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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. 4. Kroenke K, Spitzer RL, Williams JBW: The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 2002; 64:258-266. 5. Barsky AJ, Orav EJ, Bates DW: Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 2005; 62:903-910. 6. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000. 7. Briquet P: Trait clinique et therapeutique a l’hysterie. Paris: JB Ballière et Fils; 1951. 8. Purtell JJ, Robins E, Cohen ME: Observations on clinical aspects of hysteria. JAMA 1951; 146:902-909. 9. Noyes R, Stuart SP, Watson DB: A reconceptualization of the somatoform disorders. Psychosomatics 2008; 49:1. 10. 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