The somatoform disorders are a group of mental disturbances placed in a common category on the basis of their external symptoms. These disorders are characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder. In order to meet the criteria for a somatoform disorder, the physical symptoms must be serious enough to interfere with the patient's employment or relationships, and must be symptoms that are not under the patient's voluntary control.
It is helpful to understand that the present classification of these disorders reflects recent historical changes in the practice of medicine and psychiatry. When psychiatry first became a separate branch of medicine at the end of the nineteenth century, the term hysteria was commonly used to describe mental disorders characterized by altered states of consciousness (for example, sleepwalking or trance states) or physical symptoms (for example, a "paralyzed" arm or leg with no neurologic cause) that could not be fully explained by a medical disease. The term dissociation was used for the psychological mechanism that allows the mind to split off uncomfortable feelings, memories, or ideas so that they are lost to conscious recall. Sigmund Freud and other pioneering psychoanalysts thought that the hysterical patient's symptoms resulted from dissociated thoughts or memories reemerging through bodily functions or trance states. Prior to the categorization all mental disorders that were considered to be forms of hysteria were grouped together on the basis of this theory about their cause. Since 1980, however, the somatoform disorders and the so-called dissociative disorders have been placed in separate categories on the basis of their chief symptoms. In general, the somatoform disorders are characterized by disturbances in the patient's physical sensations or ability to move the limbs or walk, while the dissociative disorders are marked by disturbances in the patient's sense of identity or memory.
As a group, the somatoform disorders are difficult to recognize and treat because patients often have long histories of medical or surgical treatment with several different doctors. In addition, the physical symptoms are not under the patient's conscious control, so that he or she is not intentionally trying to confuse the doctor or complicate the process of diagnosis. Somatoform disorders are, however, a significant problem for the health care system because patients with these disturbances overuse medical services and resources.
Somatization disorder (Briquet's syndrome)
Somatization disorder was formerly called Briquet's syndrome, after the French physician who first recognized it. The distinguishing characteristic of this disorder is a group or pattern of symptoms in several different organ systems of the patient's body that cannot be accounted for by medical illness. The criteria for this disorder require four symptoms of pain, two symptoms in the digestive tract, one symptom involving the sexual organs, and one symptom related to the nervous system. Somatization disorder usually begins before the age of 30. It is estimated that 0.2% of the United States population will develop this disorder in the course of their lives. Another researcher estimates that 1% of all women in the United States have symptoms of this disorder. The female-to-male ratio is estimated to range between 5:1 and 20:1.
Somatization disorder is considered to be a chronic disturbance that tends to persist throughout the patient's life. It is also likely to run in families. Some psychiatrists think that the high female-to-male ratio in this disorder reflects the cultural pressures on women in North American society and the social "permission" given to women to be physically weak or sickly.
Conversion disorder is a condition in which the patient's senses or ability to walk or move are impaired without a recognized medical or neurological disease or cause and in which psychological factors (such as stress or trauma) are judged to be temporarily related to onset or exacerbation. The disorder gets its name from the notion that the patient is converting a psychological conflict or problem into an inability to move specific parts of the body or to use the senses normally. An example of a conversion reaction would be a patient who loses his or her voice in a situation in which he or she is afraid to speak. The symptom simultaneously contains the anxiety and serves to get the patient out of the threatening situation. The resolution of the emotion that underlies the physical symptom is called the patient's primary gain, and the change in the patient's social, occupational, or family situation that results from the symptom is called a secondary gain. Doctors sometimes use these terms when they discuss the aftereffects of conversion disorder or of other somatoform disorders on the patient's emotional adjustment and lifestyle.
The specific physical symptoms of conversion disorder may include a loss of balance or paralysis of an arm or leg; the inability to swallow or speak; the loss of touch or pain sensation; going blind or deaf; seeing double; or having hallucinations, seizures, or convulsions.
Unlike somatization disorder, conversion disorder may begin at any age, and it does not appear to run in families. It is estimated that as many as 34% of the population experiences conversion symptoms over a lifetime, but that the disorder is more likely to occur among less educated or sophisticated people. Conversion disorder is not usually a chronic disturbance; 90% of patients recover within a month, and most do not have recurrences. The female-to-male ratio is between 2:1 and 5:1. Male patients are likely to develop conversion disorders in occupational settings or military service.
Pain disorder is marked by the presence of severe pain as the focus of the patient's concern. This category of somatoform disorder covers a range of patients with a variety of ailments, including chronic headaches, back problems, arthritis, muscle aches and cramps, or pelvic pain. In some cases the patient's pain appears to be largely due to psychological factors, but in other cases the pain is derived from a medical condition as well as the patient's psychology.
Pain disorder is relatively common in the general population, partly because of the frequency of work-related injuries in the United States. This disorder appears to be more common in older adults, and the sex ratio is nearly equal, with a female-to-male ratio of 2:1.
Hypochondriasis is a somatoform disorder marked by excessive fear of or preoccupation with having a serious illness that persists in spite of medical testing and reassurance. It was formerly called hypochondriacal neurosis.
Although hypochondriasis is usually considered a disorder of young adults, it is now increasingly recognized in children and adolescents. It may also develop in elderly people without previous histories of health-related fears. The disorder accounts for about 5% of psychiatric patients, and is equally common in men and women. Hypochondriasis may persist over a number of years but usually occurs as a series of episodes rather than continuous treatment-seeking. The flare-ups of the disorder are often correlated with stressful events in the patient's life.
Body dysmorphic disorder
Body dysmorphic disorder is a new category of somatoform disorders. It is defined as a preoccupation with an imagined or exaggerated defect in appearance. Most cases involve features on the patient's face or head, but other body parts—especially those associated with sexual attractiveness, such as the breasts or genitals—may also be the focus of concern.
Body dysmorphic disorder is regarded as a chronic condition that usually begins in the patient's late teens and fluctuates over the course of time. It was initially considered to be a relatively unusual disorder, but may be more common than was formerly thought. It appears to affect men and women with equal frequency. Patients with body dysmorphic disorder frequently have histories of seeking or obtaining plastic surgery or other procedures to repair or treat the supposed defect. Some may even meet the criteria for a delusional disorder of the somatic type.
Somatoform disorders in children and adolescents
The most common somatoform disorders in children and adolescents are conversion disorders, although body dysmorphic disorders are being reported more frequently. Conversion reactions in this age group usually reflect stress in the family or problems with school rather than long-term psychiatric disturbances. Some psychiatrists speculate that adolescents with conversion disorders frequently have overprotective or overinvolved parents with a subconscious need to see their child as sick; in many cases the son or daughter's symptoms become the center of family attention. The rise in body dysmorphic disorders in adolescents is thought to reflect the increased influence of media preoccupation with physical perfection.
Causes and symptoms
Because groups the somatoform disorders are categorized on the basis of symptom patterns, their causes as presently understood include several different factors.
Family stress is believed to be one of the most common causes of somatoform disorders in children and adolescents. Conversion disorders in this age group may also be connected with physical or sexual abuse within the family of origin.
Somatization disorder and hypochondriasis may result in part from the patient's unconscious reflection or imitation of parental behaviors. This "copycat" behavior is particularly likely if the patient's parent derived considerable secondary gain from his or her symptoms.
Cultural influences appear to affect the gender ratios and body locations of somatoform disorders, as well as their frequency in a specific population. Some cultures (for example, Greek and Puerto Rican) report higher rates of somatization disorder among men than is the case for the United States. In addition, researchers found lower levels of somatization disorder among people with higher levels of education. People in Asia and Africa are more likely to report certain types of physical sensations (for example, burning hands or feet, or the feeling of ants crawling under the skin) than are Westerners.
Genetic or biological factors may also play a role. For example, people who suffer from somatization disorder may also differ in how they perceive and process pain.
Accurate diagnosis of somatoform disorders is important to prevent unnecessary surgery, laboratory tests, or other treatments or procedures. Because somatoform disorders are associated with physical symptoms, patients are often diagnosed by primary care physicians as well as by psychiatrists. In many cases the diagnosis is made in a general medical clinic. Children and adolescents with somatoform disorders are most likely to be diagnosed by pediatricians. Diagnosis of somatoform disorders requires a thorough physical workup to exclude medical and neurological conditions, or to assess their severity in patients with pain disorder. A detailed examination is especially necessary when conversion disorder is a possible diagnosis, because some neurological conditions—including multiple sclerosis and myasthenia gravis—have on occasion been misdiagnosed as conversion disorder. Some patients who receive a diagnosis of somatoform disorder ultimately go on to develop neurologic disorders.
In addition to ruling out medical causes for the patient's symptoms, a doctor who is evaluating a patient for a somatization disorder will consider the possibility of other psychiatric diagnoses or of overlapping psychiatric disorders. Somatoform disorders often coexist with personality disorders because of the chicken-and-egg relationship between physical illness and certain types of character structure or personality traits. At one time, the influence of Freud's theory of hysteria led doctors to assume that the patient's hidden emotional needs "cause" the illness. But in many instances, the patient's personality may have changed over time due to the stresses of adjusting to a chronic disease. This gradual transformation is particularly likely in patients with pain disorder. Patients with somatization disorder often develop panic attacks or agoraphobia together with their physical symptoms. In addition to anxiety or personality disorders, the doctor will usually consider major depression as a possible diagnosis when evaluating a patient with symptoms of a somatoform disorder. Pain disorders may be associated with depression, and body dismorphic disorder may be associated with obsessive-compulsive disease.
Relationship with primary care practitioner
Because patients with somatoform disorders often have lengthy medical histories, a long-term relationship with a trusted primary care practitioner (PCP) is a safeguard against unnecessary treatments as well as a comfort to the patient. Many PCPs prefer to schedule brief appointments on a regular basis with the patient and keep referrals to specialists to a minimum. This practice also allows them to monitor the patient for any new physical symptoms or diseases. However, some PCPs work with a psychiatric consultant.
Patients with somatoform disorders are sometimes given antianxiety drugs or antidepressant drugs if they have been diagnosed with a coexisting mood or anxiety disorder. In general, however, it is considered better practice to avoid prescribing medications for these patients since they are likely to become psychologically dependent on them. However, body dysmorphic disorder as been successfully treated with selective serotonin reuptake inhibitors (SSRI) antidepressants.
Patients with somatoform disorders are not considered good candidates for psychoanalysis and other forms of insight-oriented psychotherapy. They can benefit, however, from supportive approaches to treatment that are aimed at symptom reduction and stabilization of the patient's personality. Some patients with pain disorder benefit from group therapy or support groups, particularly if their social network has been limited by their pain symptoms. Cognitive-behavioral therapy is also used sometimes to treat pain disorder.
Family therapy is usually recommended for children or adolescents with somatoform disorders, particularly if the parents seem to be using the child as a focus to divert attention from other difficulties. Working with families of chronic pain patients also helps avoid reinforcing dependency within the family setting.
Hypnosis is a technique that is sometimes used as part of a general psychotherapeutic approach to conversion disorder because it may allow patients to recover memories or thoughts connected with the onset of the physical symptoms.
Patients with somatization disorder or pain disorder may be helped by a variety of alternative therapies including acupuncture, hydrotherapy, therapeutic massage, meditation, botanical medicine, and homeopathic treatment. Relief of symptoms, including pain, can occur on the physical level, as well as on the mental, emotional, and spiritual levels.
The prognosis for somatoform disorders depends, as a rule, on the patient's age and whether the disorder is chronic or episodic. In general, somatization disorder and body dysmorphic disorder rarely resolve completely. Hypochondriasis and pain disorder may resolve if there are significant improvements in the patient's overall health and life circumstances, and people with both disorders may go through periods when symptoms become less severe (remissions) or become worse (exacerbations). Conversion disorder tends to be rapidly resolved, but may recur in about 25% of all cases.
Generalizations regarding prevention of somatoform disorders are difficult because these syndromes affect different age groups, vary in their symptom patterns and persistence, and result from different problems of adjustment to the surrounding culture. In theory, allowing expression of emotional pain in children, rather than regarding it as "weak," might reduce the secondary gain of physical symptoms that draw the care or attention of parents.
Eisendrath, Stuart J. "Psychiatric Disorders." In Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.
Briquet's syndrome— Another name for somatization disorder.
Conversion disorder— A somatoform disorder characterized by the transformation of a psychological feeling or impulse into a physical symptom. Conversion disorder was previously called hysterical neurosis, conversion type.
Dissociation— A psychological mechanism in which the mind splits off certain aspects of a traumatic event from conscious awareness. Dissociation can affect the patient's memory, sense of reality, and sense of identity.
Hysteria— The earliest term for a psychoneurotic disturbance marked by emotional outbursts and/or disturbances of movement and sense perception. Some forms of hysteria are now classified as somatoform disorders and others are grouped with the dissociative disorders.
Hysterical neurosis— An older term for conversion disorder or dissociative disorder.
Primary gain— The immediate relief from guilt, anxiety, or other unpleasant feelings that a patient derives from a symptom.
Repression— A unconscious psychological mechanism in which painful or unacceptable ideas, memories, or feelings are removed from conscious awareness or recall.
Secondary gain— The social, occupational, or interpersonal advantages that a patient derives from symptoms. A patient's being relieved of his or her share of household chores by other family members would be an example of secondary gain.
Somatoform disorder— A category of psychiatric disorder characterized by physical complaints that appear to be medical in origin but that cannot be explained in terms of a physical disease, the results of substance abuse, or by another mental disorder.
Frey, Rebecca. "Somatoform Disorders." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Encyclopedia.com. (May 24, 2016). http://www.encyclopedia.com/doc/1G2-3451601518.html
Frey, Rebecca. "Somatoform Disorders." Gale Encyclopedia of Medicine, 3rd ed.. 2006. Retrieved May 24, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3451601518.html
Somatoform (so-MAT-a-form) disorders are a group of conditions in which physical symptoms suggest a disease or medical condition, but no physical cause can be found. The term “somatoform” is derived from the Greek “soma,” meaning “body.” A “somatoform disorder” is one in which emotional problems are transformed into body symptoms.These disorders include hypochondria (hy-po-KON-dree-a), conversion disorder, and somatization (so-ma-ti-ZA-shun) disorder. Somatoform disorders do not include malingering or Munchausen syndrome, both of which involve pretending to be physically ill or intentionally producing the symptoms of an illness.
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Somatoform disorders are alike in that they each involve physical symptoms without evidence of physical disease. The symptoms stem from an emotional cause. To understand how the disorders differ from each other, consider three young people in a doctor’s waiting room who are all having trouble with their voices. Tommy, a teenager, was only hoarse, but he feared this meant that he was getting throat cancer. Nine-year-old Mary had suddenly lost her voice completely and could not speak. Lilian, who was 25, was also hoarse and coughing, but she had many other symptoms, including dizziness and a stomachache.
As it turned out, Tommy was suffering not from cancer but from hypochondria. He had been much too worried about his hoarseness, which had come from cheering for his high school football team. The doctor could find nothing wrong with Mary’s larynx, or voice box. Her mother said that Mary had been punished severely for “talking back,” and the doctor suspected that she had lost her voice because of conversion disorder. None of Lilian’s many symptoms, which had come and gone for years, could be traced to any physical disorder. The doctor thought that she must have somatization disorder. Tommy, Mary, and Lilian were referred to mental health professionals for treatment.
People with hypochondria have the fear or belief that they have a serious illness, such as heart disease or cancer, even though medical tests show no sign of disease. People with this condition may be excessively concerned with a wide range of common, usually minor, symptoms, such as coughing, nausea, dizzy spells, and various aches and pains. When their physicians reassure them that these symptoms do not mean that they are seriously ill, they are not always convinced and may remain anxious, worried, and preoccupied with their symptoms. They may then go to one doctor after another for a “true” diagnosis of the same symptoms.
Conversion disorder, a much rarer somatoform disorder, might cause people to lose their voice, sight, or hearing or to become paralyzed in one or more of their limbs. They also may have trembling or lose feeling in various parts of their bodies. The condition is psychological, because medical examination can find no physical explanation for the symptoms. It typically begins suddenly after an extremely stressful event in a person’s life. The symptom or affected body part is usually related in some way to the trauma or stress that triggered the conversion reaction. For example, a soldier who is extremely distressed after killing people during battle might develop “paralysis” in his weapon arm. Conversion disorder resulting from war experience has also been called shell shock or battle fatigue. Someone who has witnessed the murder of a loved one may develop “blindness” as a conversion symptom.
In somatization disorder, there are many different recurring symptoms in various parts of the body. They may include headache, backache, and pains in the abdomen, chest, and joints. There also may be digestive symptoms, such as nausea and abdominal bloating, or symptoms that involve the reproductive and nervous systems. As in other somatoform disorders, medical examinations and testing generally find no clear physical cause for the symptoms.
Pain disorder and body dysmorphic disorder
Two other kinds of somatoform disorders are pain disorder and body dysmorphic (dis-MOR-fik) disorder. Pain disorder is similar to somatization disorder, except that pain is the main symptom. The pain may be in one or several areas of the body, but it doesn’t fit a pattern of any particular medical illness or injury, and diagnostic tests fail to show the presence of any disease. In body dysmorphic disorder, a person becomes extremely concerned about some imagined or very slight body defect. Sometimes called “imagined ugliness,” body dysmorphic disorder can cause great distress and cause a person to avoid being seen in public. In some cases, a person may seek unnecessary plastic surgery.
The causes of somatoform disorders are not clearly understood. In hypochondria, a person may be overly sensitive to body sensations or overinterpret the meaning of normal body sensations. A distressing memory of childhood illness may also play a part. It is believed that conversion disorder, somatization disorder, and pain disorder are all caused by the conversion, or shifting, of stressful emotional events or feelings of conflict into body symptoms to relieve anxiety*. Body dysmorphic disorder involves a distorted body image, and may be influenced by cultures that emphasize the importance of physical appearance, and early experiences which may have interfered with developing self-esteem.
- * anxiety
- (ang-ZY-eh-tee) can be experienced as a troubled feeling, a sence of dread, fear of the future, or distress over a possible threat to a person’s physical or mental well-being.
Somatoform disorders are diagnosed by performing a medical evaluation and testing to determine whether there is a physical reason for a patient’s symptoms and complaints. If there is not, a somatoform disorder may be diagnosed by looking closely at the particular signs and symptoms. A correct diagnosis is important, in order to avoid unnecessary surgery and other medical procedures and to begin proper treatment for the particular disorder.
Psychotherapy is the appropriate treatment for somatoform disorders. With the help of a mental health professional, a person tries to understand and resolve anxiety, trauma, or conflicts that are behind these conditions. Treatment may take varying lengths of time, depending on the severity of a disorder in a particular person.
Anxiety and Anxiety Disorders
Body Dysmorphic Disorder
U.S. Surgeon General Dr. C. Everett Koop http://www.drkoop.com
Nemours Center for Children’s Health Media, A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803. This organization is dedicated to issues of children’s health. Their website has much valuable information for children, teens, and parents. http://www.KidsHealth.org
"Somatoform Disorders." Complete Human Diseases and Conditions. 2008. Encyclopedia.com. (May 24, 2016). http://www.encyclopedia.com/doc/1G2-3497700365.html
"Somatoform Disorders." Complete Human Diseases and Conditions. 2008. Retrieved May 24, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3497700365.html
"somatoform disorders." A Dictionary of Nursing. 2008. Encyclopedia.com. (May 24, 2016). http://www.encyclopedia.com/doc/1O62-somatoformdisorders.html
"somatoform disorders." A Dictionary of Nursing. 2008. Retrieved May 24, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1O62-somatoformdisorders.html