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15 Managing somatoform disorders
Bruce S Singh Psychiatrists rarely manage the majority of patients with somatoform disorders -- this difficult undertaking falls predominantly on general practitioners. |
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Synopsis - Introduction - The transcultural perspective - Sex and somatisation - Somatisation in general practice - Diagnosis - Presentation and management - Overview of psychopharmacological treatments - Non-pharmacological treatments - Somatisation in the new millennium - References - Author's details - Box 1: Definitions - Box 2: Somatoform disorders of various cultures - Box 3: Symptoms of somatisation disorder - Box 4: Expert rating of diagnostic usefulness of somatisation syndromes - Box 5: Managing chronic somatisation disorder - Case history 1: Acute form of hypochondriasis - Case history 2: A culturally determined form of somatisation - Case history 3: Somatisation disorder - a salutary tale - Short course - --> Contents list |
Synopsis | |
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Introduction | |
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The general practitioner commonly encounters patients expressing
bodily complaints for which no organic cause is readily apparent.
Studies have shown that such people form anything from a quarter to
half of patients attending general practitioners.1 Many are
persistent attenders who don't get better despite the doctor's best
efforts. Many reasons have been put forward to explain their
behaviour, but none so straightforward as that postulated by Ford:
that these are often people for whom symptoms or illness have become a
way of life.2
Psychiatrists have not been particularly helpful to their general practitioner colleagues in managing these problem patients. Apart from liaison psychiatrists practising in general hospital settings, most rarely encounter somatoform disorders. Even the term "somatoform" may be unhelpful. It means having the form of a physical or organic illness but not the reality (more terms are defined in Box 1). To those trained within the philosophical tradition of Western medicine (going back to Descartes), the division of mind from body implied in this definition is not problematic, but to thinkers in other cultures such a dichotomy makes no sense and may be one reason why Western-trained doctors have so much difficulty with these patients. As Escobar puts it: "Because his phenomenology goes against prescribed allopathic rules, the somatiser is the pariah of modern medicine."6 |
The transcultural perspective | |
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Box 2:
Box 3:
Box 4: |
Rather than an aberration, the expression of psychological and
social distress through physical symptoms is the norm in many
cultures of the world.7-9 The strict
differentiation that Western psychiatrists have made between
affective, anxiety, somatoform and dissociative disorders forces
what might be called a "diagnostic dismemberment" of popular
illnesses that combine all of these features of suffering, such as
neurasthenia in the Chinese (Box 2 lists common examples of such
illnesses).
The International classification of diseases (ICD-10) gives the commonest symptoms of somatisation disorder world-wide as gastrointestinal complaints and abnormal skin sensations.10 In a survey in the United States, the most common symptoms were painful menstruation, closely followed by excessive gas or abdominal pain, and palpitations or chest pains.3 DSM-IV criteria for somatisation disorder are given in Box 3. The largest survey of somatisation disorder was that carried out in a sample of 20 000 people across five sites in the United States, the Epidemiological Catchment Area (ECA) Study.11 The lifetime prevalence of somatisation disorder was 0.13%. Most sufferers were female, unmarried and non-white, living in rural settings and less educated than average. Also associated with the diagnosis were reports of poor physical health, nervousness, depression, some psychotic and suicidal symptoms, and drug abuse and sexual problems. In the ECA study a partial form of the disorder was recognised and designated "somatisation syndrome", which affected 11.6% of the population at some time in life.11 Both non-whites and women were over-represented among those with the syndrome. Those with the syndrome were also less likely to be employed, had lower incomes, were more frequently dependent on welfare payments and were four times more likely to be institutionalised in chronic care facilities than those without the syndrome. Such data are not available for Australia, but the similarity of prevalence data on common disorders in the recent Australian National Survey of Mental Health and Well Being12 to ECA figures suggests that the findings on somatisation would be similar here. In an international collaborative study of psychological problems in general health care recently conducted by WHO, more than 25 000 patients in 14 countries were screened, and 5500 of these were assessed in detail with a set of standardised diagnostic instruments.13 In both developed and developing countries most of the patients with definite psychological disorders presented with complaints similar to those usually associated with somatic illness, such as back pain, shortness of breath and dizziness, rather than psychological symptoms. Another study canvassed the views of 42 experts from around the world14 on the frequency and diagnostic usefulness of somatoform symptoms (Box 4). Several symptoms and characteristics were more common in certain cultures: e.g., body odour (Japan), body heat and coldness (Nigeria), loss of semen while urinating (India), weakness of the kidneys (China). African experts pointed out that in their countries somatoform disorders were equally distributed between men and women. Arab experts pointed out that in their culture somatic complaints are often heavily dramatised, whereas in other cultures (e.g., Iran and Australian Aboriginal) there are limited words to describe subjective experiences. |
Sex and somatisation | |
| Wool and Barsky15 concluded that the higher prevalence of somatisation in women than in men could be explained by five mechanisms: their greater willingness to admit discomfort; greater readiness to seek medical attention; higher incidence of psychiatric disorders in which somatic features occur; higher incidence of predisposing factors such as physical and sexual abuse; and finally innate differences in bodily perception, with women being more focused on their bodies than men. | |
Somatisation in general practice | |
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Because the traditional psychiatric categories (Box 1) do not
translate well into the primary care setting, three forms of
somatisation encountered in primary care have been
proposed:16
1. High level of functional symptoms (= somatisation syndrome) 2. Hypochondriasis or "illness worry" 3. Somatic manifestation of anxiety and depression. Each of these groups may occur acutely, intermittently or chronically, and this has implications for management. It is also crucial to remember that somatisation may coexist with or overlie established medical illness. | |
| Diagnosis |
Somatisation is best regarded as a process rather than a diagnosis and
does not indicate the specific nature of the symptoms, complaints,
attributions or behaviours. The term is primarily concerned with the
process of inappropriate focus on physical symptoms and denial of
psychosocial problems.
1. Somatisation syndrome: Symptoms that experts contend suggest somatisation syndrome or disorder are detailed in Box 4. For the busy general practitioner, the mnemonic introduced by Othmer and DeSouza, which requires screening of only seven symptoms, may be useful.17 If three of these are present, there is a greater than 90% probability that a patient has somatisation syndrome: Somatisation Disorder Besets Ladies And Vexes Physicians (= Shortness of breath, Dysmenorrhoea, Burning in sex organs, Lump in throat, Amnesia, Vomiting, Painful extremities). If menstrual difficulties and/or sexual problems are not present the diagnosis should be made with caution. It is characteristic of these patients that they:
Dependency: The pervasive need to be taken care of by others and associated fear of separation and rejection or abandonment. Such patients are often in so-called hostile dependent relationships with parents, spouses and occasionally children, where they are very needy, but are angry at themselves and the person they depend on because of this neediness. Passive aggression: A pattern of negative attitudes and passive resistance to demands for adequate performance in social and occupational situations. These individuals habitually resent, oppose and resist demands to function at levels expected by others, but do not show aggression to others overtly, but through passive resistance and negativity. Masochism: The tendency to seek pleasure or satisfaction through psychologically or physically painful mechanisms. Associated with this is an acceptance of suffering and a view that this is inevitable and "natural". 2. Hypochondriasis: The hypochondriac is hypervigilant or hypersensitive to physical sensation and tends to interpret any sensation, normal or abnormal, as evidence of serious physical illness.4 The main difference from somatisation syndrome is that, whereas in the syndrome the patient's focus is on the symptoms, in hypochondriasis the focus is on the obsessive rumination about what the symptoms signify, or the preoccupation with the fear of disease or death. The task of the doctor is to identify the underlying psychic state of obsessional thinking or disease phobia. Illness obsessions are recurrent intrusive thoughts which impinge on the patient intermittently or chronically, and which they attempt to resist. In disease phobia, the predominant feature is the constant fear that death or illness will supervene if the patient does not remain vigilant in regard to bodily functions. Hypochondriacal patients are characteristically difficult to reassure; they tend to ask themselves "What if the doctor is wrong?". 3. Somatic manifestations of other psychiatric disorders: The commonest presentations of anxiety and depressive disorders are somatic. To diagnose these readily treatable conditions, the doctor needs to screen for the other features of the condition (see the article by Ellen et al. in this series19). Drug and alcohol abuse or withdrawal can also lead to confusing somatic presentations, with diffuse aches and pains, headaches, and gastrointestinal and sleep disturbances. Occasionally psychosis may present with a physical symptom. Such symptoms tend to occur more in paranoid or delusional disorders, where a solitary somatic delusion may be the only symptom of psychosis (e.g., in the condition designated monosymptomatic hypochondriacal delusional disorder, the patient may believe, for example, that his nose is misshapen despite all evidence to the contrary). Clinicians need to be particularly alert in trying to probe the reasons for the belief. If the patient cannot give an adequate explanation and the belief is fixed, a delusional disorder should be suspected.5 |
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Presentation and management
Case history 1:
Case history 2:
Case history 3:
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Experienced general practitioners will recognise two kinds of
presentation of patients with somatoform disorders.
1. Occasional or intermittent somatisers: Some patients only present intermittently with somatoform disorders and tend to respond rapidly to medical attention. Often these are people under particular life stress at the time. The diagnosis is difficult when patients with established medical conditions (e.g., asthma or diabetes) appear to superimpose exaggerated concern on their medical symptoms, particularly when exacerbation of episodes or decompensation of their medical problem is directly related to stressful life events. Management of the occasional somatiser is relatively straightforward. It rests on the observation that in the process of somatisation the sufferer transforms or converts a psychosocial stress or conflict into a physical symptom or concern, becomes preoccupied with such a symptom or concern and seeks treatment for it. Diagnosis depends on recognising through a sensitive interview the link between the stress and the symptom or concern, pointing it out to the patient and giving a plausible psychophysiological explanation of how the stress could have led to it. The focus should then move to managing the underlying problem, whether by counselling or occasionally by formal psychotherapy. Occasionally, brief treatment with antianxiety agents or antidepressants may be indicated if an underlying psychiatric diagnosis can be made. 2. Chronic somatisers: These patients have a chronic tendency to express distress and concern about their physical state and are generally not amenable to change. They resist psychological intervention because they regard themselves as physically ill. They present considerable problems to all their medical attendants because of their inappropriate demands on medical services and persistent pursuit of ineffective treatments. Managing this group of patients calls for special skills and strategies (Box 5). The key element is care rather than cure. Chronic somatisers, in one sense, cannot bear to be cured. Illness has become their way of life. Although the psychiatrist is often eventually contacted, most of these patients are treated by their general practitioners. Factors associated with a better response to treatment are younger age, continuing employment, work satisfaction and the absence of pain-contingent compensation payments.20 Poor prognostic factors are constant unremitting pain, pain that is not aggravated by stress or anxiety, a long history of unsuccessful surgery for pain, and a continuing belief that symptoms have a physical cause when evidence for anxiety and depression is clearly present.20 |
| Overview of psycho-pharmacological treatments |
Psychopharmacological treatments have a very limited role in the
treatment of somatisation syndromes. In particular, antianxiety
and analgesic agents must be used judiciously because of the high
propensity of these patients to use medication for a long time,
risking tolerance and dependence. If used, pharmacological
treatment should be combined with non-pharmacological treatment.
When depression is diagnosed, the use of antidepressants is
indicated. There is also some evidence that antidepressants may also
have a role in various functional pain syndromes as detailed below.
In monosymptomatic hypochondriacal delusional disorder, pimozide has been found to be particularly efficacious.21 Tricyclic antidepressants: The use of these drugs in various pain syndromes has been endorsed in the United States. Some controlled studies suggest clinical efficacy in both functional organic pain syndrome22 and also in illness phobia, a form of chronic hypochondriasis.23 Monoamine oxidase inhibitors: These drugs have been considered efficacious in some pain conditions when depression is also present, as well as in idiopathic facial pain.24 Selective serotonin reuptake inhibitors: Case reports have suggested their efficacy in the treatment of chronic pain syndromes including fibrositis, neuropathy and migraine.25 In addition, in atypical cardiac pain (of presumably psychogenic origin) imipramine has been reported to be more effective than placebo.26 |
| Non-pharmacological treatments |
Pilowsky has emphasised that all non-pharmacological treatments
for somatising patients have a cognitive approach at their
core.5 They focus on assisting
patients to reattribute their symptoms from physical to
psychological causes if this is still possible, or, when it is not,
assisting them to cope with their symptoms and the life problems that
lie behind them.
General techniques of education, reassurance and explanation are particularly suitable for use by the general practitioner, as is problem-solving therapy, in which patients learn to use their own skills and resources to cope with present and future problems. Psychotherapy, particularly cognitive-behavioural techniques, is also useful, on the premise that abnormal illness behaviour has been learned and can therefore be unlearned, regardless of why it was adopted in the first place.27 A randomised controlled trial of a highly structured short term educational intervention with small groups of patients with somatisation disorder showed significant physical and mental health benefits and reduced medical costs. These findings are more remarkable because, while subjects were invited to eight group sessions, on average they attended only two.28 In a similar study, patients with atypical non-cardiac chest pain were randomly allocated to receive either a standard psychiatric intervention (counselling) or a more structured brief intervention concentrating on problem solving and behaviour control performed by a primary care physician. The latter intervention was significantly better in controlling pain and achieving functional adjustment.29 Pilowsky has emphasised the need to combine these psychological therapies with biological treatments, such as physiotherapy and possibly antidepressants in chronic pain.5 He emphasises that effective treatment essentially requires a shift in both the doctor's and the patient's perspective from viewing the symptoms as evidence of a condition requiring cure to a psychological condition requiring care. Many patients find such a transition difficult or impossible to make. Nonetheless, they can be assisted provided the doctor does not directly confront their belief system. A particular problem arises when the doctor cannot make such a shift and continues to use more and more aggressive treatments which carry complications of their own (e.g., surgery for idiopathic chronic abdominal pain, or escalating doses of narcotic analgesics). |
Somatisation in the new millennium | |
| The somatoform symptoms of the 1990s are not very different from those of the 1920s. Now, as then, pain and fatigue tend to be the commonest complaints. But there are two significant differences. Sufferers today are more "tuned in" to their bodies and more sensitive to the signals their bodies give off. They are also more ready to attribute symptoms to an organic disease. This increase in illness attribution stems from a weakening of medical authority, strengthening of individual patient rights, and an increase in the capacity of the media to spread information about new and exotic conditions. One possibility is that these new patterns may result from an increasing isolation of individuals and a disaffiliation from family life. The emphasis on self-actualisation and personal growth may have many positive connotations in Western society, but one consequence may be an increasing focus on the "bodily self" and an increasing tendency to be intolerant of imperfections and dis-ease. | |
References | |
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Author's details | |
| Department of Psychiatry, the University of Melbourne, Melbourne,
VIC.
Bruce S Singh, FRACP, FRANZCP, Cato Professor and Head. Correspondence: Professor B S Singh, Department of Psychiatry, The University of Melbourne, Grattan Street, Parkville, VIC 3062.
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