UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis

Author
Donna B Greenberg, MD
Section Editor
Joel Dimsdale, MD
Deputy Editor
David Solomon, MD

INTRODUCTION

Somatization is a syndrome of physical symptoms that are distressing and may not be fully explained by a known medical condition after appropriate investigation. In addition, the symptoms may be caused or exacerbated by anxiety, depression, and interpersonal conflicts, and it is common for somatization, depression, and anxiety to all occur together [1-5]. Somatization can be conscious or unconscious and may be influenced by a desire for the sick role or for personal gain [5].

Somatization often occurs in primary care patients [4]. It increases use of medical services independent of any accompanying psychiatric or nonpsychiatric disorder and leads to frustration in both the patient and the clinician [3,6-9].

This topic reviews the following issues related to somatization: epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis of specific disorders. Treatment of somatization and prognosis are discussed separately. (See "Somatization: Treatment and prognosis".)

TERMINOLOGY AND DSM-5

The term "somatization" as used in this topic refers to a syndrome consisting of physical symptoms that cause substantial distress and psychosocial impairment, and are not explained by a known general medical disease. Somatization has also been referred to as medically unexplained symptoms and functional somatic symptoms.

Somatization is an overarching term that encompasses many different illnesses and terms including “somatoform disorders,” which is a group of disorders that are recognized in the World Health Organization's International Classification of Diseases-10th Revision (ICD-10) [10], and were previously described in the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) (table 1) [11]. (See 'Somatoform disorders' below.)

                              

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Wed Jan 27 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Lipowski ZJ. Somatization: the experience and communication of psychological distress as somatic symptoms. Psychother Psychosom 1987; 47:160.
  2. Kellner R. Hypochondriasis and somatization. JAMA 1987; 258:2718.
  3. Kroenke K, Rosmalen JG. Symptoms, syndromes, and the value of psychiatric diagnostics in patients who have functional somatic disorders. Med Clin North Am 2006; 90:603.
  4. Löwe B, Spitzer RL, Williams JB, et al. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry 2008; 30:191.
  5. Hamilton JC, Hedge KA, Feldman MD. Excessive illness behavior. In: Psychiatric Care of the Medical Patient, 3rd ed, Fogel BS, Greenberg DB. (Eds), Oxford, New York 2015. p.743.
  6. Smith GR. Somatization in the Medical Setting, American Psychiatric Press Inc., Washington, DC 1991.
  7. Barsky AJ, Ettner SL, Horsky J, Bates DW. Resource utilization of patients with hypochondriacal health anxiety and somatization. Med Care 2001; 39:705.
  8. Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 2005; 62:903.
  9. Creed F, Barsky A. A systematic review of the epidemiology of somatisation disorder and hypochondriasis. J Psychosom Res 2004; 56:391.
  10. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed on June 08, 2012).
  11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC 2000.
  12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  13. Löwe B, Mundt C, Herzog W, et al. Validity of current somatoform disorder diagnoses: perspectives for classification in DSM-V and ICD-11. Psychopathology 2008; 41:4.
  14. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989; 86:262.
  15. Katon W, Ries RK, Kleinman A. The prevalence of somatization in primary care. Compr Psychiatry 1984; 25:208.
  16. Katon WJ, Walker EA. Medically unexplained symptoms in primary care. J Clin Psychiatry 1998; 59 Suppl 20:15.
  17. Kroenke K, Price RK. Symptoms in the community. Prevalence, classification, and psychiatric comorbidity. Arch Intern Med 1993; 153:2474.
  18. Wittchen HU, Jacobi F. Size and burden of mental disorders in Europe--a critical review and appraisal of 27 studies. Eur Neuropsychopharmacol 2005; 15:357.
  19. Jackson JL, Kroenke K. Prevalence, impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med 2008; 70:430.
  20. Harris AM, Orav EJ, Bates DW, Barsky AJ. Somatization increases disability independent of comorbidity. J Gen Intern Med 2009; 24:155.
  21. van der Leeuw G, Gerrits MJ, Terluin B, et al. The association between somatization and disability in primary care patients. J Psychosom Res 2015; 79:117.
  22. Barsky AJ, Wyshak G, Klerman GL, Latham KS. The prevalence of hypochondriasis in medical outpatients. Soc Psychiatry Psychiatr Epidemiol 1990; 25:89.
  23. Kellner R. Somatization. Theories and research. J Nerv Ment Dis 1990; 178:150.
  24. Simon GE, VonKorff M. Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area study. Am J Psychiatry 1991; 148:1494.
  25. Craig TK, Bialas I, Hodson S, Cox AD. Intergenerational transmission of somatization behaviour: 2. Observations of joint attention and bids for attention. Psychol Med 2004; 34:199.
  26. Craig TK, Cox AD, Klein K. Intergenerational transmission of somatization behaviour: a study of chronic somatizers and their children. Psychol Med 2002; 32:805.
  27. Deary V, Chalder T, Sharpe M. The cognitive behavioural model of medically unexplained symptoms: a theoretical and empirical review. Clin Psychol Rev 2007; 27:781.
  28. Yutzy SH, Parish BS. Somatoform disorders. In: The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th ed, Galanter M, Kleber HD. (Eds), American Psychiatric Publishing, Washington, DC 2008. p.609.
  29. Noyes R Jr, Holt CS, Happel RL, et al. A family study of hypochondriasis. J Nerv Ment Dis 1997; 185:223.
  30. Morrison J. Childhood sexual histories of women with somatization disorder. Am J Psychiatry 1989; 146:239.
  31. Eberhard-Gran M, Schei B, Eskild A. Somatic symptoms and diseases are more common in women exposed to violence. J Gen Intern Med 2007; 22:1668.
  32. Roelofs K, Spinhoven P. Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts. Clin Psychol Rev 2007; 27:798.
  33. Paras ML, Murad MH, Chen LP, et al. Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. JAMA 2009; 302:550.
  34. Nemiah JC. A reconsideration of psychological specificity in psychosomatic disorders. Psychother Psychosom 1982; 38:39.
  35. Noyes R Jr, Stuart SP, Watson DB. A reconceptualization of the somatoform disorders. Psychosomatics 2008; 49:14.
  36. Rief W, Broadbent E. Explaining medically unexplained symptoms-models and mechanisms. Clin Psychol Rev 2007; 27:821.
  37. Waddell G, Bircher M, Finlayson D, Main CJ. Symptoms and signs: physical disease or illness behaviour? Br Med J (Clin Res Ed) 1984; 289:739.
  38. Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993; 52:157.
  39. Barsky AJ, Wyshak G. Hypochondriasis and somatosensory amplification. Br J Psychiatry 1990; 157:404.
  40. Steinhausen HC, Winkler Metzke C. Continuity of functional-somatic symptoms from late childhood to young adulthood in a community sample. J Child Psychol Psychiatry 2007; 48:508.
  41. Dhossche D, Ferdinand R, van der Ende J, Verhulst F. Outcome of self-reported functional-somatic symptoms in a community sample of adolescents. Ann Clin Psychiatry 2001; 13:191.
  42. Janca A, Isaac M, Ventouras J. Towards better understanding and management of somatoform disorders. Int Rev Psychiatry 2006; 18:5.
  43. Simon GE, VonKorff M, Piccinelli M, et al. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999; 341:1329.
  44. Zaroff CM, Davis JM, Chio PH, Madhavan D. Somatic presentations of distress in China. Aust N Z J Psychiatry 2012; 46:1053.
  45. Hoedeman, R, Blankenstein, NA, van der Feltz-Cornelis, CM, et al. Consultation letters for medically unexplained physical symptoms. Cochrane Database of Syst Rev 2007; :CD006524.
  46. Fink P, Steen Hansen M, Søndergaard L. Somatoform disorders among first-time referrals to a neurology service. Psychosomatics 2005; 46:540.
  47. Tomenson B, Essau C, Jacobi F, et al. Total somatic symptom score as a predictor of health outcome in somatic symptom disorders. Br J Psychiatry 2013; 203:373.
  48. Sharpe M. Somatic symptoms: beyond 'medically unexplained'. Br J Psychiatry 2013; 203:320.
  49. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient: prevalence, psychopathology, and functional impairment. J Gen Intern Med 1996; 11:1.
  50. Hahn SR, Thompson KS, Wills TA, et al. The difficult doctor-patient relationship: somatization, personality and psychopathology. J Clin Epidemiol 1994; 47:647.
  51. Mari F, Di Bonaventura C, Vanacore N, et al. Video-EEG study of psychogenic nonepileptic seizures: differential characteristics in patients with and without epilepsy. Epilepsia 2006; 47 Suppl 5:64.
  52. Kroenke K, Spitzer RL, Williams JB, et al. Physical symptoms in primary care. Predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994; 3:774.
  53. Clarke DM, Piterman L, Byrne CJ, Austin DW. Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice. Med J Aust 2008; 189:560.
  54. Rost KM, Akins RN, Brown FW, Smith GR. The comorbidity of DSM-III-R personality disorders in somatization disorder. Gen Hosp Psychiatry 1992; 14:322.
  55. Hasin D, Katz H. Somatoform and substance use disorders. Psychosom Med 2007; 69:870.
  56. Dimsdale JE, Dantzer R. A biological substrate for somatoform disorders: importance of pathophysiology. Psychosom Med 2007; 69:850.
  57. Bensing JM, Verhaak PF. Somatisation: a joint responsibility of doctor and patient. Lancet 2006; 367:452.
  58. Ring A, Dowrick CF, Humphris GM, et al. The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Soc Sci Med 2005; 61:1505.
  59. Spiegel BM, Kanwal F, Naliboff B, Mayer E. The impact of somatization on the use of gastrointestinal health-care resources in patients with irritable bowel syndrome. Am J Gastroenterol 2005; 100:2262.
  60. Bi X, Moos RH, Timko C, Cronkite RC. Family conflict and somatic symptoms over 10 years: a growth mixture model analysis. J Psychosom Res 2015; 78:459.
  61. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and "hysteria". BMJ 2005; 331:989.
  62. Kroenke K. Diagnostic testing and the illusory reassurance of normal results: comment on "Reassurance after diagnostic testing with a low pretest probability of serious disease". JAMA Intern Med 2013; 173:416.
  63. Rolfe A, Burton C. Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis. JAMA Intern Med 2013; 173:407.
  64. Greene RL. The relative efficacy of F-K and the obvious and subtle scales to detect overreporting of psychopathology on the MMPI. J Clin Psychol 1988; 44:152.
  65. Hathaway SR, McKinley JC. Minnesota Multiphasic Inventory Manual, Psychological Corp, New York 1983.
  66. Greene RL. Assessment of malingering and defensiveness by objective personality inventories. In: Clinical Assessment of Malingering and Deception, Rogers R. (Ed), Guilford Press, New York 1988. p.124.
  67. Faust D. The detection of deception. In: Neurologic Clinics, Malingering and Conversion Reactions, Weintraub SM. (Ed), Saunders, Philadelphia 1995. p.255.
  68. Clarkin JF, Howieson DB, McClough J. The role of psychiatric measures in assessment and treatment. In: The American Psychiatric Publishing Textbook of Psychiatry, 5th ed, Hales RE, Yudofsky SC, Gabbard GO. (Eds), American Psychiatric Publishing, Washington, DC 2008. p.73.
  69. Dimsdale J, Creed F, DSM-V Workgroup on Somatic Symptom Disorders. The proposed diagnosis of somatic symptom disorders in DSM-V to replace somatoform disorders in DSM-IV--a preliminary report. J Psychosom Res 2009; 66:473.
  70. Sharpe M, Carson A. "Unexplained" somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med 2001; 134:926.
  71. Epstein RM, Quill TE, McWhinney IR. Somatization reconsidered: incorporating the patient's experience of illness. Arch Intern Med 1999; 159:215.
  72. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130:910.
  73. Gierk B, Kohlmann S, Kroenke K, et al. The somatic symptom scale-8 (SSS-8): a brief measure of somatic symptom burden. JAMA Intern Med 2014; 174:399.
  74. Barsky AJ. Assessing somatic symptoms in clinical practice. JAMA Intern Med 2014; 174:407.
  75. Toussaint A, Murray AM, Voigt K, et al. Development and Validation of the Somatic Symptom Disorder-B Criteria Scale (SSD-12). Psychosom Med 2016; 78:5.
  76. Barsky AJ. Assessing the New DSM-5 Diagnosis of Somatic Symptom Disorder. Psychosom Med 2016; 78:2.
  77. Herzog A, Voigt K, Meyer B, et al. Psychological and interactional characteristics of patients with somatoform disorders: Validation of the Somatic Symptoms Experiences Questionnaire (SSEQ) in a clinical psychosomatic population. J Psychosom Res 2015; 78:553.
  78. Barsky AJ, Stern TA, Greenberg DB, Cassem NH. Functional and somatic symptoms and somatoform disorders. In: Massachusetts General Hospital Handbook of General Hospital Psychiatry, 4th ed, Cassem NH, Stern TA, Rosenbaum JF, Jellinek MS. (Eds), Mosby, New York 1997. p.305.
  79. Feldman MD, Ford CV. Patient or Pretender: Inside the Strange World of Factitious Disorders, John Wiley and Sons, New York 1995.
  80. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999; 282:1737.
  81. Grassi L, Caruso R, Nanni MG. Somatization and somatic symptom presentation in cancer: a neglected area. Int Rev Psychiatry 2013; 25:41.