All patients with chronic physical pain are not alike and shouldn’t be treated the same. That’s the basis of this article on somatoform disorders. Somatoform disorders refer to aches and pains that are amplified (blown out of proportion) because of underlying psychologic or emotional distress. Vague complaints of muscle or joint pain, fatigue, stomach problems, numbness and tingling, headaches, and so on are typical physical complaints associated with somatoform disorders. But despite all medical tests and lab work ordered, the physician is unable to find anything wrong. Treatment is general, rather than specific to the problem.
Somatoform disorders include a number of different problems all placed in this one category. These include somatization disorder, conversion disorder, hypochondriasis, body dysmorphic disorder, and factitious disorder. The common feature of all these disorders is symptom amplification. The main symptom is usually, but not always, pain. The lack of any evidence that there’s anything physically wrong to explain these disorders has led some experts to suggest dropping somatoform disorders as a real diagnosis.
But that’s where the authors of this article differ. They suggest that there’s a definite need to look deeper and not only find ways to diagnose these problems but also to treat each one specifically. That’s a concept they refer to as diagnosis-specific and patient specific treatment. And after briefly describing each condition, they offer some treatment guidelines with the hope that someday we will have specific guidelines for each different disorder, rather than general management techniques.
Health care professionals, especially psychologists and psychiatrists, depend on a publication put out by the American Psychiatric Association called the Diagnostic and Statistical Manual or DSM as it is more commonly referred to. The DSM includes criteria for each somatoform disorder such as signs and symptoms and known causes or risk factors. In addition to a brief review of each disorder, the authors added an extensive table comparing each disorder and offering physicians some treatment guidelines for each one.
Here’s a brief summary of the main disorders. Somatization disorder includes vague reports of pain, gastrointestinal problems, sexual problems, and symptoms that suggest a neurologic problem but with no identifiable cause. The problems described by patients last for years and no medical condition can be found to explain them. Conversion disorder describes neurologic symptoms (e.g., numbness, paralysis, blindness, unable to speak) in response to mental, psychologic, and/or emotional stress. Usually, there is a conflict or stress that occurs just prior to the conversion taking place. In the past, conversion was referred to as hysteria. Women are affected more often than men (2:1 ratio).
Most people are familiar with the term hypochondriac — someone who is always sick, afraid of getting sick, and preoccupied with various physical symptoms or bodily functions. Hypochondriasis is a chronic problem that doesn’t go away with time. Men and women are affected equally. Many of these folks have additional disorders such as anxiety, depression, panic, obsessive-compulsive disorders, and high rates of substance abuse.
Body dysmorphic disorder refers to an imagined or exaggerated fault in a person’s physical appearance. Most often, this is displayed by individuals who are obsessively preoccupied with body size and/or shape. Men focus on height, penis size, and body hair while women obsess about their skin, hips, breasts, and legs. And the last disorder in the group: factitious disorder isn’t technically a somatoform disorder but should be considered as a possibility in the differential diagnosis. Factitious disorder describes a situation in which the person pretends to have signs and symptoms and assumes the role of a sick person to gain attention.
The authors encourage all physicians and health care professionals to have a good understanding of each of these conditions based on available information to date. Applying the following suggested treatment guidelines is based on an accurate differential diagnosis (recognizing one disorder from the other). The goals of treatment include reducing emergency department and doctor visits (thereby also reducing costs), improving physical symptoms even if psychologic distress remains unchanged, and/or improving function even if physical symptoms are not relieved.
The use of antidepressants should be restricted to those individuals who have a diagnosed depressive or mood disorder. Just having a somatoform disorder is not sufficient reason to prescribe these medications. Teaching patients how to evaluate their own symptoms (serious versus those that can wait until an appointment is made) is essential. Patients with body dysmorphic disorder should be discouraged from pursuing plastic surgery or skin treatments. There is evidence to show these treatments do not change how the patient views himself or herself and may even result in more dissatisfaction with the defect.
Referral for cognitive behavioral therapy has been shown helpful for somatization disorder, hypochondriasis, and body dysmorphic disorder.
Some disorders such as conversion are unconscious — in other words, the person is not faking or pretending the symptoms. Directly confronting them with the diagnosis and insisting there is no real physical problem doesn’t usually work. It may be better to try and deal with the underlying trigger while reassuring the patient that all will be well in time. Resolving conversion symptoms may take some time but is usually not a permanent health problem. People carrying out a factitious disorder can be directly confronted — gently and with the backup support of friends and family.
The authors suggest that frequent, perhaps regularly scheduled appointments between patient and physician may be helpful with somatoform disorders. Setting the physician or other health care provider up as an ally rather than seeking to confront and change the patient’s view of the situation is a good place to start. The health care provider will have to establish some boundaries to prevent too many visits, phone calls, and requests for various tests, procedures, and treatments. Physicians are advised to avoid ordering unnecessary tests and medical procedures and to encourage patients to consider cognitive-behavioral therapy.
In summary, with a careful evaluation and working knowledge and understanding of somatoform disorders, the physician can accurately identify underlying somatoform disorders. Treatment should be directed toward both the disorder and the patient specifically. The physician should avoid jumping to conclusions that the patient’s symptoms are all in their head and that he or she needs to see a shrink. Instead, it’s important to make sure there isn’t a more serious disease going on.
If there isn’t an organic disease present, then after establishing a collaborative relationship with the patient, the physician can recommend referral to a psychologist. The physician can avoid doing so in a way that suggests rejection of the patient — perhaps as a one-time appointment to learn ways of reducing stress, learning relaxation techniques, and/or pain management skills. More studies are needed to help us expand the limited knowledge we have of these disorders. Applying a one-treatment-fits-all approach may not be in the best interest of those affected by somatoform disorders.