Essay on Somatoform Disorders

The somatoform disorders consist of “physical symptoms suggesting physical disorder for which there are no demonstrable organic findings or known physiologic mechanisms, and for which there is positive evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts” (Qtd in Stoudemire 1988:533). A patient’s emotional problems are expressed not as such but in physical terms, as a medical disorder, like gastritis, or as a neurological disorder, like a weakness of the muscles of the hand. This condition is often misdiagnosed even by the experienced clinicians: emotional problems are treated as the result of the physical condition, when, in reality, they are the primary cause of a disease a hand.

Although somatoform symptoms are extremely common in the workplace and create much unnecessary suffering for workers and unnecessary expense for their employers, the workers themselves, the companies that employ them, and the therapists that treat them tend either to overlook them entirely or to misdiagnose them and then mistreat them accordingly.

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Somatoform disorder can be the result of endogenous or exogenous psychological factors. A conflict or some stressful situation may result in the somatoform problem. In this case the somatoform disorder is a symbolic expression, in body language, of the patient’s conflicts and their attempted resolution. Or it may be the result of stress, in which case the somatoform disorder is in effect a primitive reaction, like developing gooseflesh or passing out when danger looms.

In both cases there is what Felix Deutsch called in the title of his book a “mysterious leap from the mind to the body.” (Deutsch 1959:1) This leap, in turn, has the effect of hiding what patients are really thinking and feeling both from themselves and others, with two main consequences, one for the patient and one for the patient’s therapist. For the patient, insight is compromised, so the patient cannot connect emotional cause with physical effect and then disavows a personal contribution to the disorder, which ultimately gives the disorder a not-me quality.

The following are DSM-IV somatoform disorders (American Psychiatric Association 1994:471-475).

1. Somatization disorder, such as gastric reflux.
2. Conversion disorder, such as emotionally induced paresis of the hand that is part of carpal tunnel syndrome.
3. Pain disorder, such as some cases of emotionally induced low back pain.
4. Hypochondriasis, such as constant worrying about health.

Somatization disorder is characterized by multiple persistent somatic complaints that express general emotional distress more than specific psychological conflict. As a result, somatization symptoms seem empty of idea, and the patients themselves seem nonverbal.

According to Martin Kantor patients with somatization symptoms tend to present their symptoms in dramatic terms, underscoring what they say with charade or pantomime to catch their audience’s eye, keep their interest, and impress them with how much they are suffering. Often they soon become annoying (Kantor 1988:23). They seem insensitive to the reactions their listeners are having to them. Such people tend to concentrate on their own feelings. They employ numerous means designed to illustrate others that their feelings and the way of life are the most important matters in the universe and no one can have the freedom to spoil them.

Conversion disorder is responsible for many of such emotionally caused physical blocks as depression. Descriptively, in conversion normal body function may be quantitatively diminished, as in numbness; quantitatively increased, as in tremor; or qualitatively altered (American Psychiatric Association 1994:478). Conversion signs, differing from somatization indicators, often appear as single ones. They may be acute and transient, or may persist and become chronic. In the acute stage, organic end-stage pathology, such as contractures, is unusual. But it is prevalent in the unceasing stage and is likely to turn into the irreversible if the symptoms endure for a considerable period of time. As a point of comparison to somatization symptoms, that tend to favor an autonomic pathway for appearance and expulsion, adaptation indicators tend to prefer a sensorimotor trail for appearance and expulsion.

Somatoform pain disorder is illustrated by harsh or continuous pain with the effect surpassing ordinary physical pain, if present, so that psychological determinants are considered to play a significant role (Condrau 1988:215). An example is a dull ache in the back, attributed to arthritis, in the absence of significant arthritic changes, as demonstrated by X-ray findings. Another example would be a continuous tooth pain, resulting in a number of dental surgeries upon patient’s strong demands, even though the doctor may not see the direct or immediate need for such operations.

According to Kantor hypochondriacs are obsessive worriers (Kantor 1988:342-357). Such individuals tend to be overprotective about their health condition, which, in turn, makes them wear very heavy clothes even in hot weather because of their fear to catch cold. They hold onto the railing as they walk because they are afraid they will fall and break a brittle, decalcified bone. On the job they may be observed avoiding the onslaught of germs by carefully checking the rim of their water glass for smudges or lipstick prints, taking pills from a bottle, or sipping sugar fluids from a vial. Such individuals prefer to wear an austere black suit, as if they were getting ready to die. These people prefer to hold a fixed corpselike posture (often leading to muscle strain), only because of their determination to behave in a certain, strained way (Kantor 1988:342-357).

According to Stoudemire, developmentally speaking an infant originally expresses ideation and affect nonverbally, for example in autonomic responses. These nonverbal cues can become the exclusive basis of communication when the environment suppresses more direct expression of ideas and feelings. This leaves the “individual developmentally fixated at a predominately somatic level of experience, conceptualizing...communicating” and resolving conflicts, leading to a “reliance on somatic complaints to express oneself and to get attention and support” (Stoudemire 1988:534).

According to Stoudemire 1988 most somatoform disorders are “multifactorily determined” and have to be evaluated from several theoretical perspectives. While psychodynamic perspectives are valuable, to provide a complete causal picture clinicians must also study “linguistic development, family dynamics, cultural factors, and behavioral conditioning” (Stoudemire 1988:534). Stoudemire emphasizes how the somatoform disorders are reinforced by the attitudes and reactions of others. Parents who “respond more readily to physical complaints than [to] signs of emotional distress in their children” fix the somatic mode of expression as do cultural attitudes and educational limitations which can account for whether or not the individual “welcomes the sick role” and uses it for gain (Stoudemire 1988:535). Educational barriers and limited learning abilities can impose additional strain on the student’s willingness to express him or herself verbally in the classroom (Stoudemire 1988:535).

According to Stoudemire, masked expression of forbidden impulses, punishment for guilty wishes, a desire for removal from an overwhelming threatening life situation at times of stress, a need to assume the sick role, and a “communication of helplessness, which facilitates an environment in which attention and support are gained and aggression impulses avoided” are dynamic aspects of many, and probably all, the somatoform symptoms/somatoform occupational disorders (Stoudemire 1988:537). There are three possible causes for a given so-called physical disorder: a somatoform disorder, a physical disorder, or a combination of physical and emotional disorder. For example, in writer’s cramp, a given cramp may be a conversion disorder, a physical dystonia, or a true dystonia made worse when the patient tenses for emotional reasons. Although causally distinct, these symptoms look alike clinically -- that is, they present in rather similar ways, but the structural and dynamic differences between them are not always immediately apparent.

Today’s clinicians, however, usually do not see it that way. Instead they take a one-or-the-other view, lining up in two camps. Some are anti-psychiatric and will not admit that disorders like RSI can be emotionally caused; that emotions can contribute to symptoms that are physically caused, as when a hand tensed for emotional reasons becomes more vulnerable to physical injury because of the position in which it is held. They do not have to have new headaches. The old ones they already have will, unfortunately, do. Other clinicians are excessively pro-psychiatric (Kantor 1992:45-49). They see emotional causation everywhere; overlook the possibility that somatoform physical symptoms can actually be physically caused; and buttress their view by denying that physical disorder can occur in the absence of actual physical evidence, such as X-ray changes or abnormal laboratory tests. Such clinicians forget that it is not very difficult to produce wrist pain experimentally (Kantor 1992:89).

In making the diagnosis of a somatoform disorder, it is not enough to rule out physical disorder; one must also rule in emotional disorder. In order to achieve a desired result, health professionals are to very carefully and painstakingly evaluate the patient’s condition. The hint is to find the similarity between the patient’s symptoms and the ones depicted in the medical books or articles on similar diseases. For instance, a disease characterized by the uncontrolled movements of the hand may be RSI and not conversion as conversion usually influences the proximal part of the extremity in a greater way than distal, the arm more than the hand.

Examining the patient’s mental condition or susceptibility to certain types of mental diseases comes as a next step. The mental status evaluation is the equivalent of the physical examination of psychiatry. For example, both Stoudemire (988:540) and Wilfred Abse (1959:23-35) stress that in evaluating possible somatoform symptoms, clinicians have to evaluate the patient’s concurrent mood and degree of anxiety. Conversions, in particular, are associated with a specific affective state called striking indifference, in which the predominant affect is detached and there is a certain removed attitude about even the most serious paralyses or sensory loss, without the anxious affect one would expect given the degree of impairment.

The mental status evaluation should include specific questions of proven diagnostic value, like “What do you think is causing your problem?”; “Do you think your problem is physical or mental?”; and “What do you think will happen to your job because of your problem?” (Stoudemire 1988:540) Abse states that the examination of a conversion symptom must not rely on descriptive clinical illustration alone (Abse 1959:279). On the contrary, it should be based as well on dynamic and developmental characteristics.

One goal of understanding a patient’s individual dynamics is to understand the interplay between the patient’s psychological problems and his or her on-the-job stress. Stress is itself traumatic, but it is more likely to cause symptoms when today’s stress reminds the patient of yesterday’s trauma. Another goal is to understand the psychodynamics of a given somatoform symptom.