Somatoform Disorders

» Psychiatry

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