rome III definitions were used to identify people with FGIDs, and GER was defined by weekly or more frequent heartburn or acid regurgitation. The prevalence of people meeting multiple symptom complexes was estimated.[ncbi.nlm.nih.gov]
Angioedema
  • […] dysesthesias associated with pain, numbness and pruritus; traumatic memories in post-traumatic stress disorder (PTSD) which are experienced on a sensory level as 'body memories' and may present as local or generalized pruritic states, urticaria and angioedema[ncbi.nlm.nih.gov]
Dysesthesia
  • These include the unexplained cutaneous sensory syndromes especially the cutaneous dysesthesias associated with pain, numbness and pruritus; traumatic memories in post-traumatic stress disorder (PTSD) which are experienced on a sensory level as 'body[ncbi.nlm.nih.gov]
Dysmenorrhea
  • […] pain, vomiting, nausea, bloating and diarrhea Musculoskeletal symptoms such as back pain, joint pain, and pain in legs and arms Neurological symptoms including headaches, dizziness, amnesia, and muscle weakness Urogenital symptoms like dyspareunia, dysmenorrhea[symptoma.com]

Workup

Complete medical history and thorough physical examination are core to the evaluation of somatic symptoms disorder. Further tests are used to exclude medical reasons for the symptoms. Specific laboratory studies help to rule out the chances of medical conditions. Some of the common laboratory studies recommended for somatization are thyroid function studies, urine test, blood test, and pheochromocytoma screening. A positive Minnesota Multiphasic Personality Inventory (MMPI) test indicates chance of somatic symptom disorder while a negative test needs further tests to diagnose the underlying medical cause. Imaging studies are not very useful in the diagnosis of these disorders. Individuals presenting with unexplained visual loss may be suggested MRI to check for the medical reason [8]. During the procedures, the physician should also look out for psychological distress, if any. The diagnostic criteria for the disorders include a history of physical complaints which has lasted for several years and affect the daily life considerably.

Treatment

Somatic symptoms disorder is a chronic condition. Once a physical cause is ruled out, unnecessary medical intervention for treatment is limited. As the physician’s explanation is contradictory to the beliefs of the patient, the doctor should take care to make the explanations more empowering for the patient [9]. The next step is to help the patient learn ways of controlling the symptoms. BATHE technique is used to assess the psychosocial stress factors [10]. Methods to reduce sources of stress is helpful in relieving symptoms. Physical exercise are recommended to improve fitness and self-esteem of the patient [11].

Cognitive behavioral therapy helps to change negative thoughts and feelings that are often sources of somatic symptoms [12]. This therapy helps to identify the negative, dysfunctional thoughts and deal with it successfully, and also to develop a rational explanation for it. Behavioral part of the therapy aims to improve activity gradually. Relaxation training, good sleep habits, and training in communication skills are also recommended.

Psychiatric disorders associated with somatization like anxiety disorder or depression may be treated pharmacologically. Antidepressants are used to improve symptoms of depression. Combination of serotonin reuptake inhibitors and the antidepressant paliperidone is found to be effective in many somatic symptom disorders [13].

Prognosis

The disorders may be mild in some, while it manifests with severe symptoms in others. Somatic symptom disorder often remains a chronic condition in many patients. The specific symptoms of the condition may appear or disappear at intervals. Severity of the symptoms may also vary with time. Early treatment is a good prognostic factor in this disorder.

Etiology

Somatization may have multiple etiological factors, and more than one may be involved in somatic manifestation. Stress or anxiety is known to cause autonomic arousal leading to somatization. This is seen in increased esophageal motility caused by stress, expressed as chest pain. Psychological distress including illness, breakup in a relationship, or a bereavement, may all express as physical symptoms. Some sociocultural factors are also known to influence the expression of somatic symptoms and hence the symptoms are more prevalent in some cultural groups like Hispanics and Asians. Further, if mental illness is a stigma in a society, physical symptoms is an acceptable way to express the mental distress. In some rare cases, a genetic component is found to be associated with somatization. Childhood trauma like sexual or physical abuse may be precipitated in the form of somatic symptoms. Some learned behavior during childhood may also play a role in the development of somatization in adulthood. For example, a child exposed to chronic illness of one of the parents or dear ones may express their distress as somatic symptoms when they reach adulthood. Somatization can be a conscious expression for personal gain too [3].

Epidemiology

Somatic symptom disorder is very common among general population and more than 50% of the outpatients have medically unexplained physical symptoms [4]. In primary care, about 20-30% of the patients present with somatization [5]. This disorder is rare among males in US [6]. But, prevalence is higher among males from some cultural and ethnic backgrounds. Prevalence of somatization ranges from 0.2 to 2% among women, while less than 0.2% of men are reported to have somatic symptoms. This variation may be because of the difference in reporting for medical help. The female-to-male ratio is around 2:1 for conversion disorder and pain disorder.

Symptoms may differ among the different cultures. A study conducted in a representative sample of general population in Florence reports a higher prevalence rate for undifferentiated somatoform disorder (13.8%) [7]. Approximately 0.7% has dysmorphic disorder, 0.3% has conversion disorder, and 4.5% has hypochondriasis. This disorder may have onset during childhood, adolescence or adulthood. Adult onset may be related to an underlying medical illness or a major depression. This group of disorders is more prevalent among less educated and socioeconomically underprivileged group.

Sex distribution
Age distribution

Pathophysiology

Pathophysiology of somatic symptoms disorder is not clearly defined yet. Many patients find it difficult to express their psychological distress in words and take help of physical symptoms to communicate the same. For certain others it is a way to escape from psychological stress. Some patients have an increased awareness of physical sensations and they react with intense fear to minor changes in the internal environment including breathing or heartbeat. Some others have negative beliefs that minor physical symptoms are indicative of serious medical disorder and look for medical help. When they are not able to diagnose the underlying cause, they focus more intensely on the symptoms leading to increased distress, and thus disability.

Prevention

Increased awareness about the disorder is helpful in early identification and initiation of treatment. Early treatment helps in controlling the symptoms and thus reduce disability. Counselling may be helpful in learning other ways of dealing with stress, particularly in people who are susceptible to somatic syndrome disorder.

Summary

Somatization refers to a group of disorders in which psychological distress is denied and experienced and communicated in the form of physical symptoms. Diagnosis of somatization is now replaced by somatic symptom disorder as per the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition, Text Revision (DSM-V) [1]. It includes conversion disorder, factitious disorder and other disorders with nonspecific symptoms related to psychological conditions. In these disorders, thoughts and feelings of an individual are related to the physical symptoms expressed. The physical symptoms experienced remain medically unexplained or would be in excess of the medical condition, if present. In this condition, a physician needs to examine the involvement of psychological distress in causing the somatic symptoms.

Anxiety disorder and mood disorders result in physical symptoms which can be relieved by treating the underlying psychological disorder. It is a prevalent condition in primary care setting, and many more cases may remain unrecognized [2]. Treatment of somatic symptom disorder is quiet challenging as the symptoms may persist even after treatment or management.

Patient Information

Somatization or somatic symptom disorder is a chronic condition characterized by one or more physical symptoms that are not supported by any underlying medical condition. The physical complaints are often very serious and affects the routine activity of the person. Many of the symptoms resemble that of genuine diseases while some others do not. In certain cases somatization may be risky as the affected person may take different medications to control the symptoms which lack a medical explanation.

Somatization is presumed to be a way to escape from psychological distress in many individuals. Further, in many societies mental disorders are a stigma and the person may resort to physical symptoms to avoid it. Somatic symptom disorder may also arise from an increased awareness of the physical sensations. These people may react very intensively to minor changes in heartbeat or breathing. Negative beliefs about physical sensations may also result in somatizations. They often consider physical symptoms to be indicators of serious diseases. Physical symptoms of somatization may last for several years. Chronic pain and problems with digestive, nervous and reproductive system, are the most common symptoms of somatic symptom disorder. Symptoms often interfere with work and daily life.

A thorough physical examination, complete medical history and diagnostic tests are conducted to identify the causes of the symptom. When no underlying medical conditions are identified, a psychological evaluation is suggested.

The treatment method focuses on controlling the symptoms of the condition. There is no complete cure for somatization. Physician may have to provide empowering explanations for the presence of symptoms. Interventions try to reduce sources of stress and how to deal with it. Physical exercises help to keep the person fit and to improve self-esteem. Practicing stress management techniques is useful in controlling symptoms. One of the most successful intervention in the treatment of somatization is cognitive behavioral therapy. It focuses on stress management, problem solving techniques, training in social and communication skills. It helps to challenge the negative thoughts and beliefs and convert them into more acceptable, adaptive behaviors. Medications are used only when the symptoms are caused by psychiatric disorders like anxiety disorder or depression. Low doses of medications are given initially which is gradually increased to improve the symptoms. One of the complication associated with this disorder is the dependency on pain killers and sedatives. Increased awareness about the disorder and counselling will help in preventing complications.

References

Article

  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
  2. Fink P, Sørensen L, Engberg M, Holm M, Munk-Jørgensen P. Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition. Psychosomatics. 1999;40(4):330-338.
  3. Folks DB, Feldman MD, Ford CV. Somatoform disorders, factitious disorders, and malingering. In: Stoudemire A, Fogel B, Greenberg DB. (Eds). Psychiatric Care of the Medical Patient, 2nd ed, Oxford, NY. 2000:459.
  4. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med. 1989; 86:262.
  5. Toft T, Fink P, Oernboel E, Christensen K, Frostholm L, Olesen F. Mental disorders in primary care: prevalence and co-morbidity among disorders. results from the functional illness in primary care (FIP) study. Psychol Med. 2005;35(8):1175-1184.
  6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th Edition. Washington, DC: American Psychiatric Association; 2000:Text Revision.
  7. Faravelli C1, Salvatori S, Galassi F, Aiazzi L, Drei C, Cabras P. Epidemiology of somatoform disorders: a community survey in Florence. Soc Psychiatry Psychiatr Epidemiol. 1997;32(1):24-29.
  8. Werring DJ, Weston L, Bullmore ET. Functional magnetic resonance imaging of the cerebral response to visual stimulation in medically unexplained visual loss. Psychol Med. May 2004;34(4):583-589.
  9. Kallivayalil RA, Punnoose VP; Understanding and managing somatoform disorders: Making sense of non-sense. Indian J Psychiatry. 2010;52(Suppl 1):S240-5.
  10. 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 ;40(6):407-11.
  11. Servan-Schreiber D, Tabas G, Kolb R; Somatizing patients: part II. Practical management. Am Fam Physician. 2000;61(5):1423-1428.
  12. Bleichhardt G, Timmer B, Rief W. Cognitive-behavioural therapy for patients with multiple somatoform symptoms--a randomised controlled trial in tertiary care. J Psychosom Res. Apr 2004;56(4):449-454.
  13. Huang M, Luo B, Hu J, Wei N, Chen L, Wang S, et al. Combination of citalopram plus paliperidone is better than citalopram alone in the treatment of somatoform disorder: results of a 6-week randomized study. Int Clin Psychopharmacol. 2012;27(3):151-8.

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Last updated: 2019-07-11 22:17