If you’ve ever had a stomachache before an exam or important meeting, or developed a headache during an argument, you have some idea of what somatization is. Although it’s common to experience these types of medically unexplained symptoms, such as pain and digestive upset under stress, somatization is often a part of serious disorders such as depression, anxiety, and schizophrenia.
“Somatization is a normal, daily experience. It’s highly situational, [with] marked individual differences and marked cultural differences, and associated clearly with psychosocial stress,” stated Normal Jensen, M.D., a professor at the University of Wisconsin in Madison. Jensen addressed an audience of physicians at the annual meeting of the American College of Physicians/American Society of Internal Medicine in Philadelphia last week.
Although “full blown” somatization disorder is fairly rare — less than two percent of Americans are diagnosed with it — Jensen explained that features of the disorder are common. “In primary care, anywhere up to three quarters of our patients have medically unexplained symptoms,” he reported. “The impact on health care services is HUGE.”
Physicians who see patients with complaints that can’t be explained are often distressed and frustrated, noted Jensen. And that frustration is shared by patients, who often consult a long series of physicians and specialists who fail to identify what’s wrong. Some doctors, Jensen said, may turn their frustration on the patient, telling them “it’s all in their head.”
But somatization, he emphasized, is real. Our understanding of pain and other somatic complaints has evolved in recent decades to reveal that sensations are affected by thoughts, emotions, and prior experience. In addition, new discoveries about the role of opioid receptors in the nervous system have provided increasing evidence for a physical basis for somatic complaints.
“Patients appreciate knowing that there are possible molecular and neurophysiological reasons for why their sensations vary from [those of] others, and within themselves from day to day,” Jensen explained.
Patients with these kinds of symptoms shouldn’t be told that there’s no physical reason for their complaints, said Jensen. “I tell them that in fact there is a good physiological reason for their symptoms. I tell them that ‘you’ve either acquired, or were born with, an abnormal nervous system.’ I tell them that ‘your nervous system is allowing you to feel sensations that normal people, or you when you are normal, don’t feel.’
“The nervous system quite naturally filters out unnecessary, confusing, distracting information,” Jensen continued. “Think how it would be if I was constantly aware of my clothes, and my watch, and my jewelry. If I had to process all that information all the time, what else would I be able to do? I wouldn’t even be able to read a book!”
One of the difficulties in treating patients with somatic symptoms is that many patients have an additional illness. “It’s not just somatization. It’s somatization with an anxiety disorder, or with a bad mood disorder, or a thought disorder, or a personality disorder,” said Jensen. He noted that he refers patients to psychiatrists when he wants “to be sure that there isn’t a comorbid condition… or when I want help with treating one of these disorders.”
Another concern, according to Jensen, is that one patient may consult a number of doctors, and specialists may diagnose serious medical conditions based on a patient’s complaints. “These people can get in trouble, because if you look closely enough at any of us, you’re going to find something wrong that could be treated,” he explained.
“What that means is that [generalists] and [their] sub-specialty colleagues have to learn to work together with our patients,” stated Jensen.
Right now, there are no medications that modify sensory perception by targeting opioid receptors, and none specifically for somatization symptoms, noted Jensen. In his own practice, he reported, he looks for symptoms of depression and/or anxiety, and tries antidepressant or anti-anxiety medications if the patient has such symptoms, even if they don’t meet the diagnostic criteria for one of these disorders.
Cognitive behavior therapy has proven helpful for patients with somatic symptoms, too. This therapy, which can be delivered by a trained general practitioner or by a mental health professional, focuses on the relationship between variability of a patient’s symptoms and changes in mood and life events.
As for the future, Jensen reports that there has been some recent evidence that gabapentin (neurontin), an anti-epileptic medication used to prevent seizures, may affect the body’s opioid receptors and thus alter sensory perceptions.
It’s important to remember that somatic symptoms can also mask emotional distress, said Jensen. Patients who have been taught or conditioned not to express emotions, particularly negative ones, may not even realize they’re depressed, anxious, fearful, or grief-stricken. “I do believe that there is a sort of transformation of psychological distress into physical symptoms,” he stated.