Clinical Vignette

At age 35 years, Barbara W. already had a 15-year career as a medical patient. When she consulted a new rheumatologist for unexplained fatigue, arthralgias, and muscle tenderness, a thorough examination revealed only an overweight, deconditioned, angry, and sullen woman demanding nonspecific relief from her suffering. She was dependent on an oral opiate and a benzodiazepine, which she simultaneously insisted were ineffective and necessary for her continued functioning. She also consumed startling quantities of nonsteroidal anti-inflammatory drugs and over-the-counter hypnotics.

A careful review revealed that she had seen at least 15 physicians in the past 5 years, had been hospitalized at four different institutions, and had undergone an appendectomy, two subsequent exploratory laparotomies for unexplained abdominal pain, and numerous steroid injections of her knees, shoulders, and lower back. She was an avid consumer of medical literature and believed herself to be suffering from fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivities, sick building syndrome, chronic lyme disease, and mercury poisoning. When gently confronted about the absence of clinical findings and her lengthy history of unresponsiveness to medical intervention, she accused the rheumatologist of labeling her “a mental patient” and left angrily.

Clinical Presentation

Somatization and other somatoform disorders are hard to diagnose. By definition, they are disorders of exclusion, and a full medical workup always precedes the diagnosis. This step is complicated by the common presence of real physical illnesses in somatizing patients. Moreover, and confusingly, some real illnesses predispose to somatization.

Second, somatoform disorders must be distinguished from deliberately feigned illness (malingering) and the intentional production of physical symptoms (factitious disorder). This distinction is notoriously tricky, especially in cases where insurance settlements and disability awards are at stake. There are two other disorders, namely fibromyalgia and chronic fatigue syndrome, that need consideration within the somatoform rubric as to date no specific organic definition process has been uncovered.

Fibromyalgia (see Fig. 28-1) is a common clinical syndrome typically found among women. It is characterized by complaints of widespread, migratory body pain, particularly myalgias and arthralgias (Fig. 26-1). These individuals frequently experience various combinations of psychological symptomatology, including an incapacitating fatigue, anxiety, depression, and poor sleeping. Often such patients are obsessed with finding a specific organic disorder as an explanation. In the neurologic clinic, one may see individuals who are convinced that they have a peripheral neuropathy, radiculopathies, or even complex regional pain syndromes. Because there is some clinical overlap with various neurologic and rheumatologic disorders, it is sometimes difficult to make a differential diagnosis in these patients between an organic versus somatoform disorder. As there is no specific neurologic testing modality that allows one to assign a formal pathophysiologic mechanism in these individuals, and the most detailed evaluations, including electromyography and muscle biopsy are normal, many neurologists conclude that these patients have a somatoform process. However, the neurologist must always maintain an open mind as each patient is evaluated.

Figure 26-1 Fibromyalgia Tender Points.

Chronic fatigue syndrome is another commonly observed clinical entity that is also typically referred to the neurologist. Frequently these persons will relate the onset of their symptoms to a recent infectious illness such as Lyme disease of a viral disorder. These individuals are often convinced that they have a more serious illness such as amyotrophic lateral sclerosis (ALS) or multiple sclerosis. It is relatively easy to exclude the former with a careful clinical neurologic examination and electromyography. Multiple sclerosis (MS) offers a little more of a challenge as early on, the often diagnostic magnetic resonance imaging is sometimes normal. Careful clinical follow-up is necessary here to reassure physician and patient alike. Early-onset Parkinson disease is another important organic consideration that must also be considered in this setting.

Treatment

Somatization disorder and other somatoform disorders are rarely cured but they can be well managed. Somatizers need a primary doctor and should have regularly scheduled doctor visits, regardless of the level of their distress—if they get to see their doctor only when symptomatic, they get more symptomatic. These individuals need to be protected from both medical and surgical overtreatment and from quackery. Paradoxically, and most importantly, these patients always need close medical attention—as ALS, MS, and Parkinson disease are easily overlooked in somatizers and, despite their preoccupation with illness, these patients often neglect their health, especially by becoming physically inactive.

Somatizing patients benefit from psychiatric treatment. They are often concrete in their thinking and alexithymic—deficient in verbal access to their emotional state. These deficits are a suitable target for psychotherapy. But the biggest barrier to such treatment (apart from failing to diagnose the problem) is finding a way to tell the patient that he or she has a psychiatric disorder. Perhaps the best way to do so is to tell the patient that he or she has a chronic medical illness of unknown etiology whose symptoms are exacerbated by stress. This is both tactful and true.