Somatisation Disorder

Synonyms: Briquet Syndrome, Brissaud-Marie Syndrome, Hypochondriasis, fat-file syndrome

• Usually the complaints involve chronic pain and problems with the digestive system, the nervous system, and the reproductive system. The disorder usually begins before the age of 30 and occurs more often in women than in men.
• Recent research has shown higher percentages of this disorder in people with irritable bowel syndrome and chronic pain patients.
• Antisocial personality disorder is associated with a risk for somatisation disorder.²
• The somatising patient seems to seek the sick role, which affords relief from stressful or impossible interpersonal expectations ("primary gain")
  • In most societies this provides attention, caring and sometimes even monetary reward ("secondary gain").
  • This is not malingering, because the patient is not aware of the process through which the symptoms arise, cannot will them away and genuinely suffers from the symptoms.
• Several studies have suggested an association between somatisation and a history of sexual or physical abuse in a significant proportion of patients.³

• Prevalence rates for the most strict criterion diagnosis of somatisation disorder appear low in community samples (0.1%).⁴
• Low community prevalence rates may be due to reporting bias.
• Medical record studies suggest the rate of somatisation disorder in the community among women may be as high as 2%.

The symptoms are generally severe enough to affect work and relationships and lead the person to consult a doctor and take medication. A lifelong history of "sickliness" is often present:

• Despite thorough investigation, no specific underlying physical cause is ever identified to account for the symptoms.
• Stress often worsens the symptoms.

Symptoms

Some of the numerous symptoms that can occur with somatisation disorder include:

• Cardiac
  • Shortness of breath
  • Palpitations
  • Chest pain
• Gastrointestinal
  • Vomiting
  • Abdominal pain
  • Difficulty swallowing
  • Nausea
  • Bloating
  • Diarrhoea
• Musculoskeletal
  • Pain in the legs or arms
  • Back pain
  • Joint pain
• Neurological
  • Headaches
  • Dizziness
  • Amnesia
  • Vision changes
  • Paralysis or muscle weakness
• Urogenital
  • Pain during urination
  • Low libido
  • Dyspareunia
  • Impotence
  • Dysmenorrhoea, irregular menstruation and menorrhagia

• A thorough physical examination and diagnostic tests are performed to rule out physical causes - which tests are done is determined by the symptoms present.
• A psychological evaluation should also be performed to rule out related disorders:
  • However, finding evidence of a psychiatric condition does not rule somatisation in or out.
  • It can be a clue to the diagnosis.
  • There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea.

Somatisation is often a diagnosis of exclusion, however it is much more effective to pursue a positive diagnosis of somatisation when the patient presents with typical features:⁵

• Multiple symptoms, often occurring in different organ systems⁶
• Symptoms that are vague or that exceed objective findings
• Chronic course
• Presence of a psychiatric disorder
• History of extensive diagnostic testing
• Rejection of previous physicians

The general practitioner's emotional response to a patient can serve as an early cue to pursue a somatisation diagnosis:

• A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person
• A sense of being overwhelmed by a patient who has had numerous evaluations by other physicians

These can be a signal to the clinician to consider somatisation in the differential diagnosis early in the patient's evaluation.

The first occasion that the diagnosis is discussed (after the initial investigations have failed to show any organic pathology) is a key moment in the physician-patient relationship. The challenge is to describe the condition to the patient in a manner that avoids any implication of a psychosomatic illness. One journal suggests the following:
"The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, you do have a serious and impairing medical condition, which I see often but which is not completely understood. Although no treatment is available that can cure it completely, there are a number of interventions that can help you deal with the symptoms better than you have so far."⁸

Once other causes have been ruled out and a diagnosis of somatisation disorder is secured, the goal of treatment is to help the person learn to control the symptoms:

• There is often an underlying mood disorder which can respond to antidepressants.
• Unfortunately, persons with this disorder rarely admit that it can be caused, at least in part, by mental health problems, and may refuse psychiatric treatment.

It is important to ask open-ended questions. The BATHE technique provides a framework for exploration of psychosocial stressors in less than 5 minutes:⁹

• In severe cases of somatoform disorder, symptoms are unlikely to resolve completely. Therefore avoid making the goal of the treatment plan to relieve the patient's illness. The physician and patient will soon become frustrated and tempted to engage in a new flurry of diagnostic tests and invasive procedures.
• Attempts to "take away the symptom" may cause the patient to substitute another symptom as a result of the need-to-be-sick phenomenon.

A better goal is to help the patient succeed in coping with the symptoms. Treatment is successful if it keeps the patient out of the hospital.

General advice

• The whole primary care health team should be aware of the diagnosis and management plan. This will make the approach to management consistent across the practice.
• Interventions directed at reducing specific sources of stress are most helpful, these may include advice about dealing with marital conflict.
• Some physical exercise is important as it prevents loss of fitness, enhances self-esteem and provides an opportunity for patients to take a break from oppressive duties or unpleasant situations. A minimum of three 20-minute exercise sessions per week is desirable.
• The importance of pleasurable private time should be emphasised. This may include yoga classes or meditation, bowling or nature walks, which, under the general title of "stress management," can be presented as necessary medical treatments.

Some patients may request tests repeatedly, but they should be reminded that they will be followed with frequent and regular visits so that any problems will be identified early. Sometimes requesting investigations becomes a "negotiating" process designed to give the patient some control over what test is performed and to enhance the trust level between the physician and patient.

Psychotherapy

Approaches derived from cognitive behavioural therapy have been shown to reduce the intensity and frequency of somatic complaints and to improve functioning in many somatising patients:¹⁰

• This type of treatment starts with the mutual agreement that whatever the patient has been thinking and doing about the condition has not been successful.
• It then begins to challenge the patient's beliefs and maladaptive behaviours in a caring manner.
• Short course intervention therapy (eight to 16 sessions) specifically for treatment of somatising patients have been shown to be remarkably effective in improving function and reducing distress.¹¹
• The sessions combine general advice such as stress management, problem solving and social skills training with specific interventions targeted at the amplification and need-to-be-sick features of somatisation.

Pharmacological

There are psychiatric disorders associated with somatisation, specifically anxiety and depression. These respond well to treatment but, especially with antidepressants, it is important to start with low doses and to increase progressively to avoid side effects that may be present at the beginning of treatment and discourage the patient from continuing.

• Complications may result from invasive testing and from multiple evaluations that are performed while looking for the cause of the symptoms.
• A dependency on pain relievers or sedatives may develop.
• A poor relationship with the health care provider seems to worsen the condition, as does evaluation by many providers.