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Somatoform disorders are characterized by physical complaints which have no organic basis and are commonly seen by both generalists and specialists. A case report and clinical descriptions of the major somatoform disorders are presented and recommendations for clinical management made.
Somatoform disorder (SD) is recognized as an important clinical entity in general medicine although its psychiatric nature is insufficiently appreciated. Its prevalence and descriptive validity among psychiatric patients have not been investigated. These two aspects of SD are examined by comparing it with depressive and anxiety disorders, both of which include somatic symptoms and often are confounded with it. A semistructured evaluation procedure applied in a naturalistic clinical setting yielded a diagnosis and ratings of a large array of symptoms. The relative rarity of SD stands out, as well as the unique way in which it tends to be used in diagnostic formulations of psychiatric patients seeking evaluation and care. These results may reflect these patients' reluctance to seek psychiatric care and to define their problems as mental, as well as the bias of clinicians working in psychiatric settings geared to looking for traditional psychopathology. The distinguishing symptoms of SD vis-à-vis depressive and anxiety syndromes are outlined. These symptoms suggest that SD patients resemble depressives, but harbor traits that reflect personality and interpersonal difficulties. However, rater bias may have influenced these results as well.
This article reviews the relationship between depressive disorders and somatoform disorders, somatization, and pain. These disorders and symptoms are clinically interrelated, yet the nature of the interrelation is not well understood. This review of the literature from 1975 through mid-year 1990 addresses the epidemiology and treatment of these conditions and/or symptoms when they occur together. When robust criteria are used to determine which publications are included, only 14 are available that address depressive disorders, somatoform disorders, and somatization. Similarly, there are only 13 that address depressive disorders and pain. Taken together, these studies indicate that 1) in somatization disorder patients, there is a high prevalence of depression; 2) in patients with major depression, there are substantial levels of hypochondriacal and somatizing symptoms; 3) that depression in the face of coexisting somatization disorder can be successfully treated; 4) in chronic pain patients, there is a high prevalence of depressive disorders; 5) in patients with major depression, pain is a frequent complaint; 6) and finally, that pain improves with the treatment of depression. What is most striking from this review, however, is the very limited number of studies that address these important problems. This lack of research-based data calls for new aggressive research efforts in this area.
Thirty inpatients with somatoform disorders were examined with the structured clinical interview SCID for psychiatric lifetime diagnosis. In the present diagnoses, we found a concordance of 63% for somatoform and affective disorders and the lifetime comorbidity of both disorders was 87%. Additionally, patients with somatoform disorders frequently had a history of other psychiatric disorders (for example, anxiety disorders, 40%). For 73% of patients with somatoform disorders and a history of affective disorders, the onset of the somatoform disorder was prior to the onset of another psychiatric disorder. The time interval between the onsets of somatoform disorders and affective disorders was greater than 1 year for most patients; for 46% of the patients with a history of both disorders, the time interval between the two disorders was more than 5 years. The course of illness for somatoform and affective disorders was quite different; while affective disorders tended to episodic periods with interim remissions, the somatoform disorders usually showed long, chronic courses (mean duration of the current somatoform disorder was 11.9 years). Finally, the Symptom Check List SCL-90R demonstrated good discrimination between patients with affective and anxiety disorders. However, the SCL-90R failed to discriminate patients with somatoform disorders from affective- and anxiety-disordered subjects. Therefore, the development of other psychometric scales is necessary for the evaluation of patients with somatoform disorders.
Patients with "hysterical" neurologic symptoms have long puzzled neurologists and psychiatrists. "Hysteria" has recently been subdivided into conversion and somatoform disorder. We applied computerized EEG frequency analysis to 10 patients with diagnosed conversion disorder, 10 somatoform disorder patients, and 10 control subjects. One minute EEG samples composed of 4 sec epochs were recorded from left frontal (F7-C3), right frontal (F8-C4), left posterior (T5-01) and right posterior (T6-02) derivations. Spectral power was calculated for 4 bands (0.25-4HZ, 4.25-8Hz, 8.25-13Hz, and 13.25-30Hz), and for the full frequency range. Low (0.25-8Hz) and high (8.25-30Hz) frequency bands were compared to determine high/low power ratios on the left and right (PHLL) and (PHLR), ratios of left/right front (PLRF) and posterior (PLRP) power, mean alpha frequency deviation frontally (FLRF) and posteriorly (FLRP), and mobility of left and right frontal power (MOLF and MORF). No significant differences were found between conversion disorder patients and controls in PHLL, PHLR, PLRP, and MORF. PLRF, FLRF and MOLF differed significantly between patients and controls. Power and frequency ratios of right frontal mobilities suggested a decrease in high frequency power, reduction in mean alpha frequency, and lower predominant frequency in the right frontal area in somatoform disorder patients as compared to controls, but significance was not reached. Somatoform and conversion disorder patients differed significantly in these spectral measures. These observations suggest that the two "hysterical" disorders may have distinct pathophysiology, and may be due to eventually identifiable cerebral dysfunction in some cases.
The somatoform disorders present dilemmas on acute inpatient medical/surgical services because they may closely mimic authentic physical illness and result in misapplied medical treatment. However, there have been few diagnostic studies of this important group in the medical/surgical inpatient setting. Inpatient psychiatric consultations at Mount Sinai Medical Center during 1980-1987 were recorded using a 384-item computerized data base protocol. DSM-III somatoform disorders were identified in 33 of 1801 initial consultations (1.8%) and in 35 of 1363 at time of termination (2.6%); demographic and diagnostic characteristics of somatoforms and others were compared. The question of a psychogenic component to the illness and problem with pain management were the most common stated reasons for consultation. Somatoform patients were more likely than others to be female (p less than 0.05), Hispanic (p less than 0.05), and to have Axis II comorbidity (p less than 0.001). Axis III comorbidity was present in 94%. Thirty-one percent of patients diagnosed as somatoform on final follow-up assessment had not been diagnosable as somatoform on initial assessment. The findings emphasize the necessity of ongoing assessment in improving diagnostic certainty, as well as the prevalence and importance of medical comorbidity among patients with somatoform disorders in this setting.
I investigated the contribution of hereditary factors in somatoform disorders. Fourteen monozygotic and 21 dizygotic index twins and their co-twins were personally interviewed. The results showed a concordance of 29% in monozygotic and 10% in dizygotic pairs. However, similarity in childhood experience seemed to influence the concordance rates. Thus, even if somatoform disorders appear familial, the transmission may be environmental. Furthermore, the study showed a high frequency of anxiety disorders, especially generalized anxiety disorders, in the co-twins of somatoform-disordered twins.
This is a pilot study of the use of cognitive therapy theories and techniques in a time-limited Balint group of family physicians with a focus on the care of the somatoform disorders. Family physicians often find these patients difficult and unpleasant to treat. Physicians in the group were compared with other family physicians in a pre and post test of attitudes towards patients with somatoform disorders. In addition, the beliefs of the physicians were elicited. After the 13 session Balint group was completed, attitudes of the family physicians in the group improved so that they were less likely to feel that somatizing patients take up too much of their time (p less than 0.05). Underlying beliefs about somatoform disorder patients were identified in the group and subsequently modified. This study suggests that a time-limited cognitive therapy Balint group, focusing on somatoform disorder patients, results in improved attitudes toward the care of these patients.
An aviator with concentration deficit, Lyme disease organic diagnostic evaluation, and a somatoform disorder. The clinical presentation, evaluation and diagnosis of an aviator being evaluated for vague cognitive deficits of episodic and long duration with a history of rigid ideation concerning Lyme disease. The patient was diagnosed as having an atypical somatoform disorder. The aeromedical disposition of this patient is also presented.
An overview of the literature shows that shift work is linked with an enhanced risk of psychiatric disorders. A number of authors have reported anxious and depressive symptomatology in shift workers, but there are no data about the frequency of somatoform disorders associated with this type of work. Psychosocial stress and low socio-economic status, both often found among shift workers, are regarded as risk factors for somatoform disorders. The connection of shift work and somatoform disorders is discussed with examples of four case reports. It is suggested that shift work, which is known to be associated with an increased incidence of cardiovascular diseases, may promote the occurrence of vegetative symptoms, such as feelings of weakness and dizziness, and eventually leads to intensified self-observation, anxiousness and hypochondriasis with predominantly somatic symptoms.
Psychiatrists in Australia were asked to recommend treatments for several anxiety and somatoform disorders. In previous surveys they had agreed about the preferred treatments for schizophrenia and major affective disorder but not about treatments for "neurotic depression" or agoraphobia. In the present survey, no treatment was regarded as critical by a majority of psychiatrists for any of the five anxiety and somatoform disorders studied. The authors conclude that because neurotic disorders form an important part of the workload of psychiatrists, consensus procedures should be used to develop guidelines for treatment until the research literature can provide more adequate guidance.
This study examined the efficacy of the Schizophrenic-Organicity (Sc-O), Psychiatric-Organic (P-O), the Pseudo-Neurological (P-N), and the Schizophrenia (Sc) MMPI subscales in differentiating the following four groups of outpatients: brain-damaged (n = 35), brain-damaged schizophrenics (n = 10), non-brain-damaged schizophrenics (n = 15), and somatoform disorders (n = 45). Both unmatched and matched samples were used in the analysis, and cut-off scores were obtained. In an unmatched sample, results suggested that the Sc scale was useful in differentiating brain-damaged schizophrenics from brain-damaged and somatoform disorders. With matched samples, the Sc differentiated brain-damaged schizophrenics well from other clinical groups, while the P-O scale differentiated the non-brain-damaged schizophrenics from brain-damaged and somatoform disorders. Furthermore, the P-N scale discriminated brain-damaged schizophrenics from non-brain-damaged schizophrenics, while the Sc-O scale was no longer significant. Results suggest that caution should be used in generalizing from previous studies (which used inpatient samples) to outpatient populations.
The results of the ICD-10 field trial in German-speaking countries relevant to sections F4 (neurotic, stress-related and somatoform disorders) and F5 (physiological dysfunction associated with mental or behavioural factors) show a comparatively low level of acceptance. Interrater-reliability in various diagnostic categories is not always adequate. In particular the allocation of some of the "old" diagnostic entities of ICD-9 to various sections of ICD-10, and in part unsatisfactory classificatory distinctions gave rise to certain problems.
Three cases of adolescents with respiratory stridor of psychiatric etiology are described. All three fulfilled DSM-III-R criteria for diagnoses of somatoform disorders and showed characteristics of repressive defense style. Such patients are likely to undergo extensive medical investigation and treatment if the psychiatric nature of their disorder is not recognized, but few data describing their psychological characteristics or treatment exist. Repressors are typically unaware of emotional arousal and do not recognize the negative affects which lead to their somatic symptoms. They therefore respond poorly to confrontational psychotherapy and are at risk of discontinuing treatment and repeating their maladaptive symptom cycle. Identification of repressive defense style in patients with stridor which has no obvious organic cause may be useful both as a possible "marker" of psychiatric disorder and as a guide to treatment.
A case is described of cyproheptadine dependence in a woman with a persistent belief that she was too thin, and diagnosed with an atypical somatoform disorder. The cyproheptadine was initially prescribed to promote weight gain but its continued use seemed related to other psychological and/or pharmacological effects. Cognitive impairment was present, possibly as a result of the longstanding cyproheptadine abuse. There have been no previous reports of cyproheptadine dependence or of CNS toxicity from its long-term use.
We present a case of tabes dorsalis, which consisted of intermittent, sharp pains and diffuse neurological abnormalities, and was initially considered to be a somatoform disorder. The unusual behavioural presentations of neurosyphilis may lead to premature psychiatric diagnoses. It is thus important that psychiatric consultants be aware of the myriad manifestations of the disease.
The Quality Assurance Project is developing explicit and detailed treatment outlines for each of the major psychiatric disorders. Three sources of information are used: the treatment outcome literature, the opinions of a sample of practising psychiatrists and the views of a panel of nominated experts. The recommendations for the treatment of somatoform disorders were as follows: brief dynamic psychotherapy, family therapy and excellent medical consultation are the basis for the treatment of hypochondriasis. Limited long-term supportive psychotherapy and good medical consultation are important in somatization disorder. Symptom relief, psychotherapeutic support and meticulous collaboration with physicians are the keys to managing psychogenic pain disorder. Physiotherapy to improve physical functioning and patient education to facilitate the distinction between normal symptoms and abnormal illness behaviours are important in all three conditions. Neither the benzodiazepines nor behaviour therapy appear to be of use in these conditions.
In this paper, a plea is made for establishing the dimension communication of emotional meaning as a descriptive axis in biopsychosocial diagnosis. Studies on alexithymia and somatic illness suggest that this dimension possesses not only diagnostic implications but also prognostic and therapeutic ones. A transactional viewpoint considering the definitions and expectations of patients, professionals and society would convert multiaxial into multidimensional diagnosis adapted to a given culture. Somatoform disorders are taken as illustration of the usefulness of the proposed dimension for further research and theorizing.