somatoform (psychosomatic) disorder; somatic symptom & related disorders (SSRD)
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Introduction
A group of disorders characterized by physical symptoms for which there are no demonstrable organic findings.
Classification
- body dysmorphic disorder
- conversion disorder
- hypochondriasis
- hysteria
- somatization disorder
- somatoform pain disorder
- undifferentiated somatoform disorder
- somatic symptom disorder
Etiology
- predisposing factors
- frequent of severe illness during childhood
- overprotective parents
- personal or family history of psychiatric illness
- alcoholism or drug addiction
- history of physical or sexual abuse
- divorce
- antisocial behavior
- low educational achievement
- low socioeconomic class
- precipitating factors
- stressful life events
- bereavement
- acute physical illness or injury
- overwork or strenous activity prior to illness ("burnout")
- stressful life events
- perpetuating factors
- development & maintenance of the "sick role"
- poor self esteem
- impaired social & occupational skills
- psychologic factors are presumed to play a strong role in the onset & persistence of the physical symptoms
- ongoing disability claims & other forms of secondary gain
- physicians' somatization through excessive diagnostic testing or an unwillingness to explore psychosocial concerns
Epidemiology
- far more common in women than men
- tend to begin in adolescence or young adulthood
- undifferentiated somatoform disorder* & hypochondriasis are the most common forms seen in the elderly[3]
* not the same as unspecified somatic symptom disorder[3]
Clinical manifestations
- multiple diffuse or vague complaints
- fear & conviction of serious illness
- preoccupation or exaggeration of bodily symptoms
- abnormal affect
- pain not in dermatomal distribution
- multiple tender (trigger) points & low pain threshold
- voluntary weakness
- extensive use of the medical system
- iatrogenic illness is common
- patients generally not reassured by negative test results[2]
- associated with significant distress or impairment in function[3]
Diagnostic criteria
- at least 1 somatic symptom causing distress or interference with life
- excessive thoughts, behaviors & feelings associated with the somatic symptom(s)
- persistent somatic symptoms for >= 6 months[2]
* at least 2 GI, 1 sexual & 1 pseudoneurologic symptom are required for severe form
Laboratory
- no laboratory tests are pathognomonic
- extensive laboratory testing is common
- symptomatic findings in excessive of laboratory findings
- extensive diagnostic testing is counterproductive
Differential diagnosis
- psychiatric disorders
- major depression
- anxiety disorder
- substance abuse
- personality disorder
- schizophrenia
- illness anxiety disorder
- excessive rumination serious illness
- one somatic concern
- delusional disorder
- symptoms must be present >= 1 month
- minimal functional impairment
- may or may not be distressing to patient
- medical disorders
- hypothyroidism & hyperthyroidism
- hypoadrenalism & hyperadrenal state
- hyperparathyroidism
Management
- attempt to establish long-term relationship of trust & mutual respect
- listen patiently to patient's complaints
- take each symptom seriously
- negotiate symptoms to evaluate during visit
- perform brief, focused examination
- do NOT promise quick relief or cure
- do NOT tell the patient "it's all in your head"
- tell patient that life-threatening conditions have been ruled-out[2]
- give plausible explanation of symptom(s) if possible[2]
- validate symptoms & need for ongoing treatment
- encourage the patient to correlate symptoms with events
- ask patient to keep a diary
- focus on functioning with symptoms rather than eliminating symptoms[2]
- use of psychotropic agents for treatment of depression & anxiety
- multimodal approach including fitness training, relaxation, & stress management
- cognitive behavioral therapy
- evidence-based treatment of choice[2]
- follow-up with brief, regularly scheduled visits (same health care provider)
- 1 to 4 weeks initially
- thereafter every 1-3 months
- limit the number of unscheduled appointments
- coordinate care with psychiatrist[2]
More general terms
More specific terms
- body dysmorphic disorder
- conversion disorder/functional neurologic symptom disorder
- hypochondriasm; illness anxiety disorder
- hysteria
- somatic symptom disorder
- somatization disorder (Briquet's syndrome)
- somatoform pain disorder (psychogenic pain, psychalgia)
- undifferentiated somatoform disorder
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1105-1107
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007 Dec;69(9):881-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18040099 - ↑ 3.0 3.1 3.2 3.3 Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016 - ↑ Oyama O, Paltoo C, Greengold J Somatoform disorders. Am Fam Physician. 2007 Nov 1;76(9):1333-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18019877
- ↑ Dimsdale JE, Creed F, Escobar J et al Somatic symptom disorder: an important change in DSM. J Psychosom Res. 2013 Sep;75(3):223-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23972410