Somatoform Disorders

Somatoform disorders are mental disorders characterized by physical symptoms that suggest but are not fully explained by a physical disorder. Treatment includes establishing a consistent, supportive physician-patient relationship; cognitive-behavioral therapy is sometimes effective. SSRIs may be helpful for severe hypochondriasis.

Geriatric Essentials

• Three somatoform disorders are relevant to the elderly: somatization disorder, undifferentiated somatoform disorder, and hypochondriasis. Diagnosis is by history.
• Somatoform disorders are not particularly different in the elderly compared with adults of other ages, but the higher prevalence of chronic physical disorders among the elderly makes diagnosing somatoform disorders more difficult.
• Unnecessary testing may lead to complications.
• Elderly patients who are unnecessarily given drugs to treat symptoms secondary to somatoform disorders may be at increased risk of dysfunction resulting from adverse drug reactions.
• When possible, a primary care physician treating an elderly patient with a somatoform disorder should avoid referring that patient to a specialist.

Somatization is the expression of mental phenomena as physical (somatic) symptoms. Typically, the symptoms cannot be explained by a physical disorder. Disorders characterized by somatization extend in a continuum from those in which symptoms develop unconsciously and nonvolitionally to those in which symptoms develop consciously and volitionally. This continuum includes somatoform disorders, factitious disorders, and malingering. Somatization typically leads to seeking medical evaluation and treatment.

Among the elderly, factitious disorders and malingering are rare. Both are characterized by conscious or intentional attempts to appear physically ill. In factitious disorder, the conscious motivation is to assume the sick role and therefore obtain medical evaluation and treatment. In malingering, rewards, such as financial compensation or avoidance of responsibilities, are gained by remaining ill.

Somatoform disorders are somewhat more common. In somatoform disorders, symptom development is unconscious and nonvolitional. Symptoms cannot be explained by an underlying physical disorder. Somatoform disorders are distressing and often interfere with social, occupational, or other functioning. Among the somatoform disorders included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), 3 are relevant to the elderly: somatization disorder, undifferentiated somatoform disorder, and hypochondriasis.

Somatization disorder: Somatization disorder is a chronic condition that is somewhat more common among elderly women (0.2 to 1.0%) than among elderly men (< 0.2%). Symptoms are not intentionally produced, and they usually begin by age 30. Severity fluctuates, but symptoms persist even into old age. Complete symptom relief for any extended period is rare. Patients may become extremely dependent. They increasingly demand help and emotional support and may become very displeased when they feel their needs are not met. They typically go from one physician to another or seek treatment from several physicians concurrently. These patients are unaware of their underlying mental problem and believe that they have physical ailments, so they pressure physicians for tests and treatments.

Diagnosis requires an extensive history of many physical symptoms that cannot be explained fully by a physical disorder. Diagnosis also requires that the symptoms fall into 4 categories: pain symptoms in at least 4 different locations (eg, the head, abdomen, back, extremities), plus at least 2 GI symptoms (eg, nausea, vomiting, diarrhea), plus at least one sexual or reproductive symptom (eg, erectile dysfunction), and at least one neurologic symptom (eg, impaired coordination, paralysis, difficulty swallowing). Diagnosis also requires that symptoms impair functioning.

Physicians usually conduct many examinations and tests to eliminate a physical disorder as the cause. Because patients with somatization disorder may develop concurrent physical disorders, appropriate examinations and tests should also be done when symptoms change or when objective signs develop.

Undifferentiated somatoform disorder: Undifferentiated somatoform disorder, a less severe form of somatization, occurs more often and affects 3 to 5% of elderly people. The central feature is one or more physical symptoms that persist for 6 mo without objective findings. The symptoms are fewer and need not fall into the 4 categories noted previously; however, they must cause distress or functional impairment for the diagnosis to be made. The most common symptoms are chronic fatigue, appetite loss, abdominal pain, and GU symptoms.

Hypochondriasis: Hypochondriasis is preoccupation with the fear of having or the idea of having a serious disease. This concern is based on the elderly patient's misinterpretation of normal bodily processes or functions (eg, borborygmi, abdominal bloating and crampy discomfort, awareness of heart beat, sweating). Hypochondriasis usually begins in early adulthood but can persist into old age and seems to occur equally among men and women. Symptoms are nonvolitional. The location, quality, and duration of symptoms are often described in minute detail, but symptoms are usually not associated with abnormal physical findings. Although specific symptoms may vary over time, hypochondriacal concerns last for at least 6 mo despite appropriate medical evaluation and assurance. Symptoms adversely affect social and occupational functioning or cause distress.

Treatment

The goal of treatment is to improve the patient's quality of life and to control the use of medical services. The primary care physician should always observe the dictum primum non nocere--"first do no harm." Great, ongoing caution must be exercised to avoid recommending diagnostic procedures or therapies that may cause harm while trying to identify or treat a physical disorder that does not exist.

The patient should be examined on a regular basis for 4 to 6 wk. After that, the time between appointments usually can be lengthened. Each appointment should last for a specified period of time; limits on appointment length should be explained to the patient at the beginning of treatment. The physician should end the appointment on time, even if the patient communicates what seems to be important information at the end. The patient should be encouraged to discuss concerns only during the scheduled appointment; phone calls and other methods of seeking additional attention should be discouraged. When possible, the primary care physician should avoid referring the patient to a specialist. If the patient is seeing multiple physicians simultaneously, then coordinating treatment is complicated and extremely time consuming.

Treatment of somatization disorder and undifferentiated somatoform disorder focuses on establishing a consistent, supportive physician-patient relationship that avoids exposing the patient to unnecessary and potentially unsafe diagnostic testing and therapies. Treatment is difficult. Patients tend to be frustrated and angered by suggestions that their symptoms are mental. Drug treatment may help concurrent mental disorders (eg, depression). Psychotherapy, particularly cognitive-behavioral therapy, emphasizes self-management of the disorders. It is important for the patient to have a supportive relationship with a primary care physician who offers symptomatic relief, sees the patient regularly, and protects the patient from unnecessary tests and procedures.

Treatment of hypochondriasis includes establishing a consistent, supportive physician-patient relationship; psychotherapy and drug therapy may help. The course is often chronic--fluctuating in some, steady in others; some patients recover. Treatment is difficult because the patient believes that something is seriously wrong and that the physician has failed to find the real cause. A trusting relationship with a caring, reassuring physician can still prove beneficial. If symptoms are not adequately relieved, the patient may benefit from a psychiatric referral while continuing under the care of the primary care physician. Treatment with SSRIs may be helpful, as may cognitive-behavioral therapy.

This topic was last updated July 2006.