The prevalence of somatization in primary care

Preparing psychosocial nurse practitioners for health care delivery

A central task for faculty in programs preparing health care practitioners is to remain timely in educating for the prevailing and future social and health services context. Current considerations in preparing advanced practice psychiatric nurses include the need for greater recognition of comorbidity, concerns about health care access and utilization for vulnerable populations, and changing patterns of practice. In addition, there is a great need to expand the cultural competence and diversity of the population of advanced practice nurses who deliver care to recipients in an increasingly multicultural society. This article describes the educational program developed at the University of Washington to prepare expanded role Psychosocial Nurse Practitioners and sets forth the rationale for major decisions and current directions.

The somatizing patient

Somatization is the experience of physical symptoms in response to emotional distress. It is common, costly, and frustrating to both the patient and physician. Successful treatment of somatization requires the physician to pursue a positive diagnosis rather than rely on a diagnosis of exclusion. Treatment consists of giving an acceptable explanation of the symptoms to the patient, avoiding unwarranted interventions, and arranging brief but regular office visits for which the patient does not need to develop a new symptom to receive medical attention.

Three forms of somatization presenting in primary care settings in Spain

The objective of this paper is to study the prevalence and clinical characteristics of functional, hypochondriacal, and presenting somatization (FSTS, HSTS, and PSTS, respectively) defined by standardized criteria, as well as the validity of their distinction in primary care in Spain. A two-stage epidemiological study of a representative sample (N = 1559) of primary care patients was carried out. In the first phase, the validated Spanish versions of General Health Questionnaire, Mini-Mental State Examination, and CAGE were used. In the second phase, the Standardized Polyvalent Psychiatric Interview, an interview for the multiaxial assessment of medical patients, was employed. The prevalence of any form of somatization in Spain was 21.3% (FSTS: 16.2%, PSTS: 9.4%, HSTS: 6.7%). Overlap of any of the three clinical forms was very frequent (42.7%). FSTS patients tended to be more chronic and showed higher scores in fatigue but lower scores in both depression and anxiety. Chronicity was frequent among somatizers, particularly in those who fulfilled more than one kind of somatization. Differences in diagnostic distribution among the three groups were also observed. In conclusion, this is the first study giving support to the validity of the distinction among three types of somatization in Spain, but overlap was more frequent than reported in North American studies.

Interpreting bodily changes as illness: a longitudinal study of older adults

Research on elders' health behavior has largely ignored the stage between experiencing a bodily change and defining it as an illness. This paper addresses the question of what explains such definitions of bodily complaints as illness symptoms. The issue is examined in a longitudinal study with a random sample of 350 community dwelling persons aged 65 and over. Multiple regression was used to analyze the effects of external stresses, psychological factors and health attitudes as well as contextual variables, on three types of illness representations. These consisted of giving the bodily changes an illness label, initiating contact with a physician, and/or using some form of self care. These illness representations were treated as outcome variables singularly and in combination. The findings revealed that the overall frequency of a person's bodily changes was the best predictor of an illness designation. Other significant predictors at Time 4 of the study included belief in the seriousness of a complaint, the occurrence of prior illness representations and self-assessed health. This research study on the elderly is unique in that it seeks to explain, within a longitudinal design, the intermediate step between the experience of a bodily change and the definition of the change as an illness.

Group therapy for somatization disorders in general practice: effectiveness of a short cognitive-behavioural treatment model

The objective of this study was to evaluate the effect of a short cognitive behavioural group therapy programme for somatization disorder in primary care. The treatment model was focused on patient education and stress relaxation. A controlled and prospective study design was used with repeated assessments of the patients' perception of their psychosocial problems, psychological distress and medication usage. The results were analysed up to 6 months after treatment and showed the treated patients to be moderately but significantly improved with respect to physical illness and somatic preoccupation, hypochondriasis, and medication usage. In a control group of untreated patients no such improvements were observed. In summary, the short group treatment programme used in this study may be beneficial for patients with somatization disorders. With some modifications it might be useful to practitioners in primary care for the management of psychosomatic disorders.

Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics

We examined the cognitive and sociodemographic characteristics of patients making somatic presentations of depression and anxiety in primary care. Only 15% of patients with depressive symptomatology on self-report, and only 21% of patients with current major depression or anxiety disorders on diagnostic interview, presented psychosocial symptoms to their GP. The remainder of patients with psychiatric distress presented exclusively somatic symptoms and were divided into three groups-initial, facultative and true somatizers-based on their willingness to offer or endorse a psychosocial cause for their symptoms. Somatizers did not differ markedly from psychologizers in sociodemographic characteristics except for a greater proportion of men among the true somatizers. Compared to psychologizers, somatizers reported lower levels of psychological distress, less introspectiveness and less worry about having an emotional problem. Somatizers were also less likely to attribute common somatic symptoms to psychological causes and more likely to endorse normalizing causes. In the 12 months following their initial visit, somatizers made less use of speciality mental health care and were less likely to present emotional problems to their GP. Somatizers were markedly less likely to talk about personal problems to their GP and reported themselves less likely to seek help for anxiety or sadness. Somatization represents a persistent pattern of illness behaviour in which mental health care is not sought despite easily elicited evidence of emotional distress. Somatization is not, however, associated with higher levels of medical health care utilization than that found among patients with frank depression or anxiety.

Clinical practice issues in consultation-liaison psychiatry

OBJECTIVE

To overview and highlight the issues currently challenging and confronting consultation-liaison (C-L) psychiatry and to present them for discussion in a wider forum.

METHOD

Following preliminary discussions, the authors (members of the New South Wales C-L Interest Group) undertook to selectively review a number of issues relevant to C-L psychiatry. A preliminary paper was prepared and then presented to the membership of the interest group. Feedback from this meeting was incorporated into the final version of the paper.

RESULTS

Issues selected as a nidus for further discussion include economic issues, changing models of C-L practice, service issues as well as ethical, issues. In addition, recognition of C-L psychiatry as a true subspeciality is foreshadowed.

CONCLUSION

This paper highlights some of the challenges for C-L psychiatry both now and in the future. Intuitive beliefs in our efficacy will not suffice in this era of economic rationalisation. Disciplined and focused research substantiating our value is imperative. Subspeciality recognition is likely to ensure uniformity of standards as well as providing the structure and direction required to consolidate C-L psychiatry's future.

Neuroticism in a family practice population in India

This study was conducted to assess the prevalence of neuroticism and its correlation with the various sociodemographic factors and presenting complaints among patients attending a family practice outpatient clinic. One hundred and forty two consecutive patients attending the outpatient clinic were administered PGI Health Questionnaire N2. Higher incidence of neuroticism was observed in middle age group population, in females (especially housewives), unskilled workers, patients with lower educational status and those belonging to small and nuclear families. A significant number of such patients had presented with vague symptoms, were visiting the clinics frequently and had associated chronic diseases. The results suggest that patients visiting the family practice clinics frequently with multiple somatic complaints with no suggested organic basis should undergo an in-depth psychiatric evaluation.

The structure of psychological distress

In this study we describe the factor structure of the Psychological Distress Index used in the Quebec Health Survey and compare a model that includes psychophysiologic symptoms (29 items) with a model restricted to cognitive and affective symptoms only (18 items). Three samples (n = 2,000) were used to test the likelihood of these two models. Confirmatory factor analyses were carried out using LISREL VII. Logistic regression was then used to examine the association of the two versions with demographic variables and health indicators. Analysis indicates that both versions show satisfactory construct validity. Except for age, the associations observed between both versions and respondents' demographic characteristics are similar; however, the 29-item version is more strongly associated with health status indexes, suggesting a possible bias attributable to somatic items.

Psychiatric screening in geriatric primary care: should it be for depression alone?

Depression in the elderly is highly prevalent, associated with functional disability and increased medical costs, and treatable; however, it is infrequently recognized and treated. The Agency for Health Care Policy and Research has advocated, therefore, increased case-finding efforts for depression in primary geriatric care. Anxiety, substance, and somatoform disorders in the elderly are similarly prevalent, associated with disability and cost, treatable, and also infrequently detected and treated. We believe that psychiatric case-finding in geriatric primary care should attend to these disorders, therefore, as well as to depression. In the present study, we examined whether the association between depressive and nondepressive forms of psychopathology was similar in geriatric and nongeriatric medical patients. We also examined the relationship between each type of pathology and health care utilization and global ratings of physical and mental health. In a VA hospital general medical outpatient clinic, 508 patients completed the SCREENER, which is a brief self-report questionnaire that screens for a range of psychiatric disorders, along with a self-report questionnaire regarding subjective health and medical care utilization. Of these patients, 98% were male, and the median age was 63 years. Patients aged 63 and over were compared to younger patients. In both geriatric and younger adult patients, we found substantial comorbidity between depressive and nondepressive forms of pathology. Moreover, in both age groups, there were significant associations between both depressive and nondepressive symptoms and fair-to-poor self-rated physical and mental health and increased medical care utilization. Approximately half of the cases of nondepressive disorders in the elderly were not comorbid with depression, and thus would not have been detected by screening for depression alone. Therefore, psychiatric case finding in primary care of geriatric males should be directed at anxiety, substance, and somatoform disorders, as well as at depression, for treatment resources to be triaged to maximally decrease morbidity and cost.

Effects of psychiatric consultation on medical consumption in medical outpatients with abdominal pain

A randomized controlled clinical trial was conducted in an outpatient clinic of internal medicine to test the hypothesis that a protocol of cooperation and communication between internist and general practitioner, sustained with psychiatric consultation, would reduce medical consumption in a group of medical outpatients with abdominal pain (N = 106). A reduction in medical consumption could not be demonstrated. However, a great variation in protocol adherence was found, partly related to the severity of the psychological problems. There is some evidence that the protocol, if restricted to cases with more severe psychiatric comorbidity, might reduce medical consumption.

Screening for depression in medical patients. Is the focus too narrow?

There is growing consensus that depression is a major public health problem causing significant psychosocial morbidity and mortality which should be addressed by case-finding effects in primary care settings. A large amount of literature has examined the ability of self-report questionnaires to detect depression in medical patients and the results have been encouraging. However, studies of general population and psychiatric patient samples indicate that depression is frequently comorbid with other psychiatric disorders, and that psychiatric disorders other than depression are also associated with significant morbidity and mortality. Consequently, we believe that psychiatric screening in primary care should be broad based. We administered a newly developed, multidimensional questionnaire (the SCREENER), that simultaneously screens for a range of DSM-III-R psychiatric disorders, to 508 medical outpatients attending a VA general medical clinic. Compared with nondepressed cases, the depressed patients significantly more often reported all of the nondepressive symptoms. Nine of the ten nondepressive disorders screened for by the SCREENER were significantly more frequent in the depressed group. Most patients who screened positive for depression also screened positive for at least one nondepressive disorder. Compared with patients who only screened positive for depression, those who screened positive for both depression and a nondepressive disorder rated their physical and emotional health more poorly and made more visits to the doctor. Compared with patients who did not screen positive for any disorder, those who only screened positive for a nondepressive disorder rated their physical and emotional health more poorly, and more frequently had a history of mental health treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Somatothymia in chronic pain patients

Somatothymia is the use of somatic language to communicate affective distress. A total of 152 chronic pain patients completed a systems review checklist and the Minnesota Multiphasic Personality Inventory. Associated features of somatic symptoms and the meaningfulness of somatic symptoms as a communication, common physical areas of somatic focus, patterns of affective distress in high and low somatothymics, and the utility of select variables classifying high and low somatothymics were evaluated. The results indicate that a systems review checklist can be used as a quick, useful, and initial screen for somatothymia and that somatic symptoms can in fact communicate affective distress.

Admission patterns of persistent somatization patients

Persistent somatization patients put a serious burden on the health care system with multiple admissions, tests, surgeries, and medications. This study reports on factors relevant to the health-seeking behavior of somatizing patients and aspects of the health care system that facilitate their overutilization of health resources. Individuals (age 17-49 years) from the general population of two Danish municipalities with at least 10 general admissions during an 8-year period were studied comparing persistent somatizers with other high utilizers of medical admissions. Results are reported on geographical mobility, change in family doctors, route and distribution of admissions by time of day or week, discharges against medical advice, physical disease overlooked, and distribution of admissions to specialties. Although the health-seeking behavior of persistent somatizers may in part explain their overutilization of health care resources, such overutilization could be reduced and much suffering avoided if physicians displayed the same enthusiasm in diagnosing somatization as in ruling out organic pathology.

The management of chronic somatisation

'Somatisation' is a process in which there is inappropriate focus on physical symptoms and psychosocial problems are denied. In some patients this process becomes chronic (in excess of six months). Special skills and strategies are required by non-psychiatrists to manage these patients, for whom the acceptance of psychiatric treatment should be facilitated. When taking the history, doctors should be aware of psychosocial cues; thereafter they should be consistent and unambiguous in their management. An agenda should be set early on, with limits on investigations. Failure to manage this group of patients is costly, and further intervention studies are required not only to reduce health service and other costs, but also to relieve the non-monetary burden of physical and psychosocial disability on patients and their relatives.

The relationship of presenting physical complaints to depressive symptoms in primary care patients

OBJECTIVE

To assess the relationship of specific patient chief physical complaints to underlying depressive symptoms in primary care practice.

DESIGN

A cross-sectional study that was part of a larger prevalence study of depression in primary care.

SETTING

A general medical primary care practice in a teaching medical center in rural New England.

PATIENTS

1,042 consecutive outpatients screened for depression with the Hopkins Symptom Checklist 49-item depression scale and for whom physicians filled out a form recording both specific chief complaints and two aspects of complaint presentation style, clarity and amplification.

INTERVENTIONS

None.

RESULTS

Complaints that discriminated between depressed and non-depressed patients (at the p = 0.05 level) were sleep disturbance (PPV 61%), fatigue (PPV 60%), multiple (3+) complaints (PPV 56%), nonspecific musculoskeletal complaints (PPV 43%), back pain (PPV 39%), shortness of breath (PPV 39%), amplified complaints (PPV 39%), and vaguely stated complaints (PPV 37%).

CONCLUSIONS

Depressed patients are common in primary care practice and important to recognize. Certain specific complaints and complaint presentation styles are associated with underlying depressive symptoms.

The recognition and management of somatization. What is needed in primary care training

This article addresses the medical education issues associated with teaching primary care residents about somatization. Specific training designed to recognize and manage somatization involves a hierarchical series of five knowledge domains with associated discrete skills. As a foundation, a biopsychosocial model must be embraced by the medical leadership of the training program. Second, because psychosocial stresses play a critical etiologic role in somatization, the ability to identify relevant psychosocial issues during medical interviewing is a fundamental skill. Third, basic psychiatric diagnostic areas (depression and anxiety) must be mastered as a prerequisite for identifying somatization. Specific interviewing and management techniques are reviewed, along with two current programmatic approaches. Finally, the concept of physician countertransference also must be explicitly addressed as part of the curriculum. Without assuring that these building blocks are in place, residents are likely to become overwhelmed by the management of somatizing patients and continue the pattern of frustration associated with these patients.

Symptoms in medical patients: an untended field

Somatic symptoms are one of the leading reasons for medical outpatient clinic visits, with the most common symptoms having a prevalence of 10% or more. However, the usual diagnostic workups are often unproductive, with less than 1 in 5 symptoms having an organic explanation after the initial physical examination and laboratory testing. Therapy appears more effective for some symptoms than for others. Of patients with unspecified pain or gastrointestinal complaints, greater than 70% state that some type of treatment has been helpful, whereas less than 50% of individuals with fatigue, dizziness, numbness, insomnia, sexual dysfunction, anxiety, or depression report any relief. Future educational efforts and research need to focus on that majority of symptoms that are either psychiatric or unexplained, in order to improve our current evaluation and management strategies.

Idioms of distress: somatic responses to distress in everyday life

In-depth interviews were conducted among 50 subjects residing in the industrial town of Newcastle, Australia. Half of these subjects were from the general population and half were currently seeking counselling for personal/family problems. None of the subjects were receiving any medical care at the time of interview, though seven had done so during the episode of distress they were discussing. The study shows that while the subjects psychologized their 'problems', members of both groups tended to somatize at a rate proportional to the level of distress. Subjects were unaware of any relationship between the distress they were experiencing and their physical complaints. The results of this study support previous research which argues that those experiencing distress and those who tend to introspect are also those who are likely to amplify somatic symptoms. At the same time these results depart from findings in the United States which suggest that in the West, people learn to express social and personal distress in psychological terms, thereby reducing the level of somatization. Though not representative of the population as a whole, the findings raised questions warranting further study.

The Bradford Somatic Inventory. A multi-ethnic inventory of somatic symptoms reported by anxious and depressed patients in Britain and the Indo-Pakistan subcontinent

In the development and evaluation of a multi-ethnic inventory (the BSI) of somatic symptoms associated with anxiety and depression, symptoms were derived from psychiatric case notes of Pakistani and indigenous British patients with a clinical diagnosis of anxiety, depression, hysteria or hypochondriasis. The inventory was constructed simultaneously in Urdu and English. A pilot version of the BSI was checked against psychiatric case notes in north and south India, and Nepal. The revised BSI achieved over 90% coverage of all somatic symptoms recorded in each centre. The linguistic equivalence of the Urdu and the English versions was established in a bilingual student population in Pakistan. Conceptual equivalence of the BSI was explored using factor analysis of responses by functional patients presenting to medical clinics in Britain and Pakistan. Four principal factors (head, chest, abdomen, fatigue) were similar in both populations.

The changing faces of somatization

The prevalence of several diseases popularized by the media is examined in a group of 50 consecutive patients allegedly suffering from environmental hypersensitivity disorder. Ninety percent of patients reported suffering from at least one other "fashionable" condition, including food allergies that cause psychological symptoms, postinfectious neuromyasthenia, candidiasis hypersensitivity, and severe premenstrual syndrome. Each of the conditions named above was endorsed by at least 50% of patients. Multiple endorsements were common, and the patients' attribution of the etiology of their symptoms varied with time. Physicians must become adept at identifying and managing somatizing patients, and the public must be educated about somatization and provided with reliable information about "fashionable" illnesses.

Hypochondriasis

Hypochondriasis and other syndromes in which health anxiety is prominent are frequently seen in clinical practice and often pose problems of management. In contrast with other anxiety problems, the conceptualization and treatment of health anxiety has developed very little in recent years. Behavioural approaches to treatment have only recently been applied. In the present paper, current theoretical models are critically evaluated and a cognitive-behavioural approach is proposed to account for the development and maintenance of hypochondriacal problems. Principles of cognitive-behavioural treatment based on this approach are outlined, together with some suggestions for research.

The Diagnostic Knowledge Inventory: a measure of knowledge about psychiatric diagnosis

A psychometrically sound measure of knowledge of psychiatric disorders and diagnoses (consistent with both DSM-III and DSM-III-R) was constructed for use by mental health and health care professionals. No such measure otherwise exists, in spite of its potential value as an educational tool and in research on clinical diagnosis. The diagnostic accuracy (content validity) of a large item pool of brief case vignettes was verified in a prestudy by a team of experts. This item pool then was reduced by half, and two forms of the measure were constructed based on an item analysis that used a heterogeneous sample of clinically trained and untrained respondents (Study 1). Reliability and validity were demonstrated using a cross-validation sample (Study 2). Finally, comparisons were made between practicing mental health professionals and controls; these supported the measure's validity (Study 3). Overall, the measure demonstrated concurrent validity (by distinguishing clinically trained from untrained respondents) and reliability (by showing internal consistency and inter-form association). Potential uses of the measure in research and training concerned with clinical diagnosis are discussed.

Symptomatology of minor psychiatric morbidity: a crosscultural comparison

The basic symptoms of minor psychiatric morbidity (MPM) reported elsewhere were also found in a community survey in Taiwan. However, differences in the patterns of and manifestations of the symptoms were evident. Contrary to most Western surveys, the prevalence of anxiety (24.7%) was found to be higher than that of depression (8.3%) in Taiwan. Possible explanations based on sociocultural characteristics of the Chinese family were proposed. The notion of somatization as a predominant symptom in Chinese neurotic patients advocated by some research workers was not supported in this study. As a result of findings in community cases, it is argued that the importance of somatization has been considerably overemphasized as a factor in the illness behaviour of neurotic cases in Chinese and other cultures, and it is therefore not a culture-specific disease phenomenon. It is also suggested that certain culture-specific neurotic syndromes reported in Chinese, such as shen-ching-shuai-jo (neurasthenia) and shen-k'uei (semen loss syndrome), are clinically equivalent to MPM. Implications of the present findings on crosscultural research and management of MPM were discussed.

Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome

PURPOSE AND PATIENTS AND METHODS

Many symptoms in outpatient practice are poorly understood. To determine the incidence, diagnostic findings, and outcome of 14 common symptoms, we reviewed the records of 1,000 patients followed by house staff in an internal medicine clinic over a three-year period. The following data were abstracted for each symptom: patient characteristics, symptom duration, evaluation, suspected etiology of the symptom, treatment prescribed, and outcome of the symptom. Cost estimates for diagnostic evaluation were calculated by means of the schedule of prevailing rates for Texas employed by the Civilian Health and Medical Program of the Uniformed Services for physician reimbursement.

RESULTS

A total of 567 new complaints of chest pain, fatigue, dizziness, headache, edema, back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation were noted, with 38 percent of the patients reporting at least one symptom. Although diagnostic testing was performed in more than two thirds of the cases, an organic etiology was demonstrated in only 16 percent. The cost of discovering an organic diagnosis was high, particularly for certain symptoms, such as headache ($7,778) and back pain ($7,263). Treatment was provided for only 55 percent of the symptoms and was often ineffective. Where outcome was documented, 164 (53 percent) of 307 symptoms improved. Three favorable prognostic factors were an organic etiology (p = 0.006), a symptom duration of less than four months (p = 0.009), and a history of two or fewer symptoms (p = 0.001).

CONCLUSION

The classification, evaluation, and management of common symptoms need to be refined. Diagnostic strategies emphasizing organic causes may be inadequate.

Somatization in primary care: patients with unexplained and vexing medical complaints

Somatizing patients experience or express emotional discomfort and psychosocial distress as physical symptoms. Somatization occurs in a broad spectrum of illnesses, in association with a wide variety of mental disorders, including depression, anxiety, and the somatoform disorders. Primary care providers must detect and treat these patients. Diagnosis is based on positive criteria. Care rests upon conservative medical management and evaluation; a physician-patient relationship based on acceptance, caring, and trust; reinforcement of positive behaviors and elimination of destructive ones; and the gradual use of the relationship to promote healthy relating in the patient.

Behavioural treatment of illness phobia and hypochondriasis. A pilot study of 17 cases

Illness phobia and hypochondriasis can be associated with severe disability and requests for reassurance. Exposure to illness cues and prevention of reassurance produced rapid improvement in both health anxiety and in social functioning. Our uncontrolled results warrant a controlled prospective trial with follow-up.

Family morbidity in chronic pain patients

Family morbidity in chronic pain patients could indicate genetic vulnerability to depressive spectrum disorders or presence of pain behaviour models. Assessment of family morbidity is an area of chronic pain research which has been neglected. In the present study, the frequency and nature of the family psychiatric morbidity of 203 consecutive chronic pain patients has been assessed and compared with that of 140 non-pain psychiatric patients. 30% of chronic pain patients and 33.6% of non-pain psychiatric patients had family psychiatric morbidity. The commonest illness in families of pain patients were found to be alcoholism, psychosomatic disorders and chronic pain. Schizophrenia and affective disorders were reported significantly more often in families of non-pain patients. 53% of psychogenic pain disorder patients had a positive family morbidity. Alcoholism among male relatives, and chronic pain and hypertension more often among female relatives, was another significant observation. No significant difference was found between chronic pain patients with and without family morbidity with regard to socio-demographic variables and clinical diagnosis.

Prevalence of chronic pain in psychiatric patients

Five hundred consecutive patients attending a psychiatric clinic were examined in order to ascertain the prevalence of chronic pain in various psychiatric illnesses and demographic categories. Chronic pain was found to be a frequent symptom in anxiety neurosis (60%), neurotic depression (45%) and hysteria (24.3%). Less than 3% of psychotic patients reported chronic pain. Females and those patients who had entered further education beyond secondary level were found to have significantly higher (P less than 0.001) representation as compared to the psychiatric population without pain. The results are in accordance with certain earlier studies carried out almost two decades ago. Chronic pain was found to be a common symptom of psychiatric illness, reported by 18.6% patients, especially those diagnosed as having neurosis. It was also reported more often by females and by those with a higher education. The reasons for these observations require investigation.

Masked depression: its interrelations with somatization, hypochondriasis and conversion

Masked depression appears to be a common clinical phenomenon. Most depressions present with some somatic complaints in addition to affective and cognitive ones. About one half of all depressions seen by primary care physicians initially present predominantly or exclusively with somatic symptoms. Many of these depressions are not recognized or are misdiagnosed and mistreated. The possible reasons for this are discussed here. The phenomenon of somatization in depressions and other conditions is reviewed and the interface with other related clinical problems like hypochondriasis and conversion is delineated. It is hypothesized that the proportion of depressions that are masked is positively correlated to the patients' tendency to somatize and negatively correlated to the doctors' ability to recognize depressions that hide behind somatic complaints. Suggestions for the diagnosis and treatment of masked depressions are given.

The importance of hysteria

Hysteria has been a topic of interest throughout the history of medicine; those who have been concerned with it include Galen, Paré, Sydenham, Charcot and Freud. Anyone who chooses to proclaim its importance, therefore, might be asked to provide some reason for gilding the lily. Controversies have always attended the subject, and different disciplines still disagree over it. The diagnosis, which occurs in the International Classification of Diseases (ICD-9, 1978) has been deprecated on both sides of the Atlantic (Slater, 1965; DSM-III, 1980) and also advocated with varying degrees of fervour (Walshe, 1965; Lewis, 1975; Merskey, 1979). It is a subject of historical study (Veith, 1965; Walker, 1981; Shorter, 1984); there have been at least nine monographs on it since 1977 (Horowitz, 1977; Krohn, 1978; Jakubik, 1979; Merskey, 1979; Roy, 1982; Riley & Roy, 1982; Colliganet al.1982; Weintraub, 1983; Ford, 1983), and there is a steady flow of paper on the topic of hysteria or its major subdivisions (eg, hysterical personality, conversion symptoms) or pseudonyms and partial pseudonyms (eg, somatisation disorders, borderline personality, and operant pain).

Chronic idiopathic pain disorder

Chronic pain may be non-organic and also may be non-psychogenic as well. This report pertains to the socio-demographic, clinical, psychometric description and follow-up of 21 such cases. Though these are not different from psychogenic pain disorder as regards clinical presentation, idiopathic pain is more often observed in those elderly, town dwellers and those who received higher education. On the other hand psychogenic pain disorder has significantly higher (p less than 0.01) neuroticism scores. The prevalence and significance of idiopathic pain disorder is discussed. The identification of such a category is important in management of chronic pain patients.

Chronic pain in a psychiatric clinic

Prevalence rate of chronic pain in a psychiatric outpatient clinic has been evaluated in this study and characteristics of chronic pain patients have been compared with non-pain psychiatric patients. Chronic pain was reported by 14.37% of psychiatric patients. Of these, 43% had dysthymic disorder, 20% had anxiety states and 20% somatoform disorders. As compared to the control group, chronic pain patients belonged more often to the middle age group (p less than 0.05), were more frequently females (p less than 0.001), married (p less than 0.02) and from an urban habitat. There is a marked difference in the diagnostic breakdown between the two groups with a predominance of dysthymic and anxiety disorders in pain patients. Very few chronic pain patients had psychosis. Major depression was found in equal proportions in pain and non-pain patients. The study identifies variables which differentiate chronic pain patients from other psychiatric patients.

Depression and hypochondriasis in family practice patients with somatization disorder

The relationships specified in DSM-III between somatization disorder and depression, and somatization disorder and hypochondriasis require further validation and easier methods of detection for use by primary care physicians. The authors investigated hypochondriacal and depressive symptoms in 13 family practice outpatients with somatization disorder. Pain complaints and depressive symptomatology were present in over 75% of this group, while hypochondriacal symptoms were present in 38%. The mean score on the somatization scale of the Hopkins Symptom Check List (HSCL-90) was greater than that reported for any other group. These findings support the separation of somatization disorder and hypochondriasis and suggest the need for better delineation of depressive subtypes in somatization disorder. The somatization scale of the HSCL-90 should be a useful screen for somatization disorder in future research.

An exploration of somatization among Asian refugees and immigrants in primary care

The clinical records of Chinese, Filipino, Vietnamese, Laotian, and Mien patients in primary care were reviewed to determine the prevalence of somatization, its associated patient characteristics, and the manifested illness behavior. Patients in this study were generally poor, unemployed, and spoke little English. Somatization accounted for 35 per cent of illness visits. These visits were also more costly. Refugees had a higher rate of somatization (42.7 per cent) than immigrants (27.1 per cent). Although sociodemographic characteristics did not strongly differentiate patients with somatization from others, ethnicity and indicators of decreased resources such as large households with low income, households headed by single women, or a limited English proficiency were associated with somatization in certain ethnic groups. Somatization is thus an important health problem among Asian refugees and immigrants.