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When Depression and Anxiety Start Showing up in the Body
The Challenge of Somatization Disorder

By Dr. SHAFIQ QAADRI, MD

Typical Case
Cathy is one of the sickliest “healthy” patients that you have. She is barely in her 30s, but over the past several years, Cathy has complained of an unending list of symptoms, including various aches and pains, nausea, diarrhea, excessive menstrual bleeding, and palpitations.

Numerous diagnostic tests have failed to show a physical cause for any of these ailments, yet Cathy insists that her symptoms are “unbearable.” She is frustrated that there isn’t more that you can do for her. You, on the other hand, are frustrated with her constant physical concerns, and the elusiveness of a cause or cure.

Somatization disorder – the physical manifestation of mental pain
Somatization disorder is a chronic psychiatric disorder characterized by a history of diverse physical complaints that are not caused by any “real” physical illness. Symptoms begin in adolescence or early adulthood, and can occur as a general “sickly” condition or as specific symptoms. In North America, typical symptoms include headaches, nausea, vomiting, bloating, abdominal pain, diarrhea or constipation, dysmenorrhea, fatigue, fainting, sexual indifference, and dysuria.

Exaggeration of symptoms
Generally, patients are very dramatic and exaggerated when describing their symptoms, and often display exhibitionistic, dependent, manipulative, and sometimes suicidal behaviour. These patients may undergo numerous diagnostic procedures and unnecessary treatments or surgeries, and typically move from one physician to another, often dissatisfied with their medical care. While the symptoms are usually physical, somatization often is comorbid for other psychiatric conditions, including major depression (55% of patients), anxiety disorders (34%), personality disorders (61%), and panic disorders (26%).

Diagnosis of somatization disorder is a challenge, as before a diagnosis can be made, the physician must rule out physical causes and other psychiatric conditions associated with somatic complaints (such as depression, anxiety, substance abuse/dependence). Even specialists have difficulty determining whether patients have somatization disorder or an anxiety/mood disorder. According to the American Psychiatric Association, in order for a diagnosis of somatization disorder to be made, the following criteria must be met, with individual symptoms occurring at any time during the course of the disturbance:

Individual Symptoms
Four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)

Two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)

One sexual symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)

One pseudoneurologial symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

Onset of physical complaints before the age of 30

As well as one of the following:
After appropriate investigation, each of the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings.

The patient’s physical complaints must not be intentionally induced or feigned, and must result in medical attention or significant impairment in social, occupational, or other important areas of functioning.
Somatization disorder is distinguished from generalized anxiety disorder, conversion disorder, and major depression by the predominance, complexity, and persistence of physical complaints; the absence of biologic indicators characterizing major depression, and the superficial, manipulative nature of the suicidal behaviour. The disorder is reported to occur predominantly in women; in fact, it is ten times more common in women than in men. Male relatives of women with the disorder tend to have a high incidence of antisocial personality and substance related disorders.

Recent studies have also linked somatization to child abuse, particularly sexual abuse. Somatization disorder fluctuates in severity but persists throughout life, manifesting itself most noticeably in early adulthood. Treatment is extremely difficult, and full remission is rare.

A deep psychological need for pain
While there is no physical cause for the symptoms that the somatization patient is experiencing, there are several theories as to its psychological roots. There are four psychologic mechanisms linked to somatization, and by understanding these mechanisms, the physician can develop greater empathy towards the patient, thereby helping to minimize the frustration that is often associated in dealing with this type of patient.

Psychological mechanisms
Amplification of Body Sensations – concerns about physical health can cause the patient to be more attuned to even small variations in bodily sensations to the point that they become disturbing and uncomfortable. This serves to provide the patient with “further evidence” of their suspected condition, and causes further anxiety regarding the state of their physical health.

The Identified Patient – when a family system is under stress, the illness of one of its members can provide an alternative focus which provides a distraction from feelings of anxiety, thereby providing stability to the family unit. Family members tend to strive to behave more harmoniously in the context of an illness. This pattern becomes dysfunctional when one member consistently takes on the role of the “sick one.” This can become a pattern that is hard to break, even though the improved health of the identified patient may be desired, due to the stability it gives to the family unit.

The “Need to be Sick” – by assuming the sick role, the somatizing patient receives indirect benefits derived from their illness. Benefits such as absolution from stressful or impossible interpersonal expectations – after all, others cannot place excessive demand on a person when they are sick. Illness also provides attention, caring, and sometimes even monetary reward to the patient. This cannot be confused with malingering, or “faking” the symptoms, as the patient is not consciously aware of this process, and genuinely suffers from the symptoms.

Dissociation – dissociation is the ability of the brain to have complete and detailed sensory experiences in the absence of actual sensory stimulation. Patients with somatization report having dissociative symptoms - such as flashbacks, out-of-body experiences, and depersonalization, or phantom pains - more often than patients with other psychiatric conditions. As a result, it is logical that some somatized symptoms are the result of dissociation.

There is also some evidence which suggests that there is a link between somatization disorder and certain personality traits. The prime candidates are people with histrionic or narcissistic personality types – people who tend to be self-centered, excitable, highly emotional and dramatic, are intolerant of frustration, and have a marked emotional dependence on others. Such people thrive on the attention they get when they become ill, and the physical symptoms manifest themselves from an unconscious somatized plea for attention and care. Somatized patients become extremely dependent in their personal relationships, and the intensity and persistence of symptoms reflect the patient’s strong desire to be cared for in every aspect of life.

Care, not Cure
People with this disorder are generally very resistant to treatment, as they often identify themselves by and relate to others through their symptoms. Their symptoms are in integral part of who they are and how they perceive themselves. Symptoms also serve to assist the patient in avoiding adult responsibilities, in addition to providing much desired attention by family, friends, and medical professionals.

While most general medical patients tend to be proactive in researching new treatments that they have learned about through the media, and are eager to find effective treatments for their ailments, the somatization patient is passive and displays little interest in finding a cure. They are unlikely to cooperate in or respond to their treatment, and if they do, it tends to be short lived. There is a strong psychological need for these patients to develop and maintain their symptoms, as they are a deeply entrenched part of their personal identity. Herein lies the physician’s dilemma, as the more the physician does to find a cure, the more symptoms the patient acquires, creating a vicious cycle for both the patient and the physician.

In dealing with a patient such as Cathy, the best treatment is often a calm, firm, supportive long therapeutic relationship with a designated physician, who offers symptomatic relief and spares the patient unnecessary diagnostic or interventions. The goal of treatment is to help the person learn to control their symptoms, yet quite often, the somatization patient is either resistant to treatment or is non-compliant, because, by definition, most patients with this condition do not want to be cured.

As the primary care physician, you need to realize that attempting to treat patients who are unwilling to change will be counterproductive and frustrating for both yourself and the patient. In this age of technical advances in treatment, physicians may forget the benefits that simple reassurance brings to a patient. This reassurance from a caring physician will both satisfy their need for attention, and will also reduce their anxiety, knowing that they are being well looked after.

Once you have ruled out a true organic cause of the symptoms, it is important to consistently remind the patient that they are healthy and that no physical disorder can be found without, however, suggesting that the symptoms are “just in your head.” These patients tend to get angry and defensive when it is suggested that their symptoms are psychological in nature, and usually reject psychiatric treatment. Physicians must reinforce to the somatizing patient that while there is no medical cause for their symptoms, they understand that their suffering is real. One of the best ways to provide support to this type of patient is to schedule regular appointments. By seeing the patient on a regular basis, you are able to review symptoms, as well as minimize the patient’s need to develop more symptoms in an attempt to receive care. This will also minimize the need for hospital admissions and emergency visits.

The BATHE technique can be used as primary care counseling of psychosocial concerns. It involves the following steps:

BATHE technique

B – Background: “What is going on in your life?”

A – Affect: “How do you feel about it?”

T – Trouble: “What troubles you most about the situation?”

H – Handle: “ What helps you handle the situation?”

E – Empathy: “This is a tough situation to be in”
“Anybody would feel as you do”
“Your reaction makes sense to me”

Nurses may also be advised to follow up with patients by making routine phone calls to check in with the patient. A simple phone call from the Nurse saying, “The Doctor wanted me to remind you that, at your next visit, he will be asking you about….” .

This is a cost effective way for the physician to reinforce their concern for and availability to the patient. First and foremost, clinicians should remember the mantra, “Care, not cure.” The somatization patient benefits most from a solid, long term therapeutic relationship with a consistent health care provider, while a poor relationship tends to worsen the condition, as does evaluation by numerous physicians.

Potential drug treatments
Other treatments include appropriate use of psychopharmacologic drugs, as well as psychotherapy. SSRIs are somewhat efficacious and cost effective treatment option, as the incidence of depression and anxiety is quite common in this patient type. Participation in support groups, individual or group therapy, as well as other methods of stress reduction (e.g. yoga, meditation) can be helpful. Consultation with a psychiatrist can also be beneficial to the patient and can supplement the care of the general practitioner. While it is often such a team approach, including the setting of modest but concrete goals, which is most beneficial to the patient, most patients tend to resist this type of treatment.

The need to be sick
Since the somatizing patient typically expresses the symptom of pain, it may be tempting to prescribe analgesics, but it is best to avoid this if possible so as to minimize the risk of dependency. If it is deemed necessary to prescribe an analgesic, the use of Tylenol or NSAIDs is the best initial route to take. The use of narcotics should be avoided, as they can cause adverse side effects such as constipation and sedation which may add to the patients list of symptoms, have addictive potential, and do not cure the somatizer’s need to be sick. If narcotics are needed, the use of low, fixed doses of slow onset, long lasting drugs should be employed.

Taxing for the physician
It is important to acknowledge that treating the somatization patient is undoubtedly taxing for the physician. Treatment of these individuals is often unsuccessful, and relapses do occur, even in the most “successful” cases. The unending physical ailments, the inability to find a cure, patient’s lack of compliance, and the pressure to “do more” can lead to feelings of disappointment, and can erode the physician’s feelings of effectiveness.

In order to prevent burnout, it is important for the physician to share their feelings and expectations with the patient by setting boundaries on the number of visits per month (e.g. one 15 minute visit every two weeks), and minimizing frequent telephone calls (e.g. emphasize that frequent calls are very time consuming). Setting such boundaries is important, as it prevents the physician from being overwhelmed by the patient, thereby allowing him or her to be truly attentive and compassionate when they do interact.
Somatization disorder is one of the most frustrating and complex problems in primary care. Patients with a plethora of undiagnosed physical symptoms are time and resource consuming, placing excessive burdens on the already taxed medical system, as well as excessive strain on their physicians, their family, and themselves. While on the surface, somatization patients may appear to be seeking help, they are actually help-rejecting, and typically deplete the therapeutic repertoire of one physician before moving on to another. And in spite of all this expended effort and resources, the outlook for these patients is guarded.

Conclusion:
Once the possibility of organic medical and other psychiatric conditions has been eliminated, and a positive diagnosis of somatization has been made, often the best treatment for these patients is simply the support and reassurance of a caring physician. Because these patients have a psychological need for pain, and unconsciously value their symptoms as an integral part of their personal identity, they often have no true desire for a cure. That means that the physician who tries to treat such a patient with various medications and procedures will often be unsuccessful and frustrated. Often the best treatment strategy for these patients is a long term supportive relationship with one specific physician who provides a safe place for the patient to be heard and understood.

Dr. Shafiq Qaadri is a Toronto family physician and Continuing Medical Education lecturer. www.doctorQ.ca

REFERENCES:

American Psychiatric Association Diagnostic and sta-
tistical manual of mental disorders (IV R) 2001.

Asher R, Munchausen’s syndrome. Lancet 1951,1:339-341.

Cloninger C, et al. A prospective follow-up and family study of somatization in men and women. Am J of Psych 1986;143:873-878.

Eisendrath S, et al. Management of factitious disorders.The spectrum of factitious disorders. American Psychiatric Press 1996;195-231.

Escobar J, et al. Somatization in the community. Arch of Gen Psych 1987;44 (8):713-718.

Gureje O, et al. The natural history of somatization in primary care. Psychol Medicine 1999;29 :669-676.

Holloway KL, et al. Simplified approach to somatization disorder, when less may prove to be more. Postgraduate Medicine 2000;108:6-16.

Servan-Schreidber D, et al. Psychiatry Applied to Modern Life. Am Family Physician 2000;61:1073-8

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