CHAPTER 11 Somatisation and the somatoform disorders
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)
|
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) |
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).
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.
