Undifferentiated Somatoform Disorders

Clients with symptoms that are out of proportion to impairments most often manifest one of the somatoform disorders, in which symptom magnification is subconscious and unintentional (Table 15-1).

Clients with hypochondriasis show excessive concern about minor health disturbances or intense worry over the possibility of future ill health. Clients with body dysmorphic disorder become preoccupied with imagined or innocent variations in appearance. Clients with conversion disorder have a bodily event (for example, paralysis or seizure) that is psychologic in origin. Clients with psychogenic pain and unspecified psychophysiologic dysfunction have persistent symptoms without apparent organic origin and without other distinctive classifying features. Clients with medically unexplained pain may have other diagnostic features as well, which could lead to a diagnosis of one of the somatization disorders below.

Somatization Disorders

More controversial are the somatization disorders, in which clients experience persistent or recurrent symptoms without objective or measurable medical evidence of impairment. Although these disorders occur frequently, general agreement is lacking on the cause and the treatment, and even on the status of some of them as legitimate diagnoses. However, questioning the validity of the diagnosis does little to help the client become more functional and may do irreparable harm to the therapeutic relationship. This chapter makes no judgment on the diagnostic legitimacy of the somatization disorders, but it recognizes the high level of distress in many clients diagnosed with these conditions.

Fibromyalgia

Fibromyalgia is perhaps the most common somatization disorder. The criteria for a diagnosis of fibromyalgia, established in 1990 by the American College of Rheumatology, include pain on both sides of the body, above and below the waist, accompanied by tenderness at eleven or more of eighteen specific tender point sites.² Fibromyalgia affects approximately 2% of the population, although clients with fibromyalgia may account for 10% to 20% of visits to rheumatology clinics. The prevalence is inversely related to income and level of education, and females are affected more frequently than males at a ratio of up to 6:1. Fifty-nine percent of clients with a diagnosis of fibromyalgia rate their health as fair or poor.³ Clients with this diagnosis commonly have other, associated symptoms, including nonrestorative sleep, fatigue, headaches, diarrhea or constipation, numbness, tingling, stiffness, a sensation of swelling, anxiety, and depression. Clients with rheumatoid arthritis and osteoarthritis report similar levels of distress, according to one measurement tool, the Rheumatology Distress Index;⁴ however, clients with fibromyalgia report higher levels of distress in the areas of anxiety, depression, sleep disturbance, global severity, and fatigue.⁴ Fatigue is also prominent in another disorder in this classification, chronic fatigue syndrome.

Chronic Fatigue Syndrome

The case definition of chronic fatigue syndrome (CFS), or chronic fatigue and immune dysfunction syndrome (CFIDS), includes several important criteria: (1) the fatigue cannot be explained by other diagnoses; (2) it must persist for longer than 6 months; (3) it must have a definite time of onset; (4) it must result in a decreased activity level but cannot be the result of ongoing exertion; and (5) it must not be substantially relieved by rest.⁵ This case definition, like that for fibromyalgia, was established primarily to identify subjects for clinical research. Salit⁶ notes that these criteria “are not suitable for the determination of the presence and severity of illness, either in general medical settings or for medicolegal or insurance purposes” and that “clinical management should be based on an assessment of the client” (Box 15-1).

The case definitions for fibromyalgia and CFS overlap substantially. About 70% of clients with CFS meet the case definition for fibromyalgia, and 70% of clients with fibromyalgia meet the case definition for CFS.⁷ Both disorders result in a high prevalence of work disability. Bombardier and Buchwald⁸ found that 37% of clients with a diagnosis of CFS were unemployed. The prevalence of unemployment rose to 52% for clients diagnosed with CFS and fibromyalgia.⁸

Multiple Chemical Sensitivity Syndrome

A third somatization disorder that can affect perceived ability to work is multiple chemical sensitivity (MCS) syndrome. Clients with multiple chemical sensitivities, or idiopathic environmental intolerance (IEI), experience medically unexplained symptoms in response to low-level, identifiable environmental exposures.⁹ Among the postulated mechanisms for MCS syndrome are time-dependent sensitization (TDS) and the development of conditioned responses. In TDS, repeated stressful episodes make an individual increasingly sensitive to low-level environmental stimuli.¹⁰ With conditioned responses, cardiovascular, respiratory, gastrointestinal, or immunologic responses are triggered by heightened perception of environmental stimuli.¹¹

Psychogenic Tremors

As with MCS syndrome, stress can be a factor in the development of psychogenic tremors. Psychogenic tremors of the hands and arms can manifest in unusual ways and have variable clinical characteristics. The severity of the tremor may be task specific, with the tremor often improving when the client is distracted.¹² Shaking of the limbs or body can appear exaggerated, whereas finger tremors often are absent. A twisting or ballistic component to the tremor can create the appearance of chorea.¹³ Psychogenic tremor as a somatization disorder appears unintentionally and without conscious client awareness of motivation.

Factitious Disorders

Factitious disorders result from intentional client action, but without conscious client awareness of motivation. They more often arise from a psychologic need to be sick than from a conscious effort for material gain.¹⁴ Clients with factitious disorders knowingly cause their own disease but are unaware of the underlying reason or reasons for their behavior. Several factitious disorders can affect clients’ hands.

Munchausen’s syndrome derives its name from Baron Karl Friedrich Hieronymous von Munchausen, an eighteenth century nobleman known for telling vivid but untrue stories. Clients with Munchausen’s syndrome may cut, bruise, bite, or inject their hands and then give an untruthful history to the medical professionals who care for the resulting injuries.¹⁵

Clients with clenched fist syndrome have stiff, tightly curled fingers that resist extension.¹⁵ The thumb and index fingers often are spared, enabling the client to maintain a level of function with the involved hand. Nerve block of the affected upper extremity or examination under anesthesia produces some relaxation of the hand, but often not full extension of the involved fingers. Some edema of the hand may be present, but it is not as great as in a hand that is repeatedly traumatized. (See Case Study 15-1.)

Clients who repeatedly strike their hands on a wall or other hard surface eventually develop chronic dorsal hand edema, a condition that has been called secretan’s syndrome.¹⁵ The fibrotic changes that develop in a repeatedly traumatized hand eventually create an appearance similar to the brawny edema that develops in the lower legs of clients with chronic vascular insufficiency.

Malingering

Malingering can be defined as the intentional presentation of false or misleading health information for personal gain. This personal gain is described as secondary gain, distinct from the primary gain of recovery from illness. Some malingering clients are seeking financial gain, whereas others are consciously seeking social or interpersonal benefits.¹⁶ Although malingering generally is recognized as an uncommon condition (prevalence 5% or less), Mittenberg and colleagues¹⁷ estimate that 29% of personal injury cases, 30% of disability cases, 19% of criminal cases, and 8% of medical cases probably involve malingering and symptom exaggeration.¹⁷