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Somatization in the Primary Care Setting

Somatization in the Primary Care Setting

Primary care physicians encounter
perplexing complaints in up
to 40% of their patients.1,2

Patients are often frustrated with troublesome
symptoms that are inexplicable
and refractory to multiple treatment
regimens. Because there is variability
in how patients present and no apparent cause for their symptoms, this clinical
situation has historically been difficult
to conceptualize, categorize, and
treat effectively. A review of somatization
in the primary care setting is germane
to psychiatrists who function as
consultants to primary care practitioners,
since they are often asked to evaluate
patients with somatoform disorders.

DIAGNOSTIC CONSIDERATIONS

Ancient Egyptian healers noticed that
women were affected with perplexing
somatic complaints more often than
men and concluded that a "floating
uterus" was the culprit. In the 17th
century, Thomas Sydenham believed a
multifactorial process that included
"antecedent sorrows" should be considered
for both men and women.3

Charcot—and then Freud—used the
word "hysteria" to describe a condition
they thought was largely based on unconscious
emotional conflict with a related
maladaptive somatic response. This term
was commonly used until 1980, when
the DSM-III changed the diagnosis to
Briquet syndrome, in honor of the work
done in this area by the 19th century
French physician Paul Briquet. Currently,
in primary care settings, the informal
diagnosis of somatization is broadly
used to describe patients with physical
complaints that cannot be totally explained
by physical examination and a
corresponding diagnostic workup.

With a focus on the need to "exclude
occult general medical conditions or
substance-induced etiologies for the
bodily symptoms," DSM IV4 includes
7 diagnoses under the category of
somatoform disorders: somatization
disorder, undifferentiated somatoform
disorder, conversion disorder, pain
disorder, hypochondriasis, body dysmorphic
disorder, and somatoform
disorder not otherwise specified (Table
1
). It is important to note that the grouping
of these disorders does not necessarily
imply shared pathogenesis. The
somatoform disorders are not fully
explained by a general medical condition
or other mental disorder and, in
order to meet diagnostic criteria, must
cause significant impairment or distress.
Also, unlike a diagnosis of malingering
or factitious disorder, patients with
a somatoform disorder do not intentionally
produce their symptoms.

Alternatives to the DSM-IV nomenclature
have been suggested because of
the perceived rigid diagnostic criteria,
frequent overlap between the somatoform
disorders, and the resultant impractical
application to clinical practice. For example,
in order to establish a DSM-IV diagnosis
of somatization disorder, one must
have 4 pain symptoms, 2 GI symptoms,
1 sexual symptom, and 1 pseudoneurologic
symptom during the course of the
illness. This somewhat arbitrary combination
of symptoms is not always relevant
to commonly encountered
somatization in the primary care setting.
Also, a person with a diagnosis of somatization
disorder must have had multiple
somatic complaints before the age of 30.
However, studies have shown that patients
are often unable to reliably recall their
medical history with sufficient detail.5

The wide clinical spectrum of somatization
has prompted some medical
specialties to develop their own system
to identify unexplained somatic symptoms.
Some common examples include
irritable bowel syndrome, chronic fatigue
syndrome, and fibromyalgia.
Because many patients do not meet full
diagnostic criteria for somatization disorder,
Escobar and colleagues6 introduced
the abridged somatization disorder as a
less restrictive alternative. This syndrome
is based on lifetime symptoms
and the presence of 4 somatic complaints
in men and 6 in women. Several reports,
including the World Health Organization
Psychological Problems in General
Health Care multicenter study, indicate
high instability of recall when it comes
to lifetime symptoms.5 In this study, 61%
of unexplained somatic symptoms
reported at baseline were not reported
1 year later. Multisomatoform disorder
(MSD) is another diagnostic option for
primary care patients with somatization
that addresses this issue.7 Multisomatoform
disorder is defined as the
presence of 3 or more acutely distressful,
medically unexplained symptoms
from a checklist of 15 common symptoms
found in the primary care setting
(developed using the Primary Care
Evaluation of Mental Disorders
[PRIME-MD] scale that measures
psychopathology7). Patients with MSD
must have active symptoms with at least
a 2-year history of somatization.

The differential diagnosis for somatization
seen in the primary care setting
is extensive. It is important to keep in
mind that inexplicable illness can refer
to a general medical condition, confirmation
of which cannot be found, after
a complete assessment, or it can explain
a general medical condition that exists
but medical evidence for which has not
been discovered after a comprehensive
workup. Lyme disease is an example of
the latter. Before Lyme disease was
discovered in 1982, children and adults were presenting with arthritis, myalgias,
and fatigue with no known precipitant
or cause. It is beyond the scope of this
paper to discuss a full differential diagnosis
for somatization, but it is important
to do a complete diagnostic workup
while considering somatization disorder
a diagnosis of exclusion.

Before establishing a diagnosis of
somatization disorder, one must attempt
to rule out the intentional production of
false physical or psychological symptoms.
A patient in whom malingering
is diagnosed is focused on feigning
illness in an attempt to gain external
incentives such as financial compensation,
shelter, or escape from military duty
or criminal prosecution. Factitious disorder
also involves the purposeful and
sometimes elaborate self-report of
somatic complaints with the objective
of assuming the "sick role." People with
this disorder have no obvious external
secondary gain beyond the sick role.
When evaluating either condition, the
physician should obtain collateral history
(particularly from other area hospitals),
complete a focused examination and, as
with somatization disorder, consider
both of them as diagnoses of exclusion.

CLINICAL SIGNIFICANCE

People with somatoform disorders experience
high levels of physical discomfort
and tend to be unsatisfied with life.8

A retrospective review of more than
13,000 psychiatric consultations found
that somatization disorder resulted in
more disability and unemployment than
any other psychiatric illness.9 It is difficult
to accurately establish the prevalence
of somatization because of
wide-ranging definitions and patients'
limited ability to accurately recall symptoms
from the distant past. Medical
explanations for common somatic complaints,
such as malaise, fatigue, abdominal
discomfort, and dizziness, are found
only 15% to 20% of the time.10
Somatization disorder has an estimated
prevalence of 0.2% to 1.0% in primary
care settings and is 5 times more
common in women.6 The abridged
somatization disorder has a higher
prevalence in the primary care setting
of about 20%.6 Multisomatoform disorder
is uniquely based on current symptoms
and is found in primary care patients 13% to 20% of the time.11,12

Patients with somatization in the
primary care setting have more than
twice the outpatient utilization and overall
medical care cost when compared
with patients without somatization.13
This often translates into increased frustration
and low levels of professional
satisfaction for physicians who manage these patients.14 Part of the problem may
be a lack of psychiatric supervision and
instruction during residency training.
Sullivan and associates15 surveyed 348
primary care program directors and
found that two thirds of them believed
more psychiatric education (particularly
in the area of somatoform disorders) was
needed for residents. Smith and coauthors16
showed that health care utilization
and cost decreased by more than
50% when primary care physicians
effectively treated their patients who had
unexplained medical symptoms. An
increase in training of primary care
physicians in this area could result in
improved job satisfaction and decreased
patient morbidity.

Table 1
Brief definitions of commonly used somatoform disorders4,6,7
 DSM-IV     Definition
Somatization disorder • Many unexplained physical complaints before age 30
• 4 pain, 2 GI, 1 sexual, 1 pseudoneurologic symptom(s)
Undifferentiated somatoform
disorder
• ≥1 unexplained physical complaint
• Duration ≥ 6 months
Conversion disorder • ≥1 unexplainable, voluntary motor or sensory symptom or deficit
• Directly preceded by a psychological stress
Pain disorder • Pain in ≥ 1 site that is largely caused
by psychological factors
Hypochondriasis • Preoccupation with a nonexistent disease despite
a thorough medical workup

• Does not meet criteria for a delusion
Body dysmorphic disorder • Preoccupation with an imagined defect
in physical appearance
Somatoform disorder
Not otherwise specified
• Somatoform symptoms that do not meet criteria for any specific somatoform disorder
 Non-DSM-IV
Abridged somatization disorder • Presence of 4 unexplained somatic complaints
in men and 6 in women
• Long history of physical complaints
Multisomatoform disorder

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

PRIME-MD, Primary Care Evaluation of Mental Disorders.
All above disorders: (1) cause significant social/occupational dysfunction, (2) are not caused by other general
medical or psychiatric conditions, and (3) are not intentionally produced or related to secondary gain.

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