دارو درمانی اختلالات شبه جسمی

This paper reviews the published literature on the pharmacologic management of somatoform disorders. Methods Using Medline, the author identified all articles published between 1970 and 2003 on this topic, selecting the best-designed studies for inclusion. Results The review reveals that patients with the obsessional cluster of somatoform disorders (hypochondriasis and body dysmorphic disorder [BDD]) respond well to serotonin reuptake inhibitors (SRIs). Less is known about the pharmacologic responsiveness of patients with the primarily somatic cluster of somatoform disorders (somatization, pain), a patient group that is common in the health provider's office.

Over the last decade, there has been a resurgence of hope that pharmacologic strategies might be helpful for patients with somatoform disorders. Recent reports support that hope and point to a need for additonal research to investigate the efficacy of novel pharmacologic strategies for patients with illness/fears and unexplained bodily sensations. In DSM-IV [1], the disorders included under the somatoform heading are somatization disorder, undifferentiated somatoform disorder, pain disorder, hypochondriasis, body dysmorphic disorder (BDD), conversion disorder, and the residual category somatoform disorder not otherwise specified. This review paper will focus on the pharmacotherapy of hypochondriasis, BDD, somatization disorder, and pain disorder. Two terms commonly used in any discussion of somatoform disorders include unexplained or “functional” somatic symptoms and hypochondriasis. These terms differ in crucial ways [2]. The former is a term used to describe somatic symptoms not caused by physical disease or tissue damage. The latter is a term that indicates an unrealistic fear or belief that one has a disease, most often based on the perception of an unexplained somatic symptom. To the extent that these two terms indicate different phenomena and perhaps different pathophysiology, the treatment response to one type of somatoform disorder (e.g., hypochondriasis) may have only limited bearing on the treatment responsiveness of another type of somatoform disorder (e.g., somatization disorder). The overarching category of somatoform disorders includes conditions that share the common feature of physical symptoms that induce undue discomfort, distress, or dysfunction. In the case of hypochondriasis and BDD, the disorders carry the additional component of intrusive unpleasant thoughts about disease or bodily appearance, compulsions to check for reassurance, and an accompanying negative appraisal of bodily symptoms that results in fear or avoidance. In these disorders, the meaning and implications of the symptoms are more distressing than the symptoms themselves. In the case of somatization disorder and pain disorder, the symptoms themselves are the primary focus of discomfort and distress. Because the terms hypochondriasis and somatization disorder are often used interchangeably by primary care clinicians, it is worth emphasizing that in hypochondriasis the fear of a serious illness preoccupies the patient and the compulsive checking serves to temporarily reduce the anxiety, creating a mental state and behavioral response that is quite similar to obsessive–compulsive disorder. In somatization disorder, on the other hand, the primary concern is not catastrophic, life-threatening illness but concern about multiple unexplained somatic symptoms. Hypochondriasis and BDD then might be considered to fall primarily within an “obsessional/cognitive cluster,” whereas somatization and pain disorders would fall primarily within a “somatic/sensory cluster.” A somatoform disorder that may not fit well into either of these clusters is conversion disorder. Conversion disorder, unlike the other somatoform disorders, requires a stressor to precede the onset of the loss of function. Given the oft-cited symbolic significance to the part of the nervous system that is affected and given the lack of conscious awareness by the patient of the relationship between the stressor and the area of somatic dysfunction, it is clear that patients with conversion symptoms have more of a dissociative process at work rather than a primarily obsessional or somatizing one. Within any one individual, there may be a mix of these various processes but most often one predominates over the others. Further investigation of this cluster concept is required. The majority of research on the pharmacotherapy of somatoform disorders over the last decade has been conducted on the obsessional cluster of somatoform disorders. To the extent that hypochondriasis or BDD falls within the domain of “obsessive–compulsive spectrum” disorders [3] and [4], it should not be surprising that patients with these disorders would have a preferential pharmacologic response to agents also found to be helpful for the obsessive–compulsive disorders. At present, it remains an open, relatively unexamined question whether the agents demonstrated to be helpful for patients with hypochondriasis and BDD would also be helpful for patients with the more somatic-focused somatoform disorders (e.g., somatization disorder).