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11 Articles in Volume 17, Issue #4
Algopathy—Acknowledging the Pathological Process of Pain Chronification
Are Abuse-Deterrent Opioid Products A Double-Edged Sword?
CMS Tackles Opioid Prescribing
How do you handle end-of-life care in a patient who does not know they are dying?
Letters to the Editor: Functional Medicine, Naloxone, Hormone Testing, CRPS
Look at the Patient’s Life Story, Then Implement a Management Plan
Myofascial Pain: Overview of Treatment Options
Pain in Parkinson’s Disease: A Spotlight on Women
Parkinson's Initiative—Women and PD Talk
Patient in Pain? When to Refer for Physical Therapy
Somatic Symptom Disorder: DSM-5's Removal of Mind-Body Separation

Somatic Symptom Disorder: DSM-5's Removal of Mind-Body Separation

A newly conceptualize diagnosis of somatic symptom disorder appears in the DSM-5; this updated terminology is the focus of this month's A to Z Mental Health Series.

The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)1 updated its terms for somatic symptoms from somatoform disorders to somatic symptom disorder (SSD). About 80% of the general population reports somatic symptoms weekly.2 Unexplained somatic symptoms account for about 25% to 50% of presentations in both primary care and secondary consultations.3 However, these somatic symptoms are no longer considered “disordered” unless they are associated with significant distress and impairment (eg, abnormal thoughts, feelings, and behaviors).

The key change in the DSM-5 criteria is that an SSD diagnosis no longer requires that the somatic symptoms be medically unexplained. According to Dimsdale et al, the DSM-5 “deemphasizes the centrality of medically unexplained symptoms and defines the disorder on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms.”4 It follows that the absence of a medical explanation for the somatic symptoms’ existence is not enough nor an appropriate criterion to diagnose a mental disorder.

Somatic symptom disorder is newly defined in the DSM-5.

Many factors contribute to SSD, such as genetic/biological vulnerability (increased sensitivity to pain); early traumatic experiences (eg, violence, abuse, and deprivation); learned behavior (eg, experiences from prior illness that were reinforced rather than other ways of expressing distress); and, cultural/social norms (devalue and stigmatize psychological suffering compared to physical suffering).5 The new chapter of SSD contains several disorders, including illness anxiety (or hypochondriasis), functional neurological symptoms (or conversion disorder), factitious disorder, and psychological factors affecting other medical conditions, such as pain.3 These newly conceptualized diagnoses have proven more useful for primary care and medical specialists than for mental health clinicians, perhaps because patients view the reporting of somatic symptoms  as a more appropriate route for seeking treatment.6

The precise prevalence of these disorders is unknown, but estimates project 5% to 7% of the general population is affected by SSD.7 The frequency of the diagnosis is believed to be higher than the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition’s (DSM-IV) somatization disorder (<1%) and lower than that of undifferentiated somatoform disorder (~19%).2,8 The 1- to 2-year prevalence estimates of illness anxiety disorder in community surveys and population-based samples range from 1.3% to 10%;9,10 and the 6-month to 1-year prevalence rates in ambulatory medical populations are 3% to 8%.11,12

Referral incidence to neurology clinics for functional neurological symptom disorder is approximately 5%; and for individual persistent conversion disorder symptoms, the incidence is around 2 to 5/100,000 per year.13,14 It is estimated that about 1% of people have symptoms that meet the criteria for factitious disorder in hospital settings.15,16 According to private insurance billing data in the United States, the prevalence of psychological factors affecting other medical conditions is more common than the other SSDs.17

There is sparse research on SSD in chronic pain patients. The lifetime rates of the diagnoses among chronic low back pain patient samples are low, and are comparable to rates found in community and primary care settings.18 The lifetime prevalence rate of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) somatoform pain disorder was 34% with a 6-month rate of 17%, which dropped to 12% and 5%, respectively, when the new criterion for the DSM-IV was applied to the diagnoses.19

Another study found that more than 95% of patients with chronic low back pain in an intensive rehabilitation setting had SSD.20 There is also evidence to suggest a correlation between pain intensity and the presence of somatization and hypo- chondriasis.21 The frequency of SSD in chronic pain patients varies from 0% to 53%.22-24

More specifically, the frequency of conversion disorder ranges from 2% to 38%.23,24 The discrepancy may be due to the subjectivity of pain, but it may also reflect how the diagnostic classification of somatization has changed over time.

The History of Somatization and Chronic Pain

The philosophical, political, and religious meanings of pain have defined individual suffering throughout history. Examples of pain, such as flogging, crucifixions, and walking barefoot through the scorching desert, appear in the oldest known religious texts. Before the 17th century,  people believed that pain symptoms, such as pseudoseizures and fits, were manifestations of evil, magic, or demons. Sufferers sought relief from sorcerers, shamans, priests, or priestesses who used herbs, rites, and ceremonies as treatments.  

In 1697, Sydenham wrote that hysterical patients often had pain and were “miserably tormented with hysterical clavus [thickening of the skin] in which there is a most vehement pain in the head.”25 In the 18th century, medical scholars and practitioners believed the motor variety of hysteria (eg, paralysis) was influenced by various reflexes, darting widely about the body. Dubois D’Amiens (1833), Brodie (1837), and Landouzy (1846) further explored the relationship between hysteria and pain and found that pain was present independent of primary symptoms.26 The 19th century became the era of motor hysteria, with an epidemic of women having brief periods of paralysis (unable to move legs and unclench fists).

The focus on functional illness shifted from the easily disproved motor side of the central nervous system to the harder-to-disprove sensory side. Around World War I, 2 new sensory symptoms—functional chronic pain and fatigue—arose and became pervasive. In the 20th century, these psychosomatic symptoms became more problematic and represented the bulk of somatization.27

Today, the media broadcasts the “the disease of the month,” which is based on the notion that consumers know more about their bodies than doctors. This behavior encourages the public to fixate on new diseases and causes a “somatic hypervigilance,” which may cause distress.28 Once medicine is able to disprove the latest sensory symptoms, new psychosomatic symptoms arise.27

Why Was Somatic Symptom Disorder Redefined?

The diagnosis of somatoform disorder in the DSM-IV had several shortcomings that were identified in past research: the terminology was unacceptable to patients; the diagnosis was inherently dualistic; the disorders were not coherent together; the diagnoses were incompatible with other cultures; and the diagnoses were ambiguous, unreliable, and lacked clarity.29 Until now, somatoform disorder was believed to represent only the “tip of the iceberg” of people who somatize.30 It was thought that somatization had a spectrum of severity—somatoform disorder was at one extreme, and subsyndromal forms were at intermediate and lower levels of complaint.31

Thus, the DSM-5 replaced somatoform disorders with SSD and made significant changes to the criteria (Table 1). In the DSM-IV, there was a great deal of overlap across the somatoform disorders and a lack of clarity about the boundaries of diagnoses, which made it difficult to distinguish and use. The DSM-5 recognized the overlap of diagnoses, so it reduced the total number of disorders and their subcategories. Several DSM-IV disorders, such as somatoform, undifferentiated somatoform, somatization, and pain disorders, have been recategorized in an SSD dimensional scale ranging from mild to severe.

The SSD criteria no longer require a specific number of complaints from 4 symptom groups. Instead, the DSM-5 criteria emphasize the degree to which a patient’s thoughts, feelings, and behaviors about somatic symptoms are disproportionate or excessive, such as in cases of heart disease or cancer. Thus, the diagnosis of SSD can occur in the context of a serious medical illness, much like depression. This change emphasizes how the DSM-5 removed the mind-body separation implied in the DSM-IV, and encourages providers to make a comprehensive assessment and use clinical judgment.

Patients who suffer from SSD are often given inappropriate diagnoses, treated for non-existent depression, and exposed to multiple, superfluous interventions.5 In addition, the International Statistical Classification of Diseases and Related Health Problems (ICD-10) still defines somatization as “repeated presentation of physical symptoms, together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis.”32 Unexplained somatic symptoms also often are classified in medicine as functional somatic syndromes.33 Furthermore, providers may still encounter some of the old diagnoses in patients’ charts and would benefit from a review of how the old diagnoses are distinct from one another.

It is common for providers to use the terms malingering, factitious disorder, and somatization interchangeably. This is a group of illnesses where the patient reports symptoms that have no medical explanation. When providers see these diagnoses, there is a tendency to jump to the conclusion that a patient is “faking it,” often without gathering sufficient evidence to support that conclusion. These diagnoses raise uncertainty about whether the patient is deliberately misleading the physician, and agreeing to unnecessary treatments and diagnostic tests. Table 2 shows the distinction between these old terms.

Assessing for Somatization

Inventories have measured somatization in the past, including the hypochondriasis scale of the Minnesota Multiphasic Personality Inventory (MMPI)34 and the Rating Scale for Somatic Symptoms.35 Other useful scales include the Symptom Checklist-90-R (evaluates a broad range of psychological symptoms), the Illness Behavior Questionnaire (delineates patients’ attitudes, affects, and attributions related to illness), the Illness Attitude Scale (assesses hypochondriacal fears and beliefs), the Primary Care Evaluation of Mental Disorders (covers physical symptoms that patients present to primary care providers), the Whitney Index (screens for hypochondriasis), the Health Attitude Survey (focuses on dissatisfaction with health and distress), and the Somatosensory Amplification Scale (measures sensitivity to bodily sensations).21

Pain remains part of the SSD spectrum as a specifier. In 1996, the International Association for the Study of Pain defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” There are several key functions one should consider assessing when dealing with pain, including pain intensity, pain quality, mood, personality characteristics, beliefs, coping, functioning, and quality of life. Table 3 delineates some of the most widely used instruments to measure aspects of pain.36 The validity and reliability of the measure may be considered by the clinician, as well as the thesis used for testing. Determining which scale to select should be guided by the intended purpose and its ease of use by the patient. Finally, the same scale should be used consistently throughout the case process.

SSD Treatment

The diagnosis of SSD offers practitioners few specific guidelines about treatment beyond clinical management to minimize use and avoid adverse effects caused by a medication.37 However, antidepressants reportedly have analgesic properties in the treatment of SSD.38 Past structured, evidence-based reviews have also concluded that SSD improves with pain treatment.21

Cognitive-behavioral approaches have become widely accepted in the management of chronic pain. Research strongly supports cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT), among other interventions, for the treatment of chronic pain, according to Division 12 of the American Psychological Association’s Society of Clinical Psychology.39,40 Behavioral interventions also show cost-effectiveness for managing chronic pain.41

Psychological treatment modestly improves pain and emotional functioning, but there is insufficient evidence to recommend a specific therapeutic approach (eg, behavioral therapy, CBT, ACT, psychodynamic therapy, stress management, emotional disclosure, biofeedback, or hypnosis).42-46 Although some psychological interventions may effectively apply to all types of chronic pain, other psychological interventions may have greater effectiveness if targeted toward specific pain types or specific aspects of chronic pain conditions.

In the next installment of A to Z Mental Health, the author will discuss Schizophrenia Spectrum.

 

 

Last updated on: June 15, 2017
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