Unexplained Physical Symptoms

CHECK POINTS

• Medically unexplained physical symptoms are more common in women, in persons from lower socioeconomic backgrounds, and in certain ethnic groups, as well as in children and adolescents.

• Unexplained physical symptoms tend to have a chronic, protracted course, and the causes are multifactorial.

• In treating somatization disorder (SD), psychiatric comorbidities such as significant depression and anxiety symptoms should be specifically addressed.

• Because patients with SD may be at higher risk for addiction or dependence, caution is advised for the use of medications with addictive potential, especially opiate analgesics and tranquilizers, such as benzodiazepines.

The key manifestations of DSM-IV somatoform disorder are unexplained physical symptoms or complaints that tend to coexist with other psychiatric syndromes or are linked to psychological issues. These symptoms typically lead to repeated medical or emergency department visits; are associated with serious discomfort, dysfunction, and disability; and lead to significant health expenditures. Despite their frequency and relevance to both primary care and psychiatric practices, the definition, classification, and management of these disorders remain difficult and controversial. Moreover, there are little systematic research data available for these disorders across medical disciplines. Diagnostic changes made on the basis of capricious committee recommendations often become a “moving target,” thus decreasing the ability to compare studies over time.

A Brief History

Dramatic and peculiar somatic manifestations that perplex clinicians have been with us since ancient times. A brief review of their historical evolution shows that they metamorphose as medical paradigms change. For example, labels such as hysteria, hypochondria, spleen, English disease, soldier’s heart, neurocirculatory asthenia, neurasthenia, surmenage, humoral disorders, psychosomatic disorders, and many others have been fashionable or relevant during certain periods, but most eventually faded into oblivion or were replaced by more technical terminology. Despite steady efforts to eradicate them, the survival of some of these terms (hysteria, neurasthenia) is probably proof of their validity.

In psychiatry, the term “somatization” has been used for decades to label these somatic presentations. The classical concept of somatization was coined by Wilhelm Stekel,¹ a Viennese psychoanalyst who immigrated to America. He described it as a “deep-seated neurosis” or as the “process by which neurotic conflicts appear as a physical disorder.” In North American psychiatry, this concept was expanded by Zbigniew J. Lipowski,² who described somatization as the “tendency to experience, conceptualize, and/or communicate psychological states or meanings as corporeal sensations, functional changes, or somatic metaphors.”

The psychogenic view generally considered somatic presentations as ancillary manifestations of psychological discomfort. The more direct and pragmatic approach to somatization that would eventually lead to the atheoretical frame of modern nomenclatures began with French psychopathologist Pierre Briquet,³ who, in 1859, brought an observational or experiential perspective to the study of hysteria during the golden age of French psychopathology. His description of a syndrome inclusive of multiple motor and sensorial symptoms (pseudoneurological symptoms) made possible the separation of somatization from conversion.

In the 1950s, a group of investigators at Washington University–Renard Hospital in St Louis resurrected Briquet’s concept of hysteria in several clinical studies. They formulated criteria for the diagnosis of hysteria that required the presence of a specified number of symptoms from a comprehensive list that included physical and psychological manifestations, personality traits, and behavioral expressions, in addition to the neurological symptoms from the traditional French definition.^4,5

With a few modifications, these were the criteria for somatization disorder proposed by Feighner and colleagues⁶ in 1972 in their seminal paper, “Diagnostic Criteria for Use in Psychiatric Research.” After Robert Spitzer and his colleagues⁷ coined the term “somatoform disorder” (inclusive of the Greek soma and the Latin form), it officially entered American and world psychiatric terminology with the publication of the International Classification of Diseases criteria in the late 1970s and the DSM-III in the 1980s.

Somatoform Disorders in DSM
Following the publication of DSM-III in the 1980s, somatization disorder (SD) became the key somatoform diagnosis. In DSM-III and its subsequent revisions, SD turned into a simple somatic symptom list that contracted or expanded rather capriciously. Partly because the atheoretical perspective of DSM discarded any presumptions of causality, other manifestations of the syndrome were not included in the criteria.

Internal server error