The somatoform disorders are a group of mental problems characterized by physical complaints that aren't caused by a physical disease or condition. Generally, the patient complains of uncomfortable physical sensations or the inability to walk or move the arms or legs. The physical symptoms must be serious enough to interfere with the patient's job or relationships, and must be symptoms that the patient can't control voluntarily.
As a group, the somatoform disorders are difficult to recognize and treat because patients often have long histories of medical or surgical treatment withseveral different doctors. In addition, the physical symptoms are not underthe patient's conscious control, so that he or she isn't intentionally tryingto confuse the doctor or complicate the process of diagnosis. Somatoform disorders are, however, a significant problem for the health care system becausepatients with these disturbances overuse medical services.
Somatization disorder was formerly called Briquet's syndrome, after the French physician who first recognized it. The distinguishing characteristic of this disorder is a pattern of symptoms in several different parts of the patient's body that can't be accounted for by medical illness. For a diagnosis, there must be complains of pain in the digestive system, sex organs, and the nervous system.
Somatization disorder usually begins before the age of 30. It is estimated that 0.2% of the United States population will develop this disorder sometime in their lives. Another researcher estimates that 1% of all women in the United States have symptoms of this disorder. The female-to-male ratio is estimated to range between 5:1 and 20:1.
Somatization disorder usually persists throughout the patient's life. It alsotends to run in families. Some psychiatrists think that the high female-to-male ratio in this disorder reflects the cultural pressures on women in NorthAmerican society and the social "permission" given to women to be physicallyweak or sickly.
Conversion disorder is a condition in which the patient's senses or ability to walk or move are impaired without a recognized medical or neurological disease. With this condition, psychological factors (such as stress or trauma) are temporarily related to the symptoms. The disorder gets its name from the notion that the patient is "converting" a psychological problem into an inability to move specific parts of the body or to use the senses normally. A patient who suddenly can't speak during a situation in which he or she is afraid tospeak might be suffering from a conversion disorder. The symptom simultaneously contains the anxiety and serves to get the patient out of the threateningsituation.
The specific physical symptoms of conversion disorder may include a loss of balance or paralysis of an arm or leg; the inability to swallow or speak; theloss of touch or pain sensation; going blind or deaf; seeing double; or having hallucinations, seizures, or convulsions.
Unlike somatization disorder, conversion disorder may begin at any age, and it does not appear to run in families. As many as 34% of the population experiences conversion symptoms over a lifetime, but the disorder is more likely tooccur among less educated people; 90% of patients recover within a month, and most don't have recurrences. Male patients are likely to develop conversiondisorders in occupational settings or military service.
Pain disorder is marked by the presence of severe pain. This category coversa range of patients with a variety of ailments, including chronic headaches,back problems, arthritis, muscle aches and cramps, or pelvic pain. In some cases the patient's pain appears to be largely due to psychological factors, but in other cases the pain is derived from a medical condition as well as thepatient's mental problems.
Pain disorder is relatively common in the general population especially amongolder adults; the sex ratio is more nearly equal
Hypochondriasis is a somatoform disorder marked by excessive fear of or preoccupation with having a serious illness that doesn't get better in spite of medical testing and reassurance. It was formerly called hypochondriacal neurosis.
Although hypochondriasis is usually considered a disorder of young adults, itis now increasingly recognized in children and adolescents. It may also develop in elderly people without previous histories of health-related fears. Thedisorder accounts for about 5% of psychiatric patients, and is equally common in men and women. Hypochondriasis may persist over a number of years but usually occurs as a series of episodes rather than continuous treatment-seeking. The flare-ups of the disorder are often correlated with stressful events inthe patient's life.
A patient with body dysmorphic disorder has a preoccupation with an imaginedor exaggerated defect in appearance. Most cases involve features on the patient's face or head, but other body parts (especially those associated with sexual attractiveness, such as the breasts or genitals) may also be the focus ofconcern.
Body dysmorphic disorder is regarded as a chronic condition that usually begins in the patient's late teens and fluctuates over the course of time. It wasinitially considered to be a relatively unusual disorder, but may be more common than was formerly thought. It appears to affect men and women with equalfrequency. Patients with body dysmorphic disorder often try to have plasticsurgery or other procedures to repair or treat the supposed defect.
The most common somatoform disorders in children and adolescents are conversion disorders, although body dysmorphic disorders are being reported more frequently. Conversion reactions in this age group usually reflect stress in thefamily or problems with school rather than long-term mental health problems.Some mental health experts speculate that adolescents with conversion disorders often have overprotective or overinvolved parents with a subconscious needto see their child as sick; in many cases the son or daughter's symptoms become the center of family attention. The rise in body dysmorphic disorders inadolescents may reflect American society's preoccupation with physical perfection.
The somatoform disorders are grouped together on the basis of symptom patterns, so their causes include several different factors. Family stress is believed to be one of the most common causes of somatoform disorders in children and adolescents. Conversion disorders in this age group may also be connected with physical or sexual abuse within the family of origin.
Somatization disorder and hypochondriasis may result in part from the patient's unconscious imitation of their parents' behavior. This "copycat" behavioris particularly likely if the patient's parent benefitted in some way from symptoms.
Cultural influences appear to affect the somatoform disorders. Some cultures(for example, Greek and Puerto Rican) report higher rates of somatization disorder among men than is the case for the United States. In addition, somatization disorder is less common among people with higher levels of education. People in Asia and Africa are more likely to report certain types of physical sensations (for example, burning hands or feet, or the feeling of ants crawling under the skin) than are Westerners.
Genetic or biological factors may also play a role. For example, people who suffer from somatization disorder may also perceive pain differently.
Accurate diagnosis of somatoform disorders is important to prevent unnecessary surgery, lab tests, or other procedures. Diagnosis of somatoform disordersrequires a thorough physical exam to rule out medical and brain conditions, or to assess their severity in patients with pain disorder. A detailed examination is especially necessary when conversion disorder is a possible diagnosis, because some neurological conditions (such as multiple sclerosis and myasthenia gravis) have sometimes been misdiagnosed as conversion disorder.
In addition to ruling out medical causes for the patient's symptoms, a doctorwho is evaluating a patient for a somatization disorder will consider the possibility of other mental diagnoses. Patients with somatization disorder often develop panic attacks or agoraphobia (fear of going out in public) togetherwith their physical symptoms. In addition to anxiety or personality disorders, the doctor will usually consider major depression as a possible diagnosiswhen evaluating a patient with symptoms of a somatoform disorder. Pain disorders may be associated with depression, and body dismorphic disorder may be associated with obsessive-compulsive disease.
Patients with somatoform disorders are sometimes given antianxiety drugs or antidepressant drugs if they have also been diagnosed with a mood or anxiety disorder. In general, however, it is considered better to avoid prescribing medications for these patients since they are likely to become psychologicallydependent on them. (However, body dysmorphic disorder as been successfully treated with selective serotonin reuptake inhibitors (SSRI) antidepressants).
Patients with somatoform disorders can benefit from supportive approaches totreatment that are aimed at easing symptoms and stabilizing the patient's personality. Some patients with pain disorder benefit from group therapy or support groups, particularly if their social network has been limited by their pain symptoms.Family therapy is usually recommended for children or adolescentswith somatoform disorders, particularly if the parents seem to be using thechild as a focus to divert attention from other difficulties. Working with families of chronic pain patients also helps avoid reinforcing dependency within the family setting.
Hypnosis is a technique that is sometimes used to treat conversion disorder because it may allow patients to recover memories or thoughts connected with the onset of the physical symptoms.
Patients with somatization disorder or pain disorder may be helped by a variety of alternative therapies including acupuncture, hydrotherapy, therapeuticmassage, or meditation.
The prognosis for somatoform disorders depends on the patient's age and whether the disorder is chronic or episodic. In general, somatization disorder andbody dysmorphic disorder rarely disappear completely. Hypochondriasis and pain disorder may get better if there are great improvements in the patient's overall health and lifestyle. People with both disorders may go through periods when symptoms become less severe or become worse. Conversion disorder responds quickly to treatment, but may recur in about 25% of all cases.
Because these syndromes affect different age groups, have different symptom patterns and are caused by different problems of adjustment, it's hard to describe one way to prevent them all. In theory, allowing children to express emotional pain rather than regarding it as "weak" might reduce the attention that physical symptoms that bring from parents.