What's ‘in the body’ is actually ‘in the mind’!

Of the many controversies, debates, confusions and disagreements the term ‘somatic symptoms’ means different symptoms to different professionals across the world and in major classifications. What are ‘somatic symptoms’—bodily symptoms or melancholic features? Whereas the DSM IV includes changes in appetite and weight, sleep disturbances, lack of concentration or diminished ability to think or indecisiveness as somatic symptoms, most clinicians and patients talk about headache, body ache, fatigue, tiredness, bodily sensations and other sensory changes. Melancholic features like diurnal variation, early awakening, and retardation are also referred to as somatic symptoms when sub-classifying major depressive disorders.

Diagnostic uncertainty of the somatoform disorders has been another issue. The reluctance of clinicians in acceptance of somatoform disorders and its sneaking into psychiatric classifications has not resolved any controversy.

Uncertainty about the nature of somatic symptoms itself has been rift with controversy—as absence of organic pathology implies a lack of sensitive and appropriate investigations to explain the pathology, for example, computerized tomography, magnetic resonance imaging, and computerized thermography have explained many an unexplained pathology. There are Somatic Inkblot Tests (Cassell, [1990]), like the Rorscharch inkblots, to help psychologists understand the meaning and genesis of somatic symptoms for the individual. One wonders whether there is a need for a somatometer! Would somatic symptoms still be considered as symptoms which cannot be measured or are unexplained medically, once future investigations are able to measure or explain them? Further, even clinically, there is little agreement about the number of somatic symptoms and their relation to somatoform disorders—somatoform pain disorder may have just one symptom, where as somatization disorder may have more than a dozen symptoms!

One approach to understanding somatizing behaviours is to consider the somatic language of patients as a form of communication, even though it may be concrete and lacking symbolic psychological abstraction (Stoudemire, [1991]). This way, somatizing patients may be understood as communicating their subjective perceptions of somatic sensations that accompany their affective distress. This communicative function of the somatic language employed by the somatizing patient has been termed somatothymia by Stoudemire ([1991]). On similar lines persons may have alexisomia, a difficulty in the awareness and expression of bodily feelings (Ikemi & Ikemi, [1986]), and hence ignore the somatic manifestations and verbalize the affective, cognitive experiences.

The help-seeking behaviour of persons with somatoform disorders is difficult to understand due to the attitudes of the professionals. The patients do not understand that their physicians do not understand their problems, let alone the illness. Even in this high-tech era there are no ways to explain or understand the pathophysiological mechanisms underlying the complex symptoms (which have no reason to be there, from the physician's point of view). The doctors search for gains for the patient, little realizing that the main gain is perhaps relief of symptom, understanding their symptom and explaining it to them. Patients’ points of view or evaluation and their experiences need to be given due importance. The degree of discrepancy between somatic pathology and patients’ reactions is a complex phenomenon based on multiple factors, many of which are addressed in this special issue of the International Review of Psychiatry.

This special issue is unique in a number of ways. It has perspectives from leading professionals from different parts of the world—Japan, Germany, Australia, Canada, UK, and the India-Pakistan subcontinent. It also has reviews related to somatization in organ systems less talked about like dermatology, diseases where somatization is not expected like cancer, and environments where it has been less studied, like the workplace. There are, in addition, reviews on recent advances in understanding the formation of symptoms or nature of symptoms—identification, symbolism, past memories, childhood experiences, illness behaviour, somatic amplification, sensory distortions, and somatic focusing.

The category of somatoform disorders lies on the boundary between somatic medicine and psychiatry. Ever since its inception as a separate diagnostic category, the classification and operationalization of somatoform disorders has drawn much debate and controversies. In this issue, Janca, Isaac and Ventouros have reviewed the developments in the understanding and management of somatoform disorders. Their review covers the field from a number of different perspectives including epidemiological (in terms of prevalence and variations across cultures), conceptual, terminological and nosological aspects, service use and related health care costs, and development and evaluation of novel treatment and management strategies. There is an almost unanimous agreement amongst clinicians and researchers working in this area that the concept of somatization and its operationalization into the categories of somatoform disorders should be substantially revised prior to their inclusion and placement in the next revision of the international classificatory systems in psychiatry and medicine.

In terms of aetiology, there is a strong presumption that multiple factors make a contribution, including both biological and psychosocial risk factors. Regarding psychological factors there is increasing evidence that somatoform disorders are linked to dysfunction in personality. Among the various personality traits emotion-regulation focus, as well as interpersonal personality traits, have been placed in a central position in influencing symptom reporting and help-seeking behaviour. An overview of contemporary theories in the field of psychosomatic medicine that links deficits in emotion-regulation to the process of somatization has been presented by Waller and Scheidt. They review recent empirical research that focuses on the association between affect regulation and somatoform disorders, with an emphasis on studies investigating the alexithymia construct.

Somatic symptoms have been conceptualized in many different ways in the literature. Current classifications mainly focus on the numbers of symptoms, with relative neglect of the underlying psychopathology. Researchers have emphasized the importance of a number of experiential, perceptual and cognitive-behavioural aspects of somatization. A review focusing on the existing literature on the role of somatosensory amplification, attribution styles, and illness behaviour in somatization has been presented by Duddu et al. A role for both somatosensory amplification as well as attribution styles in the somatizing process, along with other factors like emotional state, cultural background, and quality of the doctor-patient interaction, neuroticism, negative affectivity, and illness behaviour could also have an important influence.

Shima and Satoh have pointed out the paucity of the literature related to somatoform disorders in the workplace, although these disorders should be paid enough attention by mental health professionals in the workplace as well as employers. They report the findings of a large survey where they observed that employees with neurotic states manifested physical symptoms more frequently than those without. Young employees reported physical symptoms more frequently including general malaise, nausea, constipation, diarrhoea, headache, stiff shoulder, and dizziness. Shima and Satoh call for a rational new classificatory system to tackle the important psychopathology often seen among employees.

A wide range of somatization related symptoms are encountered in dermatology, asserts the review by Gupta, which is well illustrated by interesting case examples. These include the unexplained cutaneous sensory syndromes, especially the cutaneous dysesthesias, associated with pain, numbness and pruritus. Somatization can also present as ‘dermatological non-disease’ and body dysmorphic disorder where the patient is excessively preoccupied by a minimal or imagined ‘defect’ in their appearance, and has little psychological insight.

Somatic symptoms and the process of somatization are of importance in cancer patients since it contributes to their suffering. It is likely that one may attribute somatic symptoms wrongly to cancer resulting in not only neglect of important psychological, and social aspects of aetiology and management of cancer, but also taking inappropriate steps to treat the cancer even more aggressively. These aspects have been dealt with in the review by Chaturvedi, Maguire and Somashekar.

In non-Western cultures, most individuals with mental disorders spontaneously express their experience not in psychological symptoms, but as somatic complaints. Therefore, if a screening instrument or a case finding method is based primarily on psychiatric symptoms, then many cases of affective disorders are likely to be missed by researchers. Minhas and Nizami have elucidated how in Pakistan research has been done using scales and methods that entertain the somatic complaints of the patients.

The somatoform disorders are a disabling group of conditions occurring with high frequency in both general practice and hospital environments. Consultation-liaison teams operate within and amongst medical and surgical teams, gaining an understanding of how they operate, and the unique emotional problems troubling the patient in the general hospital. They have expertise in the assessment, treatment and management of medically unexplained symptoms. It is these aspects of their practice that allows them to coordinate and treat individuals with somatoform disorders. Because of their place within the medical structure, they are ideally placed to lead research into somatoform disorders and therefore to address the concerns expressed about the relative lack of research in this area. A review of the role of consultation liaison psychiatry has been presented by Jorsh.

The behavioural mechanisms and applications of cognitive-behavioural therapeutic (CBT) intervention of somatoform disorders are reviewed by Tazaki and Kenneth. Somatoform disorders can be explained in the process of both respondent and operant conditioning. Patients with somatoform disorders may have some conditioned reflex due to a particular situation. The causes of somatoform disorders are not always clear; CBT can be suitable for treatment because CBT intervention need not assume a psychological aetiology of the illness. Cognitive-behavioural therapeutic intervention would seem to be acceptable to patients of somatoform disorders when presented as a means of coping with physical problems. In CBT intervention, at first, automatic thoughts and distortions of perceived physical sensations are modified, and subsequently, sensations are reattributed to ordinary events while undesirable behaviours are modified by changing reinforcement contingencies. Randomized controlled trials are limited, but the efficacy of the intervention is quite impressive. However, since most of the studies use multiple treatment strategies, the differential treatment effects are unknown, and no standardized treatment methods have been established, therefore it would be difficult to apply them in a clinical setting. Patients with persistent somatization are often observed to demonstrate abnormal illness behaviour. The co-existence of somatization and abnormal illness behaviour is well known, but the exact cause-effect or any other relationship is not fully understood. This review examines the available evidence to understand these two clinically important, common and inter-related phenomena, their measurements and management.

Finally, one wonders about psychological symptoms in medical disorders as compared to somatic symptoms in psychiatric disorders—is there an analogy? Do the psychological symptoms associated with hypertension, cancer or meningitis raise as much controversy as somatic symptoms in relation to psychological disturbances? Hopefully, this issue on somatoform disorders will generate more discussion and debate before heading to some consensus.