Somatization Disorder

Timothy F. Landers MA, MS, CRNP

Somatization disorder (SD) is a clinical syndrome characterized by the presence of multiple unexplained physical complaints without a known physical cause. SD is an important condition in primary care because it is responsible for unnecessary diagnostic testing and therapeutic interventions. It is well known in primary care that patients express emotional or psychological symptoms physically and respond to these symptoms differently.

Somatization can be seen as one end of a continuum in which physical complaints are perceived to be debilitating, either because of the patient’s preoccupation with the symptoms or because the experience of the symptoms is intense. For these patients, somatic complaints tend to be more debilitating, involve a greater number of clusters of complaints, and occur over a longer period of time. At the other end of the continuum are patients who describe what has been called symptom sensitivity. These patients are acutely aware of the presence of physical symptoms to a greater degree than many other patients.

Patients with SD tend to have a greater-than-expected degree of disability from their complaints. In some cases, what appear to be minor complaints may cause such psychological distress that social or occupational functioning is compromised. This is one of the hallmarks of SD. Situation one provides an example of a patient with complaints that are seriously affecting his quality of life.

The diagnosis of SD must be made carefully to exclude underlying physical conditions that have not been diagnosed. Often years of medical records need to be reviewed to ensure that adequate testing has been undertaken to exclude physical complaints. Thorough attention must be paid to atypical presentations of common illnesses and to rarer illnesses. Treatment involves the development of a therapeutic relationship over an extended period of time, one in which patients feel that their complaints are taken seriously. Often, the development of a therapeutic relationship is troubled by doubt and frustration by both the patient and the provider. It is important that while this relationship is forming, the primary care provider maintains an open, nonjudgmental, and caring demeanor.

ANATOMY, PHYSIOLOGY, AND PATHOLOGY

As with many illnesses, there appears to be a strong familial link in SD. It is unknown whether this is the result of environmental or genetic influences. For example, some families may sanction the expression of physical complaints to a greater degree than other families. Researchers have postulated that there are biochemical influences on the expression of SD, but this has not been proven (Smith, 1995).

In SD, physical complaints are presented without adequate physical findings. This lack of presence of an organic pathology can be frustrating to even the most experienced primary care provider. There is little if any match between the symptoms and the actual physical findings (Barsky, 1995).

EPIDEMIOLOGY

Much has been written about the social, gender, and situation influences on somatization. SD has been found to be expressed differently in different cultural groups. It is thought to have a much higher prevalence among women than men. In general, the lifetime prevalence of SD is 0.2% to 2% (American Psychiatric Association [APA], 1994). However, rates of SD vary greatly depending on the population studied, the definition of the syndrome, and the practice setting. Rates as high as 8% have been reported in psychiatric settings, and higher rates tend to occur in patients with other conditions such as irritable bowel disease, polycystic ovary syndrome, and chronic pain, where the rate may be as high as 28% (Smith, 1995).

Recent research has suggested that environmental factors may play a role in the expression of SD (Gothe et al, 1995). Certain environmental factors, such as exposure to certain chemicals, are thought to cause or aggravate physical complaints. In cases of this environmental somatization syndrome, no cause can be found for these physical complaints based on the suspicious agent. An example of this syndrome is the association of disease or illness with office buildings. Although there are no environmental or physical causes for these beliefs, groups of people may come to see the building itself as the cause of this syndrome. In addition, patients tend to downplay the importance of other explanations for the cause of their symptoms. Patients become convinced that the facility is to blame for their illness and often refuse suggestions that other factors, such as stress or tobacco use, may be involved. Because of the link of this syndrome and geography, environmental somatization syndrome tends to appear in clusters (Gothe et al, 1995).

It is thought that because different social groups may sanction the expression of physical complaints through different symptoms, there is likely to be a large cultural component to the expression of SD. For example, in one study of African patients, common somatic complaints included heat radiating from the head, generalized aches and pains, crawling sensations, and muscle fasciculations (Ohaeri & Odejide, 1994). Among Hispanic patients, common complaints included headache, excessive gas, chest pain, and gynecologic complaints (Hulme, 1996). The differences in SD between men and women is being studied (Wool & Barsky, 1994).

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