Somatization

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[edit] Somatization

Charles C. EngelJr.a

Wayne J. Katon

aThe views expressed by Dr. Engel in this article are his own and do not reflect the official policy or position of the Uniformed Services University Department of the Army, Department of Defense, or the U.S. Government. Mention somatization, and many physicians respond with animated tales about their most frustrating patients. Physicians' frustration over somatization occurs for a number of reasons. Somatization contradicts most physicians' professional sense that people with psychiatric disorders present with emotional symptoms. Similarly, physicians often believe that physical symptoms in the absence of “hard” supporting evidence (examination or test findings) are less serious or debilitating than symptoms occurring in the context of an identifiable disease. Instead, somatizing patients may minimize the extent of their psychologic distress and describe high levels of disability, even though accompanying diagnostic evaluations offer few satisfying leads. Disability often persists in spite of reasonable physician reassurances. Requests for time off work or to fill out disability forms often add to physician discomfort. The somatizing patient may further alienate physicians by challenging their reassurances or even questioning their competence.

Fortunately, troublesome patients with puzzling chronic physical symptoms are not the rule for somatization. This chapter emphasizes that somatization is:

• Ubiquitous in medical practice and human experience
  
• Associated with substantial unrecognized morbidity and high health care costs
  
• Shaped by predisposing, precipitating, and perpetuating factors into a continuum of severity and duration that includes acute, subacute, and chronic types
  

Somatization has been defined as a psychologic defense mechanism, a physical symptom caused by a psychiatric disorder, or a physical expression of psychosocial distress. This chapter considers somatization broadly, as any physical symptom that prompts the sufferer to seek health care but remains unexplained after an appropriate medical evaluation. Somatization is therefore perceptual (a person feels symptoms), cognitive (the person experiencing symptoms decides they are ominous), and behavioral (the person with symptoms seeks health care for them). Physician-patient conflict often occurs because of the mismatch between the patient's view (the symptom is ominous) and the physician's view (the symptom has no biomedical basis).

The purpose of this chapter is to help primary care physicians recognize, diagnose, and manage the spectrum of somatization. Chronic somatization, a relatively unusual and disabling form of somatization, lies at one end of the spectrum. People with chronic somatization have long histories of unexplained physical symptoms with associated episodes of high health care use, and often present for care of many simultaneous physical symptoms spanning multiple body systems. They typically deny or minimize their distress despite its obvious clinical manifestations and its frequent associations with extensive childhood and adulthood adversity. At the other end of the spectrum is acute somatization. Acute somatization is very common in clinical practice and is marked by the absence of a significant history of unexplained symptoms, fewer numbers of physical symptoms on presentation, the usual presence of a precipitating stressful life event, and a more transient course (depending on the duration of the stressful event). In the middle of the spectrum lies subacute somatization. This is characterized by recurrent bouts of several unexplained physical symptoms interspersed with asymptomatic periods. Symptomatic periods are usually associated with treatable anxiety or depressive disorders.

[edit] EPIDEMIOLOGY

Symptom diaries show that primary care patients record an average of one new symptom every 7 days, the most common being headaches, fatigue, muscle aches, and gastrointestinal (GI) or respiratory symptoms. One community study found that more than 4% of people had multiple, chronic, unexplained physical complaints. Only about 5% of symptoms experienced by community respondents are reported to physicians. Studies of medical patients with unexplained symptoms reveal high rates of major depression and panic disorder (Tables 50-1 and 50-2). Individuals with unexplained physical complaints and coexisting psychiatric disorders tend to use inordinate amounts of medical care at great cost to society. In a 3-year retrospective study of 1000 ambulatory care patients, 38% had new complaints of at least 1 of 14 common symptoms. Two thirds of symptoms were evaluated diagnostically, but only 10% to 15% of evaluations yielded a physical explanation not apparent at the initial visit. This 1988 study also found that the average cost per physical explanation was then $2252. An estimated 25% to 35% of primary care patients have current psychiatric disorders, but these are missed 50% to 80% of the time, largely because of inaccurate diagnosis in those patients who complain of medical illness or physical symptoms rather than emotional concerns.

Table 50-1 Prevalence of Major Depressive Disorder Among Patients With Medically Unexplained Physical Symptoms vs. Control Patients With Clearly Explained Physical Symptoms

Table 50-2 Panic Disorder Among Various Samples With and Without Medically Unexplained Physical Symptoms

There is a strong relationship between unexplained physical symptoms and psychiatric disorders, especially anxiety and depression. One study of the general population showed that 49% of subjects reporting five or more functional symptoms (vs. 6% of control subjects with no symptoms) had at least one current psychiatric disorder. Seventeen percent of the group with five or more symptoms had current panic disorder (vs. 0.1% of controls), and 15% had current major depression (vs. 1% of controls). Research suggests a similar relationship between the number of pain complaints a person has and his or her level of anxiety and depression.

[edit] PATHOPHYSIOLOGY

[edit] Hereditary Factors

Family studies have been completed for only the most severe forms of somatization. Patients with somatization disorder, a prototypical chronic somatization problem (Box 50-1), have an increased prevalence of somatization disorder among first-degree female relatives and antisocial personality disorder, alcohol abuse, and possibly attention deficit disorder among first-degree male relatives. Adoption and twin studies are inconclusive regarding the relative genetic and environmental contributions to these associations.

[edit] Neurophysiologic Explanations

Neurobiologic theories propose central nervous system (CNS) modulation of peripheral physical sensations. For example, chronic pain perception is dampened centrally via the endogenous opioid system. Monoamine neurotransmitters serotonin and norepinephrine may interact to alter chronic pain perception. Research suggests that CNS alterations in monoamines also occur among patients with anxiety and mood disorders, disorders often associated with somatization. Tricyclic antidepressants reduce presynaptic reuptake of these neurotransmitters, have documented analgesic effects in both depressed and nondepressed patients with chronic pain, and reduce other physical symptoms among patients with panic disorder and major depression.

Stress and emotions appear related to body symptoms via altered physiologic arousal. Autonomic arousal increases smooth muscle contractions and skeletal muscle tone. Smooth muscle contractions in the GI tract are temporally related to physical discomfort. Painful skeletal muscles often have higher electromyographic potentials than do control muscles, and evidence suggests that skeletal muscle contractions may coincide with back and myofascial pain syndromes.

One study observed that fibromyalgia patients have alpha-wave intrusion into slow-wave sleep. The demonstration that experimental disruption of stage IV sleep in normal subjects results in musculoskeletal and mood symptoms led to postulation that fibromyalgia is a nonrestorative sleep disorder. Over half of chronic pain patients report a sleep disturbance. Disruption of sleep patterns by anxiety and depressive disorders, as well as psychosocial stressors, may also cause physical symptoms.

Studies of patients with somatization disorder have revealed abnormal auditory-evoked potentials, abnormal right frontal electroencephalographic (EEG) frequencies, and bifrontal impairment and nondominant hemispheric dysfunction on neuropsychologic testing. Most unilateral conversion symptoms involve the left side of the body in right-handed individuals, and nondominant hemispheric dysfunction is one possible explanation.

[edit] Psychologic Explanations

Cognitive-behavioral, behavioral, and psychodynamic theories offer ways of understanding and treating somatization. Cognitive-behavioral psychology (CBP) postulates that perceived symptoms are linked to emotions, care seeking, and disability via underlying beliefs regarding cause (sometimes called explanatory illness beliefs). Fig. 50-1 shows how one's beliefs regarding the cause of a physical symptom can result in an escalating cycle of anxiety, physiologic arousal, and physical symptoms. The figure depicts this cycle for a man with recurrent musculoskeletal chest discomfort who has recently lost a close friend from an acute myocardial infarction. Previously unnoticed chest pain prompts worry and fears of sudden death. Worry and fear promote psychophysiologic arousal, manifesting as sweating, shortness of breath, and more chest discomfort. Cognitive-behavioral therapy (CBT) helps patients assess potentially harmful illness beliefs and replace them with more appropriate ones.

Figure 50-1 Cycle of anxiety, physiologic arousal, and somatic symptoms in a person with chest pain whose friend recently suffered a fatal myocardial infarction (MI).

Behavioral psychology posits that behaviors are learned. Two ways of learning relevant to somatization are modeling (learning by imitating) and operant conditioning (learning by rewards and punishments). Modeling may explain why disabled or chronically ill family members are common among somatizing patients. Operant conditioning explains why patients receiving illness “rewards” (e.g., workers' compensation or relief from aversive responsibilities) may be prone to chronic disability.

Psychodynamic psychology views somatization as a defense against conscious awareness of (or an unconscious solution to) conflicting psychologic needs or fears. A woman who has always subordinated her emotional needs and fears being alone may, for example, develop sudden paralysis of her legs as she prepares to leave an abusive husband. This “conversion” of psychologic conflict to physical symptoms is the historical reason that neurologic symptoms occurring in relation to identifiable stressors were usually diagnosed as conversion disorder.

[edit] Sociocultural Theories

Mentally ill patients are too often ostracized and viewed by society as irresponsible and unworthy of social assistance. Patients with physical illness, however, are usually seen as victims who are sick and deserving of sympathy, care, and relief from work and other taxing responsibilities. This undoubtedly causes some distressed patients to preferentially report their physical rather than their emotional concerns to their physicians. Families are another social system that can affect symptom reporting. For example, a child may develop abdominal pain to distract parents from arguing, violence, or other family strife.

[edit] DIFFERENTIAL DIAGNOSIS

Differential diagnosis varies according to the severity and duration of functional symptoms. Table 50-3 outlines the relative importance of various psychiatric disorders to acute, subacute, and chronic forms of somatization.

Table 50-3 Duration and Severity of Somatization (Acute, Recurrent, Chronic) and the Likelihood of Potentially Coexisting Psychiatric Disorders

[edit] Undiagnosed Medical Illness

Somatization, distress, and physical illness frequently coexist, so evaluation for one should not come at the expense of the others. Physicians should carefully consider illnesses that can present in vague, unusual, or multisystem patterns. Multiple sclerosis, collagen vascular diseases, endocrine diseases, and other conditions should be weighed against the patient's presentation.

[edit] Psychiatric Disorders Associated with Unexplained Physical Symptoms

Most, if not all, psychiatric disorders are associated with unexplained physical symptoms. Most somatization is associated with common treatable anxiety and depressive disorders or precipitating psychosocial stressors. Physicians must be alert to recognize and treat these disorders. Chapters 48 and 49 describe them in detail, and only issues pertaining to somatization are discussed here.

[edit] Anxiety Disorders.

Criteria for a panic attack include sudden bouts of palpitations, sweating, shaking, shortness of breath, choking, chest pain, nausea or other GI distress, dizziness, numbness or tingling, or chills. Criteria for generalized anxiety disorder (GAD) include muscular tension, sleep disturbance, fatigue, and concentration and memory problems. The link between anxiety and physical symptoms exists, however, even when anxiety is measured without using these physical symptom criteria. Anxiety can increase attention to and worry about any coexisting physical symptoms. Panic disorder occurs in 6% to 8% of primary care patients, and in addition to physical symptoms, is strongly associated with amplified physical health concerns and high medical care use. If undiagnosed, the protean physical manifestations of panic disorder may cause affected patients to visit many doctors and emergency rooms. Appropriate pharmacologic treatment can ameliorate disabling panic attacks, physical symptoms, and health concerns.

[edit] Depressive Disorders.

Depression has been shown to be associated with increased physical symptoms in multiple research studies. Physical symptoms in depressed patients may result from vegetative symptoms such as fatigue; increased symptom sensitivity; pessimistic symptom interpretations; a mode of communicating distress; a mood-state- dependent memory of prior physical illness; and somatic delusions (e.g., fixed, false belief one's “insides are rotting”) from major depression with psychotic features. Major depression and dysthymic disorder are easily overlooked when patients describe only physical symptoms or describe depressive symptoms as secondary to their pain or somatic discomfort. Physicians must have a high index of suspicion to look past physical manifestations to assess vegetative and emotional symptoms of depression. Past or family history of depression, antidepressant treatment, or psychiatric hospitalization can provide diagnostic clues.

[edit] Somatoform Disorders

Somatoform disorders are psychiatric disorders in which one or more unexplained physical symptoms are the central defining feature. The physical manifestations of somatoform disorders do not involve conscious intent by the patient.

[edit] Conversion Disorder.

Conversion disorder is similar to a somatically expressed adjustment disorder. It is characteristically acute, is associated with a precipitating life event or conflict, and has a good prognosis (passing of the precipitating event is usually associated with symptom resolution). Classic conversion symptoms have become less common over time. Most people with conversion disorder describe characteristic neurologic symptoms such as paralysis, numbness, or blindness in association with a significant psychosocial stressor. Past or coexisting mood, anxiety, or substance use disorders are risk factors for conversion disorder, and conversion disorder is a risk factor for somatization disorder (a lifetime pattern of multisystem conversion symptoms). Women are most often affected, but men with acute, severe stressors (e.g., war or natural disaster) or occupational injuries may be at elevated risk.

Anatomic, physiologic, or other inconsistencies in the symptom presentation may cause the physician to suspect conversion. In many cases, conversion causes amplification of a symptom caused by a neurologic or other physical illness. For example, many patients with epilepsy also have intermittent pseudoseizures.

[edit] Pain Disorder with Psychologic Features.

Pain disorders include pain in one or more anatomic sites that requires clinical attention, causes significant distress or impairment, and is initiated, exacerbated, or perpetuated by psychologic factors. Common anatomic sites for pain include low back, head, pelvis (in women), abdomen, and chest. General medical conditions or injuries are often present in conjunction with psychosocial factors. Psychosocial factors should be investigated if pain persists beyond the normal tissue healing time (3 months is generally adequate) or if the patient's disability exceeds that expected by objective findings. Excessive use of the health care system, failure of the patient to accept physician reassurance, or prolonged or excessive use of narcotic analgesics, sedative-hypnotics, or alcohol suggests psychiatric complications. Symptoms of anxiety or depression are typically disabling, and routine assessment of chronic pain patients for these conditions is recommended.

[edit] Somatization Disorder.

Patients with somatization disorder manifest a pattern of significant impairment due to multiple unexplained physical symptoms that prompt medical visits beginning before age 30 and lasting for several years. Individuals with somatization disorder tend to view themselves as having been in poor health their entire life. To be diagnosed with somatization disorder, a patient must have had at any time during the course of the disorder: four pain symptoms, two GI symptoms, one sexual symptom, and one symptom the patient interprets as neurologic. If a medical explanation is present, then physical symptoms or disabilities are in excess of what is expected.

Somatization disorder is unusual in the general population (0.1%) but overrepresented in primary care practice (0.4% to 5%). Studies show it occurs frequently among psychosocially distressed persons with high use of ambulatory care (20%), women undergoing hysterectomy for a reason besides cancer (27%), and patients with chronic pain (12%), irritable bowel (17% to 28%), fibromyalgia (70%), chronic fatigue syndrome (10% to 20%), and multiple chemical sensitivity (27%). Coexisting psychiatric disorders are the rule. Recurrent major depression or anxiety disorders are present in the majority. As the number of physical symptoms increases, so does the likelihood of coexisting alcohol problems, prescription drug misuse, early life adversity, and chronic maladaptive coping. Patients with somatization disorder often relate destructively to health care systems. Their lengthy medical records often reveal “doctor shopping,” prescription drug dependence, multiple unrevealing invasive procedures or surgeries, and iatrogenic injuries.

[edit] Hypochondriasis.

Hypochondriasis is the nonpsychotic but persistent concern that one has a serious disease, despite medical evidence and reassurance to the contrary. Hypochondriasis is closely associated with depression, anxiety, and psychosocial stressors, leading some to doubt if hypochondriasis ever occurs independently. Patients with panic disorder often think they are dying during attacks and are difficult to reassure. Depressed patients may manifest pessimism about their health or obsessive ruminations about imagined disease. Transient hypochondriasis sometimes occurs after an acute stressor. For instance, after myocardial infarction, patients may become excessively preoccupied with minor physical symptoms such as GI discomfort or palpitations. About 4% to 6% of medical outpatients have hypochondriasis, independent of the severity of their medical illness. Hypochondriasis usually starts in the third decade of life, and males and females are equally affected.

[edit] Malingering and Factitious Disorder

Perhaps the most important difference between the somatoform disorders and malingering or factitious disorder is that the latter disorders involve conscious patient attempts to misrepresent or even manufacture physical illness.

In malingering, an external incentive drives the deceit over illness. Malingering is often suspected but seldom “proved.” It should be considered when clear incentives exist, such as pending litigation or avoidance of military conscription; when severe disability and symptoms occur without objective findings; or when the patient is uncooperative with diagnostic evaluations or treatment efforts. Patients with a history of criminal acts, lying, stealing, cheating, gambling, or substance abuse may malinger to avoid the adverse consequences of their previous actions.

Deceit over illness in factitious disorder may be quite driven and self-destructive. In contrast to malingering, external illness incentives are typically absent. The medical literature contains many colorful but morbid descriptions of this rare psychiatric disorder. Factitious fever may be most common; other types include factitious diarrhea, acquired immune deficiency syndrome (AIDS), urinary tract infection, skin rash, anemia, hypoglycemia, thyrotoxicosis, pheochromocytoma, asthma, psychosis, and dementia. “Münchausen's by proxy” occurs when a mother feigns illness in her child. Most patients with factitious disorder are women less than 40 years old. Many have worked in medical settings, allowing them to achieve an unusual level of medical sophistication. There may be a range of associated psychopathology from mild depression or hypochondriasis to severe personality problems characterized by poor tolerance of minor stress, erratic behavior, impulsive relationships, substance misuse, and early life adversity leading to intense anger at authority figures and themselves. Some with factitious disorder have gained the medical sophistication to alter diagnostic tests through a background as a patient, nurse, physician, or technician. Diagnosis involves medical staff detective work and can result in difficult ethical dilemmas.

[edit] Other Disorders

Bereavement, the normal reaction to the loss of a loved one, can precipitate a “lump in the throat” or other physical symptoms. Substance misuse may cause minor physical complaints during intoxication, “hangovers,” or withdrawal. Less commonly, somatization is an easily recognizable feature of psychosis from schizophrenia, mania, depression, delusional disorder, or delirium or dementia.

[edit] HISTORY

[edit] Chart Review

Chronic somatization often leads to long, confusing medical records bearing witness to doctor shopping, repeated visits to medical specialists for ambiguous symptom clusters, equivocal diagnostic tests, and negative trials of empiric treatment. The chart must be carefully reviewed to avoid overlooking progressive or catastrophic disease and to find clues to a psychiatric disorder. Symptoms may relate temporally to psychosocial stressors, and potential symptom incentives may be discovered. Recurrent urgent or emergent care for sudden, ominous, episodic symptoms followed by negative evaluations suggests panic disorder. Excessive prescription drug use, elevated blood alcohol levels, macrocytic anemia, or elevated liver enzymes may suggest substance abuse.

[edit] Present Illness

Focus first on the patient's chief concern: physical symptoms. Vague, multiple, or inconsistently presented symptoms suggest somatization. While listening to the history, strive to assume the patient's perspective of the symptoms to secure his or her cooperation and enhance empathy and rapport. Understanding the patient's symptoms in a biopsychosocial framework is essential. Many patients troubled by physical symptoms reveal feelings of being trapped by their life situation or powerless over personal circumstances. Several visits will pass before many patients entrust their psychosocial concerns to their physician, and some never do, especially if they feel the physician is minimizing or belittling of their health concerns. Some patients will only (but readily) discuss their psychosocial issues if they are asked, so early and direct questioning regarding these issues, as well as anxiety, depression, and substance misuse, is important for all patients in whom somatization is suspected. If the patient is unreceptive, then delay the issue without persistence, since confrontation early in the physician-patient relationship almost always leads to unfavorable results. Depressed patients who are defensive often minimize or deny a depressed or anxious mood but will relate vegetative symptoms. Those with panic disorder will often minimize anxiety but will acknowledge sudden and recognizable physical symptom spells. Consider whether stressors and changes in functioning are temporally related to vegetative symptoms or symptom spells. Impairment out of proportion to symptom severity suggests psychiatric illness. Investigate the extent and quality of patients' support systems. Supporters may perpetuate disability by relieving patients of responsibilities that are undesirable to either the patient or their supporters. Look also for financial, legal, or other factors that may perpetuate symptoms.

[edit] Past Medical History

Determine levels and types of health care used over the previous 5 years including number of visits, number of physicians, surgical procedures and indications, and chronic pain or psychophysiologic problems (e.g., GI distress, palpitations). Listen to patients' descriptions: those with chronic somatization often view previous physicians with exaggerated scorn but are overly optimistic about their new physician's abilities. Clarify patients' past psychiatric history (substance abuse, hospitalizations, medications, suicide attempts, violence, criminal acts, or psychotherapy) and assess indicators of early life adversity such as childhood abuse, neglect, parental death, or chronic illness. Inquire about family history of depression, anxiety, substance abuse, suicide, crime, violence, and somatization. Chronic illness or physical disability in the nuclear family may serve as learning models for the patient.

[edit] PHYSICAL EXAMINATION

A thorough initial physical examination including mental status assessment is necessary, with a brief examination performed at subsequent visits. This serves as a cost-effective screening device and reassures and validates patients' concerns. Physical stigmata of alcoholism and intravenous or intranasal substance use can confirm substance misuse. Musculoskeletal injuries, scars, burns, lacerations, bruises, and abrasions may be clues to undisclosed abuse, violence, suicide attempts, or self-injury and should always result in direct, respectful questioning about how they were obtained.

[edit] LABORATORY AND DIAGNOSTIC ASSESSMENT

The main benefit of testing is additional information regarding patients' physiologic status. However, the costs associated with diagnostic testing for patients suspected of somatization are often subtle but high. The likelihood of a false-positive result increases with the number of tests performed. The false-positive rate also increases when testing is used to rule out clinically unlikely diagnoses. Testing is expensive, and it often wrongly suggests to the patient that the physician suspects serious undiagnosed disease. Therefore a conservative approach to testing is advised. Objective examination findings or classic symptom constellations are the main indications for laboratory assessment, and normal or equivocal test results should seldom be repeated. Sometimes, reviewing the medical record or talking with past practitioners provides enough information to dispel current medical concerns. When tests or imaging studies must be done, reduce iatrogenic worries by diligently reviewing them with the patient, emphasizing normal findings when appropriate.

[edit] MANAGEMENT OF THE SOMATIZATION SPECTRUM

A stepped care approach to somatization management aims to match the intensity of treatment to the severity of somatization. For most patients, somatization is acute, mild, and self-limited. For a relatively few patients, somatization is chronic, disabling, and relatively unremitting. It is not possible to know which patients will progress from acute to chronic somatization, even though it is possible to identify patients at relatively high risk. Instead, it is prudent to monitor patients for persistence of symptoms and progression of disability and increase the intensity of care accordingly. The basic elements of stepped care for somatization include routine primary care, collaborative primary care, and intensive specialty care.

[edit] Routine Primary Care Management

Routine primary care is most appropriate for patients with acute somatization. In routine primary care, the physician is the primary provider and care is delivered in the context of the usual office visit. The success of psychosocial intervention depends on development of a supportive, caring, respectful, and empathetic physician-patient relationship. It is important to inquire about patient fears of illness (e.g., “I'm afraid I have cancer”). Important psychosocial elements of care are physician-initiated reassurance, education, problem solving, patient activation, and bolstering of support. Education typically focuses on information about physiologic effects of stressors, anxiety, and mood and reassurance about specific illness fears. Especially in the setting of some acute stressor, the physician should convey optimism regarding unexplained physical symptoms, allow time for patients to ventilate frustrations, help them delineate problems, and suggest simple, action-oriented solutions for them to try. Emphasize the importance of maintaining usual life routines and roles to the maximum extent possible. Recommendations for rest or time away from work are seldom necessary; the relief from potentially undesirable responsibilities that rest affords may eventually reinforce patterns of disability. Encourage significant others to join the patient in the office because they often have questions regarding the nature of acute somatization symptoms and may encourage the patient to rest and break from routines unless advised otherwise.

Ask patients undergoing a stressor or crisis if they would prefer discussing their problems with a mental health professional. Defensive patients can be reassured that such suggestions are routine for unexplained physical symptoms because they are often distressing for the sufferer, not because symptoms are imaginary. A brief course of a sedative-hypnotic can improve sleep and bolster patient coping during or immediately after an acute stressor (e.g., rape, abuse, assault, unexpected loss) precipitates physical symptoms. Either an antihistamine like diphenhydramine or a short-acting sedative can reduce transient stress-related insomnia. Courses of sedative-hypnotics longer than 5 weeks are rarely appropriate, since these drugs can set up harmful illness incentives and their side effects can impair function.

[edit] Collaborative Primary Care Management

If a patient's somatization is more intermittently relapsing or subacute in nature, then a collaborative multidisciplinary intervention based in the primary care setting is frequently indicated. Patients with subacute somatization most often have a coexisting anxiety or mood disorder creating or compounding episodic physical symptoms. Increasingly, many primary care practices are integrating on-site mental health professionals within their clinics, an arrangement that supports primary care physician efforts to reduce the likelihood of refractory symptoms and impaired functioning. Implementing mental health care in the primary care setting normalizes the experience for patients, increases the likelihood of completed mental health referral, and creates opportunities for “curbside” dialogue between mental health care providers and the primary care physician.

The more persistent the unexplained symptoms, the more frustrating the primary care physician's experience, especially in the absence of on-site collaboration. If symptom eradication is the goal, this will further strain the physician-patient relationship. Rather than targeting physical symptoms per se, it is usually more rewarding and clinically useful to focus on patient functioning as the outcome of interest. The importance of an empathic physician-patient relationship is even greater for subacute than acute somatization. On-site collaboration can assuage the daunting task of achieving a psychotherapeutic posture while addressing biomedical concerns, all during the usual 15-minute primary care visit. The collaborative care plan should call for time-contingent rather than symptom-contingent visits to the physician. In between these physician visits, patients meet with mental health care specialists who can clarify the psychosocial history, evaluate for treatable anxiety or depressive disorders, monitor adherence to treatment while helping patients implement activation strategies, identify problems, and implement practical solutions. Collaborating providers can also engage patients' significant others and help teach patients and supporters about anxiety and depression.

On-site collaboration affords primary care physicians with rewarding opportunities to improve their somatization management skills, something they generally prefer to simply referring interesting patients to an outside specialist. Reassurance in the setting of subacute and chronic somatization involves more than simply assuring patients that their symptoms are not serious, an approach they may find belittling. Instead patients should be reassured of the physical reality of their symptoms. Illness beliefs must be elucidated and assurances directed at those concerns through counseling, education, prognostication, and treatment recommendation. Examples of some common but harmful illness beliefs are: (1) “My symptoms are a sign of disease”; (2) “When I hurt it means I am seriously injuring myself” (e.g., pinching a nerve); and (3) “When I have symptoms, I can't make it without rest and a break from my responsibilities.” Physicians should refine their ability to offer one or two simple medical explanations for the common psychiatric disorders complicating somatization. Patients with panic disorder, for example, can be told that the disorder involves dysregulation of the “stress thermostat” that controls their “fight-or-flight” mechanism. Such explanations destigmatize anxiety and depression, leading to improved rapport and treatment adherence. It helps to tell some patients that physical symptoms often are distressing and that this distress, in turn, can impair their ability to cope effectively with the symptoms. Self-help materials such as audiotapes and books about stress reduction, relaxation techniques, depression, and anxiety are widely available.

Psychopharmacologic interventions are an essential aspect of the management of subacute somatization. Antidepressants can reduce unexplained physical symptoms and physical health concerns among patients with chronic pain, panic disorder, and major depression. Doses should start low and increase slowly, since somatically focused patients are more sensitive to side effects. Before starting medication, offer patients a complete explanation of common side effects. Then, if side effects occur, the physician's expertise and trustworthiness are reinforced rather than diminished. Routinely instructing somatizing patients to call before they discontinue treatment on their own often avoids the situation in which the patient is seen some weeks later and has made little progress. Inform patients that it takes 3 to 5 weeks for full antidepressant effects to occur while side effects lessen during the period. Weekly follow-up visits during the first month of treatment (either in-person or via telephone) optimize patient education and adherence for the depressed or anxious somatizing patient.

[edit] Intensive Multidisciplinary Care

Chronic somatization is the most severe, yet least common, form of somatization and requires the most intensive collaboration to manage effectively. As the duration and number of unexplained physical symptoms increase, so does the likelihood that patients will manifest persistent coping deficits, erratic behavior, relapsing mental disorders, and personality problems. Primary care management of chronic somatization requires careful physician adherence to the following strategies:

• The patient should have only one primary care physician.
  
• Appointments should occur at regular, time-contingent intervals of about every 4 to 6 weeks.
  
• A brief physical examination is performed at each visit to address new physical concerns.
  
• Diagnostic evaluations should be done only for classic symptom constellations or acute objective signs.
  
• Gradually shift the focus of care from rehashes of “old” symptoms to discussions of current functioning, psychosocial stressors, and support structures.
  
• Corroborate interval history, disability, treatment adherence, substance use, and health care use by integrating family and other available support resources into the care plan.
  

This level of structure and emphasis on physician-patient rapport and trust is difficult but essential. Consistency requires limit-setting on patient-initiated visits or those precipitated by an exacerbation of chronic symptoms, so it is important to negotiate an advanced plan with the patient regarding how these visits will be handled. Empathic but direct reminders of the plan can quell patient concerns about rejection when limit-setting becomes necessary.

Other intensive strategies can bolster primary care management. Physical therapy programs of paced and gradually increasing exercise can help patients discharge stress, increase stamina, improve function, and reverse weight gain that has occurred after chronic avoidance of significant physical activity. A vocational counselor can help unemployed patients return to work, reducing dependence on disability compensation, improving morale and self-confidence, and maximizing ability to meet financial obligations and other role expectations.

[edit] Suggestions for Specialty Consultation

Coordination of specialty care is an essential aspect of managing somatizing patients. Chronic somatization often requires intensive collaboration with specialists to reduce doctor shopping and avoid unnecessary diagnostic tests and invasive procedures. It is best to know a consultant in each specialty who orders tests conservatively and understands the management of somatization. If possible, refer a somatizing patient to a specialist only after informing the specialist of the patient's propensity to report medically unexplained symptoms. Some consultants typically initiate lengthy diagnostic evaluations, tend to assume the care of patients rather than collaborate in their management with primary care physicians, or rely on prescriptions for narcotics or sedative- hypnotics for management. The best somatization consultants recommend care rather than assume it, because multiple providers increase the opportunity for uncoordinated care and unnecessary or iatrogenic services.

Most somatizing patients are best managed in primary care settings; indeed, many will actively resist psychiatric consultation. Some, however, require or request direct psychiatric assistance. The best psychiatric consultants usually have a subspecialty interest or training in consultation-liaison psychiatry. Unfortunately, many general psychiatrists have only infrequent exposure to somatizing patients and often do not readily appreciate the need to collaborate carefully with primary care. Psychiatric consultation often helps to:

• Suggest ways of improving treatment adherence.
  
• Elucidate stressors in defensive patients.
  
• Confirm diagnoses of anxiety, depressive, somatoform, or other psychiatric disorders.
  
• Decide about psychopharmacologic treatment for patients with many past treatment failures or complicating medical problems.
  
• Answer questions about suicide or violence potential in those with past attempts or current ideation.
  
• Evaluate for involuntary treatment or hospitalization.
  

Patient defensiveness, erratic style, and excessive rejection fears, as well as social stigmas associated with psychiatric care, are among the obstacles to effective psychiatric consultation for somatization. When somatization is suspected, mention psychiatric consultation early rather than waiting for the completion of an exhaustive negative diagnostic evaluation. Reassure patients that you respect their struggle with real and debilitating symptoms, and explain that the suffering their symptoms cause is often reduced through proper mental health assistance. The patient may be less than receptive at first, but over time they may be less prone to viewing psychiatric referral as rejection. Another strategy to minimize rejection concerns is to routinely schedule patients for a return primary care visit after psychiatric consultation.

[edit] ADDITIONAL READINGS

• WJ Katon: Panic disorder in the medical setting Washington, DC: American Psychiatric Press; 1991:
• WJ Katon, M Sullivan: Antidepressant treatment of functional somatic symptoms. RA Mayou C Bass M Sharpe Treatment of functional somatic symptoms. New York: Oxford University; 1995:
• W Katon, E Walker: Medically unexplained symptoms in primary care. J Clin Psychiatry 1999; 59 (suppl 20):15 - 21.
• LJ Kirmayer JM Robbins Current concepts of somatization: research and clinical perspectives. Washington, DC: American Psychiatric Press; 1991:
• K Kroenke: Symptoms in medical patients: an untended field. Am J Med 1992; 92 (suppl 1A):1A - 3S.1A6S
• K Kroenke, RL Spitzer, JBW Williams,et al.: Physical symptoms in primary care. Arch Fam Med 1994; 3:774 - 779.
• ZJ Lipowski: Somatization: the concept and its clinical application. Am J Psychiatry 1988; 145:1358.
• GE Simon, M Von Korff: Somatization and psychiatric disorder in the NIMH Epidemiologic Catchment Area Study. Am J Psychiatry 1991; 148:1494.
• GR Smith: Somatization disorder in the medical setting Washington, DC: American Psychiatric Press; 1991: