each complaint in terms of disturbed organ system, cellular, or molecular function. ...... sician and view symptoms as the "ticket" to this rela- tionship, attempting to ...
CLINICAL REVIEWS Somatization in Primary Care: Patients with Unexplained and Vexing Medical Complaints CRAIG KAPLAN, MD, MACK LIPKIN, JR., MD, GEOFFREY H. G O R D O N , MD
PATIENTS WHO HAVE UNEXPLAINED COMPLAINTS are common in both primary c a r e a n d specialty medical practices, l Most physicians recall vexing patients who suffer from persistent physical complaints that r e m a i n unexplained in spite of every diagnostic a n d therapeutic effort. These patients use much medical care, l"s are frequently subjected to r e p e a t e d diagnostic tests a n d invasive procedures, a n d often frustrate a n d a n g e r their physicians, s Most a r e individuals who "transduce" psychologic or social distress into aversive somatic sensations. They seem u n a b l e to a c k n o w l e d g e or complain directly about psychologic or social distress, experiencing it physically instead. While we do not presently u n d e r s t a n d their d i s e a s e processes (in the biomedical s e n s e of disturbed cellular or o r g a n function), these patients do suffer from their illnesses. This p a p e r presents for the clinician the differential diagnosis, developmental etiology, detection, a n d m a n a g e m e n t of the somatizlng/llnesses. Barsky a n d Klerman 7 define somatization a s " . . . the expression of emotional discomfort a n d psychosocial stress in the physical l a n g u a g e of bodily symptoms." Smiths defines it as "an alternative w a y (somatic) to express psychiatric d i s e a s e or psychological stress w h e n a patient is u n a b l e to use the emotional route of expression." The t h r e a d common to these a n d other definitions is the patient's experie n c e of sensory bodily complaints w h e n psychologic or social problems are present a n d w h e n there is no presently m e a s u r a b l e pathophysiologic disturb a n c e sufficient to explain the symptoms. We will label such bodily complaints as being somatized. Somatizaton c a n occur in association with a number of different disorders a n d is therefore not, in a n d of itself, a diagnostic entity. Hather, it describes a transduction mechanism, a w a y in which some patients experience a n d / o r express underlying psychosocial distress, illness, or mental disorder. It is a
Receivedfrom the Divisionof GeneralInternal Medicine,University of Kentucky and VA MedicalCenter, Lexington, Kentucky: the Divisionof Primary Care. Department of Medicine, New York University School of Medicine.New York, New York: and the Ambulatory and MedicalServices. Portland VA Health SciencesUniversity, PortJand.Oregon. Address correspondenceand reprint requests to Dr. Kaplan: VA MedicalCenter. MedicalService(I 1 I J), Lexington. KY 4051 I.
w a y for us to label, understand, a n d a p p r o a c h such physical symptoms. 9 W h e r e a s a d i s e a s e is a disturbance in structure or function at molecular, cellular, or o r g a n system levels, a n illness consists of both a d i s e a s e a n d its experience by the individual. Diseases c a n be explained by molecular, anatomic, or physiologic der a n g e m e n t s alone. Illnesses require the additional u n d e r s t a n d i n g of persons in their life contexts. Somatization often occurs in the a b s e n c e of detectable disturbances in o r g a n system or cellular functioning; these patients h a v e disturbances at higher cortical, intrapsychic, interpersonal, or social levels. Somatization m a y occur in the p r e s e n c e of disease, however. When a n underlying d i s e a s e is present, symptoms that seem out of proportion to w h a t might be expected from objective findings or that fail to respond symptomatically despite a n objective response to treatment m a y be in part somatizations arising from psychological processes. Somatization is a n illness that c a n n o t be fully understood from the traditional disease-oriented biomedical point of view, which seeks to explain e a c h complaint in terms of disturbed o r g a n system, cellular, or molecular function. It requires instead a systems, or biopsychosocial, perspective in which complaints are viewed as arising from the complex interactions of biologic systems with person, family, social, a n d cultural systems (Fig. 1). Engel ]° h a s written eloquently about the biopsychosocial perspective, as h a v e Schwartz a n d Wiggins.n
SIGNIFICANCE Somatizing patients are a n important problem for primary care physicians. Katon a n d co-workers l concluded that 25 - 75% of visits to primary care physicians were primarily due to psychosocial stress manifested by somatic complaints. In a busy Birmingham, A l a b a m a , practice, Bumum s found that, of 909 patients seen in three months, 98 h a d major psychiatric problems a n d 65 combined them with physical disease. Collyer, 4 a family physician, estim a t e d that 28% of his patient contacts involved emotional illness, a n d that these contacts took up 48% of his t/me. He found that 3.6% of families accounted for 177
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SOMATIZATIONIN PRIMARYCARE
Biosphere Society-Nation Culture-Subculture Community Family Two-person
Nervous system Organs/organ systems Tissues Cells Organelles Molecules Atoms Subatomic particles RGURE 1. Hierarchyof natural systems, lo
32% of his time in practice, a n d that n e a r l y all of these families included two or more patients who h a d depression a n d v a g u e complaints. Cummings a n d VandenBos 6 state that a s m a n y a s 60% of prim a r y care patients recurrently present with somatic symptoms that a r e a n expression of psychosocial distress. In their review of studies of mental disorder in health m a i n t e n a n c e organizations, they concluded that "the failure to provide mental health service [had] the potential of bankrupting the health care financing system due to over uH|iTation of prim a r y care physicians by somati74ng patients." The importance of somatization h a s also b e e n emphasized by two major epidemiologic studies. The Epidemiologic Catchment A r e a (ECA) study, l= using a probability sample in five well-defined pop-
ulation groups, found that, of patients with a n y of 13 common mental disorders, 58% h a d s e e n their genera] medical practitioner in the prior six months. C o m p a r e d with patients without mental disorder, these patients h a d a twice-increased probability of using medical care. Although not all patients identified in these studies as h a v i n g emotional or mental disorders somatize, m a n y of them do. Regier et al.|s a n d S c h u r m a n et al.~4 used d a t a from the National Ambulatory Medical C a r e Survey to demonstrate that approximately 70% of patients with primary or s e c o n d a r y diagnoses of emotional disorders g a v e a somatic complaint as the r e a s o n for their visits to physicians. Among the most common complaints were constitutional symptoms, h e a d a c h e , diT.7.iness, a b d o m i n a l or extremity pain, a n d requests for check-ups. Internists, family practitioners, a n d g e n e r a l practitioners e a c h carry about 25% of these patients. ~4 Primary care physicians frequently fail to detect the emotional disorders that c a n underlie somatized medical complaints. For example, depression is not recognized or treated in roughly 18-50% of affected primary care patients. ~5' ~eThis is a particularly serious oversight in view of the frequency with which affective disorders occur. The population-based prevalence of affective disorders is 7.7%. 17 Structured interview surveys of primary c a r e practices h a v e shown that the prevalence of major depression is approximately 5.8%. ~aThese d a t a place affective disorders a m o n g the most common problems in prim a r y care, yet they a r e frequently neither detected nor treated. Attempts to study somatization epidemiologicaUy are difficult due to the complexity of positive diagnosis, ruling out organic explanations, a n d identifying subjects. Lipkin a n d Lamb ~9 used couvade, or pregnancy-like symptoms, in the mates of expectant w o m e n as a tracer condition in a health m a i n t e n a n c e organization. They found that during the expectant period 22.6% of the m e n h a d c o u v a d e symptoms that were not present before a n d after p r e g n a n c y a n d that were not explained by other conditions. Lack of stability or relevance of the American Psychiatric Association's Diagnostic a n d Statistical M a n u a l (DSM-III) 2° diagnoses w h e n applied to primary c a r e patients m a y also confound epidemiologic research. For example, Kessler et al.=l used the Diagnostic Interview Schedule twice in the s a m e group of medical outpatients, six months apart, a n d found that only one-third of patients who h a d a n active psychiatric diagnosis at either interview were consistently d i a g n o s e d at both interviews (most of the disorders detected in the study were chronic a n d episodic). Cross-cultural study of somatization suggests it is probably a universal h u m a n phenomenon, 2z = oc-
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curring in m a n y if not all cultures. It m a y also occur in n o n - h u m a n mammals, as suggested, for example, in Darwin's classic work on the experience of emot/ons in animals. 24 DIFFERENTIAL DIAGNOSIS S o m a t i z a t i o n is t h e p a t h o l o g i c e n d of a s p e c t r u m
of p h e n o m e n a that overlap normal experience. Most individuals experience minor pains or sensory disturbances in the course of daffy act/vity. When such disturbances a r e labeled a b n o r m a l by the individual a n d l e a d to the seeking of medical care, they b e c o m e symptoms. Such labeling often occurs in association with specific emotional disorders. Somatization is found in association with the disorders listed in Table 1. Studies in varied populations L s0-s2 suggest that somatization is most frequently associated with depression, anxiety reactions, a n d somatofonn disorders in primary c a r e populations. Depression Depression is the most common m e n t a l disorder in the g e n e r a l population after substance a b u s e a n d anxiety,~2 a n d is one of the most common disorders underlying somat/zation in primary care. ss-s7 There are two m a i n categories of depression according to DSM-III. Major depressive disorder, the most important category, h a s the features outlined in Table 2. Minor depression is d i a g n o s e d w h e n the symptoms a r e more chronic a n d less severe. The diagnosis, differential diagnosis, a n d treu~i,ent of major depression in medical patients h a v e b e e n reviewed elsewhere, se-4~ Depressed patients m a y selectively focus on the somatic manifestations of their d i s e a s e a n d ignore, or not experience, affective or mood disturb a n c e s4, 42 These patients often present to primary c a r e physicians with the classic depressive somatic complaints (Table 1) or nonspecific cardiopulmo-
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TABLE Z Criteria for the Diagnosisof Major Depression2° Depressed mood for at least 2 weeks At least 4 of 8 symptoms every day for 2 weeks: Appetite or weight change Sleep disorder Psychomotor change Anhedonia Fatigue Guilt3/ruminations Cognitive impairment ideas of death, suicide
n a r y a n d gastrointestinal complaints or loc~]JTed pain, lacking the symptoms of d e p r e s s e d affect. Patients with this " m a s k e d depression" m a y lack the ability to label a n d report emotions ("alexithymia" or inability to reveal feelings using usual words or langnage). 4s They m a y also use coping m e c h a n i s m s to selectively d e n y or minimize the feelings associated with depression. Such m a s k e d depression m a y account for some of the consistently low rates of recognition of depression reported in primary care settings (although index of suspicion, recording habits, a n d training deficits also contribute). Somatized symptoms associated with depression m a y respond to appropriate antidepressant therapy. Lesse 42 described favorable responses to a n t i d e p r e s s a n t medication in his neuropsychiatric practice; however, Rickels 44 d e m o n s t r a t e d that depressed patients in a g e n e r a l practice r e s p o n d e d differently to medication t h a n those in a psychiatric clinic. Depressed patients with m a s k e d diurnal variat/ons in mood, sleep disturbances, severe anorexia, psychomotor changes, a n d guilty rum/nat/on m a y be more likely to respond to medication than those with unexplained or atypical somatic complaints. 4s So m a y those s e e n in psychiatric as opposed to medical practice. Anxiety Disorders
TABLE 1 Settings in Which Somatization Is Found Affective disorders Anxiety/panic disorder Somatoform disorders Hypochondriasis Conversion Somatization disorder Psychogenicpain Factitial disorders and malingering Psychophysiologicdisorders Character or personality disorders Psychoses Transient emotional stress
Anxiety disorders are second only to substance a b u s e in prevalence in the g e n e r a l population. In the Epidemiologic Catchment Area Study, m the lifetime prevalence of anxiety w a s 15.5%, a n d the sixmonth prevalence w a s 9.6%. About 60% of patients w/th a primary diagnosis of depression also h a v e some anx/ety, a n d 20-45% of anxious patients develop depressive symptoms. DSM-III distinguishes two major categories: generalized anxiety disorder a n d panic disorder. Generalized anxiety disorder is anxious mood for at least one month in a patient 18 y e a r s old or older, with symptoms from three of four categories: motor tension (tremors, muscle aches), autonomic hyperactivity (sweating, palpitations, dry mouth, lump in throat, urinary or bowel
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180 TABLE 3
Symptoms Required for the Diagnosisof Panic Attacks z° 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 1 1. 12.
Dyspnea Palpitations Chest pain Choking/smothering Dizziness Unreality Paresthesias Hot/cold flashes Sweating Faintness Trembling Fear of dying or losing control
urgency), a p p r e h e n s i v e expectation (worry, fear, anticipating the worst), a n d vigilance a n d scanning (hyperattent/veness to the point of distractib/1/ty a n d e a s y startle). The applicability of these criteria to the diagnosis of anxiety in primary c a r e is not established. Patients w h o h a v e gener,-,li~ed anxiety disorder usually respond to short-term treatment with benzodiazepines, followed b y nonpharmacologic methods. 4e-s° P a n i c disorder m a y occur in up to 1 - 5% of the population, with p r e v a l e n c e s of 6 - 1 0 % in a primary c a r e setting a n d 10- 14% in o n e cardiology clinic, s| Patients with panic disorder h a v e periods of apprehension or fear, with at least four of the symptoms in Table 3. Attacks begin suddenly a n d stop slowly, lasting less than a n hour. Panic disorder is diagn o s e d w h e n three or more attacks occur in a threew e e k period. Patients w h o h a v e panic attacks m a y focus selectively on one or more physical symptoms a n d d e n y a s s o c i a t e d anxious feelings. Katon s| studied 55 patients with panic disorder referred from a primary c a r e service. Presenting somatic complaints were: epigastric pain (28%), t a c h y c a r d i a (25%), chest pain (22%), dizziness or vertigo (18%), shortness of breath (13%), h e a d a c h e (11%), a n d sync o p e (9%). The symptoms w e r e p a r o x y s m a l a n d w e r e frequently a s s o c i a t e d with certain environmental stimuli or situations. Panic disorder is often unrecognized. In one study, 70% of patients h a d visited more than ten physicians before they w e r e d i a g n o s e d a n d treated, s2 Treatment of panic attacks with imipramine d e c r e a s e s the frequency a n d severity of attacks. Phobias, the most common anxiety disorder in the g e n e r a l population, a r e believed b y s o m e to represent psychological adaptations to panic attacks, ss S o m a t o f o r m Disorders
Patients w h o somatize but do not h a v e another primary psychiatric disorder a r e classified b y DSMIII a s having a somatoform disorder. Somatoform disorders a r e defined a s "symptoms suggesting a
physical disorder for which there a r e no demonstrable organic findings or known physiologic m e c h a nisms, a n d for which there is positive evidence, or a strong presumption, that the symptoms a r e linked to psychological factors or conflicts." There a r e four major somatoform disorders: somatization disorder, conversion disorder, hypochondriasis, a n d psychogenic pain. The clinical features of these disorders m a y overlap considerably with one another a n d with those of anxiety a n d depression, which often a c c o m p a n y them. Patients with strictly defined somatization disorder h a v e histories of multiple physical symptoms of several years' duration, beginning before the a g e of 30, for which they h a v e taken medications a n d b e e n s e e n b y physicians, or which h a v e c a u s e d them to alter their life patterns. To satisfy DSM-III criteria, there should b e at least 12 (in men) or 14 (in women) of a list of 37 possible symptoms in s e v e n areas: neurologic, gastrointestinal, female genital tract, psychosexual, cardiopulmonary, regional pain, a n d "sickly all their liyes." Somatization disorder h a s b e e n studied extensively under older n a m e s of hysteria or Briquet's syndrome, a n d the diagnosis h a s high stability a n d validity over time. Most patients a r e female, with a n estimated prevalence of a r o u n d 1%. Patients with somatization disorder often complain of emotional a s well as somatic disturbances, a n d m a y h a v e chaotic relationships with others. Srrdth et al.s4 described the relationship b e t w e e n somatization a n d excessive medical c a r e in patients referred from primary c a r e practices a n d found that their per capita personal health c a r e expenditure w a s roughly nine times a n d physician expenditure 14 times that of a n a g e - m a t c h e d control group. Most of this increase w a s related to inpatient charges. A single psychiatric consultation with recommendations to the primary provider d e c r e a s e d the cost of caring for this group of patients, primarily b y d e c r e a s i n g inpatient charges, without detrimental effects on their functional status, ss Conversion symptoms a r e defined a s a n alteration in physical functioning or symptoms suggesting a physical disorder, but without a pathophysiologic explanation. Psychological factors a r e j u d g e d to b e etiologically important, a s e v i d e n c e d b y a close temporal relationship of symptom onset with psychological stress, or b y observation that the symptoms either unconsciously resolve a conflict (primary gain) or e n a b l e the patient to avoid s o m e nox/ous activity a n d obtain support from the environment (secondary gain). Conversion symptoms usually conform to the patient's concept of d i s e a s e ("symptom model") a n d m a y h a v e symbolic import a n c e to the patient. ~ In previous generations, these patients usually p r e s e n t e d with losses or alterations in sensory or voluntary motor function such a s blind-
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h e s s or various d e g r e e s of a n e s t h e s i a or loss of motor function. Currently they present with symptoms such as chest a n d a b d o m i n a l pain. Most partients with conversion symptoms h a v e other psychiatric disorders, but, b y DSM-III convention, conversion disorder is d i a g n o s e d only w h e n no other psychiatric disorder is present. Accurate diagnosis c a n b e difficult. In one study 20-50% of patients initially given this diagnosis eventually develo p e d recognizable d i s e a s e s (for example, multiple sclerosis) that explained their symptoms, ss Hypochondriasis is a n a b n o r m a l r e s p o n s e to a normal sensation (regarding it a s pathologic), or a n amplified r e s p o n s e to a minor a b n o r m a l s e n s a tion.T, STMost individuals experience minor pains or sensory disturbances in the course of usual daily activity. Instead of ignoring them or accepting them a s part of their usual experience, h y p o c h o n d r i a c a l patients b e c o m e fearful a n d convinced that they h a v e a serious illness. These fears a n d beliefs persist despite medical r e a s s u r a n c e a n d impair social a n d occupational function. Hypochondriacal patients b e c o m e preoccupied with their bodies a n d m a y b e m e a s u r a b l y more skilled than other people at detecting a n d quantitating b o d y sensations.58 Hypochondriasis m a y b e a presenting feature of arndety a n d depression, a n d it is important to s e a r c h for these conditions since they often a c c o m p a n y - t h e disorder, sT Hypochondriacal patients often feel a b a n d o n e d a n d m a y b e hostile toward others, including doctors. The epidemiology a n d treatment of hypochondriasis in the primary c a r e setting a r e not well studied. Factors a s s o c i a t e d with better prognosis include acute onset, short duration, y o u n g age, high socioeconomic status, a n d no organic d i s e a s e or doctor-shopping, se The final major somatoform disorder is psychogenic pain. In this condition, s e v e r e a n d prolonged pain is the prominent disturbance. The pain is inconsistent with or out of proportion to the physical findings, a n d there m a y b e e v i d e n c e of a temporal relationsh/p of symptoms to psychological stress. For s o m e s h a m e d or guilty patients, pain m a y s e r v e a s unconscious punishment, s° The diagnosis of psychogenic pain overlaps with that of chronic pain syndrome, which is defined a s more than six months of pain in one or more b o d y sites that significantly interferes with life activities. Although chronic pain syndrome is not a DSM-III diagnosis, it is a common form of somatization in the United States today, most often d i a g n o s e d in p a i n clinics a n d b y psychologists. Chronic pain h a s m a n y features of depression, including similar findings on psychological testing a n d response to antidepressant trect~,nent, e° In a study of patients in the chronic pain program at the University of Washington, 57% satisfied DSM-III cri-
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teria for major depression a n d 35%, those for psychogenic pain. el The foregoing discussion reveals that diagnostic categorization of the somatoform disorders is confusing. Definitions overlap a n d DSM-III categories m a y not b e mutually exclusive. When somat/zation occurs without other concomitant psychological disorders, it m a y not b e v a l u a b l e to attempt to categorize it b e y o n d the label "somatoform disorder." In our view, the individual somatoform disorders m a y represent a common psychologic r e s p o n s e with a b r o a d illness spectnnn. Somatization m a y occur a s a n acute single symptom (conversion), a s chronic symptoms (pain-prone patient, psychogenic pain, chronic pain syndrome), a n d (in the most disturbed patients) a s multiple, long-term symptoms (Briquet's syndrome; somatization disorder). Current definitions b a s e d on psychiatric experience, such a s those u s e d in DSM-III, require adaptation a n d validation in the primary c a r e setting w h e r e the phenomenolo g y m a y b e different.
Other Associated Disorders Other disorders associated with somatization include factitious disorders and malingering, psychoses, and personality disorders. Unlike the somatoform disorders, in which underly/ng processes are unconscious, factitious disorders and malingering a r e conscious production of simulated or actual somatic illness. Patients with factitious disorders h a v e no a p p a r e n t goals except those of receiving medical c a r e a n d preserving s e c o n d a r y gain, w h e r e a s malingerers seek specific goals such a s winning lawsuits or obtaining disability payments. Psychotic p a tients m a y h a v e somatic delusions that present a s bizarre complaints ("I h a v e fire shooting up my spine a n d out my ears." "My insides a r e rotting out."). Patients with borderline or narcissistic personality disorders m a y relate to others in pathologic w a y s through their somatic complaints.
MECHANISMS OF SOMATIZATiON Patients w/th the disorders described above all experience emotional discomfort as abnormal physical sensations, expressing their problems in the language of bodily symptoms. Four types of theoretical explanations have been offered for this phenomenon: neurobiologic, psychodynamic, behavioral, and sociocultural. While they are discussed separately, these theories, in our view, are not mutually exclusive. For a given patient with somafization, a combination of theoretical perspectives m a y give the clinician more insight a n d help in m a n a g e m e n t than a single, relatively n a r r o w viewpoint.
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Neurobiologic Theories Neurobiologic theories of somatization h a v e b e e n reviewed by Miller, s~ who emphasizes two ideas. First, the theory of corticofugal inhibition states that somatization is related to a b n o r m a l central nervous system regulation of incoming sensory information. This theory postulates that afferent sensory p a t h w a y s are subject to central inhibition by corticofugal neurons in order to regulate the a m o u n t of incoming sensory information. Abnormalities in corticofugal inhibition m a y occur, causing either over- or underinhibition of sensory input. Ludwigss theorized that conversion disorder might be c a u s e d by selective inhibition of information to a n d from a psychologically meaningful a r e a of the body, resulting in a n e s t h e s i a a n d paralysis. Ludwig also hypothesized that the opposite p h e n o m e n o n might occur in hypochondriasis. D e c r e a s e d corticofugal inhibition might increase appreciation of sensory stimuli a n d result in the amplification a n d conscious a w a r e n e s s of sensory stimuli that would not ordinarily be perceived. Such stimuli would then be labeled a b n o r m a l a n d acted upon. The second neurobiologic theory of somatization is b a s e d on the observation that the two sides of the h u m a n brain a r e not symmetric in their functions. For most individuals, the right hemisphere is considerably less involved t h a n the left hemisphere with l a n g u a g e but m a y be more involved in emotion-processing. Patients with deficient communication between hemispheres might be u n a b l e to express emotions verbally since such verbal expression requires communication of emotions from right to left hemispheres prior to verbalization. Such patients would therefore be u n a b l e to express emotions directly, expressing them instead in the l a n g u a g e of physical complaints. Some d a t a e2 suggest this occurs in some patients with divided corpora callosa. Neurobiologic theories of somatization must also include processes at cellular a n d molecular levels. Neurophysiologic, neuroendocrinologic, a n d neuroimmunologic processes are all c a p a b l e of producing or modifying somatic symptoms, s4. es These processes m a y ultimately play a role in a unified neurobiologic theory of somatization.
Psychodynamic Theories P s y c h o d y n a m i c theories of somatization h a v e b e e n recently reviewed by Rodin. ee T h e s e theories view somat/zation as physical sensations that occur as expressions of underlying conflict. In the psychod y n a m i c perspective, somatizations are defense mechanisms that resolve conflicting emotions. Other p s y c h o d y n a m i c theories view somatiT.ing patients as manifesting a latent n e e d for nurturance a n d support, which they obtain from the medical a n d
p a r a m e d i c a l community. Other theories speculate that somatizing patients are unable to clearly separate physical from psychologic experiences a n d that this inability might be related to unempathic parents who e n c o u r a g e d them (not a l w a y s consciously) as children to respond to feelings in somatic terms rather than by direct verbaHTafion. Behavioral Theories
Behavioral theories a r e b a s e d on the idea that patient behaviors a r e reinforced by the environment in which they occur. Balinte7 observed that patients "negotiated" the form of their illness with their physicians. Patients presented to their physicians with several interpretations of the illness, some emotional ("I'm sad.") a n d some somatic ("My chest hurts."). The doctor then reinforced those symptoms that were important a n d meaningful to him or her ("Tell me about your chest pain."), thereby reinforcing the patient's somatic complaints a n d diminishing the perceived importance of feelings. Physician responses " s h a p e d " patient behavior a n d the ultimate form of the illness. The different behaviors that fll patients exhibit are called "illness behavior." 6s, e9 Parsons conceptualiTed the "sick role" as a socially a p p r o v e d illness behavior which is g r a n t e d by society to a n individual. As part of the sick role, the sick person's disability a n d incapacity a r e something for which he or she is not responsible. In order to gain the sick role, the patient must recognize the obligation to b e c o m e well a n d actively seek help to do so. In addition, the patient must accept a n d follow medical r e c o m m e n d a tions to b e c o m e well. Pflowsky~°' ~l defined "abnormal illness behavior" as "the persistence of a n inappropriate or m a l a d a p t i v e m o d e of perceiving, evaluating, a u d acting in relation to one's own state of health." Somatizing patients h a v e a b n o r m a l illness behavior in that their symptoms frequently persist in spite of seemingly a d e q u a t e investigation, explanation, a n d reassurance. Katon a n d co-workers I conceptualized "illness m a i n t e n a n c e systems" as the set of environmental reinforcers that maintain a b n o r m a l illness behavior. These systems consist of beneficial (from the patient's psychologic perspective) c h a n g e s in family structure, disability payments, or attention from a medical care system which arise from, reinforce, a n d maintain the patient's behavior. To correct abnormal illness behavior, these m a i n t e n a n c e systems must be identified a n d altered.
Sociocultural Theories The final theoretical explanation for somatization behavior is sociocultural. Proponents of sociocultural theories postulate that members of a n y cul-
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F"
FIGURE Z. Melzack and Walrs7s gate-control theory of pain (see text).
II
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J~ ~/1, I I---[~ AFFECT,vEsYsTEM IGATE
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ture learn "correct" behaviors for dealing with emotions a n d feelings. In some cultures direct express/on of emotions is permissible; in others it is not. When a culture does not allow direct communication of emotional content, somatization m a y serve indirectly to communicate psychosocial stress to others. ~2 In effect, they somatize in a c c e p t e d w a y s , w h e n direct emotional expression would b e highly stigmatizing. Since different cultures h a v e different "rules" for the expression of emotions, somatized behavior varies from culture to culture. Physicians come from a biotechnical medical culture that differs from that of m a n y of their patients. When they fail to a p p r e c i a t e the patient's cultural rules for cornmunication of emotional suffering, physicians don't understand or properly translate these somatized symptoms. Misunderstanding the indirect communication c o n v e y e d b y somatized behaviors, physicians take patients' physical complaints literally. An e x a m p l e of this misunderstanding is given b y a study done in the setting of a rural A p p a l a c h i a n health c a r e clinic. 7s Anthropologists interviewed patients following v/sits with their physicians, el/citing the patients' views a b o u t the sources of their complaints: The patients' explanations w e r e then comp a r e d with the biomedical d i a g n o s e s m a d e b y their physicians. The five most common patient explanations elicited b y the anthropologists w e r e "high blood," " w e a k a n d dizzy," "nerves," "sugar," a n d "muscles swelling up." "High blood" w a s commonly a s s o c i a t e d with complaints of dizziness, visual disturbances, blackout spells, a n d h e a d a c h e s . W h e n a s k e d w h a t they believed c a u s e d high blood, over two-thirds of the patients r e s p o n d e d that emotions a n d stress contributed to this disorder. S/milarly, p a tients who believed that they w e r e " w e a k a n d d i ~ y " often complained of fatigue, fainting, palpations, a n d staggering gait. Over half of these patients attributed " w e a k a n d dizzy" to stress. "Nerves" w a s believed d u e to major life stresses, with patients most commonly complaining of sleep disturbances, nervousness, tiredness, a b d o m i n a l pain, shortness of breath, a n d anxiety attacks. F e w physicians elic-
ited the emotions that w e r e bel/eved to b e associated with these somatic complaints. By failing to elicit the patients' underlying c a u s a l explanations, the physicians failed to s e e that they w e r e using their symptoms to c o n v e y their emotional stress in a nonthreatening, culturally a c c e p t a b l e manner. Other investigators, particularly Kleinman, v2 h a v e noted that such widely discordant physician a n d patient health beliefs a r e a s s o c i a t e d with patient dissatisfaction a n d poor compliance. While seemingly different, these four theoretical perspectives m a y simply represent explanations for somatization at different levels of the biopsychosocial hierarchy. Just a s heart failure c a n b e e x a m i n e d from the perspectives of the myofibril (cellular level), the heart (organ level), or the whole organism, so m a y somatization b e e x a m i n e d from neurobiological, psychodynamic, behavioral, or cultural perspectives. Each perspective provides its o w n unique contribution to understanding a n d treating the phenomenon. We believe that these different perspectives c a n b e integrated 74 b y viewing somat/zation a s a biopsychosocial p h e n o m e n o n which simultaneously is c a u s e d b y a n d affects multiple systems ranging from cellular to societal. The revised gate theory of pain (Fig. 2) provides a useful model for this integration. In Melzack a n d Wall's g e n e r a l theory of m a m m a l i a n pain,~5 sensory p a t h w a y s carrying painful stimuli from the periphery to the central nervous system p a s s through a s e q u e n c e of neuronal "gates," syna p s e s subject to inhibitory a n d excitatory influences. The first g a t e is peripheral, located at the initial spinal s y n a p s e in the substantia gelatinosa. Subsequent g a t e s occur at s y n a p s e s in both the paleothalamic a n d neothalamic p a t h w a y s . This s e q u e n c e of g a t e s c a n b e open, allowing painful stimuli to p a s s through to higher cortical levels, or closed, blocking or altering conscious perception of sensory input. Various physiologic a n d psychologic p h e n o m e n a a r e c a p a b l e of o p e n i n g or closing the gates. The status of the g a t e system varies within one individual over time, b e t w e e n different individuals, a n d from
Kaplan etaL. SOMATIZATION IN PRIMARYCARE
184
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SOCIETY CULTURE FIGURE3. Generalizedschemeof somatization: gate-contTolmechanismsare relat~l to pastexperienceand placedin the largercontextsof personal, societal, and cultural systerns (emphasis).
culture to culture. The uniqueness of this system of g a t e s accounts for the observations that similarly painful stimuli c a n b e perceived a s different b y one individual at different times or b y different individuals at the s a m e time, a s classically illustrated b y Beecher's studies. 76 In our view, Melzack a n d Wall's theory c a n b e applied to the b r o a d r a n g e of somatization phenome n a in g e n e r a l b y b r o a d e n i n g its scope to include sociocultural influences on symptom occurrence a n d perception (Fig. 3). We believe that all somatic stimuli a r e subject to modification at g a t e s a s they travel from the peripheral to the central nervous systems. The moment-to-moment status of a given individual's unique system of g a t e s is determined b y early childhood developmental a n d cultural patterning, b y current physiologic or psychologic inputs, a n d b y ongoing environmental stimuli. Individuals prone to somatization m a y h a v e a system of g a t e s that is relatively open to all perceptual stimuli, normal a n d abnormal. Normal stimuli such a s intestinal peristalsis, pressure on b o d y parts, or temporary stiffness of muscles a n d joints m a y b e p e r c e i v e d a s abnormal, particularly if they h a v e special psychologic import for the person, w h o m a y then b e c o m e a patient. Abnormal stimuli arising from d i s e a s e p r o c e s s e s m a y b e greatly amplified. Regardless of whether they a r e normal or abnormal, these stimuli a r e p e r c e i v e d at higher cortical levels, given meaning, a n d a c t e d upon, resulting in illness behavior. Reinforcers in the society a n d culture m a y then serve to further amplify a n d perpetuate such
conduct, eventually resulting in a b n o r m a l illness behavior. We strongly believe that a view of somatization which integrates theories involving processes at levels ranging from cellular to sociocultural is necess a r y for fully understanding a n d treating these p a tients. Somatization is truly a biopsychosocial phen o m e n o n in which biologic, psychologic, a n d social systems all interact closely to p r o d u c e symptoms, perceptions, a n d behavior. In order to help somatizing patients, physicians n e e d to a p p r e c i a t e all of these interactions, a n d n e e d a multisystem approach to diagnosis a n d therapy.
DIAGNOSIS Recogr~iT.ing somatizations c a n b e difficult a n d frustrating. Certain clues m a y indicate that symptoms arise from underlying psychosocial distress, however. Diagnosing somatization is not a process of "ruling out" other organic etiologies. Rather, it is a positive process, a c h i e v e d b y carefully listening to symptoms, discovering their p l a c e in the patient's life, a n d learning of the patient's cultural a n d personal habits of sensory perception. Diagnosis involves carefully obtaining detailed information about the patient a n d the illness through a sensitive, thorough s e r i e s of interviews, while listening for clues to somatization. Barsky a n d Klerman 7 s u g g e s t e d that physicians suspecting somatization first determine whether the patient is suffering from multiple unexplained complaints, a fear a n d conviction of disease, a n d bodily
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preoccupation. In addition, coexisting depression, schizophrenia, a n d anxiety should b e considered. Second, the physician should look for a s s o c i a t e d problems such a s anger, hostility, d e p e n d e n c e , ina d e q u a t e e g o development, diminished self-esteem, or guilt. Next, the role the symptoms p l a y in patient's life should b e a s s e s s e d , estimating such a s p e c t s a s the patient's pattern of u s e of medical services, family dynamics, a n d the d e g r e e to which the patient h a s l e a r n e d to use to illness to c o p e with interpersonal conflicts a n d stressful life events. Finally, the physician should s e e k to u n d e r s t a n d the patient's personal beliefs about the illness. These personal beliefs constitute the patient's "explanatory model." 77 Kleinman77 lists s o m e questions that a r e helpful in determining patients' explanatory models for their symptoms (Table 4). Eliciting all of this information usually takes several e x t e n d e d o p e n - e n d e d interviews. 7s In one author's (ML) consultation practice, four interviews a r e alloted with difficult patients to a s s e s s the possibility of somatization. Throughout this lengthy information-gathering process, the physician should b e alert to clues for somatization. Lipkin 74 s u g g e s t e d 1 1 positive criteria useful for the diagnosis of "psychogenic" symptoms (Table 5). The p r e s e n c e of several of these criteria increases the likel/hood that somat/zation exists. Yet another clue to somatization is the "disease s y n d r o m e - i l l n e s s behavior discrepancy" noted b y Pflowsky7~ in patients with a b n o r m a l illness b e h a v ior. When told b y physicians that they a r e healthy or given a relatively benign explanation for their complaints, these patients react with persistent complaints a n d demands, in contrast to most patients, w h o react with relief or resignation to the physician's explanations. Detecting this behavioral d i s c r e p a n c y m a y help to identify patients w h o a r e somatizing. Formal a s s e s s m e n t techniques h a v e also b e e n u s e d for detecting somatization a n d related emo-
185 TABLE S
Positive Criteria for Diagnosis of Psychogenic SymptomsTM 1. Patient has features of the hystericalpersonality style--dramatic, shallow affect, vague, contradictory or inconsistent, quickly relating emotionally (positively or negatively), distractable, suggestible, unrealistic 2. The illness begins in a psychologicallymeaningful set~'ng 3. The illness or symptom has an idiosyncratic (symbolic) meaning for the patient 4. The description of the symptom is vague, inconsistent, or bizarre 5. The symptoms have persisted despite allegedly specific medical therapy 6. There is much doctoring and litide curing (many doctors or many visits) 7. The patient denies the psychological role of the symptoms (a normal person would consider the psychological possibility) 8. There is associated psychiatric illness--depression, schizophrenia, schizoaffective disorder, addiction, other disorders 9. Polysurgery has occurred (usually to less important organs such as the appendix or gallbladder, or for adhesions or trapped nerves) 10. Alexithymia is present 11. The symptom functions to communicate for the patient to the doctor (or significant others) about psychological conflicts or pains
tional disorders in the medical setting. Some tests for depression h a v e b e e n u s e d extensively in medical patients. 79-s2These brief, self-administered tests c a n b e completed b y patients in the office a n d a r e e a s y to score. However, they a r e more sensitive than specific; a normal score virtually rules out significant depression, but a n a b n o r m a l score d o e s not confirm it. Patients with a b n o r m a l scores should b e investig a t e d more fully. For somafi'7.1ug patients, the Somat/zation, Anxiety, a n d Depression s u b s c a l e s of the Minnesota Multiphasic Personality Inventory ~ m a y b e helpful. The Illness Behavior Questionnaire dev e l o p e d b y Pilowsky 7°' 71h a s also b e e n u s e d to study somafiT.ing patients. We emphas/ze strongly that, although these tests m a y provide adjunctive information to the clinician, they should not take the p l a c e of the sensitive, thorough interview process w e h a v e outlined. MANAGEMENT
TABLE 4 Questions Used to Elicit the Patient's Illness Model~ 1. What do you think has caused your problem? 2. Why do you think it started when it did? 3. What do you think your sickness does to you? How does it work? 4. How severe is your sickness? Will it have a long or short course? S. What kind of therapy do you think you should receive? 6. What are the most important results you hope to receive from this therapy?. 7. What are the chief problems your sickness has caused for you? 8. What do you fear most about your illness?
Somatization in patients undergoing acute situational stress is often transient a n d h a s a good prognosis. These patients do not h a v e long histories of somatization a n d a r e often wi11ing to consider or accept a psychologic or psychophysiologic explanation for their symptoms, or improve with supportive c a r e without insight. They respond to education a n d appropriate reassurance, e4"8s Chronically somatizing patients require a more complex m a n a g e m e n t strategy, however. B e c a u s e these patients consider their symptoms to b e physical problems, they frequently present to primary
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TABLE 6
Specific ManagementSuggestionsfor Patients with Somatization 1. Encouragepersonalgrowth through establishmentof a trusting. caring relationship 2. Don't dispute the reality of the complaint 3. Respectfullyevaluatesymptoms as they occur, conservativelyin stepwise fashion, avoidingthe temptation to prematurely link physical symptoms with psychologicalstresses 4. Establishappropriate therapeutic goals; don't always aim for cure 5. Follow-up should be scheduledregularly at 1 -4-week intervals, independentof symptom status 6. Treat depression,anxiety, or other psychiatric disorders as appropriate; otherwise, try to avoid medications 7. Referonly as appropriate and emphasizereferral is not dismissal
c a r e physicians. M a n a g e m e n t also will most often take place at the primary c a r e level since these patients usually refuse psychiatric referral a n d few respond to insight-oriented psychotherapy. Effective treatment of somatizing patients in the primary c a r e setting c a n reduce costs. Smithss red u c e d the hospital d a y s a n d health c a r e c h a r g e s of a group of 40 patients with somatization disorder by sending their primary physicians a confirmation of the diagnosis a n d a list of m a n a g e m e n t techniques appropriate for office practice. Furthermore, a recent analysis of 58 controlled studies a n d claims files of major health insurance carriers r e v e a l e d that, for medical patients, the cost of brief psychiatric consultation a n d tre~hiient is offset by the savings from d e c r e a s e d hospital admissions, if the majority of care continues to occur in the primary care setting, ss Specific m a n a g e m e n t suggestions are outlined in Table 6. In general, the most important aspect of m a n a g e m e n t in a n y setting is the development of a n empathic, trusting, caring p h y s i c i a n - p a t i e n t relationship. The complexity of this relationship c a n n o t be stressed too greatly. Strong negative reactions of physicians to somatiTing patients m a y be a n important barrier to the development of a relationship, however. Physicians often find themselves feeling angry, hopeless, or helpless w h e n faced with somatization.S~, ss Groves s noted that somafi~ing or other "hateful" patients stimulated aversion, fear, counterattack, guilt, i n a d e q u a c y , malice, a n d the secret wish that the patient "die a n d get it over with." In order for a successful a n d therapeutic p h y s i c i a n patient relationship to occur, physicians must learn to recognize a n d use rather t h a n instinctively react to their emotional responses. Several core attitudes help the authors to d e a l with these emotions. Rem e m b e r that these patients are reacting in the best a n d (without help) only w a y available to them. In addition, they challenge both our diagnostic a n d our therapeutic skill.~ in a w a y that more routine patients
do not. Finally, they a r e fascinating. They hold a key to our u n d e r s t a n d i n g of the relationship of mind a n d body. Establishing the therapeutic relationship is critical to both diagnosis a n d treulment. Its constancy a n d dependabil/ty should be r e p e a t e d l y e m p h a sized to the patient. Over time, the relationship c a n be used to promote h e a l t h y growth a n d development. Expression of feelings a n d emotions c a n be e n c o u r a g e d and, through physician demonstrations of acceptance, respect, a n d positive regard, s9 patients c a n grow towards greater self-esteem. It is usually not helpful to dispute the reality of the physical complaint with the patient. This argument m a y convince the patient that the complaints are not being taken seriously. Patients are helped by feeling that w e as physicians truly believe w h a t they s a y they experience. The best w a y to accomplish this is to p a y close attention to a n d clarify fully the patient's story of illness, underlying beliefs, a n d expectations for care. Each n e w symptom should be respectfully evaluated. It is important to do a careful physical examination, no matter how unusual the symptoms, a n d to use diagnostic tests in a conservative, stepwise fashion. Even after the probability of obvious organic d i s e a s e h a s b e e n reduced by a thorough initial assessment, moving too explicitly from a patient's physical complaint to his or her emotions is usually met with resistance a n d hostility. Explanations that attempt to relate the symptom to anxiety or depression frequently prove fruitless. Patients h a v e usually h e a r d them before a n d quickly anticipate rejection. M a n y patients actually hold to the opposite explanation ("I feel depressed b e c a u s e of m y symptoms."). It is much more helpful to b a s e d a y - t o - d a y interaction on the somatic complaint initially, slowly eliciting the psychologic issues. In the setting of a trusting relationship, patients will often themselves initiate exploration of the relationship of underlying psychosocial issues to their symptoms. Attention to affect a n d nonverbal communication is important. Commenting on a patient's feeling or expression of emotion at the moment m a y be a turning point in the interview. The relevant psychosocial issues will usually become a p p a r e n t ff patients are e n c o u r a g e d to describe their illnesses in their own words a n d in the context of events, circumstances, a n d other people. The physician n e e d s to establish realistic a n d appropriate therapeutic goals. Rather t h a n cure or complete resolution of symptoms (an end-point that is rarely possible), it is better to set less global, more realistic goals. Some examples of such goals might be d e c r e a s i n g the numbers of urgent telephone calls a n d unscheduled or e m e r g e n c y visits, d e c r e a s i n g doctor-shopping, a n d avoiding u n n e c e s s a r y hospitalizations or invasive procedures. Positive goals
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might include increasing patients' feelings of control of themselves or their symptoms, improving their social or occupational function, helping them to identify a n d communicate their feelings with or without recognition of their linkage with somatic symptoms. To reinforce the i n d e p e n d e n c e of symptoms a n d the relationship, follow-up visits should b e scheduled at regular intervals a n d should n o t b e contingent on the p r e s e n c e of symptoms. By seeing the patient e v e r y o n e to four weeks, whether or not the symptoms h a v e a b a t e d , the physician reinforces the patient relationship instead of the symptoms. Bec a u s e patients value their relationship with the physician a n d view symptoms a s the "ticket" to this relationship, attempting to lengthen times b e t w e e n appointments m a y l e a d to worsening symptoms. On the other hand, the patient should b e held to the regularly scheduled appointments a n d unscheduled visits should b e minimized. Eventually these visits c a n b e c o m e shorter. Medications should b e a v o i d e d in most instances. If used, they should b e prescribed to treat defined disorders or reduce (not remove) specific target symptoms a n d to restore optimal function. Patients should b e told of these conditions for prescribing at the onset of drug t r e u i ~ e n t a n d a specific time should b e set, after which the medications will b e discontinued if benefit is not o b s e r v e d or is lost. 44, 4s Some associated conditions should b e treated, however. Major depression, if present, should b e treated, since antidepressants h a v e proven efficacy. Severe somatizers often d e s e r v e a n empiric trial of tricyclic antidepressants b e c a u s e of the frequency of concomitant m a s k e d depression. Anxiolytics m a y help ff u s e d specifically for anxiety or panic disorder. Treatment with narcotics, hypnotics, or sedatives is ineffective, a n d the d a n g e r s of addiction a r e real. The authors a r e frequently referred patients with suspected somatization, a s well a s patients w h o a r e simply difficult to m a n a g e . In undertaking to s e e such patients, initial statements b y the physician a r e a n important part of the patient's understanding of the relationship. We typically state complete belief in a n d a c c e p t a n c e of the patient's complaints a n d a willingness to help the patient. W e emphasize a s well that this usually takes time since, if c a r e of this situation w e r e simple, it would a l r e a d y h a v e b e e n d o n e satisfactorily. The initial a g r e e m e n t is for a s e r i e s of one-hour sessions, followed b y a n a s s e s s m e n t a n d discussion of plans. During these first interviews, major goals in addition to informationgathering a r e to create a strong alliance a n d to develop a n understanding of the developmental setting of the illness a n d the meaning(s) it m a y h a v e for the patient. In the first session, the interview is conducted a s described b y Lipkin. ~s Beginning with the patient's dominant complaints, c a r e is t a k e n to
18'/
listen for psychologic, developmental, or life context material a n d to digress w h e n e v e r such themes arise or w h e n e v e r significant affect is shown. Later sessions involve explorations of early development (using the family history a s a n introduction if necessary) a n d relationships with k e y individuals. The practitioner keenly listens for h o w the patient h a s related to other helpers, authority figures, a n d intimates. Also listened for a r e the patient's ideas about the nature a n d c a u s e s of the illness a n d a n y symbolic meanings it m a y have. Doing all of this requires time. The narrative thread m a y not b e completed in the first visit or e v e n the first four. Gradually, however, the alliance bet w e e n patient a n d physician should b e c o m e closer a n d more secure. W h e n e v e r possible, the autonomy a n d e g o of the patient a r e actively supported through a c c e p t a n c e of symptoms a n d expressions of respect for w h a t e v e r positive attempts at coping the patient m a y make, a n d b y pointing out positive character attributes that m a y contribute to healthy behaviors. As the patient increasingly feels understood, secure in the relationship, a n d hopeful, the practitioner m a y begin to explore conflicts a n d destructive behaviors, a l w a y s in b a l a n c e with constructive a n d positive discussions. Common barriers to the progress of the relationship include patients' reluctance to discuss psychologic issues (particularly a s they relate to symptoms), d e m a n d s for d i a g n o s e s a n d cures, d e p e n d e n c y issues, disability, a n d emotional reactions to patients. As the pattern of the patient's malfunctioning a n d psychologic conflicts b e c o m e s clear, a decision must b e m a d e a s to h o w explicit to b e in discussion. M a n y patients, especially those with a d e e p l y ingrained pattern of somatization, will not tolerate a n y explicit discussion of core conflicts or their relationship to physical symptoms. Many such patients m a y l e a v e if confronted directly; however, others will gradually introduce such topics themselves (once they feel secure a n d accepted) a n d m a y eventually a c k n o w l e d g e the connection b e t w e e n their problems a n d their symptoms. Such understanding, if it occurs at all, frequently takes months to achieve, a n d much patience is required. It is important to rem e m b e r that improvement does not d e p e n d solely upon patients' explicit recognition of the relationship b e t w e e n psychological conflict a n d symptoms. With or without explicit understanding, patients will often begin to get better in a trustworthy a n d empathic relationship. Early in the relationship, patients often m a k e shrill d e m a n d s for d i a g n o s e s a n d cures. Emphasizing that e a s y or simple d i a g n o s e s would h a v e b e e n m a d e much earlier, w e h a v e found that m a n y p a tients will a c c e p t physiologic or descriptive explanations for symptoms such a s increased muscular ten-
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sion, a b n o r m a l peristaltic movements, or anterior chest wall dysesthesia. By n a m i n g the condition descriptively a n d avoiding deception, the physician satisfies patients that their suffering h a s b e e n acknowledged a n d gives them a respectable term with which to describe the illness to family a n d friends. As stressed above, attempts to link such physiologic "diagnoses" with underlying psychologic problems m a y or m a y not be a c c e p t e d a n d it is best to allow the patient to develop this level of u n d e r s t a n d i n g at his or her own pace. D e m a n d s for cure m a y be viewed as d e m a n d s for continued caring. The authors stress to patients that symptoms m a y be with them in some form or another for life (patients often suspect this is true at the outset) a n d that the physician's goal is to m a k e them more tolerable or unders t a n d a b l e rather t h a n curing them. This negative prognostic information is a c c e p t e d more easily if acc o m p a n i e d by r e a s s u r a n c e s that the relationship with the physician will continue w h a t e v e r the patient's symptomatic status. Some patients m a y actually be disturbed by promises of cure since they view symptoms unconsciously as m e a n s to a c h i e v e caring a n d support. Confidence in the relationship provides the basis for continued h e a l t h y relating a n d insight. M a n y patients a r e involved in disability proceedings w h e n first seen, or soon become involved in them. We attempt to estimate the d e g r e e of the patient's psychologic rather t h a n physical disability. Immediate coping n e e d s often dictate a brief respite from circumstances causing psychologic stress, but we emphasize that such respites should be limited a n d coupled with positive expectations about future functional recovery. Long-term or p e r m a n e n t disability probably harms most patients, a n d we attempt to avoid such outcomes. SomafiTing patients often manifest d e p e n d e n t behaviors in the form of numerous phone calls a n d "drop-in" visits. It is helpful to set rules for care early in the relationship. One rule is that patients consider the practitioner the primary care physician a n d a g r e e not to doctor-shop or to see other practitioners without mutual discussion. Another rule is that the patient will reserve all but e m e r g e n c y complaints for regularly scheduled sessions. If the patient cal].~ in b e t w e e n scheduled visits, the discussion should be limited to assessing that there is no objective emerg e n c y or psychologic crisis requiring immediate action. If not, further discussion should be deferred until the next regular session. Surprisingly, patients almost a l w a y s accept such arrangements, particularly w h e n they realiTe that the relationship is not d e p e n d e n t on the continued presence of physical symptoms a n d complaints. A final major barrier to a successful relationship is the emotional reaction of the physician to the pa-
tient. As pointed out above, physicians often h a v e strong reactions to somatizing patients, r a n g i n g from despair to outright anger. We find that m a n y of these occur as a result of frustration with one's inability to achieve cure or resolution of symptoms. Abandoning such unreali.qtic goals in favor of more limited goals of reducing destructive behaviors a n d improving coping improves negative emotional reactions. Openly discussing these emotional responses with other c a r e providers will also help practitioners to u n d e r s t a n d a n d cope with them. As mentioned previously, these patients a r e h a r d for primary c a r e providers to refer. M a n y of the somatoform disorders do not respond well to insightoriented t h e r a p y offered by psychiatrists, a n d these patients e n d up in medical settings. When referral is necessary, helpful suggestions for discussing it with patients h a v e b e e n offered by Goldsmith~ a n d Bursztajn. 91 Perhaps better t h a n referral is c a r e conjointly provided by primary c a r e a n d psychiatric personnel (as well as other ancillary services). This is facilitated by multidisciplinary settings. 92
SUMMARY SomafiTing patients experience or express emotional discomfort a n d psychosocial distress a s physical symptoms. Somatization occurs in a b r o a d spectrum of illnesses, in association with a wide variety of mental disorders, including depression, anxiety, a n d the somatoform disorders. Primary c a r e providers must detect a n d treat these patients. Diagnosis is b a s e d on positive criteria. C a r e rests upon conservative medical m a n a g e m e n t a n d evaluation; a p h y s i c i a n - p a t i e n t relationship b a s e d on acceptance, caring, a n d trust; reinforcement of positive behaviors a n d elimination of destructive ones; a n d the g r a d u a l use of the relationship to promote h e a l t h y relating in the patient. The authors gratefully acknowledgethe advice,encouragement,and contributionsof William Clark. MD, Arnold Ludwig. MD, and members of the Society of General Internal Medicine'sTask Forcefor the MedicalInterview and RelatedSkills; and the patienceand effort of Ann Haddix in preparingthe manuscript.
REFERENCES I. Eaton W, Ries RK, Kleinman A. The prevalence of somatization in primary care. Compr Psychiatry 1984:25:208-15 2. Hankin J, Oktay JS. Mental disorder and primary medical care: an analytic review of the literature. In: National Institutes of Mental Health (Rockville, MD): Series D, No. 7 DHEW Publication No. (ADM) 7 8 - 6 6 I. Government Printing Office, 1979 3. Burnum JF. Is writing a list of symptoms a sign of an emotional disorder? N Engl J Med 1985;313:690-I 4. Collyer JA. Psychosomatic illness in a solo family practice. Psychosomatics 1979;20:762-7 5. Groves JE. Taking care of the hateful patient. N Engl J Med 1978;298:883-7 6. Cummings NA, VandenBos GR. The twenty-year Kaiser- Permanent experience with psychotherapy and medical utilization: implications
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REFLECTIONS Over-specialisation It is right that a d o c t o r should h a v e s p e c i a l interest a n d k n o w l e d g e a b o u t o n e subject. It is w r o n g for him to s h o w s p e c i a l indifference a n d i g n o r a n c e a b o u t all other subjects. A g o o d doctor should b e a j a c k - o f - a l l - t r a d e s a n d m a s t e r of one. For e x a m p l e , a s u r g e o n should b e a b l e to a d v i s e a p a t i e n t with simple o b e s i t y a b o u t h e r diet a n d not refer h e r to a n e n d o c r i n e clinic; a g y n a e c o l o g i s t should b e c a p a b l e of t r e a t i n g a mild iron-deftc i e n c y a n a e m i a without referring h e r to a n a n a e m i a clinic; a n d a p h y s i c i a n ought to s q u a s h a small g a n g l i o n on the b a c k of the h a n d with his thumbs (or bible). I h a v e k n o w n a n e y e s u r g e o n after s e e i n g a c a s e of retinitis p i g m e n t o s a write in the notes: 'This might b e p a r t of the Laurence-Moon-Biedi s y n d r o m e ; is t h e r e a n y e v i d e n c e of p o l y d a c tyly?' For a n o p h t h a l m o l o g i s t to feel himself i n c a p a b l e of counting fingers is surely t h e limit of o v e r - s p e c i a l i s a t i o n ; a n d , if nothing is d o n e to stop this t e n d e n c y , w e shall h a v e o n e p h y s i c i a n w h o s p e c i a l i s e s in the first h e a r t sound, a n d the other w h o is only conc e r n e d with the s e c o n d . P e r h a p s the worst f e a t u r e of s p e c i a l i s a t i o n is that it m a k e s doctors feel t h e y a r e d o i n g w r o n g to d e a l with e v e n the simplest c a s e if it lies within the p r o t e c t e d a r e a of s o m e b o d y e l s e ' s specialty. Particularly is this the c a s e with psychiatry, w h i c h is r e g a r d e d b y other doctors with a mixture of suspicion, r e v e r e n c e , a n d ridicule. In Noel C o w a r d ' s B//the Spirit a c h a r a c t e r , referring to p s y c h o t h e r a p y , s a y s : 'I refuse to g o t h r o u g h months of e x p e n s i v e humiliation in o r d e r to find that a t the a g e of t e n I w a s d e s p e r a t e l y in love with m y rocking-horse.' A s u r g e o n or a p h y s i c i a n f a c e d with a p a t i e n t exhibiting s o m e 'functional' s y m p t o m s is likely to t a k e a similar attitude, feeling that the origin of the simplest p s y c h o n e u r o t i c s y m p t o m s lies b u r i e d in a n u n c h a r t e d s w a m p in w h i c h only the e x p e r t c a n p o k e with i m p u n i t y - - a s w a m p c r a w l i n g with c o m p l e x e s a n d repressions, w h e r e nothing is w h a t it s e e m s a n d e v e r y t h i n g s y m b o l i s e s s o m e t h i n g i n d e c e n t . This is a foolish attitude to take; a s e n s i b l e p h y s i c i a n or s u r g e o n should b e a b l e to g i v e w i s e c o u n s e l in the simpler c a s e of neurosis. Further, t h e r e is a c o m p l i c a t i o n of s p e c i a l i s a t i o n - - t h a t it a l l o w s b e e s to r e m a i n undist u r b e d within their m a s t e r s ' b o n n e t s so that the allergist looks a t the world through allergic-colourecl g l a s s e s a n d b e a m s m y o p i c a l l y a t a w o r l d w h e r e e v e r y t h i n g is allergic. - - R i c h a r d Asher, The s e v e n sins of medicine. L a n c e t 1949;257:358-60
