Deciphering somatoform disorders

Somatoform disorder is a mental health condition where a person experiences physical symptoms without a medical cause, often stemming from psychological factors, causing significant distress and impairment. Research suggests that one out of six patients seen by general practitioners could be regarded as having a somatoform disorder, almost all in the non-specific category of undifferentiated somatoform disorder.

Here, Dr Cristina Lopez-Chertudi, a revered consultant clinical and health psychologist and systemic family psychotherapist deciphers these disorders.

What does somatoform mean?

The term "somatoform" refers to symptoms that mimic a physical illness but lack a medical cause. "Somatisation" involves an undue focus on physical symptoms while ignoring psychological issues. It is considered a type of 'illness behaviour' where psychological distress is expressed through physical symptoms, prompting individuals to seek medical attention.

For those trained in the Western medical tradition, the separation of mind and body in these definitions is typically unproblematic. However, such labels may reinforce dualism. Traditionally, medicine has viewed illnesses as resulting from disease pathology, while psychiatry has seen somatic complaints are based purely on psychopathology.

Presentation of patients with somatoform

Patients with somatoform presentations have been regarded as:

• Having a tendency to be poor historians.
• Giving exaggerated and dramatic descriptions of symptoms.
• Playing down or denying any psychosocial links with symptoms.
• Being convinced they have an organic illness.
• Having difficulty in expressing emotion.
• Having recurrent depressive disorder and a long-standing difficulty with personal relationships and may misuse substances.

These issues are often linked to an emotionally deprived childhood and childhood physical and sexual abuse. Some patients may present with general disturbances of personality.

Why was this category introduced?

The category of somatoform disorders was introduced into DMS–III to accommodate those patients who had medically unexplained somatic symptoms and too few psychological symptoms to merit an alternative psychiatric diagnosis. The ICD–10 classified them within a broader category of neurotic, stress-related and somatoform disorders. 

Somatoform disorders include a heterogeneous group of diagnoses united by their tendency to present with somatic complaints. In DSM-III-R these included somatisation disorder, hypochondriasis, body dysmorphic disorder, conversion disorder, and chronic pain disorder. However, this classification was insufficient for clinical use. Consequently, DSM-IV introduced the broader category of undifferentiated somatoform disorder. This non-specific diagnosis, which essentially re-labels the patient's own complaints, has become the most common somatoform disorder.

There have been core changes in the diagnostic classification criteria of somatoform disorders both in the DSM-5 and the ICD-11 to include specific psychological criteria such as health anxiety, catastrophising, or high time or energy devoted to the preoccupation with somatic symptoms, reassurance seeking, body checking, a self-concept of bodily weakness, avoidance behaviour, and negative affect.

Are there any limitations to the somatoform disorder concept?

The somatoform disorder concept has a main theoretical limitation which is the questionable aetiological assumption of psychogenesis (the cause of the symptoms relates to psychological difficulties). Psychologisation describes the emphasis on psychological factors where there may not be enough evidence to justify them. It can lead to misdiagnosis, inappropriate treatment and unnecessary psychological distress. 

In complex cases reflecting a multi-factorial aetiology, a psychological diagnosis can offer an explanation for the inexplicable by medical means. The main practical limitation of the somatoform disorder concept is that the psychogenic implication of the diagnosis is simply unacceptable to many patients, making it a poor basis for collaborative management. In addition, the labelling of a somatic presentation as a somatoform disorder may lead to the underdiagnosis of depression. As a result, it remains a difficult taxonomic challenge in need of significant revision given that current classifications do not correspond with clinical realities

Due to social and cultural values, people today are more “tuned in” to their bodies, more sensitive to bodily signals, and more likely to attribute symptoms to organic diseases. This rise in illness attribution may be linked to a weakening of medical authority, a strengthening of patient rights, and increasing media influence, resulting in an intolerance of disease. 

The overall aim of offering psychological perspectives when managing medically unexplained symptoms is that the person changes their view from that of their experience being the result of failed medical procedures to beginning to understand that they can have some control to minimise the impact of symptoms in their lives. 

What can be done to further understand these disorders?

The cause of somatic symptoms without disease pathology is not well understood. Evidence suggests it is likely multifactorial, involving physiological (or minor pathological), psychological, and social factors. Greater emphasis should be placed on understanding and managing patients' symptoms as significant in their own right, rather than just indicators of a diagnosis. Patients' defensiveness about emotional problems might be a response to the threat of stigmatisation, therefore, any effective psychologically-based treatment needs to be integrated into medical care.

Medically unexplained symptoms and somatoform disorders can be alleviated with appropriate cognitive-behavioural therapies. These therapies aim to change specific illness behaviours and belief systems, while also addressing the relational aspects affected by these complex clinical presentations and the needs of family members.

If you would like to learn more about somatoform disorders or the psychological impact of physical illnesses book a consultation with Dr Lopez-Chertudi via her Top Doctors profile today.