Somatization Disorder

CHAPTER I

INTRODUCTION

Somatoform disorders are a group of psychiatric disorders, in which patients

present with a large number of unexplained physical symptoms. These disorders

include somatization disorder, hypochondriasis, conversion disorder and other

unspecified somatoform disorders. These disturbances cause emotional distress to the

patient and are a challenge for the family doctor.1

There are three clinical criteria required to meet a somatoform disorder: (1)

clinical symptoms that cannot be fully explained by a medical condition, other mental

disorder, or the effects of a substance; (2) not caused by a factitious disorder or

malingering disorder; (3) and causes significant impairment in social, occupational

and other functions. In patients with somatization disorder, unexplained physical

symptoms begin before age 30 and persist for several years and include at least two

gastrointestinal complaints, four painful symptoms, one pseudoneurologic symptom,

and one sexual symptom.1

This reference is made to increase knowledge regarding the definition, causes,

prevalence, diagnosis, differential diagnosis and management of somatization

disorder.

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 CHAPTER II

LITERATURE REVIEW

A. Definition

The term "somatization" was originally a mistranslation from German by

the psychoanalyst Wilhelm Stekel around the 1920s. Somatization gained

worldwide attention, especially after 1980, when it was first introduced as a

psychiatric diagnostic term in the Diagnostic and Statistical Manual of Mental

Disorders Third Edition (DSM-III). The DSM-III also uses “Briquet's syndrome”

as a synonym for somatization disorder to honor the contribution made by the

great 19th century physician, Pierre Briquet.2,3

In the DSM-IV the diagnosis of undifferentiated somatoform disorder was

made because somatization disorder describes only a minority of somatized

individuals, but the disorder has not proven to be a useful clinical diagnosis.

Because the distinction between somatization disorder and undifferentiated

somatoform disorder is unclear, the two diagnoses are combined in the DSM-V

to become somatic symptom disorder, and no specific somatic symptoms are

required.4–6

B. Diagnosis

Patients with somatic symptom disorder believe they have a severe disease

but go undetected, and evidence to the contrary is inconclusive. They may

maintain the belief that they have a certain disease. They fixate on one or more

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 somatic symptoms that they believe to be evidence of disease. In some

individuals, this belief persists despite negative laboratory results and doctors

reassuring them that there is nothing wrong with them. Patients with somatic

symptom disorder often experience symptoms of depression and anxiety.7,8

The following are the diagnostic criteria for somatic symptom disorder

according to the Diagnostic and Statistical Manual of Mental Disorders Fifth

Edition (DSM-V):7,9

1. One or more somatic symptoms causing distress or interference with daily

life.

2. Excessive thoughts, feelings or behaviors related to somatic symptoms, or

associated with a feeling of concern for health as reflected by at least one of:

a. Persistent thoughts about the seriousness of the symptoms.

b. Persistent severe anxiety about your health or symptoms.

c. Excessive time and energy devoted to worrying about symptoms or

health.

3. Although one of the somatic symptoms may not last until recently, the

symptomatic state is persistent (usually longer than 6 months).

C. Somatization Disorder in DSM-IV TR

The hallmark of somatization disorder is a clinically significant, recurrent,

and multiple pattern of somatic complaints. Somatic complaints are considered

clinically significant if they warrant medical attention or cause significant

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impairment in social, occupational, or other important areas of functioning. The

following are the diagnostic criteria for somatization disorder in the Diagnostic

and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-

IV TR):10

1. Many had a history of physical complaints beginning before the age of 30

years that persisted for several years and led to treatment seeking or

significant impairment in social, occupational, or other important areas of

functioning.

2. Each of the following criteria must be present, with individual symptoms

occurring at any time during the disturbance:

a. Four pain symptoms: history of pain in four different sites or functions

(eg, head, abdomen, back, joints, extremities, chest, rectum, during

menstruation or during urination).

b. Two gastrointestinal symptoms: a history of at least two gastrointestinal

symptoms other than pain (eg, nausea, bloating, vomiting not caused by

pregnancy, diarrhea, or intolerance to some foods).

c. One sexual symptom: at least one history of sexual or reproductive

symptoms other than pain (eg, erectile or ejaculatory disorders, irregular

menstrual cycles, heavy periods).

d. One pseudoneurological symptom: at least one history of neurologic

symptom or deficit other than pain (conversion symptoms such as

impaired coordination or balance, paralysis, difficulty swallowing or

lump in throat, aphonia, urinary retention, hallucinations, loss of touch or

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 pain sensation, double vision, blindness , deafness, seizures; dissociative

symptoms such as amnesia; or loss of consciousness other than fainting).

3. Either (a) or (b):

a. After adequate investigation, any of the symptoms in criterion 2 cannot

be fully explained by a medical condition or the effects of a substance

(eg substance abuse or medication).

b. When there are associated medical conditions, physical complaints or

social or occupational impairments that are more severe than would be

expected from the history, physical examination or laboratory findings.

4. The symptoms are not intentionally or feigned (as in factitious disorder or

malingering).

D. Etiology

The exact etiology of this disorder is not known with certainty. Somatic

symptom disorder is not only caused by one thing, but many factors cause this

disorder. There are theories about the causes of somatic symptom disorder,

namely:2,11

1. Psychosocial factors

Psychosocially, the symptoms of this disorder are forms of social

communication aimed at avoiding obligations, expressing emotions, or

symbolizing feelings. The learning aspect (learning behavior) emphasizes

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 that teaching from parents and culture teaches children to use somatization.

Social, cultural and ethnic factors are also involved in the development of

somatization symptoms.

2. Biological factors

Genetic data indicate the presence of genetic transmission in somatization

disorder. Occurs in 10-20% of women, while their brothers tend to be

substance abusers and antisocial personality disorder. In monozygotic twins

occurs 29% and 10% dizygotic.

E. Prevalence

The prevalence of somatic symptom disorder in the general population is

estimated at 5-7%, which makes it the most common category that occurs in

patients in primary health care facilities. It is estimated that about 20-25% of

patients who present with acute somatic symptoms will develop chronic somatic

disease. This disorder can begin in childhood, adolescence or adulthood. Women

more often experience somatic symptom disorder than men, with a ratio of

10:1.12

F. Differential Diagnosis

If the somatic symptoms are consistent with those of another mental

disorder (eg, panic disorder), and the diagnostic criteria are met, then that mental

disorder should be considered as an alternative or additional diagnosis.7,13

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1. Other medical conditions

The presence of somatic symptoms of unclear etiology is not sufficient to

establish the diagnosis of somatic symptom disorder. The symptoms in many

individuals with disorders such as irritable bowel syndrome or fibromyalgia

will not meet the criteria necessary to diagnose somatic symptom disorder.

Conversely, the presence of somatic symptoms of an established medical

disorder (eg diabetes or heart disease) does not rule out the diagnosis of

somatic symptom disorder if the criteria are met.

2. Panic disorder

In panic disorder, somatic symptoms and anxiety about one's health tend to

be present in acute episodes, whereas in somatic symptom disorder, the

anxiety and somatic symptoms are more persistent.

3. Generalized anxiety disorder

Individuals with generalized anxiety disorder worry about events, situations,

or activities and have little anxiety about their health. The primary focus is

usually not somatic symptoms or fear of illness, as is the case with somatic

symptom disorder.

4. Depressive disorder

Depressive disorders are usually accompanied by somatic symptoms.

However, depressive disorders are distinguished from somatic symptom

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 disorders by their primary symptoms of low mood (dysphoric) and

anhedonia.

5. Illness anxiety disorder

Individuals have concerns about their health but without or are not

accompanied by somatic symptoms.

6. Conversion disorder (functional neurological symptom disorder)

In conversion disorder, the presenting symptom is loss of function (eg,

limbs). While in somatic symptom disorder, the focus is distress regarding

the cause of certain symptoms.

7. delusional disorder

In somatic symptom disorder, the individual's belief that somatic symptoms

may reflect an underlying serious physical illness is not affected by the

intensity of the delusions. But the belief of individuals who are concerned

about somatic symptoms can be restrained. In contrast, in the somatic subtype

of delusional disorder, the somatic symptoms are stronger than those found in

the somatic symptom disorder.

8. Body dysmorphic disorder

In body dysmorphic disorder, the individual is excessively worried and

preoccupied with defects in his or her physical characteristics. In contrast, in

somatic symptom disorder, concern about somatic symptoms reflects fear

about the underlying disease, not about defects in appearance.

9. Obsessive-compulsive disorder

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 In somatic symptom disorder, recurrent thoughts about somatic symptoms or

illness are less intrusive, and individuals with this disorder do not show an

association with repetitive behaviors aimed at reducing anxiety, as occurs in

obsessive-compulsive disorder.

G. Governance

Treatment should be done by one doctor, because if it is done by more than

one doctor, the patient will have more opportunities to express his somatic

complaints. The meeting interval is once a month. Although a physical

examination should be performed for any new somatic complaints, the doctor or

therapist should listen to somatic complaints as an emotional expression and not

as a medical complaint.11,14

Psychotherapy both individually and in groups will reduce spending on

health care funds, especially for hospitalization. Psychotherapy helps patients

deal with their symptoms, express underlying emotions and develop alternative

strategies for expressing their feelings.11,14

Pharmacotherapy therapy is recommended if there are other disorders

(comorbid). Strict supervision of drug administration must be carried out because

patients with somatization disorder tend to use drugs alternately and

irrationally.11,14

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 CHAPTER III

CONCLUSION

Somatization disorder first appeared as a diagnostic criterion in the Diagnostic

and Statistical Manual of Mental Disorders Third Edition (DMS-III), survivingn in

DSM-IV, and changed to somatic symptom disorders(somatic symptom disorder) in the

DSM-V. The diagnosis of somatic symptom disorder can be made by meeting the diagnostic

criteria of the DSM-V. The etiology of somatic symptom disorder is not known with certainty

but there are two theories, namely psychosocial factors and biological factors. The

prevalence of somatic symptom disorder in the general population is estimated at 5-7%,

approximately 20-25% of patients presenting to primary facilities will have chronic somatic

disease. This disorder is more common in women than men with a ratio of 10:1. Somatic

symptom disorder must be differentiated from the differential diagnosis because of the

different management. Management of somatic symptom disorder centers on the physician

listening to somatic symptoms as a medical symptom. Treatment centered on

psychotherapy

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 BIBLIOGRAPHY

1. Oyama O, Paltoo C, Greengold J. Somatoform disorders. Am Fam Physician.

2007;76(9):1333–8.

2. Mai F. Somatization Disorder: a Practical Review. Can J Psychiatry.

2004;49(10):652–62.

3. Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, et al.

Somatic Symptom Disorder: an Important Change in DSM. J Psychosom Res.

2013;75(6):223–8.

4. American Psychiatric Association. Highlights of Changes from DSM-IV to

DSM-5. Focus (Madison). 2013;11(4):525–7.

5. Mayou R. Is the DSM-5 Chapter on Somatic Symptom Disorder any Better

Than DSM-IV Somatoform Disorder? Brother J Psychiatry. 2014;204(6):418–

9.

6. Ghanizadeh A, Firoozabadi A. a Review of Somatoform Disorders in DSM-IV

and Somatic Symptom Disorders in Proposed DSM-V. Psychiatrist Danub.

2012;24(4):353–8.

7. Kaplan HI, Sadock BJ. Kaplan & Sadock's Synopsis of Psychiatry. Twelfth

Ed. Boland RJ, Verduin ML, Ruiz P, editors. Wolters Kluwer. 2022.

8. Barski AJ. Assessing the New DSM-5 Diagnosis of Somatic Symptom

Disorder. Psychosom Med. 2016;78(1):2–4.

9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders Fifth Edition. Fifth Edit. First MB, editor. American Psychiatric

12
 Association. Washington DC: American Psychiatric Publishing;2013.

10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders Fourth Edition Text Revision. Fourth Tex. Vol. 1, Psychiatry: Third

Edition. Arlington: American Psychiatric Association; 2000.

11. SD Elvira, Hadisukando G. Textbook of Psychiatry. Key Edition. Jakarta:

Publishing Board of the Faculty of Medicine, University of Indonesia; 2017.

12. Kurlansik SL, Maffei MS. Somatic Symptom Disorder. Am Acad Fam

Psysicians. 2016;211–4.

13. Dimsdale J.E. Research on Somatization and Somatic Symptom Disorders.pdf.

Psychosom Med. 2017;79(9):971–3.

14. Henningsen P. Management of Somatic Symptom Disorder. In: Dialogues in

Clinical Neuroscience. 2018. p.m. 23–31.

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