Armando Hasudungan
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Somatoform Disorders

Overview

Overview Doctors and patients often experience frustration and helplessness in consultations around medically unexplained symptoms. Up to 50 percent of primary care patients present with physical symptoms that cannot be explained by a general medical condition. Although most do not meet the strict psychiatric diagnostic criteria for one of the somatoform disorders, they can be referred to as having “somatic preoccupation,”. The unexplained symptoms of somatoform disorders often lead to general health anxiety. Common underlying diagnoses include major depression, panic disorder and dysthymia.

Definition
Somatisation: Patient experiences and seeks medical help for medically unexplained somatic symptoms and distress which they consider to have arisen from a physical cause

Types

The somatoform disorders are a group of psychiatric disorders that cause unexplained physical symptoms. They include:

  • Somatization disorder
  • Undifferentiated somatoform disorder
  • Conversion disorder
  • Pain disorder
  • Hypochondriasis
  • Body dysmorphic disorder
  • Somatoform disorder not otherwise specified
Somatoform disorders Features
Somatisation disorder A form of chronic somatisation characterised by multiple symptoms in various domains over many years, starting before age 30
Undifferentiated somatoform disorder A sub-syndromal form of somatisation disorder: one or more physical complaints, lasting more than six months, not fully explained by a medical condition, or in excess of what would be expected from findings
Pain disorder Significant pain, with psychological factors important in the onset, severity, exacerbation or maintenance of the pain
Conversion disorder Neurological symptoms or deficits not fully explained by organic causes and when psychological factors are associated with the initiation or exacerbation of the condition
Hypochondriasis Preoccupation with fears of having a serious illness, based on the misinterpretation of bodily symptoms, persisting despite appropriate medical assessment and reassurance
Somatoform disorder not otherwise specified Sub-syndromal somatising conditions lasting less than six months
Body dysmorphic disorder Preoccupation with an imagined defect in appearance, associated with significant distress or impairment

Risk Factors

  • Female
  • Sexual Abuse
  • Childhood adversity

Signs and Symptoms

Remember It is most important to adopt a flexible and empathic approach to the patient.

There are no symptoms specific to somatisation. Symptoms can include:

  • Headaches
  • Diffuse pain
  • Abdominal discomfort
  • Bloating/excessive gas
  • Constipation or diarrhoea
  • Dizziness
  • Palpitations
  • Chest pain
  • Difficulty swallowing
  • Dyspareunia
  • Marked period pain
  • Excessive menstrual bleeding
  • Difficulty urinating
  • Fatigue
  • Nausea
Tips for interviewing somatising patients
Use empathic comments, such as “You’ve clearly had a terrible time”
Listen attentively
Let the patient tell their story
Ask open-ended questions
Minimise interruptions
Remember Common forms of somatisation seen in general practice include somatic presentations of underlying psychiatric disorders, hypochondriasis and patients with medically unexplained symptoms

Differential Diagnosis

  • Undiagnosed medical condition
  • Underlying psychiatric disorder
  • Malingering
  • Factitious disorder
Malingering is when the patient is intentionally producing symptoms for external gain, such as avoiding legal consequences.
Factitious disorder is when the patient intentionally produces symptoms not for external gain, but for the less obvious benefits of the sick role. These patients often have a history of health training and often have features suggestive of a borderline personality disord

Investigations

  • Avoid unnecessary medical tests and specialty referrals, and be cautious when pursuing new symptoms with new tests and referrals
  • Assess for mental illness

Management

In chronic somatisers, the aim is care, not cure. Focus on coping, not symptoms

  • Maintain a good doctor-patient relationship
  • Cognitive behavioural therapy
  • Mindfulness
  • Dynamic psychotherapy
  • +/- treat underlying mental illness
  • Schedule regular, brief follow-up office visits with the patient

References

Australian Doctor 20 July 2007 – The somatising patient
Oliver, O., Paltoo, C., & Greengold, J. (2007). Somatoform Disorder. American Family Physician. 76 (9). 1333-1338.
Stone, L. (2014). Blame, shame and hopelessness: medically unexplained symptoms and the ‘heartsink’ experience. Australian Family Physician. vol. 43 (4). 191-195.