Dr. Andrew Howard (biography and disclosures)
Somatoform and conversion disorders are common psychiatric presentations in general practice (De Waal et al, 2004) reported in 16%, and up to 30% in general practice depending on the sample studied. While reported universally, higher prevalence occurs in cultures, families, and neurodevelopmental conditions in which the capacity to express emotion directly is attenuated. Somatoform disorders are characterized by physical complaints that appear physical in origin but cannot be explained in terms of physical disease. Presentations are heterogeneous with nonepileptic seizures, chronic pain, fatigue, irritable bowel syndrome, and a host of other functional somatic syndromes presenting together commonly but with no pathognomonic presentation nor any physical presentation pointing specifically at an underlying specific psychiatric condition. When chronic, like most psychiatric conditions, they commonly cause leave from work, poor quality of life for patients and supports, and heavy burden on medical practices.
What I did before
Diagnosis
I over investigated, placing more diagnostic confidence in a negative test result than on my and the other consultants’ clinical examinations. I remained concerned about misdiagnosing unexplained physical symptoms as psychiatric, colluding with the patients at times by imagining highly unlikely disease outcomes rather than treating what was most likely a psychiatric condition.
Formulation
I over attributed somatoform presentations to difficulties in relationships or to stress, minimizing the condition and falsely reassuring patients that with time they would surely improve. I was easily frustrated by patients’ resistance to accepting the emotional basis to their condition yet not proactive in setting aside adequate time to help patients understand exactly how I came to this conclusion.
Management
I would offer patients psychopharmacological treatment before ensuring they or I properly understood the underlying psychiatric condition. I was overly cautious about being deceived, but apprehensive about addressing secondary gain.
What changed my practice
Literature
The rate of misdiagnosis of this condition especially in highly specialized centres has dropped to levels consistent with our misdiagnosis of most other conditions (Stone et al, 2005). While somatoform disorders are highly treatable, their chronicity and a non-psychiatric explanation are poor prognostic factors in this condition and a more prompt referral to a psychiatrist changes outcomes (Smith et al, 1995).
Patient feedback
Patients accused of malingering report that the need to defend their physical suffering delayed appropriate diagnosis for so long that it negatively affected their functional outcomes. Patients prefer a straightforward yet empathic explanation. It takes time for them to understand that the brain can do this to their bodies and that they have been misled. They particularly want to hear that the process has been largely involuntary and it is clear that they are suffering. They have, understandably, misinterpreted the source of their suffering to be physical rather than emotional (and, in fact, they have had mixed messages from well-intended but misinformed health care practitioners that their symptoms may in fact represent disease) but our assessments can help them correct this misinterpretation.
Long-term follow-up
“Stress” is often an unsatisfactory explanation for many of the patients’ presentations and in fact minimizes the severity of their psychopathology. Even for the patients who do accept the psychiatric formulation, their condition may be too entrenched or psychiatric management too inadequate to improve them.
What I do now
Diagnosis
I assume the patient is suffering, regardless of how voluntary their presentation appears.
I ensure a consultant in the area(s) of the presenting complaint(s) can confidently deem the presentation atypical, functional, and unlikely to represent disease. A consultant’s opinion of the atypical presentation is far preferable to the subjective Patient Health Questionnaire or any other screen which lacks a comprehensive look at a person’s symptomatology.
I ask about a personal and family history of unexplained physical symptoms or syndromes currently and in the past (fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivities, irritable bowel syndrome, any other functional somatic syndrome, or persistent but unexplained neurological symptom). I look for functional signs on physical and cognitive examination (atypical patterns which help reinforce the diagnosis of a functional disturbance).
I ask the consultants to re-assess the patients annually to help me prevent misdiagnosis. I tell the patient the possibility of misdiagnosis is extremely rare and that they mustn’t focus on this possibility (unless they develop new or different symptoms) or it will affect their prognosis.
Formulation
I then share with the patient and their support(s) all the data (including the consultant’s letter) that proves that the condition is brain-based and psychiatric and not physical (even though it is experienced in the body).
I emphasize the expected reversibility with psychiatric treatment, explaining that the prognosis depends on the underlying psychopathology.
I do not explain the cause as stress but rather as “emotional distress” especially if no Axis I or II pathology is readily apparent. Not all sources of emotional distress are readily identifiable. I explain that these manifest over time. I assertively treat any sleep disturbance, anxiety and depressive symptoms. In patients in their fifth decade of life or older, I assume the cause of the psychiatric disturbance may well be an organic condition of the brain and ensure that this is properly investigated.
I reassure patients that the condition is universal, common, disabling, and involuntary, and I provide them with a brochure and website (see below) so they feel validated and they have some means of handling their own and others’ stigma that they have a mental/emotional condition.
I try to elicit the patient’s belief(s) about the non-psychiatric origin of the condition. I share with the patient that it is understandable that they came to this conclusion given the evidence that was there previously. I try to reassure them that all they are losing is this incorrect explanation.
Management
I inform the patient that the symptoms will likely resolve within several months but that a psychiatric referral will be necessary if it persists. I initiate a prompt psychiatric referral if the symptoms persist six months and cause functional disability, stating that the patient has a somatoform/conversion disorder that requires treatment for the underlying Axis I and/or II condition(s). I instruct the patient that delaying a psychiatric assessment worsens prognosis. Patients improve with pharmacotherapy and cognitive-behavioural therapy. When general psychiatrists continue to struggle with patients convinced they are ill despite all evidence to the contrary, some benefit from subspecialty referral to the British Columbia Neuropsychiatry Program.
I address secondary gain acknowledging that it is an adaptive way of handling disability when it first occurs but that is also may deter recovery. I explain to the patient that unemployment is a negative prognostic factor and I ensure that they are compliant with a psychiatric referral prior to completing any necessary medical authorization for leave from work.
I ensure the patient is receiving cognitive-behavioural therapy for this condition, which involves replacing the belief that one is ill with the belief that one is suffering yet equally deserving of help, and replacing health care-seeking behavior with more direct expressions of the patients’ emotional distress.
I ask to see patients’ primary supports to educate them and to help them limit pathological methods of coping with physical complaints (colluding, dismissing, etc).
I expect that most patients with longstanding somatization are primitive in their coping mechanisms and that they will manifest dysfunction in many other different ways over time.
I accept that for some patients the idea that they are emotionally suffering or that they require psychiatric attention is too unpalatable. I tell them that this is sad and frustrating but understandable. I also accept that our current methods of psychiatric management will not help a proportion of somatoform patients despite all efforts.
Suggested readings
- Somatoform Disorder Brochure: www.bcnp.ca (British Columbia Neuropsychiatry Program): Forms & Resources: Somatoform Brochure.
- Website for patients/clinicians (designed by Dr. Jon Stone): www.neurosymptoms.org
- De Waal MWM, Arnold IA, Eekhof JAH & AM Van Hemert (2004). Somatoform disorders in general practice: Prevalence, functional impairment and comorbidity with anxiety and depressive disorders; British Journal of Psychiatry; 184: 470-6. (View article)
- Smith GR et al (1995). A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Archives of General Psychiatry 52: 238-43. (View with CPSBC or UBC)
- Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, & M Sharpe (2005). The misdiagnosis of conversion symptoms/hysteria – a systematic review. British Journal of Psychiatry; 331: 989-91. (View article)
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Wow! Thank you so much for this article. I find your approach to this problem to be a significant advance on what I’ve been taught before about managing these difficult conditions. I also appreciate that it is patient centered, addressing their most significant concerns while not diminishing them. I would really love to see more from you along the same lines. As I get more experienced in the practice of medicine, it’s the conditions that medicine traditionally does not treat well that have become the most challenging. There are so many patients suffering from these conditions who are not served well by our traditional views of illness and patterns of practice.
Both conditions are so common in our practice. I was happy reading a topic difficult to approach. Thank you I liked the you addressed, not to blame the patient, acknowledge his complaint even refer the. Psychiatric management
Good topic
It is important to examine the patient.
I appreciate the author’s thorough, well-contemplated, comprehensive approach to primary care patients with unexplained medical symptoms and traits of somatoform disorder.
Ideas I may incorporate into my own practice:
– Screening for family history of similar functional or like disorders
– Avoiding the use of the generic term “stress” as a label for unexplained cause of symptoms, instead using a more applicable term such as “emotional distress” when communicating diagnosis and possibility of somatoform disorders to patients.
– I like the structured approach to specialist psychiatry referral, which I believe I underuse for such patients in my own practice
– Giving the patient literature regarding the disorder to confirm its authenticity and not downplay its significance as a medical/psychological entity
Ideas that I disagree with:
– While appropriate limited specialist consultation(s) to initially rule out organic causes or potential missed diagnoses of potential life-threatening diseases is certainly warranted, I particularly disagree with the author’s request for annual specialist follow-up for patient reassurance for unusual symptoms or missed diagnoses. There is great risk of iatrogenic harm with multiple consults and ongoing follow-up without adequate clinical suspicion of a particular medical diagnosis, particularly the more consultants that are involved in the patient’s care and for the greater length of follow-up time. These ongoing reassessments without specific indication are also costly and may lead to further inappropriate testing given the atypical and evolving nature of somatoform symptoms and natural fear of MDs of misdiagnosis or litigation.
This approach may also allow the primary care physician to “collude” with the patient’s disorder, continuing the low-yield pursuit of a secondary cause for symptoms, giving further credence to the “medical” nature of the symptoms. Medical evidence suggests that negative diagnostic testing and reassurance from consultants has poor efficacy in reassuring such patients, addressing their fears or relieving their symptoms. I suspect that these reassessments by specialist colleagues do more to allay fears in the primary care physician rather than the treated patient.
This recommendation seems to go against current evidence and recommendations for somatoform conditions emphasizing that care should be provided by a designated physician on a scheduled, structured basis, limiting the number of frivolous testing and associated physicians providing ancillary care.
I like how secondary gain is explained to patient as unintended consequence of handling their disability at the same time acknowledging their difficultied. This approach increases the chance of long term follow up.
This is quite educative
When we don’t have the proper diagnostics, patients get thrown into a somatization diagnosis which can destroy their lives. If psychiatrists see them as “easy to treat” when, in fact, they have a serious illness that needs an alternate approach, the patient will worsen and be blamed for it. Psychiatry is not a hard science. Doctors should admit that they don’t know, or that they cannot help a patient instead of erroneously pigeon-holing them with an inappropriate diagnosis. We have a lot to learn about the body and many diseases. Just a few decades ago, MS was blamed on “demons”; just a decade ago, I watched a PPMS Pt get ridiculed for being a drug-seeking psychosomatic whiner by hospital staff simply because the first MRI was negative. The second wasn’t. And, this is only regarding a Pt case where diagnostics are mostly reliable. What about lupus, ME, and the myriad other conditions that don’t have hard bio-markers or adequate diagnostics yet? It doesn’t mean they don’t exist. It means no epoch is finally privileged; we are all tomorrow’s food (thanks, Ken Wilber).