Somatization Disorders

Matthew Reed, MD, MSPH

Amir Ramezani, PhD

FAST FACTS

Somatization is commonly encountered in the outpatient setting and often requires a long-term treatment plan.
Psychiatric disorders, such as depression and anxiety, frequently coexist with somatic symptom and related disorders. We suggest using the anxiety, mood, psychotic and substance use disorders (AMPS) screening tool (inquiring about anxiety, mood, psychotic, and substance use disorders, see Chapter 2) when assessing the psychiatric review of systems. The prognosis of someone with a somatic symptom disorder will usually improve when comorbid psychiatric illness is promptly identified and treated.
Although most patients with a somatic symptom and related disorder may benefit from psychiatric consultation, they often initially refuse to see a psychiatrist. Therefore, primary care practitioners play a key role in the treatment of these disorders.
The CARE MD treatment plan (see Table 10-1) may be a useful approach for patients who have somatic symptom and related disorders.

A 32-year-old man with no previous medical history presents to an urgent care clinic complaining of “gas in the stomach,” shortness of breath, and squeezing back pain that prevents him from working. Other symptoms include a “jumping sensation in the legs” and “poor circulation in the hands and feet.” He is unsure about what condition he might have. He is so concerned about his health that he has been sleeping in his car near the hospital for the past few days. He has seen numerous doctors over the past 6 months and, after an extensive medical workup, has been told there are no obvious medical problems.

CLINICAL SIGNIFICANCE

Primary care practitioners encounter unexplained and perplexing somatic complaints in up to 40% of their patients.¹^,² However, medical explanations for common physical complaints such as malaise, fatigue, abdominal discomfort, and dizziness are found only 15% to 20% of the time.³ Patients and primary care practitioners alike can become frustrated when symptoms persist without a clear cause or when symptoms seem out of proportion for any of the patient’s known medical conditions. Frustration is compounded when treatments targeting the symptoms are only partially effective. Abnormal thoughts, feelings, and behaviors may develop in response to somatic symptoms and can significantly disrupt daily life. This process of developing abnormal thoughts, feelings, and behaviors in relation to bothersome somatic symptoms is loosely termed somatization. Although it is difficult to reliably determine the prevalence of somatization because of changing definitions, most studies estimate a prevalence of 16% to 20% in primary care settings.⁴

The common occurrence of somatization carries a large financial burden. A retrospective review of over 13,000 psychiatric consultations found that somatization resulted in more disability and unemployment than any other psychiatric illness.⁵ Moreover, patients with somatization in
the primary care setting have more than twice the outpatient utilization and overall medical care costs when compared with patients without somatization. The direct costs related to the management of unexplained physical symptoms approach 10% of medical expenditures or over $100 billion annually in the United States.⁶

TABLE 10-1 CARE MD—Treatment Guidelines for Somatic Symptom and Related Disorders

CBT/Consultation	Follow the CBT treatment plan
Assess	Exclude general medical causes and treat comorbid psychiatric disorders
Regular visits	Schedule short frequent visits with focused Discuss recent stressors and healthy coping strategies Over time, excessive health care utilization will decrease
Empathy	“Become the patient” for a brief time During visits, spend more time listening and acknowledge patient’s reported discomfort
Med-psych interface	Help the patient self-discover the connection between physical complaints and emotional stressors (“the mind-body” connection) Avoid comments which may be perceived as condescending or judgmental such as, “your symptoms are all psychological” or “there is nothing wrong with you medically”
Do no harm	Avoid unnecessary diagnostic procedures When possible, minimize unnecessary requests for referral to medical specialists
Adapted from McCarron R. Somatization in the primary care setting. Psychiatric Times. 2006;23(6):32-34.
CBT, cognitive-behavioral therapy.

DIAGNOSIS

Disorders involving somatization are defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) under the category of “somatic symptom and related disorders.”⁷ There are 5 key disorders from this category, including somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, and factitious disorder. Prior editions of the DSM included a requirement that general medical conditions be excluded before diagnosing a somatic symptom disorder. With the release of DSM-5, this requirement has been eliminated.

To meet criteria for any of these disorders, one must have distressing somatic symptoms in addition to abnormal thoughts, feelings, and behaviors in response to the symptoms. These symptoms must also result in a significant disruption of daily life (For details please see Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) pages 309-327).

PATIENT ASSESSMENT

Other than completing a thorough history and physical examination with indicated laboratory or radiographic tests, there are no specific diagnostic protocols for patients who have a somatic symptom disorder. It is important to review collateral history from other health care providers and family to help confirm the diagnosis and reduce redundant and unnecessary medical evaluations or interventions.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis for unexplained physical symptoms seen in the primary care setting is extensive. It is important to keep in mind that “unexplained” somatic symptoms may be due to (1) a medical condition that has not yet been diagnosed; (2) a medical condition that is present but not yet known to the medical community at large; (3) a psychiatric condition such as malingering, factitious disorder, or one of the somatic symptom and related disorders; or (4) both a general medical condition and one of the above-mentioned psychiatric conditions. Somatic symptom disorder is no longer a “diagnosis of exclusion,” but is instead based on the presence of distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to those symptoms. Patients may have a chronic medical condition with somatic symptoms, but their abnormal thoughts, feelings, and behaviors related to those symptoms may qualify them for an additional diagnosis of somatic symptom disorder.

Before establishing the diagnosis of a somatic symptom disorder, one should attempt to rule out the intentional production of physical or psychological symptoms. A patient with malingering is focused on feigning illness to gain external incentives such as financial compensation, controlled substances, shelter, or escape from occupational duty or criminal prosecution. Factitious disorder involves the purposeful and sometimes elaborate self-report of somatic complaints with the objective of assuming the “sick role.” People with factitious disorder have no obvious external secondary gain. When treating either condition, it is important to obtain collateral history (particularly from other area hospitals and providers), conduct a focused physical examination, and consider both as diagnoses of exclusion. People who are malingering are not usually “antisocial.” Instead, they are often emotionally troubled and under so much psychological stress that they engage in maladaptive and deceitful coping strategies, with resultant isolation from family, friends, and medical providers. Once a diagnosis of malingering is established, one should attempt to confront the patient in a supportive and reassuring way while trying to problem solve using a multidisciplinary team approach. Assisting malingerers with urgent stressors and attempting to find appropriate ways to meet their needs can be effective and a psychiatric referral is not normally indicated. However, if a diagnosis of factitious disorder is made, psychiatric consultation is strongly advised because this disorder can be difficult to treat and carries a poor long-term prognosis.

BIOPSYCHOSOCIAL TREATMENT

The treatment approach to somatic symptom and related disorders exemplifies the “art of medicine.” Because these disorders occur on a wide-ranging diagnostic continuum, with elusive causes, it is difficult to apply a strict, evidence-based approach to treatment.⁸^,⁹ We propose a simplified treatment plan that is described by the acronym CARE MD (Table 10-1).¹⁰ This approach encourages patients to be active participants in their care and serves as a guide to help primary care practitioners effectively work with people who have somatoform disorders. Additionally, we provide a “crosswalk” reference to help practitioners achieve the correct ICD-10 diagnosis from the DSM-5 diagnosis (Table 10-2). This facilitates use of appropriate medical coding for compliance with health information privacy, billing and medical documentation.

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