SOMATIZATION & somatIC symptom dIsorders Fatih Kokdere Yeditepe University School of Medicine

INTRODUCTION Somatization is a syndrome of physical symptoms that are distressing and may not be fully explained by a known medical condition. The symptoms may be caused or exacerbated by anxiety, depression, and interpersonal conflicts; and it is common for somatization, depression, and anxiety to all occur together. Somatization can be conscious or unconscious. It increases use of medical services, leads to frustration in both the patient and the clinician.

TERMINOLOGY AND DSM-5 Somatization is an overarching term that encompasses many different illnesses and terms including “somatoform disorders”, which is a group of disorders that are recognized in the ICD-10 and were previously described in the DSM-IV-TR. DSM-5 does not use the term somatization, and has eliminated the category of diagnoses called somatoform disorders. For patients with prominent somatic symptoms that cause distress and impair psychosocial functioning, DSM-5 has replaced the category of somatoform disorders with a category called somatic symptom and related disorders.

EPIDEMIOLOGY Somatization is common in the general population. More than 50 percent of patients presenting to outpatient medical clinics with a physical complaint do not have a medical condition. Somatization, defined in one study as four or more unexplained physical symptoms in men and six or more unexplained physical symptoms in women, occurred in 17 percent of patients in primary care settings and 4 percent of the general US population A systematic review of 21 European studies found the median 12-month prevalence rate for any somatoform disorder was 6 percent of the general population

RISK FACTORS Female sex Fewer years of education Minority ethnic status Low socioeconomic status Childhood sexual abuse and recent exposure to physical or sexual violence

CLINICAL PRESANTATION The essential feature of somatization is a history of physical symptoms that the patient attributes to a nonpsychiatric disease. Pain symptoms, including headache, back pain, dysuria, joint pain, diffuse pain, and extremity pain Gastrointestinal symptoms, including nausea, vomiting, abdominal pain, bloating, gas, and diarrhea Cardiopulmonary symptoms, including chest pain, dizziness, shortness of breath, and palpitations  Neurologic symptoms, including fainting, pseudoseizures, amnesia, muscle weakness, dysphagia, double or blurred vision, difficulty walking, difficulty urinating, deafness, and hoarseness or aphonia Reproductive organ symptoms, including dyspareunia, dysmenorrhea, and burning in sex organs

Coexisting psychIatRIC IlLnesses Somatization is strongly associated with anxiety and depression.  In a study of 10,000 primary care patients, those with somatization were six times more likely to manifest anxiety or depression compared to those without somatization (30 versus 5 percent). In addition to depression and anxiety, somatization is often associated with personality disorders. In a study that assessed 94 patients with somatization disorder with structured interviews, at least one personality disorder was found in 61 percent . The most common were avoidance, paranoia, self-defeating, and obsessive-compulsive. It is unclear whether there is an association between somatization and substance use disorder.

SOMATIC SYMPTOM AND RELated dIsorders In DSM-5, the category of somatic symptom and related disorders encompasses disorders that are marked by prominent somatic symptoms as well as substantial distress and/or psychosocial impairment Somatic symptom disorder Illness anxiety disorder Conversion disorder (functional neurological symptom disorder) Psychological factors affecting other medical conditions Factitious disorder

SOMATIC SYMPTOM DISORDER A DSM-5 diagnosis of somatic symptom disorder requires each of the following criteria; One or more somatic symptoms that cause distress or psychosocial impairment Excessive thoughts, feelings, or behaviors associated with the somatic symptoms, as demonstrated by one or more of the following: - Persistent thoughts about the seriousness of the symptoms - Persistent, severe anxiety about the symptoms or one’s general health - The time and energy devoted to the symptoms or health concerns is excessive Although the specific somatic symptom may change, the disorder is persistent (usually more than six months)

SOMATIC SYMPTOM DISORDER

SOMATIC SYMPTOM DISORDER

ILlNESS ANXIETY DISORDER A DSM-5 diagnosis of illness anxiety disorder requires each of the following criteria Preoccupation with having or acquiring a serious, undiagnosed illness Somatic symptoms are mild or nonexistent at most Substantial anxiety about health and a low threshold for becoming alarmed about one’s health Either excessive behaviors related to health (eg, repeatedly checking oneself for signs of illness), or maladaptive avoidance of situations or activities (eg, exercise) that are thought to represent health threats The illness preoccupation is present for at least six months The illness preoccupation is not better explained by other mental disorders (eg, somatic symptom disorder, generalized anxiety disorder, or somatic type of delusional disorder)

CONVERSION DISORDER Conversion disorder (functional neurologic symptom disorder) is characterized by neurologic symptoms (eg, weakness, abnormal movements, or nonepileptic seizures) that are inconsistent with a neurologic disease, cause distress and/or psychosocial impairment. The diagnosis of conversion disorder (functional neurologic symptom disorder) should be made after the neurologist has established positive clinical findings that are incompatible with disease or are inconsistent across different parts of the examination  In DSM-5, the diagnosis of conversion disorder does not require that clinicians identify psychological factors associated with the conversion symptoms

CONVERSION DISORDER

CONVERSION DISORDER

CONVERSION DISORDER

FACTITIOUS DISORDER(munchausen syndrome) Patient consciously creates physical and/or psychological symptoms in order to assume sick role and to get medical attention. Characterized by a history of multiple hospital admissions and willingness to undergo invazive procedures. Two types: Imposed on self and Imposed on another (child, older adult..)  In contrast to malingering, in which the patient wishes to obtain external gains such as disability payments or to avoid an unpleasant situation, such as military duty. Health care workers !

FACTITIOUS DISORDER(munchausen syndrome) A DSM-5 diagnosis of factitious disorder on self requires each of the following criteria Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception The individual presents himself or herself to others as ill, impaired, or injured The deceptive behavior is evident even in the absence of obvious external rewards The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

Munchausen syndrome by proxy Factitious disorder imposed on another. Illness in a child or elderly patient is caused or fabricated by the caregiver. Motivation is to assume a sick role by proxy. It is a form of child/elder abuse.

When to suspect ? Inconsistencies in the history, examination, and laboratory tests Refusal to grant access to information from external sources such as prior medical records as well as family and friends Tests and procedures, including those that are risky, are eagerly accepted Lengthy and extensive clinical evaluation (eg, large number of consultations and tests) that is negative Opposition to consulting psychiatry Use of multiple healthcare facilities Course of illness is unusual

FACTITIOUS DISORDER(munchausen syndrome)

Malingering Patient consciously fakes, profoundly exaggerates or claims to have a disorder in order to attain a spesific secondary gain(avoiding work…) Characterized by poor compliance with treatment or follow-up diagnostic tests and ceasing of complaints after gain(vs factitious disorder)

Malingering

Psychological factors affecting other medical conditions Psychological factors affecting other medical conditions (PFAOMC) is a disorder that is diagnosed when a general medical condition is adversely affected by psychological or behavioral factors; the factors may precipitate or exacerbate the medical condition, interfere with treatment, or contribute to morbidity and mortality. In addition, the factors are not part of another mental disorder (eg, unipolar major depression).

DIAGNOSTIC CRITERIA A general medical symptom or disorder is present The diagnosis of PFAOMC requires each of the following criteria A general medical symptom or disorder is present Psychological or behavioral factors negatively affect the medical condition in one or more of the following ways, such that the factors: -Pose additional health risks for the patient -Aggravate the underlying pathophysiology of a medical condition and precipitate or exacerbate symptoms -Affect the course of the medical condition, as manifested by a close temporal relationship between the factors and the onset or exacerbation of the medical condition -Disrupt treatment of the general medical condition   Other mental disorders do not better explain the psychological or behavioral factors

Psychological factors affecting other medical conditions A previously healthy 45 year old male reports chest pain that only occurs when he loses his temper and yells at his assistant, wife, and children. A Holter monitor shows signs of ischemia and premature ventricular contractions while yelling, and a stress test and cardiac catheterization confirm a diagnosis of coronary artery disease. The temporal link between anger and angina supports a diagnosis of PFAOMC.

Key features

treATMENT Pharmacotherapy and psychotherapy are each beneficial, and there is no evidence to indicate one is better than the other. Patients with somatization often have comorbid depressive and anxiety disorders. Somatization frequently resolves when these psychiatric syndromes are appropriately treated. Cognitive Behavioral Therapy- the evidence supporting CBT is stronger than it is for any other psychotherapy. Tell patients that their symptoms are taken seriously Avoid describing symptoms as entirely psychogenic (“all in your head”) Avoid further referrals and laboratory tests unless there is a clear indication of a general medical disorder. Schedule regular visits.

treATMENT - pharmacotherapy SSRI (NNT:3) : Initial treatment with fluoxetine 20 mg per day. TCAs : Side effects ?

References Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis. [online] Available at: https://www.uptodate.com/contents/somatization-epidemiology-pathogenesis-clinical-features-medical-evaluation-and- diagnosis [Accessed 12 Apr. 2017]. Conversion disorder in adults: Clinical features, assessment, and comorbidity. [online] Available at: https://www.uptodate.com/contents/conversion-disorder-in-adults-clinical-features-assessment-and- comorbidity?source=search_result&search=conversion+disorder&selectedTitle=1~44 [Accessed 12 Apr. 2017]. Psychological factors affecting other medical conditions: Clinical features, assessment, and diagnosis. [online] Available at: https://www.uptodate.com/contents/psychological-factors-affecting-other-medical-conditions-clinical-features-assessment- and-diagnosis?source=search_result&search=psychologic+factors+affecting&selectedTitle=1~150 [Accessed 12 Apr. 2017]. Somatization: Treatment and prognosis. [online] Available at: https://www.uptodate.com/contents/somatization-treatment- and-prognosis?source=search_result&search=somatization+treatment&selectedTitle=1~150 [Accessed 12 Apr. 2017]