Psychosomatic disorders are frequently misunderstood. The term is used when a psychiatric problem, such as depression, anxiety or another disturbance, manifests itself as seemingly unrelated physical symptoms.
To make a diagnosis of a psychosomatic disorder, there must be no other medical explanation for the symptoms. This is not unusual. In fact, one survey has suggested that as many as 5% of complaints in the primary care setting are those that can't be explained by a known medical condition, toxin, or medication. While not all of these cases are psychosomatic, it is certainly not uncommon for problems with stress, mood, or other psychiatric disturbances to appear in seemingly unusual ways.
While the spectrum of psychosomatic complaints is very broad, some of the better described disorders are below.
To make a formal diagnosis of somatization disorder, a person needs four pain symptoms, two gastrointestinal symptoms (such as diarrhea or constipation), one sexual problem, and one pseudo-neurological problem. These complaints may be dramatic, but may also come and go. These symptoms often go hand in hand with symptoms of anxiety or a mood disorder. Furthermore, as patients with these problems often go to multiple doctors trying to find a diagnosis other than somatization disorder, they may also be suffering from side effects of many different medications.
If the main symptoms cannot be attributed to a known general medical condition or the direct effects of some substance, or if the physical complaints and resulting impairment are greater than what would be expected based off the physical exam, history and lab studies, the patient meets most criteria for a diagnosis of somatization disorder. The remaining DSM-IV criterion is that the symptoms must not be "intentionally produced or feigned." This is important to note -- by making a diagnosis of somatization disorder, the physician must believe that you are not faking the symptoms in any way.
Conversion disorder is also not intentionally produced or simulated. Again, the symptoms must not fit with any other known diagnosis. In conversion disorder, the symptoms are more suggestive of a purely neurological condition. For example, the symptoms of conversion disorder usually affect voluntary motor or sensory function. These can be just about any neurological deficit imaginable. Instances of abnormal walking, vision changes, sensory changes, pain, and seizures have all been described. Some inciting stressor usually precedes the symptoms; however, this stressor can happen years before symptoms begin.
While hypochondria has historically been classified among psychosomatic illnesses, it is perhaps better considered a phobia. Hypochondriasis involves someone believing that they are seriously ill, despite their having been adequately evaluated and all medical evidence being to the contrary. Like the psychosomatic disorders discussed above, people with hypochondria usually have a history of having been to multiple doctors, and may be upset that no one has found some other cause for their discomfort.
What Does This Diagnosis Really Mean?
The old phrase "it's all in your head" encapsulates much of what makes a diagnosis of a psychosomatic disorder so problematic. In reality, many neurological complaints are "all in your head." Alzheimer's disease, Parkinson's disease, epilepsy and many other neurological problems are all due to problems with the way the neurons of the brain communicate with each other. The same is also true of depression, mood disorders, anxiety and more. In essence, all of these disorders are similar in that they are caused by brain dysfunction. The fact that psychiatrists manage one kind of disorder and neurologists manage the other is mostly for historical reasons, not because the diseases are fundamentally different.
But the term "all in your head" is not only so vague as to be useless, it is also pejorative. As our culture developed, the biochemical changes that cause depression and anxiety somehow became less acceptable and more stigmatized than the biochemical changes that cause Parkinson's disease. Neither are fully within the victim's control. To be more accepting of one than another is not only unfair, but causes people to resist being diagnosed with a psychiatric illness, even if that diagnosis could help them get the treatment they need.
Many resist the possibility of their symptoms being psychiatric in origin because "they feel so real." Perhaps what they mean is that the symptoms are not under their control. This is absolutely true. It is crucial to recognize that the symptoms of psychosomatic illness are not imaginary. The symptoms are not faked.
It is also critical to recognize that having a psychosomatic disorder does not make somebody "crazy." While some people with psychosomatic disorders also have other psychiatric conditions, many do not. The symptoms are simply prompted by a psychiatric disturbance that may be as common as high stress or anxiety. Furthermore, many physicians believe that psychosomatic disturbances result from feelings that cannot be expressed through other means. In Freudian terms, these feelings may be unconscious, so that you are not even aware of them.
I sometimes find it helpful to compare the phenomenon of psychosomatic symptoms to the more familiar act of blushing. No one thinks twice if someone blushes when they are embarrassed. This is a clear example of an emotion causing a physical symptom that is out of the person's control. A psychosomatic disorder is similar, but instead of blushing because of embarrassment or trembling because of anxiety, the brain may express distress by causing the body to act in less usual ways. Just as it would be inappropriate to treat common blushing with a medication meant to treat more severe flushing disorders, such as carcinoid syndrome, it would be inappropriate to treat tremor due to a psychiatric illness like anxiety with a medication meant for Parkinson's disease.
While it may not feel like it at the time, in many ways, being diagnosed with a psychosomatic disorder is great news. Doctors who provide this diagnosis should have ruled out more serious, life-threatening diseases that could cause your symptoms. A diagnosis of a psychosomatic illness can also prevent you from being prescribed numerous medications in a fruitless effort to treat your illness, thereby saving you from various side effects. Furthermore, many patients with psychosomatic disease find their symptoms improve when the underlying problem is recognized.
As I've touched on, all of the psychosomatic disorders are known as diagnoses of exclusion, meaning that it is necessary to do a thorough work-up for more serious diseases before the diagnosis is made. It is important that doctors remain open-minded about patients with a diagnosis of a psychosomatic disorder so that they do not overlook a serious illness. It is equally important that patients remain open-minded about the diagnosis of a psychosomatic illness, so that they can obtain the help they need if this diagnosis is correct. It is a good idea to get a second and even a third opinion, but one needs to be cautious about unnecessary and invasive testing or treatments. Getting an opinion from a psychiatrist or psychologist may help answer more of your questions. If nothing else, many people with debilitating neurological symptoms have emotional trouble as a result, and a mental health professional can help.
Braunwald E, Fauci ES, et al. Harrison's Principles of Internal Medicine. 16th ed. 2005.
American Psychiatric Association. "Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision" 2000 Washington, DC: Author.