What is somatization disorder

Somatization — or psychosomatic disorder — is no longer a recognized mental disorder ¹. In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-5 ¹, somatoform disorders are now referred to as somatic symptom and related disorders. The DSM-5 classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed ¹. Individuals previously diagnosed with somatization disorder will usually have symptoms that meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms. Because the distinction between somatization disorder and undifferentiated somatoform disorder was arbitrary, they are merged in DSM-5 under somatic symptom disorder.

Individuals previously diagnosed with hypochondriasis who have high health anxiety but no somatic symptoms would receive a DSM-5 diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety disorder). Some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate.

The information provided below is here for historical purposes only.

Somatization disorder symptoms include a history of many physical complaints beginning before age 30 years that occur over a period of several years. The symptoms tend to result in a person seeking out treatment for them through multiple healthcare providers. The disorder also typically results in significant impairment in social, occupational, or other important areas of functioning.

Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

• A) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
• B) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
• C) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
• D) one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

Either (1) or (2):

1. after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings

The symptoms are not intentionally feigned or produced (as in factitious disorder or malingering).

What is Somatic Symptom Disorder

Somatic symptom disorder is a recently defined diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) ¹. Somatic symptom disorder has replaced what was formerly known as “somatization disorder” in previous editions of the diagnostic and statistical manual of mental disorders (DSM). It reflects a great understanding and more knowledge about what was previously known about this condition and psychosomatic symptoms.

Somatic symptom disorder involves a person having a significant focus on physical symptoms, such as pain, weakness or shortness of breath, accompanied by excessive thoughts, emotion, and/or behavior related to the symptom, which causes significant distress and/or dysfunction ². Somatic symptom disorder results in major distress and/or problems functioning ³. The individual has excessive thoughts, feelings and behaviors relating to the physical symptoms. The physical symptoms may or may not be associated with a diagnosed medical condition, but the person is experiencing symptoms and believes they are sick (that is, not faking the illness).

The two major changes to the DSM-4 criteria included eliminating the requirement that somatic symptoms be organically unexplained and adding the requirement that certain psychobehavioral features have to be present to justify the diagnosis. The new criteria also eliminated somatization disorder, undifferentiated somatoform disorder, hypochondriasis, and pain disorder from the previous definitions. These revisions were intended to increase the relevance of somatic symptom disorder and its use in the primary care setting.

A person is not diagnosed with somatic symptom disorder solely because a medical cause can’t be identified for a physical symptom. The emphasis is on the extent to which the thoughts, feelings and behaviors related to the illness are excessive or out of proportion.

People with somatic symptom disorder typically go to a primary care provider rather than psychiatrist or other mental health professional. Sometimes it can be difficult for individuals with somatic symptom disorder to understand that their concerns about their symptoms are excessive. They may continue to be fearful and worried even when they are shown evidence that they do not have a serious condition. Somatic symptom disorder usually begins by age 30.

The prevalence of somatic symptom disorder is estimated to be 5% to 7% of the general population, with higher female representation (female-to-male ratio 10:1), and can occur in childhood, adolescence, or adulthood ². The prevalence increases to approximately 17% of the primary care patient population ⁴. The prevalence is likely higher in certain patient populations with functional disorders including fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome ⁵.

Somatic symptom disorder key facts

• Somatic symptom disorder involves being distressed or having one’s life disrupted by concerns involving physical symptoms when there is no obvious physical or medical cause for the symptoms.
• A person with somatic symptom disorder may worry excessively over certain health sensations and symptoms, such as stomach pain, that generally healthcare professionals cannot explain. A person with somatic symptom disorder may believe the sensation indicates a serious illness, like stomach cancer, although they may not have objective evidence from a doctor to substantiate that concern.
• A person with somatic symptom disorder may go to great lengths to attend to or to investigate their health symptoms. They typically will visit multiple doctors and multiple specialists in an effort to have their physical symptoms properly diagnosed and explained. Many doctors feel like a patient with this condition may be “faking” or exaggerating their symptoms or their severity.
• The diagnostic criteria for somatic symptom disorder states that the person must exhibit signs of the condition (e.g., concern over physical health or anxiety over somatic sensations) for at least 6 months, although the actual pain or symptom does not have to be present the entire duration. For most people with this concern, the symptoms are serious enough to cause significant problems in multiple aspects of their life. Additionally, most have tried multiple forms of treatment with little or no success.
• Before a person is diagnosed with somatic symptom disorder, a full medical workup and physical examination is warranted, to rule out any medical or physical causes. For instance, some types of cancer can have unusual symptom presentations that may be left undiagnosed by inexperienced healthcare providers.

How can family members best support and help someone with somatic symptom disorder?

Somatic symptom disorder is a complex illness that calls for consistent and reassuring relationships with confident and supportive healthcare providers. Often at the center is uncertainty and lack of trust in one’s own ability to tell the difference between normal bodily sensations and those that signal harm. It can be very challenging for individuals, family members and healthcare professionals alike to tell if new symptoms relate to a major illness or routine feelings of discomfort.

Further complicating the picture is the fact that often people with the disorder have ongoing chronic illnesses which can change and worsen over time. The art of managing somatic symptom disorders is therefore balancing the need for a prudent medical evaluation with over-diagnosis and over-treatment. This balance can only be achieved through a trusting relationship with a knowledgeable clinician, usually a primary care provider or primary care team.

Family members can assist an individual with somatic symptom disorders with ongoing support and understanding, and encouragement of stable and consistent healthcare relationships. Additionally, family members can help to follow treatment plans that aim to avoid urgent and emergent medical care settings in favor of outpatient appointments with a consistent provider. Family can also assist the person suffering to track and record symptom information for later discussion with his/her provider. Family members can also play a valuable role in reassurance and communication with the person’s healthcare team.

Is somatic symptom disorder the same as being a hypochondriac?

Firstly – the term hypochondriac is a loaded term that rarely opens doors to quality conversations about what is going on and what problems are supposed to be fixed. Secondly – and to answer the question – No. Persons with Illness Anxiety Disorder (newer term for ‘hypochondriasis’) do not usually complain of symptoms, but rather express an intense fear of becoming ill. Consequently, they focus on monitoring for the onset of a feared illness, or avoiding exposure to situations which could lead to illness.

My wife has been diagnosed with somatic symptom disorder. She continues to get angry with doctors and can’t accept that they can’t find anything physically wrong. What can I do to get her to accept help?

As mentioned above, the name of the game is balancing prudent medical investigations and treatments with over-diagnosis and treatment. The ultimate shared fear of patients and healthcare providers dealing with somatic symptom disorders is that we’ve all gotten it wrong – that we’ve missed a rare disease and caused undue suffering and/or death as a result. Put another way – that we’ve identified something as being “all in their head” when, in fact, they weren’t “making it up”. Experienced clinicians reassure their patients that, though the tests run so far have been normal, it doesn’t necessarily mean that what the patient is experiencing isn’t happening. I frame normal lab tests as reassurance that nothing catastrophic is going on, highlight the number of diagnoses that we’ve “ruled out” as a result and pledge support to continue to work with the patient to improve functionality and monitor symptoms for any change in quality or quantity warranting further investigation.

It’s important to also acknowledge the toll these symptoms can take in loss of functioning, and to express empathy with the shared fear and confusion that inevitably occur with these disorders. Spouses and family members can take the same approach. Avoid direct confrontation about the truthfulness of the symptoms and help the person identify creative and practical solutions and coping strategies that can minimize the problems caused by the symptoms. Recognizing the emotional toll of feeling isolated through this process and encouraging attention to mental health concerns that could be framed as “side effects” of these symptoms may be a segue into more formal mental health treatments. Furthermore, spouses can help through the profession of unconditional love and support.

My friend is perfectly healthy but constantly worries about being seriously ill. It is really disrupting her life and keeping her from being able to enjoy life. I’d like to encourage her to get help, what should I suggest?

Focus on why you’d like her to get help by expressing your concern that you’ve lost a friend to this constant suffering. Avoid the pitfalls of sending an accidental message that it’s all “in her head” by suggesting they see a psychiatrist directly about it. Instead, find out what her needs are and helping her to seek help and guidance within her own framework. When friends and family members are completely non-judgmental with an attitude of acceptance and humility I’ve often found that the person suffering can maintain remarkable insight into the emotional and social connections of their symptoms and fears. As a friend, your role is to be supportive, and your goal should be to get your friendship back, not necessarily fix her. When viewed under this light, offerings of assistance and advice can become more palatable. A clearer, more appropriate end-goal can be established – namely to regain your friendship.

Somatic symptom disorder complications

Alcohol and drug abuse are frequently observed ⁶ and sometimes utilized to alleviate symptoms, increasing the risk of dependence on controlled substances. If the provider decides to pursue invasive diagnostic procedures or surgical interventions, iatrogenic complications may arise.

Somatic symptom disorder complications prognosis

Longitudinal studies show considerable chronicity, with up to 90% of somatic syndrome disorder cases lasting longer than 5 years ⁷. Systematic reviews and meta-analyses have revealed that therapeutic interventions only yield small-to-moderate effect sizes ⁸. Chronic limitation of general function, significant psychological disability, and decreased quality of life are frequently observed ⁷.

What causes somatic symptom disorder

Somatic symptom disorder arises from a heightened awareness of various bodily sensations, which are combined with an inclination to interpret these sensations as indicative of medical illness. While the cause of somatic symptom disorder is unclear, studies have investigated risk factors including childhood neglect, sexual abuse, chaotic lifestyle, and history of alcohol and substance abuse ². Furthermore, severe somatization has been associated with axis 2 personality disorders, particularly avoidant, paranoid, self-defeating, and obsessive-compulsive disorder ⁹. Psychosocial stressors, including unemployment and impaired occupational functioning, have also been implicated ¹⁰.

Somatic symptom disorder diagnosis

Three requirements fulfill the diagnostic criteria for somatic syndrome disorders according to the American Psychiatric Association’s 2013 DSM-5 ¹¹:

1. One or more physical symptoms (somatic symptoms) that cause significant distress or disruption in daily living
2. Excessive thoughts, feelings or behaviors related to the physical symptoms or health concerns with at least one of the following:
   • Ongoing thoughts that are out of proportion with the seriousness of symptoms
   • Ongoing high level of anxiety about health or symptoms
   • Excessive time and energy spent on the symptoms or health concerns
3. Symptoms lasting for more than 6 months

The presence of somatic symptom disorder may be suggested by a vague and often inconsistent history of present illness, symptoms that are rarely alleviated with medical interventions, patient attribution of normal sensations as medical illness, avoidance of physical activity, high sensitivity to medication adverse effects, and medical care from multiple providers for the same complaints.

In addition to a thorough history, a full review of systems (not only at the location of the symptom) and a comprehensive physical exam is required to evaluate for physical causes of somatic complaints. Given frequent comorbid psychiatric disease, a mental status examination should be performed, noting appearance, mood, affect, attention, memory, concentration, orientation, the presence of hallucinations or delusions, and suicidal or homicidal ideation ¹². Ultimately, the physical examination may provide a baseline for monitoring over time, assure patients that their complaints are acknowledged, and help validate the primary care provider’s concern that the patient does not have a physical medical illness. If a disease is present, the exam may provide information on severity.

Limited laboratory testing is recommended as it is common for patients with somatic syndrome disorder to have had a thorough prior workup ¹³. Excessive testing introduces the risk of false-positive results which can subsequently lead to additional interventional procedures, its associated risks, and increased costs. While some clinicians order tests to provide reassurance to the patient, studies reveal that such diagnostic testing does not alleviate somatic symptom disorder symptoms. A meta-analysis by Rolfe and colleagues compared diagnostic testing versus a non-testing control condition, demonstrated that resolution of somatic symptoms and reduction of illness concern and anxiety was comparable between both groups. There was only a modest decrease in subsequent visits in the group that received diagnostic testing ¹⁴.

If it is necessary to rule out somatization due to medical conditions, specific studies may be ordered, including but not limited to thyroid function tests, urine drug screen, limited blood studies (i.e., alcohol level), and limited radiological testing.

Conversion disorder vs somatization

Conversion disorder is a mental illness when neurological symptom exists without an explanation. Conversion disorder is also known as functional neurological symptom disorder or in the past hysterical neurosis, is a condition in which symptoms affect a person’s perception, sensation or movement with no evidence of a physical cause. A person may have numbness, blindness, trouble walking, paralysis or general nervous system malfunctions. The symptoms tend to come on suddenly and may last for a while or may go away quickly. People with conversion disorder also frequently experience depression or anxiety disorders.

Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).

The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally-sanctioned behavior or experience.

The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.

Here are 16 signs and symptoms of conversion disorder:

1. You experience sudden blindness.
2. You can’t speak.
3. You experience numbness.
4. You suffer from paralysis.
5. You can’t control your movements.
6. You experience sudden hearing loss.
7. You have body weakness.
8. You lose your sense of balance.
9. You have difficulty swallowing or have a continuous lump in the throat.
10. You experience seizures and/or convulsions.
11. You have a pre-existing medical illness.
12. You already suffer from a dissociative disorder and/or a personality disorder.
13. You have a family member who has conversion disorder.
14. You have a history of physical or sexual abuse or neglect in childhood.
15. You have a neurological disease that has similar symptoms, such as epilepsy.
16. You’re female — women are much more likely to develop the condition than men.

The most recommended treatment for conversion disorder is talk therapy (psychotherapy) and/or hypnosis ¹⁵. Hypnosis may effect a remission; however, early
relapses tend to occur. Another approach involves viewing the symptoms as a kind of “sign language,” deciphering what the sign means, and then assisting the patient in putting that meaning into words and taking appropriate action. Such an approach is often labor intensive, yet the clinical impression is that it may produce solid results.

Somatization disorder treatment

Treatment for somatic symptom disorder is intended to help control symptoms and help the person function as normally as possible.

Treatment for somatic symptom disorder typically involves the person having regular visits with a trusted health care provider. The provider can offer support and reassurance, monitor heath and symptoms and avoid unnecessary tests and treatments. Psychotherapy (talk therapy) can help the individual change their thinking and behavior, and learn ways to cope with pain or other symptoms, deal with stress and improve functioning.

The primary objective is to help the patient cope with physical symptoms, including health anxiety and maladaptive behaviors, as opposed to eliminating the symptoms. Caution must be exercised when conveying to patients that their physical symptoms are exacerbated by anxiety or excessive emotional problems as patients may be resistant to this suggestion. The primary care provider should schedule regular visits to reinforce that symptoms are not suggestive of a life-threatening or disabling medical condition ¹⁶. Diagnostic procedures and invasive surgical treatment are not recommended. Sedative medications, including benzodiazepines and narcotic analgesics, are avoided. Early psychiatric treatment is recommended. Studies have shown that cognitive-behavioral therapy (CBT) is associated with significant improvement in patient-reported functioning and somatic symptoms, a decrease in health care costs ¹⁷ and a reduction in depressive symptoms ¹⁸.

Somatization disorder treatment medication

Antidepressant or anti-anxiety medications can be useful if the person is also experiencing depression or anxiety. Pharmacologic approaches should be limited, but antidepressants can be initiated to treat psychiatric comorbidities (anxiety, depressive symptoms, obsessive-compulsive disorder). Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have shown efficacy with an improvement of somatic symptom disorder compared to placebo ¹⁹. However, medications should be initiated at the lowest dose and increased slowly to achieve a therapeutic effect as patients with somatic symptom disorder may have a low threshold for perceiving adverse effects, introducing another source of concern.

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