Somatic Symptom Disorder

00:05 So, Somatization Disorder, traditionally as it was called. Let me give you a case example.

00:12 “A middle-aged woman presents to her primary care doctor multiple times over the course of only 1 month with numerous vague complaints. So she is complaining of pain in every joint, nausea on a daily basis, sexual dysfunction and tremor but you’re not able to elicit any physical problems when you examine her. She becomes upset when you ask her whether or not she has felt anxious and she refuses a referral to a psychiatrist.” So, when it comes to a presentation like this, patients presenting with multiple vague complaints affecting multiple organ systems, probably visiting the doctor very frequently and symptoms really can’t be explained by a general medical condition. So, the characterization of somatization disorder is really the absence of any organic etiology. Patients will experience and communicate somatic distress in response to an actual psychosocial trigger and the attributing distress to physical illness really supersedes any kind of acknowledgment of stressor and emotional problem, patients tend to seek out medical help from their primary care doctors very frequently. Healthcare utilization can be very much overburdened in patients presenting with a somatoform-type disorder. So, this can also lead to a burden on the healthcare system and also for individual patients so it really can affect their functionality and their livelihood. In terms of healthcare utilization, somatization increases the use of medical services far higher than other fields and somatizising patients have significantly more annual primary care visits and specialist visits not to mention emergency room visits than other patients and there’s a disproportionate number of users of medical care, lab tests and other ancillary expensive tests when people have a somatization problem. So, there is a lot of controversy existing over whether or not this is considered a purely psychiatric disorder such as a learned behavior or if it’s viewed as a syndrome of multiple unexplained symptoms that are actually caused by general medical conditions and this is why the APA continues to consider whether or not this diagnosis has validity but it’s still something you may encounter in practice so let’s keep reviewing it. So what are the common theories about somatization? Well we tend to think it might run in families. Historically speaking, they used to think that there was something called the wandering womb which is where hysteria was actually caused by the uterus migrating around the body. As theories evolved, people started to think that maybe somatization is some kind of a defense mechanism or it’s a way to assert to doctors that one is deserving of care and it’s a way to communicate that something is wrong. There is also a learning theory that implicates patient’s ability to recall symptoms from either their own or role model’s experiences as a means of expressing distress. So for example, somebody growing up who, maybe, was in a household with a sick or ailing parent might have been adopted the idea of getting sick and being ill as a way to communicate that they have needs as well and needs some attention.

03:56 There is a cultural stigma associated with certain kinds of mental illnesses like anxiety and depression. For example, people living in Asia will often not acknowledge that they have emotional distress or any depression and instead they manifest the problem as a physical complaint, because that’s more socially acceptable and carries less of a stigma. There is also some biological theories. Thinking that there may be structural defects in the brain that can contribute to anxiety and somatoform-type disorders. Then there’s the interpersonal model, that hypothesizes that somatic symptoms represent a care-seeking behavior and people who have very insecure attachments. So it’s a way for them to reach out and feel connected to someone whether it’s a nurse or doctor. Then there’s also a theory that maybe people exposed to childhood trauma are going to be predisposed to later in life having some physical complaints or somatic disorders. There is also potential benefits from having somatic complaints. There can be extra social supports, escape from obligations, people may get disability from this and it may be a way to evade interpersonal conflicts by attributing problems to some pinpointed physical problem.

05:20 So when it comes to patients in outpatient medical clinics, actually more than 50% of patients presenting to the outpatient clinic with a physical complaint may not actually have a medical condition and might be something else going on. So we tend to think that people who complain of somatic-type symptoms more often will be females. They’ll often be a little bit undereducated, maybe a minority status, have some low socio-economic status and it’s again much more common in women than in men. The lifetime prevalence though is fairly low and about half of these patients do have a comorbid mental disorder or another type of mental disorder like an anxiety or depression. It tends to run in families as we talked about before and another note is that male relatives, female patients with the somatization disorder are actually more likely to have an antisocial personality disorder. So a link that’s interesting to note. Now there are comorbidity factors with somatization so people who tend to have a lot of physical complaints may also suffer from mood disorders, anxieties, substance abuse problems, posttraumatic stress disorder, personality disorders and also maybe childhood abuse or neglect.