Understanding Somatic symptom Disorder

Understanding Somatic Symptom Disorder is something everyone should aim for as it is one of those illnesses that are misunderstood to be supernatural.

This is due to its signs and symptoms which are usually confusing for both the patients and physicians.

Typical Scenario of Somatization Disorder

Patient A presents to the clinic with complaints of headache and gastrointestinal upset.

He is thoroughly evaluated by his doctor who made the following findings:

History – nil

Examination – nil

What could then be the reason for his patient’s symptom.

I know you are probably trying to come with something.

Sometimes patients do present with genuine symptoms and after medical evaluation, nothing is identified as the cause of said symptoms.

It does not mean the patient is reporting false symptoms or faking them, or that the doctor got a thing or two wrong.

Conditions like that do exist and we’ll be looking at just that.

So, welcome to the home of weird illnesses; SOMATIC SYMPTOM DISORDERS.

HISTORY

Somatization disorder was first described by Paul Briquet in 1859 and was subsequently known as Briquet syndrome. He described patients who had been sickly most of their lives and complained of multiple symptoms from different organ systems. Symptoms persist despite multiple consultations, hospitalizations, and investigations.[1]

Understanding Somatic Symptom Disorder

DEFINITION:

Somatic symptom disorder
What Is Somatic Symptom Disorder?

Somatic symptom disorder previously known as somatoform disorder is a group of mental disorders where the patient experiences physical/bodily (somatic) symptoms that can not be medically explained.

They are a group of disorders, all of which fit the definition of physical symptoms similar to those observed in physical disease or injury for which there is no identifiable physical cause. [1] Somatization is said to be present when psychological-emotional distress is manifested in the form of physical symptoms that are otherwise medically unexplained. [2]

This condition is more common in females than males and is usually diagnosed in adolescents and adults before the age of 30.

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The following disorders are members of somatic symptom disorders:

  • Conversion disorder: here there is the loss of bodily function as a  result of unresolved conflicts. For example, a patient becomes unable to move her limbs (paralysis) after a fight with her partner. Conversion disorder is defined by neurologic symptoms without evidence of an underlying neurologic disease and generally appears as a motor or sensory complaints or seizure-like activity. [3]
  • Somatization disorder: Typical of this disorder is the simultaneous manifestation of symptoms in different parts of the body (for example pain in multiple body parts, gastro-intestinal problems, menstruation problems, loss of libido, impotence problems, dizziness, a feeling of a blockage in the throat, muscle weakness). According to the ICD-10 system, the duration is specified as 2 years. [4]
  • Pain disorder: In this case, chronic pain lasting at least six months is typical, the origin of which is not clear. Excessive focus on the pain and significant levels of suffering are also characteristic. [4] Pain disorder is characterized by pain disproportionate to any underlying injury or illness, to the point of significant functional impairment. [3]
  • Hypochondriasis: here the patients believe they have an illness and are really concerned about it. They frequently order investigations to be reassured they are free of said illness.
  • Body dysmorphic disorder:  patients in this category are preoccupied with worries about physical defects in their bodies, showing concern about their body image. The physical defect they are worried about might be real or imagined.
  • Undifferentiated somatoform disorder: This disorder is characterized by one or more physical symptoms that last for at least six months and which produce significant limitations in various aspects of life. [4]

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AETIOLOGY/CAUSES OF SOMATIC SYMPTOM DISORDER

The aetiology is not understood but there are some factors that predispose to it.

  1. Personality disorder or mood disorder eg; anxiety and depression.
  2. Childhood Trauma which could be physical or sexual abuse
  3. History of substance abuse, either dependence or misuse
  4. History of similar illness in first degree relatives
  5. Style of upbringing: [4]
  6. in which children are not allowed to express feelings
  7. in which violence is prevalent, to which children respond with physical symptoms instead of fear
  8. in which the child receives attention any of they have physical symptoms.

Although the biological basis of these disorders remains elusive, a leading theory is that patients with somatoform disorders are — when compared with healthy people — more sensitive to the effects of negative sensations (such as noxious smells), less resilient in response to stressful situations, and more prone to catastrophic thinking and negative interpretation of life events.[5]

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SYMPTOMS OF SOMATIC SYMPTOM DISORDER

They can present with symptoms seen in other illnesses eg, headache, body pain, gastrointestinal upset, chest pain, blindness, hearing loss, etc

Pain is the most common symptom, but whatever the symptoms, they have excessive thoughts, feelings, or behavior related to those symptoms, which cause significant problems, making it difficult to function and sometimes can be disabling.  [6]

The symptoms of somatic symptom disorder is genuine to the patients unlike the symptoms in some other conditions like those of factitious disorders or malingering where the symptoms are been construed by the patient to achieve secondary gains.

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DIAGNOSIS OF SOMATIC SYMPTOM DISORDER

In making a  diagnosis of somatic symptom disorder, efforts should be made to obtain a good medical evaluation since it is a diagnosis of exclusion. This implies every other possible cause of said symptom must be ruled out, and this can be done with a good medical history and examination.

To make a diagnosis of somatic symptom disorder, one needs to have a high index of suspicion. Individuals with disorders with prominent somatic symptoms are commonly encountered in primary care and other medical settings but are less commonly encountered in psychiatric and other mental health settings. Failure to make an accurate diagnosis of this disorder when present leads to numerous unnecessary testing and medications.

Somatic Symptom Disorder emphasizes diagnosis made on basis of positive symptoms and signs (distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors) – Distinctive characteristic is not the somatic symptom but the way they present and interpret it. [8]

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DSM-5 Diagnostic criteria: [2]

  1. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
  2.  Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
  3. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
  4. Persistently high level of anxiety about health or symptoms.
  5. Excessive time and energy devoted to these symptoms or health concerns.
  6.  Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

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Specify if:

With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.

Specify if:

Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).

Specify current severity:

Mild: Only one of the symptoms specified in Criterion B is fulfilled.

Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

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MANAGEMENT OF SOMATIC SYMPTOM DISORDER

Somatic symptom disorder has a poor prognosis. People with this condition rarely attain remission hence the aim of management is to alleviate the symptoms.

For a condition with no known underlying cause, medications are not of much help. Physicians should focus on treating the somatoform disorder instead of the symptoms.

Adequate care, empathy and patience should be employed in the management of somatic symptom disorder. Since psychological stress worsens the symptoms, devoting adequate time during patient’s visits to listen to their symptoms and reassure them goes a long way in reducing psychological distress. Hence, quality and adequate doctor-patient interaction is key in the management of this disorder.

Patients appreciate a discussion and explanation of their symptoms. The doctor should sensitively explore possible psychological and social difficulties. Such discussion usually gives information that can be used to formulate an agreed plan of management.

There are 2 modalities of treatment

  1. Psychotherapy
  2. Pharmacotherapy

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Psychotherapy options include:

  1. Cognitive-behavioral therapy: this approach focuses on improving symptoms by changing thought patterns and behaviors. It is the mainstay of treatment of somatic symptom disorders.

Cognitive-behavioral therapy (CBT) is a short-term, goal-oriented psychotherapy treatment that takes a hands-on, practical approach to problem-solving. Its goal is to change patterns of thinking or behavior that are behind people’s difficulties, and so change the way they feel. [10]

CBT can help you: [6]
  • Examine and adapt your beliefs and expectations about health and physical symptoms
  • Learn how to reduce stress
  • Learn how to cope with physical symptoms
  • Reduce preoccupation with symptoms
  • Reduce avoidance of situations and activities due to uncomfortable physical sensations
  • Improve daily functioning at home, at work, in relationships, and in social situations
  • Address depression and other mental health disorders
  • Mindfulness-based therapy: Mindfulness-based cognitive therapy (MBCT) combines cognitive-behavioral techniques with mindfulness strategies in order to help individuals better understand and manage their thoughts and emotions in order to achieve relief from feelings of distress.

Pharmacotherapy involves the use of medications which includes antidepressants, and antipsychotics.

Antidepressant medication has also been used to treat some of the symptoms of depression and anxiety that are common among people who have somatic symptom disorder. Medications will not cure somatic symptom disorder, but can help the treatment process when combined with CBT. [1]

The CARE MD approach [2]

The CARE MD treatment approach was developed to help primary care clinicians work more effectively with patients who have somatic symptom disorder

C – Consultation (psychiatry or cognitive behavior therapy): Consult and collaborate with mental health professionals

A – Assessment: Evaluate for other medical and psychiatric diseases

R – Regular visits: Schedule short-interval follow-up to stop overuse of medical care (e.g., inappropriate emergency department visits, excessive calls) and avoid the need for symptoms to get an appointment; stress coping rather than cure

E – Empathy: Spend most of the time listening to the patient and acknowledge that what he or she is feeling is real

M – Medical-psychiatric interface: Emphasize the mind-body connection; avoid comments such as “there is nothing medically wrong with you”

D – Do no harm: Limit diagnostic testing and referrals to subspecialists; reassure the patient that serious medical diseases have been ruled out

CONCLUSION

Given the chronicity, behavior, and thought pattern associated with somatic symptom disorders, chances are that the afflicted persons will seek medical care. It, therefore, is the duty of the physician to be equipped with the knowledge on how to appropriately make a diagnosis and manage these patients without incurring any unnecessary costs.

Physician-patient interaction is key.

Author:

Ogbochie Emmanuel (Medical Student at the University of Nigeria)


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