Indian Write-Ups
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| Somatization - Its significance in Psychiatric Disorders - Prof. Dr. Manilal Gada | ||
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It is a well known fact of clinical medicine that a significant number of patients consult doctors with complaints of physical symptoms or signs for which, no adequate objective pathophysiological evidence exists to explain their distress. Usually such patients consult general practitioners or specialists whose scope of practice includes the area of the patient’s complaint or symptoms. However after the entire diagnostic workup proves unrewarding, the physician or the patient may turn to a psychiatrist for help in understanding and managing their problems. Both International Classification of Diseases 10thRevision, 1992 (ICD-10), of World Health Organization and Diagnostic and Statistical Manual of Mental Disorders 3rd Edition Revised, 1987(DSM-III-R), of American Psychiatric Association, have included a separate diagnostic category known as “Somatoform Disorders”. The essential features of this group of disorders are physical symptoms suggesting physical disorder (hence somatoform) for which there are no demonstrable organic findings or known patho-physiological mechanisms, but for which there is a positive evidence or a strong association with psychological factors or conflicts. Unlike in Factitions Disorder or Malingering the symptom production in somatoform disorders is not intentional i.e. the person has no voluntary control over the production of symptoms. Although the symptoms of somatoform disorders are “physical”, the specific pathophysiologic processes involved are not demonstrable or understandable by existing laboratory procedures, and the mental states and personal distress are conceptualized most clearly as bodily complaints and as clinical manifestations e.g. pain, weakness etc. There would be little interest in these patients beyond academic curiosity, were this group of patients very small in number. However a large number of patients suffer from this disorder and the prevalence ranges from 12% to 40% in various medical settings. This disorder is also sometimes referred to as Functional Somatic Symptom (FSS). It is interesting to note that 40% of patients attending orthopedic outpatients of a general hospital in a large metropolitan city suffer from recognizable psychiatric illness. The impact of this disorder on the resources of the health care system is however disproportionate to their numbers. These patients frequently consult numerous physicians in a never-ending quest to find someone who can treat them. They often undergo repetitive, costly and at times dangerous diagnostic studies. When these procedures fail to reveal any organic basis for their complaints, they continue to seek other medical opinions to provide them with the answers they want. The cost to the health care system for treating these patients in U.S.A. has been conservatively estimated to be around US $20 billion per year. The chances of purely psychological symptoms being dismissed as inconsequential and not a part of medical illness or disease are rather high in our society and culture. If a person complains of too many thoughts, confusion and indecisiveness about a few things, the reaction of family members usually is “forget the thoughts and you will be all right”. If the same person then goes to the doctor with these complaints, a similar reaction follows from the doctor. However, if the person reports that he has bodily symptoms such as a headache or pain in extremities, he is sympathetically advised by his family members to consult a physician. The doctor also examines the patient with concern, requests for some investigations and may prescribe some medicines. Thus in Indian society, the psychological symptoms and associated disease, are not given the status of medical illness compared to physical symptoms. The Indian patients, therefore, use the medium of body more often for expressing their inner tensions. Physical symptoms were recorded as the sole presenting symptoms of depressive disorder in 66% of patients and in another 29% both physical and psychological symptoms were the presenting symptoms. The patients usually present with a long history of multiple somatic complaints for which, numerous medical diagnosis and investigations have been undertaken with negative outcome. Operations have also been carried out in some instances. Though complaints may pertain to any party of the body, the commonly reported symptoms are:
Symptoms of anxiety and depressive disorders of varying severity are frequently present. Often there is a long standing disruption of social, interpersonal and family behaviour. Management Management of somatoform disorders mainly involves early diagnosis, avoiding unnecessary medical and investigative procedures and helping the patients to turn their attention off from their somatic symptoms. This requires establishment of rapport and an empathic relationship with the physician, based on trust and confidence. In addition it is important to explain to the patient that he has a somatisation disorder. The patient should be explained that it is a real disorder which causes various types of symptoms that the patient is experiencing, and that it is not imaginary. This reassures the patient that his illness has been understood and diagnosed. Due to limited interpersonal and social skills, the patients may have difficulties in dealing with various stressful interpersonal problems which precipitate these physical symptoms. Hence supportive psychotherapy that is educational in tone in quit helpful. Using simple behavioural management techniques can lessen these problems. The physician should show minimal interest in physical complaints and more in personal and social problems. Relaxation techniques are useful. Counseling to family members is also important. Use of appropriate psychotropic drugs is indicated but use should be kept to a minimum. |
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