History

Fact Explanation
Pain This is a common symptom at presentation. Patients may complain of abdominal pain, knee pain or limb pain, however there is no specific underlying cause. They have potential to be worsened by iatrogenic factors such as disturbed sleep . The symptoms can't be traced back to any physical cause. Symptoms are not the result of substance abuse or another mental illness. It may be result of repressed emotions or due to persistent psychological stress. People with somatoform disorders are generally not faking their symptoms. The pain and other problems they experience are real. The symptoms can significantly affect daily functioning.[3]
Fatigue This is common , and unexplained by other medical causes.[3] Especially present as chronic fatigue syndrome.The symptoms can't be traced back to any physical cause, and they are not the result of substance abuse or another mental illness.
Loss of appetite Associated with loss of weight, is one of the common complaint [3]The symptoms can't be traced back to any physical cause. And they are not the result of substance abuse or another mental illness.
Gastrointestinal symptoms such as loose stools , constipation, early satiety, regurgitation etc. Gastrointestinal distress is a common presentation it often points towards medical diseases like Crohn's disease or Rectal Carcinoma. [4] The symptoms can't be traced back to any physical cause. And they are not the result of substance abuse or another mental illness.
Urinary symptoms such as retention or frequency Non specified urinary symptoms such as retention, increased frequency are common presenting symptoms which often confused with lower urinary tract symptoms. [1],[3]
Signs of pregnancy: including an expanding abdomen; feeling labor pains, nausea, breast changes, fetal movement; breast changes; and cessation of the menstrual period This is the mistaken belief of being pregnant based on other signs of pregnancy, this is known as pseudocyesis. [6] The symptoms can't be traced back to any physical cause. And they are not the result of substance abuse or another mental illness.
References
  1. YEUNG A, DEGUANG H. Somatoform disorders West J Med [online] 2002 Sep, 176(4):253-256 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071744
  2. KALLIVAYALIL RA, PUNNOOSE VP. Understanding and managing somatoform disorders: Making sense of non-sense Indian J Psychiatry [online] 2010 Jan, 52(Suppl1):S240-S245 [viewed 02 July 2014] Available from: doi:10.4103/0019-5545.69239
  3. DIMSDALE JE, DANTZER R. A Biological Substrate for Somatoform Disorders: Importance of Pathophysiology Psychosom Med [online] 2007 Dec, 69(9):850-854 [viewed 03 July 2014] Available from: doi:10.1097/PSY.0b013e31815b00e7
  4. GABEL K, COUTURIER J, GRANT C, JOHNSON-RAMGEET N. Delayed Diagnosis of Crohn's Disease in an Adolescent: Psychiatric Implications J Can Acad Child Adolesc Psychiatry [online] 2010 Aug, 19(3):209-211 [viewed 03 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938754
  5. AL BUSAIDI ZQ. The Concept of Somatisation: A Cross-cultural perspective Sultan Qaboos Univ Med J [online] 2010 Aug, 10(2):180-186 [viewed 03 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074701
  6. YADAV T, BALHARA YP, KATARIA DK. Pseudocyesis Versus Delusion of Pregnancy: Differential Diagnoses to be Kept in Mind Indian J Psychol Med [online] 2012, 34(1):82-84 [viewed 03 July 2014] Available from: doi:10.4103/0253-7176.96167

Examination

Fact Explanation
General Appearance Normal[3]
Attitude and behaviour [3] Attitude is appropriate Behavior demonstrates preoccupation with physical complaints and symptoms[1]
Speech Normal[3]
Mood [3] Mildly anxious and depressed. Depression and anxiety are commonly associated with somatoform disorder [2]
Thoughts [3] form of thoughts and thought content are normal
Perception Normal [3]
Attention and concentration- Within normal range. [3] Can be tested by asking the patient to tell the days of week or months of year backwards, or with the serial sevens test.
Memory [3] Both long and short term memory are preserved and within normal range
Orientation Oriented to time, place, and person[3]
Insight impaired [3]. Insight appears limited in that non medical causes of symptoms are not considered; however judgment appears unimpaired. [1]
References
  1. AL BUSAIDI ZQ. The Concept of Somatisation: A Cross-cultural perspective Sultan Qaboos Univ Med J [online] 2010 Aug, 10(2):180-186 [viewed 03 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074701
  2. MAHARAJ R, ALEXANDER C, BRIDGLAL CH, EDWARDS A, MOHAMMED H, RAMPAUL T, SANCHEZ S, TANWING G, THOMAS K. Somatoform disorders among patients attending walk-in clinics in Trinidad: prevalence and association with depression and anxiety Ment Health Fam Med [online] 2013 Jun, 10(2):81-88 [viewed 03 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822639
  3. MORIARTY J. RECOGNISING AND EVALUATING DISORDERED MENTAL STATES: A GUIDE FOR NEUROLOGISTS J Neurol Neurosurg Psychiatry [online] 2005 Mar, 76(Suppl 1):i39-i44 [viewed 03 July 2014] Available from: doi:10.1136/jnnp.2004.06043

Differential Diagnoses

Fact Explanation
Probable organic causes This should be the first possibility that should be considered. The patient might be actually having an undiagnosed medical condition. Work up should be carried out according to the presenting symptoms in order to exclude any organic causes.
Depression with somatic symtoms Depression is known to cause somatic symptoms such as burning sensation of the body or aches and pain. History and mental state examination will reveal positive findings towards depression such as loss of energy, low mood, loss of interest etc.[1]
Anxiety disorders Patient can present with symptoms such as fatigue, chest tightness, breathlessness which are unexplained medically. Detailed history will reveal specific fear, underlying feeling of death will point towards an anxiety disorder.[1][2]
Substance abuse diorder Substance abuse comes with multiple somatic symptoms . Especially with alcohol abuse eg: numbness, aches , insomnia, palpitations, etc. careful history and examination will lead to differentiation.[3][4]
Malingering disorder Malingering is the intentional production or feigning of either physical or psychological symptoms or disabilities. In somatoform disorders patient does not fake or induce symptoms he actually feels them. Clue to the diagnosis is finding some sort of connection between symptoms and a medico legal cause. [1]
References
  1. YEUNG A, DEGUANG H. Somatoform disorders West J Med [online] 2002 Sep, 176(4):253-256 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071744
  2. BEESDO K, KNAPPE S, PINE DS. Anxiety and Anxiety Disorders in Children and Adolescents: Developmental Issues and Implications for DSM-V Psychiatr Clin North Am [online] 2009 Sep, 32(3):483-524 [viewed 02 July 2014] Available from: doi:10.1016/j.psc.2009.06.002
  3. BRADY KT, HAYNES LF, HARTWELL KJ, KILLEEN TK. Substance Use Disorders and Anxiety: A Treatment Challenge for Social Workers Soc Work Public Health [online] 2013, 28(0):407-423 [viewed 02 July 2014] Available from: doi:10.1080/19371918.2013.774675
  4. ALAVI SS, FERDOSI M, JANNATIFARD F, ESLAMI M, ALAGHEMANDAN H, SETARE M. Behavioral Addiction versus Substance Addiction: Correspondence of Psychiatric and Psychological Views Int J Prev Med [online] 2012 Apr, 3(4):290-294 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3354400
  5. KRASNIK C, GRANT C. Conversion disorder: Not a malingering matter Paediatr Child Health [online] 2012 May, 17(5):246 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3381915

Investigations - for Diagnosis

Fact Explanation
When patient presents with symptoms, relevant investigations should be carried out in order to exclude probable medical conditions that can cause a similar kind of presentation. Investigations should be tailored to the patient's presenting symptoms. In order to rule out an organic pathology.
References

Management - General Measures

Fact Explanation
Deciding the treatment setting Usually patients with somatoform disorder present to the outpatients department setting or to a General Practitioner. Patients should be managed in the same setting with the involvement of a psychiatrist. Patients with somatoform disorder very rarely need in patient care.[3]
Educating the patient. The doctor should show a genuine interest and be empathetic , respectful as well as non judgemental. Doctor has to accept that there is a problem with the patient which can not be explained medically and carefully elaborate the fact that psychological stress can make the patient ill.[1]
Treatment of coexisting psychiatrist disorder Depression and certain personality disorders co exist with somatoform disorders. Treatment for the underlying disorder is important[1]
Minimising the risk Patients with somatoform disorder tend to engage in doctor shopping for purposes of seeking medical reassurance. The condition should be carefully explained and there should be a caring, supportive environment. [1]
Supportive medications Supportive medications should be provided such as analgesics for pain or antispasmodics and antacids for abdominal discomfort, and short-term hypnotics for insomnia. [1][2]
References
  1. YEUNG A, DEGUANG H. Somatoform disorders West J Med [online] 2002 Sep, 176(4):253-256 [viewed 02 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071744
  2. KALLIVAYALIL RA, PUNNOOSE VP. Understanding and managing somatoform disorders: Making sense of non-sense Indian J Psychiatry [online] 2010 Jan, 52(Suppl1):S240-S245 [viewed 02 July 2014] Available from: doi:10.4103/0019-5545.69239
  3. OLIVER OYAMA, CATHERINE PALTOO, JULIAN GREENGOLD, Somatoform disorder:Am Fam Physician[online]. 2007 Nov 1;76(9):1333-1338.[viewed 02 July 2014] Available from:http://www.aafp.org/afp/2007/1101/p1333.html

Management - Specific Treatments

Fact Explanation
Physiotherapy This is specially recommended for patients with musculoskeletal pain. [1]
SSRI's Combination of the serotonin reuptake inhibitors (SSRI) such as citalopram with the atypical antidepressant paliperidone is more effective than citalopram alone for the treatment of somatoform disorder. [2]
Cognitive behaviour therapy Symptoms and anxiety about the symptoms arise from misinterpretation of bodily symptoms. Patients are taught to identify triggers , bodily symptoms and illness related thoughts. [3]
References
  1. KALLIVAYALIL RA, PUNNOOSE VP. Understanding and managing somatoform disorders: Making sense of non-sense Indian J Psychiatry [online] 2010 Jan, 52(Suppl1):S240-S245 [viewed 02 July 2014] Available from: doi:10.4103/0019-5545.69239
  2. HUANG M, LUO B, HU J, WEI N, CHEN L, WANG S, ZHOU W, HU S, XU Y. Combination of citalopram plus paliperidone is better than citalopram alone in the treatment of somatoform disorder: results of a 6-week randomized study. Int Clin Psychopharmacol [online] 2012 May, 27(3):151-8 [viewed 02 July 2014] Available from: doi:10.1097/YIC.0b013e328351c7e8
  3. PRAZERES AM, NASCIMENTO AL, FONTENELLE LF. Cognitive-behavioral therapy for body dysmorphic disorder: a review of its efficacy Neuropsychiatr Dis Treat [online] 2013:307-316 [viewed 02 July 2014] Available from: doi:10.2147/NDT.S41074