Somatoform Disorders

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Clinical Manifestations
Patients with multiple somatic complaints that cannot be explained by a known medical condition or by the effects of alcohol or of recreational or prescription drugs are commonly seen in primary care practice; one survey indicates a prevalence of such complaints of 5%. In somatization disorder, the patient presents with multiple physical complaints referable to different organ systems (Table 371-13). Onset is usually before age 30, and the disorder is persistent.

Formal diagnostic criteria require the recording of at least four pain, two gastrointestinal, one sexual, and one pseudoneurologic symptom. Patients with somatization disorder often present with dramatic complaints, but the complaints are inconsistent. Symptoms of comorbid anxiety and mood disorder are common and may be the result of drug interactions due to regimens initiated independently by different physicians.

Patients with somatization disorder may be impulsive and demanding and frequently qualify for a formal comorbid psychiatric diagnosis. In conversion disorder, the symptoms focus on deficits that involve motor or sensory function and on psychological factors that initiate or exacerbate the medical presentation. Like somatization disorder, the deficit is not intentionally produced or simulated, as is the case in factitious disorder (malingering). In hypochondriasis, the essential feature is a belief of serious medical illness that persists despite reassurance and appropriate medical evaluation. As with somatization disorder, patients with hypochondriasis have a history of poor relationships with physicians stemming from their sense that they have been evaluated and treated inappropriately or inadequately. Hypochondriasis can be disabling in intensity and is persistent, with waxing and waning symptomatology.

In factitious illnesses, the patient consciously and voluntarily produces physical symptoms of illness. The term Munchausen’s syndrome is reserved for individuals with particularly dramatic, chronic, or severe factitious illness. In true factitious illness, the sick role itself is gratifying. A variety of signs, symptoms, and diseases have been either simulated or caused by factitious behavior, the most common including chronic diarrhea, fever of unknown origin, intestinal bleeding or hematuria, seizures, and hypoglycemia. Factitious disorder is usually not diagnosed until 5 to 10 years after its onset, and it can produce significant social and medical costs. In malingering, the fabrication derives from a desire for some external reward, such as a narcotic medication or disability reimbursement.

Treatment
Patients with somatization disorders are frequently subjected to multiple diagnostic testing and exploratory surgeries in an attempt to find their “real” illness. Such an approach is doomed to failure and does not address the core issue. Successful treatment is best achieved through behavior modification, in which access to the physician is tightly regulated and adjusted to provide a sustained and predictable level of support that is less clearly contingent on the patient’s level of presenting distress. Visits can be brief and should not be associated with a need for a diagnostic or treatment action. Although the literature is limited, some patients with somatization disorder may benefit from antidepressant treatment. Fluoxetine and MAOIs have both been found to be useful in reducing obsessive ruminations, dysphoria, and anxious preoccupation in patients with multiple somatic complaints.

The treatment of factitious disorder is complicated in that any attempt to confront the patient usually only creates a sense of humiliation and causes the patient to abandon treatment from that caregiver. A better strategy is to introduce psychological causation as one of a number of possible explanations and to include factitious illness as an option in the differential diagnoses that are discussed. Without directly linking psychotherapeutic intervention to the diagnosis, the patient can be offered a face-saving means by which the pathologic relationship with the health care system can be examined and alternative approaches to life stressors developed.

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