Smoking and mental health - NCSCT

Mental disorders 1
1.4.4 Somatisation disorder
Somatisation disorder is the most severe form of a group of conditions
collectively known as somatoform disorders, in which the patient presents with a
physical health complaint, the doctor fails to find a conventional physical cause
and the reason for the presentation is thought to have a psychological basis.
These are difficult conditions to diagnose and research because diagnosis is to a
large extent a function of the interaction between doctor and patient. Defining
when a complaint has a satisfactory biomedical explanation can be very difficult,
and the diagnoses defined under the rubric of somatoform disorders are a
somewhat arbitrary collection of presentations defined by the presence of
symptoms (eg somatisation disorder), the presence of overwhelming and
troubling beliefs that one is ill (eg hypochondriasis) or the loss of neurological
function (eg conversion disorder). These disorders represent extreme
manifestations of a major clinical problem faced by most medical disciplines:
that of medically unexplained symptoms.
Medically unexplained symptoms are a universal experience 31 and are
sometimes referred to as ‘functional’, indicating that they are caused by
(reversible) alterations in the body’s function rather than pathological changes.
People with such symptoms may understandably become concerned and seek
explanations and help in doing so. 32 Although such presentations may be an
indication of an underlying psychiatric disorder, particularly anxiety or
depression, not all are. 33 However, psychological processes are always important
in understanding symptoms, and include perceptual processes related to the
selective attention that a symptom is given, cognitive processes that might relate
to the meaning that the patient puts on the symptoms, affective responses such
as fear and behavioural processes such as avoidance. Hence someone might
experience a headache, find it hard to ignore this, become anxious about it and
perhaps attach a meaning that is understandable although incorrect (eg thinking
‘maybe it’s a brain tumour’), and respond by seeking help and taking time off
work. Such individuals are readily treated using approaches such as
cognitive–behavioural therapy. 34
For individuals with somatisation disorder such symptoms come to dominate
life. To diagnose the disorder, unexplained symptoms have to be present in
several bodily symptoms, start before the age of 30 and cause significant
disruption to life. DSM-IV requires the presence of four pain symptoms, two
gastrointestinal symptoms, one sexual symptom and one pseudo-neurological
symptom to make the diagnosis; however, these thresholds are somewhat
arbitrary and there is a strong case for a so-called ‘abridged’ somatisation
disorder which has fewer symptoms. 35 The condition is present in approximately
1% of the population, with a strong female preponderance and associations with
abusive experiences in childhood, physical illness in a relative during childhood,
and co-morbid depression or anxiety. 36 Patients typically go through life seeking
help from multiple doctors, undergoing unnecessary interventions (eg surgery)
© Royal College of Physicians 2013 5