Psychosomatics 44:435-436, October 2003
© 2003 The Academy of Psychosomatic Medicine
"Free-Floating" Somatoform Disorder
Ian Tofler, M.D., Drew University, Los Angeles, Calif.
TO THE EDITOR: A parsimonious DSM-IV diagnostic approach to the somatoform diagnostic spectrum deems that the primary diagnosis be only the somatoform diagnosis. A greater clinical need may be for the patient's global symptom profile to be represented diagnostically.
Not only is this helpful for diagnostic accuracy, but it may also benefit the comprehension of overlap between somatoform and other psychiatric illness, while enabling better treatment strategies.1–5 Contextualizing a diagnosis within a developmentally oriented diagnostic framework, such as an attachment disorder, early abuse, neglect, or posttraumatic stress disorder, could also be usefully appended to the diagnosis, even for adults.5
A recent clinical case encapsulates the shortcomings inherent in unitary diagnoses, such as factitious illness, even when it clearly appeared to be the primary diagnosis. A developmentally based, more robust DSM categorization of somatoform spectrum illness is encouraged. This could include a combined or "free-floating" somatoform spectrum category, whereby features of multiple diagnoses are simultaneously present. This could be included in the somatoform disorder not otherwise specified category.
Case Report
Ms. A, a 43-year-old single white woman of middle-class background, lived at the time of admission in a battered women's shelter. She was seen with reported pain in the pancreatic sphincter of Oddi and subsequently reported chest, heart, abdominal, and genital pain, although she did not exhibit any pseudoneurological symptoms. She was seeking a prescription for meperidine throughout this admission. Trials with 20 mg/day of fluoxetine, 1 oral mg b.i.d. of risperidone, and a low dose of lorazepam for severe anxiety did prove beneficial, in conjunction with daily supportive psychotherapy, relaxation training, distraction, and a sitter.
During her admission, she was observed by her physician and medical students injecting herself in the lower abdomen with blood from a collecting bowl. She provided different answers to different members of the clinical team, such as "I didn't have any pads, so I had to collect the menstrual blood in a bowl with syringes," or " I did it so I could help my anemia; that is what naturopaths do." The blood was most likely harvested from her central line, but this was not confirmed. An exploratory laparotomy was performed after 2 days of observation of new-onset right lower quadrant pain. Cellulitis in the abdominal wall and a previous appendicectomy were noted. Ms. A was given intravenous antibiotics and was noted to be interfering with the intravenous equipment and strongly reprimanded. Her discharge medications were 20 mg/day of fluoxetine, 1 mg b.i.d. of risperidone, and 1 oral mg t.i.d. of clonazepam for depression, anxiety, borderline characterological disturbance, and augmentation of pain management.
Discussion
The dilemma is whether to include and appropriately treat additional somatoform spectrum diagnoses beyond clear factitious illness. With this patient, criteria for hypochondriasis, undifferentiated somatization disorder, and pain disorder (with associated opiate substance abuse disorder) were all met.
The addition of an attachment disturbance to implicate the long-term hypothetical effects of reactive attachment disorder of infancy or other attachment disturbance may echo or parallel the non–DSM concept of alexithymia by Nemiah6 and Sifneos7 and Stoudemire's concept of somatothymia.8 A "due-to" psychiatric diagnosis, of, for example, "major depression" or "reactive attachment disorder" in the same way that delirium is "due to medical disorder X" could help contextualize the somatoform diagnoses as physical complaints representing underlying developmentally and culturally mediated psychic distress.
Somatoform disorders are generally diagnoses of comorbidity. That is, they are not functional illnesses standing alone as symptom complexes, as current DSM criteria seem to imply. There tend to be powerful developmental, cultural, social, or traumatic processes at work. One somatoform illness may merge into another. This is not unlike a patient with a dissociative disorder, in which the dissociation appears in terms of multiple distinct somatoform spectrum symptoms.9
Traumatic attachment disturbance is likely to be a significant etiological factor in these cases. The affective skill to differentiate subjective and emotional feelings from bodily, physical sensations and the ability to acknowledge their association is learned during development. Similarly, verbalizing bodily sensations, such as pain, in acceptably modulated fashion is a skill we gradually acquire within our family and cultural systems.
The innovative approach of Kroenke et al.,10 who suggested multisomatoform disorder, could perhaps be modified to include the type of cross-diagnostic free-floating symptom profile of somatoform spectrum illness seen in this instance.
Free-floating somatoform spectrum symptoms reflect the innate, plastic human ability to use, in varying degrees, nonverbal somatic communication and memory distortion to express underlying psychological distress. The distress that occurs in underlying attachment disturbances can be integrated with psychiatric illness and personality disorder and filtered through the expression of somatoform spectrum illness, as represented in this case. One hopes it can be better reflected in DSM's future iterations, perhaps as suggested as a subcategory of somatoform disorders not otherwise specified.
REFERENCES
- American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington, DC, APA, 2000, pp 507, 517
- Lipowski ZJ: Somatization: the concept and its clinical application. Am J Psychiatry 1988; 145:1358–1368[Abstract/Free Full Text]
- Meadow R: Munchausen syndrome by proxy: the Hinterland of child abuse. Lancet 1977; 2:342–345[CrossRef][Medline]
- Schrier H, Libow J: Hurting for Love: Munchausen by Proxy Syndrome: The Perversion of Mother. New York, Guilford, 1993
- Stuart S, Noyes R Jr: Attachment and interpersonal communication in somatization. Psychosomatics 1999; 40:34–43[Abstract/Free Full Text]
- Nemiah JC: Alexithymia: theoretical considerations. Psychother Psychosom 1977; 28:199–206[Medline]
- Sifneos PE: The prevalence of "alexithymic" characteristics in psychosomatic patients. Psychother Psychosom 1973; 22:225–262
- Stoudemire A: Somatothymia. Psychosomatics 1991; 32:365–381[Abstract/Free Full Text]
- Elzinga BM, Beromnd B, Van Dyck R: The relationship between dissociative proneness and alexithymia. Psychother Psychosom 2002; 71:104–111[CrossRef][Medline]
- Kroenke K, Spitzer R, DeGruy F III, Hahn SR, Linzer M, Williams JB, Brody D, Davies M: Multisomatoform disorder: an alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1997; 54:352–358[Abstract/Free Full Text]
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