What are somatic symptoms?

Introduction

Somatic symptom and related disorders, previously known as somatoform disorders, occur when a psychological conflict is expressed through a somatic, or physical, complaint. The main disorders in this category are somatic symptom disorder, illness anxiety disorder, conversion disorder, factitious disorder, and psychological factors affecting other medical conditions.

Conversion Disorder

When an individual suffers from conversion disorder, also known as functional neurological symptom disorder, the psychological conflict results in some type of disability. Symptoms vary widely; some of the most common involve blindness, deafness, paralysis, and anesthesia (loss of sensation). For a diagnosis of conversion disorder to be made, medical examinations must show that there is nothing wrong physiologically with the individual. The handicap stems from a psychological or emotional problem.

In many instances, the handicap is thought to develop because it gives the person an unconscious way of resolving a conflict. For example, an adult who is feeling powerful yet morally unacceptable feelings of anger and rage may wish to strike his or her young child. Rather than carry out this dreadful action, this person will suddenly develop a paralyzed arm. The unacceptable emotional impulse is then “converted” (thus the term “conversion”) into a physical symptom. When this happens, individuals will sometimes seem strangely unconcerned about their new physical disabilities. They will have what is known as la belle indifférence (beautiful indifference). Although most people would be quite upset if they suddenly became blind or paralyzed, conversion patients will often be rather calm or nonchalant about their disability, because their symptom unconsciously protects them from their desire to act on an unacceptable impulse.

Illness Anxiety Disorder

The situation is somewhat different for individuals with illness anxiety disorder (formerly known as hypochondriasis), since individuals with this disorder do not experience a dramatic physical disability. Rather, they are preoccupied with anxieties about having or acquiring a serious illness. For a diagnosis of illness anxiety disorder to be made, the individual must suffer from minimal or no somatic symptoms; otherwise a diagnosis of somatic symptom disorder is considered more appropriate.

An individual with illness anxiety disorder often misinterprets ordinary physical symptoms as a sign of some extremely serious illness. Mild indigestion may be interpreted as a heart attack; a mild headache may be interpreted as a brain tumor. People with this disorder are usually quite interested in medical information and will keep a wide array of medical specialists at their disposal. Even after physician visits reveal that the patient does not suffer from some dreaded disease, the individual persists in this preoccupation.

Somatic Symptom Disorder

While the hypochondriac is typically afraid of having one particular disease, the individual with somatic symptom disorder will often have numerous medical complaints with no apparent physical cause. Somatic symptom disorder is also sometimes known as Briquet syndrome, after the physician of that name who described it in detail in 1859. A person suffering from somatic symptom disorder is not bothered by the fear of disease but rather by the actual symptoms that he or she reports. This individual will generally describe numerous aches and pains in a vague and exaggerated manner. The American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (rev. 4th ed., 2000) stated the patient must have a history of pain related to at least four different sites or functions as well as at least two gastrointestinal symptoms, at least one sexual or reproductive symptom, and at least one symptom or deficit suggesting a neurological condition. However, the DSM-5 (2013) revised this to require a minimum of one somatic symptom resulting in significant disruption to everyday life, lasting more than six months, and causing a level of anxiety disproportionate to the seriousness of the symptom.

Like the hypochondriac, the somatizer will often seek out frequent, unnecessary medical treatment. The somatizer, however, will be a particularly difficult patient for the physician to handle. The somatizer will often present the physician with a long, vague, and confusing list of complaints. At times, it may seem as if the somatizer is actually developing new symptoms while talking to the physician. The dramatic and disorganized manner in which these patients describe their problems and their tendency to switch from one doctor to the next with great frequency make somatizers some of the most frustrating patients that medical professionals are likely to encounter.

It will also be difficult for even the most capable of medical professionals to work effectively with an individual who is suffering from somatic pain. Pain disorder is a relatively new diagnostic category, in which the individual experiences physical pain for which psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance. Somatic pain is similar to conversion disorder, except that the individual experiences only pain rather than other types of disability or anesthesia. Because pain is a subjective sensory experience rather than an observable symptom, it is often quite difficult for physicians to determine whether pain is caused by psychological or physical factors. It is therefore very hard to diagnose somatic pain with any certainty.

Psychological Factors Affecting Other Medical Conditions

Psychological factors can also affect many real medical conditions, making the symptoms more severe or slowing recovery. This phenomenon was added to the Somatic Disorders chapter of the DSM-V under the name of Psychological Factors Affecting Other Medical Conditions (PFAMC). A diagnosis of PFAMC is made when an individual has a non-mental medical condition, such as asthma, migraine, fibromyalgia, diabetes, or heart disease, which is significantly aggravated by feelings of stress, anxiety, denial, or similar factors. However, the main cause of the symptoms must be physical; otherwise one of the other somatic disorders PFAMC has not been studied as much as some of the other somatic disorders, and its prevalence rate is unknown, but it can occur at any stage of life.

Factitious Disorder

Factitious disorder is a condition in which a person deliberately creates or exaggerates symptoms of mental or physical illness in him- or herself or in another person, usually a child or an elderly or disabled adult under his or her care. The latter, formerly known as factitious disorder by proxy, is called factitious disorder imposed on another in the DSM-5. Factitious disorder with primarily physical symptoms is popularly known as Münchausen syndrome, although this is not an official diagnosis category.

Factitious disorder ranges widely in severity; some individuals with the disorder simply lie about symptoms, some falsify records or alter diagnostic tests in order to make themselves or others seem sick, and some go so far as to intentionally induce infections or injure themselves or others.

Little is known about which treatments for factitious disorder are most effective, although psychotherapy is generally considered more useful than medication. The disorder is not common, but is estimated to affect about 1 percent of patients admitted to hospitals.

The Case of Anna O.

The somatic symptom disorders, like all psychiatric diagnoses, are worth studying only when they can contribute to an understanding of the experience of a troubled individual. In particular, the somatic disorders are useful when they help show that although an individual may genuinely feel sick, or believe he or she has some physical illness, this is not always the case. There are times when a psychological conflict can manifest itself in a somatic form.

A classic example of this situation is a famous case of conversion disorder that was reported by Josef Breuer and Sigmund Freud in 1895. This case involved “Anna O.,” a well-educated and extremely intelligent young Viennese woman who had rapidly become bedridden with a number of mysterious physical symptoms. By the time that Anna O. sought the assistance of Breuer, a prominent Austrian physician, her medical condition was quite serious. Both Anna O.’s right arm and her right leg were paralyzed, her sight and hearing were impaired, and she often had difficulty speaking. She also sometimes went into a rather dreamlike state, which she referred to as an “absence.” During these periods of absence, Anna O. would mumble to herself and appear quite preoccupied with disturbing thoughts.

Anna O.’s symptoms were quite troubling to Breuer, since she did not appear to suffer from any particular physical ailment. To understand this young woman’s condition, Breuer encouraged her to discuss her symptoms at length, and he used hypnosis to explore the history of her illness. Over time, Breuer began to get Anna O. to talk more freely, until she eventually discussed some troubling past events. Breuer noticed that as she started to recall and discuss more details from her emotionally disturbing history, her physical symptoms began to go away.

Eventually, under hypnosis, Anna O. described what Breuer thought was the original trauma that had precipitated her conversion reaction. She indicated that she had been spending a considerable amount of time caring for her seriously ill father. After many days of patiently waiting at her father’s bedside, Anna naturally grew somewhat resentful of the great burden that his illness had placed on her. These feelings of resentment were morally unacceptable to Anna O., who also experienced genuine feelings of love and concern for her father. One day, she was feeling particularly tired as she sat at her father’s bedside. She dropped off into what Breuer describes as a waking dream, with her right arm over the back of a chair. After she fell into this trancelike state, Anna O. saw a large black snake emerge from the wall and slither toward her sick father to bite him. She tried to push the snake away, but her right arm had gone to sleep. When Anna O. looked at her right hand, she found that her fingers had turned into little snakes with death’s heads.

The next day, when Anna O. was walking outside, she saw a bent branch. This branch reminded her of her hallucination of the snake, and at once her right arm became rigidly extended. Over time, the paralysis in Anna O.’s right arm extended to her entire right side; other symptoms began to develop as well. Recalling her hallucination of the snake and the emotions that accompanied it seemed to produce a great improvement in her condition. Breuer hypothesized that Anna O. had converted her original trauma into a physical symptom and was unable to recover until this traumatic memory was properly expressed and discussed. The way in which Breuer treated Anna O. eventually became known as the cathartic method.

Mind and Body

Anna O.’s case and the development of the cathartic method eventually led to widespread interest in conversion disorders, as well as in the other types of somatic disorders. Many mental health professionals began to suspect that all the somatic disorders involved patients who were unconsciously converting unpleasant or unacceptable emotions into somatic complaints. The manner in which somatic patients could misinterpret or misperceive their bodily sensations, however, remained rather mysterious. For example, how can an individual who has normal vision truly believe that he or she is blind? Research conducted by the team of Harold Sackheim, Johanna Nordlie, and Ruben Gur suggested a possible answer to this question.

Sackheim and his colleagues studied conversion patients who believed they were blind. This form of blindness, known as hysterical blindness, can be quite debilitating. Patients who develop hysterical blindness are generally unable to perform their usual functions and often report total loss of vision. When the vision of these patients was tested in an empirical fashion, an interesting pattern of results emerged. On each trial of a special visual test there were two time intervals, each of which was bounded by the sounding of a buzzer. During each trial, a bright visual target was illuminated during one of the intervals. Hysterically blind subjects were asked to report whether the visual target was illuminated during the first or the second interval. If truly blind subjects were to attempt this task, they should be correct by chance approximately 50 percent of the time. Most hysterically blind subjects were correct only 20 to 30 percent of the time, as if they were deliberately trying to demonstrate poor vision. A smaller number of hysterically blind subjects were correct on almost every trial, suggesting that they were actually able to see the visual stimuli before them.

Sackheim and his colleagues suggested that a two-state defensive reaction can explain these conflicting findings. First, the perceptual representations of visual stimuli are blocked from conscious awareness, so that subjects report that they are blind. Then, in the second part of the process, subjects continue to gain information from the perceptual representations of what they have seen. The performance of subjects on a visual task will then depend on whether the subjects feel they must deny access to the information that was gained during the second part of the visual process. If subjects believe that they must deny access to visual information, they will perform more poorly on a visual task than would be expected by chance. If subjects believe that they do not need to deny access to visual information, they will perform like a normal subject on a visual task. In other words, according to Sackheim and his colleagues, hysterically blind patients base their responses on the consequences of their behavior.

The way in which hysterically blind patients can manipulate their ability to see has led many scholars to question whether these patients are being truthful. Sackheim, Nordlie, and Gur, however, report that there are patients with lesions in the visual cortex (a part of the brain that processes visual information) who report that they are blind. These patients believe that they cannot see, even though they have normal eyes and can respond accurately to visual stimuli. They believe they are blind because they have trouble processing visual information. It is thus possible that an individual can have normal eyesight and still believe that he or she is blind. It is widely accepted in the psychological community that individuals with somatic disorders, aside from those with factitious disorder, truly and honestly believe that they have a physical symptom, even though they are actually quite healthy.

Metaphorical and Real Illnesses

The study of somatic disorders is an important area of concern for both medical professionals and social scientists. The somatic disorders are relatively common, and their great prevalence poses a serious problem for the medical establishment. A tremendous amount of professional energy and financial resources is expended in the needless medical treatment of somatic patients, who really suffer from emotional rather than physical difficulties. For example, when Robert Woodruff, Donald Goodwin, and Samuel Guze compared fifty patients with somatic symptom disorder with fifty normal control subjects in 1974, they found that the somatization patients had undergone major surgical procedures three times more frequently than had the normal controls. Since an effort was made to match the somatizing and control patients on the basis of their actual medical condition, one can assume that much of the surgery performed on the somatization patients was unnecessary.

On the other hand, there is also considerable evidence to indicate that many people who are genuinely ill are misdiagnosed with somatoform disorders. Charles Watson and Cheryl Buranen published a follow-up study of somatization patients in 1979 which found that 25 percent of the patients actually suffered from real physical disorders. It seems physicians who are unable to explain a patient’s puzzling medical problems may be tempted to label the patient prematurely with a somatic disorder. The diagnosis of a somatic disorder needs to be made with great caution, to ensure that a genuine medical condition will not be overlooked. There is also a need for further research into the causes and nature of the somatic disorders, so that they can be diagnosed in a more definitive fashion.

Further research is also needed to shed light on the ways in which somatic disorders can be treated. Most somatic patients are truly in need of assistance, for while their physical illness may be imaginary, their pain and suffering are real. Unfortunately, at this time, it is often difficult for mental health professionals to treat somatic patients effectively since these individuals tend to focus on their physical complaints rather than on their emotional problems. More research is needed on the treatment of somatoform patients so that they can overcome the psychological difficulties that plague them.

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