Which nursing diagnosis should be investigated for patients with somatoform disorders?

Principles

Somatic symptom disorders (SSDs), formerly known assomatoform disorders, are described as the borderland between psychiatry and medicine and are responsible for some of the most frustrating and the least understood patient encounters in the emergency department (ED). As such, it is important that emergency clinicians recognize and treat this disorder appropriately to avoid patient suffering, unnecessary testing, iatrogenic injuries, and inappropriate resource utilization. Patients with SSD are often labelled as “difficult” patients, yet appropriate mental health referrals are not made, while psychological and psychosocial causes for their presentation remain unaddressed.1

SSD patients present with multiple physical symptoms in the absence of detectable physical disease, and harbor excessive health concerns that are expressed emotionally, cognitively, and behaviorally.2 These patients perceive a wide range of severe symptoms including pain, gastrointestinal, cardiovascular, sexual, and pseudo-neurological symptoms, which cause inappropriate and persistent worry, distress, and social dysfunction. Biological, psychological, and psychosocial factors interact as precipitating, aggravating, and maintaining factors of psychopathology. Somatization is best understood by focusing on the abnormalities in the patient's response to their somatic symptoms, rather than on the absence of a discernible medical cause for those symptoms. The patient's maladaptive response to somatic symptoms is the reason this behavior is classified as a psychiatric disorder. The major diagnosis in this diagnostic class, of which SSD is the most prominent, hinges on the existence of the patient's distinctive abnormal thoughts, feelings, and behaviors in response to somatic symptoms.3

Somatoform disorders because of their very nature and presentation have consistently been diagnoses that are difficult to make with any certainty, even after multiple visits with the same primary care physician. It is therefore a challenging diagnosis to make within the busy confines of a brief visit to the ED. For patients with functional symptoms, the strategy of pursuing a medical cause with invasive diagnostic procedures, unnecessary surgeries, and misdirected drug trials can be life-threatening, and the unwarranted costs of these measures strain limited medical resources.

SSD are typically more common in women of low socioeconomic status who present between 20 and 30 years old, with a high incidence of comorbid anxiety or depression.4 The diagnosis of SSD is made when there are persistent and clinically significant physical complaints that are accompanied by excessive and disproportionate health-related thoughts, feelings, and behaviors regarding these symptoms.5

There has been much debate regarding how to name and define SSD patients, with the latest (fifth) version of theDiagnostic and Statistical Manual of Mental Disorders (DSM-5) reconceptualizing the category almost entirely. The previous criteria for SSD was criticized for being overly inclusive in certain areas and difficult to employ in either real life practice or research.5 The new diagnostic category of SSD in the DSM-5 is a radical construct change in which the number of symptoms plays only a minor role, while the distress of symptoms associated with psychological features and symptom consequences are emphasized.3,6

Abstract

After defining somatoform disorders (SDs) with subtypes according to the DSM-IV-classification system, we give a short historical overview and convey how SD in the ICD-10 system, medically unexplained (physical) symptoms (MUSs/MUPSs), and/or functional somatic syndromes fit in the DSM-IV SD taxonomy. We evaluate somatoform symptoms/syndromes, especially how they approach the taxonomic borders of the recognized medical conditions or other mental Axis I disorders, but also epidemiological and treatment considerations. When this article is written, there is an intense debate going on with the intention of changing the taxonomy of SD. We have, for several years, used the term complex symptom disorders in addition to relevant existing diagnoses to characterize conditions appearing with somatic symptoms without provable somatic or psychological pathology.

Definition

Somatic symptom disorder (SSD) is the diagnostic entity subsumed withinDSM-5 under somatic symptom and related disorders (SSRDs) replacing somatization disorder, somatoform disorder, hypochondriasis, and pain disorder.DSM-5 SSD with predominant pain replacedDSM-IV TR pain disorder. Likewise, an estimated 75% of patients previously diagnosed with hypochondriasis would now meet criteria for SSD due to prominent physical complaints. Patients with SSDs are usually encountered in primary medical settings, and thus the diagnoses have been reconceptualized to make them more useful for nonpsychiatric providers. Previous criteria for somatization overemphasized the concept of medically unexplained symptom(s), which was discarded in favor of incorporating affective, cognitive, and behavioral components to more accurately reflect the clinical picture. In SSD, patients often present with one or more somatic symptoms that are perceived as distressing and significantly disrupt daily life. They interpret or understand bodily symptoms as harmful and threatening. It is crucial to understand that somatic symptoms without a medical explanation are insufficient to make the diagnosis. The differential diagnosis of SSD includes related disorders under the sameDSM-5 category (SSRD): Illness anxiety disorder, conversion disorder/functional neurologic symptom disorder, psychological factors affecting other medical condition, factitious disorder, and other specified somatic symptom and related disorders such as pseudocyesis (a false belief of being pregnant with associated signs and reported symptoms).

Etiology

Some studies suggest that somatoform disorders may have a genetic component and are associated with family history of depression, antisocial personality disorders, and alcohol abuse. According to Freudian psychoanalytical theory, the physical symptom results from an intrapsychic conflict between an unconscious wish and the superego inhibition of this wish, especially if it is associated with strong aggressive or sexual impulses. The somatic symptom relieves the anxiety caused by the conflict and keeps the wish in the unconscious. Others have hypothesized that childhood development has a component in producing the condition. As children, these patients may have found their families more responsive to physical symptoms than emotional complaints. This may lead to an unconscious pattern of seeking attention for somatic symptoms as adults. Additionally, some studies have indicated that many patients with somatoform disorders have a history of being exposed to a chronically ill household member while growing up. It is thought that this may set up a behavior model for them to follow as adults. Finally, there may be an association between history of sexual abuse and somatoform disorder, especially for patients presenting with gastrointestinal or genitourinary symptoms.

Many psychiatric illnesses, such as depression and anxiety, have somatic symptoms as part of their phenomenology. It is thought that some patients with somatoform disorders actually have a psychiatric condition such as depression or anxiety, but the patients interpret their symptoms to be due to a physical condition rather than psychiatric factors. For example, a depressed patient might say they are feeling sad because they are unable to sleep and have poor appetite rather than directly attributing the symptoms to depression. It is common for patients with somatoform disorder to have an additional psychiatric diagnosis.

The patient's social and cultural background is also thought to be an important factor in how these disorders manifest. If the patient lives in a culture that stigmatizes mental illness, they will find a physical diagnosis more permissible. Also, the patient might find medical services more accessible than mental health since care for physical illness is generally more often covered by managed health care organizations.

Somatic Symptom Disorder

SSD can be defined as idiopathic physical symptoms that begin before age 30, that over time are located in different parts of the body, and that cause disproportionally severe disability and impaired function. The main symptom is pain. There is no evidence that pain in patients with SSD is intentionally feigned or exaggerated, but there is no way to prove that it is not (see alsoChapters 12 and 22Chapter 12Chapter 22).

The onset of physical symptoms often closely follows a traumatic event, and the physical symptoms may coexist with other psychiatric disorders such as depression. A large majority of patients are female. The patients seek medical care for their symptoms, but no authentic medical explanation can be found. Secondary gain from assumption of the “sick role” is often apparent. In some patients, symptoms and illness become a means of communication,41 and a way of controlling their environment. The dysfunction and disability attributed to the symptoms often appear to be out of proportion to the severity of the symptoms. The course of SSD is usually chronic. Once established at a young age, it can continue into advanced age.42 An example of SSD is presented inCase 3.

The underlying etiology of SSD is unknown, but several mechanisms have been proposed. They include the hypothesis that patients with SSD experience psychologic distress in the form of physical symptoms.44 Another theory is that the patient learns the behavior that manifests his or her belief in the supposed affliction and that the resulting “illness” helps the patient to cope.45 The boundaries of SSD are obviously not sharp, merging imperceptibly with illness anxiety disorder on one side and with FD on the other side.45

Diagnosis of SSD depends on recognizing 2 features of the patient’s illness. First, there has been illness-seeking behavior for multiple idiopathic symptoms related to different organ systems; and second, the disability and dysfunction attributed to the symptoms are disproportionally high. In one report, patients with SSD spent 7 days in bed each month, compared with 0.48 days for a general population.46 Patients with SSD are not as fascinated by doctors as patients with FD.

Unfortunately, even highly skilled physicians repeatedly fail to recognize SSD,42 and they, therefore, obtain diagnostic tests for rare and then very rare conditions. These patients are highly vulnerable to such practice because repeated diagnostic tests often reveal questionable abnormalities that can lead to complications from medical treatments (e.g., glucocorticoids or narcotics), invasive procedures, or surgeries.

Pathogenesis/Pathophysiology

Conceptualizations regarding pathogenesis of somatoform disorders have addressed considerations of predisposition, precipitating influences, and perpetuating influences.

Predisposition includes biological factors (e.g., genetics and emerging data on immunological factors influencing amplification of symptom sensitivity), past experiences (e.g., trauma, abuse, or exposure to disabling physical illness in oneself or others), and personality factors (e.g., internalizing, as opposed to externalizing style). A variety of family studies show higher rates of somatoform and related disorders (i.e., depression and obsessive compulsive disorder) in first-degree relatives. For instance, genetic factors are suggested by pedigree studies finding a higher incidence of somatization disorder in female first-degree relatives of index cases, whereas male first-degree relatives have a higher incidence of alcoholism and antisocial (externalizing) personality features. Additionally, recent advances in understanding of psychoneuroimmune pathophysiology, including the role of cytokines in illness behavior, suggest that some individuals are more vulnerable to experiencing amplified somatic symptoms and pain sensitivity. Past experiences such as trauma or illness may underlie chronic activation of the immune system. Comorbid psychiatric or neurological disorders may also be contributory. Biologic factors can be compounded by limitations of communicative ability due to intellectual, emotional, or social constraints predisposing some to a ‘body language expression of distress.’

Precipitating stressors may involve proximate activation of psychological conflicts, such as those regarding sexual, aggressive, or dependency issues. Traumatic events, such as those threatening one's physical integrity or self-esteem, are commonly cited precipitants.

Perpetuating factors include ‘primary gain’ or the ways in which the symptom may resolve or diminish the psychological conflict that generated the symptom, as well as ‘secondary gain’ or the pragmatic benefits of the symptom.

Somatoform disorders embody dissociative features, since they involve development of somatic symptoms or preoccupations based on psychological mechanisms outside the individual's conscious awareness. One may conceptualize such an individual as overwhelmed with stress beyond the capacity for effective, conscious processing of the related affect, leading to communication of distress via ‘somatic metaphor’ or symptom production.

6.24.4.1 Somatoform Disorders vs. General Medical Conditions

The presence of a general medical condition that could account for the presenting symptoms must be carefully examined and considered in every case where physical problems are the focus of a patient's complaints. Symptoms such as pain or fatigue may be related to a wide array of problems ranging from normal sensations to fatal diseases. Health professionals are very much aware of the danger of misdiagnosing a somatoform disorder and of missing the presence of actual physical problems—particularly diseases with a slow or diffuse onset such as multiple sclerosis, brain tumors, or systemic lupus. Some patients diagnosed with somatoform disorders or “functional problems” are ultimately diagnosed with a demonstrable medical condition and must be regarded as initial false-positives (for a particularly poignant example, see Fishbain & Goldberg, 1991). On the other hand, advances in medical diagnostic procedures (e.g., PET and magnetic resonance imaging (MRI) scans) have resulted in more accurate diagnostic decisions and reduced the number of false-positive diagnoses of somatization disorder (Kent, Tomasson, & Coryell, 1995).

Any diagnosis of somatoform disorders should be made with caution and only after careful physical examination. This recommendation is also supported by the fact that it is occasionally difficult for physicians and psychologists alike to determine the “true” nature of somatic complaints. In a study of 200 successive patients undergoing cardiac catheterization, it was found that neither standard medical tests before catheterization nor standard psychological questionnaires alone were able to discriminate reliably chest pain patients with coronary artery disease from patients without heart disease. Diagnostic accuracy only improved when cardiac catheterization was considered along with results from psychological assessments (Eifert, Edwards, Thompson, Haddad, & Frazer, 1997).

In addition, there is at times a reciprocal relationship between health anxiety and somatic symptoms. For instance, Salkovskis (1996) describes how the very safety-seeking behaviors designed to reduce anxiety frequently increase the symptoms that are the focus of anxiety. He cites the example of patients who palpate or rub lumps until they swell and cause pain. Several authors also point to potential pathophysiological mechanisms that may underlie unexplained physical symptoms. Sharpe and Bass (1992) describe various pathophysiological mechanisms in abdominal pain, chest pain, chronic fatigue, breathlessness, and irritable bowel syndrome that can be detected by routine or advanced medical evaluation. For instance, symptoms can be due to excessive physiological activity (e.g., smooth-muscle contraction, striated-muscle contraction, changes in endocrine secretion and in blood flow) that may be accentuated by stress and intense emotions. Both in fairness to the patient, and to design the most appropriate intervention, we should be careful in the use of such terms as unexplained physical symptoms and functional defects. Terms such as “nonorganic …” should be avoided completely.

Somatoform Disorders

Somatoform disorders are a group of psychiatric disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM), 4th edition, Text Revision (DSM-IV-TR)4 as the presence of physical symptoms suggestive of an underlying medical condition but for which the medical condition is neither found nor fully accounts for the level of functional impairment. In medicine, these conditions are classified as functional somatic syndromes.5 DSM-IV-TR somatoform disorders include somatization disorder, conversion disorder, pain disorder, undifferentiated somatoform disorder, hypochondriasis, and body dysmorphic disorder. Except for body dysmorphic disorder, characterized by a preoccupation with an imagined or exaggerated defect in physical appearance, all the other somatoform disorders frequently have pain as part of the presenting complaint. Thus, the other somatoform disorders are included in this chapter, with the recognition of the limited research base in children and adolescents. However, because there may be precursors of adult somatoform disorders identifiable in children, we believe it is important to be inclusive of them in our review.

Etiology

Somatoform disorders replaced the broad category of ‘hysteria’ in the DSM beginning in the late 1960s. The field of psychoanalysis, made popular by Sigmund Freud, began with the treatment of patients who had physical symptoms without evidence of an organic disease. Somatic symptoms were thought to express psychological conflicts that were out of awareness for the patient. More recent research and clinical findings suggest that those with somatoform disorders may have had families in which physical symptoms were reinforced more so than emotional ones. Some studies have found that those with somatoform disorders were exposed to someone with a chronic illness in childhood. Moreover, there is data that some groups (e.g., those with chronic abdominal pain) report histories of child sexual abuse. However, child abuse is a predictor for many mental disorders. It may also be that people predisposed to somatoform disorders have a genetic component. In other words, some people are more prone to the expression of distress through bodily symptoms, as opposed to psychological symptoms. Cultural factors are also important; some cultural groups, including the elderly, are more likely to express psychological distress vis-à-vis bodily complaints.

Somatization Disorder

The somatoform disorders (see Chapter 16) comprise a group of disorders in which complaints and anxiety about physical illness are the predominant clinical features. These complaints exist in the absence of sufficient organic findings to explain the pain. Pain may be present in somatization disorder, conversion disorder, hypochondriasis, and pain disorder. Somatoform disorders occur in 5% to 15% of treated patients with chronic pain, and somatizers account for 36% of all cases of psychiatric disability and 48% of all occasions of sick leave.42

Among somatizers, pain in the head or neck, epigastrium, and limbs predominates. Visceral pain from the esophagus, abdomen, and pelvis associated with psychiatric co-morbidity, especially somatoform disorders, can be challenging to diagnose.43 Missed ovarian cancers, central pain following inflammatory disorders, and referred pain are often overlooked because of the nonspecific presentations of visceral pain. In one study, 64% of women with chronic pelvic pain reported a history of sexual abuse.44 The two most common co-morbid conditions associated with somatoform disorders among MGH pain patients are MDD and anxiety disorders. Surprisingly, drug and alcohol abuse and personality disorders are not significantly associated with somatoform disorders. Patients with somatization disorder consume health care resources at nine times the rate of the average person in the United States.45

Sufferers from somatoform disorders often have painful physical complaints and excessive anxiety about their physical illness. Most of their pain complaints to physicians do not have a well-defined cause, and a psychiatric diagnosis is often particularly difficult to establish (Table 18-4).