Somatic symptom disorder

Somatic symptom disorder is characterized by a combination of distressing symptoms and an excessive or maladaptive response or associated health concerns without significant physical findings and medical diagnosis. Patients’ suffering is authentic, and they typically experience a high level of functional impairment.

The predominance of women with somatization is significant. It has been proposed that women are more aware of their bodily sensations, have different health-seeking behaviors when faced with physical and psychological distress, and use more health care services than men (So, 2008). In particular, young women, aged 16 to 25, are more likely to receive a somatic diagnosis than men or older individuals (Huang & McCarron, 2011).

Symptoms may be initiated, exacerbated, or maintained by combinations of biological, psychological, and sociocultural factors. Somatic symptom disorder is difficult to distinguish from physical disorders with organic causes, and the patient’s history is extremely important for accurate diagnosis. Often, the patient has a comorbid psychiatric disorder such as depression, anxiety, and/or a personality disorder.

There may be a high level of medical care utilization, which rarely alleviates the patient’s concerns. Included in the most common symptoms for visits to primary care providers are chest pain, fatigue, dizziness, headache, swelling, back pain, shortness of breath, insomnia, abdominal pain, and numbness. They account for 40% of all visits to primary care providers; however, a biological cause for these symptoms is identified in only 26% of patients (Edwards et al., 2010). Health-related quality of life is frequently severely impaired, and patients appraise their bodily symptoms as unduly threatening, harmful, or troublesome, often fearing the worst about their health.

Some patients feel that their medical assessment and treatment have been inadequate. When the health care provider is unable to provide a clear diagnosis for discomfort, patients can feel discounted and misunderstood. These patients tend to be devalued, stigmatized, and told that the problem is only in their heads (Noyes et al., 2010).

Likewise, health care workers experience frustration in providing care for people who are not organically ill. Providers tend to use less patient-centered communication in comparison to patients with straightforward symptoms, even though somatic symptom visits are longer (Huang & McCarron, 2011). A “difficult” patient may receive a somatic diagnosis more readily than a “pleasant” patient, which could contribute to an inadequate workup. Studies show that the strongest predictor of misdiagnosing somatic disorders is the primary care provider’s dissatisfaction with the clinical encounter (Huang & McCarron, 2011).

Illness anxiety disorder

Previously known as hypochondriasis, illness anxiety disorder results in the misinterpretation of physical sensations as evidence of a serious illness. Illness anxiety can be quite obsessive as thoughts about illness may be intrusive and hard to dismiss even when the patients realize their fears are unrealistic (MacDonald, 2011). People experience extreme worry and fear about the possibility of having a disease. Even normal bodily changes, such as a change in heart rate or abdominal cramps, can be seen as red flags for serious illness.

In response to these symptoms, primary care providers may suggest a consultation with a mental health professional, but the suggestion is typically refused. The course of the illness is chronic and relapsing, with symptoms becoming amplified during times of increased stress (Braun et al., 2010). Depression may play a role. Consider the case of a 72-year-old woman with illness anxiety who was treated with electroconvulsive therapy (ECT), a treatment most often used for depression. After one session her somatic complaints stopped abruptly. This patient’s success with ECT may indicate that depressive symptoms may have been the catalyst for her symptoms, leading to the diagnosis of illness anxiety (Dols et al., 2012)

Overall, the illness anxiety patient uses about 41% to 78% more health care services per year, excluding laboratory tests and x-rays prescribed in primary care, than patients with well-defined medical conditions (Fink, 2010). As illness anxiety is so prevalent, it is important that clinicians achieve basic skills in treating and identifying this disorder. If patient health concerns are addressed at an early stage, repeated consultations, multiple trials of medications, and medical examinations may be prevented (Fink, 2010). Frequent exposure to media messages reminding us to seek regular medical screenings may also contribute to fears about health (MacDonald, 2011). Studies show a relationship between exposure to breast cancer coverage in television programs to heightened fear of breast cancer (Lemal & den Bulck, 2009).

Conversion disorder

Conversion disorder (also known as functional neurological disorder) manifests itself as neurological symptoms in the absence of a neurological diagnosis (Feinstein, 2011). Conversion disorder is marked by the presence of deficits in voluntary motor or sensory functions, including paralysis, blindness, movement disorder, gait disorder, numbness, paresthesia (tingling or burning sensations), loss of vision or hearing, or episodes resembling epilepsy.

Conversion disorder is a clinical problem that requires the application of multiple perspectives—biological, psychological, and social—to fully understand the symptoms of individual patients. Patients with conversion disorder symptoms may be found to have “no neurological disorder” by the neurologist and “no psychiatric disorder” by the psychiatrist (Stone et al., 2010).

Conversion disorder is attributed to channeling of emotional conflicts or stressors into physical symptoms; however, some MRI studies suggest that patients with conversion disorder have an abnormal pattern of cerebral activation (Feinstein, 2011). Many patients show a lack of emotional concern about the symptoms (la belle indifference) although others are quite distressed. Imagine someone casually discussing sudden blindness. Care providers should assume there is an organic cause to the symptoms until physical pathology has been ruled out. Patients truly believe in the presence of the symptoms; they are not fabricated or under voluntary control.

Childhood physical or sexual abuse is common in patients with conversion disorder, and comorbid psychiatric conditions include depression, anxiety, posttraumatic stress disorder, other somatic disorders, and personality disorders. There are also cases in which a comorbid medical or neurological condition exists, and the conversion disorder is an exaggeration of the original problem (Nicholson et al, 2011).

The course of the disorder is related to its acuity. In cases with acute onset during stressful events, remission rate is high; in cases with a more gradual onset, the disorder is not readily treated. Cases generally remit by themselves 95% of the time (Sadock & Sadock, 2008). Recurrence is as high as 25%, often within the first year.

Psychological factors affecting medical condition

Both the medical and mental health communities recognize the interrelationships between psychiatric and medical comorbidities. Psychological factors may present a risk for medical disease, or they may magnify and/or adversely affect a medical condition. Studies in recent years have contributed to the growing body of evidence for links between mental disorders and cardiovascular disease; in particular, major depressive disorder is now seen as a risk factor in the occurrence of coronary heart disease (Charlson et al., 2011). Also, a link between a history of depression and cancer incidence has been postulated since the time of the ancient Greeks, with statistical evidence reported as early as 1893. A recent study on depression as a risk factor for the incidence of cancer, conducted between 1981 and 2005, showed a significant relationship between history of depression and risk of overall cancer (Gross et al., 2010)

Stress is certainly a psychological factor that can affect the disease process. Hans Selye (1956) was the first to introduce the concept of stress into the fields of medicine and physiology. Stress can lead to changes in physical and mental health in many ways. Cannon’s identification of the fight-or-flight response (1914) and Selye’s description of the general adaptation syndrome provided insight into the biological and molecular reactions to stressors in the sympathetic nervous system, the pituitary-adrenocortical axis, and the immune system. Extensive studies have left little doubt that psychosocial stress can affect the course and severity of illness (Table 17-1).

Chronic stressors cause components of the immune system to be affected in detrimental ways. Research in the field of psychoneuroimmunology has provided insights into the relationship between psychological and physiological health in human immunodeficiency virus (HIV) and other diseases (Temoshok et al., 2008). This research explains the negative impact of perceived stress on HIV disease progression, primarily as a function of immunosuppression mediated by elevated cortisol. Being able to reduce the stress response within this patient population is important because we can potentially positively affect not only the quality of life but also the illness trajectory of persons living with HIV. A variety of other medical disorders have been studied with regard to the effects of stress on the course of the illness. In fact, anyone experiencing a serious medical condition needs a variety of supports and may benefit from learning new coping skills.

Any abnormality in the structure of the brain or the function of the neurotransmitters can lead to a misinterpretation of ordinary events. For example, the brain may misunderstand (or amplify) a stimulus, identifying a minor gas pain as a serious abdominal injury (somatization); the brain may also overreact in its analysis of the stimulus, deciding that the same minor gas pain is a sign of colon cancer (illness anxiety).

Remember that research into anxiety disorders has demonstrated structural changes in the brain that may result from prolonged stress or trauma as well as imbalances in neurotransmitters. In the case of anxiety disorders, these abnormalities create altered feeling and thinking processes whereas the processes of perception and interpretation of bodily sensations are fairly intact. It is not known why some patients develop an anxiety disorder and others develop a somatic symptom disorder.

Biological factors

Somatic disorders tend to run in families, occurring in 10% to 20% of first-degree female relatives of women with somatization disorder (Sadock & Sadock, 2008). Twin studies show an increased risk of conversion disorder in monozygotic twin pairs. First-degree biological relatives of people with chronic pain disorder are more likely to have chronic pain, depressive disorder, and alcohol dependence.

Psychological factors

Environmental factors

We know that adverse childhood events result in lifelong problems, including somatization disorders. The Adverse Childhood Experiences Study (ACE) (Fuller-Thomson et al., 2011) surveyed more than 16,000 adults and discovered that childhood trauma exposure accounted for negative outcomes across a variety of diagnoses in later life, including multiple somatic symptoms diabetes, heart disease, cancer, gastrointestinal conditions, and immune functioning. Childhood maltreatment has been associated with elevated levels of C-reactive protein, a biomarker of inflammation that may play a role in autoimmune diseases in adults 20 years later (Dube et al., 2009). The Evidence-Based Practice Box provides more information on the connection between childhood trauma and subsequent somatization.

Cultural considerations

The type and frequency of somatic symptoms vary across cultures. Burning hands and feet or the sensation of worms in the head or ants under the skin is more common in Africa and southern Asia than in North America. Alteration of consciousness with falling is a symptom commonly associated with culture-specific religious and healing rituals. Somatization disorder, which is rarely seen in men in the United States, is often reported in Greek and Puerto Rican men, which suggests that cultural customs may permit these men to use somatization as an acceptable approach to dealing with life stress. Somatization related to posttraumatic stress and depression was the most prevalent psychiatric symptom in North Korean defectors to South Korea (Kim et al., 2011)

West Indians (Caribbean) attribute somatic symptoms to chronic overwork and the irregularity of daily living, citing symptoms such as dizziness, fatigue, joint pain, and muscle tension. Patients from Korea may explain some distress as “hwa-byung,” a syndrome of both somatic and depressive symptoms, commonly attributed to suppressed anger or rage (Edwards et al., 2010).

In some cultures, certain physical symptoms are believed to result from the casting of spells. Spellbound individuals often seek the help of traditional healers in addition to modern medical staff. The medical provider may diagnose a non–life-threatening somatic symptom disorder whereas the traditional healer may offer an entirely different explanation and prognosis. The individual may not show improvement until the traditional healer removes the spell.

In contemporary Western culture, there has been unprecedented growth and comfort in the past few decades; however, levels of health have not increased. Core values such as materialism, consumerism, and individualism may be damaging to individuals’ sense of well-being and health, including a high incidence of somatization. A study of children reared in the United States from 1970 through the 1990s shows these adults as tolerant, confident, open-minded and ambitious, but also cynical, depressed, lonely, and anxious, characteristics that contribute to the development of somatic symptomatology (Carlisle & Hanlon, 2007).

Abraham Maslow in his “hierarchy of needs” theorizes that humans are inclined to shift attention to higher-level needs (social, intellectual, spiritual) once lower-level needs of food, shelter, and clothing are attained; however, Western consumer culture has become extremely adept at persuading people to remain fixated upon materialism, resisting movement to higher-level needs such as love, belonging, and respect for others (Schumaker, 2007). This current consumer culture of individualism with decreased interest in family/group needs negatively impacts supportive development of communities, socialization, and overall mental and physical health, including somatic responses of individuals.

In addition, somatization among the immigrant population in the United States in primary care is significantly related to traumatic events (see Considering Culture box). Immigrants frequently experience multiple traumatic events, both intentional and unintentional, in premigration as well as postmigration life. A study of asylum seekers reported 79% had experienced a traumatic event such as witnessing killings, being assaulted, or suffering torture and captivity. It is important for primary care providers evaluating immigrants to be aware of the possible link between somatization symptoms reported by the patient and undisclosed traumatic experiences (Aragona et al., 2010).

Patients across cultures with somatic symptoms often offer clues about their underlying concerns and want more emotional support from their health care provider in comparison to other patients, and they are most satisfied with their care when their health care provider shares their understanding of the presenting problems and treatment options (Edwards et al., 2010).