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The term “somatization” describes a tendency to experience and communicate psychological distress in the form of physical symptoms. Somatic symptoms occur commonly in reaction to stressful situations and are not considered abnormal if they happen sporadically.Some individuals, however, experience continuing somatic symptoms, attribute them to physical illness in spite of the absence of medical findings, and seek medical care for them.[i]Somatization may also coexist with a medical disease, but when it does the symptoms are out of proportion to the demonstrable medical findings.Persistent somatization affects a significant percentage of patients in the primary care setting, and is associated with considerable distress and disability. In a recent study of 1,456 primary care patients, 22 percent were found to have several persistent, impairing and medically unexplained symptoms that led to physician visits.[ii]Somatization leads to over-utilization of medical care and often to increased hospitalization rates.[iii]^,[iv] Unnecessary medical tests and procedures place patients at risk for iatrogenic complications.At times, a medical disease may be misdiagnosed as somatization.In addition, the care of patients with somatization often results in a great deal of frustration on the part of both physician and patient.Some patients have received pejorative labels such as “crocks,” “hysterics” and “difficult patients.”

Somatizing patients do not represent a homogeneous group.Not all somatizing patients are motivated by an unconscious wish to adopt the sick role, as is observed in patients with factitious disorder and in some patients with somatization disorder.Patients also vary in their degree of conviction that their symptoms are caused by a physical disease.Patients with medically unexplained symptoms in the primary care setting may be grouped into three broad categories: patients who present with multiple unexplained somatic symptoms, patients who exhibit predominantly illness worry or hypochondriacal beliefs, and patients in whom somatization is actually a manifestation of major depression or an anxiety disorder.[v]Unexplained somatic symptoms are more frequent in women than men.[vi]However, men are more often “true somatizers,” meaning that they are more likely to deny a psychological component to their physical symptoms when asked about them.[vii]Illness worry affects both sexes equally.⁵

Patients with multiple unexplained somatic symptoms have significantly higher rates of depressiveand anxiety disorders.³As mentioned above, there are patients for whom somatization may be primarily a manifestation of a depressive or an anxiety disorder.Cross-cultural studies have shown that individuals from some ethnic groups, such as Hispanics, have a higher tendency to exhibit medically unexplained symptoms when depressed.[viii]Other patients suffer from an independent chronic somatoform disorder but are at risk for developing a superimposed depressive or anxiety disorder.The higher the number of medically unexplained symptoms, the higher is the likelihood of having a depressive or anxiety diagnosis.[ix]A primary care study found that as the number of physical symptoms reported by a patient increased from 0 to 9 or more, the likelihood of a mood disorder diagnosis increased from 2 percent to 60 percent, and the likelihood of an anxiety disorder diagnosis increased from 1 percent to 48 percent.[x]

It is thus important to screen all somatizing patients for depressive and anxiety disorders.Patients in the primary care setting tend to report physical symptoms more readily than they report psychological distress.This may in part explain physician underdetection of depressive and anxiety disorders.[xi]Although patients with somatized depression or anxiety may not spontaneously bring up psychosocial issues, most are willing to discuss emotional distress and related psychosocial stressors if asked appropriately.⁷Patients with somatoform disorders vary in their degree of openness to considering a psychological component to their symptoms. 

Although knowledge about how to best approach somatizing patients is limited, some generally useful principles have been described.The physician evaluating a patient with difficult-to-explain somatic symptoms must establish an alliance with the patient and understand that the symptoms are not intentionally produced.The initial evaluation consists of excluding significant medical disease while simultaneously looking for evidence of psychological distress.[xii]It is important to assess whether the symptoms are acute or chronic, and whether they seem precipitated or maintained by any identifiable psychosocial stressors.The physician must also determine whether the patient currently suffers from a psychiatric disorder such as depression or anxiety, even if the patient denies any contributory psychosocial issues.Following the steps described below in the Patient Interview and Diagnosis section will assist the physician in evaluating the patient and devising an appropriate treatment plan.

Etiology

Somatization encompasses a number of heterogeneous conditions with a wide range of proposed etiological factors,¹more than one of which may be involved in a particular patient’s presentation.In some cases, somatization may be a result of autonomic arousal under the influence of stress or anxiety - for example, stress-induced increased esophageal motility can cause chest pain, and respiratory alkalosis due to hyperventilation can lead to paresthesias.[xiii]In fact, somatization is commonly precipitated by stressful life events, such as bereavement, physical illness, and breakup of a relationship.¹Somatization may also be a manifestation of depression or of an anxiety disorder.³Sociocultural factors may additionally contribute to its etiology, as indicated by the finding that unexplained somatic symptoms are more prevalent in some cultural groups, including Hispanics and Asians; in societies were mental illness is stigmatized, somatization may provide a socially acceptable way of communicating distress.[xiv]A more extreme but infrequent form of somatization, somatization disorder, appears to have a possible genetic component; this is supported by adoption studies showing a higher prevalence of antisocial behavior in the biological parents of adopted-away women with somatization disorder.[xv]

Other research studies have shown that hypochondriasis and somatization are associated with a history of childhood trauma – such as sexual or physical abuse – and with traumatic experiences in adulthood.⁹,[xvi]Exposure to parental chronic illness or illness behavior during childhood also increases the risk of somatization in adulthood, suggesting that learned behavior during development may play a role.[xvii]Later in life, illness behavior may be maintained by external reinforcers –families, physicians, or disability payments.¹In patients with conversion symptoms, psychoanalytic theory has proposed that the symptoms may “solve” an unconscious conflict (primary gain); for example, a person may experience arm weakness after angrily wishing to punch a friend but fearing the consequences of this action.Secondary gain refers to the unconscious benefits that patients derive from the sick role.[xviii]This term is often misused to indicate the conscious pursuit of external incentives, such as purposely avoiding work or evading criminal prosecution.It is sometimes difficult to ascertain whether a patient’s motivations are conscious or not.However, in the absence of external incentives, living life as a sick person can hardly be an appealing conscious choice for patients with chronic somatization.

Patient Interview and Diagnosis

A basic general evaluation can often be completed during the first patient visit.Further assessment generally continues during subsequent visits, especially in more complex cases.Patient evaluation should obviously include a complete history, physical examination, and appropriate laboratory tests in order to exclude the possibility of underlying physical disease.Patients with illnesses that tend to present initially with nonspecific or vague symptoms, such as multiple sclerosis or lupus erythematosus, may be mistakenly identified as somatizers.[xix]^,[xx] While proceeding with the medical work-up, the physician should simultaneously look for evidence of psychological distress.The following steps should guide the physician evaluating a patient with difficult-to-explain somatic symptoms:

·As in any medical interview, begin by asking open-ended questions.The patient’s answers may yield spontaneous information about the context of symptom emergence and about how the symptoms are affecting the patient.Open-ended questions also facilitate the establishment of an alliance with the patient.

·From the beginning of the assessment, pay close attention to any salientpsychosocial issues or stressors in the patient’s life, and in particular to those that appear temporally linked to the onset or exacerbation of the symptoms under investigation.As mentioned above, examples include bereavement, physical illness, and breakup of a relationship.¹Another example may be the cumulative stress resulting from immigration to a new country. Stressors may be more easily identified when somatization is of relatively recent onset.¹Patients may not volunteer psychosocial information, and even if they do, they may not be aware of a connection between a particular event in their life and the emergence of a symptom.Of note, identifying a psychosocial precipitant does not rule out physical disease, since physical disease may also be precipitated by stress.However, this information is clinically valuable when coupled with a negative medical work-up.

·If the patient becomes tearful, gently explore the patient’s feelings while providing empathy and support.

·Find out what the patient thinks might be causing the symptoms and if the patient knows anybody else with this kind of problem (symptom model).¹²

·Inquire about a possible history of domestic violence or childhood sexual abuse, given the association between unexplained somatic symptoms and a history of abuse.

·Inquire about the patient’s social supports.

·Consider obtaining collateral information in more complex cases.

·Determine whether the patient appears to have acute somatic symptoms as manifestations of current psychosocial distress or chronic somatic symptoms (these may also be associated with psychosocial distress, but they are chronic).[xxi]Even if the symptoms appear to be acute, determine whether the patient has a past history of somatization – perhaps in the setting of a past adjustment disorder or major depressive episode.

·Assess the patient for any evidence of a currentpsychiatric disorder, since somatization is not an actual diagnosis but a nonspecific expression of several possible conditions.This assessment is important in all patients, whether they have acute or chronic somatic symptoms.It is helpful to obtain a past psychiatric history, since episodes of a psychiatric disorder tend to recur.Determine if the patient’s current presentation fits one of the following four major categories: a normal reaction to stressful circumstances, an adjustment disorder, somatization due to major depression or an anxiety disorder, or a primary form of chronic somatization (somatoform disorder).³Pay attention to the possibility of psychotic symptoms or substance abuse.Consider obtaining a psychiatric consultation to clarify the patient’s diagnosis in complex cases.What follows is a review of the specific DSM-IV psychiatric disorders that may be diagnosed in patients with medically unexplained symptoms.(See Table I for a list of these psychiatric disorders).

Psychiatric Disorders

Somatization and Adjustment Disorder:

Although medically unexplained symptoms are not explicitly mentioned in the DSM-IV definition of Adjustment Disorder, acute somatic symptoms are a common response to stress.Adjustment disorder is defined as clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors.³,[xxii]Patients with this condition may exhibit depressed mood, anxiety or both.By definition, the symptoms of an adjustment disorder do not last more than six months after the stressor has terminated and do not meet severity criteria for major depression or an anxiety disorder. 

Somatization and Mood Disorders:

Mood disorders commonly associated with unexplained somatic symptoms include Major Depression and Dysthymic Disorder.Patients with current or past depression report higher numbers of somatic symptoms than patients without a mood disorder.[xxiii]Pain is a particularly common symptom in depression, e.g. back pain, headaches and muscle soreness.¹,7Over half of depressed patients report pain symptoms, and women may be more likely than men to exhibit pain as a symptom of depression.[xxiv]^,[xxv]Depression may decrease the threshold for pain from any etiology.Studies have also found that depression is associated with illness worry and a negative view of one’s health.[xxvi]This implies that some patients who appear to suffer from hypochondriasis may actually have a major depression.In depressed patients, both illness worry and reporting of physical symptoms diminish with treatment of depression.³The assessment of patients for major depression or dysthymic disorder is reviewed in Chapter 33.

Somatization and Anxiety Disorders:

Most patients with Panic Disorder report primarily somatic symptoms.This makes them vulnerable to underdiagnosis.[xxvii]Often, after a negative medical work-up, patients are told that they do not have evidence of a medical condition, but panic disorder remains undiagnosed and untreated.Panic attacks are episodic and may include a variety of symptoms such as chest pain, tachycardia, nausea, dizziness, shortness of breath, numbness, or tingling, among others.In one study, 30 to 50 percent of ambulatory patients with chest pain and negative work-ups for coronary artery disease were found to have panic disorder.²⁷Some patients with irritable bowel syndrome are also found to have panic disorder, and symptoms often resolve with treatment of panic disorder.²⁷Treatment of panic disorder also improves hypochondriacal worry when it accompanies panic disorder.³Other anxiety disorders that may present with unexplained somatic symptoms in the primary care setting include Generalized Anxiety Disorder and Posttraumatic Stress Disorder.See Anxiety chapter for a description of the individual anxiety disorders.

Somatoform Disorders:

The Somatoform Disorders are a group of heterogeneous disorders characterized by physical symptoms that suggest a general medical condition, but are not fully explained by a general medical condition, the effects of a substance, or another mental disorder.The symptoms are not intentionally produced and cause significant distress or impairment in functioning.A somatoform disorder is diagnosed only if the medically unexplained symptoms are not primarily the result of another psychiatric disorder, such as major depression or panic disorder.However, major depression or panic disorder may coexist with one of the somatoform disorders.The somatoform disorders include Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, Pain Disorder, Body Dysmorphic Disorder, Conversion Disorder, and Somatoform Disorder Not Otherwise Specified.²²These disorders are grouped together based on clinical utility rather than a shared etiology or pathophysiology.²²

TABLE 1: Psychiatric disorders that may be associated with somatization
 

·Adjustment Disorder ·Mood Disorders Major Depression Dysthymic Disorder Other ·Anxiety Disorders Panic Disorder Generalized Anxiety Disorder Post Traumatic Stress Disorder Other ·Somatoform Disorders Somatization Disorder Undifferentiated Somatoform Disorder Hypochondriasis Pain Disorder Conversion Disorder Body Dysmorphic Disorder Somatoform Disorder Not Otherwise Specified ·Other Psychiatric Disorders Alcohol or Substance Abuse Psychotic Disorders Personality Disorders Factitious Disorder

Somatization Disorder:

Somatization Disorder is a chronic condition with a waxing and waning course. Patients with this disorder have multiple medically unexplained physical complaints. Although by definition these physical complaints must begin before age 30, symptoms usually begin in the teens or early twenties.  The symptoms lead patients to seek treatment or result in significant impairment in social or occupational functioning. If the patient has a coexisting medical condition, the physical complaints or level of impairment are in excess of what would be expected from the history, physical examination, or laboratory tests. In order to meet DSM-IV criteria for somatization disorder, a patient must have a history of at least four pain symptoms, two gastrointestinal symptoms other than pain, one sexual symptom, and one pseudoneurological symptom (e.g. weakness or double vision) over time. Patients see themselves as “sickly” and often have multiple psychosocial problems.¹⁹

Most primary care patients with unexplained somatic symptoms do not meet full criteria for somatization disorder.⁸,[xxviii] Its prevalence rate in primary care is two to five percent.⁹It is more common in women.⁵As many as 75 percent of patients with somatization disorder have other co-morbid psychiatric disorders, most commonly major depression, panic disorder and dysthymic disorder.³,19Some patients have a co-morbid personality disorder or a history of substance abuse.¹⁹Patients with somatization disorder may be particularly frustrating to work with.It is important to remain aware of countertransference feelings and to remember that the patients’ symptoms are not intentionally produced.

Undifferentiated Somatoform Disorder:

The essential feature of this disorder is one or more unexplained physical complaints that persist for six months or longer and cause significant distress or impairment.²²Many primary care patients with multiple unexplained medical symptoms who do not meet the strict diagnostic criteria for somatization disorder may fall in this category.Patients initially diagnosed with undifferentiated somatoform disorder are often eventually diagnosed with a medical condition or another mental disorder.²²

Hypochondriasis:

Patients with Hypochondriasis experience fears of having, or believe that they have, a serious disease based on their misinterpretation of bodily symptoms.This preoccupation persists despite appropriate medical evaluation and reassurance, and causes significant distress or impairment in function.²²This disorder is diagnosed when fear of illness, rather than somatic symptoms, is more prominent.A classic example is that of a patient who remains convinced that he has cancer in spite of a negative work-up and repeated reassurances to the contrary.In order to diagnose hypochondriasis, this fear or belief must persist for at least six months and cannot be due primarily to another psychiatric disorder.“Doctor-shopping” and high medical utilization are common, as are frustration and anger on the part of both patient and physician.²²

Hypochondriasis affects approximately 3 percent of primary care patients and is equally prevalent in men and women.[xxix]As discussed above, patients with depressive or anxiety disorders also commonly experience increased illness worry, so it is important to determine whether a patient has major depression, an anxiety disorder, or primary hypochondriasis.³On the other hand, patients who have hypochondriasis are at risk for co-morbid major depression, so both disorders may be present in some patients.

Pain Disorder:

In this disorder, pain is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.In order to make this diagnosis, psychological factors must be judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.²²The pain causes significant distress or impairment in function, and is not intentionally produced or feigned.If another psychiatric disorder better accounts for the pain, then that disorder is diagnosed instead.Patients with pain disorder are at risk for iatrogenic complications such as dependence on narcotic analgesics or unnecessary surgical interventions.¹⁹In patients with pain disorder, both a medical condition and psychological factors may coexist.Patients with chronic pain often have co-morbid major depression.²⁵

Conversion Disorder:

The essential feature of Conversion Disorder is the presence of motor or sensory symptoms or deficits that suggest a neurological or other medical condition (e.g. impaired balance, weakness, or double vision) but cannot be fully explained by a medical condition, the effects of a substance, or a culturally-sanctioned experience.²²This diagnosis is made when psychological factors, such as conflicts or stressors, are judged to be temporally associated with the onset of the symptoms or deficits.The symptoms cause significant distress or impairment.Careful consideration of possible medical diagnoses is advised, given the frequency of cases misdiagnosed as conversion disorder.²⁰

Body Dysmorphic Disorder:

Patients with Body Dysmorphic Disorder are preoccupied with an imagined defect in appearance.If a slight physical anomaly is actually present, the patient’s concern is markedly excessive.This preoccupation causes significant distress or impairment in function.²²Patients with this disorder more commonly present to surgery clinics.Up to 50 percent of patients may have co-morbid major depression.¹⁹In some patients, preoccupation with an imagined defect in appearance may represent a delusional belief. 

Somatoform Disorder Not Otherwise Specified:

This diagnosis applies to patients with medically unexplained symptoms that do not meet criteria for any specific somatoform disorder, e.g. hypochondriacal or somatic symptoms of less than 6 months’ duration.²²

Somatization and Other Mental Disorders:

Patients with alcohol or substance abuse, patients with psychotic disorders, and patients with personality disorders may also present with medically unexplained symptoms.¹⁹,23

Factitious disorder:

Factitious Disorder is not considered a somatoform disorder but shares some characteristics with the somatoform disorders. It is characterized by physical or psychological symptoms that are intentionally produced or feigned. The motivation for this behavior is to assume the sick role. External incentives – as in malingering – are absent.²² The extreme form of factitious disorder is often called Munchausen’s syndrome.

Malingering:

Malingering is not a psychiatric disorder.Its essential feature is the intentional production of false or exaggerated symptoms, motivated by external incentives such as avoiding prosecution or obtaining financial compensation.²²In some cases, it may be adaptive, e.g. a prisoner of war who feigns illness.²²

Treatment

Acute Somatic Symptoms:

If the patient’s symptoms are part of a normal reaction to stress or an adjustment disorder, the physician should reassure the patient that there is no disease that requires medical treatment, and explain that physical symptoms are a common reaction to stressful events.²¹Listening to the patient’s concerns and supporting the patient’s natural coping skills is often sufficient.Patients with an adjustment disorder by definition exhibit a higher level of distress.A reasonable first strategy is to observe the patient over time, provide counseling in the office, and encourage the patient to seek support from family and friends.Some patients may benefit from a psychotherapy referral to help them cope with acute stressors.The physician should also keep in mind that in some cases acute somatic symptoms represent the onset of major depression or panic disorder.In these cases, treatment should be instituted early.

Chronic Somatic Symptoms:

Whether the physician is initiating medical care for a new patient with a history of somatization or continuing care for a well-known patient, the following management techniques may be helpful in working with patients who exhibit chronic somatization:⁴,21,[xxx]

·Remember to treat depressive and anxiety disorders whenever they are present. Patients who do not admit to psychological distress may be more open to treatment if the physician explains that major depression and anxiety disorders are medical illnesses.In some patients, persistent somatic symptoms may be due to non-compliance with antidepressant medication or an incomplete response to the current medication.

·If present, address and treat other psychiatric disorders and co-morbid substance abuse.

·Focus on management of the somatic symptoms instead of cure; adopt a chronic diseasemodel.[xxxi]

·It does not help to tell patients “it’s all in your head.”

·In many cases, the patient wants a relationship with the physician that is based on understanding and physician willingness to agree that the patient is ill. 

·Meet the patient “half-way”: “The work-up did not show evidence of a disease, but it is clear that you don’t feel well.”

·Focus on helping the patient gain increased function.

·Only gradually introduce the idea that stress may play a role (not that it is the exclusive cause of the symptoms).

·Respond to the patient’s request for medical care by scheduling regular follow-up appointments (every four to six weeks), so that the patient will not need to have new symptoms in order to see you (behavioral intervention).

·Follow-up visits can be brief and include performing a focused physical examination to look for signs of disease, providing emotional support, and gently praising increased functioning (positive reinforcement of non-illness behaviors).

·Discourage “doctor shopping,” and function as the central medical provider.

·Set appropriate limits to unusually demanding behavior or persistent phone calls.

·Only perform diagnostic procedures, especially invasive ones, if there are clear signs of new illness, not just symptoms.

·Minimize polypharmacy.

·Institute a program of gradually increasing exercise – walking, swimming, or physical/occupational therapy.

·Consider psychiatric consultation to help with diagnosis and treatment planning.Make it clear that the psychiatrist will assist in the care of the patient, not replace you as primary physician.Some patients may be open to ongoing psychiatric treatment.

·Remain aware of countertransference feelings of anger and frustration.Try to identify a likable or interesting aspect of the patient.In the most complex of cases, “it may simply be a sense of amazement at the degree of disturbance.”¹⁹If you find it extremely difficult to work with a particular patient, it may be best to transfer that patient to another provider.

Examples of Treatments for Specific Disorders:

More specialized treatment is best instituted by a psychiatrist or in consultation with a psychiatrist: 

·Symptoms of hypochondriasis and chronic somatization may improve with cognitive, group or family psychotherapy.¹⁹

·Pain Disorder with or without coexisting depression may improve with tricyclic antidepressants.²⁵,[xxxii],[xxxiii]Nortriptyline is the least anticholinergic and best tolerated.

·Hypochondriasis may respond to high-dose fluoxetine.[xxxiv]

·Body dysmorphic disorder may respond to serotonin-reuptake inhibiting antidepressants (SSRIs).¹⁹

·Patients with factitious disorder may respond to a non-confrontational approach that offers a “face-saving” avenue for symptom improvement, such as physical therapy.[xxxv]

Somatization is a general term that describes the presence of medically unexplained symptoms and implies a psychological component to the symptoms.Persistent somatization is associated with increased rates of disability and health care utilization. Patients should be assessed for the presence of a psychiatric disorder, especially a depressive or an anxiety disorder.Therapeutic interventions consist of treating depressive and anxiety disorders when present and instituting a general approach to the patient aimed at maintaining the therapeutic alliance, improving the patient’s functional status, and minimizing unnecessary medical tests.A referral for psychiatric consultation or treatment should be considered.

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