Somatization disorder

Somatization disorder is a psychiatric condition marked by multiple medically unexplained physical, or somatic, symptoms. In order to qualify for the diagnosis of somatization disorder, somatic complaints must be serious enough to interfere significantly with a person's ability to perform important activities, such as work, school or family and social responsibilities, or lead the person experiencing the symptoms to seek medical treatment.

Somatization disorder has long been recognized by psychiatrists and psychologists, and was originally called Briquet's syndrome in honor of Paul Briquet, a French physician who first described the disorder in the nineteenth century. It is included in the category of somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the professional handbook that aids clinicians in diagnosing patients' mental disorders. The term "somatoform" means that the physical symptoms have a psychological origin.

Individuals with somatization disorder suffer from a number of vague physical symptoms, involving at least four different physical functions or parts of the body. The physical symptoms that characterize somatization disorder cannot be attributed to medical conditions or to the use of drugs, and individuals with somatization disorder often undergo numerous medical tests (with negative results) before the psychological cause of their distress is identified. They often use impressionistic and colorful language to describe their symptoms, describing burning sensations, pains that move from place to place, strange tastes on the tongue, tingling, or tremors. While many symptoms resemble those associated with genuine diseases, some of the symptoms reported by people with somatization disorder are not. The individual usually visits many different physicians, but the information they provide about the patient's symptoms can be inconsistent. It is important to note that while the physical symptoms of somatization disorder frequently lack medical explanations, they are not intentionally fabricated. The typical person with somatization disorder has suffered from physical pain, discomfort, and dysfunction for an extended period of time and consulted several doctors; they are hopeful that they one can be found who can identify the cause of their illness and provide relief.

Somatization disorder can be dangerous, since patients may end up taking several different medications, thereby risking harmful drug interactions.

Symptoms 

Gastrointestinal (GI) complaints, such as nausea, bloating, diarrhea, and sensitivities to certain foods are common, and at least two different GI symptoms are required for the diagnosis. Sexual or reproductive symptoms, including pain during intercourse, menstrual problems, and erectile dysfunction are also necessary features for a diagnosis for somatization disorder. Other frequent symptoms are headaches, pain in the back or joints, difficulty swallowing or speaking, and urinary retention. To qualify for the diagnosis, at least one symptom must resemble a neurological disorder, such as seizures , problems with coordination or balance, or paralysis.

To receive a diagnosis of somatization disorder, the individual must have a history of multiple physical complaints that began before age 30 and that continued for several years ( DSM-IV-TR ). These symptoms must cause significant impairment to social, occupational or other areas of functioning—or lead the patient to seek medical treatment.

Each of the following four criteria must be met.

• The individual must report a history of pain affecting at least four different parts or functions of the body. Examples include headaches, back, joint, chest or abdominal pain, or pain during menstruation or sexual intercourse.
• A history of at least two gastrointestinal symptoms, such as nausea, bloating, vomiting, diarrhea, or food intolerance must be reported.
• There must be a history of at least one sexual or reproductive symptom, such as lack of interest in sex, problems achieving erection or ejaculation, irregular menstrual periods, excessive menstrual bleeding, or vomiting throughout pregnancy.
• One symptom must mimic a neurological condition. Examples include weakness, paralysis, problems with balance or coordination, seizures, hallucinations , loss of sensations such as touch, seeing, hearing, tasting, smelling—or difficulty swallowing or speaking, or amnesia and loss of consciousness. Pseudo-neurologic symptoms like these are the primary characteristics of another somatoform disorder known as "conversion disorder."

If a thorough medical evaluation reveals no evidence of an underlying medical- or drug- or medication-induced condition, the diagnosis of somatization disorder is likely. People with genuine medical conditions can qualify for the diagnosis if the level of functional impairment reported is more than would be expected based on medical findings. The symptoms must not be intentionally produced. If the patient is feigning symptoms, a diagnosis of factitious disorder or malingering would most likely be considered.

Treatments 

Cognitive behavior therapy

Cognitive-behavioral therapy (CBT) for somatization disorder focuses on changing negative patterns of thoughts, feelings, and behavior that contribute to somatic symptoms. The cognitive component of the treatment focuses on helping patients identify dysfunctional thinking about physical sensations. With practice, patients learn to recognize catastrophic thinking and develop more rational explanations for their feelings. The behavioral component aims to increase activity. Patients with somatization disorder have usually reduced their activity levels as a result of discomfort or out of fear that activity will worsen symptoms. CBT patients are instructed to increase activity gradually while avoiding overexertion that could reinforce fears. Other important types of treatment include relaxation training, sleep hygiene, and communication skills training. Preliminary findings suggest that CBT may help reduce distress and discomfort associated with somatic symptoms; however, it has not yet been systematically compared with other forms of therapy.

Medications

Antidepressant medications may help to alleviate symptoms of somatization disorder. According to one study, patients with somatization disorder who took the antidepressant nefazodone (Serzone) showed reductions in physical symptoms, increased activity levels, and lower levels of anxiety and depression at the end of treatment.

Trichotillomania

Trichotillomania (trik-o-til-o-MAY-ne-uh) is an irresistible urge to pull out hair from your scalp, eyebrows or other areas of your body. Hair pulling from the scalp often leaves patchy bald spots, which people with trichotillomania may go to great lengths to disguise.

For some people, trichotillomania may be mild and generally manageable. For others, the urge to pull hair is overwhelming and can be accompanied by considerable distress. Some treatment options have helped many people reduce their hair pulling or stop entirely.

Signs and symptoms of trichotillomania often include:

• Repeatedly pulling your hair out, typically from your scalp, eyebrows or eyelashes, but it can be from other body areas as well
• A strong urge to pull hair, followed by feelings of relief after the hair is pulled
• Patchy bald areas on the scalp or other areas of your body
• Sparse or missing eyelashes or eyebrows
• Chewing or eating pulled-out hair
• Playing with pulled-out hair
• Rubbing pulled-out hair across your lips or face

Most people with trichotillomania pull hair in private and generally try to hide the disorder from others.

For some people, hair pulling is intentional and focused. They're aware that they're pulling their hair out and may even develop elaborate rituals for doing so. Other people pull their hair unconsciously. The same person may also do both, depending on the situation and mood. For example, focused hair pulling may occur when you're frustrated in the car. Or you may unconsciously pull hair when you're bored. Certain positions or rituals may trigger hair pulling, such as resting your head on your hand or brushing your hair.

Your doctor will perform a thorough evaluation to determine if you have trichotillomania, which may include examining how much hair loss you have, having you fill out a questionnaire and eliminating other possible causes of hair pulling or hair loss. In some cases, your doctor may also take a biopsy of your hair or skin to try to pinpoint the problem.

To be diagnosed with trichotillomania, you must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association.

DSM criteria for the diagnosis of trichotillomania include:

• Repeatedly pulling out your hair, resulting in noticeable hair loss
• An increasing sense of tension before pulling, or when you try to resist pulling
• Pleasure or relief when pulling
• Your hair loss isn't attributed to another medical or dermatologic condition
• Hair pulling causes you significant distress

There is some debate among mental health providers — and people with trichotillomania — about these criteria, and they may change in the future.

Research on treatment of trichotillomania is limited. Current approaches focus on:

Psychotherapy. A form of psychotherapy called habit reversal training may be an effective treatment for trichotillomania. This type of therapy helps you learn how to recognize situations where you're likely to pull and how to substitute other behaviors instead, such as clenching your fists for a period to "freeze" the urge, or redirecting your hand from your hair to your ear. Sometimes elements of other therapies may be blended with habit reversal training. For instance, your care provider may use cognitive therapy to help you challenge and examine distorted beliefs you may have in relation to hair pulling. Another treatment, acceptance and commitment therapy (ACT), helps people learn to accept their hair-pulling urges while at the same time teaching them how to avoid acting on their impulses.

Medications. Your doctor may also recommend that you take an antidepressant, such as clomipramine (Anafranil).