Somatoform disorders involve unexplained physical symptoms that bring significant distress and functional impairment. They present one of the more common and most difficult problems in primary care. They are seldom “cured” and should be approached as a chronic disease. Recognition, a patient-centered approach, and specific treatments may help alleviate symptoms and distress. Factitious disorder and malingering, although not true somatoform disorders, are addressed separately in this chapter because of their similarity in the form of medically unexplained symptoms.

Features that characterize the spectrum of somatoform disorders include the following:

• Physical symptoms or irrational anxiety about illness or appearance, for which biomedical findings are not consistent with a general medical condition. Somatoform disorders have specific courses, symptoms, and complaints (Table 55-1).
  
• Symptoms develop with or are worsened by psychological stress, and are not intentional.
  
• Extensive utilization of medical care. Paradoxically, treatment and attempts to reassure patients can be counterproductive.
  
• Feelings of frustration on the part of the physician. Patients are often seen as “difficult patients.”

Somatic expression of psychological distress can be normal, and degree of dysfunction determines whether the symptoms constitute a disorder. Furthermore, symptoms may be sufficient to suggest that the patient’s condition is better described by a primary or comorbid mental disorder that may respond to specific therapies.

Presentations of illness without complete physical explanation have a significant impact on primary care practice. Ten percent of all medical services are provided to patients with no organic disease. Twenty-six percent of primary care patients meet criteria for somatic “preoccupation”: 19% of patients have medically unexplainable symptoms and 25%-50% of visits involve symptoms that have no serious cause. Where true somatoform disorders are present, symptoms persist much longer and the cost of ambulatory care is 9-14 times greater than in controls. Individuals with somatoform disorders undergo numerous medical examinations, diagnostic procedures, surgeries, and hospitalizations. They risk increased morbidity from these procedures. Eighty-two percent stop working at some point because of their difficulties. With appropriate recognition and treatment, costs of care may be reduced by 50%.

To some degree, somatic symptoms related to psychological and emotional states are common and should be considered normal. Examples include the experience of anger through jaw tightening, tension through shoulder stiffening, loss or grief through chest discomfort, disappointment or fear through a sinking feeling in the gut, and shame through a reddening of the face, and so on. Children often feel ill when they learn that a friend is sick or when family stress is high. An example of nonpathologic fear of having a disease is “student’s syndrome,” perception of medical students in pathology class that every symptom they experience could represent a serious diagnosis.

Genetic factors, demonstrated in adoption studies, appear to play a role in the development of somatic sensitivities and obsessive tendencies. Traumatic experiences in the form of sexual, physical, and emotional abuse and witnessing violence are predictive of somatoform disorders. Operant reinforcements and classically conditioned associations will also play a role, both in changes in perception of physical sensations and in pain-related behaviors. In particular, some individuals are susceptible to overexperiencing sensations. This phenomenon may occur through a difference in neuron gating, in which the threshold of firing is reduced by anxiety or psychological stress. Patients with hypochondriasis can experience a cycle of symptom amplification whereby obsession about the body focuses attention on sensations, which causes anxiety, increasing sensations and further worsening obsessiveness. Other disorders, such as body dysmorphic disorder, may be related to obsessive-compulsive disorders or even a mild thought disorder.

Because families differ in how they respond to symptoms and illnesses, individual differences in health beliefs and illness-related behaviors are to be expected. Families also shape the tendency to experience, display, and magnify somatic symptoms; thus, somatoform disorders or malingering in children may be modeled or reinforced by adults. Social risk factors include single parenthood, living alone, unemployment, and marital and job difficulties.

Gender ratios and prevalence of somatoform disorders differ across cultures. In North America, somatization, conversion, and pain disorders are more frequent in women whereas hypochondriasis and body dysmorphic disorder involve men and women equally. Somatoform symptoms are more prevalent among Chinese American, Asian, and South American patients. These differences are most likely due to Western/empirical explanatory models contrasted with culturally based understandings in which ancient people’s associations of phenomena and symptoms still affect the beliefs and expectations of modern populations.

Disorders with somatoform characteristics specific to certain cultures include the dhat syndrome in India, which is a concern about semen loss, and koro in Southeast Asia, a preoccupation that the penis will disappear into the abdomen. A sense of having worms in the head or burning hands is sometimes reported by people in Africa and Southeast Asia. Cultures influence how emotions should be expressed and sanction religious and healing rituals that may appear conversion-like. Thus, somatoform-like symptoms should be evaluated for appropriateness to the patient’s social context. Behaviors sanctioned by the culture are typically not considered pathologic.

Symptoms and Signs

Diagnosis of somatoform disorders involves both exclusion of general medical conditions and inclusion of somatoform features. The following features should increase suspicion of a somatoform presentation:

• Unexplained symptoms that are chronic or constantly change.
  
• Multiple symptoms. Fainting, menstrual problems, headache, chest pain, dizziness, and palpitations are the symptoms most likely to be somatoform.
  
• Vague or highly personalized, idiosyncratic complaints.
  
• Inability of more than three physicians to make a diagnosis.
  
• Presence of another mental disorder, especially depressive, anxiety, or substance use disorders.
  
• Distrust toward the physician.
  
• Physician experience of frustration.
  
• Paradoxic worsening of symptoms with treatment.
  
• High utilization, including repeated visits, frequent telephone calls, multiple medications, and repeated subspecialty referrals.
  
• Disproportionate disability and role impairment.

Diagnostic Criteria

Somatoform disorders are mental disorders that involve physical symptoms or irrational anxiety about illness or appearance, and for which biomedical findings are not consistent with a general medical condition. Specific diagnosis requires that the symptoms have brought unneeded medical treatment or significant impairment in social, occupational, or other important areas of functioning. Somatoform disorders cannot be caused by a general medical condition or by direct effects of substances. If the disorder occurs in the presence of a general medical condition, complaints or impairment must be in excess of what would be expected from the physical findings and history. Although somatoform disorders may occur concurrently with other mental disorders, other diagnoses such as depression or anxiety may be sufficient to supersede the somatoform diagnosis.

Somatization Disorder