Somatization Disorder

Somatization disorder is an illness of multiple somatic complaints in multiple organ systems that occurs over a period of several years and results in significant impairment or treatment seeking, or both. Somatization disorder is the prototypic somatoform disorder and has the best evidence of any of the somatoform disorders for being a stable and reliably measured entity over many years in individuals with the disorder. Somatization disorder differs from other somatoform disorders because of the multiplicity of the complaints and the multiple organ systems (e.g., gastrointestinal and neurological) that are affected. The disorder is chronic and is associated with significant psychological distress, impaired social and occupational functioning, and excessive medical -helpseeking behavior. Somatization disorder has been recognized since the time of ancient Egypt. An early name for somatization disorder was hysteria , a condition incorrectly thought to affect only women. (The word hysteria i s derived from the Greek word for uterus, hystera .) In the 17th century, Thomas Sydenham recognized that psychological factors, which he called antecedent sorrows, were involved in the pathogenesis of the symptoms. In 1859, Paul Briquet, a French phy sician, observed the multiplicity of symptoms and affected organ systems and commented on the usually chronic course of the disorder. Because of these clinical observations, the disorder was called Briquet's syndrome until the term somatization disor der became the standard in the United States.

Epidemiology
The lifetime prevalence of somatization disorder in the general population is estimated to be 0.2 percent to 2 percent in women and 0.2 percent in men. Women with somatization disorder outnumber me n 5 to 20 times, but the highest estimates may be because of the early tendency not to diagnose somatization disorder in male patients. Nevertheless, it is not an uncommon disorder. With a 5 -to-1 female-to-male ratio, the lifetime prevalence of somatizatio n disorder

among women in the general population may be 1 or 2 percent. Among patients in the offices of general practitioners and family practitioners, 5 to 10 percent may meet the diagnostic criteria for somatization disorder. The disorder is inversely r elated to social position and occurs most often among patients who have little education and low incomes. Somatization disorder is defined as beginning before age 30; it usually begins during a person's teenage years. Several studies have noted that somati zation disorder commonly coexists with other mental disorders. About two thirds of all patients with somatization disorder have identifiable psychiatric symptoms, and up to half have other mental disorders. Commonly associated personality traits or persona lity disorders are those characterized by avoidant, paranoid, self-defeating, and obsessive-compulsive features. Two disorders not seen more commonly in patients with somatization disorder than in the general population are bipolar I disorder and substance abuse.

Etiology
Psychosocial Factors
The cause of somatization disorder is unknown. Psychosocial formulations of the cause involve interpretations of the symptoms as social communication whose result is to avoid obligations (e.g., going to a job a person does not like), to express emotions (e.g., anger at a spouse), or to symbolize a feeling or a belief (e.g., a pain in the gut). Strict psychoanalytic interpretations of symptoms rest on the hypothesis that the symptoms substitute for repressed insti nctual impulses. A behavioral perspective on somatization disorder emphasizes that parental teaching, parental example, and ethnic mores may teach some children to somatize more than others. In addition, some patients with somatization disorder come from u nstable homes and have been physically abused. Social, cultural, and ethnic factors may also be involved in the development of symptoms.

Biological Factors

Some studies point to a neuropsychological basis for somatization disorder. These studies propose th at the patients have characteristic attention and cognitive impairments that result in the faulty perception and assessment of somatosensory inputs. The reported impairments include excessive distractibility, inability to habituate to repetitive stimuli, g rouping of cognitive constructs on an impressionistic basis, partial and circumstantial associations, and lack of selectivity, as indicated in some studies of evoked potentials. A limited number of brain -imaging studies have reported decreased metabolism i n the frontal lobes and the nondominant hemisphere.

Genetics

Genetic data indicate that, in at least some families, the transmission of somatization disorder has genetic components. Somatization disorder tends to run in families and occurs in 10 to 20 perc ent of the firstdegree female relatives of probands of patients with somatization disorder. Within these families, first degree male relatives are susceptible to substance abuse and antisocial personality disorder. One study also reported a concordance ra te of 29 percent in monozygotic twins and 10 percent in dizygotic twins, an indication of a genetic effect. The male relatives of women with somatization disorder show an increased risk of antisocial personality disorder and substance related disorders. Having a biological or adoptive parent with any of these three disorders increases the risk of developing antisocial personality disorder, a substance-related disorder, or somatization disorder.

Cytokines
Cytokines are messenger molecules that the immune system uses to communicate within itself and with the nervous system, including the brain. Examples of cytokines are interleukins, tumor necrosis factor, and interferons. Some preliminary experiments indicate that cytokines contribute to some of the nonspecif ic symptoms of disease, such as hypersomnia, anorexia, fatigue, and depression. The hypothesis that abnormal regulation of the cytokine system may result in some of the symptoms seen in somatoform disorders is

under investigation.

Diagnosis

For the diagnosis of somatization disorder, DSM -IV-TR requires onset of symptoms before age 30 (Table 17 2). During the course of the disorder, patients must have complained of at least four pain symptoms, two gastrointestinal symptoms, one sexual symptom, and one pseudoneurological symptom, none of which is completely explained by physical or laboratory examinations.