Somatoform disorders are a group of psychological conditions where the physical symptoms are present in the patient and it cannot be attributed to any medical condition or substance abuse. The term somatoform disorder has been replaced by a newer term in DSM 5 namely the somatic symptom disorder. The cognitive behavioral therapy constitutes the main mode of treatment of this disorder. The antidepressant has shown beneficial effect in the pain of the somatoform disorder. This disorder would be described in detail in this article.
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biopsychology


Definition

Somatoform disorders represent a group of nonspecific physical conditions in the form of symptoms which may not be fully related to an already recognized medical or neurological condition.  The unexplained medical and physical symptoms represent about 50% of out-patient visits.

Epidemiology

Gender and Race

There is an increase in the preponderance of the occurrence of the somatoform disorder with the female when compared to the male(3). Other risk factor include illiteracy and the belongingness to the minority groups in terms of the race and the lower socioeconomic status.

Attention seeking behavior

Many of the people who come with the somatoform disorder basically have an attention seeking behavior with that of the healthcare community (though it does not qualify to that of the malingering). This results in the increase in the amount and the number of visit by the patient to the hospital.

Impairment of the routine activities

The people with this condition also have the habit of impairment in the activities of their occupational work. This results in deterioration as decrease in the work related activity may culminate in the loss of the employment. This creates further stress and would aggravate the symptoms of the somatoform disorder.

Etiology

Link between depression and anxiety

The condition has linking with that of the depression and the anxiety and many studies demonstrated that there is a two-way link between these disorder and the somatoform disorder.

Familial preponderance

There are studies which highlights the increased prevalence of the somatoform disorder among the person with the family history of the somatoform disorder(4). This outlines the genetic factor may play a role, although the genes responsible have not been identified.

Stressful events

The other significant etiologies for this disorder include the exposure of the patient to the sexual abuse and the physical violence in the younger age. The physical symptoms are basically a means of expressing the distress and discomfort which a person experiences.

Escape mechanism by seeking medical attention

As described in the epidemiology the patient with this disorder feel good health with the medical examination which happens with this disorder. These are exhibited as an escape mechanism by the patient against any work, which he is bound to do.

Classification

The classification of somatoform disorder include the following types according to DSM IV(5)

This includes

  1. Somatization disorder
  2. Undifferentiated somatoform disorder
  3. Pain disorder in which the patient will be experiencing physical symptoms of pain
  4. Body dysmorphic disorder in which the patient will be having the believe that his body parts are defective. There will also be excessive concern over the body image.

For example: the patient will think that he has crooked nose and he would be seeing the mirror for the whole day. He might even wear a camouflage for the nose. But the fact is that his nose is either not crooked or might be crooked for a small degree.

  1. The symptom will be minor such as headache but the patient will think that it is caused by a serious underlying condition such as head injury or tumor.
  2. Conversion disorder(the bodily function will be lost and the patient will suffer from condition such as blindness, paralysis). These symptoms might arise as a response to stressful condition.
  3. Somatoform disorder not otherwise specified

According to the DSM -5(6). These include :

  • The somatic symptom disorder (presence of one of the somatic symptom lasting for at least 6 months’ duration)
  • Conversion disorder (physical and sensory symptom but incongruent with the normal function and the pathology)
  • Disorder which is factitious (patient fakes the condition but the important feature is that there is no gain motive in the mind of the patient).
  • Disorder which are mainly constituted by the illness anxiety
  • Psychological factors

Pathophysiology

The etiology constitutes the main pathological reason behind the occurrence of the disease. The disease is not associated with well-known changes in the brain as well as neurotransmitter signaling.

Symptoms

The person becomes increasingly recognized of the discomfort which occurs normally to anyone. These discomfort are presented as physical symptoms by the patient. The patient report of a large collection of the symptoms which could not be clearly attributed to any of the medical disorder. This is the characteristic feature for the diagnosis of this condition. 

Variety of symptoms

The symptom might be related to :

  • Pain (back pain, joint pain)
  • Cardiovascular related symptoms (pain in the chest, shortness of the breath)
  • Neurological symptoms (seizures which are known as pseudoseizures , loss of memory , walking difficulty)
  • Gastrointestinal tract related symptoms ( vomiting sensation, bloating gas)
  • Female sexual gland related problems (excessive bleeding during the menstrual cycle., pain during the passage of the urine).

The patient goes from one doctor to another in order to get treated for the symptom. This is known as doctor shopping. 

Missing for an organic lesion

The chance of missing an organic condition (due to some lesion or disease) and falsely tagging a particular patient as suffering from the somatoform disorder is rare. Even if this wrong classification occurs, that would only constitute a small proportion of patients. 

Progression and Special forms

The occurrence of the conversion disorder, hypochondriasis, development of the anxiety/ depression and factitious disorder constitute the progression from initial presentation of the somatoform disorder patient with only a few symptoms. In the case of the conversion disorder the patient experience actual physical symptoms such as blindness, paralysis 

Diagnosis

Differentiation from the comorbid psychiatry condition

There is a significant amount of controversy in the diagnosis of the somatic symptom disorder. These patient generally present with depression and anxiety as comorbid condition(7). Some also have personality disorder as an additional feature with the somatization disorder.

Presence of history of doctor shopping

The patient need to be given attention to his symptom in order to get the confidence of the patient. The doctor shopping which the patient would have done by means of visiting many doctor will also aid the doctor in identification of the patient.

Reason behind the manifestation

The doctor should be trying to identify the reason behind the manifestation of the somatoform disorder, which could be due to some personal or social stress which the patient would have undergone in the past.

The patient should also be asked regarding the physical abuse and social abuse, which could be the reason for the patient current manifestation.

In addition to this, in order to rule out other condition the history of the substance abuse and the alcoholic addiction should be asked to the patient.

Note:

The older name of the Somatoform disorder (DSM IV and ICD 10) has been replaced by the Somatic Symptom Disorder (DSM -5).

Differential diagnosis

  • Anxiety, depression and panic attacks
  • The key differential diagnosis includes depression and anxiety. The person might be on the substance abuse and that may manifest of the constellation of the symptom. The person might have had some panic attack.
  • Malingering
  • It is very important in distinguishing this condition from that of malingering which is intentionally faking a condition but it is for the gains in personal or achieving a criminal motive.
  • Organic disorder
  • There is also a possibility that an organic disorder might be actually present in the patient and thus leading to the manifestation of the symptom. Generally, when there are many symptoms which are unrelated,than the diagnosis of the somatoform disorder is made.
  • Unknown disease condition
  • There is also another possibility that the symptoms may be real and the symptoms are due to a disease whose etiology is not fully explored and diagnosed.

Therapy

The two main modalities of the treatment which are recognized for the somatoform disorder are behavioral psychotherapy and pharmacotherapy. Both have its own role and the physician need to strike a balance in the employment of both the strategies for the benefit of the patient. The behavioral psychotherapy is widely employed.

General treatment attributes

The patient should be assured that his clinical scenarios is overlooked and the physician should gain confidence of the patient. This will essentially treat the attention seeking behavior part of the somatoform disorder. The clinician should also spend time in listening to the grievances of the patient and address them with concern.

  • Attention by the clinician:
  • The attention needs to be given to the symptoms of the patient by the clinician and this will instill a positive feeling in the patient. The patient should be then gradually advised to avoid presenting to the clinic with symptoms.
  • Insignificance of numerous laboratory investigations
  • The unnecessary laboratory investigation which are done with the intent of pleasing the patient have not resulted in the improvement of the symptoms. Hence the laboratory investigation should be restricted to the minimum (just to aid the diagnosis). 

Cognitive behavioral therapy

The cognitive behavioral therapy is superior over the pharmacological therapy in the treatment of the somatoform disorder. The patient should not be directly questioned about his symptom and this will affect his perception about sharing the information to the clinician. In addition to this, other psychological therapy which has shown beneficial effect include relaxation therapy, family therapy, the education of the patient himself.

Pharmacotherapy

Antidepressants and other agents

The antidepressant has shown beneficial effect in the treatment of pain of the somatoform disorder. There is no difference in terms of the efficacy of the various antidepressant, although some results has shown that the tricyclic antidepressant are more likely to respond when compared to that of the SSRI(9). There is also a role in the addition of typical antidepressant such as SSRI in the therapy for the treatment. The other therapy includes SNRI(Serotonin and Noradrenaline Reuptake Inhibitor), atypical antipsychotics and medication of herbal origin.

Treatment of special form

In special form such as hypochondriasis, body dysmorphic syndrome, SSRI has shown beneficial effect. SNRI has shown to be more effective in conditions in which the pain is the predominant symptom.It is recommended to avoid opioid drugs in the treatment of pain in these patients.

Complications

The complication includes :

  • Deterioration in the health of the person
  • The development of the disability in the patient
  • Development of anxiety and depression in the later stage
  • The risk of suicide
  • The problem in the family and in the occupation
  • The problem in the finance of the patient.

Prevention

Though the exact method of prevention of these somatoform disorder is not well established, one of the important factor is to avoid is the vulnerability of the person to get sexually or physically abused. The person who have experienced abuse in physical or mental form should be given proper counselling and support. The prevention of the substance abuse in the early stage along with proper realisation of the patient in the initial stage itself that he needs psychiatric counselling for the control of his symptom will avoid the progression of the symptom in the future.

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