In somatoform disorders, physical symptoms suggest a physical disorder, but there are no demonstrable organic findings and there is strong evidence for link to psychological factors or conflicts. In the middle ages, these disorders were believed to be spiritual disorder of evil and demonic possession. In the 17th century, Sydenham said, “hysteria could simulate any medical disease”. In the 19th century, it was Briquet who made the first systematic description of hysteria with 430 cases. Briquet, Reynold, Charcoat all believed that hysteria is a CNS disease. ‘Studies on Hysteria’ (1893-95) by Breur and Freud gave new insights. Freud explained the syndrome of hysteria as “conversion of emotional distress into physical symptoms”. Later, hysteria became less popular as a diagnosis. The term ‘somatization’ was introduced by Stekl to denote “the expression of emotional distress as bodily symptoms”. Hysteria has pejorative associations. It might represent misdiagnosis of organic disorders. It was the St Louis group Perley and Guze who described the Briquet’s syndrome as “chronic multiple somatic symptoms, with no identifiable organic cause”. They had regarded this as a form of hysteria.
Somatic symptoms may result from a heightened awareness of certain bodily sensations, combined with a tendency to interpret these sensations as indicative of a medical illness.
- Childhood neglect, sexual abuse, chaotic lifestyle
- History of alcohol and substance abuse
- Association with personality disorders
The main feature of these disorders is a concern with physical symptoms that are attributed to a non-psychiatric disease. This concern can manifest as one or more somatic symptoms that result in excessive thoughts, feelings, or behaviors related to those symptoms and that are distressing or result in significant disruption of daily life.
DSM-5 diagnostic criteria for somatic syndrome disorders (SSDs):3 requirements need to fulfill the diagnostic criteria
- Somatic symptom(s) that cause significant distress or disruption in daily living
- One or more thoughts, feelings, and/or behaviors that are related to the somatic symptom(s) which are persistent, excessive, associated with a high level of anxiety, and results in the devotion of excessive time and energy
- Symptoms lasting for > 6 months
- Conversion disorder: One or more symptoms of altered voluntary motor/sensory function inconsistent with a known condition
- Factitious disorder: Falsification of physical/psychological symptoms, or induced injury/disease; can be with regard to self or imposed on others, although not for personal gain (as with malingering)
- Illness anxiety disorder: Preoccupation with getting/having a serious medical disorder; the two types include care-seeking and care-avoidant; previously included in hypochondriasis
- Psychological factors affecting other medical conditions: A medical condition must exist and psychological factors must negatively affect the condition
- Other specified somatic symptom and related disorders: Symptoms consistent with somatic symptom disorder are present, but do not meet full criteria for any of the above disorders
- Unspecified somatic symptom and related disorders: Symptoms consistent with somatic symptom disorder are present, but do not meet criteria for any of the above disorders; should be used only when there is insufficient information to make a more specific diagnosis
- Patient Health Questionnaire-15: M/C used screening instrument to detect somatization symptoms in the general population
- Somatic symptom scale-8: Measures somatic symptom burden
Differential diagnosis:The following diagnoses should be considered in patients with suspected somatic symptom disorder because the symptoms may be indicative of other mental health disorders
- Depression, panic disorder, generalized anxiety disorder, substance use disorder
- Syndromes of unclear etiology (e.g., nonmalignant pain syndrome, chronic fatigue syndrome)
- Nonpsychiatric medical conditions
The management of somatic symptom disorders requires a multifaceted approach tailored to the individual patient. To choose the correct treatment plan, primary care clinicians should keep in mind psychological, social, and cultural factors that influence somatic symptoms.
CARE MD treatment approach:Consultation/cognitive behavior therapy (CBT), assessment, regular visits, empathy, medical/psychiatric interface, do no harm
Psychothearpy:These have proven highly effective in managing somatoform disorders
- Cognitive behavior therapy
- Mindfulness-based therapy
- Natural products