SYMPTOMATOLOGY AND COMORBIDITY OF SOMATIZATION DISORDER AMONGST GENERAL OUTPATIENTS ATTENDING A FAMILY MEDICINE CLINIC IN SOUTH WEST NIGERIA.

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A.M. Obimakinde¹, M.M. Ladipo² and A.E. Irabor³

1. General Outpatients Department, Ekiti State University Teaching Hospital, Ekiti State, Nigeria.
2. General Outpatients Department, University College Hospital, Ibadan.
3. Family Physician Department, University College Hospital, Ibadan, Oyo State, Nigeria.

Abstract

Background: Individuals with somatization may be the most difficult to manage because of the diverse and frequent complaints across many organ systems. They often use impressionistic language to describe circumstantial symptoms which though bizarre, may resemble genuine diseases. The disorder is best understood in the context “illness” behaviour, masking underlying mental disorder, manifesting solely as somatic symptoms or with comorbidity.

Objective: To evaluate somatization symptoms and explore its comorbidity in order to improve the management of these patients.

Methods: A cross-sectional survey of 60 somatizing patients who were part of a case-control study, selected by consecutive sampling of 2668 patients who presented at the Family Medicine Clinic of University College Hospital Ibadan, Nigeria between May-August 2009. Data was collected using the ICPC-2, WHO- Screener and Diagnostic Schedule and analysed with SPSS 16.

Results: There were at least 5 symptoms of somatization in 93.3% of the patients who were mostly females. Majority had crawling sensation, “headache”, unexplained limb ache, pounding heart, lump in the throat and insomnia. The mean age at onset was 35yrs with 90% having recurrence of at least 10yrs. Approximately 54% had comorbidity with cardiovascular disease being the most prevalent.

Conclusions: The study revealed that somatization is not a specific disease but one with a spectrum of expression. This supports proposition that features for the diagnosis of somatization could be presence of three or more vague symptoms and a chronic course lasting over two years. It is important to be conversant with pattern of symptoms and possible comorbidity for effective management of these patients.

Keyword: Somatization, Bizarre Symptoms, Comorbidity, Crawling sensation

Introduction

Somatization disorder constitutes majority of the somatoform ailments and is at the extreme end of severity of this group of disorders.¹ The more common somatization pattern seen in outpatient settings may not reach the diagnostic threshold but are clinically and functionally significant.1 The medical histories are often circumstantial, inconsistent and disorganized.² The symptoms are non-specific in character, of low diagnostic value and some patients may exhibit ‘la belle indifference’ which is astounding discrepancy between their behaviour and subjective complaint.³ The disorder is associated more with emotional regulation and brain function, other than the area of the body that has become the focus of the patient’s attention.⁴ The presenting complaint varies throughout life and its nature varies with respect to the sociocultural environment and life experience of the patient. The complaints frequently include chronic pain, problems with the digestive system, nervous system and the reproductive system.⁵ Somatizing patients are unaware of their underlying psychiatric disturbance and are not deliberately faking their symptoms.⁴ The specific form of illness that surfaces reflects the patient’s conscious beliefs about how disease should present.⁵ How or why a patient chooses a specific symptom is also unclear, an explanation includes a symbolic connection to underlying conflict or alternatively, symptom modelling in which patients mimic somatic symptoms that have previously occurred in themselves or in a family member as a result of organic disease.⁶ These symptoms reflect a patient’s concept of sickness, rather than organically disturbed anatomy or physiology and so they appear bizarre to the attending physician.⁵

Somatization is not a specific disease but rather a process with a varied manifestation and doubt remain whether its classification really captures a uniform entity.⁷ The presence of more than three vague or exaggerated symptoms in different organ systems and a chronic course lasting over two years has been proposed for diagnosis.^3,7 Escobar et al, proposed the Somatic Symptoms Index (SSI),which required a history of six medically unexplained symptoms for women and four for men.^8,9 The risk of developing the disorder is higher in females and when confounded by emotional liability, the risk increases by six fold.⁵

The disorders can affect anyone of any age. Age incidence has been reported to vary from early childhood to mid-thirties, severity may fluctuate but symptoms persist for several years and complete relief for an extended period is rare.^2,10 It is said that these patients have a lifetime median of 22 admissions distributed all over medical and surgical specialties.¹¹ It is noted too that cases of depression and anxiety disorders may present to family physicians with nonspecific somatic symptoms similar to those of somatization.⁷

The family physician frequently attends to patients with unexplained medical symptoms. These may either be patients with no physical disease, or those with coexisting physical disease that does not account for the presenting symptoms. Somatization is often a diagnosis of exclusion, which can be costly and frustrating in patients with multiple and chronic complaints.^4,7 The challenge in working with these patients is to simultaneously exclude medical causes for physical symptoms while considering a mental health diagnosis.^1,7 Medical training emphasizes the management of organic problems and may leave physicians unprepared to recognize or address somatoform complaints.^1,2 It is not helpful to tell these patients that their symptoms are imaginary, as it is recognized that true physical symptoms can result from psychological stress.⁵ Physicians should prevent iatrogenic harm especially when new symptoms arise, limited physical examination and invasive diagnostic or therapeutic procedures should be permitted only on objective evidence.^3,7,12

Painstakingly attending to these patients can be rewarding for both the patients and the health care system, as the patient goes away feeling good with eventual better prognosis. The attending physician then reduces the peculiar burden these patients can be to the health system especially in the area of repeated unsatisfactory visit and seemingly ineffective treatment plan.