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CHAPTER 113 Somatoform Disorders
Adria Ottoboni Winter
PERSPECTIVE
Patients occasionally present to the emergency department (ED)
with myriad physical symptoms in the absence of signs of physical
disease. Whereas some harbor underlying medical disorders,
many suffer from somatoform disorders, in which they experience
and communicate psychological distress as one or more physical
symptoms.1,2 These patients have persistent distress related to
the symptoms that inhibits their ability to function. Even when
a somatoform disorder is strongly suspected, emergency physicians are reluctant to attribute physical complaints to a psychiatric
disorder for fear of missing the subtle presentation of physical
disease.
Somatoform disorders are among the most prevalent of psychiatric disorders in the primary care setting, occurring in at least 10
to 15% of primary care patients.3,4 The annual cost to evaluate
these patients medically is estimated at $100 billion.5
Somatoform disorders are an enormous source of angst for
physicians as they can easily frustrate even the best attempts to
place human suffering into well-defined categories based on physical disease. Somatoform disorders are unlikely to be diagnosed in
a single visit; in fact, a definitive diagnosis requires multiple visits
and an in-depth knowledge of the patient. Nevertheless, proper
diagnosis and treatment of patients with a somatoform disorder
are essential; misidentification and mismanagement prolong the
patient’s suffering and add immensely to excess health care costs,
with unnecessary diagnostic testing and hospitalization.5
CLINICAL FEATURES
Seven somatoform disorders are listed in the fourth edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV):
(1) somatization disorder, characterized by many physical complaints affecting many organ systems; (2) conversion disorder,
characterized by one or two neurologic complaints; (3) hypochondriasis, characterized by patients’ beliefs that they have a specific
disease; (4) body dysmorphic disorder, characterized by a false
belief or perception that a body part is defective; (5) pain disorder,
characterized by symptoms of pain that are solely due to or exacerbated by psychological factors; (6) undifferentiated somatoform
disorder, which includes somatoform disorders not otherwise
described that have been present for 6 months or more; and
(7) somatoform disorder not otherwise specified, for those
somatoform symptoms that do not meet any of the criteria
otherwise described and classified.6
The general category of somatoform disorders was first explicitly defined in the DSM-III and updated in the DSM-IV; its revision is pending in the DSM-V. The initial criteria were based on
descriptions by Briquet and Purtell7,8; however, the initial perspectives on hysteria and hypochondriasis have changed markedly and
are likely to continue to do so. There is ongoing controversy about
whether the somatoform disorders require a reclassification
because the diagnosis does not explain the etiology, nor does it
predict treatment response.9
The phenomenon of somatization extends across a broad spectrum of expression, from mild stress-related symptoms to chronic
debilitating presentations that destroy a patient’s ability to function socially or occupationally.10,11 Patients with an underlying
somatoform disorder can be particularly frustrating for the emergency physician because they cannot be approached from the
practical standpoint of cause and effect, which is the bedrock of
training and analysis for most physicians. It is not unusual for
physicians to think that patients with somatoform disorders have
nonlegitimate disturbances and are using medical care to treat
their underlying emotional needs, with the resulting mismatch in
the patient-physician relationship.12
It is important to recognize when a patient has a somatoform
disorder, if only to avoid multiple unnecessary and timeconsuming tests; however, the diagnosis itself is typically one of
exclusion. In addition, somatizers typically steadfastly insist that
their symptoms are caused by serious physical disorders even in
the presence of conclusive evidence to the contrary.13
Historically referred to as hysteria, somatization disorder was
given the eponym Briquet’s syndrome by Guze in 1975 to avoid
the pejorative connotations associated with the traditional
terms.14,15 Somatization disorder is the prototypic somatoform presentation, differing from the other somatoform disorders in the
multiplicity of complaints and organ systems affected. As the
number of physical symptoms increases, so does the patient’s
functional impairment and distress.16 Research has shown that
patients with somatization are more likely to be women, nonwhite,
and less educated than nonsomatizers.17
The diagnosis of somatization disorder requires several criteria
(Box 113-1).6 It can be summarized as a polysymptomatic dis­
order that begins before the age of 30 years; extends for a period
of years; and is characterized by pain, gastrointestinal, sexual,
and pseudoneurologic symptoms. Somatization disorder is restrictive and represents only a small subset of patients who have
moderate yet clinically significant somatization.18 Somatization
disorder, as currently defined, is present in less than 0.5% of the
general population and in 1 to 4% of patients who present in
general practice.19
Once referred to as hysterical neurosis and originally described
by Breuer and Freud,20 conversion disorder is characterized
by abnormalities or deficits in voluntary motor or sensory function that are medically unexplained, including pseudoseizures,
1481
1482 PART III ◆ Medicine and Surgery / Section Eight • Psychiatric and Behavioral Disorders
BOX 113-1 Diagnostic Criteria for Somatoform Disorders
Physical symptoms that are misinterpreted or exaggerated, not
accounted for by a diagnosable illness
Symptoms are not intentionally feigned or produced
Somatization Disorder
Unexplained physical symptoms that are manifested before the
age of 30 years, that last several years, and that result in
treatment being sought with significant impairment in social,
occupational, or other important areas of functioning
Presence of the following at any time during the course of the
disorder:
Four pain symptoms
Two gastrointestinal tract symptoms
One sexual symptom
One pseudoneurologic symptom
Undifferentiated Somatoform Disorder
One or more physical symptoms that cause significant distress
or impairment in functioning, lasting at least 6 months
Conversion Disorder
A single unexplained symptom affecting voluntary or sensory
function that suggests a neurologic or general medical
condition and is associated with psychological stressors
Pain Disorder
Pain symptom is the predominant focus, causing significant
distress or impairment and associated with psychological
factors that play a role in the perception and maintenance of pain
Hypochondriasis
Preoccupation with fear of having a serious medical condition
Body Dysmorphic Disorder
Preoccupation with real or imagined physical defect
Somatoform Disorder Not Otherwise
Specified (NOS)
Somatoform symptoms that do not meet criteria for other
somatoform disorders, including unexplained physical
complaints less than 6 months in duration
Modified from Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text
rev. Washington, DC, American Psychiatric Association, 2000; and Oyama O,
Paltoo C, Greengold J: Somatoform disorders. Am Fam Physician 76:13331338, 2007.
pseudoparalysis, psychogenic movement disorders, and blindness.
Typically, there is a sudden dramatic onset of a single symptom,
simulating some nonpainful neurologic disorder for which there
is no pathophysiologic or anatomic explanation.6,21 In contrast
to somatization disorder, conversion disorder typically revolves
around a single physiologically impossible condition that is not
under the patient’s voluntary control but probably represents the
patient’s own perception of neurologic illness. Some symptoms
provide gratification for unconscious dependency needs, whereas
others may provide escape from painful emotional stimuli (e.g.,
hysterical paralysis in battle).22,23 Conversion disorder tends to
occur more often in young, naïve, and uneducated women, except
for those in military service and industrial accidents.23 Typical
comorbid diagnoses include mood disorders, panic disorder, generalized anxiety disorder, post-traumatic stress disorder, dissociative disorders, social or specific phobias, and obsessive-compulsive
disorders. Patients with conversion disorder often have a history
of physical or sexual abuse21,24 (Box 113-2).
According to DSM-IV, pain disorder requires psychological
factors that are important in the onset, severity, exacerbation, or
maintenance of that pain and is characterized by clinically significant pain in one or more anatomic sites.6 The primary and often
exclusive symptom is distressful pain that is not intentionally
BOX 113-2 Presentations of Conversion Disorder
1. Motor disturbances
a. Tremors (that worsen when attention is called to the
movements)
b. Seizures (wild, thrashing, writhing, often mimicking
copulation)
c. Paralysis or paresis (often a monoplegia, stocking-glove
weakness, with normal reflexes and limb circumferences)
d. Aphonia (wherein the patient can whisper and cough
normally and vocal cords move normally with respiration)
e. Coordination disturbances
2. Sensory disturbances
a. Anesthesia (the patient may not find this symptom
disturbing)
b. Blindness and tunnel vision16,17
3. An occasional patient may present with other non-neurologic
symptoms, such as vomiting or pseudocyesis.13
feigned, is persistent in nature, limits daily function, involves
one or more organ systems, and cannot be pathophysiologically
explained.6,25
The term hypochondriasis comes from regio hypochondriaca, a
Latin term referring to the upper lateral region of the abdomen
inferior to the costal cartilages, especially the area of the spleen,
which early physicians presumed to be the seat of this disorder.
Hypochondriasis is defined as the preoccupation, despite medical
evaluation and physician reassurance, that one has a serious
disease based on the misinterpretation of symptoms.6 Patients
must have a preoccupation with their symptoms for at least 6
months before the diagnosis can be made. These patients typically
have four characteristics: (1) physical symptoms disproportionate
to demonstrable organic disease; (2) fear of disease and a conviction that they are sick, leading to “illness-claiming behavior”; (3)
preoccupation with their body; and (4) persistent and unsatisfying
pursuit of medical care with a history of doctor shopping and an
eventual return of symptoms.26
These unfortunate patients manifest both a heightened awareness and an unrealistic interpretation of normal physical signs or
sensations, such as bowel habits, heartbeat, sweating, or peristalsis.
These sensations are perceived as abnormal, noxious, and alarming, a phenomenon known as amplification.27 These aberrant perceptions result in a chronic morbid preoccupation with body
functions and a lingering fear of having a disease despite medical
reassurance.6,25,26 A distinguishing feature of hypochondriasis is
the presence of real symptoms that are often confirmed by physical
examination, but the patient exaggerates and misinterprets them.
Hypochondriasis is relatively common. Its prevalence in general
medical practice ranges from 4 to 9%.6 It has a peak incidence
among men in their 30s and women in their 40s, affecting men
and women equally.28-30 Hypochondriacs have an increased sense
of responsibility for and place a high value on their personal health
and physical appearance. They have an acute sense of body vulnerability and a heightened aversion to death and aging.31 There is a
strong correlation between hypochondriasis and major depression.32 A milder form of this disorder may be an exaggerated
interest in body function and health.33
The hypochondriac complains at length and in detail, using
medical jargon. Hypochondriacs often believe that they have lost
control of their lives and have been described as “experts at defeating doctors in order to feel more powerful.”26 Consequently, physicians perceive hypochondriacal patients as more angry and hostile
than other patients.34 The diagnosis may be suggested when the
physician feels “frustration, helplessness, or anger associated with
a wish to be rid of the patient.”26,35
Chapter 113 / Somatoform Disorders 1483
Reactive hypochondriasis, or transient hypochondriasis, is an
acute response to a psychosocial stress or life crisis, such as an
acute myocardial infarction, terminal illness, or recent loss of a
family member. In contrast to true hypochondriasis, this form is
reversible and does respond to reassurance.26,33
DIAGNOSTIC STRATEGIES
Physicians are often reluctant to include a somatoform disorder
in their differential diagnosis when patients present to the ED with
unexplained symptoms. Their dramatic presentations and persistent preoccupation with a multitude of symptoms can overwhelm
even the most pragmatic diagnostician. Yet repetitive or extensive
diagnostic testing rarely excludes organic disease with absolute
certainty and may yield false-positive results, which prompts
further unneeded testing.36,37 Unfortunately, somatizing patients
are more likely to have morbidity from repeated diagnostic
tests than from an undiagnosed physical disease.38,39 In addition,
patients with somatoform disorders often find frustration not
only with their symptoms but also with the excessive testing and
ineffective treatments that occur concurrently.
Yielding to the temptation to institute further diagnostic procedures or interventions typically leads to a temporary improvement, closely followed by a renewal of symptoms and mutual
physician-patient disappointment. This gives rise to inevitable dissatisfaction of the patient with the physician and vice versa, leading
to an unsatisfactory parting of ways and a perpetuation of the
doctor-shopping cycle.40
Managed care and capitated reimbursement have created an
additional quandary by restricting the supply of care in a time of
rising demands from patients whose symptoms are relatively
minor.41,42 The most effective diagnostic tool with somatizers is the
interview. Evaluation starts with a thorough but focused history
and, if available, a review of the patient’s medical record. This is
followed by a careful problem-oriented physical examination, with
meticulous inspection of the area of complaint and simple or
routine diagnostic testing, when appropriate, until one attains a
reasonable level of diagnostic certainty.42 Further investigations or
hospital admissions should be initiated solely on the basis of new
objective signs of disease and only after confirming that the tests
have not previously been performed. A rule of thumb in considering ancillary tests is to order exactly what would be done if the
patient were not a somatizer.35,42 However, the clinician should
resist the impassioned entreaties of the patient when it is clear that
further complex or hazardous studies are unlikely to be productive.28,29,42,43 Multiple medical and surgical consultations generally
prove counterproductive. Hypochondriacs perceive this as a test
of their claim to illness and respond simply by propagating and
demonstrating symptoms with redoubled zeal.26
Discussion of the diagnosis of somatoform disorder with these
patients is fraught with potential pitfalls, especially in the ED, but
it can be managed with some careful forethought. Somatizing
patients are keenly aware of diagnostic labels, and all therapeutic
alliance will be lost if the physician even hints at the possibility that
their symptoms are “all in their head.” It is important to discuss the
possibility of the disorder with the patient after any underlying
medical causation has been ruled out to lay the groundwork for any
future psychiatric consultation and treatment.13,28,44
DIFFERENTIAL CONSIDERATIONS
Distinguishing between the various somatoform disorders is less
important than the diagnosis of treatable organic disease or the
detection of anxiety and depression, which are both more common
and more likely to respond to treatment. Coexistent depression or
anxiety disorder should always be considered.45,46 Compared with
patients with long-standing complaints, patients with a relatively
recent onset of somatization are more likely to have underlying
but subtle signs of acute psychosis, organic brain syndrome, grief
reaction, depression, or anxiety.
Depression
Approximately 50 to 70% of depressed patients consult their physician for various somatic complaints.47 Depressed patients may
not be aware of a depressed mood or may believe that their depression is secondary to the somatic symptoms.46 As a result, depression is the psychiatric disorder most often mistaken for somatoform
disorder.25
Although somatoform disorders often coexist with depression,
the two conditions must be distinguished if possible. Depression
is worse in the morning, better at night, and often associated with
a positive family history. The patient is reluctant to describe the
symptoms and has vegetative signs of depression (e.g., sleep disturbances, decreased appetite with weight loss, and loss of interest
in normally enjoyable activities).43,48 Pain is a common symptom,
particularly headache and pain involving the back, chest, or pelvic
area.46,47 Patients with somatoform disorders, on the other hand,
are worse at the end of the day, have a marked propensity to
discuss their symptoms, do not usually have a family history, and
show no vegetative signs.26
In general, elders do not have more physical symptoms than
younger patients do. Multiple somatic complaints should not be
dismissed as a normal consequence of aging but rather considered
a symptom of another underlying problem, usually depression or
medical disease. Older patients may communicate somatic complaints as a way of expressing anger and provoking guilt among
family members.30 Depression is discussed in more depth in
Chapter 111.
Anxiety
Patients with acute anxiety often hyperventilate and frequently
exhibit physical signs of increased sympathetic activity. They may
be hypervigilant and irritable and may show signs of muscle
tension.26 They may offer a history of excessive worrying about
their health, feeling “on edge” or irritable, having difficulty relaxing, sleeping poorly, or having trouble falling asleep, and report
symptoms of headache, tingling, dizzy spells, and diarrhea.48
Patients with somatoform disorders have a high prevalence of
anxiety disorders, especially generalized anxiety disorder.49 Anxiety
disorders are discussed in more depth in Chapter 112.
Physical Illness
When patients with somatization disorder have true organic
disease, their presentation is similar to that of other patients, with
specific complaints, clear chronology, and objective findings that
should be appropriately investigated.50 Unfortunately, subjective
reports of distress are often not dependable in these patients, and
the physician should rely on more objective evidence, including
physical examination and routine laboratory tests.35 Multiple
physical symptoms starting late in life are frequently the result
of physical disease.6 In addition, patients who have a short duration of symptoms are more likely to have organic disease.
Patients with conversion disorder who present with the acute
onset of neurologic symptoms can be particularly challenging. For
example, an anxious young woman with apparently severe neuromuscular weakness and findings on neurologic examination that
are inconsistent with an identifiable lesion or disorder may be
suffering from a conversion reaction or any number of rarely
encountered neurologic disorders (Box 113-3). 25 It may, at times,
1484 PART III ◆ Medicine and Surgery / Section Eight • Psychiatric and Behavioral Disorders
Organic Diseases That May Be Mistaken
BOX 113-3 for Somatoform Disorders
Endocrine disorders: hyperparathyroidism, thyroid disorders,
Addison’s disease, insulinoma, panhypopituitarism
Poisonings: botulism, carbon monoxide, heavy metals
Porphyria
Multiple sclerosis
Systemic lupus erythematosus
Wilson’s disease
Myasthenia gravis
Guillain-Barré syndrome
Uremia
require imaging studies and both neurologic and psychiatric consultations to arrive at a clear diagnosis.
Factitious Disorder and Malingering
Patients with somatoform disorders are not deliberately feigning
illness; they are exhibiting the result of an unconscious behavior
modification. For a subset of patients, secondary gain is unintentionally secured from the sick role in the form of sympathy,
encouragement, attention, support, and relief from responsibilities and challenges without significant loss of self-esteem.33
In contrast, factitious disorder and malingering are both characterized by the intentional and conscious simulation, exaggeration, or
self-induction of illness for an identifiable secondary gain.51,52
Because such deception is difficult to uncover in the ED, these
patients are often mistaken for having a somatoform disorder.
Factitious disorder and malingering are discussed in more depth
in Chapter 114.
MANAGEMENT
The symptoms of a somatoform disorder may provide a protective
coping value for the patient, and the physician should be cautious
about removing them without first providing adequate psychological support and treatment. Otherwise, new symptoms may
arise to replace old ones. The external precipitating stress or cause
of anxiety should be removed if possible. These patients require
psychiatric evaluation and management,28,29 and psychiatric consultation in the ED can be beneficial.53
For conversion disorder in particular, recurrence is common,
but the prognosis associated with an individual episode is good
and the likelihood of recovery from symptoms exceeds that of
other somatoform disorders.6,23,30 Factors associated with a good
prognosis include good premorbid health; absence of organic
illness or concomitant major psychiatric syndromes; acute and
recent onset; definite precipitation by a stressful event; and presenting symptoms of paralysis, aphonia, or blindness.6
Reassurance
Young patients with no underlying medical or psychiatric illnesses who present with somatization in response to a clear psychosocial stress can often be reassured successfully with an
appropriate explanation of their symptoms. Patients with chronic
somatization, however, perceive this as an official denial of their
sick role and are almost invariably unwilling to accept reassurance. Because they desire the acknowledgment and recognition
that come with the designation of illness, which they think is
rightfully theirs, they are disappointed when no pathologic condition is discovered. Conversely, they are elated when given a
diagnosis, but they resist recovery because subconsciously the
“specter of cure” poses a threat to their sick role.33 Accordingly,
attempts to cure the condition are countered with side effects,
allergic reactions, and new symptoms. Such patients require
another management strategy.
Legitimization of Symptoms
Most patients with chronic somatization interpret a psychological
explanation for their symptoms as an accusation of lying or feeblemindedness. It is important to convince them that the physician
believes in their symptoms and will not try to “talk them out of
it.” The priority is to listen and truly understand what the patient
is feeling and trying to convey. Suffering is a subjective phenomenon and, in that sense, is genuine in these patients.35 The physician should convey empathy for the patient’s physical discomfort.
If the physician acknowledges the legitimacy of the claim to illness
and assures the somatizer of ongoing care, limits may be set on
the patient’s illness behavior.26,28,29,42
Patients should be allowed to tell their story without interruption. They should be told that they have an illness that causes them
to experience many symptoms but that these symptoms will not
lead to medical deterioration.38,54 The physician should offer only
guarded projections about chances for complete “cure” of the
condition. Ironically, this may be better received by these patients
than overly optimistic assurances because it serves to safeguard
their sick role and shifts the physician away from an adversarial
position.42,43
Diagnosis
Diagnostic labels are of critical importance for somatizers, but the
precise meaning of the term should be clarified for the patient to
avoid misinterpretation. Explanations for symptoms that incorporate somatic responses and descriptions, such as hyperventilation,
tension headache, muscle tension, muscle strain, chest wall muscle
spasm, and stress, may be better accepted than purely psychiatric
diagnoses. This reassures the patient that the physician shares the
belief that the symptoms result from socially acceptable ailments
while allowing more in-depth explanations that incorporate the
relationship of body function to psychological stress. This, in turn,
serves as a preparation for future psychiatric consultation or psychotropic medication.13,28,29,43
At times, the best approach may be to share the diagnostic
uncertainty with the patient, using such terms as “atypical pain”
or “multiple complaints following injury.” On a broader scale,
managed care organizations can be encouraged to educate their
enrollees about the process of somatization, the negative side
effects of medications and other interventions, and the range of
body symptoms in healthy people.41
Medications
Patients with somatoform disorder have a high affinity for
medications and are reluctant to discontinue drugs, even those
with no benefit.26 Physicians should avoid drugs that produce an
abstinence syndrome or dependence and those that cannot be
safely continued indefinitely.50 Pain medications, if given, should
be prescribed on a regular schedule, not “as needed.”26 Patients
with somatoform pain disorder may benefit significantly from
treatment with antidepressants, including tricyclic antidepressants.55 Patients with somatization disorder with major depression may also improve with pharmacologic management of the
depression.32
Therapy should be kept simple and limited to exercise, diet,
physical therapy, and vitamins when possible.43 Hospitalization
and narcotics should be avoided. Benign remedies, such as lotions,
nutritional supplements, elastic bandages, and heating pads, may
be helpful.42,35 Drug regimens should be simplified and only the
Chapter 113 / Somatoform Disorders 1485
most distressing symptoms addressed. Before any type of symptomatic drug treatment is started, specific target symptoms should
be identified. The goal is to restore function and to make the target
symptoms tolerable, not to remove them completely. If patients
request an increase in dosage or a stronger medication, they
should be told to review their medications with their regular physician before any changes are made. Insistent patients should be
informed that long-term opioid use is associated with significant
adverse effects, especially constipation, sedation, impaired cognition, and progressive development of tolerance and addiction.35
Mental Health Consultation
Patients with somatoform disorders have difficulty in confronting
their own emotions, view psychiatric evaluation as threatening to
their sick role, and take offense at any suggestion that their fears
or beliefs may be unwarranted.56 They usually resist psychiatric
consultation, which they interpret as an attempt to be “dumped
on the psychiatrist.”26 Nevertheless, psychiatric consultation may
be appropriate to confirm the diagnosis or to discuss medications,
when the patient has coexistent manifestations of chronic depression or psychosis, when symptoms suddenly change or become
bizarre, when the patient expresses suicidal ideation or severely
disruptive behavior, when current management is not working, or
when the patient requests psychotherapy.26,28,29 Favorable prognostic indicators include youth, acute onset, concurrent anxiety or
depression, and limited medical comorbidity.57 Approximately
one third of patients with conversion disorder also have major
depression, and successful treatment of the depression may lead
to improvement or resolution of the conversion disorder.
Many patients accept psychological treatment under the rubric
of “stress management” as long as it targets physical symptoms
and somatic distress.42 Group therapy techniques presented as
education rather than as psychotherapy have had some limited
success.58 Patients should be reassured that their relationship with
the primary physician will continue to avoid the interpretation
that the referral is an abandonment.
Physician Attitudes
The key to diagnosis and treatment of patients with somatoform
disorder is effective and appropriate communication skills of the
physician. Somatizing patients can present a challenge because it
is tempting to point out to them that there is nothing “wrong”
with them and that their symptoms need no treatment. Physicians
caring for these patients predictably react with feelings of uncertainty, helplessness, anger, or guilt when they can find no physiologic process to explain the patient’s distress. Patients with
somatoform disorders can become as frustrated with their physician as the physician is with them. It is common for a patient with
a somatoform disorder to be quickly labeled a “difficult patient”
by the physician and staff.59,60 Unfortunately, the frustration of
working with these patients quickly overwhelms the physician’s
natural tendency toward compassion and can lead to a swift breakdown in communication. Despite the large number of distressing
symptoms reported, physicians rarely demonstrate empathy with
these patients.61,62
Treatment Goals
Somatizing patients, despite lack of objective pathophysiologic
changes, are, in fact, patients who are in need of and benefit from
tangible and effective help. For some, attaining invalid status
enables them to be cared for and nurtured. It offers them a sense
of self-importance and respect not otherwise available to them as
well as an honorable release from noxious personal and vocational
responsibilities and duties.22 To attempt a cure poses a threat to
this role, and unduly positive projections by physicians are therefore understandably met with disappointment, disbelief, and even
thinly veiled reproaches about their professional competence.42,43,63
Thus the goal of therapy should be control of disability and appropriate referrals rather than cure.30,57 The course of management
most likely to prove successful begins with the physician’s performing a sympathetic and thorough problem-oriented history
and physical examination, then offering the patient the paradoxical reassurance that he or she will probably always be ill. When
pain is the dominant feature, the patient should not be promised
complete relief; rather, a major task of the patient should be to
“learn to live with some pain.”30
Treatment goals should focus on modification of illness
behavior and improvement of functional status.22 Achievable endpoints include decreased frequency and urgency of medical use,
in particular a reduction in ED and unscheduled office visits;
avoidance of expensive and hazardous procedures; improved work
or school performance; more social activities; and better personal
relationships.25,28,35
These principles apply equally to children with somatoform
disorders. Unnecessary tests and procedures, in addition to
placing the patient at risk, may encourage somatization. Physician acknowledgment of the patient’s suffering and family concerns, a “rehabilitative” approach emphasizing return to normal
activities before definitive symptom relief, rewarding of healthy
behavior and discouragement of the sick role, assumption by the
patient of responsibility for coping with the symptoms, and treatment of coexistent anxiety or depression are the cornerstones
of therapy.64
Patients with somatoform disorder have been described as the
“least insightful, the least introspective and the least cognitively
oriented patients one is likely to encounter.”50 Understanding of
the link between emotional and somatic distress need not be a
treatment goal for these patients, and insight-oriented psychotherapy is neither productive nor cost-effective.30,35,42,50 On the
other hand, both the physician and the patient can benefit by
accepting fundamental alterations in the traditional paternalistic
physician-patient relationship. Increasing responsibility for health
and disease management should be incrementally turned over to
the somatizing patient.30
DISPOSITION
Appropriate psychiatric referrals should be provided for the
patient. Outpatient tests or hospitalization should be avoided
unless clear objective signs indicate a need for diagnostic investigation or therapeutic intervention.30,50
As a rule, management is best carried out by a single primary
care physician who becomes the gatekeeper for all medical consultation and care.* The patient should be told that no alarming
findings have come to light, that further testing and additional
medications are not indicated at this time, and that ongoing care
and periodic reassessment are indicated and will be arranged.
Patients with chronic somatization should initially be seen every
2 to 4 weeks, preferably by the primary care physician, even if their
symptoms are stable. The visits should be on a time-contingent,
not a need-contingent, basis. For the patient, this severs the association between medical contact and the necessity for worsening
or additional symptoms and complaints. It also decreases the
patient’s fear of abandonment by the physician and permits
repeated evaluation for early detection of objective signs of organic
disease.25,30 The patient seems to value the visit to the physician
more highly than any treatment.50
*References 13, 28, 25, 26, 29, 42, 43, 57.
1486 PART III ◆ Medicine and Surgery / Section Eight • Psychiatric and Behavioral Disorders
KEY CONCEPTS
■ The differential diagnosis of patients with apparent
somatoform disorders includes depression, anxiety, factitious
disorder, malingering, and true underlying physical disease.
■ Patients with conversion disorder who present with the acute
onset of neurologic symptoms can be particularly challenging.
It may, at times, require imaging studies and both neurologic
and psychiatric consultations to arrive at a clear diagnosis.
■ The behavior of patients with somatoform disorders is
unconsciously driven. They are not “faking” the symptoms or
their distress.
■ ED management of known or suspected somatoform
disorders includes legitimization of symptoms, communication
of compassion, and assurance that ongoing vigilance of the
patient’s medical condition will be arranged and maintained.
■ Long-term cure of somatization disorder is unlikely. However,
a steady state of symptom coping with improved function is
an achievable goal. This can be done only in the primary care
setting, not in the ED.
■ In general, laboratory tests, specialty consultations, initiation
of medications, and hospitalization should be avoided in
patients with known or suspected somatoform disorders
unless new objective clinical findings are found.
■ Whenever possible, treatment decisions should be deferred
to the patient’s primary care physician.
The references for this chapter can be found online by
accessing the accompanying Expert Consult website.
Chapter 113 / Somatoform Disorders 1486.e1
References
1. Folks DG, Feldman MD, Ford CV: Somatoform disorders, factitious
disorders, and malingering. In: Fogel B, Greenberg DB, Stoudemire A,
eds: Psychiatric Care of the Medical Patient, 2nd ed. Oxford, NY: Oxford
University Press; 2000:459.
2. Lipowski ZJ: Somatization: The experience and communication of
psychological distress as somatic symptoms. Psychother Psychosom 1987;
47:160.
3. Ormel J, et al: Common mental disorders and disability across cultures.
Results from the WHO collaborative study on psychological problems in
general health care. JAMA 1994; 272:1741-1748.
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