Somatization disorder: Course, Natural History and Prognosis

Course, Natural History and Prognosis

Somatization disorder is rare in children younger than 9 years of age. Characteristic symptoms of somatization disorder usually begin during adolescence, and the criteria are met by the mid-twenties. Somatization disorder is a chronic illness characterized by fluctuations in the frequency and diversity of symptoms. Full remissions occur rarely, if ever. Whereas the most active sympto-matic phase is in early adulthood, aging does not appear to lead to total remission. Pribor and colleagues (1994) found that women with somatization disorder older than 55 years did not differ from younger somatization patients in the number of somatic symp-toms. Longitudinal follow-up studies have confirmed that 80 to 90% of patients initially diagnosed with somatization disorder will maintain a consistent clinical picture and be rediagnosed similarly after 6 to 8 years. Women with somatization disorder seen in psychiatric settings are at increased risk for attempted suicide, although such attempts are usually unsuccessful and may reflect manipulative gestures more than intent to die. It is not clear whether such risk is true for patients with somatization disorder seen only in general medical settings.

Treatment

First, a “management” rather than a “curative” strategy is rec-ommended for somatization disorder. With the current absence of an identified definitive treatment, a modest, practical, em-pirical approach should be taken. This should include efforts to minimize distress and functional impairments associated with the multiple somatic complaints; to avoid unwarranted diagnos-tic and therapeutic procedures and medications; and to prevent potential complications including chronic invalidism and drug dependence.

In such regard, the general recommendations outlined for somatoform disorders should be followed (see Table 54.3). The patient should be encouraged to see a single physician with an understanding of and, preferably, experience in treating somatization disorder. This helps limit the number of unneces-sary evaluations and treatments. Most clinicians advocate rou-tine, brief, supportive office visits scheduled at regular intervals to provide reassurance and prevent patients from “needing to develop” symptoms to obtain care and attention. This “medical” management can well be provided by a primary care physician, perhaps with consultation with a psychiatrist. The study by Smith and colleagues (1986) demonstrated that such a regimen led to markedly decreased health care costs, with no apparent decre-ments in health or satisfaction of patients.

The foundations of treatment for this disorder are: 1) es-tablishment of a strong physician–patient relationship or bond; 2) education of the patient regarding the nature of the psychiatric condition; and 3) provision of support and reassurance.

The first component, establishing a strong therapeutic bond, is important in the treatment of somatization disorder. Without it, it will be difficult for the patient to overcome skepti-cism deriving from past experience with many physicians and other therapists who “never seemed to help”. In addition, trust must be strong enough to withstand the stress of withholding unwarranted diagnostic and therapeutic procedures that the pa-tient may feel are indicated. The cornerstone of establishing a therapeutic relationship is laid when the psychiatrist indicates an understanding of the patient’s pain and suffering, legitimizing the symptoms as real. This demonstrates a willingness to provide direct compassionate assistance. A full investigation of the medi-cal and psychosocial histories, including extensive record review, will illustrate to patients the willingness of the psychiatrist to gain the fullest understanding of them and their plight. This also provides another opportunity to evaluate for the presence of an underlying medical disorder and to obtain a fuller picture of psychosocial difficulties that may relate temporally to somatic symptoms.

Only after the diagnosis has been clearly established and the therapeutic alliance is firmly in place can the psychiatrist confidently limit diagnostic evaluations and therapies to those performed on the basis of objective findings as opposed to merely subjective complaints. Of course, the psychiatrist should remain aware that patients with somatization disorder are still at risk for development of general medical illnesses so that a vigilant per-spective should always be maintained.

The second component is education. This involves advis-ing patients that they suffer from a “medically sanctioned ill-ness”, that is, a condition recognized by the medical community and one about which a good deal is known. Ultimately, it may be possible to introduce the concept of somatization disorder, which can be described in a positive light (i.e., the patient does not have a progressive, deteriorating, or potentially fatal medical disorder, and the patient is not “going crazy” but has a condition by which many symptoms will be experienced). A realistic discussion of prognosis and treatment options can then follow.

The third component is reassurance. Patients with soma-tization disorder often have control and insecurity issues, which often come to the forefront when they perceive that a particular physical complaint is not being adequately addressed. Explicit reassurance should be given that the appropriate inquiries and investigations are being performed and that the possibility of an underlying physical disorder as the explanation for symptoms is being reasonably considered.

In time, it may be appropriate gradually to shift emphasis away from somatic symptoms to consideration of personal and interpersonal issues. In some patients, it may be appropriate toposit a causal theory between somatic symptoms and “stress”, that is, that there may be a temporal association between symp-toms and personal, interpersonal and even occupational prob-lems. In patients for whom such “insight” is difficult, behavioral techniques may be useful.

Even following such therapeutic guidelines, patients with somatization disorder are often difficult to treat. Attention-seek-ing behavior, demands and manipulation are common, necessi-tating firm limits and careful attention to boundary issues. This, again, is a management rather than a curative approach. Thus, such behaviors should generally be dealt with directively rather than interpreted to the patient.

Pharmacological and Other Somatic Treatments

No effective somatic treatments for somatization disorder itself have been identified.

Patients with somatization disorder may complain of anxi-ety and depression, suggesting readily treatable comorbid psy-chiatric disorders. As previously discussed, it is often difficult to distinguish actual comorbid conditions from aspects of somato-form disorder itself. Pharmacological interventions are likely to be helpful in the former but not in the latter. At times, such discrimination will be impossible, and an empirical trial of such treatments may be indicated. Patients with somatization disor-der are often inconsistent and erratic in their use of medications. They will often report unusual side effects that may not be ex-plained pharmacologically. This makes evaluation of treatment response difficult. In addition, drug dependence and suicide ges-tures and attempts are not uncommon.