I read with interest Dr McCarron's article (Psychiatric Times, May 2006, page 32), "Somatization in the Primary Care Setting"--an important topic indeed.
He described irritable bowel, chronic fatigue, and fibromyalgia syndromes as systems developed by medical specialists to describe unexplained somatic symptoms. However, chronic fatigue and fibromyalgia are codified diseases with specific criteria.1,2
Dr McCarron described patients with somatization as having "more than twice the outpatient utilization and overall medical care cost" as patients without somatoform disorders and noted that physicians who manage such patients often become frustrated. He acknowledged that patients felt discounted when referred to psychiatrists for their conditions. He advised physicians to "obtain patient agreement to stop overuse of medical care," to not order unnecessary diagnostic tests, and to minimize referrals to medical specialists. His comments brought to mind the following case.
A woman in her 40s with dyspepsia was treated for depression and anxiety when she became critically ill following a biopsy-related esophageal rupture. She had a chaotic recovery marked by nausea, pain, and vomiting. She had endoscopies and testing for inflammatory bowel disease, with no specific cause found for persistent pain and nausea. She did have an elevated sedimentation rate.
Her primary care team felt she was medication seeking when she went to the emergency department (ED) for abdominal pain management. The psychiatrist felt the patient was appropriately distressed about her continuing discomfort (no sign of "la belle indifference") and cited her elevated sedimentation rate, but a request for further workup was denied.
The year after the esophageal rupture, the patient suffered 3 GI bleeds, each requiring transfusion at an unaffiliated hospital. During these outside admissions, the patient's sedimentation rate remained elevated. Additional procedures were performed, including tests that suggested biliary dyskinesia and pyloric outlet syndrome and a laparoscopy to remove adhesions. No further surgery was undertaken, but elective pyloroplasty was recommended. After discharge, the patient continued to experience abdominal pain, nausea, and diarrhea, but dutifully tried to minimize her ED visits because of her primary care team's concern about medication seeking--a view they communicated to the patient's family.
The psychiatrist continued to ask about the patient's sedimentation rate and other findings. The primary care team maintained that the sedimentation rate was a nonspecific finding and that the patient's main problem was addictive behavior. They suggested that the psychiatrist's stance was interfering with team goals.
