Somatoform Disorders

In addition to the Somatoform Disorders, as listed in DSM-IV, such as Somatization Disorder (SD), Conversion Disorder (CD), Hypochondriasis (HD), Body Dysmorphic Disorder (BDD), Pain Disorder, and Undifferentiated Somatoform Disorder (USD), there are a group of disorders called “Functional Somatic Syndromes” (4), such as Chronic Fatigue Syndrome, Irritable Bowel Syndrome, or Fibromyalgia. Factitious Disorder may also be included among these somatopsychic conditions. These conditions are of theoretical and clinical importance for a number of reasons. First they result in a great deal of suffering. Secondly they are important because they cross the concern of disciplines, being important to both psychiatrists and other medical physicians. And third they raise fundamental issues in medicine and psychiatry about the relationship of the mind to the body. Yet those specific Somatoform Disorders that are of interest to psychiatrist may only represent a small proportion of these conditions occurring clinically. Although the Somatoform Disorders listed in DSM-IV are of concern to psychiatrists, research shows that in primary care practices patients with Undifferentiated Somatoform Disorder or Somatoform Disorder NOS are far more common. There are also a high percentage of somatized psychiatric disorders, such as Major Depression or Panic Disorder that present in primary care. Thus there are three groups of patients with somatic presentations that are of interest to primary care physicians: those with multiple medically unexplained symptoms, hypochondriacal worries, and somatized presentations of other psychiatric conditions (4). The vast majority of these never see psychiatric care. Studies within primary care show low rates of full Somatoform Disorders, but high rates of subthreshold conditions and high rates of medically unexplained symptoms, as high as 25 to 50% (5). In the setting of unexplained medical symptoms and high distress, medical physicians react first by exploring for medically treatable conditions. If this proves fruitless, then medical practitioners tend to get frustrated and may refer to psychological practitioners, causing the patient to feel abandoned and misunderstood. On the other hand, somatizing patients run a high risk of iatrogenic harm (8). On the average about 45% of visits to primary care providers involve somatization. It has been demonstrated through a national survey that 70% of those patients who eventually end up in psychiatric care first presented to a primary care physician with a somatic complaint. In a 3-year study of 1000 primary care patients that the majority of symptoms presented were for unexplained medical problems. While diagnostic testing was done in 75% of patients, an identifiable medical cause of symptoms was found in only 16%. Therefore the cost of making a verified medical diagnosis was quite high – $7,778 per headache complaint and $7,263 per back pain complaint (8). This is not limited to primary care. Half of the patients attending a Gastrointestinal Clinic had no relevant organic disease (7). Central to these disorders is the concept of somatization. Somatization can be defined as the “tendency to experience and communicate somatic distress and symptoms unaccounted by pathologic findings, to attribute them to physical illness, and to seek medical help for them” (10). Somatization can also be defined as “the focusing of attention on internal stimuli and the denial of psychological or interpersonal difficulties,