The Prevalence of Somatization in Primary Care

Wayne Katon, Richard K. Ries, and Arthur Kleinman ABSTRACT

The authors define somatization as an idiom of distress in which patients with psychosocial and emotional problems articulate their distress primarily through physical symptomatology. Studies are then reviewed to demonstrate the inordinate amount of time and energy these patients cost the health care practitioner as well as the frequency of misdiagnosis. latrogenic harm is a common problem in somatizing patients due to unnecessary tests, hospitalizations, surgeries as well as the development of chronic illness behavior. It is essential that psychiatrists working in consultationliaison begin to develop research in the area of somatization especially at the primary care level.

LTHOUGH several studies have described the diagnoses of patients referred to a psychiatric consultation service in a general hospital,i,2 none have specifically reported the psychiatric diagnoses of patients who somatize, i.e., patients with psychosocial distress and emotional problems who articulate their distress primarily through physical symptomatology. These patients either do not have discernable organic pathology or amplify their verifiable physiologic changes. They have been shown to be high frequency utilizers of physician services3 and, when somatization is part of chronic medical disorders, to represent a major challenge for health care systems worldwide.4 Few descriptivestudies have focused on the somatizing patient yet these patients take up an inordinate amount of time and energy of the medical practitioner as well as a disproportionate share of the health care dollar. Collyers study of somatizing patients in his primary care practice revealed that 28% of his patient contacts involved emotional illness and that these consultations took up 48% of the physicians time. Overall, 3.6% of the families in his general practice accounted for 32% of his time. Nearly all of these high use families had one member diagnosed as depressed and often several family members were presenting to the physician with vague somatic complaints. Regier has shown that 60% of patients with mental illness are being seen by primary care physician9 and Hankin and Oktay have demonstrated that patients with psychiatric diagnoses tend to utilize more than two to four times as much non-psychiatric medical care. Goldberg reported in a large English primary care population that over 50% of the patients with psychiatric problems presented initially with somatic complaints.* Widmers studies of primary care patients revealed that in the 7 months prior to the diagnosis of major depression being made these patients presented with (1) an increase in the number of patient initiated office and home visits, (2) an increased incidence of hospitalizations, and (3) an increased number of presenting complaints of three types: (a) ill-defined functional complaints, (b) pain of undetermined etiology in a wide variety of sites such as the head, chest, abdomen, and extremities,

From the Division of Consultation-Liaison Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Washington: and the Harvard Medical School and The Cambridge Hospital. Address reprint requests to Wayne Katon, M.D., Dept. of Psychiatry, RP-IO, University of Washington, Seattle, Washington 98195. @ I984 by Grune & Stratton, Inc. 0010-440X/84/2502-09$01.00/0 208 Comprehensive Psychiatry, Vol. 25, No. 2, (March/April)

1984

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(c) and nervous complaints, mainly increased tension and feelings of anxiety., Widmer also demonstrated that family members of these depressed patients also had ill-defined somatic complaints and increased visits to the clinic in the same time period. Once the depressed patients affective illness was successfully treated both the patient and his familys clinic visits decreased to baseline levels. Sheehan found, in a study of agoraphobic patients who suffered from panic attacks, that 70% of the patients had visited more than ten different physicians with somatic complaints before they received accurate diagnosis and treatment.? Overall. it appears that 25% to 75% of patient visits to primary care physicians are primarily due to psychosocial distress but patients usually present with somatic complaints. Is In fact, studies from health maintenance organizations like Kaiser-Permanente have revealed that as many as 60% of primary care patients recurrently present with somatic symptoms that are an expression of psychosocial distress.J,n, Further, the Kaiser studies have revealed that when these patients are referred to short-term psychotherapy their pattern of overutilization of primary care physicians decreased significantly.6,x In a review of these health maintenance organization studies. Cummings concluded that the failure to provide mental health services has the potential of bankrupting the health care financing system due to the overutilization of primary care physicians by somatizing patients. From another perspective, many patients who do visit physicians regularly are without serious medical illness. Analyses of the content of general medical practice have shown that 68% to 92% of patients are without serious physical disorder.. Only 41%3 of identified problems of patients are clear somatic diagnoses? and the most common single diagnosis in general practice is nonsickness.? Ten to 60; of patients with each of the five most common medical complaints have been found without structural disease responsible for their symptoms.? Somatization occurs in a wide variety of clinical settings. Psychiatrically, it I\ often found in patients with depression, panic disorder, somatization disorder, histrionic personality disorder, borderline personality disorder, grief syndrome. posttraumatic stress disorder, factitious disorder, hypochondriasis, and malingering.lj It is also encountered in psychophysiologic disorders, and as a coping response to stressful life events. But oscilations between amplification and damping of symptoms occur routinely in chronic medical disorders, in which somatization owing to psychosocial and cultural contexts is a common source of clinical management problems. The most common form of somatization in American society is the chronic pain syndrome-defined as affecting an individual when he or she has suffered more than 6 months of pain in one or several bodily sites of a disabling kind that significantly interferes with life activities. In 1980. more than 10 billion dollars were spent on disability payments to American patients with chronic pam problems13 and disability payments for US postal employees with low-back pain alone amounted to 0.8 cents of each 20 cent stamp purchased.Zh Among traditionally oriented ethnic patients, members of fundamentalist religious sects that disparage the undisguised presentation of negative emotions, and working class patients, somatization may provide a culturally sanctioned idiom for expressing personal and interpersonal distress of many types as well as a socially effective means of manipulating limited sources of social power and influencing

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In interpersonal relationships somatization maldistribution of available resources. 4~27 is often used out-of-awareness to elicit social support, to avoid intimacy, to express anger, or to avoid anxiety provoking situations. It is not necessarily maladaptive in that in many families and cultures it is routinely employed as an idiom of distress and may lead to beneficial changes in the family (increased attention, nurturance, oriented Western culture, or support) or in the community. 28 In the biomedically however, it often becomes maladaptive when the somatizing patient interacts with the medical profession because patients are often diagnosed and treated exclusively laboratory tests, clinic symptomatically through a biomedical lens. 29 Unnecessary visits, hospitalizations, and even surgeries frequently result. Effective handling of personal and interpersonal problems may therefore be delayed and obstructed. Also, what may have started as somatization of a psychiatric disorder or social stress may develop into a permanent iatrogenically caused physical disability such as a spinal fusion and distortion from repeated operations for low back pain. Once somatic symptoms develop, whether secondary to psychological, social or biomedical problems, there are psychological and social consequences of illness. The patients somatic symptoms can have an effect on family homeostasis, vocational adjustment, the patients social network (friends, church) as well as the patients coping mechanisms. 3oThe patients perception and attribution of a somatic symptom or group of symptoms is not developed in a vacuum but in the plural contexts of his current social environment. People are continually influenced by feedback from the settings in which they live. Thus a persons perception and cognitive mechanisms are not just the result of past familial, cultural and interpersonal experiences but are due to interpersonal interactions and institutional roles in the present as well. 3i The psychological unit is not the individual person but the person within his significant social contexts. This systems model requires the observation of how and to what extent interpersonal transactions and social roles govern the patients range of behavior. The patients perception of his symptoms can be visualized on a continuum between amplification and damping. The social systems may reinforce illness behavior and thus amplification of symptoms by beneficial changes in family structure, disability payments, attention from the medical care system as well as psychoactive medication that provides a degree of symptom relief. These reinforcers may become illness maintenance systems such that somatic symptoms that were initially either due to organic disease or the somatization of psychosocial distress now continue as illness behavior although the physiologic changes of disease or the psychosocial distress have disappeared. Several studies validate this hypothesis. Miller determined from his study of insurance actuarial data that persons with the same type of injury or illness but different disability policies react quite differently.32 The data from 13 companies were examined covering 138,795 disability claims in which two categories of policies were compared; the first granting benefits after an injury primarily for two years and the second to age 65. The study indicated that as many as 25% of the persons disabled at least 1 year in the first group recovered who would still be asserting their claim for continuous disability benefits if insured under a long-term or unlimited benefit plan. Hirschfeld et al33 McBride,34 and Weinstein35 in three separate reviews have also documented that the disability system provides strong social reinforcements that seem to prevent recovery from the original disease or injury resulting in chronic disabling illness behavior.

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Family therapists

have often described

some families extreme resistence to change

once a new system of functioning has been set up, even systems that seem demonstrably maladaptive to outside observers. Minuchin has published extensively on his studies of psychosomatic families in which amplification of a chronic illness such as diabetes mellitus or asthma or the development of anorexia nervosa stabilizes a precarious family equilibrium at the expense of the identified patient. Fordyce3 and Hudgens have also shown that family reinforcements, i.e., increased attention or nurturance, of somatized or actual chronic pain may subsequently bring the pain under operant control such that pain behavior continues in the absence of physiologic pain. Both authors mention the social efficacy of the chronic pain in family interactions as a mechanism to control and manipulate others, justify dependency, earn rest, avoid sex, gain attention, punish others, control anger and avoid close relationships. The medical care system also reinforces somatization. Engel has pointed out that physicians armed with extensive training in the biomedical model do not evaluate the psychosocial stress that often underlies somatic complaints. Physicians, by virtue of their training that is highly technologic, are somatizers. That is, physicians preferentially look for and treat somatic complaints. The effect on the patients perception of their illness of the physicians narrow somatic model is that hypochondriacal patterns are reinforced by medical concern and substantial workups. The longer the patients perceive themselves to be somatically ill and the longer the physician focuses on the somatic aspects of illness. the more likely is the patient to develop significant secondary gain for being ill and to accept the sick role as a way of life. There is also the the danger of the medical care system becoming a social support system in itself. In considering the social context of parasuicide as well as hypochondriacal symptoms, Henderson postulated that there are substantial deficiencies in the care-giving afforded such patients by others, giving rise to careeliciting behavior to correct the deficiency in social support.H Balint has pointed out that a significant number of patients in general practice are searching for genuine interest and empathy from the physician, not relief of physical symptoms. The symptoms then are the ticket of admission to see the physician. Patient maladaptive coping mechanisms may also cause amplification of somatic symptoms. Dirks et al, in a series of studies, found that two specific coping styles of chronic asthmatic patients caused significantly higher hospitalization rates after discharge from intensive treatment, even among patient groups having similar objective disease severity. 4o Dirks et al determined that the personality traits associated with subsequent high utilization of health care resources in chronic asthtnatic patients were reflected by either extremely high scores on the MMPI panicfear personality scale or extremely low scores on this scale. Patients scoring extremely high on the panic-fear scale were characterized as ambivalent, fearful, emotionally labile, dependent, felt helpless and pessimistic about their illness and often hyperventillated during asthamatic distress. Patients with extremely low scores denied the presence of anxiety, claimed to be unusually calm and self-controlled and typically presented in a rigid, counter-dependent manner. If somatization is so prevalent in medical care, why have so few studies beer1 conducted to ascertain the psychiatric characteristics of these patients? Part of the problem is that psychiatric nosology has been developed in a partial vacuum from the rest of medicine. The most lucid example is the description of the phenomenolog!;

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of major depression. In the psychiatric literature major depression is described as an illness in which most patients readily focus on their affective and cognitive symptoms as well as their somatic complaints. Yet Weissman has shown that major depression is present in 4.3% of the population of an East Coast city, but 66% of the patients with depression were not getting any specific treatment for their illness4 Two-thirds of these unrecognized, untreated depressives made more than six visits a year to their primary care physicians for somatic complaints (which was significantly more visits than in the population who were not effected by depression). Thirty-four percent of these people with depression were treated with minor tranquilizers, 17% were taking sleeping pills whereas only 17% were treated with antidepressants. The Weissman finding that patients with depression seek help and are undetected in nonpsychiatric medical settings is consistent with the recent findings from several surveys of medical inpatient family practice and primary practice settings in both the United States and Great Britain.42A* Misdiagnosis in medical outpatients with depression has varied from 50% to 75% and in medical inpatients as high as 96%.47 The Goldberg8 and Widmer9- studies reported above suggest that the lack of detection is due to the fact that patients who seek help for major depression in primary care often focus on their somatic or vegetative symptoms and minimize or deny affective and cognitive complaints. Primary care physicians are taught psychiatric nosology in psychiatric settings where by and large patients are quite aware of psychological precipitants and symptoms. They have little training in diagnosing emotional illness in patients who present somatically, i.e., with fatigue, headaches. However patients with emotional illness are utilizing more of their care and timesI7 and often eventually do get labeled nonspecifically as hypochondriacs (or at times pejoratively as crocks or turkeys). This is especially unfortunate because major depression has been demonstrated by structured psychiatric interview to have a prevalence of 5.8% in primary care48 making it the most common overall psychiatric or medical diagnosis. Hypertension is next at 5.7%. There are also highly effective pharmacological treatments for depression. The term masked depression in psychiatric literature has been used to define patients who presented with somatic symptoms of depression but minimized or denied affective and cognitive symptoms. Masked depression has been considered a relatively rare, unusual presentation of depression but in primary care it appears to be as frequent as depression presenting psychologically.5.7 Thus one of the problems in studying somatization has been the lack of research describing the prevalence, incidence and phenomenology of DSM-III type diagnoses among primary care patients. Many questionnaire studies utilizing scales like the GHQ, Hopkins checklist, Beck and Zung Depression Rating Scales have demonstrated very high rates of mental illness in primary care.47 Hoeper conducted the only psychiatric structured interview (SADS) study in primary care and found a 26.8% rate of mental illness by RDC criteria. 4* It is unclear in this study, however, whether specific attention was focused on the diagnosis of somatizing patients, i.e., the patient presenting with back pain or headaches who denies depression but has five vegetative and cognitive symptoms. Another of the major problems in the study of somatization is to define the term so that two psychiatrists seeing the same patient have operational criteria upon

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which to base diagnoses. The old terminology for somatization was hypochondriasis. which was defined as the belief one has a disease for which medical diagnosis and treatment are needed despite repeated examinations and laboratory tests with normal results or reassurances from the physician.49 This term has the unfortunate connotation of implying a Cartesian dichotomy to patient symptoms such that the patient complaints are considered to be either organic or psychological. We prefer the broader term of somatization because of its fit with the biopsychosocial model in which the patients symptoms are considered idioms of distress in the biological, psychological and/or social parts of the patients life. Further, patients with chronic medical illness have oscillations of their illness between amplification and damping due to biological, psychological and/or social stressors. The job of the physician is to weigh each of these factors in determining a diagnosis. In fact the most difficult somatizing patients for primary care physicians are patients with verifiable organic disease who amplify their symptoms; the physician is trained to react with a biomedical focus in these patients due to the anxiety of missing a physical illness. CONCLUSION Our intent in the first of this two part series was to review the data base describing the known prevalence of somatization in medical clinics and wards. As described above patients with psychiatric disorders often present somatically (they have been labeled the hidden psychiatric morbidity of primary care? and are misdiagnosed and often eventually labeled as hypochondriacs. Studies need to be conducted to describe the DSM-III psychiatric diagnoses of these patients and our intent in part II will be to present the results of a prospective data based study of IO0 consecutive psychiatric consultation patients referred from the medical wards because either no physiologic pathology was found to explain their somatic complaints or the physiologic pathology found did not match the extent of complaints. Based on this study a new conceptualization of somatization will be explicated. REFERENCES
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