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 -help-
seeking 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 first -
degree 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.