Naming them as somatoform disorders or sub typing them into somatization disorder or pain disorder may help to differentiate them from malingering or factitious disorders but may not help much in understanding or managing them.
But if the physician can understand that these disorders are a result of abnormal processing and perception of signals in the central nervous system, it may help not only them, but also the patients or their worried relatives to make sense out of this baffling presentation.
A psychiatrist may label them as a conversion disorder or a dissociative disorder when such disorders are presumed to have a causal relationship to a psychological conflict which may be unconscious.
When he makes a referral to a psychiatrist, a medical professional is usually not bothered over these subtleties and is worried whether he is missing an organic cause, is concerned about symptom removal, and is often curious about the psychological stressor identified. One has to admit that these methods are effective at least for symptom removal. The practical difficulties in referring these patients for a psychiatric consultation often cited by physicians are also very valid in the background of our cultural context.
For the psychiatrist, this group whose main concern is not the symptoms, but the beliefs about health, disease and diagnosis may be hypochondriasis, a sub type of somatoform disorder. Understanding the relationship between health anxiety and beliefs about diseases and ill health may provide better insight for the physician in empathizing with these patients who are very likely to elicit negative emotional responses from the therapist and other care takers.
The subtle difference between factitious disorders and malingering does not bother the non-psychiatrist. The fact that these disorders are relatively rare compared to the more common place conditions described above should be imparted to them rather than heading for the hair splitting arguments over factitious versus malingering.
These six situations need not be considered essentially in the exact order given as above. The priority in this article has been assigned depending on the frequency usually encountered in clinical practice in a general hospital setting.
The clinician should use his practical wisdom in determining priorities in individual cases. Building an alliance with the patient, collaborating with referral source, reviewing the medical records, gathering collateral information from others, performing psychiatric examination and MSE and physical examination are integral to a proper diagnosis. Management strategies include i Re- attribution approach ii Pychodynamic approach and iii Directive approach.
In re-attribution approach the patient is helped to link his physical symptoms with psychological or stressful factors in his life.
This is useful in those patients with insight, in short duration illness and for use in PHCs. In the psychotherapeutic approach, the thrust is in forming a close and trusting relationship with the patient. This modality may be useful in persistent somatization. In directive approach, the patient is treated as though he has a physical problem.
Interventions are framed in the medical model. This approach is useful in hostile patients and those who deny the relevance of social or psychological factors. Principles of management are fundamentally same for management of all somatoform disorders. They are:. Explanations are given to empower the patient, emphasizing good prognosis and ensuring active involvement of the patient and x Specific treatment models like pharmacotherapy, behavior treatments including cognitive therapy and CBT, dynamic psychotherapy, group therapy, marital therapy, family therapy, physical and relaxation therapies.
Research from India: Chandrasekhara R et al. Raguram R et al. Chaturvedi et al. Nambi SK et al. Patel V found stress as common attribution for vaginal discharge. In such patients there were high scores for somatoform disorders and CMD. Malhotra S et al. Age at presentation and intelligence were significantly higher in somatoform disorders. Trivedi JK et al. This might lead to poor psychosocial functioning.
Paralikar VP et al. There is no doubt, some of these criticisms are valid and it should focus our attention on improving the classification in future. Future Perspectives: Hypochondriasis and somatization are so enduring and is it more appropriate to classify them as personality disorders? Also, physical and psychological factors contribute to the illness. Hence the dualistic view is likely to be rejected in future.
Also there is increasing acceptance that pain cannot be meaningfully classified as either somatogenic or psychogenic. First and foremost, it is crucial to accept the real nature of the symptoms, with the exception of factitious disorders. Giving an explanatory model for the patient for his symptoms is very important.
A patient with medically unexplained somatic symptoms is often at a loss to understand the why and how of his symptoms. Quite often, he is given vague and contradictory explanations which may not be suiting his belief systems and thinking. Prescriptions of psychotropic medicines given without a convincing explanation are very likely to be perceived by the patient as dishonest. A model which focuses on dysfunctional neurotransmission and brain circuits which are influenced by external stressors and internal conflicts leading on to symptoms may be appropriate in the first three situations.
Abnormal signal transmission and processing in the nervous system may also be brought in as legitimate explanations for these conditions. When pharmacological agents are prescribed, they should be explained as agents to correct these irregularities and not as tranquillizers. One cannot expect to make every doctor skilled in individual psychotherapies, but basic principles of behavioral management, counseling and communication skills can be imparted to every medical professional.
Making psychiatry a compulsory subject with at least six weeks of clinical training and examination is likely to equip any doctor with these skills.
Teaching of psychiatry at postgraduate level of every clinical subject should also be seriously considered. In post-graduate psychiatric training and examination, the importance given to consultation- liaison psychiatry should be enhanced to meet the challenges and needs in this area.
The consultation- liaison work between psychiatrists and specialists in other clinical subjects should be strengthened. Only with these policy changes, the medical profession will be able to meet the unseen but vast need in healthcare.
Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v. Indian J Psychiatry. Roy Abraham Kallivayalil and Varghese P. Punnoose 1. Varghese P. Author information Copyright and License information Disclaimer. Address for correspondence: Prof. E-mail: ni. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
This article has been cited by other articles in PMC. Antidepressants are commonly used to treat depressive or anxiety disorders and may be part of the approach to treating the comorbidities of somatoform disorders. Antidepressants such as fluvoxamine Luvox, brand not available for treating body dysmorphic disorder, and St. John's wort for treating somatization and undifferentiated somatoform disorders have been proposed.
Cognitive behavior therapy has been found to be an effective treatment of somatoform disorders. Benefits of cognitive behavior therapy include reduced frequency and intensity of symptoms and cost of care, and improved patient functioning.
Collaboration with a mental health professional can be helpful in making the initial diagnosis of a somatoform disorder, confirming a comorbid diagnosis, and providing treatment. Results of a recent, small randomized controlled trial conducted in the Netherlands, which combined cognitive behavior therapy provided by general practitioners with psychiatric consultation, suggest improvements in symptom severity, social functioning, and health care use when multiple interventions are employed.
A schedule of regular, brief follow-up office visits with the physician is an important aspect of treatment. Scheduled visits may also prevent frequent and unnecessary between-visit contacts and reduce excessive health care use. The practical management strategies described here and elsewhere are summarized in Table 3. Accept that patients can have distressing, real physical symptoms and medical conditions with coexisting psychiatric disturbance without malingering or feigning symptoms.
Consider and discuss the possibility of somatoform disorders with the patient early in the work-up, if suspected, and make a psychiatric diagnosis only when all criteria are met. Once the diagnosis is confirmed, provide patient education on the individual disorder using empathy and avoiding confrontation. Avoid unnecessary medical tests and specialty referrals, and be cautious when pursuing new symptoms with new tests and referrals.
Focus treatment on function, not symptom, and on management of the disorder, not cure. Address lifestyle modifications and stress reduction, and include the patient's family if appropriate and possible. Collaborate with mental health professionals as necessary to assist with the initial diagnosis or to provide treatment. Information from references 27 through Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. He received his doctoral degree in clinical psychology from Indiana University, Bloomington, and his master's degree in health sciences and a physician assistant certification from Duke University, Durham, N.
He received his medical degree from St. Louis Mo. Myrtle Ave. Reprints are not available from the authors. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, D. Somatization and medicalization in the era of managed care. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry. Managing somatic preoccupation.
Am Fam Physician. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry. A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost-effectiveness. J Psychosom Res. Resource utilization of patients with hypochondriacal health anxiety and somatization.
Med Care. Somatoform disorders, somatization and abnormal illness behaviour. Int Rev Psychiatry. Utility of a new procedure for diagnosing mental disorders in primary care. Body dysmorphic disorder. Psychiatr Clin North Am. Salkovskis PM. Somatic problems. New York, N. McCahill ME. Somatoform and related disorders: delivery of diagnosis as first step.
Somatizing patients: Part I. Practical diagnosis. Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder. Psychiatr Q. Treatment of somatoform disorders with St.
John's wort: a randomized, double-blind and placebo-controlled trial. Psychosom Med. Burton C. Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms MUPS. Br J Gen Pract. Treatment of somatization in primary care: evaluation of the Personal Health Improvement Program.
HMO Pract. Treatment of somatization in primary care. Gen Hosp Psychiatry. Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. A controlled trial of cognitive-behavioural treatment of hypochondriasis. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial.
Arch Intern Med. Back to Somatic Symptom Disorder. Somatic Symptom Disorder. The individual has excessive thoughts, feelings and behaviors relating to the physical symptoms. The physical symptoms may or may not be associated with a diagnosed medical condition, but the person is experiencing symptoms and believes they are sick that is, not faking the illness.
The emphasis is on the extent to which the thoughts, feelings and behaviors related to the illness are excessive or out of proportion. People with somatic symptom disorder typically go to a primary care physician rather than a psychiatrist or other mental health professional.
Individuals with somatic symptom disorder may experience difficulty accepting that their concerns about their symptoms are excessive. They may continue to be fearful and worried even when they are shown evidence that they do not have a serious condition.
Some people have only pain as their dominant symtom. Somatic symptom disorder usually begins by age
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