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As defined in DSM-IV, somatization disorder is a
polysymptomatic somatoform disorder characterized by
multiple recurring pains and gastrointestinal, sexual and
pseudoneurological symptoms occurring for a period of
years with onset before age 30 years.
In the USA, somatization disorder is found predominantly in
women, with a female/male ratio of approximately 10 : 1.
Somatization disorder seems to be more common in less
educated and lower socioeconomic groups.
The disorder is observed in 10% to 20% of female first-
degree relatives of women with the disorder.
An estimated 25% to 75% of patients presenting with
somatization disorder to primary care providers may have this
disorder resulting from psychological distress.
The exact cause of somatic symptom disorder isn't clear, but any of these
factors may play a role:
Genetic and biological factors, such as an increased sensitivity to pain
Family influence, which may be genetic or environmental, or both
Personality trait of negativity, which can impact how you identify and
perceive illness and bodily symptoms
Decreased awareness of or problems processing emotions, causing
physical symptoms to become the focus rather than the emotional issues
Learned behavior — for example, the attention or other benefits gained
from having an illness; or "pain behaviors" in response to symptoms, such
as excessive avoidance of activity, which can increase your level of
ETIOLOGY AND PATHOPHYSIOLOGY
DEFENSE AGAINST PSYCHOLOGICAL DISTRESS:
According to this model, somatization disorder is a defense against psychological pain
that allows some people to avoid the stigma of a psychiatric diagnosis.
Many patients described by Sigmund Freud would be diagnosed today with somatization
disorder. His patients were usually young women who complained of numerous physical
Although this theory offers a plausible explanation for somatization disorder, research
indicates that people with multiple physical symptoms are actually more likely to report
psychiatric symptoms than those with few physical problems.
These findings appear to support a connection between psychological and physical
distress, but are inconsistent with the idea that physical symptoms offer a defense against
overt psychiatric symptoms.
HEIGHTENED SENSITIVITY TO PHYSICAL SENSATIONS.
An alternative theory suggests that somatization disorder arises from a heightened
sensitivity to internal sensations.
People with somatization disorder may be keenly aware of the minor pains and
discomforts that most people simply ignore. A similar theory has been offered to account
for panic disorder.
The physiological or psychological origins of this hypersensitivity to internal sensations
and their relevance to somatization disorder are still not well understood.
CATASTROPHIC THINKING ABOUT PHYSICAL
According to these thoughts, somatization disorder results from
negative beliefs and exaggerated fears about the significance of
Individuals with somatization disorder are thus more likely to
believe that vague physical symptoms are indicators of serious
disease and to seek treatment for them.
Many people with somatization disorder reduce or eliminate
many activities out of fear that exertion will worsen their
symptoms. With fewer activities to distract them from their
symptoms, they spend more time worrying about physical
problems, resulting in greater distress and disability.
Mnemonic for Use as a Screening
Test for Somatization
A. A history of many physical complaints beginning before age 30 years that occur over a period of
several years and result in treatment being sought or significant impairment in social, occupational, or
other important areas of functioning.
B. Each of the following criteria must have been met, with individual symptoms occurring at any time
during the course of the disturbance:
1. Four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head,
abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or
2. Two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain
(e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several
3. One sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g.,
sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding,
vomiting throughout pregnancy)
4. One pseudoneurologic symptom: a history of at least one symptom or deficit suggesting a neurologic
condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis
or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention,
hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative
symptoms such as amnesia; or loss of consciousness other than fainting)
Diagnostic Criteria for Somatization Disorder
C. Either of the following:
1. After appropriate investigation, each of the symptoms in
criteria B cannot be fully explained by a known general
medical condition or the direct effects of a substance (e.g., a
drug of abuse, a medication)
2. When there is a related general medical condition, the
physical complaints or resulting social or occupational
impairment are in excess of what would be expected from the
history, physical examination, or laboratory findings
D. The symptoms are not intentionally produced or feigned (as
in factitious disorder or malingering).
Treatment Goals Psychotherapy and
Strategies and Techniques
Strategies and Techniques
1. Prevent adoption of the sick
role and chronic invalidism.
2. Minimize unnecessary
costs and complications by
diagnostic and treatment
procedures, and medications.
3. Pharmacological control
of comorbid syndromes.
4. Instill, whenever possible,
insight regarding temporal
symptoms and personal,
interpersonal, and situational
generally by same physician,
coordinated if multiple.
2. Supportive office visits,
scheduled at regular
3. Focus gradually shifted
from symptoms to personal
and social Problems.
4. Establish firm therapeutic
5. Educate patient regarding
6. Consistent reassurance.
1. Only as clearly
indicated, or as time-
limited empirical trial.
2. Avoid drugs with
3. Antianxiety and
antidepressant drugs for
comorbid anxiety or
depressive disorders; if
Treatment of DSM-IV-TR Somatization Disorder
No effective somatic treatments for somatization disorder
itself have been identified.
Patients with somatization disorder may complain of anxiety
and depression, suggesting readily treatable comorbid
Use of antidepressants may be required for comorbid
depression and anxiety, with tricyclics being useful in aiding
chronic tension headaches and fibromyalgia.
Fluvoxamine: 50 to 300 mg/day orally.
Amitriptyline: 50 to 100 mg orally.
Alprazolam: 0.25 to 0.5 mg orally 3 times a day.
Nefazodone: 200 mg/day, administered in two divided
Initial, 2 to 3 mg/day orally divided into 2 to 3 daily
Maintenance, 2 to 6 mg/day orally divided into 2 to 3
daily doses; dose may vary from 1 to 10 mg/day.
Identifying and restructuring cognitions
Altering illness behavior/Behavioral activation
Involvement of spouse or family member
Elicitation and expression of emotion
Others are exercise therapy, bibliotherapy, short-term
psychodynamic supportive psychotherapy, and interpersonal
COGNITIVE BEHAVIORAL THERAPY
Jerald Kay and Allan Tasman. Essentials of psychiatry.
england: John Wiley & Sons, 2006.
Oliver Oyama et al. Somatoform Disorders. American
Family Physician. 2002 Nov; 76:1334-1338.
Hani Raoul Khouzam et al. Somatization Disorder:
Clinical Presentation and Treatment in Primary Care.
Hospital Physician. 1991 Apr; 45: 20-25.
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