Somatisation

Specialties > Mental health

Background knowledge 🧠

Definition

Somatisation is the process where psychological distress is expressed through physical symptoms.
Patients present with symptoms that are inconsistent with or cannot be fully explained by any underlying medical condition.
It is considered a somatoform disorder, classified under functional somatic syndromes.

Epidemiology

Somatisation is more common in women than men.
Onset is usually in adolescence or early adulthood.
Higher prevalence in lower socioeconomic groups and those with a history of trauma.
Chronic form may affect up to 1-2% of the population.
Often coexists with other psychiatric disorders such as anxiety and depression.

Aetiology and pathophysiology

Complex interplay of biological, psychological, and social factors.
Genetic predisposition may play a role.
Stress and trauma often precipitate or exacerbate symptoms.
Neurobiological factors include dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis.
Cognitive-behavioral theories suggest maladaptive thoughts and behaviors maintain the condition.
Cultural factors can influence symptom presentation.

Types

Somatic Symptom Disorder: Multiple, recurrent somatic symptoms causing significant distress.
Illness Anxiety Disorder: Preoccupation with having a serious illness, minimal somatic symptoms.
Conversion Disorder: Neurological symptoms (e.g., paralysis, blindness) with no organic cause.
Pain Disorder: Severe pain with psychological factors playing a major role in onset, severity, and maintenance.
Body Dysmorphic Disorder: Preoccupation with an imagined defect in physical appearance.
Factitious Disorder: Intentionally produced or feigned symptoms for the primary gain of assuming the sick role.

Clinical Features 🌡️

Symptoms

Multiple physical symptoms across different organ systems (e.g., gastrointestinal, cardiovascular, neurological).
Symptoms often vague, variable, and transient.
Chronic pain, fatigue, and dizziness are common presentations.
Excessive worry about health and symptoms.
Symptoms may worsen with stress or psychological distress.
Frequently presents with coexisting anxiety or depression.

Signs

Clinical examination often normal or non-specific findings.
Discrepancy between reported symptoms and objective findings.
May exhibit signs of anxiety or depression.
Frequent healthcare visits with extensive investigations and negative results.
Patients may appear distressed or overly concerned about their health.

Investigations 🧪

Tests

Primary aim is to rule out organic causes of symptoms.
Basic blood tests: FBC, U&E, LFTs, TFTs, CRP/ESR.
Imaging: Only if clinically indicated based on symptoms (e.g., X-ray, CT, MRI).
Psychological assessment: To evaluate for coexisting mental health conditions.
Functional assessments: To assess the impact on daily life and functioning.

Management 🥼

Management

Establish a strong therapeutic alliance with the patient.
Regular, scheduled follow-ups to provide continuity of care.
Cognitive-behavioral therapy (CBT) is the most effective psychological intervention.
Medications: SSRIs or SNRIs may be used for coexisting anxiety or depression.
Address any underlying stressors or psychological issues.
Avoid unnecessary investigations and treatments to reduce iatrogenic harm.
Patient education about the nature of somatisation and the mind-body connection.

Complications

Risk of developing chronic illness behavior.
Frequent healthcare visits may lead to unnecessary interventions.
Increased risk of comorbid psychiatric disorders.
Social and occupational impairment.
Potential for substance misuse, particularly with chronic pain.

Prognosis

Varies depending on the severity and chronicity of symptoms.
Better prognosis with early intervention and appropriate management.
Chronic somatisation can lead to significant functional impairment.
Some patients experience symptom remission, while others may have persistent symptoms.

Key Points

Somatisation is a common presentation in primary care and can be challenging to manage.
It requires a biopsychosocial approach to care.
Avoiding unnecessary investigations and focusing on patient education are key management strategies.
Multidisciplinary team involvement may be beneficial.
Long-term follow-up may be required for chronic cases.

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