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A patient with psychosomatic symptoms

Essentials

  • The doctor should not doubt the existence of the patient’s symptoms, their subjective severity or the degree of consequent functional impairment, even if there would be discrepancy between the symptoms and findings.
  • The symptoms are real for the patient, and they manifest a need for help.
  • The doctor should inform the patient about the possible role of psychological factors in the symptom picture, reassure the patient regarding physical illnesses, correct wrong perceptions about illnesses and, working together with the patient, the doctor should aim to establish an explanatory model for the symptoms.
  • A long relationship with the same doctor is often necessary before the patient is ready to start gradually broaching the psychosocial problems behind the symptoms and to process their association with the somatic symptom picture.
  • Psychosomatic symptoms is often associated with somatoform disorders but they may also occur in almost any psychiatric disorders.
  • A consultation with a psychiatrist may be needed for the assessment, differential diagnostics and treatment of psychiatric disorders and, in particular, for the assessment whether the patient is in need of psychotherapy.

Somatisation

  • Somatisation denotes a tendency to experience, conceptualise and communicate psychological conflicts as somatic symptoms or changes.
  • Principally a normal phenomenon, in which case the symptom picture is very mild and temporary, but in a severe form a disease that seriously impairs functional capacity
    • In the general population, up to 80% have at least one somatic symptom that causes them some discomfort. The most common somatic symptoms which cannot be explained with bodily disturbances, even after comprehensive investigations, are abdominal complaints, backache and headache.
    • Among primary care patients, 20–35% have one or more unexplained somatic symptoms; about 70% of these patients are women.
    • Idiopathic somatic symptoms are more common in, among others, the lower social classes, the developing countries and immigrants.

Somatoform disorders

  • Medically unexplained somatic symptoms are severe and chronic, they are associated with seeking to be investigated and treated and with inappropriate illness behaviour, and the disorder causes disruption of social, occupational or other important areas of functioning. The prevalence of somatoform disorders in the general population is 6%, which is of the same order as the prevalence of depression. The subgroups (F45.0–F45.9) under the main diagnosis code are:
    • Somatisation disorder (F45.0).
      • At least 6 different somatic symptoms in two or more different organ systems of at least two years duration
      • The most severe form of the somatoform disorders
      • Prevalence 0.2–2%, almost exclusively in women
    • Undifferentiated somatoform disorder (F45.1)
      • All the criteria for the somatisation disorder are not fulfilled.
      • Prevalence 8%
    • Conversion disorder (F44.4–F44.7)
      • One or more dissociative symptoms affecting the motor or sensory function, e.g. paralysis, loss of voice, blindness, deafness and convulsions
      • Often associated with traumatic events.
      • Prevalence 1–3% among primary care patients, 2–10 times more common in women than in men
    • Hypochondriacal disorder and body dysmorphic disorder (F45.2)
      • Persistent fear of becoming ill, a belief of having a disease or a defect in the physical features, or excessive preoccupation with physical appearance
      • Prevalence: hypochondria 2–7%, body dysmorphic disorder 1–2%, among patients undergoing plastic surgery 6–15%
    • Somatoform autonomic dysfunction (F45.3)
      • An arousal of at least one organ system which is under autonomic control and at least two autonomic symptoms (e.g. palpitations, sweating, dry mouth or nonspecific epigastric discomfort) and, in addition, at least one other symptom that is more nonspecific, e.g. irritable bowel (in 10% of patients) or hyperventilation
    • Persistent somatoform pain disorder (F45.4)
      • Pain that requires clinical attention in one or more anatomic locations
      • Prevalence: chronic pain in 10% of the general population
    • Other and unspecified somatoform disorders (F45.8, F45.9)
      • For example, psychogenic dysmenorrhoea, psychogenic headache
      • Prevalence: chronic headache in 5% of the population; life time prevalence may be as high as 80%.
  • In the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013), developed by the American Psychiatric Association, the earlier diagnostic group of somatoform disorders is replaced by the title ”somatic symptom (and related) disorders”.
    • The diagnostic criteria do not anymore entail the exclusion of somatic illnesses, but it is essential to evaluate the intensity and/or appropriateness of the thoughts, emotions and behaviours elicited by the somatic symptoms in the patient. This change also more generally emphasizes the importance of recognition and treatment of mental problems in somatically ill patients.

Neurasthenia (includes chronic fatigue syndrome)

  • Disproportionately severe fatigue after slight mental or physical effort and, in addition, one other somatic symptom (F48.0)
    • The prevalence of chronic fatigue syndrome (Fatigued or tired patient) in the general population is 0.2%, four times more common in women.

Psychological factors having an influence on physical disorders

  • A physical disorder that has been diagnosed with the patient is associated with psychological or behavioural factors, which may play a part in the aetiology and clinical course of the disorder (F54).
    • For example, asthma exacerbation associated with stress J45/F54.

Differential diagnosis

  • Physical disorders (not earlier recognized)
    • Within a few years following the diagnosis of a somatoform disorder, a physical disorder that explains the somatic symptoms is found in 2–10% of patients.
    • Many physical disorders (e.g. epilepsy, MS) predispose to somatisation.
      • Adequate somatic investigations
      • Iatrogenic harm should be avoided.
  • Depressive disorders
    • Major depression may manifest itself as, for example, pain syndrome or physical fatigue state (”masked depression”).
    • About one quarter of those with chronic pain syndrome fulfil the diagnostic criteria for major depression.
    • As many as 50% of patients with major depression who seek help in primary care complain principally of somatic symptoms.
    • As many as two out of three patients with depression have disturbing pain.
  • Anxiety disorders
    • Particularly in panic disorders and generalised anxiety disorders, the patient may exhibit symptoms which are related to the hyperactivity of the autonomic nervous system (hyperventilation, palpitations, chest pain, dyspnoea, dizziness, weakness, sweating).
    • A patient with post-traumatic stress disorder (Acute stress reaction and post-traumatic stress disorder) may exhibit symptoms of hyperalertness, memory problems, somatic manifestations of anxiety, dissociative symptoms.
  • Other mental illnesses and malingering
    • Psychotic disorders
      • A psychotic disorder may be associated with somatic delusions, e.g. a conviction about a bad smell or worms that live under the skin.
    • Factitious disorders (F68.1)
      • Characterized by intentional production of either somatic or mental symptoms/signs. The central aim (mainly unconscious) of the person is the adoption of the sick role.
    • Malingering (Z76.5)
      • Not classified as psychiatric disorder
      • A malingerer aims consciously to gain personal benefit from his/her symptoms.

Associated disorders

  • Mood and anxiety disorders
    • Depressive or anxiety disorders are encountered in association with somatoform disorders in up to 50% of patients, which is more than the average number of cases seen in chronic physical conditions.
    • Depression and anxiety prolong and further increase the patient’s tendency towards somatisation.
  • Other somatoform disorders
    • A patient with one somatoform disorder often also fulfils the diagnostic criteria for another somatoform disorder.

Aetiology

  • Personal factors
    • Physiological mechanisms
      • Hyperactivation of the autonomic nervous system or the hypothalamic-pituitary-adrenal axis, muscle tension, hyperventilation, sedentary lifestyle, past and present physical illnesses.
    • Genetic factors
    • Factors associated with development and learning
      • Neglect, sexual and physical violence, parents’ illnesses and illness behaviour
    • Cognitive style, the way the person processes information
      • Observation of physical sensations and their catastrophic interpretation
    • Psychodynamic factors
      • Somatic symptoms may represent emotional distress or mental conflict which the person cannot describe verbally (alexithymia), or the somatic symptoms are a manifestation of an attempt to reconstruct a fragmented self-image (self-psychology).
    • Personality traits and characteristics
      • Low self-esteem, pessimism
      • Inability to express emotions (alexithymia)
      • Prone to self-monitoring
  • Sociocultural factors
    • There are cultural differences in the prevalence of somatisation disorders.
    • Somatoform disorders are more common in societies where psychiatric disorders are seen as ”stigmatising”.
  • Iatrogenic factors
    • Excessive investigations without appropriate treatment may increase the occurrence of somatisation.
    • Reimbursement payment entitlements for physical conditions may act as reinforcing factors for somatisation.

The course of the condition and its effect on the quality of life and functional capacity

  • Transient symptoms similar to somatisation may occur in almost anyone during a life crisis.
  • Somatoform disorders usually start during adolescence or early adulthood. The severity of the disorder may fluctuate with time.
  • Patients with somatoform symptoms characteristically seek medical investigations but rarely ask for psychiatric treatment and may even resist such a referral.
  • A study showed that the most severely somatising patients (14% peak in a questionnaire assessing somatisation) had higher medical care utilisation rates than all the rest of the patients in the study.
  • Many patients with somatoform disorders (30%) perceive their quality of life as being poor, and the functional capacity of some (10%) may be worse than that of patients with chronic physical conditions.
  • When assessing the patient's ability to work and the feasibility of rehabilitation, instead of concentrating on the scarcity of physical findings, attention should be focused on the following: the possibility of comorbid depression and its treatment and rehabilitation, possible exhaustion, the patient's overall health, personality and life situation.
  • It is a good idea to obtain a comprehensive psychological or psychiatric statement already at the early stages of the work ability assessment.

Interview and examination

  • An appointment should be long enough to allow the patient to talk about his/her somatic symptoms and to feel that he/she has been listened to and taken seriously. This will also make it easier to talk about the current life situation. What are the patient’s main symptoms or the main worry? What factors have influenced symptom onset, prolongation or aggravation? What factors have alleviated symptoms?
  • Current and past psychosocial stress factors which either preceded the symptoms or predisposed (see aetiology) the patient to symptom emergence
    • The doctor could put forward examples of common situations where stress produces somatic symptoms (e.g. tension headache, hyperventilation).
  • Significant human relationships (from childhood to the present) should be discussed together with any associated worries, problems and, on the other hand, any support gained from these relationships.
  • What effect have the symptoms had on the quality of life and functional capacity (study, work, social relationships)?
  • Somatisation tendency may be investigated by reviewing the patient’s history of symptoms regarding all organ systems and starting from childhood. Find out how the symptoms have affected functional capacity and how they have been treated.
  • All previous clinical and laboratory examinations must be carefully scrutinised before new investigations are ordered.
  • The doctor should always also personally carry out a physical examination. Laboratory investigations are indicated only as dictated by objective findings.
  • Are there signs of psychiatric comorbidity (depressive and anxiety disorders)? Screening tools can be used.
  • What is the patient’s own impression of the causes and significance of the symptoms? Does that differ from the doctor’s view?
  • It is advisable that the doctor does not put forward his/her own interpretation of the aetiology during the examination.

Treatment – general principles

  • Given that the patient perceives his/her symptoms to have an organic basis, a general practitioner or another doctor with expertise in physical illnesses is usually most suited to take overall responsibility for the care.
  • When the patient is ready for psychiatric therapy, the psychiatric unit should be ready to take up the primary responsibility for the therapy. Units of general psychiatry within hospitals are suitable for this purpose.
  • A good relationship forms an integral part of treatment (psychoeducation and supportive psychotherapy).
  • Medical expertise is required so that the patient may be reassured, wrong perceptions of illnesses corrected and adequate information provided.
  • Listening with interest and showing understanding create an atmosphere of trust. This will also facilitate the gradual introduction of more sensitive subjects into the conversation, in addition to the symptoms.
  • The patient’s symptoms must be accepted to be ”real”. If it is only stated that there is nothing wrong, the patient will leave disappointed and seek help elsewhere.
  • The patient should undergo one comprehensive and thorough examination. Further, unnecessary physical examinations should be avoided.
  • Reassurance: discuss the patient’s fears (e.g. the fear of cancer). Encourage the patient to express his/her thoughts and feelings about the current and past symptoms. In an acute phase, the patient may be reassured that no serious cause has been found for the symptoms and they will improve with time.
  • Explanation: the psychological and biological sides should both be included. Ungrounded diagnoses may only act to prolong the symptoms. It is better to admit a certain degree of uncertainty. However, the aim is to find an explanatory model for the symptoms that is acceptable to the patient; physical factors and factors relating to the current life situation should be combined.
  • A follow-up plan is decided on together with the patient. It may consist of coping mechanisms rather than a total cure.
  • Regular follow-up visits, initially more frequently
  • During a follow-up visit, the symptoms are discussed briefly. The focus of conversation should be on how the patient has coped with the symptoms. Is there something that has worsened or improved the situation?
  • The aim is to support and highlight the patient’s personal strengths and skills.
  • Unnecessary medication should be avoided. All medication that may lead to dependence should be gradually tapered off or even totally withdrawn.
  • Somatising patients often pose a challenge, and many are demanding and exhibit attention seeking behaviour. It may be beneficial to initially yield partially to the patient’s wishes whilst setting limits, for example, to the number of phone calls allowed and the duration of visits.
  • The patients may be unsatisfied and disappointed. Talking about disagreements in an understanding manner may sometimes avoid the worsening of the situation.
  • To avoid becoming exhausted the doctor may team up with a nurse or health visitor with whom he/she is professionally acquainted.
  • With time, consultation with a psychiatrist may become possible. It should particularly be considered in cases where the diagnosis remains uncertain, the treatment yields no help or patient has significant psychiatric comorbidity.
  • The treatment relationship with the general practitioner should continue even after the patient has been referred to a psychiatrist.
  • A short sick leave given at the appropriate juncture, particularly during demanding life situations, may sometimes be indicated.

Pharmacotherapy

  • Drug therapy for a somatising patient should mainly be considered for the management of psychiatric comorbidity (e.g. anxiety, depression).
  • In some studies, antidepressants (SSRIs) have been noted to have positive effects, for example in the treatment of somatoform disorders.
  • Pharmacotherapy should be combined with an evaluation of the mental state.
  • Appointments for the follow-up of medication should be organized in such a way that not only the medication is discussed, but that there is time to process also psychosocial matters.

Evidence Summaries

Psychotherapy

  • Cognitive behavioural therapy
    • Cognitive behavioural therapy, delivered either as individual or group therapy may be beneficial [Evidence Level: C].
    • Explore with the patient the factors which maintain his/her fixation with health problems, avoidance behaviour, belief in the existence of diseases and misinterpretation of symptoms. An approach of this kind aims to change the person's illness behaviour. In many cases, the patient accepts a referral for cognitive behavioural therapy even more keenly than drug therapy.
  • Trauma therapy, when a severe traumatization of the patient is established.
  • Suggestion therapy and dynamic individual or group therapy.
    • Hypnosis has been used in the diagnosis and treatment of conversion disorder.
    • Intensive psychodynamic therapy may sometimes be considered in the treatment of conversion disorder.
    • Couple therapy and family therapy may be beneficial (if the symptoms clearly appear to be a part of family-centred problems).
  • Other non-pharmacological treatment
    • A gradual and supervised increase in physical exercise is often the best form of treatment in chronic fatigue syndrome. The baseline should be set at the level of the patient’s worst days.
    • Physiotherapy may be necessary in conversion disorder if the patient has remained immobile for a long time, and sometimes it may suffice as the only treatment modality in acute cases. Psychophysical physiotherapy works well as a link between the psychological and somatic treatment.
    • Relaxation methods, biofeedback training and meditation are suitable complementary treatments.

Evidence Summaries


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TY - ELEC T1 - A patient with psychosomatic symptoms ID - 450620 BT - Evidence-Based Medicine Guidelines UR - https://evidence.unboundmedicine.com/evidence/view/EBMG/450620/all/A_patient_with_psychosomatic_symptoms PB - Duodecim Medical Publications Limited DB - Evidence Central DP - Unbound Medicine ER -