Somatization in the Primary Care Setting

Primary care physicians encounterperplexing complaints in upto 40% of their patients.^1,2

Patients are often frustrated with troublesomesymptoms that are inexplicableand refractory to multiple treatmentregimens. Because there is variabilityin how patients present and no apparent cause for their symptoms, this clinicalsituation has historically been difficultto conceptualize, categorize, andtreat effectively. A review of somatizationin the primary care setting is germaneto psychiatrists who function asconsultants to primary care practitioners,since they are often asked to evaluatepatients with somatoform disorders.

DIAGNOSTIC CONSIDERATIONS

Ancient Egyptian healers noticed thatwomen were affected with perplexingsomatic complaints more often thanmen and concluded that a "floatinguterus" was the culprit. In the 17thcentury, Thomas Sydenham believed amultifactorial process that included"antecedent sorrows" should be consideredfor both men and women.³

Charcot—and then Freud—used theword "hysteria" to describe a conditionthey thought was largely based on unconsciousemotional conflict with a relatedmaladaptive somatic response. This termwas commonly used until 1980, whenthe DSM-III changed the diagnosis toBriquet syndrome, in honor of the workdone in this area by the 19th centuryFrench physician Paul Briquet. Currently,in primary care settings, the informaldiagnosis of somatization is broadlyused to describe patients with physicalcomplaints that cannot be totally explainedby physical examination and acorresponding diagnostic workup.

With a focus on the need to "excludeoccult general medical conditions orsubstance-induced etiologies for thebodily symptoms," DSM IV⁴ includes7 diagnoses under the category ofsomatoform disorders: somatizationdisorder, undifferentiated somatoformdisorder, conversion disorder, paindisorder, hypochondriasis, body dysmorphicdisorder, and somatoformdisorder not otherwise specified (Table1). It is important to note that the groupingof these disorders does not necessarilyimply shared pathogenesis. Thesomatoform disorders are not fullyexplained by a general medical conditionor other mental disorder and, inorder to meet diagnostic criteria, mustcause significant impairment or distress.Also, unlike a diagnosis of malingeringor factitious disorder, patients witha somatoform disorder do not intentionallyproduce their symptoms.

Alternatives to the DSM-IV nomenclaturehave been suggested because ofthe perceived rigid diagnostic criteria,frequent overlap between the somatoformdisorders, and the resultant impracticalapplication to clinical practice. For example,in order to establish a DSM-IV diagnosisof somatization disorder, one musthave 4 pain symptoms, 2 GI symptoms,1 sexual symptom, and 1 pseudoneurologicsymptom during the course of theillness. This somewhat arbitrary combinationof symptoms is not always relevantto commonly encounteredsomatization in the primary care setting.Also, a person with a diagnosis of somatizationdisorder must have had multiplesomatic complaints before the age of 30.However, studies have shown that patientsare often unable to reliably recall theirmedical history with sufficient detail.⁵

The wide clinical spectrum of somatizationhas prompted some medicalspecialties to develop their own systemto identify unexplained somatic symptoms.Some common examples includeirritable bowel syndrome, chronic fatiguesyndrome, and fibromyalgia.Because many patients do not meet fulldiagnostic criteria for somatization disorder,Escobar and colleagues⁶ introducedthe abridged somatization disorder as aless restrictive alternative. This syndromeis based on lifetime symptomsand the presence of 4 somatic complaintsin men and 6 in women. Several reports,including the World Health OrganizationPsychological Problems in GeneralHealth Care multicenter study, indicatehigh instability of recall when it comesto lifetime symptoms.⁵ In this study, 61%of unexplained somatic symptomsreported at baseline were not reported1 year later. Multisomatoform disorder(MSD) is another diagnostic option forprimary care patients with somatizationthat addresses this issue.⁷ Multisomatoformdisorder is defined as thepresence of 3 or more acutely distressful,medically unexplained symptomsfrom a checklist of 15 common symptomsfound in the primary care setting(developed using the Primary CareEvaluation of Mental Disorders[PRIME-MD] scale that measurespsychopathology⁷). Patients with MSDmust have active symptoms with at leasta 2-year history of somatization.

The differential diagnosis for somatizationseen in the primary care settingis extensive. It is important to keep inmind that inexplicable illness can referto a general medical condition, confirmationof which cannot be found, aftera complete assessment, or it can explaina general medical condition that existsbut medical evidence for which has notbeen discovered after a comprehensiveworkup. Lyme disease is an example ofthe latter. Before Lyme disease wasdiscovered in 1982, children and adults were presenting with arthritis, myalgias,and fatigue with no known precipitantor cause. It is beyond the scope of thispaper to discuss a full differential diagnosisfor somatization, but it is importantto do a complete diagnostic workupwhile considering somatization disordera diagnosis of exclusion.

Before establishing a diagnosis ofsomatization disorder, one must attemptto rule out the intentional production offalse physical or psychological symptoms.A patient in whom malingeringis diagnosed is focused on feigningillness in an attempt to gain externalincentives such as financial compensation,shelter, or escape from military dutyor criminal prosecution. Factitious disorderalso involves the purposeful andsometimes elaborate self-report ofsomatic complaints with the objectiveof assuming the "sick role." People withthis disorder have no obvious externalsecondary gain beyond the sick role.When evaluating either condition, thephysician should obtain collateral history(particularly from other area hospitals),complete a focused examination and, aswith somatization disorder, considerboth of them as diagnoses of exclusion.

CLINICAL SIGNIFICANCE

People with somatoform disorders experiencehigh levels of physical discomfortand tend to be unsatisfied with life.⁸

A retrospective review of more than13,000 psychiatric consultations foundthat somatization disorder resulted inmore disability and unemployment thanany other psychiatric illness.⁹ It is difficultto accurately establish the prevalenceof somatization because ofwide-ranging definitions and patients'limited ability to accurately recall symptomsfrom the distant past. Medicalexplanations for common somatic complaints,such as malaise, fatigue, abdominaldiscomfort, and dizziness, are foundonly 15% to 20% of the time.¹⁰Somatization disorder has an estimatedprevalence of 0.2% to 1.0% in primarycare settings and is 5 times morecommon in women.⁶ The abridgedsomatization disorder has a higherprevalence in the primary care settingof about 20%.⁶ Multisomatoform disorderis uniquely based on current symptomsand is found in primary care patients 13% to 20% of the time.^11,12

Patients with somatization in theprimary care setting have more thantwice the outpatient utilization and overallmedical care cost when comparedwith patients without somatization.¹³This often translates into increased frustrationand low levels of professionalsatisfaction for physicians who manage these patients.14 Part of the problem maybe a lack of psychiatric supervision andinstruction during residency training.Sullivan and associates¹⁵ surveyed 348primary care program directors andfound that two thirds of them believedmore psychiatric education (particularlyin the area of somatoform disorders) wasneeded for residents. Smith and coauthors¹⁶showed that health care utilizationand cost decreased by more than50% when primary care physicianseffectively treated their patients who hadunexplained medical symptoms. Anincrease in training of primary carephysicians in this area could result inimproved job satisfaction and decreasedpatient morbidity.

• ≥ 3 unexplained somatic complaints from thePRIME-MD scale
• ≥ 2 years of active symptoms

TREATMENT

The treatment of somatoform disordersexemplifies the "art" of medicine.Because this condition is on a wide-rangingcontinuum with an unknown cause,it is impossible to apply a strict evidencebasedapproach to treatment.¹⁷ Theacronym CARE MD represents a set ofguidelines that can help primary carephysicians work with patients who havesomatoform disorders (Table 2).

Consultation psychiatry/Cognitive-behavioral therapy

Consultation with a psychiatrist and useof cognitive-behavioral therapy (CBT)has been shown to decrease the intensityand frequency of somatization.^18,19Kroenke and Swindle²⁰ reviewed 31controlled studies and concluded thatCBT is an effective treatment for patientswith somatization type disorders.Group therapy using CBT has also beenfound to be beneficial.²¹ CBT is generallya short-term psychotherapy (8 to 20weeks) with the goal that patients willdevelop skills that last indefinitely. Thistype of psychotherapy is based on thepremise that inaccurate or dysfunctionalthoughts are predominant in patients with somatoform disorders. Examplesof such thoughts are: "I will always besick," "No one understands my pain,"or "Everyone thinks it's all in my head."Through a variety of mechanisms,patients learn to recognize and reconstructthe dysfunctional thought patternswith resultant decreased somaticcomplaints. In collaboration with thetherapist, primary care physicians canlearn to use brief cognitive behavioraltechniques during office visits.

Assessment

Assessing patients on each visit forgeneral medical problems that mightexplain troublesome physical complaintsis important. This is particularlyessential for patients who have a longhistory of somatic preoccupation andpresent with a new complaint or worseningof existing symptoms. About 25%to 50% of patients with a diagnosis ofconversion disorder eventually have anidentifiable, nonpsychiatric disease that explains the symptoms.³ It is also importantto screen for other common psychiatricconditions. Concurrent mood oranxiety disorders affect 25% to 50% ofpatients with somatoform disorders.^22,23The number of unexplained somaticsymptoms is highly predictive of comorbidmood and anxiety disorders as wellas functional disability. Physicians canuse the PRIME-MD scale, which usesa combination of self-reporting andclinician interview, to reliably screenfor psychiatric disorders in the primarycare setting.

Regular visits

Regular visits with one physician arecritical to the management of somatoformdisorders. Short, frequent counselingappointments have been shownto decrease outpatient medical costswhile maintaining patient satisfaction.13These encounters should include a briefbut focused examination followed byopen-ended questions such as: "Howare things at home?" "What is thebiggest stress for you now?" or if thepatient is exposed to CBT, "Tell me about your most frequent dysfunctionalthoughts since your last visit." Thepatient should use this interaction in lieuof inappropriate emergency room visitsor frequent calls to the physician'soffice. Longer, less frequent "noncounseling"visits are reserved for assessmentand treatment of all other medicaldisorders. In sum, spending more that80% of each "counseling" visit on worrisomepsychosocial stressors willprovide an outlet for the patient to cope,with less somatic preoccupation as aresult.

Empathy

Empathy, or experiencing the emotionalstate of the patient, is a key ingredientto forming a healthy therapeutic allianceand optimizing treatment for patientswith somatoform disorders. The use ofempathy can also minimize negativefeelings or countertransference for thetreating physician. True empathicremarks such as, "This must be difficultfor you" or "I might feel the sameway if I were in your situation" are oftenbeneficial, particularly when frustratedfamily or friends are in the examinationroom with the patient.

Medical-psychiatric interface

Medicine and psychiatry should interfacein the treatment of every patientwith somatoform disorders. It is importantfor patients with somatization toknow that emotions and stressors canhave a direct effect on the entire body.Many patients are reluctant to acceptan explanation such as, "It's all in yourhead" or "A psychiatrist will have todeal with your symptoms" for theirdiagnosis. Instead, primary care physiciansshould provide a diagnosis and,if necessary, arrange for a psychiatricconsultation while remaining the primarycaregiver. During the short butfrequent "counseling" visits, patientsshould be asked if the unexplainedsymptoms get worse as the primarystressor worsens or if the symptomsimprove as the primary stressorimproves. If the answer is yes to bothquestions, allow the patient to slowlymake the connection by asking an openendedquestion like, "Do you have anythoughts on why that is?"

Do no harm

Doing no harm by unneeded consultationsor procedures is the most importantpart of treating patients withchronic somatoform disorders. Primarycare physicians should not deviate fromnormal practice style to appease apatient or minimize frustration. Aftertaking reasonable steps to rule out ageneral medical condition, the appropriatesomatoform diagnosis should bemade and treatment should followaccordingly.

Dr McCarron is Assistant Clinical Professor inthe Department of Psychiatry and BehavioralSciences and the Department of InternalMedicine at the University of California, Davis,in Davis, Calif.Dr McCarron has no conflicts of interest todisclose.

References:

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