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Case

• Ms. L is a 55-yo year old woman who is new to your practice, and comes to the first visit with a several page list of physical complaints dating back to age 10.
• Current stressors include husband who is always out of town on business, yet even when in town, he is busy with his various hobbies, however she denies being upset or resentful  about this.

• Childhood issues include parents who met her basic needs, but were emotionally unavailable; she also denies being upset or resentful about this.

• Although she has seen various specialists for her symptoms, she remains worried that they are a sign of a serious, undiagnosed medical illness

• You set up several regular follow-up visits while you get to know her.

• You listen and validate her medical concerns, while at the same time, you continue to gently ask about her stresses, and over time, she opens up more about how she feels.

• You both agree upon a common goal of helping her cope with her symptoms.

• The good news is that she does not have any life threatening, catastrophic medical illness, however the bad news is that she does have distressing and impairing symptoms.

• You help her find healthy ways to cope with her symptoms and deal with her stresses.

• She reconnects with healthy family and friends, as well as hobbies and interests.

• She agrees to see a counselor/therapist to help her assert herself with her husband.

• Over time, she complains less of physical symptoms, and sees you on a less frequent basis.

Definition of Somatization

• A patient with one or more somatic symptoms that lacks an adequate medical explanation, which causes the patient distress, and prompts the patient to seek help (Lipowski, 1988)

Epidemiology

• 1-year prevalence of somatoform disorders is almost 25% in primary care (Steinbrecher et al., 2011)

Pathophysiology

• Role of stress
  • Patients with somatization appear to have activation of their sympathetic nervous systems as well as hypothalamic pituitary (HPA) axis.
  • Unfortunately, chronic stress response creates wear and tear on the body (“allostatic load”), and thus, can produce or exacerbate symptoms such as headaches, non-cardiac chest pain and gastrointestinal symptoms as well as muscular tension.

• Role of emotions
  • Emotions are brain processes, some conscious and some unconscious, which can affect the body just as stress does.
  • Negative emotion and moods have been linked to various forms of disease whereas positive moods are linked to longevity and favourable health outcomes.
  • Somatization can result from blocked, partially expressed, or unexperienced emotions.
  • For example, some somatizing patients appear to have an inability to identify feelings (i.e. alexithymia).
• Cognitions and behaviours
  • Somatizing patients have excessive worries about their health, which contributes to anxiety, dysphoria and frustration, which can lead to a vicious cycle of increased. physiological arousal and physical symptomatology, which reinforces the patient’s fear that they have a serious medical illness.
  • Helping the patient with their anxiety and distress can thus reduce their need for medical help-seeking.
• Sick role
  • In many (but not all) patients, some patients that somatize come from families in which it was normal for someone to be sick, i.e. in the sick role.
  • Individuals who are chronically in the sick tend to grow more disabled and impaired over time.
• Secondary gain from somatizing
  • Avoidance of unpleasant life role or activity
  • Sympathy and concern from others
  • Importance within the family
  • Gratification of dependency needs
  • Financial awards associated with disability
  • Retaining the spouse in the marriage
  • Avoidance of sex
  • Procuring of drugs
  • Punishment of others or revenge

Types of Somatization by Time Course

1. Acute: Usually associated with a stressor; although pt may somatize, note that pt may not necessarily have a disorder.
2. Sub acute: Often associated with a depressive or anxiety disorder; although pt may somatize, note that pt may not necessarily have a disorder.
3. Chronic: Pervasive and enduring pattern of somatization

Complications

• If patients feel invalidated by the physician as a result of negative investigations, this may negatively impact therapeutic relationship; as a result, it is essential to validate and not dismiss patient concerns, even if investigations are negative.
• Patients are at risk of potential adverse effects of investigations.

History

HPI

• History of the presenting medical complaint
• Factors that may suggest somatic symptoms
  • Patient has troubles answering questions about feelings or emotions
  • Patient has difficulties identifying or expressing emotions
  • Patient have a need to ‘please others’
  • Patient has troubles setting personal limits, such as saying no to excessive requests
  • Patient finds it easier to say “no” to other’s requests if s/he is physically unwell
  • Patient worries about being valued and liked
  • Patient has a pattern of ‘all or nothing’ behaviour and has troubles pacing himself/herself

DSM-5

• Criteria for Somatic Symptom Disorder
  • Somatic symptoms persistent for 6-months or more
  • Very distressing or significant disruption of function
  • Excessive and disproportionate thoughts, feelings and behaviours regarding somatic symptoms
  • Somatic symptoms do not need to be medically unexplained
  • Somatic symptoms are not intentionally produced

• (Note that the DSM-IV category of Somatoform Disorders has been simplified in DSM-5 to be Somatic Symptom Disorder)

Differential Diagnosis

Many conditions can present with somatic symptoms including:

• Undiagnosed medical conditions
• Early presentations of many systemic illnesses may present with non-specific symptoms such as problems with sleep, poor energy, poor concentration
• Examples include:
  • Systemic Lupus Erythematosus (SLE)
  • Multiple sclerosis (MS),
  • HIV,
  • Hyperparathyroidism
  • Paraneoplastic syndromes
• Undiagnosed major psychiatric disorder
• Major depression
  • Presents with neurovegetative symptoms such as problems with sleep, appetite, fatigue, and may also have various aches and pains
  • Anxiety disorder such as
• Generalized anxiety disorder
• Panic disorder
  • May present with various symptoms such as palpitations, problems breathing, lightheadnesses
• Substance abuse/dependence
• Psychotic disorders
• Schizophrenia
• Delusion disorders including those with somatic symptoms
• Factitious Disorder (aka. “Munchausen’s Syndrome)
  • Intentionally feigning or producing physical/psychological signs / symptoms in order to assume the sick role
• Malingering
  • Intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs
• Note:
  • Factitious disorder and malingering involve the intentional production or feigning of symptoms unlike somatization, where the patient is not consciously trying to have symptoms
• Body dysmorphic disorder
  • Preoccupation with imagined defects in appearance
  • Alternatively, if the patient does have a physical abnormality, the concern about the abnormality is excessive

Comorbidity / Psychiatric disorders

There are various other conditions that are associated with somatization including:

• Mood disorders
• Anxiety disorders
• Psychotic disorders
• Adjustment disorders
• Substance-related disorders
• Psychological factors affecting a medical condition
• Somatoform Disorders

Investigations

• There are no specific investigations to perform if somatization is suspected.
• However, specific investigations may be indicated in order to rule out specific medical conditions.

Management of Somatization

General principles

• Focus on therapeutic (i.e. doctor-patient) relationship
• Focus on “caring not curing”
• Always listen, validate and empathize with the patient’s symptoms and the distress that these symptoms cause

Management of Acute Somatization

• Inquire about the patient’s fears about their illness
  • Clinician: “What are your biggest concerns or worries about these symptoms?”
     
• Provide education about symptoms:
  • Clinician: “The bad news is that you are having stomach aches. The good news, is that all the medical tests have shown that there is no life threatening, serious medical condition.  I appreciate that nonetheless, you are still experiencing stomach aches. The good news, is that there are things we can do that can help you cope with these symptoms.”
     
• Problem-solving regarding stressors:
  • Clinician: “Everyone has stresses, such as work and relationships. These stresses may or may not have triggered your symptoms. Nonetheless, having stresses doesn’t make it easier for you to deal with your symptoms. Thus, it is important for us to talk about what stresses you might be under, and come up with a way to support you with each one of them.”
     
• Encourage active, healthy coping strategies (“patient activation”)
  • Clinician: “Before you had these problems, how did you usually cope or deal with stress?” For example, were you the type of person who liked to exercise? Or be with people? Or listen to music? Etc…”
  • Clinician: “So it seems like since the symptoms started, you have been more withdrawn, and not getting out to see people nor getting any exercise…. Does this help your situation? What would it be like if we could have you getting out a bit more? Or getting just a bit more exercise?”
     
• Bolstering of existing support systems, e.g. encouraging patient to connect with supportive family and friends ; otherwise, making new supports
  • Clinician: “Who are the closet people that you can turn to? Have you been able to turn to those people these days?”

Management of Chronic Somatization

Consider chronic somatization if:

• Patient reports a lifetime history of multiple physical symptoms with unclear or no diagnosis.
• Patient reports seeing many doctors and receiving many diagnostic procedures with inconsistent findings for more than one symptom.
• Patient reports a pattern of physicians, family members and/or friends being “unable to understand”or “fed up”with the patient’s physical symptoms.
• Symptoms are described graphically or dramatically.
• There is strong evidence of secondary gain.

Principles of management of chronic somatization

• Goals
  • Help patient develop more tolerance of their symptoms.
  • Help patient be more able to wait until having their symptoms checked out.
  • Help patient become less hyper vigilant of their body sensations.
  • To reassure that there is an adequate monitoring schedule arranged so that any serious illness is not overlooked, and so that your patient continues to feel connected with you.

Management of chronic somatization

• Ensure the patient has one (as opposed to more than one) primary care physician

• Have appointments at regular time-contingent intervals

• Perform brief physical exam at each visit to address new health concerns (Remember: somatizing patients can develop organic medical conditions)

• Judicious diagnostic evaluations are initiated conservatively based on new physical findings or symptoms

• After rapport is developed, begin to shift focus to current functioning, stressors and available support systems

• Corroborate history, disability, treatment adherence, substance use and health care use by integrating family and other supports into the care plan

• Draw up a plan for regular check ups.

• As time goes on, increase the space between visits

• In between scheduled appointments, encourage patients to write new worries that develop on a list as opposed to making an early appointment

• Address the items on the list at the next scheduled appointment.

• Helping patients see the mind-body connection

• Encourage patient to use “log book”or calendar for tracking illness or pain symptoms.

• Use log book to look at emotionally significant events occurring prior to symptoms getting worse.

• Help patient make the link between life stressors/emotional events with worsening physical symptoms

• Help patient become more assertive. If the patient is more assertive, the patient may have less need to rely on illness as a way of communicating.

Other strategies

Relaxation Training

• Includes diaphragmatic breathing and progressive muscle relaxation
• Benefits include:
  • Interrupt muscle tension-pain cycle
  • May reduce generalized physiologic arousal or reactivity
  • Patient may feel less like a helpless victim of symptoms

Behavioral management

• Increased activities focused on 3 categories

1. Meaningful activities (e.g. paid or volunteer work, household projects, education)
2. Pleasurable activities (social activities, hobbies)
3. Exercise

Pharmacotherapy

• There is very little evidence to recommend medications for somatization disorders (Kleinstäuber et al., 2011) 
• When there is no clear medical indication, try to avoid narcotics for somatic pain (without a physiological basis) as narcotics tend to numb angry feelings
• Even if a patient responds to narcotics, it may not be evidence of pain relief, but rather psychological relief; tolerance to this psychological effect develops easily resulting in request for escalating doses.

When and Where to Refer

When patients in primary care do not respond to office counseling/therapy, consider other treatment options such as:

• Assertiveness training
• Cognitive behavior therapy (CBT) has been well studied for hypochondriasis; it may be the treatment of choice for many somatoform disorders
• Group therapy: Group therapy may be particularly useful in enhancing interpersonal skills e.g. assertiveness skills
• Supportive psychotherapy
• Referral to a psychiatrist

References

• Gillis, K. (2014 Oct 31). Approach to the somatizing patient for family physicians. Presentation conducted at the Regional Conference of the Collaborative Mental Health Network, of the Ontario College of Family Physicians (OCFP) in Ottawa, ON.
• Kleinstäuber M, Witthöft M, Steffanowski A, van Marwijk H, Hiller W, Lambert MJ: Pharmacological interventions for somatoform disorders in adults. Cochrane Database Syst Rev. 2014 Nov 7;11.
• Steinbrecher et al.: The prevalence of medically unexplained symptoms in primary care. Psychosomatics. 2011 May-Jun; 52(3):263-71. 

• van Dessel N, den Boeft M, van der Wouden JC, Kleinstäuber M, Leone SS, Terluin B, Numans ME, van der Horst HE, van Marwijk H: Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults. Cochrane Database Syst Rev. 2014 Nov 1;11.

About this Document

Written by Dr’s Kathy Gillis (Psychiatrist and Chair of the Department of Psychiatry, University of Ottawa) along with members of the eMentalHealth.ca Primary Care Team, which includes Dr’s M. St-Jean (family physician), E. Wooltorton (family physician), F. Motamedi (family physician), M. Cheng (psychiatrist).

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a health professional. Always contact a qualified health professional for further information in your specific situation or circumstance. 

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