Somatoform disorders revisited

Okasha A. Somatoform disorders revisitedActa Neuropsychiatrica 2003: 15:161–166. # Blackwell Munksgaard2003

Ahmed Okasha

WHO Collaborating Center for Research and Training in Mental

Health, Institute of Psychiatry, Ain Shans University, Cairo, Egypt

Keywords:

Correspondence: Prof Ahmed Okasha, 3 Ahmed Borai Street,

Off Iraq Street, Mohandesseen – Giza, Egypt.

Tel. þ(202) 3366799; Fax: þ(202) 7481786;

E-mail: aokasha@internetegypt.com

Introduction

We psychiatrists give contradictory messages toour medical colleagues and to the public opinion.We launch programs to fight stigma and discrim-ination because of mental illness; at the same timewe give names to our nosology, which can stigma-tize our specialty. One such example is the termsomatoform, implying that psychiatric illnesses donot originate from the Soma. Five thousands yearsago, Ancient Egyptians did not differentiatebetween psyche and soma. All mental illness wasattributed to either the uterus or the heart andthere was no stigma as both were treated asphysical disorders. Today we may be using a ter-minology that could create a confusion regardingthis unity (1).The history of psychiatric nosology has been a

history of attempts to demystify the vagueness ofmental disorders. One such mystery is the clinicalpresentation of somatic symptoms in the absent oforganic pathology.An outpatient clinic survey of 1000 patients at

the Ain Shams outpatient clinic in Cairo, Egypt, in1967 revealed an incidence of 11.2% of casesreceiving the diagnosis of hysteria, 61% of whompresented with motor presentation while 33.3% ofthem presented with sensory complaints. Visceralcomplaints cut across both groups with aprevalence of 80.6%. Twenty-three years later thesurvey was repeated and the percentage of patientsreceiving a diagnosis of conversion/dissociationdisorder dropped to 5%. The difference betweenboth was attributed to the development ofnew nosological categories which accommodatedthe remainder of the cases, the total of whichadded up to 10% of the studied sample, i.e. quitesimilar to the percentage revealed in the 1967survey (2).

To solve the vagueness of the term hysteria andits different implications, the DSM-III devised thecategory of somatoform disorders to solve theconfusion of the group of patients presenting‘somatizing’ features who were previouslyrecklessly labeled hysterical. Traditionally theconcept of hysteria included the following fourcriteria: the disturbance suggested physical illness;there were no demonstrable organic findings toexplain the disturbance; there was positiveevidence that the disturbance was linked topsychological factors; and the disorder was notsymptomatic of any other mental or physicaldisorder.Traditionally, the term has also been used in

medical sociology and anthropology, to describea pattern of illness behavior, especially a style ofclinical presentation, in which somatic symptomsare presented to the exclusion or eclipse ofemotional distress and social problems (3). It wasalso a form of illness presentation that impliesseveral cultural connotations, assuming that thepublic would accept, tolerate and sympathizewith suffering of somatic symptoms more thanpsychological complaints, which people tend toperceive more as under the control of the person’swill. In traditional societies, somatization is attrib-uted to the wrath of God, possession of evil spiritsand magical doing.In psychiatry, the term was expanded to provide

a diagnostic label to any constellation of somaticsymptoms that did not show evidence of medicalpathology.

Definition

Before the advent ofDSM-III, with the introductionof the new terminology ‘somatoform disorders’,

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these patients presenting with physical complaintswere loosely lumped together under the rubric‘hysteria’. This termwasmeant to convey the notionthat psychological conflict led to development ofphysical illness through the defense mechanisms ofregression and displacement.In recent official psychiatric nosology, somatiza-

tion has come to refer to a family of psychiatricdisorders [somatoform disorders in DSM-IV (4) orICD-10] presenting with somatic complaints. Theuse of the term in both references is not equivalent.It involves varying degrees of inference aboutunderlying processes that are, at present, immeas-urable. Kirmayer and Robbins (5) refer to threedifferent ways of operationalizing research intosomatization: (i) somatization in the sense of med-ically unexplained somatic symptoms (for example,in the somatization disorder module of the DIS,the Composite International Diagnostic Interviewor the WHO Somatoform Disorders Schedule) (6);(ii) as hypochondriacal worry or somatic preoccu-pation (7); and (iii) as somatic clinical presenta-tions of affective, anxiety or other psychiatricdisorders (8). An attempt to distinguish betweenthe three different definitions of somatization mayhelp to resolve some of the contradictory findingsin gross cultural literature.The most useful definition of somatization might

be that suggested by Kleinman (3), in whichsomatization is defined as a ‘somatic idiom ofpsychosocial distress’.The somatoform disorder section in DSM-IV

reflects disorders in which somatic complaints arecentral issues as opposed to merely unexplainedphysical symptoms or other applications of theconcept of somatization.Rief and Hiller (9) proposed the term ‘polysymp-

tomatic somatoform disorder’ to refer to thepresence of at least seven unexplained physicalsymptoms affecting multiple body sites duringthe past 2 years.Escobar et al. (6) also proposed a less severe

form of somatization disorder. This form requiresthe presence of four or more physical symptomsfor men and six or more symptoms for womenincluded in the Composite International Diagnos-tic Interview. Swartz et al. (10) defined a subsyn-dromal form of somatization disorder associatedwith higher rates of health care-seeking behaviorthan in patients with DSM-defined somatizationdisorder; 11.6% of the general population metcriteria for this category.Ethnographic research by Kirmayer and Young

(11) urged the inclusion of cultural meanings ofsymptoms in the development of somatizationclassification criteria. These and other researchers

proposed the potential utility of viewing somatiza-tion as a continuum on which increasing degrees ofsomatic symptoms indicate increasing distress,disability, and maladaptive illness behavior (12).

Categories

Somatoform disorder

The presentation of somatic symptoms in theabsence of physical disease represents the mostpersistent, disabling and costly form of somato-form medical disorders. Yet its prevalence is low,for it often coexists with other mental disorders,especially anxiety and depression, which present toprimary physicians with somatic symptoms.Hypochondriasis involves preoccupation with

the fear or belief of having serious disease in theabsence of relevant evidence. Its status as a sep-arate disorder has been controversial for years.While its close association with depression hasbeen noted for centuries, it should probably beviewed as a dimension rather than a disorder,which may accompany all somatoform and manyother mental disorders.Hypochondriacal symptoms were found in 38%

of family practice patients with somatizationdisorders. On the other hand, another studyshowed that 39% of hypochondriacal patientsreferred to psychiatry from general practitionerssatisfied the criteria for somatization disorder (7).Concerning somatoform pain disorder, the

essential feature is a preoccupation with pain thatlacks a detectable pathphysiological basis. It mustlast for 6months to the diagnosis and hence asimilar pain of shorter duration is excluded. Thiseffectively precludes its diagnosis at an early stagewhen intervention to prevent a chronic coursecould be effective. The criteria for this disorderare imprecise and it is scarcely diagnosed. Inchronic idiopathic pain, the most frequentpsychiatric diagnoses are depression and anxiety.It is doubtful if this disorder should be consideredas a separate category.Undifferentiated somatoform disorder is prob-

ably by far the most commonmember of this class.By definition it must be chronic, and this criterionis questionable for the same reasons as those justmentioned for somatoform pain disorder.Body dysmorphic disorder involves a preoccupa-

tion with a minor or imagined defect in physicalappearance. It often has a delusional quality, isusually seen by plastic surgeons and should beconsidered as a symptom rather than a disorder.Empirical evidence for an association with the

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somatoform disorders is lacking. In fact, manyauthors have argued that body dysmorphicdisorder is related to, or a variant of, one of thenon-somatoform disorders, including the psycho-sis, mood disorders, social phobia and obsessive-compulsive disorder.

Prevalence of somatoform disorders

Recent evidence shows that somatization – in eachof its definitions – is present in all cultural groupsand societies. This wide prevalence challenges thenotion that somatization is indicative of somespecial form of psychopathology. Differencesamong groups may reflect cultural styles of expres-sing distress (idioms of distress) that are influencednot only by cultural beliefs and practices, but alsoby familiarity with health care systems andpathways to care.Kirmayer and Young (11) and Isaac et al. (13)

argue that somatization is a universal phenom-enon and that somatic symptoms are the mostcommon clinical explanation of emotional distressworldwide. Epidemiological research on somatiza-tion in the US has been dominated by the con-struct of ‘somatization disorder’ and a formefruste termed ‘subsyndromal somatization dis-order’. The diagnosis is given based on a lifetimecount of four medically unexplained symptomsfor men and six for women in the somatizationsection of the NIMH Diagnostic Interviewschedule (termed the Somatic Symptom Indexand denoted as ‘SSI 4,6’) (6).The analysis also showed that more than 24% of

assessed patients fulfilled criteria for more thanone somatoform disorder, thus indicating insuffi-ciently clear boundaries between specific diagnos-tic categories of somatoform disorders.Somatization often coexists with depression or

anxiety. The implications of such comorbidity onthe course of somatization in primary care areunclear. In a large international study conductedin the primary care settings of 14 countries, stabil-ity of somatization over a 12-month period wasunrelated to the co-occurrence of depressiongeneralized anxiety disorder (GAD). However,persistence of somatization was a risk factor forthe emergence of new episodes of depression andof GAD after 1 year. Conversely, the incidence ofsomatization syndrome was increased amongindividuals who had either depression or GAD 1month earlier. The data provide no evidence tosuggest that the outcome of somatization is influ-enced by comorbidity with depression or GAD.However, somatization is more likely to developamong depressed or anxious primary care patients.

The WHO Cross-National Study of MentalDisorders in Primary Care studied 5438 patientsfrom 15 centers in 14 countries (14). While a highprevalence of somatization was found across allcenters, the rates varied markedly (15). The overallprevalence of somatization disorder was 0.9%, butthis varied from zero to 3.8% at specific centers;the overall frequency of abridged somatization(based on the SSI) was 19.7% and this variedalmost fivefold from 7.6 to 36.8%. The authorsemphasize the similarity of the relationshipbetween somatic, affective and anxiety symptomsacross sites but their own data also provide evi-dence of significant cultural variation.Demographic factors have been suggested as

determinants of the prevalence of somatization.Rural and urban dichotomies proved irrelevantto the prevalence of somatization. This may beexplained by the fact that the rural/urban dichot-omy itself is inaccurate in several places of theworld. This is especially the case in those countries,where urbanization of the countryside andruralization of cities are taking place. Gender andpopulation studies of prevalence have shown thatfemale patients outnumbered males in the presen-tation of somatoform disorders (5). The authorsargue that the higher prevalence of women amongsomatizers may be explained by a female patternof help-seeking behavior. Expectations fromhousewives and mothers would attribute morerespect to a somatic complaint than a psycho-logical one.While the former is frequently respected,the latter is frequently discarded as irrelevant.Katon et al. (16) have found that almost 60% of

the high users of primary health care suffered fromless severe forms of somatization. Swartz et al. (10)defined a subsyndromal form of somatization thatwas associated with higher rates of seeking healthcare that is intermediate between that of somati-zers in the general population and patients withsomatization disorder.

Critique

The clinical utility of this broader concept issignificant in that it may better identify treatablesomatizing patients with comorbid psychiatricdisorders (anxiety or depression) in primary caresettings (12).This essentially ‘negative’ definition (i.e. a defini-

tion relying primarily on the lack of a medicalexplanation of the patient’s symptoms) fails totake into account the fact that somatoformsymptoms represent a small segment within thelarge area of psychopathology reflecting abnormal

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phenomena of body awareness. The lowest com-mon denominator for these clinical problems isthat they tend to behave (to paraphrase Freud)‘as though anatomy did not exist’.The very existence of a discrete category of

somatoform disorders in psychiatric nosologyimplies a separation of affective, anxiety,dissociative and somatic symptoms that are notreflected in the co-occurrence of these symptoms insyndromes worldwide (17). This separation largelyreflects the persistent mind–body dualism ofWestern medicine: psychiatric disorders areperceived as mental disorders, notwithstandingtheir prominent somatic symptoms. The somato-form disorders are then a residual category lyingbetween the somatic and the psychic to makethe nosological system complete. This is particularlyuseful in consultation-liaison psychiatry. As a result,diagnostic categories that combine somatic andpsychological symptoms have continued to be popu-lar in many countries. An example of that is theglossary of culture-related syndromes included asAppendix (I) in DSM-IV (1). Many of these syn-dromes have predominately somatic symptoms andsomightbeviewedas formsof somatization (e.g. bilisor cholera, hwa-byung, brain fag, dhat, shenkui, fall-ing out, koro, shenjing shuairuo, and neurasthenia).These culture-related syndromes illustrate howethnophysiological ideas about the body can giverise to culture-specific somatic symptoms and com-plaints like ‘heat in the head’, ‘loss of semen in theurine’, and specific types of conversion symptoms (5).

Several authors criticized the concept of somatiza-tion as the product of Western mind–body dualism(11,13).Manson also criticized the artificial differen-tiation and separation of mental manifestations into‘psyche’ and ‘soma’ (18). It is only because cliniciansexpect patients to adopt exclusively psychologicalidiom for their distress that they treat the persistentexpression of distress in physical terms as a specialdiagnostic category (13). Results of regressionanalysis showed that somatization is related toboth anxiety anddepression and also to the durationof symptoms. However, all those factors explainedonly 30% of the variance, meaning that the otherfactors contribute to thephenomenon.This supportsthe view that somatization is a common finalpathway for expression of different types of psycho-logical distress.The definition of somatization actually describes

a peculiar social transaction between patient anddoctor, which involves:

A subjective, experiential events (on the part ofthe patient);

B cognitive events (on the part of both doctorand patient);

C theoretical concepts (on the part of the doctor)D communication.

Somatization/somatoform disorder is defined interms of what it is not (i.e. not a ‘medical’ dis-order), but both classifications fail to identify thedisorder in somatization/somatoform disorder,e.g. body dysmorphic disorder of DSM-IV isincluded in hypochondriasis in ICD-10 and thereis no exact equivalent of the ICD-10 categoryF45.3. Somatoform autonomic dysfunction inDSM-IV, the number of symptoms requiredqualifying for the disorder in ICD-10 are lessthan DSM-IV. The purposeful omission of overtlygenital and sexual complaints from the list inICD-10 made this difference. Conversion disordersare included as somatoform disorders in DSM-IV.This is not so in ICD-10, where these conversiondisorders remain together with other types ofdissociative disorders.

Nosological implications

A scientific ‘phenomenology of the body’, espe-cially if coupled with research into underlyingneurocognitive and neurophysiological mechan-isms, may eventually render concepts such assomatization and somatoform disorders obsolete.The semantic network will encompass conceptssuch as conversion, hypochondriasis, bodydysmorphic disorder, illness behavior, factitiousdisorder, malingering and psychosomatic dis-orders. It may include chronic fatigue syndrome,fibromyalgia and mitral valve prolapse. Theseconcepts share the following. First, the clinicalproblems subsumed by the network of relatedconcepts are frequent, occur in all cultures, andare associated with high direct and indirect costs toindividuals and the society. Second, salientfeatures of these disorders constitute a paradox:although the majority of the patients with suchclinical problems are seen and treated by generalpractitioners, by non-psychiatric medical special-ists, or by practitioners of ‘alternative medicine’,the definition of the nature of the problems, theirdiagnosis and classification are at present regardedas the prerogative of psychiatry, rather than ofgeneral medicine or neurology (as it was duringmost of the 19th century).To define clinical variants of somatoform was

undoubtedly innovative and overdue, but thecurrently included disorders overlap, and theirvalidity and reliability are debatable.

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Periodically a patient will meet the criteria fortwo different diagnoses in the somatoform dis-orders group depending on the presenting physicalsymptoms. One diagnosis may take precedenceover the other or the patient may be given twocomorbid diagnoses.Since it has been established, the category of

somatoform disorders has been subjected to a lotof criticism. Specific criticisms include the conten-tion that the category is superficial because it isdelineated on the basis of presenting physicalsymptoms. Furthermore, the individual disordersare not qualitatively distinct, would be betterdescribed dimensionally than categorically andare derived from hospital- rather than community-or primary care-based populations. Diagnosticcriteria have been regarded as either too restrictivefor clinical use or insufficiently operationalized.However, other opinions maintain that the

somatoform grouping represents a major advanceover previous systems. Segregation of such dis-orders into a grouping has promoted attempts toclarify concepts and to attain greater consistencyin terminology and descriptive distinction betweenspecific somatoform disorders. It is expected thatsuch clarification and consistency will foster moregeneralizable, and thereby more clinically applic-able, research. Indeed, comparison of post- versuspre-DSM-III literature reveals efforts towardgreater consistencySeveral pieces of research have revealed a differ-

ent prevalence for symptoms than that of dis-orders. When, then, should functional symptomsbe worthy of clinical attention? When do theyrequire specific treatments? When do they take achronic and invalidating course affecting quality oflife? In an attempt to answer those questions Fava(19) believes that theDSM-IV or ICD-10 criteria forsomatoform are of little help in prognostic andtherapeutic terms for approaching these symptoms.This awareness led an international group of expertson psychosomatic illness to introduce alternativecriteria for somatoform disorders.Although these criteria are still tentative and are

still in need of appropriate validation, it may beuseful to mention them at this point. They include:

1 functional somatic symptoms secondary to apsychiatric disorder (subtype for anxiety-depression and adjustment disorders)

2 persistent somatization (like undifferentiatedsomatoform disorders in ICD-10 and DSM-IV)

3 conversion symptoms (histrionic personalitynot essential)

4 disease phobia (high overlap with panic andhypochondriasis)

5 health anxiety6 thanatophobia7 illness denial – irrelevant in somatoformdisorders.

The contribution of Fava (19) in solving some ofthe problems encountered in both DSM-IV andICD-10 criteria has several beneficial aspects.The entity of ‘functional somatic symptoms

secondary to psychiatric disorder’ is very practicalin diagnosing the more frequently observed type ofsomatization disorder. It is consistent with thesuggestion that somatization disorder wouldinclude a subtype often associated with anxietyand depression as well as another type associatedwith adjustment (16). Taking into considerationthe comorbidity between somatization, anxietyand depression, it is clear that the utility of thisentity is controversial, especially as it does notrequire a specific duration or age of onset. Also,the disorder termed ‘persistent somatization’ couldeasily include the common disturbance that in theDSM-IV and ICD-10 would be subsumed underthe rubric of undifferentiated somatoform. Theentity of ‘health anxiety’ is easily applicable anddeficient in the other current classifications. It doesnot necessitate the 6 months duration so it coin-cides with the request made by Barsky (7) that thepicture of transient hypochondriasis, frequentlyencountered should be respected.And yet this diagnostic approach is not without

drawbacks. First, the entity of ‘illness denial’ hasnothing to do with somatoform disorders. Itsfeatures contradict the core presentation of soma-toform disorder, which is the preoccupation thatthey are sick in spite of all negative findings andreassurance.Second, although the criteria for ‘disease phobia’

respects the comorbidity between panic attacksand hypochondriasis, yet it will increase the over-lap in diagnosis and will add to the confusion ofhypochondriacal-related disorder. This also is thecase with the entity ‘thanatophobia’.

Policy implications

Other than the interesting nosological debatethat the nature of somatization disorders caninvoke, somatization can be challenging in otherdisciplines. It leads to particular health care-seeking behavior and may demand relevant inter-vention strategies. Like so many other developingcountries challenged by the maintenance of theirinfrastructure and subsidy of the basic needs oftheir people, priorities of health care services and

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planning are not for mental health. Since 75–80%of Egyptian psychiatric patients present withsomatic symptoms, the majority of them tendto seek help with traditional and religious healers(20).Also physicians in primary care settings frequently

have to deal with minor neurotic, psychosomaticand transient psychotic states. Patients presentingwith somatic complaints are usually referred to along list of investigations and specialists, with thepsychiatrists being the last on the list, in case noneof the former referrals proveduseful. This shouldnotnecessarily be the case. General practitioners shouldbe able to manage a great majority of psychiatricdisorders presenting with somatic complaints. Itwould therefore be considered prudent that in thetraining of the general physicians, due emphasis isput upon somatic presentation of psychologicalill-health, not only as far as diagnosis is concerned,but also to the inclusion of management.In conclusion we would argue that increasing

evidence is accumulating that somatization assuch is not necessarily a culturally bound phenom-enon. What may be unique for every country areits clinical image and the challenges it puts on theexisting mental health care facilities. The lattershould be a prime area of input and concern, tothe benefit of a considerable percentage of ourpsychiatric population.

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