Somatic symptom diagnoses in a series of university hospital psychiatric consultations.
The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5)[1] category of Somatic Symptom Disorders and Other Related Disorders represents a group of disorders characterized by thoughts, feelings, or behaviors related to somatic symptoms. This category represents psychiatric conditions because the somatic symptoms are excessive for any medical disorder that may be present.
Somatic symptom disorders and other related disorders challenge medical providers. Clinicians need to estimate the relative contribution of psychological factors to somatic symptoms. A somatic symptom disorder may be present when the somatic symptom is a focus of attention, is distressing, or is contributing to impairment.
Anxiety disorders and mood disorders commonly produce physical symptoms. Clinicians need to rule out somatic symptoms due another primary psychiatric condition before considering a somatic symptom disorder diagnosis. Somatic symptoms can dramatically improve with successful treatment of the anxiety or mood disorder.However, it bears mentioning that the presence of general medical conditions with reasonable physical explanation for symptoms does not preclude the possibility of a somatic symptom disorder diagnosis. Rather, a diagnosis of somatic symptom disorder suggests a distortion in the perception or interpretation of somatic symptoms.[1]
The DSM-5 includes 7 specific diagnoses in the Somatic Symptom Disorder and Other Related Disorder category.[1] These diagnoses include (1) somatic symptom disorder, (2) illness anxiety disorder, (3) conversion disorder (functional neurological symptom disorder), (4) psychological factors affecting a medical condition, (5) factitious disorder, (6) other unspecified somatic symptom and related disorders, and (7) unspecified somatic symptom and related disorders. This article focuses on somatic symptom disorder.
DSM-5 produced significant changes in this category of disorders. This category had previously been named Somatoform Disorders in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).[2] Somatic symptom disorder replaces the DSM-IV-TR diagnosis of somatization disorder. Approximately 75% of cases previousy diagnosed as hypochondriasis (those with predominant focus on physical symptoms) qualify for a diagnosis of somatic symptom disorder. The remaining 25% of patients have predominant anxiety concerns in the absence of somatic symptoms, and are more appropriately diagnosed with illness anxiety disorder.[1] . Pain disorder has been removed and is instead a specifier for somatic symptom disorder (with predominant pain). Psychological factors affecting a medical condition and factitious disorder have been added to the new Somatic Symptom and Related Disorders category. Finally, a residual category of other specific and nonspecific somatic symptom disorder has been created with DSM-5.
Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician.
Ms. J's primary care physician has followed her for many years and has made the diagnosis of somatic symptom disorder. The treatment plan includes regular frequent visits to monitor her chronic pain complaints. Use of medication with addictive potential is restricted. Physical symptoms are monitored with limited use of invasive diagnostic procedures. Outpatient visits focus on identifying sources of stress and encouraging healthy coping mechanisms.
The pathophysiology of somatic symptom disorder is unknown. Primary somatic symptom disorders may be associated with a heightened awareness of normal bodily sensations. This heightened awareness may be paired with a cognitive bias to interpret any physical symptom as indicative of medical illness. Autonomic arousal may be high in some patients with somatization. This autonomic arousal may be associated with physiologic effects of endogenous noradrenergic compounds such as tachycardia or gastric hypermotility. Heightened arousal also may induce muscle tension and pain associated with muscular hyperactivity, as is seen with muscle tension headaches.
There has been evidence in the basic science literature correlating certain genetic markers to the development of somatic symptoms, suggesting a possible genetic component to the development of somatic symptom disorder syndromes.[3]
Brain imaging studies support an association between one or more of the somatic symptom disorders, with reduced volume of the brain amygdala[4] and brain connectivity between the amygdala and brain regions controlling executive and motor function.[5]
United States
Prevalence rates for the most restrictive previous diagnosis of somatization disorder appear low in community samples (0.1%). Low community prevalence rates for somatic symptom disorder may be due to a reporting bias.
One review estimates that the prevalence of somatic symptom disorder in the general population is approximately 5%–7%. This suggests that these concerns are among the most common patient concerns in the primary care setting.[6]
An estimated 20%–25% of patients who present with acute somatic symptoms go on to develop a chronic somatic illness. These disorders can begin in childhood, adolescence, or adulthood.[6]
The existing evidence shows that somatoform disorders and medically unexplained symptoms are common in later life. The available data suggest that prevalence rates may decline after the age of 65 years.[7] There is evidence that somatic symptom disorder is highly prevalent in patients suffering from vertigo or dizziness symptoms.[8]
International
A study in Belgium reported that somatization syndrome is the third highest psychiatric disorder, with a prevalence rate of 8.9%. The first and second most common psychiatric disorders were depression and anxiety disorders.[9]
Somatic symptom disorders contribute a significant economic burden to the costs of brain disorders. A European survey estimated the cost of somatic symptom disorders across Europe to be 22 billion Euro/year (approximately $30 billion US dollars per year). This makes the cost of somatic symptom disorders in the range of that for multiple sclerosis, Parkinson disease, or traumatic brain injury.[9]
Somatic symptom disorders do not appear to independently increase the risk of death. Some evidence exists that somatization disorder is associated with increased risk for suicide attempts.[10]
Previous research indicates that suicidality is a substantial problem in primary care patients with somatoform disorders, especially when major depression or anxiety realm disorders are comorbid. However, dysfunctional illness perception has been demonstrated to be related to active suicidal ideation independent of other psychiatric comorbidities.[11]
Patients with somatic symptom disorders may be misdiagnosed as having a medical condition and therefore experience iatrogenic complications due to invasive diagnostic procedures or surgical operations.
Females tend to present with somatic symptom disorder more frequently than males, with an estimated F:M ratio of 10:1.[6] This may be due to a greater willingness to report somatic symptoms in the female population.
Somatic symptom disorders may begin in childhood, adolescence, or early adulthood. New onset of unexplained somatic symptom disorders in older adults should prompt a search for occult medical illness or evidence of major depression associated with somatization. An estimated 20%–25% of patients who present with acute somatic symptoms go on to develop a chronic somatic illness.[6]
History and symptoms vary depending on the specific somatic symptom disorder diagnosis.
The manner in which patients respond to a standardized review of systems differs in those with medically unexplained symptoms and in those with psychiatric disease. The review of systems offers information beyond the actual systems review, and may be useful in the identification of somatization.[12]
Somatic symptom disorder replaces somatization disorder with the following criteria:
Perform a comprehensive physical examination to rule out physical causes for the patient's somatic complaints. A detailed focus on specific systems (eg, neurological) may be necessary based on the specific complaint.
Include a full mental status examination. A patient with somatic symptom disorder typically displays the following on an examination.
No definitive causes for most of the somatic symptom disorders have been established.
Genetic and environmental influences appear to contribute to somatization. Somatic symptom disorders have been linked to internalizing genetic risk factors and share genetic overlap with other mental disorders, including eating disorders.[13] Research suggests a possible genetic component to the development of somatic symptom disorder syndromes.[3]
Somatization may involve abnormalities in tryptophan catabolism, resulting in lower serum tryptophan levels than controls. This finding is limited to the research domain at present and is not a diagnostic test.[14]
Children raised in homes with a high degree of parental somatization may model somatization. Sexual abuse may be associated with an increased risk of somatization later in life. Poor ability to express emotions (alexithymia) may result in somatization. Somatic symptom disorder may be related to a reduced threshold for tactile and pain perception.[15]
Psychodynamic causes for unexplained physical symptoms date back to Freud, who coined the term "conversion disorder". Freud viewed some unexplained neurologic symptoms as a result of conversion of intrapsychic distress into physical symptoms.
Attitudes of caregivers may have a profound affect upon the course of somatic symptom disorder in children. One study demonstrated that adolescent children of parents who accepted the validity of a somatic symptom disorder diagnosis were nearly 20 times more likely to recover compared to those of parents who rejected or only partially accepted a somatic symptom Disorder diagnosis.[16]
Alcohol and drug abuse are common in patients with somatic symptom disorders. Patients may attempt to treat their somatic pain with alcohol or other drugs.
Additionally, alcohol or drug intoxication or withdrawal may induce somatic symptoms of unclear etiology, unless the physician considers the potential role of substances.
Anxiety disorders and mood disorders commonly include physical symptoms as part of the presentation. Ruling out a primary anxiety disorder or mood disorder is key before reviewing the role of somatic symptom disorders.
The PHQ-15, WI-7, and SAIB are useful screening instruments to detect persons at risk for somatic symptom disorder, and a combination of these three instruments slightly improves diagnostic accuracy. Their use in routine care will lead to improved detection rates for somatic symptom disorder.[17] The PHQ-15, WI-7, and SAIB are useful screening instruments for detecting somatic symptom disorder as described in the DSM-5.[17] The SSS-8 is an abbreviated PHQ-15 that has been demonstrated to be a reliable and valid self-report measure for somatic symptom burden.[18]
If indicated, specific studies used to rule out somatization due to general medical conditions include the following:
Imaging studies are not routinely used in diagnosing the somatic symptom disorders. However, functional MRI may be of use in the diagnosis of some conditions such as unexplained visual loss.[19] Imaging studies also may be helpful to rule out unexplained physical symptoms due to a medical disorder.
Somatic symptom disorders may present to the emergency room for assessment and treatment during periods of acute increase in symptom severity.
Electroconvulsive therapy is not effective for somatic symptom disorders, but it may successfully treat somatic symptoms related to an underlying mood disorder.
Obtain necessary studies to rule out physical causes such as myocardial infarction or appendicitis.
Intravenous or oral acute sedation with benzodiazepines may be used. Avoid long-term benzodiazepines for somatic symptom disorders. Avoid acute or long-term narcotic analgesics for somatic symptom disorders.
Randomized trials have demonstrated the value of physician education in the management of the patient with somatization.[20, 21] Cognitive-behavioral psychotherapy strategies may be specifically helpful in reducing distress and high medical use. Psychosocial interventions directed by physicians form the basis for successful treatment. A strong relationship between the patient and the primary care physician can assist in long-term management.
Psychoeducation can be helpful by letting the patient know that physical symptoms may be exacerbated by anxiety or other emotional problems. However, be careful because patients are likely to resist suggestions that their condition is due to emotional rather than physical problems.
The primary care physician should inform the patient that the symptoms do not appear to be due to a life-threatening, disabling, medical condition and should schedule regular visits for reassessment and reinforcement of the lacking severity of ongoing symptoms.
The patient also may be told that some patients with similar symptoms have had spontaneous improvement, implying that spontaneous improvement may occur. However, the physician should accept the patient's physical symptoms and not pursue a goal of symptom resolution.
Indeed, regular, noninvasive, medical assessment reduces anxiety and limits health care–seeking behavior; this may be facilitated by regularly scheduled visits with the patient's primary care physician.
Encourage patients to remain active and limit the effect of target symptoms on the quality of life and daily functioning.
Family members should not become preoccupied with the patients physical symptoms or medical care. Family members should direct the patient to report symptoms to their primary care physician.
Regular exercise has been demonstrated to reduce functional somatic syndromes in some patients.[22]
Patients may resist suggestions for individual or group psychotherapy because they view their illness as a medical problem. Patients who accept psychotherapy may be able to reduce health care utilization. Psychosocial interventions that focus on maintaining social and occupational function despite chronic medical symptoms may be helpful. Somatic symptom disorders have been linked to impairments in emotion processing, which may contribute to the development of medically unexplained physical complaints. This may make emotion processing an important target for psychotherapeutic approaches to the treatment of somatic symptom disorders.[23]
Studies have shown that cognitive-behavioral therapy[24] reduces depressive symptoms in people with somatic diseases. In particular, this type of therapy is especially effective for patients who fit the criteria for a depressive disorder. Cognitive-behavioral therapy was superior to control conditions, with even greater effects to groups restricted to participants with depressive disorder.[25]
Based on studies of somatization disorder, medication approaches rarely are successful for this condition. Physicians should search for evidence of psychiatric comorbidity, such as depression or an anxiety disorder. If present, medication interventions specific to the diagnosis can be attempted. Successful treatment of a major depression or an anxiety disorder, such as panic disorder, also may produce significant reduction in somatization disorder.
A recent clinical trial in China found a combination of the serotonin reuptake inhibitors (SSRI) citalopram with the atypical antidepressant paliperidone to be more effective than citalopram alone for the treatment of a group of mixed group of somatoform disorder subjects.[26]
Nonmedication strategies are the most successful. See psychosocial treatment in Medical Care for more details.
Clinical Context: Imipramine hydrochloride inhibits reuptake of norepinephrine or serotonin at the presynaptic neuron. This agent is an antagonist at histamine H1 and alpha1 adrenoceptors, as well as at M2 muscarinic acetylcholine receptors.
Clinical Context: Fluoxetine selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine. It may be beneficial in the treatment of pain, morning stiffness, functional status, sleep, and global well-being.
Clinical Context: Sertraline selectively inhibits presynaptic serotonin reuptake. It may be beneficial and well tolerated in the treatment of generalized anxiety disorder.
Clinical Context: Citalopram enhances serotonin activity through selective reuptake inhibition at the neuronal membrane. It may be useful in the treatment of somatic symptoms associated with generalized anxiety disorder.
Clinical Context: Escitalopram is the S-enantiomer of citalopram. It is used for the treatment of depression. The mechanism of action is thought to be potentiation of serotonergic activity in the CNS resulting from inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief is typically after 1-2 weeks, which is sooner than that noted with other antidepressants.
Clinical Context: Fluvoxamine is a potent selective inhibitor of neuronal serotonin reuptake. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than TCAs do. In the treatment of body dysmorphic disorder (BDD), higher doses than those used for depression generally are needed. It may improve depression, anxiety, anger, and somatic symptoms.
Clinical Context: Potent selective inhibitor of neuronal serotonin reuptake. Also has a weak effect on norepinephrine and dopamine neuronal reuptake. It is approved for obsessive-compulsive disorder.
Clinical Context: Mirtazapine is an alpha-2 antagonist. Mirtazapine exhibits both noradrenergic and serotonergic activity. In some cases of depression associated with severe insomnia and anxiety, it is superior to SSRIs.
Clinical Context: Duloxetine is a potent inhibitor of neuronal serotonin and norepinephrine reuptake. Its antidepressive action is theorized to be due to serotonergic and noradrenergic potentiation in the CNS. It is approved for the treatment of somatic symptoms in patients with generalized anxiecy disorder and chronic musculoskeletal pain.
Clinical Context: Venlafaxine is structurally unrelated to other available antidepressants. It inhibits serotonin reuptake at select receptors, as well as the reuptake of norepinephrine. Venlafaxine has been shown to be effective in the improvement of core psychic anxiety symptoms and associated somatic symptoms in patients with with generalized anxiety disorder.
SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder. However, there are certain clinical settings where the use of a tricyclic antidepressant, like imipramine, may be preferred.
Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.
In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.
In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.
Somatic symptom disorders rarely require inpatient management. Consider inpatient care if a patient appears suicidal or requires detoxification from comorbid substance dependence. Additionally, inpatient care may be needed for patients whose somatic symptom disorder is incapacitating (ie, conversion disorder with motor symptoms of such severity to impair ambulation). The principles of inpatient care for somatization disorder include the following:
Iatrogenic complications may occur from invasive diagnostic or surgical procedures.
Other complications may include (1) dependence on prescription-controlled substances and (2) development of a helpless and dependent lifestyle.
Dysfunctional illness perception has been demonstrated to be related to active suicidal ideation independent of other psychiatric comorbidities.[11]
Somatic symptom disorders can range from mild and transient to severe and chronic. Early treatment improves prognosis and limits social and occupational impairment.
The key issues of patient education are outlined Medical Care. Key patient educational issues include the following:
Family education is often crucial for the successful management of somatic symptom disorders. For the patient's family members, this education should include the following:
For patient education resources, see the Muscle Disorders Center, as well as Fibromyalgia, Chronic Fatigue Syndrome, and Chronic Pain.
Other helpful Web sites include the following:
Somatic symptom diagnoses in a series of university hospital psychiatric consultations.
