SOMATOFORM DISORDERS- DOCTOR SHOPPING?

Introduction:

It is not uncommon to find some patients regularly coming for consultation with vague/exaggerated, non specific multiple complaints. Most of these patients will have a thick file of investigation reports starting from simple blood tests till the latest invasive investigations like angiogram, colonoscopy, gastroscopy etc. Paradoxically none of these reports will reveal any abnormality or very minimal abnormality which is not proportionate to the patient’s clinical presentation. They keep on changing the doctors and system of medicine and rarely they are convinced with one doctor. They stick on to one doctor in the beginning, the moment doctor says there is no problem with them, they change the doctor. A busy practitioner may find such patients as problematic or wasting the precious consultation hours of other patients and to avoid them he may refer such patients another physician or specialist. Sometimes medical professionals exploit such patients by unnecessarily doing some surgeries or some procedures just for monitory purpose. These victims are called patients of somatoform disorders.

Somatoform patients:
If a patient presents with one or more physical complaints for which an adequate physical explanation cannot be found or complaints of the patient may seem greatly exaggerated in comparison with the minor physical or lab abnormalities that are identified then he/she is likely to be a patient of Somatoform disorder. In other words it is a tendency to experience and communicate psychologic distress through physical symptoms. Patients often have low self esteem; are self conscious, vulnerable to stress, anxious, hostile, depressed and are likely to be females. They resist any psychological explanation for their symptoms and usually refuse to see a psychiatrist or psychologist.
Doctor shopping is frequent in these patients. Iatrogenic complications can result from inappropriate prescription of narcotics or unnecessary surgeries.

Physician who suggests the symptoms are ” in the patients head” will be met with anger and rejection. The wise physician will not attempt to take away the patients symptoms but will instead translate the somatic symptoms in to what the patient needs.
Infact these patients often suffer from an inability to describe their feelings in words, a phenomenon known as ‘Alexithymia’.

Types of Somatoform disorders:

1. Somatization disorder.

2. Somatoform pain disorder.
3. Hypochondiasis.
4. Body dysmorphic syndrome.

1. SOMATIZATION DISORDER:
Chronic syndrome of multiple somatic symptoms that cannot be explained medically and is associated with psychological distress and medical help seeking.
The characteristic features of this condition is patient presents with the multiple physical complaints- which are vague, imprecise, inconsistent, disorganized, dramatic, emotional and describe these symptoms in very exaggerated manner and vivid and colorful language.

Commonest presentation:
1. Pain – in leg, back, joint, head etc
2. Gastrointestinal symptoms – pain abdomen, nausea, bloating, diarrhoea.
3. Cardiopulmonary symptoms- shortness of breath, dizziness, chest pain, palpitation.
4. Neurological symptoms – loss of voice, deafness, double vision, blindness, muscle weakness, dysphagia, amnesia.
5. Sexual symptoms- indifference, dysparaunia, impotence, painful periods etc.

So if the abovementioned multisystemic symptoms are present from a long time in a young (below 30) female, and if there has no attributable physical illness , but the symptoms have caused significant distress in the patients life style it is likely to be a somatization disorder. Most of these patients have attention seeking behavior with unstable home atmosphere and a positive family history of similar complaints.

Diagnosis:
Most of the time when a patient presents with a thick investigation file in his hand revealing no abnormality in any investigation report is likely to be patient of somatization disorder. In addition when the patient reveals multiple aches and pains, and other symptoms of long standing it supports the diagnosis. According to the textbook of psychiatry to call any patient having somatization disorder there should be,
-3-4 pain symptoms in different locations.
-2 neurological symptoms.
-One sexual symptoms.

On examination patient is anxious or depressed, dependent and self-centered personality, hungry for admiration and precise and manipulative.

2. SOMATOFORM PAIN DISORDER :
When the patient presents with severe and prolonged pain for which there is no medical explanation. It is commonly seen in women of age group 30-40 years with severe low backache, headache, atypical facial pain, and chronic pelvic pain. Severe continuous pain of 6 months duration with adequate medial explanation and pain is inconsistent with anatomical distribution.
Psychodynamic theory suggests that pain has unconscious meaning which originate in infantile and childhood experiences. Pain can function as a method of obtaining love, a punishment for wrongdoing. But patients deny any emotional factors and feel that life is blissful except for the pain.

Diagnosis:
Preoccupation with pains for at least 6 months and on examination no organic pathology or if there is some abnormality, symptoms are out of proportion to it and generally incapacitated by their problem.

3. HYPOCHONDRIASIS:
Fear of having or the belief that he or she has a serious disease. These patients have excessive concern about a disease. The fear or conviction of a disease is disabling and persists despite appropriate reassurance.
Pyshodynamic theroy :
Defence against the guilt, sense of innate badness, low self-esteem, excessive self-concern and past history of disappointment-rejection-loss, insolvable problems.
Unrealistic interpretation of physical symptoms and sensations leading to preoccupation with the fear or belief that one has serious disease. Eventhough no medical disease accounts for the physical signs and sensations. For e.g. a patient with chest pain thinks that he has some cardiac problems despite normal ECG , rational explanation and reassurance.

Age group : 4-5th decade; more common in men than women. Symptoms involving multiple organ systems and many anatomical locations. Generally fear of having gastrointestinal and cardiac disease.

4. BODY DYSMORPHIC SYNDROME:
Strong, nondelusional belief that a body part is misshapen or defective in some way. Such patients are normal or they may have some defect in their appearance in face, nose, hair or genitals. But patients think that they have a distorted, dirty appearance. Their anxiety is multiplied in social situations. They may seek the help of dermatologists or reconstructive surgeons for their deformity.
They remain anxious throughout or may avoid social gathering/public contact and may remain at home always.
For e.g. a small wart on nose- feels as if their nose appears very disfigured.
Negligible nasal deviation- feels as if distorted nose.
Some scar mark on face- feels as if their face is not presentable one. So when ever they speak to someone they become anxious or try to cover their so called distorted part.

MANAGEMENT:
General guidelines:
1. Establish a good rapport with the patient.
2. Once a stable doctor-patient relationship is established introduce the patient to the mind body concept.
3. Discuss the interaction between emotions and physical symptoms and explain physical symptoms using this concept.
4. Validate the symptom as “real”, don’t try to take it away from the patient.
5. Minimize medications especially those prone to cause physical dependence or abuse.
6. Medicate patients on a fixed schedule not as needed. This will reduce the patients need to have symptoms in order to receive the medications.
7. Maximize nonmedication modalities such as exercise, physical therapy, diet, yoga.
8. Schedule regular appointments for fixed periods of time, eventhough the patient is doing well. This helps to reduce the number of crisis visit.
9. Discourage “DOCTOR SHOPPING”. One doctor should be incharge of the patients overall care and management.
10. Minimize lab testing. Only do testing if symptoms are supported by objective evidence. Avoid performing any test for subjective complaints only.
11. All explanations should incorporate Mind-Body concept.

HOMOEOPATHIC APPROACH IN SOMATOFORM DISORDERS:
Dr Samuel Hahnemann in his Organon of Medicine 6th edition mentions some special guidelines for such patients. While giving the instructions for case taking he gives caution about 2 sets of difficult patients. One set of patients whom he called as Hypochondriacs and other set of patients as Indolent patients. So Hahnemann’s Hypochondriac patients are today’s somatoform patients.
In aphorism 96 of Organon of Medicine he says “so called Hypochondriacs and other persons of great sensitiveness and impatient of suffering, portray their symptoms in too vivid colours and in order to induce the physicians to give them relief, describe their ailments in exaggerated expressions.
In foot note to aphorism 96 he continues to write on such patients and emphasizes on following points.
1. He differentiates such patients from patients who feign to be ill or fabricating patients and from insane patients.
2. People who feign to be ill are doing it intentionally whereas hypochondriac will never feign, they just exaggerate their suffering to get maximum attention from the physician.
3. Physician must reassure without giving any medicine or give something quite unmedicinal.
4. To treat the portrait of their suffering the treating physician must deduct something from their exaggeration, at all events ascribe the strong character of their expression when taking of their ailments.

So Hahnemann’s instructions are very clear. We have to have a rational humanistic approach in such patients. The treatment planned should be aimed at treating the basic anxiety about health. Most of the somatoform patients have some significant life events. Like childhood trauma, unsolved mental conflicts should be explored to plan a more effective treatment.

Repertorial reference of Somatoform patients:
There are some rubrics in synthesis repertory that can be well-utilized in managing somatoform patients.
1. Mind, Hypochondriasis- Important drugs- Aur, Con, Ign, Mag M, Nit acid, Nat c, Nat Mur, Nux vom, Puls.
2. Mind, health, own– Important drugs- Arg met, Aur, Kali ars, Nat c, Nat mur, Nit acid, Nux vom, Phos acid, Phos, Puls, Sep.
3. Mind, Anxiety, Hypochondriacal– Imp remedies- Ars, Arg nit, Ars, Calc, Caust, Con, Ign, Iod, Kali ars, Kali carb, Lach, Nat mur, Nit acid, Nux vom, Phos acid, Phos, Puls, Sep.
4. Mind, anxiety, Hypochondriacal, read medical books; mania to : Calc, nux vom, Puls, staphy, sulph.
5. Mind, delusion– disease: every disease he has: Aur mur, Stram.
6. Mind, delusion, disease: incurable disease; he has an: Arg nit, Ign, Lach, Lil tig, Nit acid, Phos, Plumb, Podo, Stan.
7. Mind, Sensitive, complaints, to the most trifling: Nux vom.
8. Mind , Lamenting, Sickness : Acon, Ambr, Apis, bufo, Calad, Calc, Can ind, Canth, Carb veg, Caust, Con, Digit, Fl acid, Graph, Hyoscy, Ign, Lach, Lil tig, Lyc, Merc, Nat carb, Nat mur, Nit acid, Nux vom, Phos acid, Phos, Pic acid, Plat, Puls, Sep, Sil, Staph, Stram, Tarent, Ver.
9. Mind, Exaggerating : Agar, Calc, Plat, Stram.
10. Mind, Exaggerating, symptoms; her : Asaf, Cham, Plb.

Considering the above rubrics and its appropriate remedies a new rubric- Somatization can be added in the repertory in the chapter MIND. All the above mentioned rubrics can appear as subrubric under the main rubric, Somatization. At present we don’t have a common rubric which will fit in to the criteria of somatoform disorder. This rubric should be useful,
1. For a patient who has multiple unexplained nonspecific physical complaints?
2. Who keeps on changing the doctors, never satisfied in one?

Rubric: Somatization.
It should contain following medicines in different gradings.
3 marks : Calc, Ign, Nat mur, Nit acid, Nux vom, Phos.

2 marks :Amb gris, Ars, Arg nit,Apis, Asaf, Aur met, Carb veg, Caust, Cham, Con,Hyos,Lach, Lilium tig, Kali ars, Kali carb Phos acid, Pic acid, Plat, Puls, Sep, Sil, Staph, Ver.

1 mark :
Acon, Agar, Bufo, Can Ind, Dig, Flouric acid, Graph, Lyco, Merc, Nat carb, Plumb, Stan, Stram, Tarent.

Conclusion:

Somatoform disorder patients are on rise. Today’s modern living and competitive world has created many Hypochondriacs who are unable to explain their emotions through words and instead expresses through multiple physical complains. We have to minimize their doctor shopping. Homoeopathic approach is very friendly to somatoform patients. Our very approach of dealing with the patient (as laid by our master- Dr Hahnemann) like detailed case taking, careful listening, free from prejudice, establishing mind- body concept will definitely a great boon for such patients.