Psychosomatic Disorders

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Conditions that vary from common to exceedingly rare and from benign to life-threatening can be confused with psychosomatic illness. While an exhaustive list of differential diagnoses would be too lengthy to be of clinical utility, clinicians should consider several easy-to-miss diagnoses. For GI complaints, these include abdominal migraines, celiac disease, eating disorders, food allergies, H.

Cardiac arrhythmias, hyperparathyroidism, hyperthyroidism, and systemic lupus erythematosus SLE are also easily-missed medical diagnoses. Psychiatric illnesses that can present with somatic chief complaints include panic disorder, generalized anxiety, and obsessive-compulsive disorder OCD. Malingering and factitious disorders should also be considered.

Psychological factors adversely affect the general medical condition in one of the following ways: One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

The symptom or deficit is not intentionally produced or feigned as in Factitious Disorder or Malingering. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance or as a culturally sanctioned behavior or experience. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder and is not better accounted for by another mental disorder.

Can be further classified as presenting with motor symptom or deficit, with sensory symptoms or deficit, with seizures or convulsions, or with mixed presentation. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. The symptoms or deficit is not intentionally produced or feigned as in Factitious Disorder or Malingering.

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The pain is not better accounted for by a Mood, Anxiety or Psychotic Disorder and does not meet criteria for Dyspareunia. If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.

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This type of Pain Disorder is not diagnosed if criteria are also met for Somatization Disorder. 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. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: Either 1 or 2: The symptoms are not intentionally produced or feigned as in Factitious Disorder or Malingering.

One or more physical complaints e. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This diagnosis can be used when patients do not meet full criteria for the other somatoform disorders. For example, when symptoms consistent with undifferentiated somatoform disorder have been present for less than six months.

Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. The belief in is not of delusional intensity as in Delusional Disorder, Somatic Type and is not restricted to a circumscribed concern about appearance as in Body Dysmorphic Disorder. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

The preoccupation is not better accounted for by another mental disorder e. Genetics -While somatization disorders do tend to run in families, there are little data to support specific genetic abnormalities as a direct cause. Biological- Abnormalities such as decreased cerebral glucose metabolism, impaired cortical somatosensory activation, elevated plasma bradykinin, decreased serum tryptophan, increased inflammatory cytokines, abnormal functional connectivity between limbic and motor regions, and enlarged caudate nuclei volumes have been linked to somatization disorders.

However, whether these findings represent cause, effect, or mere association has yet to be fully determined. Exposures- Stressful life events--such as trauma, neglect, and abuse-- place patients at risk for developing patterns of somatization. Family conflict, relationship difficulties, parental absence, and significant illness in family members have all been implicated as predisposing, precipitating, and perpetuating factors. The physiological mechanisms through which these exposures may lead to the development of somatization are not entirely clear.

However, alterations to the body's hypothalamic-pituitary-adrenal HPA axis have been implicated. Individual Factors-There are a range of personal characteristics that can place a child at risk for somatization. Some studies have found associations between somatization and anxious temperament, high conscientiousness, insecurity, ineffective coping mechanisms, increased anger, and alexithymia difficulty expressing feelings with words.

Alexithymia has been correlated with somatosensory amplification, which is a heightened sensitivity to unpleasant physical sensations--such as colonic distention. Patients with somatosensory amplification are more likely to present with physical complaints in the absence of an underlying medical disorder. Familial Factors- Families of children who present with somatoform disorders may have higher levels of conflict, overprotectiveness, rigidity, and impaired cohesion.

It has been argued that, in these families, the child's physical symptoms may function to divert attention away from distressing conflict such as marital discord. Alternatively, children in these families may be reluctant to add to or participate in family conflict. Physical illness may be the only 'safe' way to communicate distress or to avoid being pulled into the conflict. Some parents lack the comfort, ability, or willingness to respond to their child's emotional distress but find it easy to respond to their child's physical distress.

Their child, in turn, ends up learning that the most effective way to receive parental care is through being sick. Thus, the child is more likely to both experience and communicate distress through physical symptoms. In addition, given that somatoform disorders tend to run in families, the use of illness as a kind of 'get-out-of-functioning' or 'get-out-of-conflict' card can be a highly-modeled pattern of behavior that is passed from one generation to the next.

There are no fail-safe pathognomonic signs or symptoms of psychosomatic illness. However, there are certain elements of a patient's history and physical exam that can suggest or support the diagnosis. They include the following:. Waxing and waning of symptoms that is temporally associated with specific stressors, suggestion, or care-giver attention. Symptoms or impairments that are not consistent with medical knowledge. Examples would include non-dermatomal distribution of sensory deficits, a positive Hoover test in the setting of leg weakness, engagement in protective behaviors while seemingly unconscious example: There are no specific laboratory tests that can confirm the diagnosis of a psychosomatic illness.

Laboratory tests should be ordered to rule out plausible medical etiologies in the differential diagnosis. As with laboratory studies, there are no specific imaging studies that can confirm the diagnosis of a psychosomatic illness. For patients presenting with symptoms suggestive of non-epileptiform seizures, video EEG monitoring can be particularly useful for establishing the diagnosis. For patients with intermittent cardiac symptoms, Holter monitoring can also be helpful in ruling out arrhythmias. When available, clinicians should make use of algorithms for assessing the patient's chief complaint.

Pediatricians should be cautious about jumping to a diagnosis of a psychosomatic illness in patients with psychiatric histories without ruling out medical causes first. Patients with strong personal or family psychiatric histories become medically ill, too. In fact, they are more likely than their non-psychiatrically ill peers to suffer from significant medical illness. Somatoform disorders are not merely diagnoses of exclusion.

It is not enough to rule out known medical causes. Clinicians should look for positive signs that support the diagnosis of a psychological underpinning to the symptoms or the level of impairment. Conversely, the presence of an identifiable medical disorder does not rule out the possibility that there are psychological components to the patient's presentation or a concomitant somatoform disorder e.

In addition, the presence of a biological explanation for a patient's symptoms at one point in their illness--such as initial presentation--does not necessarily mean that it remains the cause. Whenever possible, psychiatric consultation should be sought while the medical investigation is ongoing.

Families tend to be more open to accepting psychiatric involvement when it is introduced early on as a means of identifying and addressing any psychosocial stressors that might be contributing to the patient's impairment and helping patients and families cope with illness.

Psychosomatic disorder

It can be particularly useful to describe the psychiatric consultants as experts at helping children cope with "what is hard about being sick" and noting that they "help patients with all different types of medical illness. Care should be taken to balance the potential benefits of medical testing e. The risks of continued testing include iatrogenic damage radiation, adverse reactions to sedation, etc. The use of placebo exposures or treatments as a diagnostic tool may be enticing, but this is ethically fraught and often clinically unproductive. When placebos are used without the family's and patient's involvement, they tend to cause anger and alienation and do not help a family accept a diagnosis of a psychosomatic illness.

Placebo tests can be helpful in certain situations, such as if the patient and family agree to food exposures where they are blinded to whether a food contains an ingredient suspected of causing physical symptoms. It is important to acknowledge that dealing with patients with psychosomatic illness can be frustrating for pediatricians. Some clinicians may feel like they are 'wasting their time' with patients who 'aren't even sick. In these circumstances, it may be useful to remember that children present with these symptoms in the setting of sometimes-extreme emotional distress.

They may be the victims of abuse or emotionally overwhelmed by stressors over which they have no control. While there may be no identifiable underlying medical pathology, these children are still suffering, and as the child's pediatrician, you may be the best or only adult in their life who is in the position to provide them with the help they need and ease their distress.

When pediatricians suspect that psychological factors are playing a significant role in a patient's identified medical illness, they should discuss their concerns openly with the family and the patient. They should engage in education with the family about how these psychological factors might be playing a role and how they can be addressed see below.

If the family is resistant, it can be useful for pediatricians to state that they would never want to treat only part of an illness or prescribe only a partial dose of medication. When a diagnosis of a somatoform disorder has been made, pediatricians are advised to convene an 'informing conference' with the family, the psychiatrist, and, when indicated, subspecialty consultants.

The patient's primary physician should run the meeting and should begin by summarizing the patient's presentation and illness course. The primary physician should also summarize the results of the medical testing.

OVERVIEW: What every practitioner needs to know

The fact that the evaluation has not turned up an underlying medical etiology for the patient's symptoms should be presented as good news. The pediatrician should subsequently explain that there are lots of ways in which the mind and the body affect one another in profound ways. It can be useful to offer everyday examples such as getting butterflies in your stomach or stress headaches and more extreme examples such as how people can faint when they are overwhelmed or abruptly scared.

Pediatricians should also provide examples of more subtle interactions--especially ones that patients are not conscious of, such as how being stressed can weaken our immune systems or alter our body's hormone levels. Providing examples of unconscious processes by which emotions affect physiology is of particular importance, since many patients will state that they aren't feeling overwhelmed or aren't aware of any stressors.

It is imperative for pediatricians to stress at this point that they believe the patient is truly experiencing their symptoms, that it isn't "all in their head," and that they aren't "faking it. If patients or families are incredulous that emotional issues can cause real physical impairment, it can be useful to describe the findings such as the results of an fMRI study that demonstrated impaired activation of the contralateral somatosensory cortex in conversion disorder patients presenting with unilateral leg numbness.

This study can be used as an example of the emotion center of the brain being "so overwhelmed that it cuts off the signals from the body to the brain" and how the patients "really weren't feeling their legs. When conveying the diagnosis of a somatoform disorder, pediatricians should be sure to stress that treatments are available and full recovery is possible. One of the most important elements of effective treatment for psychosomatic illness is ongoing involvement of the medical provider.

Pediatricians should make it clear that they remain concerned about the patient and that they are going to continue providing and coordinating their patient's care. Pediatricians should schedule frequent follow-up appointments to monitor the child's progress and to assess any new symptoms.

Frequent follow-up appointments may also help decrease the frequency of urgent calls and emergency room visits. Once a diagnosis of a psychosomatic illness has been made, pediatricians should discontinue unnecessary treatments, being careful to taper medications with significant discontinuation symptoms. Further medical evaluation should be halted, with the caveat that any new concerning symptoms will be appropriately evaluated.

Research by psychiatrist Franz Alexander and his colleagues at the Chicago Institute of Psychoanalysis in the s and s suggested that specific personality traits and specific conflicts may create particular psychosomatic illnesses, but it is generally believed that the form a disorder takes is due to individual vulnerabilities.

Emotional stress is assumed to aggravate existing illnesses, and there is some evidence that it may precipitate illnesses not usually considered to be psychosomatic e. Psychosomatic disorders resulting from stress may include hypertension, respiratory ailments, gastrointestinal disturbances, migraine and tension headaches, pelvic pain, impotence, frigidity, dermatitis, and ulcers.

Many patients suffering from psychosomatic diseases respond to a combination of drug therapy, psychoanalysis, and behaviour therapy. In less severe cases, patients can learn to manage stress without drugs. We welcome suggested improvements to any of our articles.

What is a Psychosomatic Disorder?

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The Editors of Encyclopaedia Britannica. Learn More in these related Britannica articles: A specialist may be capable of such a general assessment, but, often, with emphasis on his own subject, he fails at this point. The generalist with his broader training…. Franz Alexander , physician and psychoanalyst sometimes referred to as the father of psychosomatic medicine because of his leading role in identifying emotional tension as a significant cause of physical illness.

Stress , in psychology and biology, any environmental or physical pressure that elicits a response from an organism. In most cases, stress promotes survival because it forces organisms to adapt to rapidly changing environmental conditions. For example, in response to unusually hot or dry weather, plants prevent the loss of water…. More About Psychosomatic disorder 1 reference found in Britannica articles Assorted References difficulty in diagnosis In medicine: Administration of primary health care.

External Websites Patient - Psychosomatic Disorders. Articles from Britannica Encyclopedias for elementary and high school students.

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