170 Somatization Disorder (300.81)

DSM-IV-TR criteria

A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

• (1) 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)
• (2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
• (3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
• (4) one pseudoneurological 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, halluciantions, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)

C. Either (1) or (2):

• (1) after appropriate investigation, each of the symptoms in Criterion B 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)
• (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would e expected from the history, physical examination or laboratory findings

• D. The symptoms are not intentionally produced or feigned (as in Factitous Disorder or Malingering).

Barlow and Durand (2009) give an example of somatization disorder:

Linda, an intelligent woman in her 30s, came to our clinic looking distressed and pained. As she sat down she noted that coming into the office was difficult for her because she had trouble breathing and considerable swelling in the joints of her legs and arms. She was also in some pain from chronic urinary tract infections and might have to leave at any moment to go to the restroom, but she was extremely happy she had kept the appointment. At least she was seeing someone who could help alleviate her considerable suffering. She said she knew we would have to go through a detailed initial interview, but she had something that might save time. At this point, she pulled out several sheets of paper and handed them over. One section, some five pages long, described her contacts with the health-care system for major difficulties only. Times, dates, potential diagnosis, and days hospitalized were noted. The second section, one-and-a-half single-spaced pages, consisted of a list of all medications she had taken for various complaints.

Linda felt she had any one of a number of chronic infections that nobody could properly diagnose. She had begun to have these problems in her teenage years. She often discussed her symptoms and fears with doctors and clergy. Drawn to hospitals and medical clinics, she had entered nursing school after high school. However, during hospital training, she noticed her physical condition deteriorating rapidly: She seemed to pick up the diseases she was learning about. A series of stressful emotional events resulted in her leaving nursing school.

After developing unexplained paralysis in her legs, Linda was admitted to a psychiatric hospital, and after a yea,r she regained her ability to walk. On discharge, she obtained disability status, which freed her from having to work full time, and she volunteered at the local hospital. With her chronic but fluctuating incapacitation, on some days she could go in and on some days she could not. She was currently seeing a family practitioner and six specialists, who monitored various aspects of her physical condition. She was also seeing two ministers for pastoral counseling.

Associated features:

Patients possessing Somatization Disorder (SD) typically complain of physical symptoms that seem to have no physical origins. They describe their symptoms in colorful, exaggerated terms, but do not give specific information. They are often inconsistent as historians, so a thorough review of medical treatments and hospitalization may be necessary. They often seek treatment from several physicians at the same time, so there is a risk of complicated and dangerous combination of treatments. Experts believe that unconscious physical symptoms arise due to internal psychological conflicts. Patients will visit numerous doctors and never figure out their problems. As a result, their symptoms worsen and cause social dysfunction. In other words, SD causes it’s inhabitant to become very antisocial. They commonly have prominent anxiety symptoms and depressed mood, which symptoms may be the cause of being in a mental health setting. They may exhibit impulsive and antisocial behavior, suicide threats and attempts, and marital discord. Their lives are often chaotic and complicate. Their frequent use of medications may lead to Substance-Related Disorders. They undergo frequent examinations, procedures, surgeries, and hospitalizations. Comorbidity can occur with Major Depressive Disorder, Panic Disorder, and Substance-Related Disorder, as well as some Personality Disorders, most commonly Histrionic, Borderline, and Antisocial Personality Disorders.

Child vs. Adult Presentation:

Despite the fact that children commonly respond to psychosocial stressors with reported physical and somatic complaints, a diagnosis of Somatization Disorder in children is rare.

Gender and Cultural Differences in Presentation:

Somatization Disorder occurs in 0.2 % to 2% of females and 0.2% of males. Although the disorder occurs most often in women, the male relatives of affected women have an increased risk of substance-related disorders and antisocial personality disorders. Cross-culturally, certain symptoms of Somatization Disorder present themselves differently. For example, people in African and South Asian countries are more prone to have the symptom of worms or ants crawling in their head than those in North American countries. In addition, boys are prone to report more headaches at a younger age whereas girls are reported to have more headaches with the disorder during their teens.

Epidemiology:

• In the general population, Somatization Disorder is not common. Somatization Disorder is prevalent in 0.02% of the population. Mood and anxiety disorders are typically co-morbid with this disorder.
• Individuals typical meet diagnostic criteria before 25 years of age. The disorder is chronic and fluctuating, and it rarely remits completely. A year seldom passes without the individual seeking medical attention for some unexplained somatic complaint.

Etiology

Studies have investigated that several risk are associated with Somatization Disorder. There is evidence that parental divorce is implicated in the risk for Somatization Disorder. Also, research has proven that higher risk for Somatization Disorder occurred in families with Antisocial Personality Disorder.

Empirically Supported Treatments

Treatments for Somatization are cognitive behavioral therapy and medications. (CBT) consists of focusing on negative thoughts, behaviors, and feelings that contribute to somatic symptoms. This treatment helps patients identify the more dysfunctional thinking. Overall, they will develop a better idea to positive thinking and rational explanations. It also helps them along with being more socially active, because people who suffer from somatization usually avoid social activities. (CBT) also teaches relaxation techniques.

Anti-depression medications will sometimes be prescribed in order to help alleviate symptoms.

Comorbidity

• Somatization disorder co-occurs with the majority of Axis II PDs (Bornstein, & Gold, 2008).
• Clinicians have discussed the connections between SD and at least six Axis II PDs: antisocial, avoidant, borderline, dependent, histionic, and obsessive-compulsive (Bornstein, & Gold, 2008).
• Effect sizes linking SD with paranoid PD and obsessive-compulsive PD were small, effect sizes for antisocial, borderline, narcissistic, histionic, avoidant and dependent PD yielded effect sizes about or above 0.02 (Bornstein, & Gold, 2008).
• The co-existence of somatization and abnormal illness behaviour is well known (Chaturvedi,Desai, & Shaligram, 2006). Abnormal illness behaviour is defined as: persistence of an inappropriate or maladaptive pattern of behaviour (Chaturvedi et al., 2006).

DSM-V recommended revisions www.dsm5.org

Major changes:

#1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders.

#2: Combine somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder into a new category entitled “Complex Somatic Symptom Disorder” (CSSD).

The work group is recommending that this disorder be subsumed into a new disorder: Complex Somatic Symptom Disorder.

The following optional specifiers may be applied to a diagnosis of CSSD where one of the following dominates the clinical presentation:

1. Multiplicity of somatic complaints (previously, somatization disorder)