What is a psychosomatic disorder?

Psychosomatic Disorder: Definition and Clinical Implications

Psychosomatic disorder is a condition in which psychological stresses adversely affect physiological functioning to the point of causing distress, dysfunction, or structural damage in physical organs through inappropriate activation of the involuntary nervous system and biochemical responses. 1

Classification and Terminology

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) has updated the terminology and classification of these conditions:

• The term "psychosomatic" has been replaced with more specific diagnostic categories under "Somatic Symptom and Related Disorders" 2

• These include:

  • Somatic symptom disorder
  • Illness anxiety disorder
  • Conversion disorder (functional neurologic symptom disorder)
  • Psychological factors affecting other medical conditions
  • Factitious disorder
  • Other specified somatic symptom and related disorder
  • Unspecified somatic symptom and related disorder 2

• The term "somatic cough disorder" has replaced "psychogenic cough" to be consistent with DSM-5 classification 2

Diagnostic Criteria for Somatic Symptom Disorder

According to DSM-5, somatic symptom disorder is characterized by:

1. One or more somatic symptoms that are distressing or disrupt daily life
2. Excessive thoughts, feelings, or behaviors related to the symptoms, manifested by at least one of:
   • Disproportionate and persistent thoughts about symptom seriousness
   • Persistently high anxiety about health or symptoms
   • Excessive time and energy devoted to symptoms or health concerns
3. Persistent symptomatic state (typically more than 6 months) 2

Clinical Presentation

Psychosomatic disorders present with various physical symptoms that lack corresponding organic pathology:

• Most common presentations involve neurologic, pain, autonomic, or gastrointestinal symptoms 2
• Clinical features often include:
  • Vague, poorly described complaints
  • Recent or current stressful events
  • Symptoms that fluctuate with activity or stress
  • Lack of physical findings and laboratory abnormalities 2, 3
  • Multiple visits to healthcare providers for these symptoms 2

Cultural Considerations

Cultural factors significantly influence how psychosomatic disorders present:

• Non-Western cultures often emphasize somatic symptoms over psychological ones 2

• Common somatic manifestations across cultures include:

  • Dizziness
  • Indigestion
  • Palpitations
  • Difficulty breathing
  • Sweating 2

• Even bilingual patients may describe their symptoms differently depending on language used:

  • More somatic expressions when speaking in their native language
  • More psychological expressions when speaking in English 2

Epidemiology and Impact

Psychosomatic disorders are common and significantly impact healthcare utilization:

• In adult primary care: 10-15% of patients have a diagnosis of one of these disorders 2

• Among children and adolescents:

  • Recurrent abdominal pain accounts for 5% of pediatric office visits
  • Headaches account for 20-55% of pediatric office visits
  • 10% of adolescents report frequent psychosomatic symptoms 2, 4

• Prevalence in children and adolescents is estimated between 10-25% 4

• These disorders result in significant impairment in psychosocial functioning, affecting relationships, academic performance, and occupational functioning 2

Differential Diagnosis

Important distinctions must be made between:

• Somatic symptom disorders: symptoms are not intentionally produced
• Factitious disorders: symptoms are intentionally created
• Malingering: symptoms are associated with material gain 2, 3

A thorough medical evaluation is essential to rule out organic causes before confirming a diagnosis 3

Treatment Approaches

Evidence-based treatment approaches include:

• Cognitive behavioral therapy (CBT) as first-line treatment 3

• Systematic desensitization for gradual exposure to stressors 3

• Therapeutic communication strategies:

  • Clear but sympathetic explanation of the diagnosis
  • Acknowledgment of the involuntary nature of symptoms
  • Creating an expectation of recovery
  • Avoiding confrontation or suggesting symptoms are "made up" 3

• Addressing comorbid anxiety and depressive symptoms 3

• Clinical hypnosis and meditative states may help manage symptoms by addressing neuropsychobiological responses to stress 1

Prognosis

Prognosis varies based on:

• Duration of symptoms before treatment
• Presence of comorbid psychiatric conditions
• Quality of therapeutic relationship
• Patient's insight into psychological factors 3

Early intervention generally leads to better outcomes 3