Somatization Disorder: Frequent Travelers in the Health Care System
Somatization Disorder: Frequent Travelers in the Health Care System
Author: Richard J. Schuster, MD, FACP, Director, Primary Care Eduation in Internal Medicine, Kettering Medical Center; Associate Clinical Professor, Wright State University School of Medicine, Miamisburg, OH.
Peer Reviewer: William M. Glazer, MD, Associate Clinical Professor of Psychiatry, Harvard Medical School; Massachusetts General Hospital.
Editor’s NoteSomatization disorders are the bane of a primary care physician’s office. These patients often create frustration on the part of the caregivers and bewilderment and disbelief on the part of third-party payors. This issue provides helpful guidelines for the practitioner in identifying these patients in a practice and offers constructive management techniques with attention to cost-containment. In an increasing managed care market, care for these patients will certainly become more and more challenging.
The clinician is all too often confronted by patients who are convinced that there is something wrong with them in the face of normal findings. The physician frequently suspects that there is a hidden agenda but is unable to understand the dynamics. The encounter often ends with mutual dissatisfaction by the patient and the physician.
A patient scenario may help develop the concepts and management of Somatization Disorder.
Case Study. A 31-year-old male presents to the office with chest pain. He has had it intermittently for four weeks. It occurs at rest and with activity. It is a retrosternal pressure sensation that does not radiate. The patient becomes diaphoretic but not short of breath. He has no palpitations. He plays basketball in a league at work and has had pain sometimes while playing but has never stopped playing because of the pain. He is a manager at a local corporation and is doing well in his high pressured job.
His father had a "heart attack," two years ago. Upon further questioning, you find his father was discharged from the hospital two days after admission and takes no medicines.
His past medical history is notable for "mono" at age 14, resulting in a loss of one year of school for the patient. He had an arthroscopy of the knee at age 18 for chronic knee pain, an appendectomy at age 23, and an upper endoscopy and colonoscopy for long-standing abdominal pain at age 26. At age 28, he had a cystoscopy for an ill-defined urinary problem. Two years ago, the patient had a work-up for headache and visual loss that included a "normal" CT Scan, MRI, and EEG. A neurologist told him "there’s nothing wrong with you," and was "nasty" to the patient.
His resting EKG is normal. An exercise tolerance test is done, with normal results after 15 minutes of exercise.
After informing the patient that all of the tests are normal, he states that he has very good insurance and asks, "aren’t there any other tests to do?" The next question he asks is, "Maybe you should send me to a specialist; don’t they know more than you do?" You explain that no further consultations are required for now.
One month later, the patient presents to you with a history of intense mid-epigastric pain, present "most" of the time for the past two weeks. He has had two episodes of emesis this week, which he says look like "coffee grounds." He tells you that he came back to you because he trusts you. You are the first doctor who took him seriously.
This case highlights many of the issues faced in somatization disorder. At the end of the discussion, the management plan for this patient will be reviewed.
Details of the medical history are critical in the diagnosis of somatization disorder. These patients will typically report a history of multiple "medical problems" beginning at a relatively early age.1 Reviewing old medical records is essential to confirm previous evaluations and treatments and to clearly identify if diagnoses were actually made. All too often "colitis" turns out to be irritable bowel, "asthma," an extended upper respiratory infection, and "chronic mono" an unexplained, prolonged episode of fatigue with normal complete blood count and negative mono spot. A history of gastrointestinal illness is particularly common.2 Multiple surgeries are often an important clue.3 Patients with somatization disorder frequently have surgeries for pain-related problems. A hallmark in the definition of somatization disorder is the absence of objective findings.4 Many medical conditions are associated with poorly defined diagnoses. The clinician is required to make a "clinical diagnosis." These patients have an extraordinary record of normal or near-normal tests and procedures. Even surgeries are often associated with normal findings. The appendectomy demonstrated "minimal inflammation;" the gallbladder had a "thickened wall with no acute inflammation;" and the arthroscopy of the knee failed to find the cartilage damage expected pre-operatively.
Patients with somatization disorder often deny any psychological component.4 They have complex and often purely subconscious mechanisms driving their medical care seeking behavior. When asked directly if there is or may be an emotional component, they declare most emphatically that there is no active psychological issue. When pushed on this, they become defensive and angry at the physician. The doctor-patient relationship may begin to unravel. Patients with somatization disorder are not malingerers and do not generally have conscious factors driving their behavior.
The physician’s ego is often fed into the relationship with a somatization disorder patient.3 The patient reports that the last doctor was no good, but the current doctor is "the best." The patient will have very high expectations about the care they expect delivered. They will often speak of the physician’s reputation as a great diagnostician. Unfortunately, just when the diagnosis of somatization disorder should be entertained, the physician’s ego is being reinforced that a "bright and sophisticated" patient has finally discovered the physician’s qualities. (See Table 1.)
Many patients present to their primary care physician with problems that never result in a well-defined diagnosis. Of primary care visits, 25-50% result from primarily psychosocial factors that manifest themselves as somatic symptoms.5 Patients who fulfill all of the formal criteria for somatization disorder are much smaller in number, representing about 0.1% of the population.1,6 A primary care physician with 2000 patients, therefore, will have two patients in his or her practice that have a true somatization disorder. They will stand out in that physician’s practice once they are diagnosed because of their heavy use of services and emotional demands on the primary care physician. Many patients who present to a primary care provider with unexplained or inordinately intense symptoms will have an undifferentiated somatiform disorder, a much more loosely defined disorder.
Somatization disorder is more common in rural settings and in a less educated population.7 The incidence of somatization disorder will vary in different cultures. Irish Americans are less likely to present with somatic symptoms than are Italian Americans. There is a higher incidence of somatization in the Latino culture, although that varies among the Latino cultures, with a greater incidence in the Puerto Rican community than the Mexican. The Asian cultures also vary, but there are some sub-cultures with somatization greater than the American average. These disorders may have a variable incidence in different cultures because of increased life stresses in some groups, especially recent immigrant cultures. It is also theorized that some cultures interdict individuals from consciously expressing stress or anxiety, driving them to present with somatic symptoms instead.8
These patients receive expensive and often dangerous care. In the era of managed care, patients with somatization disorder consume significant resources and often raise anxiety in physicians who are trying to limit "unnecessary" tests, consultations, and therapies.9 They use three times more ambulatory medical services than patients without somatization disorder.10 Their total health care use is 10 times greater than the population average.11 It is important to note that somatization may occur in a family. Children of somatizers present to emergency rooms 12 times more often and miss nine times more school than children of unaffected parents.12
One of the most unfortunate clinical, professional, and economic features of somatization disorder is the high incidence of iatrogenic-induced problems.13 What often begins purely as a psychosomatic disorder becomes a mixture of psychiatric and organic problems as the patient collects multiple complications from multiple procedures and treatments. Because organic diagnoses are often illusive, ever more complex, dangerous, and expensive tests are done in quest of the diagnosis that will never be made.
There are a variety of psychological explanations for the cause of somatization disorder. Many, but not all, patients will have a history of sexual abuse.14,15 This will be frequently either denied by the patient or not be part of their conscious memories. It is critical for the physician to appreciate that this psychological process is subsconscious.14 One theory proposes that the patient is subconsciously unable to express his or her psychic stress and finds socially acceptable ways to show that he or she is "sick."14 Kaplan describes a number of more complex theories.4 The psychodynamic theory proposes that the expression of somatic symptoms demonstrates an underlying psychological conflict. Furthermore, the secondary gain the patient receives from the health care system supplies much needed nurturing and support.4 The neurobiologic theory proposes a problem of central nervous system regulation, possibly related to the corpora callosa connections between the two hemispheres. The sociocultural theory is supported by the different incidences of somatization disorder seen in different cultures. When emotional expression is culturally unacceptable, an individual may express their emotions through a somatic presentation of symptoms. This theory contends that these patients are not psychodynamically disturbed but are simply communicating from one culture (theirs) to another culture (the physician’s). In the behavioral theory, it is proposed that physicians can drive patients to somatizing behavior by obligating patients to present and express somatic symptoms as the only way they will get attention from providers.16 Managed care, particularly discounted fee-for-service, produces time pressures on practitioners that result in much more "testing" than "talking."9
Engel has stressed that in psychosomatic disorders it is critical to make an active diagnosis, rather than ruling out all other diseases and making the diagnosis by exclusion.17 Making the prospective diagnosis of somatization disorder will help avoid that pitfall.4 The chief somatic symptom must be addressed. It is key to validate the diagnosis with carefully selected tests. The modern diagnostician must be disciplined to avoid the fruitless quest for the rare disease or unusual presentation of a common disease.
The formal diagnostic criteria are listed in Table 2. Many patients who present to a primary care provider have an undifferentiated somatiform disorder that is less well defined. (See Table 3.) This is by far the more common, although less dramatic problem. Many patients with the cultural and behavioral origins to their problems often will have an undifferentiated somatiform disorder. It is the physician’s responsibility to determine where along the continuum of somatization the patient is and, therefore, how strenuously the diagnostic criteria must be met. Two key features in somatization disorder to emphasize are the presentation of multiple unexplained medical problems before age 30 and the persistent nature of their symptoms over a period of time.
The differential diagnosis requires an understanding of some of the similar psychosomatic disorders as well as classic psychiatric diagnoses.4,3,18 Anxiety disorders, including panic attacks, are extremely common presenting problems to the primary care provider.19 Patients with anxiety disorders have predominantly autonomic system symptoms, often involving multiple organ systems. Usually, these symptoms have occurred over too short a period of time and involve too many organ systems to be consistent with a somatization disorder. Depression is very frequently seen by the primary care physician and may well present with primarily somatic symptoms.20,21 Usually, depressed patients have the biological symptoms and signs of depression, but some have "masked depression," which causes them to focus on more somatic symptoms. The diagnosis of depression may be best confirmed by a therapeutic trial of antidepressants.4 It appears that there are a significant number of patients who simultaneously have somatization, depression, and anxiety. These people had childhood experiences, often deprivation, that resulted in the development of all three psychiatric disorders.22
Somatization disorder is one of the overlapping somatoform disorders. A common confusion exists between somatization disorder and hypochondriasis. (See Table 3.) Hypochondriasis is an enhanced or magnified response to a normal sensation.1 Patients often worry they have a very specific disease, often focusing on a particular organ system or diagnosis.3 Somatization disorder patients have multiple symptoms involving multiple organ systems. A conversion disorder is also one of the somatoform disorders. (See Table 4.) Like somatization disorder, this is an unconscious process. The symptoms often have symbolic meaning to the patient and are non-physiologic in character.3 The challenge to the physician is to uncover the symbolic significance of the symptom to the patient. They often occur during times of major emotional stress. Like somatization disorder, these patients often have significant secondary gain, receiving special attention from friends, relatives, colleagues, or employers.4 Finally, pain disorder, formerly known as psychogenic pain, is also included in the somatoform disorders. (See Table 5.) First described by Engel, it is a disorder identified by pain that is inappropriate in character and intensity in light of the physical problem identified.23 Pain is a purely subjective phenomena experienced only by the patient, with no objective criteria the physician can use to validate the symptoms. Like somatization disorder, these patients often have a psychic "need" to suffer. The pain often occurs as a response to a loss, either real or perceived. The pain may result from guilt associated with feelings of aggressiveness or forbidden sexual desire. These patients may well respond to antidepressants, raising the question of whether this may actually be a variant of depression.24
Somatization disorder is a difficult diagnosis to make. There is no laboratory test that is diagnostic. Organic diseases must be carefully and appropriately considered. Overlapping psychiatric diagnoses must be reviewed. The diagnosis then becomes a clinical one. In common clinical practice, the strictest diagnostic criteria cannot always be met, and the primary care provider must rely on a summation of the data available to make the diagnosis. It may be helpful to review the situation with a skilled mental health professional (psychiatrist, psychologist, or trained counselor) or refer the patient for a formal consultative opinion. This type of collaborative effort may secure the diagnosis and allow a more sophisticated approach to therapy.
"Treat the doctor first, the patient second," may be the sentinel message for practitioners. Quill eloquently describes this particular "doctor’s dilemma."3 (See Figure 1.) The solution is so challenging for clinicians because much of it is counter-intuitive to our routine practice of medicine. The physician must be able to tolerate the inherent risk in a lack of certainty of the diagnosis. Just as is done with pharmacotherapy, a therapeutic trial of a primarily behavioral approach to a patient will often help to secure the diagnosis of somatization disorder. If the provider views this limited diagnostic approach as a therapeutic trial, which can be interrupted any time by more aggressive testing if symptoms change, it may be easier to proceed with the tentative therapy of somatization disorder.
The next essential element of therapy is to understand the psychodynamics of the patient’s need to be sick and the clinician’s need not to perform unnecessary and dangerous tests and treatments. Remember that this is often a subconscious process. If the provider denies that the patient has a problem, the patient will simply increase or change the symptoms to "prove" they really are ill. It is key to acknowledge that the patient is suffering.25 This, again, may appear counter-intuitive but, in fact, may be the key to therapy. The clinician must truly accept this reality and must communicate that knowledge to the patient. Once that occurs, the therapeutic bond is established, and the management of the patient can move away from an organic, somatizing focus. Looking at a patient directly and telling them their suffering is understood may have a profound, dramatic, visible effect on the patient. They will often change instantly from a suspicious, pained individual to a relaxed, trusting person.
Visits should be regularly scheduled, not related to the level of "sickness." Encounters with patients must not focus on symptoms. This again is not how physicians are typically taught to practice medicine. Why see them if they’re not "sick?" Why not ask them what’s wrong? If patients can be freed from having to report symptoms, then clinicians free themselves from having to pursue those symptoms. The practitioner must understand that the patient is coming in to share their suffering with the doctor, not to receive a diagnostic test or even a medication. Review symptoms that the patient raises, examine what is appropriate, but focus time and energy on more general issues. A very brief regional exam may give a powerful sense of security to many patients with somatization disorder. The patient wants time and attention, not tests and treatments. A long, insight-oriented psychotherapy session is not the goal or skill of the primary care practitioner. A visit that is too brief will make the patient suspicious that the provider doesn’t really care. The traditional 15-minute visit may be just right, with the understanding by both provider and patient that more visits are already planned for the future.
It is often tempting to seek the reassurance from consultants in the care of patients with complex and unexplained symptoms. In the management of patients with somatization disorder, it is best to avoid referrals if possible. When needed, use selected consultants. Warn them what to expect. Communication among providers in the care of patients with somatization disorder is probably as critical as it is in the care of a patient in the intensive care unit. It is important to understand that consultants are often incapable of dealing with patients like this. Consultants are taught to pursue a diagnostic quest that will take the patient through every test available. Insist to both the patient and the consultant that the patient see the primary care provider before any significant treatments and tests are done. The primary care clinician is the gatekeeper (and guardian) in the care of these patients.
Treatment with antidepressants should certainly be considered for those patients who have a component of depression, and they may provide some improvement, but there is no specific pharmacotherapy for somatization disorder.4
Psychiatric consultation is inevitably done once the diagnosis of somatization disorder is established or seriously entertained by the primary care provider. Occasionally insight-oriented psychotherapy is effective, but typically the patient returns to the primary care physician much more quickly than the physician would hope, with no evident "improvement." Recently, short-term group therapy has been used with some success. Patients have fewer somatic symptoms and used fewer health care resources, which results in net economic savings in spite of the added costs of psychiatric services.26 On a long-term basis, the psychiatrist may serve as a background advisor to the primary care physician on the ongoing behavioral management of the patient. The primary clinician may feel more secure with long-term support, but the patient will often refuse to return to the psychiatrist on a routine basis.3,25,27
The primary provider must always be ready for the next set of symptoms. Even in the ideal therapeutic relationship between the physician and the patient with somatization disorder, the patient will present with new, unexpected symptoms. It is critical to diagnose carefully, as it is possible that this time the symptoms will represent a true organic illness. The sophisticated practitioner learns to rely on clinical judgment, performing the key tests to demonstrate the relatively low likelihood of a new organic problem, avoiding referral to a consultant for extensive evaluation of the new problem. Patients with somatization disorder often have significant organic problems in addition to their psychiatric problem.3 Both sets of problems must be managed simultaneously and obviously quite differently.
The patient scenario can now be reviewed and appropriate management understood. The relatively young age for the presentation of chest pain in this patient reduces the probability that this represents coronary artery disease. It does not eliminate that possibility, however. His prior medical history is impressive, with surgeries and significant health problems before age 30. The prolonged histories of abdominal pain and knee pain should be noted. The patient’s criticism of the previous physician should not be ignored. Subconsciously, he is now raising the expectations and obligations of his new doctor. Although the probability of significant coronary artery disease is low, an electrocardiogram and exercise tolerance test are appropriate. The normal results should provide enough re-assurance to the primary care physician that a thallium treadmill or cardiology referral is not indicated, even in the face of pressure from the patient. A near-term follow-up visit should be requested by the physician. That visit should not focus on the chest pain, but generally on the patient’s life, lifestyle, and work. The provider should propose, maybe insist, on regular monthly visits, indefinitely.
The presentation of new symptoms of nausea and hematemesis, are not clearly related to the chest pain. This patient could easily have peptic ulcer disease or gastritis. An investigation of his new symptoms will require either endoscopic or radiological studies.
The patient will be back again, whether his abdominal pain is a separate diagnosis or part of his somatization disorder. Anticipate new symptoms, make regularly scheduled visits, accept his "suffering," and retain the bond that has been formed with him.
Lidz has summarized the tremendous management challenge of the patient with somatization disorder.28
Good physicians have always known that the majority of their patients come to them because of emotional difficulties. People turn to physicians, the clergy, and attorneys for help with problems with which they cannot cope alone, but physicians are in a particularly difficult position. Patients come to them with physicial complaints derived from emotional difficulties and problems in living of which patients are unaware because they seek to banish them from consciousness in order to retain their equanimity, but for which substitute physical symptoms occur.28
There are few problems in primary care that demonstrate more clearly that patience and compassion are the hallmarks of the excellent physician.
References
1. American Psychiatric Association. Diagnosis and Statistical Manual of Mental Disorders, Fourth Edition. Washington: American Psychiatric Association; 1994.
2. Drossman DA, et al. Sexual and physical abuse and gastrointestinal illness. Review and recommendations. Ann Intern Med 1995;123:782-94.
3. Quill TE. Somatization Disorder: One of Medicine’s Blind Spots. JAMA 1985;143:1403-1408.
4. Kaplan C, Mack L, Gordon GH. Somatization in Primary Care: Patients with Unexplained and Vexing Medical Complaints. J Gen Int Med 1988;3:177-190.
5. Katon W. The Prevalence of Somatization in Primary Care. Comp Psychiatry 1984;25:208-215.
6. Myren J, et al. Psychopharmacologic Drugs in the Treatment of the Irritable Bowel Syndrome. Ann Gastroenterol Hepatol Paris 1984;20:117-123.
7. Swartz M, et al. Somatization Disorder in a Community Population. Am J Psychiatry 1986;143:1403-1408.
8. Castillo R, Waitzkin H, et al. Somatization in Primary Care, With a Focus on Immigrants and Refugees. Arch Fam Med 1995;4:637-646.
9. Barsky AJ, Borus JF. Somatization and Medicalization in the Era of Managed Care. JAMA 1995;274:1931-1934.
10. Swartz M. Somatization Disorder. In: Robins, LN (ed). Psychiatric Disorder in America. New York: Free Press; 1990:220-257.
11. Smith GR, et al. Patients with Multiple Unexplained Symptoms; Their Characteristics, Functional Health, and Health Care Utilization. Arch Intern Med 1986;146:69-72.
12. Livingston R, et al. Families who somatize. J Dev Behav Pediatr 1995;16:42-46.
13. Fink P. Surgery and Medical Treatment in Persistent Somatizing Patients. J Psychosom Res 1992;36:439-447.
14. Margo KL, Margo GM. The Problem of Somatization in Family Practice. Am Fam Phy 1994;49:1873-1879.
15. Walker EA, et al. Dissociation in Women with Chronic Pelvic Pain. Am J Psych 1992;149:534-537.
16. Balint M. The Doctor, the Patient, and the Illness. New York: International Universities Press; 1957.
17. Engel GL. The Clinical Application of the Biopsychosocial Model. Am J Psych 1980;137:535-544.
18. Noyes R, et al. Somatization: Diagnosis and Management. Arch Fam Med 1995;4:790-795.
19. Shear MK, Schulberg HC. Anxiety Disorders in Primary Care. Bull Menninger Clin 1995;59(Suppl A);A73-85.
20. Betrus PA, et al. Women and somatization: Unrecognized depression. Health Care Women Int 1995;16:287-297.
21. Williams JW, et al. Depressive Disorders in Primary Care: Prevalence, Functional Disability, and Identification. J Gen Intern Med 1995;10:7-12.
22. Portegijs PJ, et al. A troubled youth: relations with somatization, depression and anxiety. Fam Pract 1996;13:1-11.
23. Engel GL. Psychogenic’ Pain and the Pain-Prone Patient. Am J Med 1959;26:899-918.
24. Blumer D, et al. The Pain-Prone Disorder. Psychosomatics 1981;22:395-402.
25. Lipsitt D. Primary Care of the Somatizing Patient: A Collaborative Model. Hospital Practice 1996;31:77-88.
26. Kashner TM, et al. Enhancing the Health of Somatization Disorder Patients. Effectiveness of Short-Term Group Therapy. Psychosomatics 1995;36:462-470.
27. Craig TKJ, et al. The South London Somatization Study, I: Longitudinal Course and the Influence of Early Life Experience. Br J Psychiatry 1993;163:579-588.
28. Lidz T. The Person: His and Her Development Throughout the Life Cycle. New York: Basic Books; 1983.
29. Sternbach RA. Varieties of Pain Games. Adv Neurol 1974;4: 423-430.
Physician CME Questions
35. A patient with known somatization disorder presenting with a new somatic symptom should:
a. be referred for psychiatric consultation.
b. receive a comprehensive re-evaluation.
c. be referred for specialty consultation.
d. receive a problem focused evaluation.
36. Patients with somatization disorder typically have a history of multiple medical problems by age:
a. 12.
b. 25.
c. 30.
d. 40.
37. A patient who presents with the sudden, new onset of arm weakness without supporting evidence of organic abnormalities, most likely has:
a. somatization disorder.
b. conversion disorder.
c. hypochondriasis.
d. undifferentiated somatiform disorder.
38. Somatization disorders are particularly common in cultures that:
a. encourage emotional expression.
b. discourage emotional expression.
c. are well-educated.
d. are socio-economically stable.
39. A patient with somatization disorder should be seen by the primary care provider:
a. regularly, and fairly frequently.
b. as needed, based on symptoms.
c. annually, for a complete physical.
d. as infrequently as possible.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.