Adria Ottoboni Winter

Perspective

Patients occasionally present to the emergency department (ED) with myriad physical symptoms in the absence of signs of physical disease. Whereas some harbor underlying medical disorders, many suffer from somatoform disorders, in which they experience and communicate psychological distress as one or more physical symptoms.1,2 These patients have persistent distress related to the symptoms that inhibits their ability to function. Even when a somatoform disorder is strongly suspected, emergency physicians are reluctant to attribute physical complaints to a psychiatric disorder for fear of missing the subtle presentation of physical disease.

Somatoform disorders are among the most prevalent of psychiatric disorders in the primary care setting, occurring in at least 10 to 15% of primary care patients.3,4 The annual cost to evaluate these patients medically is estimated at $100 billion.⁵

Somatoform disorders are an enormous source of angst for physicians as they can easily frustrate even the best attempts to place human suffering into well-defined categories based on physical disease. Somatoform disorders are unlikely to be diagnosed in a single visit; in fact, a definitive diagnosis requires multiple visits and an in-depth knowledge of the patient. Nevertheless, proper diagnosis and treatment of patients with a somatoform disorder are essential; misidentification and mismanagement prolong the patient’s suffering and add immensely to excess health care costs, with unnecessary diagnostic testing and hospitalization.⁵

Clinical Features

Seven somatoform disorders are listed in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV): (1) somatization disorder, characterized by many physical complaints affecting many organ systems; (2) conversion disorder, characterized by one or two neurologic complaints; (3) hypochondriasis, characterized by patients’ beliefs that they have a specific disease; (4) body dysmorphic disorder, characterized by a false belief or perception that a body part is defective; (5) pain disorder, characterized by symptoms of pain that are solely due to or exacerbated by psychological factors; (6) undifferentiated somatoform disorder, which includes somatoform disorders not otherwise described that have been present for 6 months or more; and (7) somatoform disorder not otherwise specified, for those somatoform symptoms that do not meet any of the criteria otherwise described and classified.⁶

The general category of somatoform disorders was first explicitly defined in the DSM-III and updated in the DSM-IV; its revision is pending in the DSM-V. The initial criteria were based on descriptions by Briquet and Purtell7,8; however, the initial perspectives on hysteria and hypochondriasis have changed markedly and are likely to continue to do so. There is ongoing controversy about whether the somatoform disorders require a reclassification because the diagnosis does not explain the etiology, nor does it predict treatment response.⁹

The phenomenon of somatization extends across a broad spectrum of expression, from mild stress-related symptoms to chronic debilitating presentations that destroy a patient’s ability to function socially or occupationally.10,11 Patients with an underlying somatoform disorder can be particularly frustrating for the emergency physician because they cannot be approached from the practical standpoint of cause and effect, which is the bedrock of training and analysis for most physicians. It is not unusual for physicians to think that patients with somatoform disorders have nonlegitimate disturbances and are using medical care to treat their underlying emotional needs, with the resulting mismatch in the patient-physician relationship.¹²

It is important to recognize when a patient has a somatoform disorder, if only to avoid multiple unnecessary and time-consuming tests; however, the diagnosis itself is typically one of exclusion. In addition, somatizers typically steadfastly insist that their symptoms are caused by serious physical disorders even in the presence of conclusive evidence to the contrary.¹³

Historically referred to as hysteria, somatization disorder was given the eponym Briquet’s syndrome by Guze in 1975 to avoid the pejorative connotations associated with the traditional terms.14,15 Somatization disorder is the prototypic somatoform presentation, differing from the other somatoform disorders in the multiplicity of complaints and organ systems affected. As the number of physical symptoms increases, so does the patient’s functional impairment and distress.¹⁶ Research has shown that patients with somatization are more likely to be women, nonwhite, and less educated than nonsomatizers.¹⁷

The diagnosis of somatization disorder requires several criteria (Box 113-1).⁶ It can be summarized as a polysymptomatic disorder that begins before the age of 30 years; extends for a period of years; and is characterized by pain, gastrointestinal, sexual, and pseudoneurologic symptoms. Somatization disorder is restrictive and represents only a small subset of patients who have moderate yet clinically significant somatization.¹⁸ Somatization disorder, as currently defined, is present in less than 0.5% of the general population and in 1 to 4% of patients who present in general practice.¹⁹

Once referred to as hysterical neurosis and originally described by Breuer and Freud,²⁰ conversion disorder is characterized by abnormalities or deficits in voluntary motor or sensory function that are medically unexplained, including pseudoseizures, pseudoparalysis, psychogenic movement disorders, and blindness. Typically, there is a sudden dramatic onset of a single symptom, simulating some nonpainful neurologic disorder for which there is no pathophysiologic or anatomic explanation.^6,21 In contrast to somatization disorder, conversion disorder typically revolves around a single physiologically impossible condition that is not under the patient’s voluntary control but probably represents the patient’s own perception of neurologic illness. Some symptoms provide gratification for unconscious dependency needs, whereas others may provide escape from painful emotional stimuli (e.g., hysterical paralysis in battle).^22,23 Conversion disorder tends to occur more often in young, naïve, and uneducated women, except for those in military service and industrial accidents.²³ Typical comorbid diagnoses include mood disorders, panic disorder, generalized anxiety disorder, post-traumatic stress disorder, dissociative disorders, social or specific phobias, and obsessive-compulsive disorders. Patients with conversion disorder often have a history of physical or sexual abuse^21,24 (Box 113-2).

According to DSM-IV, pain disorder requires psychological factors that are important in the onset, severity, exacerbation, or maintenance of that pain and is characterized by clinically significant pain in one or more anatomic sites.⁶ The primary and often exclusive symptom is distressful pain that is not intentionally feigned, is persistent in nature, limits daily function, involves one or more organ systems, and cannot be pathophysiologically explained.^6,25

The term hypochondriasis comes from regio hypochondriaca, a Latin term referring to the upper lateral region of the abdomen inferior to the costal cartilages, especially the area of the spleen, which early physicians presumed to be the seat of this disorder. Hypochondriasis is defined as the preoccupation, despite medical evaluation and physician reassurance, that one has a serious disease based on the misinterpretation of symptoms.⁶ Patients must have a preoccupation with their symptoms for at least 6 months before the diagnosis can be made. These patients typically have four characteristics: (1) physical symptoms disproportionate to demonstrable organic disease; (2) fear of disease and a conviction that they are sick, leading to “illness-claiming behavior”; (3) preoccupation with their body; and (4) persistent and unsatisfying pursuit of medical care with a history of doctor shopping and an eventual return of symptoms.²⁶

These unfortunate patients manifest both a heightened awareness and an unrealistic interpretation of normal physical signs or sensations, such as bowel habits, heartbeat, sweating, or peristalsis. These sensations are perceived as abnormal, noxious, and alarming, a phenomenon known as amplification.²⁷ These aberrant perceptions result in a chronic morbid preoccupation with body functions and a lingering fear of having a disease despite medical reassurance.^6,25,26 A distinguishing feature of hypochondriasis is the presence of real symptoms that are often confirmed by physical examination, but the patient exaggerates and misinterprets them.

Hypochondriasis is relatively common. Its prevalence in general medical practice ranges from 4 to 9%.⁶ It has a peak incidence among men in their 30s and women in their 40s, affecting men and women equally.^28–30 Hypochondriacs have an increased sense of responsibility for and place a high value on their personal health and physical appearance. They have an acute sense of body vulnerability and a heightened aversion to death and aging.³¹ There is a strong correlation between hypochondriasis and major depression.³² A milder form of this disorder may be an exaggerated interest in body function and health.³³

The hypochondriac complains at length and in detail, using medical jargon. Hypochondriacs often believe that they have lost control of their lives and have been described as “experts at defeating doctors in order to feel more powerful.”²⁶ Consequently, physicians perceive hypochondriacal patients as more angry and hostile than other patients.³⁴ The diagnosis may be suggested when the physician feels “frustration, helplessness, or anger associated with a wish to be rid of the patient.”^26,35

Reactive hypochondriasis, or transient hypochondriasis, is an acute response to a psychosocial stress or life crisis, such as an acute myocardial infarction, terminal illness, or recent loss of a family member. In contrast to true hypochondriasis, this form is reversible and does respond to reassurance.26,33

Diagnostic Strategies

Physicians are often reluctant to include a somatoform disorder in their differential diagnosis when patients present to the ED with unexplained symptoms. Their dramatic presentations and persistent preoccupation with a multitude of symptoms can overwhelm even the most pragmatic diagnostician. Yet repetitive or extensive diagnostic testing rarely excludes organic disease with absolute certainty and may yield false-positive results, which prompts further unneeded testing.36,37 Unfortunately, somatizing patients are more likely to have morbidity from repeated diagnostic tests than from an undiagnosed physical disease.^38,39 In addition, patients with somatoform disorders often find frustration not only with their symptoms but also with the excessive testing and ineffective treatments that occur concurrently.

Yielding to the temptation to institute further diagnostic procedures or interventions typically leads to a temporary improvement, closely followed by a renewal of symptoms and mutual physician-patient disappointment. This gives rise to inevitable dissatisfaction of the patient with the physician and vice versa, leading to an unsatisfactory parting of ways and a perpetuation of the doctor-shopping cycle.⁴⁰

Managed care and capitated reimbursement have created an additional quandary by restricting the supply of care in a time of rising demands from patients whose symptoms are relatively minor.41,42 The most effective diagnostic tool with somatizers is the interview. Evaluation starts with a thorough but focused history and, if available, a review of the patient’s medical record. This is followed by a careful problem-oriented physical examination, with meticulous inspection of the area of complaint and simple or routine diagnostic testing, when appropriate, until one attains a reasonable level of diagnostic certainty.⁴² Further investigations or hospital admissions should be initiated solely on the basis of new objective signs of disease and only after confirming that the tests have not previously been performed. A rule of thumb in considering ancillary tests is to order exactly what would be done if the patient were not a somatizer.^35,42 However, the clinician should resist the impassioned entreaties of the patient when it is clear that further complex or hazardous studies are unlikely to be productive.^28,29,42,43 Multiple medical and surgical consultations generally prove counterproductive. Hypochondriacs perceive this as a test of their claim to illness and respond simply by propagating and demonstrating symptoms with redoubled zeal.²⁶

Discussion of the diagnosis of somatoform disorder with these patients is fraught with potential pitfalls, especially in the ED, but it can be managed with some careful forethought. Somatizing patients are keenly aware of diagnostic labels, and all therapeutic alliance will be lost if the physician even hints at the possibility that their symptoms are “all in their head.” It is important to discuss the possibility of the disorder with the patient after any underlying medical causation has been ruled out to lay the groundwork for any future psychiatric consultation and treatment.13,28,44