The Geezer’s Dirty Dozen on Somatoform Disorders

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This is another Dirty Dozen presentation, this time on Somatoform Disorders. It can be complementary to the Dirty Dozen on Factitious Disorder and Malingering.

ADDENDUM: The DSM-5 and the book “Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5 by Dr. Allen Frances, MD have a lot to say about the somatoform disorders. The DSM-5 now has a new category called Somatic Symptom and Related Disorders into which Factitious Disorder has been subsumed. While the name Conversion Disorder is still in the DSM-5, in parentheses it’s also called Functional Neurological Symptom Disorder. Dr. Frances says “This new category is ridiculously overinclusive…” recommending it be used only when clearly necessary. My opinion is that the new DSM-5 category will not change the management recommendations from psychiatric consultants. The suggestions will still be to avoid invasive procedures, medications with the potential for toxicity and addiction, and specialist referrals unless the risk to benefit ratio is safe, favorable to the patient, and address an objectively demonstrable disease process.

Slide 3: This is just an introduction to the term “Medically Unexplained Physical Symptoms” or MUPS for short, thought to be a more neutral, descriptive term which might be more acceptable to those with the condition and less stigmatizing. By whatever name, the syndrome is associated with enormous personal and health care system costs.

Slide 4: The many faces of MUPS is listed as it occurs across multiple medical specialties. A description of Somatization Disorder is listed. This disorder, formerly called Briquet’s Syndrome, is rare and tends to be more common in women.

Slide 5: The DSM-IV diagnostic criteria for Somatization Disorder.

Slide 6: Body Dysmorphic Disorder (BDD) is really thought to be more like a obsessive-compulsive disorder (with which it is often comorbid) and there is a proposal to move it into that category rather than leave in the somatoform category in DSM-5. Conversion Disorder is very difficult to distinguish from a dissociative defense mechanism and may be linked to limbic override of somatosensory and motor cortices (see slide 6). It may be renamed “functional neurological disorder which, in my opinion, will do little to change the overall clinical management of the condition. The Feinstein paper (see reference list below) discusses functional MRI work in patients with conversion symptoms and along with the fMRI image of a patient with conversion disorder whose left hand, when stimulated, showed no activity in the primary somatosensory cortex. But increased activity was seen in that area of the brain when the patient’s right hand was stimulated: “These results suggest that patients with conversion disorder have an abnormal pattern of cerebral activation in which limbic areas (or areas richly connected to the limbic system) override the activation of the motor and sensory cortices. Precisely how this happens is unclear, but one theory holds that specific regions of the cingulate cortex may function in a mutually exclusive way. A mechanism called “reciprocal inhibition” allows each region to shut off the other during the processing of information. This is relevant to conversion disorder in that the caudal segment, responsible for willed action, may be deactivated or suppressed by the pregenual anterior cingulate cortex as it processes intense emotion.”

Slide 7: Hypochondriasis and Pain Disorder will likely be renamed and/or reclassified as noted in the slide. Cognitive behavioral therapy may be helpful for the former. Chronic Pain Disorder may be moved to Axis III.

Slide 8: This slide gives a quick overview of presenting somatization of primary depression and anxiety and Factitious Disorder and malingering (which I cover in another Dirty Dozen presentation).

Slide 9: The goals of collaborative care should be informed by the usual principles of conservative management which include regular visits to a primary care physician who will avoid exposing the patient to invasive interventions, potentially addictive and toxic medications, and consultant referrals while partnering with psychiatry in the management of comorbid depression, anxiety, and substance use disorders.

Slide 10: It may be practical to identify those who are amenable to psychosocial interventions and those who may benefit more from a management approach. It’s important in either case to attempt to communicate with patients matter-of-factly, respectfully, supportively, and to validate their suffering, which doesn’t necessarily entail always agreeing with the physical causes of their suffering.

Slide 11: This is the customary selected list of references

Slide 12: A tribute slide to one of my mentors, Dr. Russell Noyes, Jr.

Abbey, S.E., , “Somatization and somatoform disorders.”, The American Psychiatric Press Textbook of Consultation-Liaison Psychiatry, 18:369-401 .

Bass, C. and S. Benjamin (1993). “The management of chronic somatisation.” Br J Psychiatry 162: 472-480.

‘Somatisation’ is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied. In some patients this process becomes chronic (in excess of six months). Special skills and strategies are required by non-psychiatrists to manage these patients, for whom the acceptance of psychiatric treatment should be facilitated. When taking the history, doctors should be aware of psychosocial cues; thereafter they should be consistent and unambiguous in their management. An agenda should be set early on, with limits on investigations. Failure to manage this group of patients is costly, and further intervention studies are required not only to reduce health service and other costs, but also to relieve the non-monetary burden of physical and psychosocial disability on patients and their relatives.

Coffman, K. (2010). Management of somatoform disorders. Psychosomatic Medicine: An Introduction to Consultation-Liaison Psychiatry. J. J. Amos, M.D. and R. G. Robinson, M.D. New York, Cambridge University Press: 73-81.

Creed, F. and E. Guthrie (1993). “Techniques for interviewing the somatising patient.” Br J Psychiatry 162: 467-471.

Liaison psychiatrists need to interview somatising patients in a way which allows a full assessment of the problem. This can best be achieved if the psychiatrist has already discussed with the referring physician the reason for referral and what the patient has been told about it. The medical notes should always be reviewed in detail and independent data obtained from a relative or other informant. During the interview itself the psychiatrist must be prepared to use techniques which deepen rapport with the patient, who may be initially wary or hostile. The psychiatrist should attempt to establish early a treatment alliance. Special aspects of the mental state need to be noted, including the patient’s attitude to his/her symptoms and the strength with which somatic beliefs are held. Different approaches may be used according to the nature of the problem and the therapeutic style of the doctor. An awareness of these interview techniques would greatly reduce the chances of fruitless interviews with a hostile patient who believes the symptoms are being dismissed as being ‘all in the mind’.

Feinstein, A. (2011). “Conversion disorder: advances in our understanding.” Canadian Medical Association Journal 183(8): 915-920.

Feldman, M. D. and S. J. Eisendrath (1996). The spectrum of factitious disorders. Washington, DC, American Psychiatric Press.

Janca, A., M. Isaac, et al. (2006). “Towards better understanding and management of somatoform disorders.” Int Rev Psychiatry 18(1): 5-12.

Much research has recently been conducted on somatoform disorders demonstrating their clinical importance, associated health-service burden and economic cost. These conditions are often comorbid with other mental and physical disorders and particularly prevalent in primary care and general medical settings. Although culture-specific manifestations and variations of somatization occur–it is now accepted that medically unexplained somatic symptoms are a universal phenomenon. The management of somatoform disorders is generally a complex and lengthy process; however, a number of recent studies have demonstrated the effectiveness of short-term treatments such as cognitive behaviour therapy and educational interventions. Despite advances in their understanding and treatment, debate still surrounds the conceptualization and categorization of somatoform disorders, with a number of experts proposing a complete re-evaluation and reassignment of this diagnostic classification category. The following paper represents a review of recently published literature on frequency, characteristics, conceptualization, impact and management of somatoform disorders.

Noyes, R., Jr., D. R. Langbehn, et al. (1999). “Health Attitude Survey. A scale for assessing somatizing patients.” Psychosomatics 40(6): 470-478.

The authors designed an instrument, the Health Attitude Survey, to assess somatization, and administered it to over 1,000 patients attending a general medicine clinic. Within this population, a series of somatizing patients and control patients were identified for purposes of developing and testing the instrument. The 27-item scale was rapidly administered and acceptable to the patients. Based on comparisons with other measures of somatization, the instrument appeared to be a valid measure of the attitudes and perceptions of somatizing patients, and it distinguished these patients from the control subjects. The measure showed acceptable predictive value and may prove useful in clinical settings, where rapid screening is desired.

Stuart, S. and R. Noyes, Jr. (1999). “Attachment and interpersonal communication in somatization.” Psychosomatics 40(1): 34-43.

The authors review the research on childhood antecedents and personality contributions to the somatoform disorders, as well as research on social influences during adulthood. Based on these data, the authors hypothesize that somatizing patients display anxious attachment behavior that derives from childhood experiences with caregivers. Early exposure to illness increases the likelihood that distress will be manifested somatically. When under stress as adults, somatizers use physical complaints to elicit care. Somatizers’ interpersonal interactions with others, including physicians, ultimately lead to rejection that reinforces the somatizer’s belief that he or she will be abandoned. Modification of physicians’ responses to these patients may improve treatment outcomes.

Yutsy, Sean H. “Somatization”. In: Blumenfield and Strain eds. Psychosomatic Medicine, Lippincott Williams & Wilkins. 2006: 537-543.

Somatoform Disorder Quiz:

1. The prevalence of Somatization Disorder in U.S. Women is:

A. 5%

B. 13%

C. 67%

D. 0.2%-2.0%

2. Malingering is a psychiatric disorder

A. True

B. False

3. Conversion Disorder is marked by

A. fMRI brain changes

B. Medically unexplained neurological problems linked to a psychosocial stressor

C. May be more like a dissociative defense than a somatoform disorder

D. All of the above

4. Body Dysmorphic Disorder is associated with a 17% suicide rate

A. True

B. False

5. Choose the one feature not associated with Hypochondriasis

A. Worry that one has a disease

B. Does not generally respond to reassurance

C. One of the defining features is pseudologia fantastica (pathologic lying)

D.  May be responsive to SSRI and cognitive behavioral therapy

Somatoform Disorders Quiz Key:

1.. D; 2. B; 3. D; 4. A; 5. C