Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder?

When physical symptoms are caused by mental (psychological) or emotional factors it is called somatisation. For example, many people have occasional headaches caused by mental stress. But, stress and other mental health problems can cause many other physical symptoms such as:

• Chest pains
• Tiredness
• Dizziness
• Back pain
• Feeling sick (nauseated)

The term psychosomatic disorder means something similar to somatisation but includes other things. See separate leaflet called Psychosomatic Disorders for more details.

The relationship between the mind and body is complex and not fully understood. When we somatise, somehow the mental or emotional problem is expressed partly, or mainly, as one or more physical symptoms. However, the symptoms are real and are not imagined. You feel the pain, have the diarrhoea, etc.

How common is somatisation?

It is common. Sometimes we can relate the physical symptoms to a recent stress or mental health problem. For example, you may realise that a bout of neck pain or headache is due to stress. Anxiety and depression are also common reasons to develop physical symptoms such as a 'thumping heart' (palpitations), aches and pains, etc. Often the physical symptoms go when emotional and mental factors ease. However, often we do not realise the physical symptom is due to a mental factor. We may think we have a physical disease and see a doctor about it.

Some doctors prefer to use the term functional when no known physical cause can be found for a physical symptom. A functional symptom means a function of the body is faulty (for example, there may be pain or diarrhoea) but we don't know the cause. The cause may be due to mental factors (somatisation), physical factors not yet discovered, or a combination of both. Another term which is sometimes used for such symptoms is medically unexplained symptoms.

The somatoform disorders are the extreme end of the scale of somatisation. So, the physical symptoms persist long-term, or are severe but no physical disease can fully explain the symptoms. Somatoform disorders include:

• Somatisation disorder
• Hypochondriasis
• Conversion disorder
• Body dysmorphic disorder
• Pain disorder

They are classed as mental health disorders, as the cause of the symptoms is thought to be mental factors. However, they cannot be fully explained by depression, substance abuse, or other recognised mental health disorders. There has recently been a renaming of these mental health disorders and they have all been put under the main heading of 'somatic symptom disorder'. Doctors used to make the diagnosis based on strict patterns of symptoms. However, they now rely much more on how much the symptoms affect the person's life and well-being. It is also recognised that somatic symptom disorder can occur in people who have physical diseases such as arthritis or cancer.

Note: this leaflet has retained the old headings where necessary. They probably still have some use in understanding the different types of symptoms that occur.

People with somatoform disorders usually disagree that their symptoms are due to mental factors. They are convinced that the cause of their symptoms is a physical problem.

People with this disorder have many physical symptoms from different parts of the body - for example:

• Headaches
• Feeling sick (nauseated)
• Tummy (abdominal) pain
• Bowel problems
• Period problems
• Tiredness
• Sexual problems

The main symptoms may vary at different times. Affected people tend to be emotional about their symptoms. So they may describe their symptoms as 'terrible', 'unbearable', etc and symptoms can greatly affect day-to-day life. The disorder persists long-term although the symptoms may wax and wane in severity.

The cause is not known. It may have something to do with an unconscious desire for help, attention or care. It runs in some families. The disorder usually first develops between the ages of 18 years and 30 years. More women than men are affected.

It is difficult for a doctor to diagnose somatisation disorder. This is because it is difficult to be sure that there is no physical cause for the symptoms. So, people with this disorder tend to be referred to various specialists, and have many tests and investigations. However, no physical disease is found to account for the symptoms.

Hypochondriasis

This is a disorder where people fear that minor symptoms may be due to a serious disease. For example, that a minor headache may be caused by a brain tumour, or a mild rash is the start of skin cancer. Even normal bodily sensations such as 'tummy rumbling' may be thought of as a symptom of serious illness. People with this disorder have many such fears and spend a lot of time thinking about their symptoms.

This disorder is similar to somatisation disorder. The difference is that people with hypochondriasis may accept the symptoms are minor but believe or fear they are caused by some serious disease. Reassurance by a doctor does not usually help, as people with hypochondriasis fear that the doctor has just not found the serious disease.

Conversion disorder is a condition where a person has symptoms which suggest a serious disease of the brain or nerves (a neurological disease) - for example:

• Total loss of vision (severe sight impairment).
• Deafness.
• Weakness, paralysis or numbness of the arms or legs.

The symptoms usually develop quickly in response to a stressful situation. You unconsciously convert your mental stress into a physical symptom.

Conversion disorder tends to occur between the ages of 18 years and 30 years. Symptoms often last no longer than a few weeks but persist long-term in some people. In many cases there is only ever one episode and no treatment is needed once symptoms have gone. Some people have repeated episodes of conversion disorder from time to time.

Body dysmorphic disorder

Body dysmorphic disorder is a condition where a person spends a lot of time worried and concerned about their appearance. See separate leaflet called Body Dysmorphic Disorder for more details.

Pain disorder

Pain disorder is a condition where a person has a persistent pain that cannot be attributed to a physical disorder.

Somatoform disorders can affect anyone of any age. The exact number of people affected is difficult to determine, as many cases are probably not diagnosed. Somatisation disorder is thought to be quite rare, perhaps affecting about 1 in 1,000 people. Hypochondriasis and body dysmorphic disorder are perhaps more common.

It is not clear why some people develop somatoform disorders. Genetic 'makeup' and environmental factors both probably play a part. Genetic makeup is the material inherited from your parents which controls various aspects of your body. This genetic makeup combined with factors such as how you were brought up, your parental and peer influences, etc, may all contribute.

Somatoform disorders are more common in people who abuse alcohol and drugs. However, drugs and alcohol may be factors in both cause and effect. For example, some people may turn to alcohol or other drugs to ease the distress of their somatic symptoms. On the other hand, excess alcohol or illicit drugs may make the symptoms worse.

Treatment is often difficult, as people with somatisation disorders commonly do not accept that their symptoms are due to mental (psychological) factors. They may become angry with their doctors who cannot find the cause for their symptoms. Another difficulty is that people with somatisation disorder, like everyone else, will develop physical diseases at some point. So, every new symptom is a challenge to a doctor to know how far to investigate.

Many people who are thought to have a somatoform disorder also have other mental health problems such as depression, anxiety or substance abuse. Treatment of these other mental health problems may improve the situation.

If the person can be convinced that mental factors may contribute to, or cause, the physical symptoms then they may accept a talking treatment. Talking treatments, such as cognitive behavioural therapy, may help people to understand the reasons behind symptoms. Such treatments aim to change any false beliefs the person may have and help them identify and deal with emotional issues.

Medication does not have much of a role except if the disorder is associated with underlying anxiety or depression. Some specific conditions such as body dysmorphic disorder and pain disorder have been helped by medicines called selective serotonin reuptake inhibitors (SSRIs).

Copyright © American Academy of Family Physicians

This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.