Need to know: Somatoform disorders
Dr Wolfgang Meyer answers questions from GP Dr Linden Ruckert
Dr Wolfgang Meyer answers questions from GP Dr Linden Ruckert
How common is somatoform disorder in general practice? At what age would it typically start?
According to new research, patients with somatoform disorder represent 25-50 per cent of patients presenting to GPs with physical complaints for which no organic cause is readily apparent and for whom symptoms, or illness, have become a way of life. Somatoform disorder is a chronic, severe psychiatric disorder characterised by persistent physical symptoms without a demonstrable organic pathology or physiological explanation allied with clinical indications that the symptoms are linked to psychological factors or conflicts. The usual onset is in adolescence or early adulthood.
The condition persists for years, with symptoms typically including a combination of pain, pseudo-neurological, digestive and sexual complaints.
How does it usually present? Are there any clues that might help us to be alert to the diagnosis earlier on?
Somatisation is best viewed as a process of inappropriate focus on physical symptoms and denial of psychosocial problems. Many of these cases involve iatrogenic complications, including unnecessary and repetitive investigations and surgery and possibly even drug dependence. Patients often indulge in 'doctor shopping'.
GPs are best able to detect these disorders because they have the full history of repeated physical complaints and accompanying investigations accumulated over the period of treatment. There are two types of presentation: occasional somatisers, who present intermittently and tend to respond quickly to medical attention possibly individuals at a particularly stressful point in their lives; and chronic somatisers, who express distress and concern about their physical state and are not amenable to change or psychological interventions because they genuinely believe they are physically ill.
Either may occur acutely, intermittently or chronically. It is important to remember that somatisation may co-exist with, or overlie, established medical illnesses.
Somatoform patients are usually quite emotional when recounting their symptoms, indicating their desire to be cared for, yet they are not consciously seeking to remain ill they are unaware of the psychological forces at work.
This might be because it is more acceptable to admit to and discuss physical problems, rather than psychological issues, or because the patient is so detached from his feelings that he is not conscious of any psychological issues and is involuntarily forced to convert them into physical symptoms.
What are the formal criteria for a diagnosis?
According to DSM-IV classification, each of the following criteria must be met, with individual symptoms occurring at any time during the course of the disturbance:
Four pain symptoms: history of pain related to at least four different sites or functions.
- Two GI symptoms: eg, nausea, bloating, food intolerance, diarrhoea.
- One sexual symptom: eg, sexual indifference, erectile or ejaculatory dysfunction, problems with menses.
- One pseudo-neurologic symptom: eg, conversion symptoms such as blindness, double vision, deafness, loss of touch, paralysis or localised weakness, difficulty swallowing or breathing, seizures or dissociative symptoms such as amnesia or loss of consciousness other than fainting.
In somatisation disorder, one of the most complex of the somatoform disorders, most symptoms begin in adolescence or early adulthood and affect all parts of the body, with headaches, back pain, gastrointestinal complaints, pelvic pains and breathing problems the most common presenting symptoms.
The typical somatisation disorder patient has a complex medical history of shopping for both diagnoses and doctors and is very concerned about his health because he does not know why he is ill, despite appropriate interventions. Obviously we must not miss organic illness nor lead the patient to feel we are not excluding this.
How can a GP differentiate it?
The best approach is a sensitive yet rigorous history-taking which elicits family history, stressors, individual and family illness, conflicts in relationships, grief over loss or separation or other significant life events; this, allied with an acknowledgment of the stress/symptoms link, will help GPs reach the correct diagnosis.
Non-directive interviewing is often more successful than direct questioning because it offers insight into the emotions that the patient associates with the symptoms. It's best to avoid suggesting cause-and-effect relationships between the patient's feelings and presenting symptoms.
What treatment is appropriate by GPs?
There are two treatment goals: return to functionality and prevention of secondary worsening of iatrogenic problems. Key factors associated with a better response to treatment include: younger age; continuing employment; work satisfaction; and the lack of pain-related insurance payments. Usually, the best treatment is a calm, firm and supportive GP who offers symptomatic relief and protects the patient from unnecessary diagnostic or therapeutic procedures.
GPs should focus on the stress associated with the disorder and on reducing help-seeking behaviour.
Pharmacological interventions are less appropriate for these patients, unless there is a co-morbid condition like depression which needs to be treated. Patients must deal with the issues driving their disorders and reduce help-seeking behaviour, so a cognitive approach that helps them to re-attribute their symptoms from physical to psychological causes is best, while group therapy and hypnosis have also been shown to be useful.
What pitfalls should the GP be aware of?
Treating somatoform patients is extremely difficult because some will not believe their emotions provide the foundations for the illness. They are unaware of the psychological factors driving their physical disorders, do not consciously cling to the role of patient and will press for medical interventions.The ever-present risk is that GPs, fearing these patients might be suffering from an undiagnosed or unusual physical problem, may put them through months or years of tests before considering psychiatric explanations.
What I'll do now
Dr Ruckert responds to the answers to her questions
- I was surprised to hear that up to 50 per cent of patients presenting with unexplained physical complaints would be diagnosable as having somatoform disorder. I will be more aware of this now.
- I will try to be more alert to the possibility of its onset in adolescents or young adults. Perhaps we can prevent chronicity and later work for ourselves.
- Preventing investigations and procedures can be difficult to achieve, especially if there is secondary gain. Sadly, specialist care and cognitive therapy are hard to come by.
Wolfgang Meyer is consultant psychiatrist and psycho-therapist at the Priory Hospital Hayes Grove and honorary clinical lecturer, Queen Mary University of London, Bart's, and the Royal London School of Medicine. Competing interests: none declared