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omatization disorder, alsotermed Briquets syndrome,is a distinct clinical andepidemiological condi-

tion that lies in the borderlandbetween clinical medicine andpsychiatry.1 Primary care pro-viders may intuitively recognizepatients with somatization disor-der and may earnestly wish torefer them to other physiciansbecause of the overwhelmingfeelings of dread that thesepatients evoke with their multi-ple medical complaints.2

Patients with somatization disorder usually presentwith numerous symptoms, such as headaches, back

pain, persistent lack of sleep, stomach upset, andchronic tiredness, all without demonstrable medicalcauses.3 Patients with somatization disorder have a per-sistent conviction of being ill, despite repeated nega-tive results on laboratory tests, diagnostic tests, consul-tations with specialists, and recurrent hospitalizations.Patients with somatization disorder continue to seekmedical care, take several medications, and submit toneedless diagnostic and surgical procedures. By thetime these patients reach middle age, they may haveundergone an average of 10 operations and acquiredseveral volumes of medical records.13

Because patients with somatization disorder feel ill

most of their lives and complain of multiple body ail-ments, these patients consume nearly half of theirphysicians time.3 With the mounting pressure to con-tain health care costs, primary care providers need acomprehensive approach to guide their clinical man-agement of patients with somatization disorder. Thisarticle reviews the epidemiology, clinical features, diag-nostic evaluation, and treatment of somatization disor-der in the primary care setting.

EPIDEMIOLOGYThe lifetime prevalence of

somatization disorder rangesfrom 0.2% to 2% among wo-

men and is less than 0.2% inmen.4The disorder usually be-gins in the teenage and youngadulthood years. Onset afterthe age of 30 years is extremelyrare.5 Somatization disorderseems to be more common inless educated and lower socioe-conomic groups.6The disorderis observed in 10% to 20% offemale first-degree relatives of

women with the disorder.4,7The male relatives ofwomen with somatization disorder have an increased

risk of antisocial personality, substance abuse disorders,and somatization disorder.4,5 A biologic or adoptiveparent with antisocial personality, substance abuse dis-orders, or somatization disorder also increases therelated patients risk of developing any or all of thesedisorders,4 thus suggesting that the combination ofboth environmental and genetic factors contributes tothe risk of developing these conditions.4,5

An estimated 25% to 75% of patients presentingwith somatization disorder to primary care providersmay have this disorder resulting from psychological dis-tress.8 Compared with patients without the disorder,patients with somatization disorder are found to have asix-times higher rate of hospital expenses, a 14-timeshigher rate of ambulatory care visits, and a nine-times

S

Dr. Khouzamis Staff Psychiatrist, Veterans Administration Medical

Center, Manchester, NH; Adjunct AssociateProfessor of Psychiatry,

Dartmouth Medical School, Lebanon, NH; and Clinical Instructor in

Medicine, Harvard Medical School, Boston, MA. Ms. Field is a nurse

practitioner, Primary Careand Womens Health, Veterans Administra-

tion Medical Center, Manchester.

20 Hospital Physician April 1999

P r act i ce S t ra tegi es

Somatization Disorder: Clinical Presentation

and Treatment in Primary CareHani Raoul Khouzam, MD, MPH

Susan Field, RNC, MSN, ARNP


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higher rate of total health care costs.7,9A typical patientwith somatization disorder spends an average of 7 daysper month sick in bed compared to 0.48 day for apatient without the disorder.2,5,9

CLINICAL FEATURES

Patients with somatization disorder have the tenden-cy to react to psychosocial distress and environmentalstressors with physical bodily symptoms.8,10Their com-plaints are usually centered on cardiovascular, gastroin-testinal, respiratory, skin, and other organ systems thathave a strong autonomic nervous system mediation.10,11

Table 1summarizes the common symptoms associatedwith somatization disorder.10

Patients with somatization disorder can be vague anddramatic in reporting their medical history.10Thesepatients frequently move abruptly from complaining of

one symptom to another symptom and subsequentlycomplicate the task of isolating one medical problem ata time, rendering the office visit an arduous and frustrat-ing task for the physician.5,6Often, the only reliable con-clusion that is reached during the initial assessment of apatient with somatization disorder is that, objectively, thereview of systems is grossly and diffusely normal.1,10

Physical examination may reveal some skin lesions orscars that resulted from previously performed surgeries;however, these minor abnormalities do not account forthe magnitude of the patients complaints.11

For a patient with somatization disorder, the demandfor attention extends beyond the medical setting to the

patients family life and professional career; as a result ofthis demand, personal relationships are sacrificed andvocational occupations are relinquished.5,10 Somati-zation disorder affects the patients perception of well-ness, and the patient begins to believe that she or he isphysically disabled and unable to work. Even if a suitable

job is found, frequent sick leaves lead to an eventual lossof employment. The crippling burden of medical ex-penses and the possible complications of unnecessarysurgical and diagnostic procedures may further magnifythe psychosocial distress and reinforce the feelings ofdiscomfort and disability, thus prolonging the course ofsomatization disorder and leading to a more chronic

and refractory condition.10,12

Patients with somatization disorder tend to obtaincare from multiple providers, to fail to keep scheduledappointments, and to use medical services in maladap-tive and inefficient ways.11 Convinced that their illnessesare medically based, patients with somatization disordercharacteristically deny the influences of psychosocialdistress in producing the symptoms of their disorderand resist psychiatric referral.11,12These patients are

often refractory to conservative, palliative, and support-ive management.12,13

Outcome of the Office Visit

Patients with somatization disorder do not feelrelieved by hearing a physicians statements such asNothing is wrong or You are fine and healthy. To the

contrary, these patients may become resentful, disap-pointed, and frustrated when told by physicians thatthey are not clinically ill. Some patients may evenexpress anger and dissatisfaction with the physiciansmedical assessment and may demand further diagnosticprocedures, ranging from routine laboratory tests, radi-ographic studies, and electrocardiographic studies tocomputed tomography, magnetic resonance imaging,endoscopy, and exploratory surgery.5,10Unconvinced by

K houzam & F i el d : Somat i za t i on D i sorder : pp. 20 24 , 45

Hospital Physician April 1999 21

Table 1.Common Symptoms Associated withSomatization Disorder

Generalized symptoms

Abdominal pain that is vague and nonfocal

Arthralgia

Backache

Chest pain that is nonspecific

Chronic tiredness

Headache

Gastrointestinal symptoms

Chronic bloating

Constipation

Diarrhea

Food intolerance to multiple foods

NauseaRectal pain

Vomiting

Genitourinary symptoms

Erectile dysfunction,ejaculatory disturbance,and impotence

Decreased libido

Dyspareunia

Dysuria

Menses that is painful,irregular,and heavy

Vomiting that is prolonged or frequent during pregnancy

Data from Cassem NH, Barsky AJ:Functional somatic symptoms and

somatoform disorder. In Handbook of General Hospital Psychiatry.

Cassem NH, ed. St. Louis:Mosby-Year Book, 1991:131157, and

Moore DP, Jefferson JW: Handbook of Medical Psychiatry. St. Louis:

Mosby-Year Book,1996:198200.


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the negative findings of these tests, patients with somati-zation disorder eventually fire the exasperated physi-cian and then move on to another physician.3,10The dif-ficult and challenging clinical features of somatizationdisorder require appropriate diagnosis and manage-ment if the patient, the primary care provider, and thehealth care delivery system are to benefit.5,11,13,14

DIAGNOSIS AND ASSESSMENT

The diagnosis of somatization disorder can be estab-lished using the Diagnostic and Statistical Manual of

Mental Disorders, Fourth Edition (DSM-IV)diagnostic crite-ria.4 Some of these criteria are summarized in Table 2.

The mnemonic Somatization Disorder Besets LadiesAnd Vexes Physicians, as outlined in Table 3, can beused as an adjunctive screening tool.

The diagnosis of somatization disorder may influencethe response of primary care providers to patients withthe disorder; therefore, it is important for physicians toexclude other medical and psychiatric conditions when

the patient presents with a new complaint.4,5,11The fea-tures that suggest the diagnosis of somatization disorderrather than a general medical condition include theinvolvement of multiple organ systems, the early onsetof disease with a chronic course of illness in the absenceof physical signs or structural abnormalities, and theabsence of laboratory abnormalities that characterizethe suggested general medical condition.4

Differential Diagnosis

General medical conditions.The physician mustrule out general medical conditions such as systemiclupus erythematosus, multiple sclerosis, sarcoidosis,and several other medical disorders that may all pro-duce many physical symptoms.l4Thus, a thoroughmedical examination with scheduled follow-up ap-pointments is always indicated in establishing the dif-ferential diagnosis in somatization disorder.5,10

Hypochondriasis.Somatization disorder differs fromhypochondriasis by the fact that the patients withhypochondriasis are not extremely concerned with

their illness and associated symptoms, but instead areconcerned with the implications of such illnesses.4,10

Patients with hypochondriasis interpret their symptomsas manifestation of a terrible and as yet undiagnoseddisease, and these patients will doctor shop until anaggressive diagnostician is found.l0 In contrast, patientswith somatization disorder are usually content with theprimary care providers who forego diagnostic measuresin favor of numerous symptomatic treatments.l0,12



Table 2.Diagnostic Criteria for Somatization Disorder

A.History of physical complaints lasting for several years andbeginning before age 30 years,resulting in the request fortreatment or leading to a significant impairment in social,

occupational,and other types of functioningB.The following four criteria must be met,with individual

symptoms occurring at any time

1.History of pain related to at least four sites orfunctions

2.History of at least two gastrointestinal symptomsother than pain

3.History of at least one sexual or reproductivesymptom other than pain

4.History of at least one symptom or deficit suggesting a

neurologic condition not related to pain

C.One of the two following criteria must be met

1.Symptoms in B cannot be explained by a medical con-dition,the effects of medication,or substance abuse

2.In the case of the presence of a medical condition,thephysical complaint or the resulting social or occupa-tional impairment is in excess of what would beexpected from the history,physical examination,orlaboratory findings

D.Somatization symptoms are not intentionally produced orfeigned

Adapted with permission from American Psychiatric Association:

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

(DSM-IV).Washington,DC:American Psychiatric Association,1994.

Table 3.Mnemonic for Use as a Screening Test forSomatization*

Somatization Disorder Besets LadiesAndVexes Physicians

Somatization Shortness of breath during restDisorder Dysmenorrhea

Besets Burning pain in sexual organs orrectum unrelated to sexualintercourse

Ladies Lump in throat

And Amnesia

Vexes Vomiting

Physicians Pain in extremities

* A positive response to two or more symptoms suggests a need for

a complete review of systems.

Adapted with permission from Othmer E, DeSouza C:A screeningtest for somatization disorder (hysteria). Am J Psychiatry 1985;142:

11461149.


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Conversion disorder and malingering. A patientwith conversion disorder presents with a relativelysmall number of symptoms that generally originatefrom one organ system, typically the central nervoussystem.l0 Other disorders not to be confused with soma-tization disorder are malingering and factitious disor-ders, which involve the conscious simulation of illnessin order to consciously manipulate or control others.

The patient with somatization disorder is truthfullyreporting her or his bodily experience and is not con-sciously manipulating or controlling others.11

Psychiatric illnesses. Psychiatric illnesses included inthe differential diagnosis for somatization disorder areschizophrenia, panic disorder, generalized anxiety dis-order, and depressive disorders.

Schizophrenia with multiplesomatic delusions. Schizo-phrenia with multiple somatic delusions must be differ-

entiated from the non-delusional symptoms of somati-zation disorder. In rare cases, somatization disorderand schizophrenia may coexist.

Panic disorder. Although it is difficult to distinguishmultiple somatic symptoms associated with panic disor-der from symptoms of somatization disorder, usually thesymptoms associated with panic disorder occur duringan episode of panic attack. If somatic symptoms occur inthe absence of a panic attack, this finding could suggestcomorbid panic disorder and somatization disorder.

Generalized anxiety disorder. In the case of somaticsymptoms associated with a generalized anxiety disor-der, the patients symptoms include excessive worry

and anxiety that are not just limited to the physicalcomplaints of the patient.4

Depressivedisorders. Although depressive disordersmay coexist with somatization disorder, the somaticcomplaints of depressive disorders are usually associat-ed with the episodes of depressed mood. In somatiza-tion disorder, the physical complaints persist even inthe absence of an underlying depressed mood.4

Sequelae of surgery. In patients with somatizationdisorder who have had multiple surgeries, primary carephysicians must identify new symptoms that develop asa result of surgery. These symptoms must be differenti-ated from complaints of somatization disorder.10,14

Comprehensive Assessment

A comprehensive assessment of the patient is anessential component of the diagnostic evaluation of som-atization disorder. Such an assessment should be con-ducted on an ongoing basis and involves a careful evalua-tion of the somatic symptoms in the context of thepatients psychosocial and cultural concerns.l,2Evaluatingfamily relationships may reveal the role that the patients

various somatic complaints play among family membersin gaining attention, seeking avoidance of responsibility,and coping with losses. Patients with somatization disor-der often have a history of inadequate coping withpainful interpersonal relationships and frequent butunsatisfying encounters with health care providers.1517

History of physical, sexual, and substance abuse must beassessed to determine the impact of these conditions onthe initial clinical presentation of somatization.15Thepossible areas of stress in the patients life must beassessed despite the absence of such a complaint. Forexample, a recent death, a loss, or a major social changemay all contribute to the symptoms of somatizationdespite the patients denial of concern about such stress-ful events.16 Exploration of the social, cultural, and spiri-tual beliefs of patients and their families must also beincluded in the assessment of somatization disorder.4,17

Such an assessment may determine the extent of howsomatic complaints are rewarded, neglected, or criticizedwithin the patients sociocultural and spiritual context.17

MANAGEMENT AND TREATMENT

Somatization disorder is a lifelong condition; thus, themanagement of patients with this disorder may be anarduous clinical endeavor.1l Most studies have deter-mined that the management of patients with somatiza-tion disorder is best handled by primary care physiciansrather than psychiatrists.l,9,13,18 Examination of the med-ical records of patients with somatization disorder revealsthat these patients resist psychiatric evaluation and resent

psychiatric referral by primary care providers.l,2,9,13A conservative treatment plan that primary care

physicians can implement includes the following steps:

1) Establishing and developing a trusting patient-physician relationship with the same primarycare physician2

2) Scheduling regular check-ups every 4 to6 weeks, even if the patient is doing well2,19

3) Conducting regular physical examinations dur-ing the regularly scheduled appointments andproviding support with empathy2,5

4) Avoiding further diagnostic evaluations or ag-gressive treatments unless physical examinationreveals new objective evidence of disease2,14

5) Gradually shifting the emphasis from listening tocomplaints of somatization to eliciting and listen-ing to information about psychosocial stressors1,2,5

6) Avoiding statements such as Its all in yourhead or There is nothing physically wrongwith you2,5,10




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In a randomized controlled clinical trial, the implemen-tation of these management strategies and treatmentplan reduced the quarterly health costs of patients withsomatization disorder by 53% without adversely affect-ing patient satisfaction with their health care.2,11,19

The essential goal of managing somatization disorderis to assist patients in coping with their symptoms ratherthan attempting to eliminate the symptoms with aggres-sive treatments.1618 Prescribing psychotropic medica-tions or analgesic agents can be helpful unless underly-ing, clearly diagnosed, comorbid medical and/ orpsychiatric conditions are present.2 If a comorbid majordepressive disorder is present, antidepressant medica-tion may be indicated; however, care must be exercisedto choose an antidepressant with few side effects to pre-vent the exacerbation of more somatic complaints.10,16

When treating a patient with somatization disorder and

comorbid panic disorder or generalized anxiety disor-der, potentially addicting medications should be avoidedif the patient also has a substance abuse disorder.5,10,14

Individual psychotherapy does not appear to beeffective in treating somatization disorder unless the ill-ness coexists with other psychiatric disorders such asdepressive disorders, panic disorder, and anxiety disor-ders.2,5 Psychotherapy aimed at uncovering hidden orunidentified emotional conflicts is likely to be counter-productive.l0 Consistent supportive inquiry into theareas of stress in the patients life and family life couldalso provide an avenue to monitor the patients contactwith other medical providers. Such a monitoring could

prevent the unnecessary diagnostic procedures andprescription medications from other physicians whomthe patient may contact.2,19

A supportive, practical, and common sense treat-ment approach by primary care physicians that focuseson palliative care rather than outright medical care canslowly move patients from their somatic preoccupationtoward the more rewarding attention to their multiplepsychosocial and personal problems.l0

CONCLUSION

Although no definite cure has been found for somati-zation disorder, a careful and comprehensive assessment

of the patients complaint(s) is an essential componentof the evaluation process. Primary care providers canplay a key role in identifying patients with somatizationdisorder and helping them avoid extensive diagnosticevaluations and unnecessary treatments. Knowledge ofthe epidemiology, clinical features, diagnostic evalua-tion, and management of patients with somatization dis-order enables primary care providers to clinically inter-

vene in a timely manner. Consultation with psychiatristsmay be considered in complicated cases with comorbidpsychiatric disorders. HP

REFERENCES

1. Escobar JI, Waitzkin HN, Silver RC, et al: Abridged som-atization: a study in primary care. PsychosomMed 1998;60: 466472.

2. Escobar JI, Golding JM, Hough RL, et al: Somatization

in the community: relationship to disability and use ofservices.AmJ Public Health1987;77:837840.

3. McCahill ME: Focus on the somataform disorders.Hospital Practice1995;30(2):5966.

4. American Psychiatric Association:Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition (DSM-IV).Washington, DC: American Psychiatric Association, 1994.

5. Cassem NH, Barsky AJ: Functional somatic symptomsand somatoform disorder. In Handbook of General

Hospital Psychiatry. Cassem NH, ed. St. Louis: Mosby-YearBook, 1991:131157.

6. Othmer E, DeSouza C: A screening test for somatizationdisorder (hysteria). AmJ Psychiatry1985;142: 11461149.

7. Zocolillo MS, Cloninger CR: Excess medical care ofwomen with somatization disorder. South Med J 1986;79:532535.

8. Katon W, Ries RK, Kleinman A: The prevalence of soma-tization in primary care. Comprehensive Psychiatry1984;25:208-215.

9. deGrug F, Columbia L, Dickinson P: Somatization disor-der in a family practice.J FamPract1987;25:4551.

10. Moore DP, Jefferson JW: Handbook of Medical Psychiatry.St. Louis: Mosby-Year Book, 1996: 198200.

11. Barsky AJ, Borus JF: Somatization and medicalization inthe era of managed care.JAMA1995;274:19311934.

12. Escobar JI, Burnham A, Karno M, et al: Somatization inthe community.Arch Gen Psychiatry. 1987;44:713718.

13. van Dulmen AM, Fennis JF, Mokkink HG, Bleijenberg G:The relationship between complaint-related cognitionsin referred patients with irritable bowel syndrome andsubsequent health care seeking behaviour in primarycare.FamPract1996;13:1217.

14. Cloninger CR: Somatization and dissociative disorder. In

TheMedical Basis of Psychiatry, 2nd ed. Winokur G,Clayton PJ, eds. Philadelphia: WB Saunders, 1994:169192.

15. Morriss R, Gask L, Ronalds C, et al: Cost-effectiveness of

a new treatment for somatized mental disorder taughtto GPs.FamPract1998;15:119125.

16. McLeod CC, Budd MA, McClelland DC: Treatment ofsomatization in primary care. Gen Hosp Psychiatry1997;19:251258.

17. Kashner TM, Rost K, Cohen B, et al: Enhancing thehealth of somatization disorder patients. Effectiveness ofshort-term group therapy. Psychosomatics1995;36:462470.



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18. Kismayer LJ, Robbins JM:Current Concepts of Somatization:Research and Clinical Perspectives. Washington: AmericanPsychiatric Press, 1991.

19. Roberts SJ: Somatization in primary care. The commonpresentation of psychosocial problems through physical

complaints. NursePract1994;19:47, 5056.

ACKNOWLEDGMENT

The authors wish to thank Paul E. Emery, MD, for hishelpful suggestions and Nancy J. Donnelly, MS, RN, CNS,for her literature search, Veterans Administration Medical

Center, Department of Mental Health, Manchester, NH.


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Copyright1999 by Turner White Communications Inc., Wayne, PA. All rights reserved.

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