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Somatic symptom disorder

(Redirected fromSomatization disorder)

Somatic symptom disorder,also known assomatoform disorder,orsomatization disorder,is defined by one or more chronic physical symptoms that coincide with excessive andmaladaptivethoughts, emotions, and behaviors connected to those symptoms. The symptoms are not deliberately produced orfeigned,and they may or may not coexist with a known medical ailment.[1]

Somatic symptom disorder
Other namesSomatoform disorder, somatization disorder
SpecialtyPsychiatry,psychology
SymptomsMaladaptivethoughts, feelings, and behaviors in response to chronic physical symptoms.[1]
ComplicationsReduced functioning,unemployment,financial stress, andinterpersonaldifficulties.
Usual onsetOften, not always, begins in childhood.[2]
DurationAt least six months.[3]
CausesHeightened awareness of bodily sensations and the tendency to misinterpret bodily sensations.[4]
Risk factorsChildhood neglectandabuse,chaotic lifestyle, history ofsubstanceandalcohol abuse,andpsychosocialstressors.[5]
Diagnostic methodPsychiatric assessment.[2]
Differential diagnosisAdjustment disorder,body dysmorphic disorder,obsessive-compulsive disorder,conversion disorder,andillness anxiety disorder.[2]
TreatmentCognitive-behavioral therapy,[6]psychiatric medication,andbrief psychodynamic interpersonal psychotherapy.[7]
MedicationSelective serotonin reuptake inhibitorsandserotonin–norepinephrine reuptake inhibitors.[6]
PrognosisOften chronic but can be managed with the proper treatment.[2]
FrequencyAbout 13–23% of the general population.[8]

Manifestations of somatic symptom disorder are variable; symptoms can be widespread, specific, and often fluctuate. Somatic symptom disorder corresponds to the way an individual views and reacts to symptoms rather than the symptoms themselves. Somatic symptom disorder may develop in those who suffer from an existingchronic illnessor medical condition.[9]

Several studies have found a high rate of comorbidity withmajor depressive disorder,generalized anxiety disorder,andphobias.[10]Somatic symptom disorder is frequently associated withfunctional pain syndromeslikefibromyalgiaandIBS.[11]Somatic symptom disorder typically leads to poor functioning,interpersonalissues,unemploymentor problems at work, and financial strain as a result of excessive health-care visits.[9]

The cause of somatic symptom disorder is unknown. Symptoms may result from a heightened awareness of specific physical sensations paired with a tendency to interpret these experiences as signs of a medical ailment.[2]The diagnosis is controversial, as people with a medical illness can be mislabeled as mentally ill. This is especially true for women, who are more often dismissed when they present with physical symptoms.[12]

Signs and symptoms

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Somatic symptom disorder can be detected by an ambiguous and often inconsistent history of symptoms that are rarely relieved by medical treatments. Additional signs of somatic symptom disorder include interpreting normal sensations formedical ailments,avoidingphysical activity,being disproportionately sensitive to medication side effects, and seeking medical care from several physicians for the same concerns.[2]

Manifestations of somatic symptom disorder are highly variable. Recurrent ailments usually begin before the age of 30; most patients have many somatic symptoms, while others only experience one. The severity may fluctuate, but symptoms rarely go away completely for long periods of time.[1]Symptoms might be specific, such as regional pain and localized sensations, or general, such asfatigue,muscle aches,andmalaise.[9]

Those suffering from somatic symptom disorder experience recurring and obsessive feelings and thoughts concerning their well-being. Common examples include severe anxiety regarding potential ailments, misinterpreting normal sensations as indications of severe illness, believing that symptoms are dangerous and serious despite lacking medical basis, claiming thatmedical evaluationsand treatment have been inadequate, fearing that engaging in physical activity will harm the body, and spending a disproportionate amount of time thinking about symptoms.[9]

Somatic symptoms disorder pertains to how an individual interprets and responds to symptoms as opposed to the symptoms themselves. Somatic symptom disorder can occur even in those who have an underlyingchronic illnessor medical condition.[9]When a somatic symptom disorder coexists with another medical ailment, people overreact to the ailment's adverse effects. They may be unresponsive toward treatment or unusually sensitive to drug side effects. Those with somatic symptom disorder who also have another physical ailment may experience significant impairment that is not expected from the condition.[1]

Comorbidities

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Most research that looked at additionalmental illnessesor self-reported psychopathological symptoms among those with somatic symptom disorder identified significant rates ofcomorbiditywithdepressionandanxiety,but other psychiatric comorbidities were not usually looked at.[2]Major depression,generalized anxiety disorder,andphobiaswere the most common concurrent conditions.[10]

In studies evaluating different physical ailments, 41.5% of people withsemantic dementia,11.2% of subjects withAlzheimer's disease,[13]25% of female patients suffering fromnon-HIV lipodystrophy,[14]and 18.5% of patients withcongestive heart failure[15]fulfilled somatic symptom disorder criteria. 25.6% offibromyalgiapatients met the somatic symptom disorder criteria exhibited higher depression rates than those who did not.[11]In one study, 28.8% of those with somatic symptom disorder hadasthma,23.1% had aheart condition,and 13.5% hadgout,rheumatoid arthritis,orosteoarthritis.[16][17]

Complications

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Alcoholanddrug abuseare frequently observed, and sometimes used to alleviate symptoms, increasing the risk ofdependenceoncontrolled substances.[18]Other complications include poor functioning, problems with relationships,unemploymentor difficulties at work, and financial stress due to excessive hospital visits.[9]

Causes

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Somatic symptoms can stem from a heightened awareness of sensations in the body, alongside the tendency to interpret those sensations asailments.Studies suggest that risk factors of somatic symptoms includechildhood neglect,sexual abuse,a chaotic lifestyle, and a history of substance and alcohol abuse.[4][5]Psychosocialstressors, such as unemployment and reduced job performance, may also be risk factors.[2][19]There could also be ageneticelement. A study ofmonozygoticanddizygotictwins found that genetic components contributed 7% to 21% of somatic symptoms, with the remainder related toenvironmental factors.[20]In another study, varioussingle nucleotide polymorphismswere linked to somatic symptoms.[2]

Psychological

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Evidence suggests that along with more broad factors such as earlychildhood traumaorinsecure attachment,negative psychological factors includingcatastrophizing,negative affectivity,rumination,avoidance,health anxiety,or a poorphysical self-concepthave a significant impact on the shift from unproblematic somatic symptoms to a severely debilitating somatic symptom disorder.[17]Those who experience more negative psychological characteristics may regardmedically unexplained symptomsto be more threatening and, therefore, exhibit stronger cognitive, emotional, and behavioral awareness of such symptoms.[21]In addition, evidence suggests that negative psychological factors have a significant impact on the impairments and behaviors of people suffering from somatic symptom disorder, as well as the long-term stability of such symptoms.[22][23][24]

Psychosocial

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Psychosocialstresses andcultural normsinfluence how patients present to theirphysicians.American and Koreans engaged in a study to measuresomatizationwithin theculturalcontext. It was discovered that Korean participants used more body-related phrases while discussing their connections with stressful events and experienced moresympathywhen asked to read texts using somatic expressions when discussing their emotions.[25]

Those raised in environments where expressing emotions during stages of development is discouraged face the highest risk of somatization.[25]Inprimary caresettings, studies indicated that somaticizing patients had much greater rates of unemployment and decreasedoccupational functioningthan non-somaticizing patients.[4]

Traumatic life events may cause the development of somatic symptom disorder. Most people with somatic symptom disorder originate fromdysfunctionalhomes. Ameta-analysis studyrevealed a connection between sexual abuse and functional gastrointestinal syndromes,chronic pain,non-epileptic seizures,andchronic pelvic pain.[25]

Physiological

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Thehypothalamo pituitary adrenal axis(HPA) has a crucial role instress response.While theHPA axismay become more active with depression, there is evidence ofhypocortisolismin somatization.[26]In somatic disorder, there is a negative connection between elevated pain scores and5-hydroxy indol acetic acid(5-HIAA) andtryptophanlevels.[25]

It has been suggested thatproinflammatoryprocesses may have a role in somatic symptom disorder, such as an increase of non-specific somatic symptoms and sensitivity to painfulstimuli.[27]Proinflammatoryactivation andanterior cingulate cortexactivity have been shown to be linked in those who experienced stressful life events for an extended period of time. It is further claimed that increased activity of the anterior cingulate cortex, which acts as a bridge between attention and emotion, leads to increased sensitivity of unwanted stimuli and bodily sensations.[28]

Painis a multifaceted experience, not just a sensation. Whilenociceptionrefers to afferentneural activitythat transmitssensory informationin response to stimuli that may causetissue damage,pain is a conscious experience requiringcorticalactivity and can occur in the absence of nociception.[25]Those with somatic symptoms are thought to exaggerate their somatic symptoms through choice perception and perceive them in accordance with an ailment. This idea has been identified as acognitivestyle known as "somatosensorial amplification".[29]The term "central sensitization"has been created to describe theneurobiologicalnotion that those predisposed to somatization have an overly sensitiveneural network.Harmless and mildstimulistimulate thenociceptivespecificdorsal horn cellsaftercentral sensitization.As a result, pain is felt in response to stimuli that would not typically cause pain.[25]

Neuroimaging evidence

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Some literature reviews of cognitive–affective neuroscience on somatic symptom disorder suggested thatcatastrophizationin patients with somatic symptom disorders tends to present a greater vulnerability to pain. The relevant brain regions include the dorsolateral prefrontal, insular, rostral anterior cingulate, premotor, and parietal cortices.[30][31]

Genetic

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Genetic investigations have suggested modifications connected to themonoaminergicsystem, in particular, may be relevant while a shared genetic source remains unknown. Researchers take into account the various processes involved in the development of somatic symptoms as well as the interactions between variousbiologicaland psychosocial factors.[25]Given the high occurrence of trauma, particularly throughout childhood, it has been suggested that theepigeneticchanges could be explanatory.[32]Another study found that theglucocorticoid receptorgene (NR3C1) ishypomethylatedin those with somatic symptom disorder and in those with depression.[25]

Diagnosis

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Because those with somatic syndrome disorder typically have comprehensive previous workups, minimallaboratory testingis encouraged. Excessive testing increases the possibility offalse-positiveresults, which may result in further interventions, associated risks, and greater expenses. While some practitioners order tests to reassure patients, research shows thatdiagnostic testingfails to alleviate somatic symptoms.[2]

Specific tests, such asthyroid functionassessments,urine drug screens,restricted blood studies, and minimalradiological imaging,may be conducted to rule out somatization because of medical issues.[2]

Somatic Symptom Scale – 8

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Main article:Somatic Symptom Scale - 8

The Somatic Symptom Scale – 8 (SSS-8)is a short self-report questionnaire that is used to evaluate somatic symptoms. It examines the perceived severity of common somatic symptoms.[33]TheSSS-8is a condensed version of the well-knownPatient Health Questionnaire-15(PHQ-15).[34]

On a five-point scale, respondents rate how muchstomach or digestive issues,back discomfort,pain in the legs, arms, orjoints,headaches,chest painorshortness of breath,dizziness,feeling tired or having low energy,andtrouble sleepingimpacted them in the preceding seven days. Ratings are added together to provide a sum score that ranges from 0 to 32 points.[33]

DSM-5

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The fifth edition of theDiagnostic and Statistical Manual of Mental Disorders(DSM-5) modified the entry titled "somatoform disorders" to "somatic symptom and related disorders", and modified other diagnostic labels and criteria.[35]

The DSM-5 criteria for somatic symptom disorder includes "one or more somatic symptoms which aredistressingor result in substantial impairment of daily life ". Additional criteria, often known as B criteria, include" excessive thoughts, feelings, or behaviors regarding somatic symptoms or corresponding health concerns manifested by disproportionate and persistent thoughts about the severity of one's symptoms ". It continues:" Although any one somatic symptom might not be consistently present, one's state of being symptomatic is continuous (typically lasting more than 6 months). "[3]

The DSM includes five distinct descriptions for somatic symptom disorder. These include somatic symptom disorder with predominant pain, formally referred to as pain disorder, as well as classifications for mild, moderate, and severe symptoms.[3]

International Classification of Diseases

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TheICD-11classifies somatic symptoms as "Bodily distress disorder". Bodily distress disorder is characterized by the presence of distressing bodily symptoms and excessive attention devoted to those symptoms. The ICD-11 further specifies that if another health condition is causing or contributing to the symptoms, the level of attention must be clearly excessive in relation to the nature and course of the condition.[36]

Differential diagnosis

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Somatic syndrome disorder's widespread, non-specific symptoms may conceal and mimic the manifestations of other medical disorders, making diagnosis and therapy challenging.Adjustment disorder,body dysmorphic disorder,obsessive-compulsive disorder,andillness anxiety disordermay all exhibit excessive and exaggerated emotional and behavioral responses. Other functional diseases with unknownetiology,such asfibromyalgiaandirritable bowel syndrome,tend not to present with excessive thoughts, feelings, ormaladaptivebehavior.[2]

Somatic symptom disorder overlaps with illness anxiety disorder andconversion disorder.Illness anxiety disorder is characterized by an obsession with having or developing a dangerous, undetected medical ailment, despite the absence of bodily symptoms. Conversion disorder may present with one or more symptoms of various sorts. Motor symptoms involveweaknessorparalysis;aberrant movements includingtremorordystonic movements;abnormal gaitpatterns; and abnormal limb posture. The presenting symptom in conversion disorder is loss of function, but in somatic symptom disorder, the emphasis is on the discomfort that specific symptoms produce. Conversion disorder often lacks the overwhelming thoughts, feelings, and behaviors that characterize somatic symptom disorder.[3]

Treatment

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Rather than focusing on treating the symptoms, the key objective is to support the patient incopingwith symptoms, including both physical symptoms and psychological/behavioral (such as health anxiety and harmful behaviors).[2]

Earlypsychiatric treatmentis advised. Evidence suggests thatSSRIsandSNRIscan lower pain perception.[6]Because the somatic symptomatic may have a low threshold foradverse reactions,medication should be started at the lowest possible dose and gradually increased to produce atherapeutic effect.[2]

Cognitive-behavioral therapyhas been linked to significant improvements in patient-reported function and somatic symptoms, a reduction in health-care expenses, and a reduction in symptoms of depression.[37][38][6]CBT aims to help patients realize their ailments are not catastrophic and to enable them to gradually return to activities they previously engaged in, without fear of "worsening their symptoms". Consultation and collaboration with theprimary care physicianalso demonstrated some effectiveness.[39][40]Furthermore, briefpsychodynamic interpersonal psychotherapy(PIT) for patients with somatic symptom disorder has been proven to improve the physical quality of life in patients with many, difficult-to-treat, medically unexplained symptoms over time[7]

CBT can help in some of the following ways:[41]

  • Learn to reducestress
  • Learn to cope with physical symptoms
  • Learn to deal with depression and other psychological issues
  • Improve quality of life
  • Reduce preoccupation with symptom

Electroconvulsive therapy(ECT) has been used in treating somatic symptom disorder among the elderly; however, the results were still debatable with some concerns around the side effects of using ECT.[42]Overall, psychologists recommend addressing a common difficulty in patients with somatic symptom disorder in the reading of their own emotions. This may be a central feature of treatment; as well as developing a close collaboration between the GP, the patient and the mental health practitioner.[43]

Outlook

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Somatic symptom disorder is typically persistent, with symptoms that wax and wane. Chronic limitations in general function, substantial psychological impairment, and a reduction in quality of life are all common.[2]Some investigations suggest people can recover; the natural history of the illnesses implies that around 50% to 75% of patients with medically unexplained symptoms improve, whereas 10% to 30% deteriorate. Fewer physical symptoms and better baseline functioning are strongerprognosticindicators. A strong, positive relationship between the physician and the patient is crucial, and it should be accompanied by frequent, supportive visits to avoid the temptation to medicate or test when these interventions are not obviously necessary.[4]

Epidemiology

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Somatic symptom disorder affects 5% to 7% of the general population, with a higher female representation, and can arise throughout childhood, adolescence, or adulthood. Evidence suggests that the emergence of prodromal symptoms often begins in childhood and that symptoms fitting the criteria for somatic symptom disorder are common during adolescence. A community study of adolescents found that 5% had persistent distressing physical symptoms paired with psychological concerns.[44]In the primary care patient population, the rate rises to around 17%.[2]Patients with functional illnesses such as fibromyalgia, irritable bowel syndrome, andchronic fatigue syndromehave a greater prevalence of somatic symptom disorder. The reported frequency of somatic symptom disorder, as defined by DSM-5 criteria, ranges from 25 to 60% among these patients.[44]

There are cultural differences in the prevalence of somatic symptom disorder. For example, somatic symptom disorder and symptoms were found to be significantly more common inPuerto Rico.[45]In addition the diagnosis is also more prevalent among African Americans and those with less than a high school education or lower socioeconomic status.[46]

There is usually co-morbidity with other psychological disorders, particularlymood disordersoranxiety disorders.[3][47]Research also showed comorbidity between somatic symptom disorder andpersonality disorders,especiallyantisocial,borderline,narcissistic,histrionic,avoidant,anddependentpersonality disorder.[48]

About 10-20 percent of female first degree relatives also have somatic symptom disorder and male relatives have increased rates of alcoholism and sociopathy.[49]

History

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Somatization is an idea that physicians have been attempting to comprehend since the dawn of time. TheEgyptiansandSumerianswere reported to have utilized the notions ofmelancholiaandhysteriaas early as 2600 BC. For many years, somatization was used in conjunction with the termshysteria,melancholia,andhypochondriasis.[50][25]

During the 17th century, knowledge of thecentral nervous systemgrew, giving rise to the notion that numerous inexplicable illnesses could be linked to the brain.Thomas Willis,widely regarded as the father ofneurology,recognized hysteria in women and hypochondria in males as brain disorders.Thomas Sydenhamcontributed significantly to the belief that hysteria and hypochondria are mental rather than physical illnesses. The term "English Malady" was used byGeorge Cheyneto denote that hysteria and hypochondriasis are brain and/or mind-related disorders.[25]

Wilhelm Stekel,a Germanpsychoanalyst,was the first to introduce the term somatization, andPaul Briquetwas the first to characterize what is now known as Somatic symptom disorder.[25]Briquetreported respondents who had been unwell for most of their lives and complained of a variety of symptoms from various organ systems. Despite many appointments, hospitalizations, and tests, symptoms continue.[51]Somatic symptom disorder was later dubbed "Briquet Syndrome" in his honor. Over time, the concept of hysteria was used in place of a personality or character type, conversion responses, phobia, and anxiety to accompanypsychoneuroses,and its incorporation in everyday English as a negative word led to a distancing from this concept.[25]

Controversy

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Somatic symptom disorder has long been a contentious diagnosis because it was based solely on negative criteria, namely the absence of a medical explanation for the presenting physical problems. As a result, any person suffering from a poorly understood illness may meet the criteria for this psychological diagnosis, regardless of whether they exhibit psychiatric symptoms in the traditional sense.[52][12]

Misdiagnosis

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In the opinion ofAllen Frances,chair of the DSM-IV task force, the DSM-5's somatic symptom disorder brings with it a risk of mislabeling a sizable proportion of the population as mentally ill.

Millions of people could be mislabeled, with the burden falling disproportionately on women, because they are more likely to be casually dismissed as 'catastrophizers' when presenting with physical symptoms.[12]

See also

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References

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Further reading

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  • Suzanne O'Sullivan (2017).Is It All in Your Head?: True Stories of Imaginary Illness.Other Press.ISBN978-1590517956.
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