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Somatic Symptom Disorders

  • Author: William R Yates, MD, MS; Chief Editor: Eduardo Dunayevich, MD  more...
 
Updated: May 07, 2014
 

Background

The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5)[1] category of Somatic Symptom Disorders and Other Related Disorders represents a group of disorders characterized by thoughts, feelings, or behaviors related to somatic symptoms. This category represents psychiatric conditions because the somatic symptoms are excessive for any medical disorder that may be present.

Somatic symptom disorders and other related disorders challenge medical providers. Clinicians need to estimate the relative contribution of psychological factors to somatic symptoms. A somatic symptom disorder may be present when the somatic symptom is a focus of attention, is distressing, or is contributing to impairment.

Anxiety disorders and mood disorders commonly produce physical symptoms. Clinicians need to rule out somatic symptoms due another primary psychiatric condition before considering a somatic symptom disorder diagnosis. Somatic symptoms can dramatically improve with successful treatment of the anxiety or mood disorder.

The DSM-5 includes 5 specific diagnoses in the Somatic Symptom Disorder and Other Related Disorder category.[1] Specific Somatic Symptom Disorders diagnoses include (1) somatic symptom disorder, (2) conversion disorder, (3) psychological factors affecting a medical condition, (4) factitious disorder, and (5) other specific and nonspecific somatic symptom disorders.

DSM-5 produced significant changes in this category of disorders. This category had previously been named Somatoform Disorders in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).[2] Somatic symptom disorder replaces the DSM-IV-TR diagnosis of somatization disorder. Hypochondriasis, pain disorder, and body dysmorphic disorder, conditions listed in the Somatoform Disorders category in DSM-IV-TR have been removed. Psychological factors affecting a medical condition and factitious disorder have been added to the new Somatic Symptom Disorders category. Finally, a residual category of other specific and nonspecific somatic symptom disorder has been created with DSM-5.

The newly defined structure of this category means few research studies of the new disorders have been completed. To address this weakness, this article will continue to include review of some of the older somatoform disorders research literature.

See the chart below.

Somatic symptom diagnoses in a series of universit Somatic symptom diagnoses in a series of university hospital psychiatric consultations.

Case study

Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician.

Ms. J's primary care physician has followed her for many years and has made the diagnosis of somatic symptom disorder. The treatment plan includes regular frequent visits to monitor her chronic pain complaints. Use of medication with addictive potential is restricted. Physical symptoms are monitored with limited use of invasive diagnostic procedures. Outpatient visits focus on identifying sources of stress and encouraging healthy coping mechanisms.

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Pathophysiology

The pathophysiology of somatic symptom disorder is unknown. Primary somatic symptom disorders may be associated with a heightened awareness of normal bodily sensations. This heightened awareness may be paired with a cognitive bias to interpret any physical symptom as indicative of medical illness. Autonomic arousal may be high in some patients with somatization. This autonomic arousal may be associated with physiologic effects of endogenous noradrenergic compounds such as tachycardia or gastric hypermotility. Heightened arousal also may induce muscle tension and pain associated with muscular hyperactivity, as is seen with muscle tension headaches.

Brain imaging studies support an association between one or more of the somatic symptom disorders, with reduced volume of the brain amygdala[3] and brain connectivity between the amygdala and brain regions controlling executive and motor function.[4]

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Epidemiology

Frequency

United States

Prevalence rates for the most restrictive previous diagnosis of somatization disorder appear low in community samples (0.1%). Low community prevalence rates for somatic symptom disorder may be due to a reporting bias.

Medical record studies suggest the rate of somatic symptom disorder in the community among women may be as high as 2%. More liberal case assignment criteria result in rate estimates of the prevalence of a broader somatic symptom syndrome to be as high as 11.6% of the population.

Other somatic symptom disorders may have significant rates in specific clinical populations. In general medical clinic populations, the prevalence rates of hypochondriasis may approach 4-6%.[5] Body dysmorphic disorder may be present in as many as 2% of patients of plastic surgery clinics. In psychiatric consultations at general hospitals, some studies document high rates (5-15%) of conversion disorder.

International

A study in Belgium reported that somatization syndrome is the third highest psychiatric disorder, with a prevalence rate of 8.9%. The first and second most common psychiatric disorders were depression and anxiety disorders.[6]

Somatic symptom disorders contribute a significant economic burden to the costs of brain disorders. A European survey estimated the cost of somatic symptom disorders across Europe to be 22 billion Euro/year (approximately $30 billion US dollars per year). This makes the cost of somatic symptom disorders in the range of that for multiple sclerosis, Parkinson disease, or traumatic brain injury.[6]

Mortality/Morbidity

Somatic symptom disorders do not appear to independently increase the risk of death. Some evidence exists that somatization disorder is associated with increased risk for suicide attempts.[7] Patients with somatic symptom disorders may be misdiagnosed as having a medical condition and therefore experience iatrogenic complications due to invasive diagnostic procedures or surgical operations.

Sex

In most somatic symptom disorder categories, a female preponderance exists. The female-to-male ratio has been estimated to be 10:1 for somatization disorder, from 2:1 to 5:1 for conversion disorder and from 2:1 for pain disorder.

Age

Somatic symptom disorders may begin in childhood, adolescence, or early adulthood. New onset of unexplained somatic symptom disorders in older adults should prompt a search for occult medical illness or evidence of major depression associated with somatization.

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Contributor Information and Disclosures
Author

William R Yates, MD, MS Research Psychiatrist, Laureate Institute for Brain Research; Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa

William R Yates, MD, MS is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Eduardo Dunayevich, MD Executive Director, Clinical Development, Amgen

Eduardo Dunayevich, MD is a member of the following medical societies: Schizophrenia International Research Society

Disclosure: Received salary from Amgen for employment; Received stock from Amgen for employment.

Additional Contributors

Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

References
  1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

  2. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. Fourth Edition. Washington, DC: American Psychiatric Association; 2000. Text Revision.

  3. Atmaca M, Sirlier B, Yildirim H, Kayali A. Hippocampus and amygdalar volumes in patients with somatization disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Aug 15. 35(7):1699-703. [Medline].

  4. van der Kruijs SJ, Bodde NM, Vaessen MJ, Lazeron RH, Vonck K, Boon P, et al. Functional connectivity of dissociation in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry. 2012 Mar. 83(3):239-47. [Medline].

  5. Baumeister H, Härter M. Prevalence of mental disorders based on general population surveys. Soc Psychiatry Psychiatr Epidemiol. 2007 Jul. 42(7):537-46. [Medline].

  6. Baruffol E, Thilmany MC. Anxiety, depression, somatization and alcohol abuse. Prevalence rates in a general Belgian community sample. Acta Psychiatr Belg. 1993 May-Jun. 93(3):136-53. [Medline].

  7. Chioqueta AP, Stiles TC. Suicide risk in patients with somatization disorder. Crisis. 2004. 25(1):3-7. [Medline].

  8. Kendler KS, Aggen SH, Knudsen GP, Røysamb E, Neale MC, Reichborn-Kjennerud T. The structure of genetic and environmental risk factors for syndromal and subsyndromal common DSM-IV axis I and all axis II disorders. Am J Psychiatry. 2011 Jan. 168(1):29-39. [Medline]. [Full Text].

  9. Maes M, Galecki P, Verkerk R, Rief W. Somatization, but not depression, is characterized by disorders in the tryptophan catabolite (TRYCAT) pathway, indicating increased indoleamine 2,3-dioxygenase and lowered kynurenine aminotransferase activity. Neuro Endocrinol Lett. 2011. 32(3):264-73. [Medline].

  10. Katzer A, Oberfeld D, Hiller W, Gerlach AL, Witthöft M. Tactile perceptual processes and their relationship to somatoform disorders. J Abnorm Psychol. 2012 May. 121(2):530-43. [Medline].

  11. Werring DJ, Weston L, Bullmore ET. Functional magnetic resonance imaging of the cerebral response to visual stimulation in medically unexplained visual loss. Psychol Med. 2004 May. 34(4):583-9. [Medline].

  12. Martin A, Rauh E, Fichter M, Rief W. A one-session treatment for patients suffering from medically unexplained symptoms in primary care: a randomized clinical trial. Psychosomatics. 2007 Jul-Aug. 48(4):294-303. [Medline].

  13. Smith GR Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med. 1986 May 29. 314(22):1407-13. [Medline].

  14. Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA. 2004 Mar 24. 291(12):1464-70. [Medline].

  15. Bleichhardt G, Timmer B, Rief W. Cognitive-behavioural therapy for patients with multiple somatoform symptoms--a randomised controlled trial in tertiary care. J Psychosom Res. 2004 Apr. 56(4):449-54. [Medline].

  16. Beltman MW, Voshaar RC, Speckens AE. Cognitive-behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials. Br J Psychiatry. 2010 Jul. 197(1):11-9. [Medline].

  17. Huang M, Luo B, Hu J, Wei N, Chen L, Wang S, et al. Combination of citalopram plus paliperidone is better than citalopram alone in the treatment of somatoform disorder: results of a 6-week randomized study. Int Clin Psychopharmacol. 2012 May. 27(3):151-8. [Medline].

  18. Egloff N, Cámara RJ, von Känel R, Klingler N, Marti E, Ferrari ML. Hypersensitivity and hyperalgesia in somatoform pain disorders. Gen Hosp Psychiatry. 2014 May-Jun. 36(3):284-90. [Medline].

  19. Harris AM, Orav EJ, Bates DW, Barsky AJ. Somatization increases disability independent of comorbidity. J Gen Intern Med. 2009 Feb. 24(2):155-61. [Medline]. [Full Text].

  20. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007 Dec. 69(9):881-8. [Medline].

  21. Olesen J, Gustavsson A, Svensson M, Wittchen HU, Jönsson B. The economic cost of brain disorders in Europe. Eur J Neurol. 2012 Jan. 19(1):155-62. [Medline].

  22. Roca M, Gili M, Garcia-Garcia M, Salva J, Vives M, Garcia Campayo J, et al. Prevalence and comorbidity of common mental disorders in primary care. J Affect Disord. 2009 Apr 9. [Medline].

  23. Sumathipala A, Siribaddana S, Abeysingha MR, De Silva P, Dewey M, Prince M, et al. Cognitive-behavioural therapy v. structured care for medically unexplained symptoms: randomised controlled trial. Br J Psychiatry. 2008 Jul. 193(1):51-9. [Medline].

  24. van Ravesteijn H, Wittkampf K, Lucassen P, van de Lisdonk E, van den Hoogen H, van Weert H, et al. Detecting somatoform disorders in primary care with the PHQ-15. Ann Fam Med. 2009 May-Jun. 7(3):232-8. [Medline].

 
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Somatic symptom diagnoses in a series of university hospital psychiatric consultations.
 
 
 
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