Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician
10.1 Somatoform disorders
The common feature of somatoform disorders is the presence of physical symptoms that suggest a general medical condition. However, these symptoms are not adequately explained by a general medical condition by the direct effects of a substance, or by another mental disorder (such as anxiety producing palpitations or breathlessness, depression causing lack of energy).
Symptoms cause significant distress or impairment in social, occupational or other areas of functioning. There is no diagnosable medical condition that can fully account for the physical symptoms. People with somatoform disorders are reluctant to accept that psychological factors may be contributing to their physical symptoms.
This expression of physical symptoms is not a conscious deception by the patient.
There are a number of diagnostic subtypes of somatoform disorders.
In addition, unexplainable physical symptoms can be seen in situations where the symptoms are intentionally expressed. If the motivator behind this is the adoption of the sick role, then the condition is termed a 'factitious disorder'; if the intent is some external gain, then the condition is termed 'malingering'.
It is important to note that while unexplained physical symptoms are extremely common, most people with such symptoms do not have a somatoform disorder - most of the 'somatizing' presentations to general practice settings would not meet the criteria for one of these disorders.
Similarly, most people presenting with pain do not have a ‘pain disorder’ or form a somatoform disorder, but rather, have pain of organic origin that may be expressed in a range of ways.
Disorders 10.1.7 to 10.1.9 are not within the group known as somatoform disorders, but may present with physical symptoms for which there is no adequate physical cause.
10.1.1 Somatization disorderThis disorder is a polysymptomatic disorder commencing before the age of 30 and extending over a period of years. It is characterised by multiple somatic symptoms in a combination of pain, gastrointestinal, sexual and pseudoneurological symptom areas.
10.1.2 Undifferentiated somatoform disorderThis disorder is characterised by unexplained physical complaints that last for at least six months and are below the threshold for a diagnosis of somatization disorder.
10.1.3 Conversion disorderThis disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function that suggests a neurological or other general medical condition. Psychological factors are judged as being associated with the symptoms or deficits.
10.1.4 Pain disorderPain is the predominant focus of clinical attention in this disorder. Additionally, psychological factors are judged to play an important role in the onset, severity, exacerbation and maintenance of the disorder.
10.1.5 HypochondriasisThis disorder involves a preoccupation with the fear of having, or the idea that a person has, a serious disease based on the individuals misinterpretation of bodily symptoms or functions.
10.1.6 Body dysmorphic disorderThis disorder involves a preoccupation with an imagined or exaggerated defect in physical appearance.
10.1.7 Chronic fatigue syndromeThis syndrome refers to a symptom complex of marked and prolonged fatigue for which no identifiable physical cause can be found.
10.1.8 Factitious disorderThis disorder is characterised by physical or psychological symptoms that are intentionally produced in order to assume the sick role (psychological reasons assumed).
- This involves intentional production of false or grossly exaggerated physical or psychological symptoms motivated by external incentives such as financial compensation, avoidance of work or obtaining drugs.
- Malingering disorders differ from factitious disorders in that external incentives are absent in factitious disorders.
Management approaches to somatoform disorders
- Patients with somatoform disorders present considerable diagnostic difficulty and treatment can be challenging. Somatisation should be best viewed as a process rather than a diagnosis(377). Many GPs report difficulties in dealing with somatising patients(377, 378).
- Referral times for clients to attend pain clinics, psychologists and psychiatrists equipped to manage clients with somatoform disorders are often long or unavailable(377). Frequently, patients fail to attend.
- It is important to develop a good working relationship with the patient. However, the major challenge is developing a common understanding of the problem(379).
- Somatoform disorders are best managed behaviourally and with cognitive therapy which has shown reductions in somatic symptoms and improved functioning***(380-386).
- Emphasis should always be placed on non-medication management of the somatoform or chronic pain disorder as a first line of treatment(377). While non-medication management can be extremely challenging at times, if the resources are available in the general practice setting and the client is willing to engage in behavioural therapy, then this should be offered.
- To engage in treatment, the patient needs to have some insight into the problem and be willing to try to approach the problem differently. If this insight cannot be achieved, then a health-system based containment strategy is required.
Understanding somatisation and somatisation disorders: A handbook for health care workers(387).