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Definition of Somatic Symptom Disorders

The term Somatoform Disorder (DSM IV and ICD 10) has been replaced with the term Somatic Symptom Disorder (DSM -5).

Somatic symptom disorders are characterized by the presence of one or more somatic symptoms that cause significant distress to the individual but have no physical cause. The patient has persistent thoughts about the seriousness of such symptoms, which can cause significant anxiety. The patient might devote excessive time and energy to figuring out why s/he has somatic symptoms and looking for a way to treat them.

Somatic symptom disorders are distinct from factitious disorder and malingering. A patient with a factitious disorder reports physical symptoms for conscious or subconscious internal gain (i.e., the patient seeks attention and sympathy due to the illness). Malingering refers to feigning physical symptoms consciously for some perceived benefit (e.g., financial gain, legal advantage, avoidance of uncomfortable situations). A patient with a somatic symptom disorder has no obvious gains or incentives. The patient’s physical symptoms feel real to him or her; however, the symptoms are the result of mental distress that may be caused by depression, anxiety, or fear.  Treatment should include ruling out a factitious disorder or malingering.

Epidemiology of Somatic Symptom Disorders

Prevalence

The estimated prevalence of somatic symptom disorders in the general population is around 0.1%, but they are most likely under-reported. Epidemiological studies that used more flexible inclusion criteria than the DSM-5 found somatic symptom disorders’ prevalence may be as high as 11%.

Plastic and cosmetic surgeons are more likely to encounter body dysmorphic disorder, a specific somatic symptom disorder. Conversion disorder, a somatoform disorder that manifests as physical and/or neurological symptoms with no cause, had a prevalence of 15% among patients in psychiatric hospitals. Therefore, specific somatic symptom disorders might be more prevalent among certain groups and populations.

Gender and race

Somatic symptom disorders are about 10 times more prevalent among females than males. Other risk factors include illiteracy and lower socioeconomic status. The disorder may have a genetic component, such as increased sensitivity to pain; individuals with depression or anxiety disorders are at higher risk of developing a somatic symptom disorder.

Interference with routine activities

People with a somatic symptom disorder may be unable to manage their workplace duties. In such instances, there may be a “vicious cycle,” in that anxiety over a somatic symptom disorder leads to deteriorating work performance that may culminate in the loss of employment. This event, in turn, creates additional stress and further aggravates the symptoms.

Age of onset

Generally, somatic symptom disorders manifest in late childhood or adolescence. Adults who present with a somatic symptom disorder for the first time should undergo a full diagnostic workup to exclude occult organic medical conditions.

Etiology of Somatoform Disorders

Link between depression and anxiety

The condition has a link to depression and anxiety. Many studies have demonstrated a two-way link between these disorders and somatic symptom disorders.

Familial preponderance

Some studies indicate that somatic symptom disorders are more prevalent among people with a family history of such disorders. However, the genes involved have not been identified.

Stressful events

Other significant etiologies for these disorders include the patient’s exposure to sexual abuse, verbal abuse, or physical violence at a young age. The physical symptoms are considered a manifestation of the patient’s ongoing mental distress.

Recent advances in understanding the pathophysiology of somatic symptom disorders

Patients with somatic symptom disorders tend to have a smaller amygdala volume than healthy individuals. Moreover, the connectivity patterns between the amygdala and the prefrontal cortex are abnormal in patients with somatic symptom disorders. These brain regions are involved with emotion, thought processing, and perception of somatic symptoms. Therefore, scientists believe these brain regions are impaired in patients with somatic symptom disorders; recent imaging studies support this theory.

Classification of Somatoform Disorders

Everyone experiences occasional aches and pains that resolve without treatment. A patient with a somatic symptom disorder considers them signs of serious illness. The patient may visit a physician and report a variety of symptoms that appear unrelated and cannot be associated with any physical cause.  

Commonly reported symptoms may include:

  • pain
  • fatigue
  • nausea
  • diarrhea
  • vomiting
  • headache
  • constipation
  • abdominal pain, bloating
  • painful intercourse
  • painful menses
  • painful urination

Body dysmorphic disorder

The patient believes that his or her body parts are defective. There may be an excessive concern with body image and obsession over minor flaws in physical appearance. The patient may perceive flaws where none actually exists. Symptoms associated with this disorder include:

  • avoiding mirrors
  • displaying symptoms of depression and anxiety
  • avoiding public places
  • withdrawing from social situations
  • checking one’s appearance in a mirror frequently
  • seeking reassurance from others about one’s appearance

Illness anxiety disorder

This is also known as hypochondriasis. The patient consistently believes minor symptoms are early warning signs of a serious medical condition. Associated behaviors include:

  • restlessness
  • depression
  • repeated visits to physicians seeking a diagnosis (sometimes referred to as doctor shopping)
  • the insistence that a physician has made a mistake by not diagnosing the causes of the symptoms

Conversion disorder

This condition is diagnosed when people have neurological symptoms with no underlying medical cause. Symptoms of this disorder may include:

  • weakness or paralysis
  • abnormal movements (such as tremor or unsteady gait)
  • blindness
  • hearing loss
  • loss of sensation or numbness

Diagnosis of Somatic Symptom Disorders

Differentiation from a comorbid psychiatric condition

Diagnosing somatic symptom disorders is controversial. These patients generally present with depression and anxiety as comorbid conditions. Some patients may present with a personality disorder as an additional feature of a somatic symptom disorder.

Reason behind the manifestation

In addition to taking the patient’s medical history and conducting a physical examination, the initial visit should involve identifying the reason for the manifestation of a somatic symptom disorder, particularly whether the patient has experienced physical and/or verbal abuse. The physician should also rule out other conditions, such as a history of substance abuse or alcohol addiction.

Differential Diagnosis of Somatic Symptom Disorders

  • Anxiety, depression, and panic attacks: The key differential diagnosis includes depression and anxiety. A panic attack can also manifest with physical symptoms.
  • Organic disorder: Generally, the patient reports many symptoms that appear unrelated, leading to a somatic symptom disorder diagnosis. However, an organic disorder might be the actual cause.
  • Unknown disease condition: The symptoms may be due to a disease where the etiology is not fully explored and diagnosed.

Therapy of Somatoform Disorders

The two main treatment modalities for somatic symptom disorders are behavioral psychotherapy and pharmacotherapy. Each has its own role, and the physician needs to strike a balance between both strategies for the patient’s benefit.

General treatment attributes

The clinician must establish a relationship of trust with the patient and reassure him or her that the clinician takes the symptoms seriously.  This will essentially treat the attention-seeking behavior aspect of somatic symptom disorder.

  • Attention by the clinician:
  • The clinician’s review of the patient’s symptoms may establish a feeling of goodwill in the patient. The patient can then be guided to reduce visits to the clinic gradually.
  • The insignificance of numerous laboratory investigations
  • The clinician should make every effort to discourage the patient from undergoing unnecessary laboratory tests by pointing out that past results have not been helpful with making a diagnosis. Hence laboratory investigations should be restricted to those necessary to help with the diagnosis. 

Cognitive-behavioral therapy

Cognitive-behavioral therapy is recommended over pharmacological therapy for treating somatic symptom disorders. The patient should not be questioned directly about the symptoms since this will affect his or her perception of sharing the information with the clinician. Other psychological therapies, such as relaxation therapy, family therapy, and patient education, have been proven effective.

Pharmacotherapy

Antidepressants and other agents

Antidepressants can be effective in treating somatic symptom disorders. There is no clear difference in terms of the type of antidepressant, although some results have shown that tricyclic antidepressants are more effective than SSRIs. Patients may also be prescribed an  SNRI (Serotonin and Noradrenaline Reuptake Inhibitor), atypical antipsychotics, or herbal medications.

Treatment of special form

In certain cases, such as hypochondriasis or body dysmorphic syndrome, SSRIs have a beneficial effect, especially if the patient reports pain as the predominant symptom. Opioid drugs should be avoided because studies have shown that patients with somatic symptom disorders have a high risk of drug dependence.

Emergency treatment

Patients with somatic symptom disorders might present to the emergency department with excessive anxiety. Benzodiazepines might be indicated to lower the patient’s anxiety level.

Complications

Complications include:

  • deteriorating health
  • developing a disability
  • developing anxiety and depression
  • increasing the risk of suicide
  • causing problems with family and in the workplace
  • incurring financial difficulties

Prevention of Somatic Symptom Disorders

Though methods for preventing somatic symptom disorders are not well established, one important factor is addressing the vulnerability of a patient who has been sexually, physically, or verbally abused. A person who has experienced abuse must be given proper counseling and support. Preventing substance abuse in the early stages, along with helping the patient recognize the need for psychiatric counseling for symptom control, will prevent symptom progression.

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