Case-Based Reviews: Somatoform disorders

Journal List > West J Med > v.176(4); Sep 2002

West J Med. 2002 September; 176(4): 253–256.

PMCID: PMC1071744

Case-Based Reviews

Somatoform disorders

Albert Yeung¹ and He Deguang²

¹Depression Clinical and Research Program Massachusetts General Hospital 50Staniford St Boston, MA 02113

²37 Crescent St Newton, MA 02465

Correspondence to: Dr Yeungayeung/at/partners.org

See "Anxiety disorders" on page 249.

see also p 249

Summary points

Somatoform disorders are characterized by bodily symptoms suggestive of aphysical disorder but for which there are no demonstrable organic causes orknown physiologic mechanisms
Patients with such disorders persistently request medical investigationsdespite reassurances by physicians that their symptoms have no physicalbasis
Traditional Chinese medicine has no concept of “medically unexplainedsymptoms”
Treatment may be less complicated in Asian patients than in white patientsbecause Asian patients recognize an interconnection between mind and body
Because Asian patients may not report anxiety or depression, which oftencoexist with somatoform disorders, these disorders may go unrecognized

Mr X, a 68-year-old married Chinese man who is a retired cook, reportssleep disturbances with irritability and loss of appetile for the past 6months. He has frequent headaches, dizziness, and a sensation of tightness inthe chest.
Three weeks before this visit, he had several episodes of chest pain andwent to the local hospital, where he was admitted for a medical evaluation.Results of all investigations, including tests for ischemic heart disease,were normal. He was referred for psychiatric consultation.
Despite sensitive probing by the psychiatrist, Mr X denies symptoms ofanxiety and depression. He has no history of psychiatric or physicalillness.

SOMATOFORM DISORDERS IN THE PRIMARY CARE SETTING

Somatoform disorders are characterized by physical symptoms that suggest aphysical disorder but for which there are no demonstrable organic causes orknown physiologicmechanisms.¹ Thesymptoms are not under voluntary or conscious control; the patient is notmalingering. Patients with these disorders make persistent requests formedical investigations, although all findings are negative and health careproviders repeatedly determine there is no physical basis for thesymptoms.

The different types of somatoform disorders are shown inbox 1.

Box 1

Types of somatoform disorders

DIFFERENTIAL DIAGNOSIS

When a patient reports symptoms that cannot be explained by an underlyingorganic problem, the primary care provider should consider psychiatricdisorders, such as major depression, anxiety disorders, and alcohol and drugabuse, in the differential diagnosis (seebox2).²

Box 2

The differential diagnosis of somatoform disorders

Somatoform disorders can coexist with other psychiatric conditions.

Two thirds of patients with somatization disorder (a type of somatoformdisorder) have symptoms of other psychiatric disorders, and one third meet thecriteria for at least one other psychiatric diagnosis
Anxiety disorders are common among patients with hypochondriasis
Personality disorders can coexist with somatoform disorders

Treating a condition that coexists with a somatoform disorder, such ascoexistent anxiety and depression, can alleviate symptoms of the somatoformdisorder.³

DIAGNOSIS

The absence of organic findings to explain patients' reported symptomssuggests the possibility of a somatoform disorder. Usually, the complaintstend to be chronic and recurrent and fluctuate corresponding to psychosocialfactors.

These complaints are common among Asian patients, but they usually do notsatisfy the stringent criteria for somatization disorder. Following formalDSM-IV classification, many patients with such complaints can becategorized as having undifferentiated somatoform disorder. The most common ofthese symptoms in Asian patients include insomnia, headache, failure toconcentrate, and symptoms of anxiety anddepression.⁴

It is important to rule out underlying mood or anxiety disorders, whichshould be treated accordingly. Many Asian patients with anxiety and depressiontend to selectively report their physical symptoms and underreport their moodsymptoms because they consider anxiety and depression normal responses to lifestresses and not symptoms of distinct disorders. They may also consider thatmood symptoms are not relevant when they see their medical practitioner.

To assess Asian patients with medically unexplained symptoms, we find ithelpful to:

Accept their somatic symptoms
Actively inquire about mood
Explore their psychosocial background
Screen for anxiety and depressive disorders, substance abuse, and psychoticsymptoms

When needed, referral to medical consultants should be directed to thosewho order tests conservatively, are experienced with somatization disorders,and can collaborate with primary care physicians.

MANAGEMENT AND TREATMENT

Primary care approach

When managing and treating somatoform disorders in Asian patients, theprimary care practitioner should take the following steps:

Show a genuine interest in the reported somatic symptoms. Inquire abouttheir onset, characteristics, location, duration, and exacerbating andrelieving factors. Find out how the symptoms affect the patient, whattreatment has been attempted, and whether or not it was effective.
Rule out concurrent physical disorders
Be nonjudgmental, respectful, and empathetic. Listening with patience ismore important than attempting to provide a quick fix.
Establish a supportive relationship. Inform patients that these symptomstend to run a long course and may fluctuate according to changing psychosocialsituations.
Treat coexisting psychiatric disorders
Provide medications for supportive treatment, such as analgesics for painand headache, antispasmodics and antacids for abdominal discomfort, andshort-term hypnotics for insomnia (being careful not to encourage dependence).These prescriptions are welcomed for symptom relief and as a sign ofacceptance of the symptoms. Antidepressants may be effective for treatingsomatoform disorders even when there is no coexisting depressivedisorder.⁵
Allow patients to participate in decisions regarding the choice oftreatment. This involvement encourages them to follow recommendations moreclosely.
Encourage rehabilitation treatment, including exercise, physical therapy,yoga, tai chi, and participation in social activities
Inform patients that improvement of their symptoms can depend on how muchthey alter their lifestyles, and that it is their responsibility to do this.Common problems include poor sleep patterns, inability to set limits onpersonal goals and on demands from other people, lack of assertiveness,inadequate social skills, and inability to set priorities in life. Patientsshould be encouraged to seek professional help when needed.
Explore relationships in the patient's family and at work and whethersignificant life events have occurred. Questions such as. “What is goingon in your family?” or “How is work?” may reveal importantinformation. Listen to the emotional tone when the patient responds to thequestions.
Look for possible relationships between what is happening in the patients'lives and their symptoms and help them see the connection
Refer patients for psychological intervention to address their current lifeevents as well as interpersonal conflicts. Many Asian patients benefit fromsuch intervention and from learning communication as well as copingskills.

When asked about his family, Mr X reports that his wife had worked for manyyears as a nanny in a distant town and they were accustomed to living apart.She retired 6 months ago and returned to live with him. He became animated andagitated when talking about his wife and described her as a headstrong womanwho always did things her way. The psychiatrist pointed out to him that hissymptoms might be related to his recent life changes because they started whenhis wife rejoined him.
Mr X was later able to tell the psychiatrist that his symptoms got worsewhen his wife aggravated him. They fought frequently about everything from howto set up a monthly budget to arranging their furniture, to what gifts to sendto their children. He remembered that before he went to the emergencydepartment at the hospital, he was angry with his wife because “she putwet dishes in the wrong place and messed up the kitchen.”

Referral to a mental health specialist

Psychiatric consultation is useful for the evaluation of:

Psychotic symptoms
Suicidal or homicidal tendencies
The need for involuntary hospitalization
The need for medication and psychological treatments

Psychiatric consultation is essential in patients with suspectedfactitious disorder (Munchausen's syndrome) to obtain help in detectingmethods of self-induced symptoms and exploring underlying psychologicpathology.⁶

Traditional Chinese medicine (TCM) approach

Asian patients with somatoform disorders may have visited a practitioner ofTCM. It is helpful to be aware of this care, to know what was recommended, andto consider incorporating TCM approaches into the treatment plan.

Western medicine relies heavily on laboratory tests; TCM does not.Consequently, “medically unexplained symptoms” do not exist inTCM. Diagnosis in TCM is based on four techniques (observing, listening andsmelling, asking, and feeling the pulse) and four types of pathologic change(Qi (air), blood, yin-yang, or an organ inside the body).Using the four techniques, TCM practitioners collect information on thepossible pathologic changes that could explain patients' symptoms and wouldallow them to provide treatment to alleviate the symptoms.

Whereas the mind and body are considered separate entities in Westernmedicine, mind and body are integrated and inseparable in TCM. Accordingly,any change of the mind will inevitably affect the body and vice versa.Psychological problems are frequently considered the causes of physicaldisorders. Emotions (eg, joy, anger, worry) are “internaletiologies” and lifestyle and circumstances (eg, eating, working,accidents) are “external etiologies” of diseases. Longstanding andintense emotional stress is thought to upset the homeostasis of the body anddisrupt the ability of the body to maintain the normal functions ofQi, blood, and organs; disease is the result. Indulgent lifestyles,such as eating unhealthy diets, overeating, overworking, and excessive sexualactivity, are thought to damage organ function.

TCM treatment of somatoform disorders includes herbal medicine,acupuncture, Tuina massage, and qigong. One or more of thesemethods are used. Practitioners of TCM generally consider the patient'spreference when deciding which treatment to use.

Mr X was encouraged to release his frustration and anger toward his wifeduring his visits to his practitioners. The psychiatrist explained therelationship between Mr X's frustrations and his physical symptoms and pointedout that spouses who do things differently could still work together. Thepsychiatrist helped Mr X learn how to communicate his ideas and opinions tohis wife and to take turns in making decisions. After four visits, Mr X'scoping skills had improved, and he reported less frustration and anger andfewer physical symptoms. He thought he was able to end treatment.

Figure 1

ROC/Taiwan Government Information Office

Notes

Competing interests: None declared

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