Somatoform Disorders and Disability
Somatoform Disorders are a broad category of psychological disorders which are characterized by diverse physical complaints with no detectable organic causes.
Most people experience minor somatoform symptoms at some time in their lives. For example, when someone is stressed and over worked, they may feel like their “stomach is in knots” or that their “head is pounding”. What they are actually feeling is a painful or unpleasant physical response to a psychological or emotional state. These symptoms are subjective; we can describe the feeling of discomfort to someone but there is no objective medical test that can confirm their validity. Most of us are aware of the relationship between these physical symptoms and our psychological states. We understand the reason we feel the way we do and we do not impart medical significance on the discomfort we feel unless there is a medical problem. However, for some individuals, these physical symptoms of discomfort persist to the stage where they begin to cause the individual significant distress or impairment in their social and occupational life. These individuals are suffering from a serious mental illness called Somatization Disorder, a specific type of Somatoform Disorder.
Somatization Disorder is a specific psychological disorder that begins before age 30, and is characterized by a combination of pain, gastrointestinal, sexual and pseudoneurological complaints.
The diagnostic criteria for Somatization Disorder is quite rigid. There are four requirements that need to be met. To make the diagnosis, the American Psychiatric Association’s current manual (DSM – IV) first requirement is the presence of at least four physical symptoms that would normally be suggestive of a general medical condition. The individual must suffer from at least four types of pain (headaches, joint pain, lower back pain), two gastrointestinal symptoms (as nausea, diarrhea or food intolerance), one sexual symptom (sexual indifference), and one pseudoneurological symptom (such as impaired coordination, paralysis or weakness).
The second diagnostic requirement is that there must be a history of physical complaints that begin prior to age 30 and last over several years. The individual must have sought medical or health related treatment for these complaints and as a result of their physical conditions there has been an impairment in the individual’s social or occupational functioning.
The third diagnostic requirement is that the individual’s symptoms after investigation cannot be fully explained by a known general medical condition or due to the direct effects of a substance (e.g., drug of abuse or a medication). When there is a related general medical condition, the physical complaints are in excess of what would be expected from the actual medical findings.
The fourth requirement is the most significant: these individuals do in fact feel the pain and disabling symptoms. These individuals are not feigning illness or malingering for secondary gain. In contrast to Factitious Disorders and Malingering, the physical conditions and symptoms the individual perceives are not intentional and not under the individual’s voluntary control.
Individuals who suffer from Somatization Disorder usually describe their complaints in colorful, exaggerated terms. The fainting spell they had will actually become a “loss of consciousness” as the years roll on. Often specific factual information is missing when you question them regarding their medical history. An individual may state that they were admitted to hospital for a myocardial infraction when actually they went to the emergency room and the electrocardiography tests showed no abnormality. The medical encounter is embelished as the years go by. When you request their medical history they will have seen many doctors and had many tests performed. The individual is very protective of their symptoms and will become very defensive when a medical professional states that there may be a psychological problem.
The social costs of Somatization Disorder are quite significant. These patients have spent more days in bed than patients with most major medical problems. Somatization Disorder is a chronic condition with a poor prognosis. These individuals suffer symptoms most floridly in adulthood and complete remission of symptoms is uncommon at any stage of life. Although the disorder runs a fluctuating course, patients are rarely asymptomatic. Due to the stigmatization and value judgments given to individuals who suffer from a mental illness, a sizable percentage of patients who have psychiatric distress seek medical care under the guise of a physical symptom and overuse our already thinly spread health resources.
Why would an individual want to live this way? It is beyond our comprehension as most of us loathe going to the doctor or having invasive medical procedures. Most of us are able to express our feelings and reactions to psychological distress. We verbalize, we seek counselling, we understand that we need help with our problems and do not feel ashamed for doing so. These individuals who suffer from Somatization Disorder verbalize their emotional and psychological discomfort through physical symptoms rather than words. The mind-body interaction is very powerful.
Individuals who are unwell usually receive sympathy from those around them. Usually illness brings support and attention from family and friends. This is one of the primary gains of Somatization Disorder. These individuals want positive attention because some how it is lacking in their life. For example, these individuals may have been physically or sexually abused as children, or grew up with harsh or inconsistent parenting and the only way the child felt loved or safe was when they were ill. The individual learned from a young age that a disabled person will receive concessions and special treatment. Their behavior may have been reinforced with sympathy and concern and being ill may have become an habitual way of dealing with psychological problems. Patients see themselves as being physically ill. These individuals chronically rely on physical symptoms that protect them from emotional discomfort. To accept the emotional roots of their illness would deprive them of the carefully constructed defences they have erected for their own self protection.
Eventually support networks begin to fade as the individual complains more about how sick they feel. Decreased social support is associated with increased medical care use as physicians become their auxillary social support network. These patients present formidable problems to doctors who often have to resist endless requests for costly investigations. Breakdown of the doctor-patient relationship often occurs with the patient seeking medical attention elsewhere. These new doctors repeat the same medical treatments and testing until they to become aware of the problem and suggest a psychological consult and the doctor-patient relationship breakdowns. This causes a never ending cycle of medical treatment.
The pain is real to the individual. The pain is disabling to the individual. Stigmatization of psychological illness and poor third-party reimbursement has become part of the problem. With the increasing need for fiscal restraint, most of these individuals have slipped through the cracks. With most disability programs focussing on objective physical symptoms as criteria for disability, these individuals often do not receive the assistance they should be entitled to. Therefore what makes a psychologically verifiable illness less disabling than an individual who is suffering through the pain of cancer? It is time for the general community to realize that these individuals are no less disabled than those who suffer from a recognized medical condition.