Management of the persistent somatizer

Reducing the costs of chronic somatisation

We report the case of a 48 year old woman who presents with a 25 year history of somatisation disorder. She has ten volumes of notes from four hospitals in one city which together weigh almost 10kg. She has been under the care of ten hospital specialities, had eleven operations, with 77 admissions and a total of 856 days in hospital over a period of twenty-five years. No physical diagnoses can satisfactorily explain her presentations which have been accurately costed to a total of over £250,000 as a conservative estimate.

Somatisation disorder is a chronic illness with financial, medical and personal costs. We report in detail recurrent dangers and pitfalls which arose during her hospital contact. By undertaking a case note review, contacting all the physicians involved and writing a “Key” summary letter outlining the contribution of psychological factors to her problems, her annual health care costs were reduced from a total of over £10,000 a year to a little over £2,000 after psychiatric intervention and the appointment of one physician to take overall charge of her case. Implications for service provision are discussed.

Somatization: a perspective from self psychology

Somatization is a complex phenomenon that occurs in many forms and diverse settings. It is not necessarily pathological and may be found in a variety of psychiatric disorders. Much of the psychiatric literature has focused on patients with conversion disorders and hypochondriasis. Psychoanalytic theories regarding such conditions were largely based upon concepts of drive, conflict, and defense. The perspective from self psychology, with its emphasis on subjective experience and the sense of self, may further enhance the psychoanalytic understanding of somatization. Individuals with disturbances in the stability and organization of the self may present with somatic symptoms and disturbances in emotional awareness. Somatization in such cases may be the experiential manifestation of a disturbance in the cohesion of the self and/or may result from defensive operations to ward off affect. The latter may be prominent when affective arousal triggers the psychological threat of fragmentation. Somatization may diminish in such individuals when a self-object relationship is formed that bolsters and consolidates the sense of self. The integration of affect into ongoing subjective experience may also be an important aspect of psychoanalytic treatment in such patients.

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 and related disorders. Assessment and management of patients referred for a psychiatric opinion

This article outlines the main components of a comprehensive plan for the assessment and management of patients referred for a psychiatric opinion with hypochondriasis and related disorders. Particular emphasis is placed on the discussion of attitudes to previous medical contact, to the value of physical investigations, and to the psychiatric referral itself; these attitudes are often neglected and yet are of clinical importance because they are usually associated with resistance to psychiatric treatment. A short-term flexible therapeutic approach to the presenting syndrome itself is outlined, which is based on cognitive-behavioral strategies used in other emotional disorders and on the literature on hypochondriasis. Clinical experience with this approach suggests that nonattendance may be high even in those who present for initial assessment, but that for attenders the prognosis may be good, with 80% showing a marked or moderate improvement on discharge. Younger patients, those with a past psychiatric history, and those receiving state benefits did worse, and those with major depression had the best prognosis. Social function, personal distress, and preoccupation with symptoms all tend to improve more than the underlying physical symptoms themselves.

A cognitive-educational treatment for hypochondriasis

Hypochondriasis may be conceptualized as a disorder of perception and cognition, in which somatic sensation is experienced as abnormally intense and is then incorrectly attributed to serious medical disease. We describe a therapy to modulate the hypochondriacal patient's somatic sensations, and to alter his or her cognitive appraisal of them, which focuses on four factors that amplify somatic symptoms: (1) attention and expectation; (2) symptom attribution and appraisal; (3) the context used for interpreting the symptoms; and (4) disturbing affect and dependency needs. This therapy, or selected portions of it, can be employed in clinical work with patients individually and in groups, in consultation work, and in more traditional psychotherapeutic settings.

Functional somatic symptoms and hypochondriasis among general practice patients: a pilot study

Within a sample of 78 general practice patients, 13 patients were diagnosed as having functional somatic symptoms (FSS). In eight of these 13 patients, the FSS were associated with hypochondriasis, as indicated through a screening instrument (the Whitely index). In the remaining five patients, the FSS were associated with various other basic problems. Different subtypes of hypochondriasis with clinical relevance could be identified among the hypochondriac FSS patients. During a 3-year follow-up period, the FSS patients with hypochondriasis demonstrated considerably elevated general practice clinic utilization, compared with FSS patients without hypochondriasis. One of the FSS patients developed a serious physical disease during the follow-up period.

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.

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.

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.

Somatic symptoms. A major feature of depression in a family practice

The complaints of depressed patients were investigated in a private, single-physician family practice clinic. Complaints and visits of depressives were compared to those of age- and sex-matched non-depressed controls over a period of 3 years beginning 18 months prior to the diagnosis of depression. Pain, functional and anxiety complaints signalled the onset and paralleled the course of depression. Somatic complaints were a conspicuous mode of presentation in this family practice. These somatic features are not among the usual diagnostic and research criteria for depression (DSM-III, Feighner Criteria and RDC) although they appear to be a major feature in the natural history of depression.

Psychiatric treatment of chronic somitizing patients: a pilot study

Somatization is a very common condition although these patients are usually seen by general medical practitioners rather than mental health professionals. In a pilot demonstration study, chronic somatizers were significantly improved in a group psychotherapy treatment modality. The somatization was ameliorated and their functioning was significantly improved. Our findings strongly suggest that these patients should be clearly conceptualized as psychiatric and would respond well to traditional psychiatric treatment modalities.