Somatizing Patients: Part I. Practical Diagnosis

Author: David Servan-Schreiber, Gary Tabas
Date: Feb 15, 2000

The phenomenon of somatization, which results in unexplained physical complaints, is ubiquitous in primary care settings although it often goes unrecognized. Medical training emphasizes the identification and treatment of organic problems and may leave physicians unprepared to recognize and address somatoform complaints. As a process, somatization ranges from mild stress-related symptoms to severe debilitation. Patients at the low end of the spectrum often respond to simple reassurance, but patients who are more impaired require interventions specifically designed to avoid unnecessary exposure to dangerous, costly and frustrating diagnostic procedures and treatments. (Am Fam Physician 2000;61:1073-8.)

In patients with somatoform disorders, emotional distress or difficult life situations are experienced as physical symptoms. Patients who somatize present with persistent physical complaints for which a physiologic explanation cannot be found. Failure to recognize this condition and manage it appropriately may lead to frustrating, costly and potentially dangerous interventions that generally fail to identify occult disease and do not reduce suffering.

Somatization is common.1,2 In one study, no organic cause was found in more than 80 percent of primary care visits scheduled for evaluation of common symptoms such as dizziness, chest pain or fatigue.3 In addition, somatizing patients use inordinate amounts of health care resources. One study4 estimated that patients with somatization disorder (the most severe form of the condition) generated medical costs nine times greater than those of the average medical patient. Despite substantial amounts of medical attention, somatizing patients report high levels of disability and suffering.5 Finally, physicians report that somatizing patients are frustrating to treat.6 Physicians lack a sense of effectiveness when multiple complaints do not fit into usual diagnostic categories or patients do not fit into a typical office schedule.

Traditional medical training is focused on the identification and treatment of organic disorders and leaves most physicians ill prepared for recognizing and managing patients who somatize. This first part of a two-part article provides an approach to diagnosing and understanding the process of somatization that may lead to more effective and satisfying relationships with these often-difficult patients.

Diagnosis of Somatization

Somatization is too often a diagnosis of exclusion. This is a costly and frustrating approach in patients with multiple and chronic complaints. It is much more effective to pursue a positive diagnosis of somatization when the patient presents with typical features. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)7 defines several different somatoform disorders. However, somatization is not a specific disease but rather a process with a spectrum of expression.8-10 Once the process of somatization is identified, management of the different somatoform disorders is based on similar principles.

The low end of the somatization spectrum includes stress-related exaggeration of common symptoms, such as headache, lightheadedness or low back pain in the context of, for example, a divorce, new family member or new job. At the high end, it includes unrelenting problems that can leave patients completely disabled and withdrawn from most aspects of personal and occupational functioning. The primary care physician's emotional response to a patient can serve as an early cue to pursue a somatization diagnosis. A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person, or a sense of being overwhelmed by a patient who has had numerous evaluations by other physicians, may be a signal to the clinician to consider somatization in the differential diagnosis early in the patient's evaluation. In addition, identifying the physician's emotional reaction to somatizing patients may help prevent deterioration of the physician-patient relationship.

Because the features of somatoform disorders are so variable, establishing specific diagnostic criteria, such as those listed in DSM- IV, can be difficult and may not be very useful. Clinical experience and existing research on diagnostic criteria for the more severe forms of somatization suggest that only two features are necessary to establish a positive diagnosis of somatization in patients in primary care settings: (1) several (more than three) vague or exaggerated symptoms in, often, different organ systems, and (2) a chronic course (i.e., a history of such symptoms for more than two years).9

Table 1 lists many of the symptoms and syndromes affecting patients with somatoform disorders. Most of these symptoms also occur in patients with organic pathology. As isolated symptoms, they would require a full medical work-up. However, somatizing patients have too many symptoms, in too many organ systems, that last too long. The intensity of the symptoms often strikes the physician as being out of proportion to the healthy appearance of the patient. The syndromes listed in Table 1 may be legitimate in many patients but are typically impossible to verify in somatizing patients.

Psychiatric and psychosocial disorders have a strong association with somatoform disorders. Finding evidence of a psychiatric condition does not rule somatization in or out; rather, it can be a clue to diagnosis. There is considerable evidence that patients with common psychiatric conditions such as depression and anxiety disorders may present to primary care physicians with nonspecific somatic symptoms, including fatigue, aches and pains, palpitations, dizziness and nausea.9,11-14 In one large family practice sample,15 multiple somatic complaints provided the best indicator of depression.

Second, patients with somatization disorder commonly have coexisting depression (up to 60 percent), anxiety disorders such as panic or obsessive-compulsive disorder (up to 50 percent), personality disorders (up to 60 percent)9,16 or a substance abuse disorder.17 In fact, the risk for a psychiatric disorder in a primary care patient increases linearly with the number of physical complaints.9

Finally, several studies have suggested an association between somatization and a history of sexual or physical abuse in a significant proportion of patients.17-21

Table 2 summarizes the typical diagnostic features of somatization. Perhaps the greatest challenge in making the diagnosis is that the presence of somatization does not exclude the presence of an organic medical condition. Therefore, medical conditions must constantly be considered, even in patients with somatization. Patients with chronic debilitating medical conditions often have features similar to those associated with somatoform disorders. However, when the symptoms appear to be in excess of the medical condition and other features of somatization are present, the physician's approach should be adjusted to address somatization in addition to appropriate work-up and treatment of the medical condition. At this point, a colleague's second opinion may be helpful in confirming the diagnosis of somatization and its relationship to the existing organic pathology.

To optimize care and limit frustration for patients and physicians, the investigation of patients with multiple vague somatic complaints should follow a standard process (Table 3). After performing an initial medical evaluation, reviewing medical records and evaluating the patient for common psychiatric conditions, the presence of the typical features of somatization (Table 2) may be sufficient to allow a firm diagnosis of somatization. Although achieving this diagnosis may require more than a single office visit, over the long run this systematic process will prevent many unnecessary acute office visits, evaluations in the emergency department, telephone calls and frustrating arguments.

Pathophysiology

No one fully understands the pathophysiology of somatization. However, four psychologic mechanisms are frequently discussed. Understanding them can help physicians develop empathy with patients and direct care more effectively. The mechanisms tend to be independent, and individual patients may show evidence of a single mechanism or any combination of the four mechanisms.

Amplification of body sensations

24. Mechanic D. Effects of psychological distress on perceptions of physical health and use of medical and psychiatric facilities. J Human Stress 1978; 4:26-32.

25. Barsky AJ, Klerman GL. Overview: hypochondriasis, bodily complaints, and somatic styles. Am J Psychiatry 1983;140:273-83.

26. Barsky AJ. A 37-year-old man with multiple somatic complaints. JAMA 1997;278:673-9.

27. Rauch SL, van der Kolk BA, Fisler RE, Alpert NM, Orr SP, Savage CR, et al. A symptom provocation study of posttraumatic stress disorder using positron emission tomography and script-driven imagery. Arch Gen Psychiatry 1996;53:380-7.

28. Nofzinger EA, Mintun MA, Wiseman M, Kupfer DJ, Moore RY. Forebrain activation in REM Sleep: an FDG PET study. Brain Res 1997;770:192-201.

29. van der Kolk BA, Pelcovitz D, Roth S, Mandel FS, McFarlane A, Herman JL. Dissociation, somatization, and affect dysregulation: the complexity of adaptation of trauma. Am J Psychiatry 1996;153: 83-93.

The Authors

DAVID SERVAN-SCHREIBER, M.D., PH.D., is chief of the Division of Psychiatry, director of the behavioral sciences curriculum for the residency programs in Family Medicine and Internal Medicine, and director of the Center for Complementary Medicine at University of Pittsburgh Medical Center-Shadyside. He completed his medical degree at Laval University in Canada, completed a residency in psychiatry at the University of Pittsburgh School of Medicine, and received a Ph.D. in cognitive neuroscience at Carnegie Mellon University, Pittsburgh.

N. RANDALL KOLB, M.D., is an associate clinical professor in the departments of Family Medicine and Clinical Epidemiology at the University of Pittsburgh School of Medicine and medical director of the Family Health Center at UPMC-Shadyside. He received his medical degree from the University of Pittsburgh School of Medicine and completed a family practice residency at Shadyside Hospital.

GARY TABAS, M.D., is clinical assistant professor of medicine at the University of Pittsburgh and director of Ambulatory Medical Education at UPMC-Shadyside. He completed his medical degree at the University of Pennsylvania School of Medicine, Philadelphia, and completed residency training in internal medicine at the University of Pittsburgh School of Medicine.

Address correspondence to David Servan-Schreiber, M.D., Ph.D., Center for Complementary Medicine, UPMC-Shadyside, 5230 Centre Ave., Pittsburgh, PA 15232. Reprints are not available from the authors.

Table 1Symptoms and Syndromes Commonly Reported by Patients with SomatizationGastrointestinal symptomsVomitingAbdominal painNauseaBloating and excessive gasDiarrheaFood intolerancesPain symptomsDiffuse pain (i.e., "I hurt all over.")Pain in extremitiesBack painJoint painPain during urinationHeadachesCardiopulmonary symptomsShortness of breath at restPalpitationsChest painDizzinessPseudoneurologic symptomsAmnesiaDifficulty swallowingLoss of voiceDeafnessDouble or blurred visionBlindnessFaintingDifficulty walkingSeizures (pseudoseizures)Muscle weaknessDifficulty urinatingReproductive organ symptomsBurning sensations in sexual organsDyspareuniaPainful menstruationIrregular menstrual cyclesExcessive menstrual bleedingVomiting throughout pregnancySyndromesVague "food allergies"Atypical chest painTemporomandibular joint syndrome"Hypoglycemia"Chronic fatigue syndromeFibromyalgiaVague "vitamin deficiency"Premenstrual syndromeMultiple chemical sensitivityInformation from Blackwell B, De Morgan NP. The primary care of patientswho have bodily concerns. Arch Fam Med 1996;5:457-63.Table 2Diagnostic Features Suggesting SomatizationMultiple symptoms, often occurring in different organ systemsSymptoms that are vague or that exceed objective findingsChronic coursePresence of a psychiatric disorderHistory of extensive diagnostic testingRejection of previous physiciansTable 3Evaluation of Somatization in Primary CareStep 1. Evaluate for organic medical conditions.Step 2. Evaluate for psychiatric conditions associated with somaticcomplaints (depression, anxiety disorders, substance abuse/dependence).Step 3. Pursue a positive diagnosis of somatization.

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