Professional Documents
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Somatization Disorder
Somatization Disorder
Objective: This paper reviews the present state of knowledge on the etiology, prevalence,
diagnosis, and treatment of somatization disorder (SD).
Method: A comprehensive review of the literature on SD is described under the above
headings.
Results: SD is a common condition that is not well managed by many physicians. Patients
with SD get caught between the cracks of the health care system, with expensive
consequences. SD is a psychiatric disorder, but patients are reluctant to see and be treated
by psychiatrists. They frequently are managed by nonpsychiatric physicians who have
limited understanding of the condition. Cognitive-behavioural therapy (CBT) is the most
efficacious treatment in SD, although antidepressants and supportive psychotherapy also
have a role for some patients.
Conclusions: A cadre of clinicians with training in the theory and practice of CBT for SD
is required. They need to be based both in the community and in tertiary health care
centres, where most patients with this condition are located.
(Can J Psychiatry 2004:49:652–662)
Information on author affiliations appears at the end of the article.
Clinical Implications
· Somatization disorder (SD) is a common condition.
· SD has a major impact on our health care system.
· Programs to train clinicians in the use of cognitive-behavioural therapy for SD need to be
established.
Limitations
· The diagnostic criteria for SD remain cumbersome.
· Long-term outcome studies are rare.
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Somatization Disorder: A Practical Review
19th-century physician, Pierre Briquet (3–5). However, the systems is essential, it is worth bearing in mind these practical
DSM-IV has discarded this eponymous diagnosis (6). limitations of psychiatric diagnosis. Changing sociocultural
Although the neutrality of the term somatization is advanta- variables also have a profound effect on diagnosis: the
geous, the long history of the term hysteria must not be forgot- definition of disease changes across societies over different
ten, because many contributions have been made to the time (10).
diagnosis and treatment of this condition under the older
The diagnostic concept of SD was based on the work of
terminology.
Perley, Guze, and Woodruff in the 1960s (11–13). Their
My interest in and curiosity about this group of conditions was objective was to identify a clinical condition that could be
aroused many years ago, when I worked as a medical intern diagnosed in a consistent and replicable manner, and they
with a respected internist at a teaching hospital in London, used the word “stable” to emphasize this replicability.
England. I was puzzled as to why, at the end of a series of neg- Although the diagnostic criteria were explicit, the number and
ative medical investigations, my chief would tell a patient, variety of symptoms meant that the full-blown condition was
“There is nothing wrong with you,” when there so patently rarely seen in practice. For this reason, the DSM-IV simplified
was something wrong! the criteria (6, Table 1), and they became easier to apply in a
clinical setting.
Definitions and Diagnosis
Merskey lists at least 7 conditions for which the term Conditions that do not meet all the specific symptomatic crite-
somatization is used (7). These include hypochondriasis, con- ria are characterized as undifferentiated somatoform disorder
version, psychophysiological events, and SD, among others. when present for 6 months or more and somatoform disorder
In general terms, somatization refers to the condition wherein not otherwise specified when present for less than 6 months.
mental states and experiences are expressed as bodily symp-
Like the DSM-IV system, the ICD-10 also uses the term
toms. The term conversion, commonly used as a synonym for
somatization disorder and has dropped Briquet’s syndrome as
somatization, usually implies that unconscious defence mech-
a synonym for SD (14). The ICD-10 lists the diagnoses and
anisms are operative.
provides general diagnostic guidelines, but it does not specify
As originally described in the DSM-III, SD was characterized or describe the symptoms required to make the diagnosis. The
by a wide variety of somatic symptoms affecting different diagnostic terminology of the 2 systems in this domain is
organ systems. The number of symptoms and systems was largely interchangeable.
precisely specified. SD is 1 of the 5 somatoform disorders, the
others being conversion, pain, hypochondriacal, and This tabulation of the diagnostic criteria and reliance on num-
dysmorphophobic disorders. They have in common the fea- bers of symptoms, systems affected, and duration is in keep-
ture of presenting with somatic symptomatology, a relative ing with the phenomenological framework and objectives of
absence of physical causation, and a presumptive, but often the DSM nosological system. However, many practical diffi-
unstated, psychological cause. culties of diagnosis remain. Some relate to the continued need
to count the number of symptoms in each category, even
The subjective element of these psychological phenomena though these are now fewer in number than in the DSM-III.
creates nosological difficulties related to the ancient monistic Other difficulties pertain to the overlap of related conditions,
vs dualistic controversy of mind–body relations. Most psychi- both organic and psychiatric. An attempt has been made to
atrists follow the phenomenological approach exemplified by further simplify the criteria by developing the concept of
the DSM systems, which are based on the presence or absence “abridged somatization,” but further work needs to be done on
of certain clinical symptoms or signs and the monistic impli- the parameters (15).
cation that mind and body are one. However, to state that the
practice of dichotomizing illness into mental and physical cat- The conditions most likely to be confused with SD are organic
egories is “archaic and deeply misleading,” as does Kendell diseases that present with multiple symptoms affecting sev-
(8), ignores the fact that some subjective psychological phe- eral bodily systems—diseases such as multiple sclerosis, sys-
nomena crucial to the expression of psychiatric illness cannot temic lupus erythematosis, and certain endocrine conditions.
be categorized, as can physical phenomena, and that a science It is, of course, essential to identify such conditions when
based on purely mental states must therefore be implausible present, but their presence or the presence of any other medi-
(9). Our psychiatric diagnostic systems incorporate into the cal disease does not rule out SD, which can coexist with an
diagnostic framework only a part of the subjective and objec- organic condition (16). Organic conditions (for example, side
tive phenomena of illness, namely, that which is observable. effects from drugs or adhesions following inappropriate
Another part—personal experience—cannot be categorized. abdominal surgery) may also develop following inappropriate
Although knowledge of current psychiatric classificatory treatment of SD. The presence of any associated organic
Table 1 Diagnostic criteria for 300.81 Somatization disorder (from the DSM-IV)
A. 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.
B. 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 4 different sites or functions (for example, head, abdomen, back, joints,
extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination).
2. Two gastrointestinal symptoms: a history of at least 2 gastrointestinal symptoms other than pain (for example, nausea, bloating,
vomiting other than during pregnancy, diarrhea, or intolerance of several different foods).
3. One sexual symptom: a history of at least 1 sexual or reproductive symptom other than pain (for example, sexual indifference,
erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy).
4. One pseudoneurological symptom: a history of at least 1 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 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).
D. The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).
disease complicates treatment and partly explains why physi- that somatic symptoms are common in patients with mood dis-
cians manage many patients with SD so poorly. order (22).
There is also an overlap between SD and functional medical For undifferentiated somatoform disorder, but not for SD, the
syndromes such as fibromyalgia, chronic fatigue, and irritable differential diagnosis section does specify that the diagnosis
bowel (17). These conditions are known to occur together fre- not be made if the symptoms “are better accounted for” by
quently. Recent evidence even questions whether they are dis- another mental disorder (for example, depression, anxiety, or
crete conditions or merely part of the same pathophysiological adjustment disorder). This leaves a substantial grey area
process (18). Another study found that a diagnosis of either between the diagnoses of SD and the mood disorders. The
SD or chronic fatigue was primarily affected by whether psy- presence of dysphoric symptoms has therapeutic implications
chiatric or physical terminology was used to interpret the (see Treatment below).
symptoms (19). A related study found that both patients with
chronic fatigue and their spouses were more likely than con- SD also largely overlaps with hypochondriasis. Briquet
trol subjects to attribute their symptoms to somatic disease, regarded it (hypochondriasis) as a separate condition from
even when they had a history of psychiatric illness (20). Both hysteria, but the conditions are more likely related and over-
the psychopathology and the pathophysiology of these condi- lapping. The DSM-IV places them both under the umbrella
tions are under continued investigation; hence, the criteria dif- category of somatoform disorder. Like SD, hypochondriasis
ferentiating them from SD are likely to change as new is characterized by a preoccupation with physical symptoms;
research evidence comes to light. however, a key feature is that it combines the fear with the
conviction that one has an organic disease. This fear may be
Symptoms of associated psychiatric conditions such as anxi-
based on the misinterpretation of a physiological symptom
ety, mood disorder, hypochondriasis, and malingering–
such as heartbeat or a relatively minor skin lesion, but the
factitious disorder can also cause diagnostic difficulties. The
misinterpretation is not of delusional intensity. In hypo-
DSM-IV criteria for SD make no mention of dysphoria, but
chondriasis, the somatic symptoms are usually not multiple,
symptoms of anxiety or depressed mood are very common in
as they are in SD, but many body systems may be involved
patients with SD (21). Their presence does not invalidate the
over a period of time. A self-confessed “hypochondriac” pub-
diagnosis. Up to 50% of patients with unexplained medical
lished a revealing and highly instructive account of her condi-
symptoms have sufficient criteria for a diagnosis of anxiety or
tion (25).
mood disorder (22). Two studies found a strong positive asso-
ciation between the number of somatic symptoms and overt Malingering and factitious disorder are conditions that by def-
psychological distress, and it was concluded that somatic inition result in symptoms produced consciously and deliber-
symptoms were an expression of distress, not a defence ately for the purposes of secondary gain. Sutherland and
against awareness (23,24). Conversely, it has also been found Rodin found a factitious disorder prevalence rate of 0.08% in
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Somatization Disorder: A Practical Review
Figure 1 Etiology of unexplained medical symptoms (from Gelder and others; 58)
Bodily sensations
physiological processes
minor pathology
â
Understanding
Cognitive Personality
knowledge experience of
illness
à interpretation ß emotional arousal
â
Symptoms
behavioral change
disability
the fathers of women with SD are more likely to have an anti- patients diagnosed with borderline personality disorder. This
social personality disorder (28). Whether this effect is medi- association may reflect a similar pattern of social interactions
ated by genetic or psychosocial factors, or a combination of between SD patients and those with Cluster B personality
both, is not known. Traditional psychoanalytic factors, disorders.
including conflicts with mother or father or difficulties in the
control and regulation of aggression and frustration, may also Life events may precipitate somatization. In a well-designed
play a part in individual cases. However, no experimental sur- study, Craig and others assessed the role played by stressful
veys have tested the validity of these hypotheses on larger life events and secondary gain in psychiatric illness (55). They
groups of patients. found that such events played a part in bringing on all psychi-
Ethnicity, education, and sex are other social factors relevant atric illness but that secondary gain was more common among
to somatization. A high correlation has been found between somatizers. They also offered 3 reasons for some patients’
somatization and ethnicity (48,49), low social class with less expression of dysphoria as a somatic symptom: 1) individual
education (50), and female sex (51,52). differences in temperament and physiological response; 2)
social, cultural, and linguistic factors; and 3) previous experi-
Doctors also play a part in the pathogenesis of SD. If patients ence of illness. As children, these patients had been neglected
are poorly managed and subjected to unnecessary specialist and were only given attention when physically ill.
referral or expensive, invasive, diagnostic and therapeutic
procedures, this will ensure that complaints become imprinted Personality factors, as expressed in the concept of “alexi-
and medicalized. In such patients, therefore, iatrogenic fac- thymia,” may be relevant to the etiology of SD in another way.
tors must be regarded as part of the etiology. The word was coined by Sifneos (56), is derived from Greek,
Personality factors influence the development of SD. Persons and literally means “no words for feelings.” The term is based
with this condition are more likely to have an underlying per- on the psychoanalytic concept that patients somatize because
sonality disorder or traits—in particular, those belonging to they are unable to express their feelings in words. There is an
Cluster B (53,54). Passive-dependent, histrionic, and extensive literature on the relation between alexithymia and
sensitive-aggressive traits were 2 times more prevalent somatization (57). Much cross-sectional research has been
among SD patients than among patients with anxiety and carried out, and most studies show a positive correlation
depression. Conversely, there was a high prevalence of SD in between alexithymia and somatization. However, there is a
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Somatization Disorder: A Practical Review
1. General principles
a) Comprehensive clinical assessment (history, mental state, and physical examination).
b) Interview key family member.
c) Minimize number of clinicians involved. Ensure a consistent, coordinated management plan.
d) Minimize invasive diagnostic and therapeutic proceedures.
e) Ensure regular, structured sessions. Avoid as-needed visits to doctors and emergency departments.
f) Recognize reality of symptoms and provide diagnostic feedback to both patient and family member. Where appropriate,
link symptoms to stressful life events.
g) Identify and minimize secondary reinforcers.
h) Treat associated medical and psychiatric conditions appropriately.
2. Cognitive-behavioural therapy
a) Develop treatment contract (listing agreed approximate frequency, duration, and number of sessions).
b) Set realistic short- and long-term goals. Review these regularly.
c) Focus on practical ways of coping with symptoms and limitations.
d) Encourage patient to keep a daily log of thoughts, feelings, and coping behaviours. Review these regularly.
e) Promote daily physical, social, recreational, and occupational activities.
f) Promote daily relaxation activities and exercises.
g) Promote patient control and autonomy.
3. Pharmacotherapy
a) Minimize use of habit-forming drugs.
b) Avoid as-needed medication.
c) Use antidepressant medication where appropriate.
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Somatization Disorder: A Practical Review
high users of the psychiatric services, a substantial proportion available in publications by Sharpe and others (81) and
of whom had a somatoform disorder (77). Patients were ran- Kuhlwein (82). These authors emphasize that the way individ-
domized to treatment and to a no-treatment control group. At uals think about their bodily sensations is central to the behav-
6-month follow-up, the treatment group had improved, and ioural model. They note that somatic symptoms cause
had made less use of services, compared with the control emotional distress and that family members and physicians
group. The authors also found that many of the patients can unwittingly reinforce the patient’s illness behaviour.
declined therapy and that there was a high dropout rate. They also emphasize the need to have treatment goals and a
When the tendency to somatize is tenacious, the treatment treatment contract in which issues such as the number and fre-
contract may need to be long-term. In patients with a quency of sessions and the requirement to do homework are
long-standing tendency to somatize, therapeutic objectives stated clearly. For homework, patients are asked to read cer-
may be limited to stabilizing the behaviour and preventing it tain relevant literature, keep a diary, record their feelings and
from escalating. Murphy has emphasized that “the essence of thoughts, and bring these topics back to the treatment sessions
the sophisticated management of hysteria is to avoid errors of for discussion. Barriers to treatment must be identified and
commission” (78). During therapy sessions, the patient’s dealt with.
attention should as far as possible be focused away from A randomized controlled trial (RCT) of CBT in the treatment
health and symptoms and more toward daily life, activities, of unexplained medical symptoms (n = 79) concluded that, at
and relationships. This may require the therapist to avoid 6-month follow-up, 82% of patients and 64% of control sub-
inquiring about the presence of specific symptoms; however, jects had improved or recovered (a significant difference) and
if these are volunteered spontaneously, the response should be that this difference was maintained at 12-month follow-up
limited to general sympathy and support, and a symptomatic ( 8 3 ) . A n o th e r s tu d y f o u n d th a t a g r o u p - b a s e d
line of inquiry should not be pursued. It may be of value to psychoeducational approach combined with relaxation ther-
give the patient specific behavioural objectives (for example, apy effectively decreased somatic preoccupation, hypochon-
walking a certain distance so many times weekly or joining driasis, and medication use in SD patients in a primary care
particular social or recreational functions). To emphasize setting (84). The National Institute of Mental Health is cur-
their importance, these objectives can be given as a written rently recruiting patients for a randomized, single-blind study
prescription, with the added request that the patient record in a of the efficacy of CBT for SD (85). A second goal is to exam-
daily diary when and for how long the activity was performed. ine the effectiveness of CBT among hispanics, since hispanics
This diary can be brought in to subsequent sessions for inspec- have a relatively high prevalence of SD.
tion and review. Goldberg and others have described an excel-
Regular structured sessions, discouraging emergency visits,
lent psychoeducational approach to the treatment of
setting behavioural goals, and avoiding the pursuit of physical
somatization (75), and Fink and others have more recently
investigations and treatments may all be seen as following the
described a 2-day educational course for therapists (79).
behavioural principles of management within a supportive,
Many of the above principles merge into the CBT model of nonauthoritarian, medical psychotherapeutic framework.
treatment for the condition. CBT must be regarded as the most
It is also valuable to work with the patient’s spouse and fam-
efficacious treatment for SD. A critical review of 31 con-
ily. They are unwittingly involved in the patient’s illness and
trolled studies published prior to 2000 concluded that it
behaviour and will harbour feelings and reactions that will
should be used either as the first-line treatment or as treatment
have a positive or negative effect on outcome. It is useful to
for patients who fail simpler strategies (80). An interesting
provide diagnostic feedback to the patient and the spouse or
finding was that the beneficial effect of CBT occurred inde-
family together. This ensures that the next-of-kin do not have
pendently of improvement in psychological distress. In other
to rely on the patient’s possibly distorted report. Conjoint
words, it was not necessary to relieve symptoms of dysphoria
feedback also gives family members the opportunity to voice
to diminish the intensity and number of somatic symptoms.
their concerns, observations, and questions, all of which may
Improvement occurred because of better coping, decreased
be essential to diagnosis and treatment. Family support is vital
illness worry, lessened avoidant behaviour, and greater per-
to an effective treatment plan. These arrangements form part
ceived control.
of the CBT process of environmental modification, that is,
In CBT, the therapist structures the patient’s social and physi- structuring or altering the patient’s social, physical, and occu-
cal environment to promote appropriate behaviour (in this pational surroundings to promote a more therapeutic milieu.
case, healthy social and personal adjustment without Relaxation therapy may be of value in this group of patients. A
somatization) and discourage inappropriate behaviour (that practical description of the technique for instructing patients
is, illness behaviour and preoccupation with physical symp- in relaxation is available (86). Patients must carry out the exer-
toms). Excellent, practical descriptions of CBT techniques are cises regularly, no less than 3 times weekly, and must persist
in this endeavour. The maximum benefit from relaxation ther- is required in both family practice and tertiary care settings,
apy occurs when it is practised frequently over an extended where most SD patients are found.
length of time. Aerobic exercise has been proposed as an aid This review shows that many advances have been made in
to treatment of SD, but an RCT found that it offered no benefit recent years, both in our understanding of SD and in its treat-
over nonaerobic exercise (87). ment. The task now is to ensure that these advances are widely
disseminated and acted upon. Hopefully, this will lead to SD’s
Pharmacologic Therapies going the way of syphilis when, in the future, a history of the
Little work has been done on the use and efficacy of pharma- condition is written.
cologic agents in SD. However, antidepressants are effective
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