Somatoform and Factitious Disorders

On any given day in the United States (and probably elsewhere), hundreds of thousands of individuals make visits to physicians with complaints unexplained by physical disease. The history of attempts to understand, classify, and minister to patients with poorly understood physical complaints ranges over a period of at least 2,000 years. There is perhaps no more controversial, ever-shifting classification of psychiatric disorders than that of the somatoform group (to which the editors of this book have added factitious disorders because, as they argue, all medically unexplained symptoms occupy points on a continuum not readily differentiated). At times, classification may appear more a matter of convenience than based on good clinical rationale. Do they belong with adjustment disorders, dissociative disorders, obsessive-compulsive disorder, depression, or other disorders?

This defiance of categorization reminds us that the truth most likely lies in the whole human being and his or her life experience; psychiatry does not live by DSM alone. Patients with somatoform disorders probably most closely resemble the human condition, with its attention to bodily or somatic perturbations. We are all imbued to some extent with some aspect of these syndromes; we are all somatizers to one degree or another. Developmentally, as proclaimed by Freud, the ego is first and foremost a body ego. Perhaps, in some measure, it is this closeness to our own experience which contributes to the difficulty in clearly medicalizing these conditions as disorders.

The editors and authors of this brief compendium are to be congratulated for their balanced, intelligent synopsis of current knowledge about this troublesome rubric of somatoform disorders. To even attempt a concise review of the history and clinical differentiation of somatoform disorders deserves an A for effort. As volume 20 of the Review of Psychiatry series of American Psychiatric Publishing, it does, as the editors advise, “the best job that can be done at this point.” Better planning of the series might more appropriately have included pain disorder in the current volume rather than in a previous one, but except for this minor caveat, the contributors to and editor of this stellar work have admirably achieved their objective.

Woefully, we must admit that our armamentarium of treatment methods for these ailments remains impoverished and rudimentary. Or, as the series editors of this book state in the introduction, “certain conditions, such as the somatoform and factitious disorders, can baffle even our most experienced clinicians.” Therapeutic issues realistically command less than one-fifth of the book and may thwart the expectations of those seeking a true how-to manual of treatment approaches. The most extensive coverage of treatment is in the chapter on hypochondriasis by Fallon and Feinstein, not surprising in view of the new perspectives on this ancient malady (1). Because some of the principles of management and treatment are common to almost all the somatoform disorders, a next edition might consider the value of including a separate chapter on management techniques, emphasizing important aspects of the patient-physician relationship across the continuum.

Some redundancy is a virtual staple of multiauthored works, but the minimal degree of repetition in this book permits each chapter to stand on its own as well as to be an integral part of the total. Each chapter is a gem of pristine prose and lucid organization, reflecting, without overstatement, what is known and what remains speculative about these disorders. In spite of omitting chapters on pain disorder and undifferentiated somatoform disorders, this little volume presents what is mostly known (and unknown) about the various so-called somatoform disorders in a highly readable, reassuring manner that helps to blunt some of the many uncertainties that surround this generally orphaned group of psychiatric disorders.

Five succinct chapters expertly describe somatization disorder, hypochondriasis, body dysmorphic disorder, conversion disorder, and factitious disorder. Even in its brevity, there is a hint of the rich, colorful, and largely anecdotal history of the many conditions alluded to as “hysterical” or “hypochondriacal” in the psychiatric literature of the past. Fortunately, the precision of this well-written, well-edited review has not completely DSM-cleansed the intriguing developmental nuances of those conditions Freud alluded to as the “mysterious leap from the mind to the body.” The chapter on conversion disorder by Maldonado and Spiegel has a particularly good section on history that reminds us of the creative ideas of Freud, Charcot, Briquet, and others who have provided such seminal insights into the somatizing process.

The authors and editors recognize that controversy and confusion continue to surround these interesting clinical conditions. After all, even in our DSM-ness, do we really know all that much more than Freud and his followers when they pursued the mystery of “somatic compliance” in their psychological explorations? Our treatment techniques may have changed, but descriptions of these curious disorders have shown remarkable endurance.

This book is a delight to read. Blaise Pascal is thought to have said, “I have written a long letter because I did not have time to write a short one.” The art of abridgment is well exercised in this useful book, helping the “consumer differentiate between sound advice and insubstantial opinion.” For the well-informed, it will momentarily clear the field; the novitiate, one hopes, will be enticed to delve more deeply. Readers whose curiosity is piqued will find a rich bibliography appended to each chapter.

Here, then, in a mere 181 pages, is a book intended to “help identify the presence of the somatoform and factitious disorders, as well as [to provide] recommendations about their treatment.” How well it does that can only be judged by the efficacy with which physicians can absorb and apply this knowledge and the extent to which patients’ ailments might benefit from that application. The pity is that this book will be read mostly by psychiatrists, not the primary care physicians who are most likely to see (and probably misdiagnose) these patients in their offices, making application of its abundant wisdom even more remote.

The book’s introduction, exclaiming that “the somatoform and factitious disorders are fascinating syndromes that are beset with contradictions,” calls to mind for me a sobering reminder of one difference between psychiatrists and other physicians. I have always kept in mind one of my earliest encounters with a frustrated physician treating the multiple factitious presentations of a patient with systemic infections when, after consultation, I said, “This is a fascinating situation.” His reply, “To you, maybe; to me, he’s a pain in the ass.” It is uncertain how much help even this fine concise volume will be to such physicians. Yet that is a large part of our challenge since most of the conditions described here are seen on the front line of medicine, not in psychiatrists’ offices. But if all psychiatrists can ingest and translate the content of this superb small volume to their nonpsychiatrist colleagues, the educational impact may be substantial and all (not least, the patient) will be richly rewarded.