Somatisation and the somatoform disorders

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CHAPTER 11 Somatisation and the somatoform disorders

Michael Salzberg, David J. Castle, Darryl Bassett

For most doctors in clinical practice, somatoform presentations of psychiatric illness are the single biggest class of symptoms they will encounter. Anxiety and depressive disorders frequently present with physical complaints, rather than by patients saying ‘I’m anxious’ or ‘I’m depressed’. Complaints of fatigue, headache, insomnia, pain, palpitations and dizziness are everyday presentations to general practitioners and specialists, and often are the surface manifestation of depression or anxiety. Depressed patients often become hypochondriacal, in the sense of becoming more anxious about and more attentive to physical symptoms, and more ready to consult a doctor about them.

In addition to these high-prevalence presentations, there is a range of less common somatoform disorders, as shown in Table 11.1. Although all are collected together under the heading of somatoform disorders, these are conditions with very different natural histories, causation and treatments. In addition, the group as a whole has contested, uneasy borders with factitious disorder, with malingering, with the culture-bound syndromes and with the concept of ‘psychological factors affecting physical illness’. For completeness, it is worth mentioning that occasionally patients with psychoses, such as schizophrenia, can present with odd physical symptoms stemming from delusions about their bodies, or from somatic or tactile hallucinations.

TABLE 11.1 Selected somatoform disorders (DSM–IVTR)

Disorder (synopsis)	Comments
Somatisation disorder: multiple symptoms occur over several years without demonstrable physical cause. Symptoms include: • four pain symptoms (e.g. head, back, joints, chest or rectum; or during intercourse, menstruation or urination) • two gastrointestinal symptoms other than pain (e.g. nausea, bloating or intolerance of certain foods) • one sexual problem other than pain (e.g. sexual indifference, irregular menses, excessive menstrual bleeding, or erectile or ejaculatory problems), and • one pseudo-neurological problem other than pain (e.g. conversion symptoms or dissociative symptoms)	This is a rare and extreme disorder involving the experience of multiple symptoms in multiple bodily systems. Given its onset in adolescence or young adulthood, the way life revolves so completely around symptoms and help-seeking, its pervasive effects on relationships, the fact that it often emerges from adverse early life experiences of emotional neglect, abuse or loss, some have argued it is a form of personality disorder
Conversion disorder: motor or sensory deficits (or seizures) suggesting a neurological or medical cause, but for which no physical explanation can be found	For largely historical reasons, when somatisation takes the form of ‘neurological’ symptoms, it has been allocated a category of its own: conversion disorder. In general hospitals, the most common presentations are psychogenic non-epileptic seizures (PNES), functional gait disorders, paralysis (including aphonia) or sensory loss (including blindness). Dizziness presents to cardiologists and ear, nose and throat specialists, as well as neurologists. For ‘fainting attacks’, patients present to cardiologists as well as neurologists
Hypochondriasis: preoccupation with having a serious physical disease, leading to seeking medical help, but failing to be reassured by ‘negative’ medical examinations and tests	Typically, these patients are preoccupied with one symptom (or a set of related symptoms) at a time, in contrast to somatisation disorder. Some experts have argued this has a lot in common with anxiety disorders and, in recent years, cognitive behaviour therapies have been developed and trialled with some success
Pain disorder: pain is the predominant symptom, and causes significant distress and disability; it is defined as acute if duration is less than 6 months, and chronic if greater than 6 months	There are two types. The first type is associated with psychological factors (i.e. psychological factors are considered the major factor associated with onset, severity, exacerbation or maintenance of the pain). The second type is associated with both psychological factors and a general medical condition (i.e. both psychological factors and a general medical condition are considered to have important roles in the onset, severity, exacerbation or maintenance of the pain)

Many doctors and medical students dislike and avoid this area of medicine. They find the ideas intellectually muddy and the terminology confusing. They may be sceptical that these are disorders, rather than malingering or ‘attention seeking’. Even when sympathetic to the patient’s plight, they feel ill-equipped to help. Doctors can quickly feel drained, angry and helpless when faced with the more severe forms of chronic somatisation; even if they retain their professional courtesy, their body language may betray their true feelings. Their reactions to patients may be constructive or destructive. It is common for patients to be told ‘there’s nothing wrong with you’, with the implication that ‘it’s all in your head’.

Medical services overall still do not deal well with these disorders. They often are missed clinically, so that it remains common for patients to undergo extensive, unnecessary referrals and investigations, which can reinforce or amplify the patient’s problem. In addition, doctors fear that in making a somatoform diagnosis they may miss a serious physical diagnosis. It is common for doctors to engage in ‘either/or’ thinking: it is either a ‘real’ illness (e.g. brain tumour), or it is ‘psychological’. In reality, physical illness and somatisation frequently coexist. A good example is psychogenic non-epileptic seizures (PNES) (unfortunately, still often termed ‘pseudoseizures’, a term which patients experience as pejorative and which should be abandoned). PNES coexist with epileptic seizures in a substantial minority of epilepsy patients (i.e. some patients have both kinds of event).

For most somatisation symptoms and somatoform disorders, the evidence for psychological causation is compelling. For example, there are clear data from cohort studies that people subjected to childhood abuse and neglect are at higher risk of a range of disorders in later life, including somatising disorders. This fits with clinical experience and with the kind of evidence that emerges from detailed case studies, such as analysis of psychotherapies of such patients. However, some argue that many of these disorders are better termed ‘medically unexplained syndromes’ (MUSs) or ‘functional somatic syndromes’ (FSSs). MUS and FSS are theoretically neutral terms: they say simply that we observe a constellation of symptoms (e.g. chronic fatigue syndrome and Gulf War syndrome) and remain agnostic about its causation. Causation may be psychological (e.g. trauma, attachment problems and anxiety), or physical (an unknown virus, environmental chemical or cytokines), or some combination of these.

Despite the gloomy tone of the preceding paragraphs, many patients can be helped and, at the very least, protected from iatrogenic harm of overinvestigation and unnecessary referrals. There is a toolbox of basic, readily acquired skills that most medical students and doctors can master.

Somatisation

Somatisation is a general, loosely defined term for the manifestation of psychological distress in somatic (physical) symptoms, and for help-seeking from doctors or other healers for these symptoms. Somatisation exists on a spectrum from transient and mild to chronic and severe. It also varies on a spectrum from normal to abnormal: transient somatisation is fairly common and normal in otherwise psychologically healthy children in situations of stress, and to some extent in adults also. Box 11.1 lists those psychiatric disorders in which somatisation may be prominent.

Somatisation also has a complicated relationship with physical illness. In some cases, there may be little or no evidence of a physical substrate (physical examination and investigations may be normal); in other cases, the patient has an objective, proven physical disorder (e.g. coronary heart disease), but the symptoms and help-seeking are out of proportion to its severity.

Patterns of somatisation differ markedly across societies and cultures. In fact, it is probably impossible to have a culturally universal definition of somatisation, as norms vary greatly regarding what kinds of symptoms are considered trivial or serious, or how appropriate it is to talk about symptoms to others or to seek medical help. So it is equally impossible to say someone’s somatisation is abnormal, unless we have an idea of the person’s sociocultural setting.

Two sets of ideas have been useful in thinking about the patterns of norms. The first is the sick role, which simply summarises core aspects of the social norms in ‘advanced’, industrialised societies about how people behave during occasions of illness. Just as there are norms for other aspects of life (e.g. courtship, marriage, and buying and selling commodities), so there are norms that apply to both the sick person and to those around him or her (see Box 11.2). The second is the idea of illness behaviour and the derived idea of abnormal illness behaviour

BOX 11.2 Sick role, illness behaviour and abnormal illness behaviour

• Sick role (Parsons 1964) is a sociological construct that says that people who are sick have certain rights (e.g. to stay home from work to be looked after) but also certain responsibilities (specifically, to follow the doctor’s instructions about how to get better).

• Illness behaviour (Mechanic 1962) refers to the behaviours people engage in while sick (e.g. going to see a doctor and taking medication).

• Abnormal illness behaviour (Pilowsky 1978) is when illness behaviour is inappropriate; this may be consciously (e.g. malingering) or unconsciously driven (e.g. factitious disorder), and be either illness-affirming (e.g. pseudoseizures) or illness-denying (e.g. ‘flight into health’).

CASE EXAMPLES: somatisation and somatoform disorders

Conversion disorder with major depression

A female patient aged 26 was working as an officer in a military force. She presented soon after being commissioned as an officer. She had originally enlisted and had been promoted to non-commissioned rank, but her service recognised her ability in her field and subsidised her attendance at university to complete a degree in civil engineering.

While at work she suffered fractures to several metatarsals in the left foot, which were satisfactorily managed. However, she developed persistent pain and loss of power in her left leg over several months, without any relevant pathology being defined. Extensive investigations followed, but no cause for her persistent symptoms could be found and she returned to restricted duties using a full leg splint.

Despite her obvious symptoms of pain and restricted function in that leg, her affect remained euthymic and reactive. She was very concerned about her leg problem, but did not allow this to interfere with her capacity to function and to carry out her duties. Over a matter of 6 months, a diagnosis of reflex sympathetic dystrophy was considered and established by several specialists. However, a number of other specialists maintained that her signs were inconsistent with this diagnosis and there was no definable pathology.

On careful exploration it was found that this young officer was feeling very awkward in her new status and felt very uncomfortable being regarded as an officer by fellow service men and women, many of whom she had known when she held a non-commissioned rank. She spoke of leaving the service because she felt that her future was now damaged by her persistent illness, but she felt guilty leaving the service that had subsidised her further education and given her substantial new career prospects.

Over the next 6 months the patient became increasingly depressed and presented for psychiatric assistance. A diagnosis of conversion disorder, compounded by major depressive disorder, was made and treatment introduced consisting of antidepressant medication, and individual and group psychotherapy. Over a period of weeks, her depressive illness improved and she came to recognise the dilemma that she now faced between the guilt of leaving her military service and the challenges of trying to persist in a situation that she found very difficult to tolerate. Power returned to her leg over several weeks, but her pain persisted. Her depressive symptoms responded well to treatment. She was given a medical discharge from military service and treatment continues.

Hypochondriasis

A female patient aged 55 years was divorced with two children. The divorce followed her husband’s revelation that he was homosexual in orientation, but had never felt able to accept this or reveal this to her. They had been married for 24 years and the patient felt that her life was totally shattered. She and her husband remained friends, but they had proceeded with divorce. Within weeks of her husband’s revelations, the patient developed abdominal pains, which were fully investigated, but no abnormality was found. However, her symptoms persisted and she underwent even more extensive and elaborate investigations. In the process, the patient became intensely concerned by the possible nature of her problem and insisted upon receiving copies of all investigations and reports. She read about physical symptoms extensively and began to attend a number of doctors to obtain further opinions. She was admitted to hospital in considerable pain and discomfort, but her symptoms resolved soon after admission, only to recur at a later time.

Over subsequent months she also suffered chest pains and some unusual difficulties with swallowing. Again, thorough investigations failed to reveal relevant pathology, but her presentations with significant symptoms and in crisis resulted in further admissions and further assessment. Syncopal episodes also developed, again without major pathology being identified. Her longstanding asthma deteriorated, but was managed successfully with appropriate medications.

Throughout this time, her treating doctors had assessed her mental state to be depressed, but she insisted that her primary problem was her severe and extensive symptoms, loss of function, and frustration at not being able to resume her normal life. She considered her depressive symptoms to be ‘understandable’ given her multiple problems.

As time passed, her depressive symptoms became more evident with typical features of depressed mood, sleep disturbance and anhedonia. However, the attempts to treat her depression with antidepressant medications were thwarted by particularly poor tolerance of the antidepressants introduced. With persistence she was able to tolerate mirtazapine and there seemed to be some improvement in her mental state. However, when she began to gain weight on this medication, she refused to continue and became concerned about the causes of her weight gain. The pattern of requesting copies of all reports and investigations continued.

Diagnoses of hypochondriacal disorder compounding a major depressive disorder were made and efforts were made to explore the unresolved grief surrounding the break-up of her marriage. She had previously resisted any attempt to explore these emotional issues, but with the persistence of multiple physical symptoms and her deteriorating quality of life, the patient became increasingly willing to consider other aspects of her life and health.

An antidepressant was slowly introduced and psychotherapy established on a regular basis. She was admitted to a private psychiatric hospital. Once in hospital, she was gently confronted with the extent of her illness preoccupation, high level of disease conviction and high level of disease phobia. These problems were approached as a reflection in her body of her emotional distress, rather than accusations of ‘inventing symptoms’. Gradually, she was able to experience her despair in this supportive environment and felt able to reduce her preoccupation with her physical symptoms and investigations. Her treatment continues, but her presentations with physical symptoms have simplified and she remains under the care of one general practitioner and one psychiatrist.

Management

General treatment

The first and most crucial principle is to establish and maintain a positive therapeutic alliance, while setting a reasonable limit to medical investigations and treatment. Somatising patients can evoke very negative reactions in treating staff. Doctors, nurses and others may feel frustrated, hostile, angry or helpless. This may lead to subtle or gross forms of rejection, including referral elsewhere or overinvestigation. Some doctors, in an effort to be sympathetic and helpful, resort to ‘heroic’ but not necessarily effective measures. Psychiatrically trained staff cope with the negative emotions of working with somatising and other challenging patients by mutual support (e.g. peer supervision groups) and/or one-on-one supervision. In this way, they are able to maintain a more objective, empathic and helpful perspective, with less risk of burning out.

Second, it is important not to invalidate the patient’s experience. The language we use can make or break the therapeutic alliance. The message that ‘there’s nothing wrong with you’ can be very damaging, rupturing trust and leading to the patient seeking help elsewhere. The antidote here is in part patient-centred interviewing. This means attempting to understand the patient’s experience in his or her own terms, such as: ‘When the dizziness started, what did you think was causing it?’ or ‘Were there any particular illnesses you were most concerned it might be?’

It is useful to get to know the patient’s own vocabulary to do with emotions and stress before offering your explanations using these terms. For example, some doctors try to explain a somatoform symptom using the term ‘stress’, only to have the patient say, ‘But I don’t have any stress in my life; everything’s OK.’ This kind of response can be expected; having limited emotional self-awareness or a limited emotional vocabulary are risk factors for somatisation and somatoform disorders.

Where possible, as in hospitals, it is often very useful for the diagnosis to be communicated to the patient by both physician and psychiatrist at the same time. This is something that can often be done when a psychiatrist is working in a so-called liaison relationship with a medical or surgical team, rather than just providing consultations.

Third, a useful strategy is to convey the ‘good news’ that thorough medical assessment has shown no evidence for any serious disease underlying the symptoms, and at the same time admitting the ‘bad news’ that we do not have a full understanding of the patient’s symptoms, but reassuring the patient we will continue to see them, review their health periodically, and assess thoroughly any new symptoms that might occur. The doctor suggests that in the meantime he or she helps the patient make the best of their situation by learning to cope more effectively with the symptoms and with life in general. This includes paying attention to the emotional aspects of day-to-day life and any stresses or predicaments the patient may be dealing with. Often, after several consultations, a transition does occur: patients talk less about their somatic complaints and more about very significant aspects of their lives that are likely to be linked to the psychological substrate from which the somatisation arose. This often occurs without any formal recommendation of or referral for psychotherapy.

Fourth, for chronically somatising patients, it is useful to schedule regular appointments, even if infrequent (i.e. to be proactive rather than reactive). There is good evidence from randomised controlled trials in primary care that this leads to less overall health service use and better functioning.

Finally, for the more severe and chronic forms of somatisation, it is essential to have excellent communication between health services and practitioners. This takes time and effort, but pays useful divi-dends. In part, it is because it is easy for overt or covert disagreement to emerge about the patient’s diagnosis. For those patients whose somatisation is accompanied by some form of personality disorder (especially borderline), this can lead to ‘splitting’, misunderstanding and hostility between services and practitioners, and iatrogenic prolongation of the patient’s illness.

Specific treatment

Specific treatment depends on specific diagnosis. For much of the burden of somatisation in the high-prevalence disorders (i.e. depression and anxiety disorders), much of the management is management of the underlying disorder. Usually, general practi-tioners and non-psychiatric medical specialists are able to do this effectively using medication and psychotherapy; in a minority of cases, referral to a psychiatrist is needed. Table 11.2 outlines techniques appropriate to the specific somatoform disorders.

TABLE 11.2 Specific treatments for selected somatoform and related disorders

Disorder	Treatment
Somatisation disorder	Various forms of psychotherapy have been advocated, but the evidence base of randomised controlled trials (RCTs) is extremely small. Types of therapies have included psychoanalytic psychotherapy, cognitive behaviour therapy (CBT), behaviour therapy, group therapy, supportive psychotherapy, psychoeducation and eclectic combinations of these. Involvement of partners and family can be very useful: they can benefit from psychoeducation, marital counselling and/or family therapy. There is no good evidence for pharmacological treatment of somatisation disorder itself (as opposed to treatment of, for example, comorbid depression)
Conversion disorder	Many episodes of conversion resolve with non-specific general measures, as described in the text, including: reassurance that no evidence has been found of serious neurological disease; positive suggestion; physiotherapy and rehabilitation; and treatment of comorbid psychiatric problems. Many psychological therapies have been proposed and are used. Barbiturate or hypnosis-facilitated interview aims to reveal information about the psychological conflicts or trauma underlying the conversion and, with hypnosis, to help the patient achieve greater control over their symptoms. Trials have been reported of CBT, behaviour therapy, psychodynamic therapy and biofeedback, among others
Hypochondriasis	The evidence base is greater than for somatisation disorder. Uncontrolled and controlled trials (including RCTs) suggest benefit from ‘explanatory therapy’, CBT, behaviour therapy (employing exposure and response prevention or EX/RP), and stress management, with little evidence of any one being superior to the others. In addition, there are case reports, open series and one placebo-controlled RCT suggesting selective serotonin reuptake inhibitors (SSRIs) are beneficial. The effect is small but useful and there is evidence of a high placebo response rate