Somatoform Disorders Referral

Somatisation disorders is a disabling condition with varying severity but poorly understood condition where patient’s presents with various symptoms indicative of a medical or neurological condition. However, detailed examination and relevant investigations do not support the diagnosis of suspected medical or neurological condition(s). It is understood that these physical symptoms, rather than indicating underlying medical illness, are manifestations of psychological distress. Over a period of time, if untreated, the symptoms tend to become an unconscious habit of the psychological system. In our neuropsychiatric clinics we see the severe end of the spectrum.

Lipowski (1987) published a paper entitled somatisation: ‘the experience and communication of psychological distress as somatic symptom’. Fink (2002) published a paper on ‘Assessment and Treatment of Functional Disorders’ where he states that the essential feature of somatisation disorder is that the patient presents with multiple, medically unexplained symptoms i.e. physical complaints suggestive of a physical disease that cannot be adequately explained on the basis of organic pathology or any known patho- physiological mechanisms.

The phenomena of medically unexplained symptoms cannot simply be classified into one or few diagnostic categories, but must be regarded as the expression of a basic mechanism by which people may respond to stressors as in the case of depression and anxiety. The disorder must be considered to possess a spectrum of severity.

Clinical features

  • Physical symptoms and complaints
  • Psychological symptoms and co-morbidity
  • Illness behaviour

Epidemiology

  • 1% of general population (1 in every 100 may suffer with this condtion)
  • 1-6% in primary care (1-2% using strict criteria, 30% somatising) and in-patient medical settings (15% liaison referral, 40% somatising)
  • Female predominance, with male to female ratio of about 1:2 to 1:6
  • Age of onset from early childhood to 30-35 years

Aetiology
Reported family transmission: due to socio-cultural learning, genetic transmission has been implicated although twin studies have been inconclusive. Childhood experiences of ssomatic complaints in parents, iillness in family (symptoms breed true), family member with physical deformity or handicap, hospitalization during childhood, lack of parental care. Predisposing factors are physical or sexual abuse.

Unspecified predisposing factors common for all the other mental disorder.

Psychological theories
Cognitive theory: misinterpretation or misattribute of benign physical symptoms.
Psychodynamic drive theory: repression of unacceptable wishes or instinctual impulses and internal psychic conflicts.
Self-psychology: anxiety connected with a threat to defragmentation or disintegration of the self. Defence against feeling of emptiness the individual focuses on physical symptoms ‘stimulus entrapment’.

Biological factors
Neuro-physiological dysfunction in the attention process has been demonstrated in somatisation disorder: reduced cortico-fugal inhibition in the diencephalon and the brainstem of afferent bodily stimuli, resulting in insufficient filtering of irrelevant bodily stimuli.
A dysfunction of secondary somatosensory area in the brain, a hypersensitivity of limbic system towards bodily stimuli may also be involved as aetiological factor.

Other factors

  • Compensation claims
  • Tendency to pursue organic possibilities and to evaluate and treat symptoms can lead to reinforcement of physical symptoms

Prognosis

  • Can have a chronic remitting/relapsing pathway
  • If identified early on and managed appropriately there is better prognosis
  • Patient who have co-morbid affective or anxiety disorders have a more favourable prognosis