Understanding Somatoform Disorder
Somatoform/psychosomatic disorder, also known as somatic symptom disorder (SSD), is a mental health condition that causes an individual to experience physical bodily symptoms in response to psychological distress.
Young people particularly find it difficult to express their feelings and because of this, it is likely that psychological distress is expressed as physical (somatic) symptoms. In light of this, it is thought that up to 10% of children in the UK that complain of aches and pains (stomach aches, joint pains, headaches, etc.) are given a diagnosis of 'medically unexplained symptoms (MUS)'. It also impacts a large proportion of adults who attend the GP.
The mind and the body are very much connected and there are many ways in which physical and psychological symptoms interact. For patients who repeatedly present with physical symptoms that are medically unexplained, it is vital to consider underlying psychological issues. This could include the presence of co-existing disorders such as:
There are different types of somatoform disorder, including chronic fatigue syndrome (CFS) and dissociative (conversion) disorder, which you can read more about in this article. There are different ways of managing psychosomatic disorders, including:
- Individual psychological work
- Family therapy
- Sleep hygiene management and dietary advice
To read more about the best treatment for somatoform disorder, please read our full article. We also discuss the common signs and symptoms and how to spot a patient who may need further assessment.
Types of somatoform disorder
It is important to remember this mental health disorder can present itself in different ways. This includes:
Persistent somatoform pain disorder
- The predominant complaint is of persistent, severe and distressing pain
- It cannot be explained fully by a physiological process or a physical disorder
- It occurs in association with emotional conflict or psychosocial problems
- The result is usually a marked increase in support and attention, either personal or medical
- A partial or complete loss of the normal integration between memories of the past, awareness of identity, immediate sensations and control of bodily movements
- Medical examination does not reveal the presence of any known physical or neurological disorder
- There is evidence of clear association in time with a stressful life event and problems
- The possibility of the later appearance of serious physical or psychiatric disorders should always be kept in mind
Chronic fatigue syndrome (neurasthenia)
- Persistent and distressing complaints of increased fatigue after mental effort
- Persistent and distressing complaints of bodily weakness and exhaustion after minimal effort
- At least two of: muscular aches/pains, dizziness, tension headaches, sleep disturbance, inability to relax, irritability, dyspepsia
- Autonomic or depressive symptoms present are not sufficiently persistent and severe enough to fulfil the criteria for any of the more specific disorders
- Considerable cultural variations occur in the presentation of this disorder
There are many different reasons why someone could develop somatoform disorder. These fall into three main categories:
Experience of physical illness, traits of vulnerable and sensitive personality, concerns about peer relationships, high achievement orientation.
Includes physical and mental health problems, parental somatisation, emotional over-involvement, limited emotional 'vocabulary'.
Includes academic pressures, teasing and bullying.
Recognising a patient with somatoform disorder
Main clinical features of this condition include:
- Persistent abdominal pain, headaches, joins pains, etc.
- Poor concentration, dizziness and moodiness
- Continual worry over decreasing physical health
- Onset of an acute flu-like illness or glandular fever
- Complete loss of bodily sensation or movements
- Loss or disturbance of motor function and pseudo-seizures (seizures that do not have the typical features of an epileptic fit and are not accompanied by an abnormal EEG)
- Symptoms usually occur after a traumatic event and last for a few weeks or months
- Generally occurs more commonly in females than males
- Symptoms usually start in childhood or early adolescence
Abdominal pains are more common in younger children whilst headaches would affect older children and adolescents, and conversion symptoms tend to occur around the age of 16.
Surveys from various countries have found that approximately 1 in 4 children complain of at least one set of somatic symptoms weekly or fortnightly.
Consider that a child has somatoform disorder if:
- There is a time relationship between psychosocial stressors and physical symptoms
- The nature and severity of the symptom or its resulting handicap is out of keeping with the pathophysiology
- There is a concurrent psychiatric disorder
Family GPs or paediatricians are likely to be the first port of call for most children. Reassurance that there is no treatable medical disorder will often relieve concerns enough for the child to improve without the need for further intervention. However, sometimes symptoms persist.
Referral to a mental health service needs to be done in a sensitive manner with acknowledgement of the symptoms, as many children and families in these circumstances might fear that they are not being taken seriously and that referral to mental health services means their physical symptoms are not believed.
Psychiatric assessment would include:
- Developmental and psychiatric history being taken
- Detailed school history investigated
- Mental health examination takes place
It is important to consider sending a patient for a psychiatric assessment if:
- Physical symptoms suggest a medical condition however, no medical disease, substance misuse or another mental disorder can be found to account for the symptoms
- The symptoms cause significant distress or impairment in social, occupational or other areas of functioning
- Physical symptoms are not intentionally produced
- The patient often resists attempts to discuss the possibility of psychological causation
General management strategies for GPs
- Make an effort to understand the family's beliefs about the illness, how convinced they are and how they feel about referral to mental health services
- Do not question the reality of the symptoms
- Acknowledge that the illness is disrupting the patient’s life and affecting the family’s functioning
- Discuss physical concerns, results of physical investigations and physiological mechanisms contributing to the symptoms e.g. contractures caused by immobilisation
- Inform family about the high prevalence of MUS (up to 10%) as this might be reassuring about the absence of an organic cause
- Be reassuring and non-judgemental when informing parents about the diagnosis of somatoform disorder or other psychiatric disorder
- Emphasise that it may take time to recover but the majority of young people do very well if they receive the correct treatment
Assessment and initial treatment is usually initiated by the GP or paediatrician. It is recommended to use the bio-psycho-social framework and when the symptoms do not improve, a psychiatric referral should be made.
Specific management strategies
Individual psychological work
- Motivational techniques
- Encouraging self-monitoring
- Developing techniques to deal with specific symptoms and impairments as well as developing active, problem-focused coping strategies and attitudes
- Encouraging self-monitoring of pain
- Reinforcing well behaviour
- Developing healthy coping skills such as relaxation, positive self-talk
- Problem solving skills
- Shifting parents' focus from physical symptoms to pleasant joint activities and symptom free periods
- Liaison with school and social services
- Sleep hygiene and dietary advise
- Medication - there is no medication specifically licensed for somatoform disorder, but some could be used for co-morbid disorders e.g. selective serotonin reuptake inhibitors (SSRIs) for associated depression or anxiety
The aim of the treatment is to develop a partnership with the child, family and all professionals involved. Hospitalisation could be considered only in severe cases and when outpatient treatment has not been successful.
Priory’s national network of hospitals and outpatient wellbeing centres are extremely well placed to treat mental health conditions such as this, and we have experts who specialise in somatoform disorder.