Etiology - Somatoform Disorders

ETIOLOGY

Psychosocial Theories

Psychosocial theorists believe that people with somatoform disorders keep stress, anxiety, or frustration inside rather than expressing them outwardly. This is called internalization. Clients express these internalized feelings and stress through physical symptoms (somatization).

Both internalization and somatization are unconscious defense mechanisms. Clients are not consciously aware of the process, and they do not voluntarily control it.

People with somatoform disorders do not readily and directly express their feelings and emotions verbally. They have tremendous difficulty dealing with interpersonal conflict. When placed in situations involving conflict or emotional stress, their physical symptoms appear to worsen. The worsening of physical symptoms helps them to meet psychologic needs for security, attention, and affection through primary and secondary gain (Hollifield, 2005). Primary gains are the direct external benefits that being sick provides, such as relief of anxiety, conflict, or distress. Secondary gains are the internal or personal ben-efits received from others because one is sick, such as attention from family members and comfort measures (e.g., being brought tea, receiving a back rub). The person soon learns that he or she “needs to be sick” to have their emotional needs met.

Somatization is associated most often with women, as evidenced by the old term hysteria (Greek for “wandering uterus”). Ancient theorists believed that unexplained female pains resulted from migration of the uterus through-out the woman’s body. Psychosocial theorists posit that increased incidence of somatization in women may be related to various factors:

·    Boys in the United States are taught to be stoic and to “take it like a man,” causing them to offer fewer physi-cal complaints as adults.

·    Women seek medical treatment more often than men, and it is more socially acceptable for them to do so.

·    Childhood sexual abuse, which is related to somatiza-tion, happens more frequently to girls.

·    Women more often receive treatment for psychiatric disorders with strong somatic components such as depression.

Biologic Theories

Research has shown differences in the way that clients with somatoform disorders regulate and interpret stimuli. These clients cannot sort relevant from irrelevant stimuli and respond equally to both types. In other words, they may experience a normal body sensation such as peristal-sis and attach a pathologic rather than a normal meaning to it (Hollifield, 2005). Too little inhibition of sensory input amplifies awareness of physical symptoms and exag-gerates response to bodily sensations. For example, minor discomfort such as muscle tightness becomes amplified because of the client’s concern and attention to the tight-ness. This amplified sensory awareness causes the person to experience somatic sensations as more intense, noxious, and disturbing (Andreasen & Black, 2006).

Somatization disorder is found in 10% to 20% of female first-degree relatives of people with this disorder. Conver-sion symptoms are found more often in relatives of people with conversion disorder. First-degree relatives of those with pain disorder are more likely to have depressive disor-ders, alcohol dependence, and chronic pain (APA, 2000).

Cultural Considerations

The type and frequency of somatic symptoms and their meaning may vary across cultures. Pseudoneurologic symptoms of somatization disorder in Africa and South Asia include burning hands and feet and the nondelu-sional sensation of worms in the head or ants under the skin. Symptoms related to male reproduction are more common in some countries or cultures—for example, men in India often have dhat, which is a hypochondriacal concern about loss of semen. Somatization disorder is rare in men in the United States but more common in Greece and Puerto Rico.

Many culture-bound syndromes have corresponding somatic symptoms not explained by a medical condition (Table 19.1). Koro occurs in Southeast Asia and may be related to body dysmorphic disorder. It is characterized by the belief that the penis is shrinking and will disap-pear into the abdomen, causing the man to die. Falling-out episodes, found in the southern United States and the Caribbean islands, are characterized by a sudden collapse during which the person cannot see or move. Hwa-byung is a Korean folk syndrome attributed to the suppression of anger and includes insomnia, fatigue, panic, indiges-tion, and generalized aches and pains. Sangue dormido (sleeping blood) occurs among Portuguese Cape Verde Islanders who report pain, numbness, tremors, paralysis, seizures, blindness, heart attacks, and miscarriages. Shenjing shuariuo occurs in China and includes physical and mental fatigue, dizziness, headache, pain, sleep dis-turbance, memory loss, gastrointestinal problems, and sexual dysfunction (Mojtabai, 2005).

Treatment

Treatment focuses on managing symptoms and improving quality of life. The health care provider must show empathy and sensitivity to the client’s physical complaints. A trusting relationship helps to ensure that clients stay with and receive care from one provider instead of “doctor shopping.”

For many clients, depression may accompany or result from somatoform disorders (Ferrari, Galeazzi, Mackinnon, Rigatelli, 2008). Thus, antidepressants help in some cases. Selective serotonin reuptake inhibitors such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) are used most commonly (Table 19.2).

For clients with pain disorder, referral to a chronic pain clinic may be useful. Clients learn methods of pain management such as visual imaging and relaxation. Ser-vices such as physical therapy to maintain and build mus-cle tone help to improve functional abilities. Providers should avoid prescribing and administering narcotic anal-gesics to these clients because of the risk for dependence or abuse. Clients can use nonsteroidal anti-inflammatory agents to help reduce pain.

Involvement in therapy groups is beneficial for some people with somatoform disorders. Studies of clients with somatization disorder who participated in a structured cognitive-behavioral group showed evidence of improved physical and emotional health 1 year later (Hollifield, 2005). The overall goals of the group were offering peer support, sharing methods of coping, and perceiving and expressing emotions. Abramowitz and Braddock (2006) found that clients with hypochondriasis who were willing to participate in cognitive-behavioral therapy and take medications were able to alter their erroneous perceptions of threat (of illness) and improve. Cognitive-behavioral therapy also produced significant improvement in clients with somatization disorder (Allen, Woolfolk, Escobar, Gara, & Hamer, 2006).

In terms of prognosis, somatoform disorders tend to be chronic or recurrent. With treatment, conversion dis-order often remits in a few weeks but recurs in 25% of clients. Somatization disorder, hypochondriasis, and pain disorder often last for many years, and clients report being in poor health. People with body dysmorphic disorder may be preoccupied with the same or a different perceived body flaw throughout their lives (APA, 2000).