8.77: Somatization Disorder (300.81)

 

In the video above Dr. Soheil Ahaddian explains what Somatization Disorder is and the symptoms that appear with it.

DSM-IV-TR criteria

A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

(1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)

(2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy diarrhea, or intolerance of several different foods)

(3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)

(4) one pseudo-neurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or a lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting.

C. Either (1) or (2):

(1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)

(2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination or laboratory findings

D. The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering)

Associated features

• Associated features of Somatization Disorder (SD) include: vomiting, chest pain, dizziness, headaches, stomachaches, pain during sex, diminished sex drive, pain while passing urine, erectile dysfunction, irregular menstruation, joint pain, and back pain. Other types of symptoms are possible, but these are the most common. These symptoms are usually severe enough to interfere with patients’ daily lives and relationships. They are not to be taken lightly.
• Individuals diagnosed with Somatization Disorder make colorful, often exaggerated complaints. The complaints are often lacking in specific factual information. A checklist approach to diagnostic interviewing may be less effective than a thorough review of medical treatments and hospitalizations in documenting the pattern of frequent somatic complaints.

Child vs. Adult presentation

Children experience many of the same symptoms adults suffer from. The age of onset is typically during adolescence and the diagnosis criteria needs to be met by the 20s. If chronic, individuals rarely remit completely. Boys and girls experience symptoms equally until adolescence is reached. Once adolescence is reached, more girls report having somatization disorder than boys. Children tend to experience somatization disorder after a traumatic event in their life has taken place, such as divorce or death of a loved one.

Gender and cultural differences in presentation

• Somatization disorder is more prevalent in women than it is in men. Some studies provide that as much as two percent of women suffer from somatization disorder. The ratio of men to women that suffer from somatization disorder is about ten to one.
• Somatization disorder is found all over the world. Many cultures present with the same symptoms that are mentioned above, but others are different. Cross-cultural studies indicate that the symptoms people with somatization disorder experience may vary greatly from culture to culture. Some symptoms specific to South Asia and Africa include burning sensations in the hands and feet and the feeling of worms crawling or ants crawling under the skin, respectively. Prevalence is about 0.2% to 2% in women and less than 2% in men.

Epidemiology

Somatization Disorder is not commonly found in the population. About 2% of women have it and 0.2% of men have it. Many people that suffer from somatization disorder also have anxiety disorders or depression or both.

Etiology

Somatization disorder is caused by stress. The patient does not want to feel stress or anxiety so the patient transmits these feelings into physical symptoms. Some people also associate a stigma onto psychological therapy and if they feel pain or other symptoms they can go to a medical doctor and not a psychologist.

Empirically supported treatments

• There is not a known treatment for somatization disorder, but there are ways to manage symptoms. Cognitive behavioral therapy is used to help the patient change and manage their thoughts. Patients are also encouraged to become more active. Anti-depressants can also be used to manage symptom, these treat by alleviating the depression or dysthymia. It is extremely difficult to treat but a combination of medical management and cognitive-behavioral therapy may be helpful.
• While empirical support may be lacking, there is a growing consensus that suggests that somatization disorder should be managed instead of treated. This simply means that primary care physicians, therapists, or any other caregivers should help patients control the behavior caused by SD instead of trying to cure it. An important goal of this method is preventing any unnecessary medical or surgical investigations. This could be accomplished by following five recommendations:

1. One long-term and supportive relationship with a primary care physician that understands the situation should be established. This can prevent doctor shopping and lead to more coordinated support.
2. Establish an appointment schedule for check-ups rather than seeing the patient on demand. This is done to avoid the reinforcement of abnormal behaviors caused by the disorder.
3. A caregiver may regard certain physical complaints as a form of communication as well as possible evidence of a disease.
4. The use of psychotropic drugs and analgesic medication should be minimized.
5. Adaptive and positive behavior should be encouraged and promoted while sick role behavior is ignored whenever possible.

Proposed DSM5 Changes (DSM5.org)

Reclassification to Complex Somatic Symptom Disorder

Complex Somatic Symptom Disorder includes: previous diagnoses of Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochonddiasis, Pain Disorder Associated With Both Psychological Factors and a General Medical Condition, and Pain Disorder Associated with Psychological Factors
To meet criteria for CSSD, criteria A,B, and C are necessary.
A. Somatic Symptoms
One or more somatic symptoms that are distressing and/or result in significant disruption in daily life.
B. Excessive Thoughts, Feelings, and Behaviors related to these somatic symptoms or associated health concerns:
At least two of the following are required to meet this criterion:
(1) High level of health-related anxiety.
(2) Disproportionate and persistent concerns about the medical seriousness of one’s symptoms.
(3) Excessive time and energy devoted to these symptoms or health concerns

C. Chronicity: Although any one symptom may not be continuously present, the state of being symptomatic is chronic (at least 6 months).
For patients who fulfill the CSSD criteria, the following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:
1. Predominant somatic complaints (previously, somatization disorder)
2. Predominant health anxiety (previously, hypochondriasis). If patients present solely with health-related anxiety with minimal somatic symptoms, they may be more appropriately diagnosed as having an anxiety disorder.
3. Predominant Pain (previously pain disorder). This classification is reserved for individuals presenting predominantly with pain complaints who also have many of the features described under criterion B. Patients with other presentations of pain may better fit other psychiatric diagnoses such as adjustment disorder or psychological factors affecting a medical condition.
For assessing severity of CSSD, metrics are available for rating the presence and severity of somatic symptoms (see for instance PHQ, Kroenke et al, 2002). Scales are also available for assessing severity of the patient’s misattributions, excessive concerns and preoccupations (see for instance Whiteley inventory, Pilowsky , 1967).

Rationale:

Major Change #1: Rename Somatoform Disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders

The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled “Somatic Symptom Disorders” because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism.

Major Change #2: Combine Somatization disorder, hypochondiasis, undiffereniated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD)

Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD) which emphasizes the symptoms plus the patients’ abnormal cognitions (Barsky, Lowe, Rief). The term “complex” is intended to denote that in order for this diagnosis to be made, the symptoms must be persistent and must include both somatic symptoms (criterion A) as well as cognitive distortions (criterion B).
This is a major change in the diagnostic nomenclature, and it will likely have a major impact on diagnosis. It clarifies that a diagnosis of CSSD is inappropriate in the presence of only unexplained medical symptoms. Similarly, in conditions such as irritable bowel syndrome, CSSD should not be coded unless the other criterion (criterion B—attributions, etc) is present.
It is unclear how these changes would affect the base rate of disorders now recognized as somatoform disorders. One might conclude that the rate of diagnosis of CSSD would fall, particularly if some disorders previously diagnosed as somatoform were now diagnosed elsewhere (such as adjustment disorder). On the other hand, there are also considerable data to suggest that physicians actively avoid using the older diagnoses because they find them confusing or pejorative. So, with the CSSD classification, there may be an increase in diagnosis.
The proposal is to group together these heretofore separately recognized disorders because in fact, there are 3 diverse sources suggesting considerable overlap among them.
1. A 2009 study found that 52% of physicians surveyed indicated that there was “a lot of overlap” and an additional 38% thought that there was “some overlap” across these disorders. In contrast, less than 2% of physician respondents felt that these were “distinctly different disorders (Dimsdale, Sharma, & Sharpe, unpublished).
2. There are limited data regarding overlap in clinical settings. One primary care study, for instance, found that 20% of somatization disorder patients also had hypochondriasis (Escobar, 1998). In primary care patients, somatization disorder was 5 times ( Fink et al 2004) to 20 times (Barsky et al 1992) more common in hypochondriasis patients as compared to primary care patients without hypochondriasis.
3. Treatment interventions are similar in this group of disorders. Cognitive behavior therapy (CBT) and antidepressant medications appear to be the most promising therapeutic approaches for hypochondriasis, somatization disorder, and pain disorder (Kroenke 2007; Sumathipala 2007). Although several variations of CBT have been employed, they share many elements in common. These include the identification and modification of dysfunctional and maladaptive beliefs about symptoms and disease, and behavioral techniques to alter illness and sick role behaviors and promote more effective coping. The literature on the use of antidepressants is more limited, but it too does not suggest any major distinctions in therapeutic response across these different disorders. In addition to these patient centered commonalities of treatment, all of these disorders benefit from specific interventions with the patient’s non-psychiatric physician (e.g. scheduling regular appointments as opposed to prn appointments, limiting testing and procedures unless clearly indicated) (Allen 2002).
A key issue is whether the guidelines for CSSD describe a valid construct and can be used reliably. A recent systematic review (Lowe, submitted for publication) shows that of all diagnostic proposals, only Somatic Symptom Disorder reflects all dimensions of current biopsychosocial models of somatization (construct validity) and goes beyond somatic symptom counts by including psychological and behavioral symptoms that are specific to somatization (descriptive validity). Predictive validity of most of the diagnostic proposals has not yet been investigated.