the prevalence of somatization in primary care

7/27/2019 The Prevalence of Somatization in Primary Care

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The Prevalence of Somatization in Primary CareWayne Katon, Richard K. Ries, and Arthur Kleinman

ABSTRACTThe authors define somatization as an idiom of distress in which patients with psychosocial andemotional problems articulate their distress primarily through physical symptomatology. Studiesare then reviewed to demonstrate the inordinate amount of time and energy these patients costthe health care practitioner as well as the frequency of misdiagnosis. latrogenic harm is a commonproblem in somatizing patients due to unnecessary tests, hospitalizations, surgeries as well asthe development of chronic illness behavior. It is essential that psychiatrists working in consultation-liaison begin to develop research in the area of somatization especially at the primary care level.

A LTHOUGH several studies have described the diagnoses of patients referredto a psychiatric consultation service in a general hospital,i,2 none have spe-cifically reported the psychiatric diagnoses of patients who somatize, i.e., patientswith psychosocial distress and emotional problems who articulate their distressprimarily through physical symptomatology. These patients either do not havediscernable organic pathology or amplify their verifiable physiologic changes. Theyhave been shown to be high frequency utilizers of physician services3 and, whensomatization is part of chronic medical disorders, to represent a major challengefor health care systems worldwide.4

Few descriptivestudies have focused on the somatizing patient yet these patientstake up an inordinate amount of time and energy of the medical practitioner aswell as a disproportionate share of the health care dollar. Collyers study of so-matizing patients in his primary care practice revealed that 28% of his patientcontacts involved emotional illness and that these consultations took up 48% ofthe physicians time. Overall, 3.6% of the families in his general practice accountedfor 32% of his time. Nearly all of these high use families had one member diagnosedas depressed and often several family members were presenting to the physicianwith vague somatic complaints. Regier has shown that 60% of patients with mentalillness are being seen by primary care physician9 and Hankin and Oktay havedemonstrated that patients with psychiatric diagnoses tend to utilize more thantwo to four times as much non-psychiatric medical care. Goldberg reported in alarge English primary care population that over 50% of the patients with psychiatricproblems presented initially with somatic complaints.*

Widmers studies of primary care patients revealed that in the 7 months priorto 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 increasedincidence of hospitalizations, and (3) an increased number of presenting complaintsof three types: (a) ill-defined functional complaints, (b) pain of undetermined etiol-ogy in a wide variety of sites such as the head, chest, abdomen, and extremities,

From the Di vi sion f Consult ati on-Li aison Psychiat ry, Department of Psychiat ry and Behavi oral Sciences,Uni versit y of Washington: and the Har vard M edical School and The Cambri dge Hospit al.

Address reprint requests to Way ne Kat on, M .D., Dept. of Psychiatr y, RP-I O, Uni versit y of Washington,Seat t le, Washingt on 98195.@ I 984 by Grune & St rat ton, I nc. 0010-440X/84/2502-09$01.00/0

208 Comprehensive Psychiatry , Vol. 25, No. 2, (March/April) 1984


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SOMATIZATION IN PRIMARY CARE 209

(c) and nervous complaints, mainly increased tension and feelings of anxiety.,Widmer also demonstrated that family members of these depressed patients alsohad ill-defined somatic complaints and increased visits to the clinic in the sametime period. Once the depressed patients affective illness was successfully treatedboth the patient and his familys clinic visits decreased to baseline levels. Sheehanfound, in a study of agoraphobic patients who suffered from panic attacks, that70% of the patients had visited more than ten different physicians with somaticcomplaints before they received accurate diagnosis and treatment.? Overall. itappears that 25% to 75% of patient visits to primary care physicians are primarilydue to psychosocial distress but patients usually present with somatic complaints.Is In fact, studies from health maintenance organizations like Kaiser-Permanentehave revealed that as many as 60% of primary care patients recurrently presentwith 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-termpsychotherapy their pattern of overutilization of primary care physicians decreasedsignificantly.6,x In a review of these health maintenance organization studies. Cum-mings concluded that the failure to provide mental health services has the potentialof bankrupting the health care financing system due to the overutilization of primarycare physicians by somatizing patients.

From another perspective, many patients who do visit physicians regularly arewithout serious medical illness. Analyses of the content of general medical practicehave 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 themost common single diagnosis in general practice is nonsickness.? Ten to 60; ofpatients with each of the five most common medical complaints have been foundwithout 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 malinger-ing.lj It is also encountered in psychophysiologic disorders, and as a coping responseto stressful life events. But oscilations between amplification and damping of symp-toms occur routinely in chronic medical disorders, in which somatization owing topsychosocial and cultural contexts is a common source of clinical managementproblems.

The most common form of somatization in American society is the chronic painsyndrome-defined as affecting an individual when he or she has suffered morethan 6 months of pain in one or several bodily sites of a disabling kind thatsignificantly interferes with life activities. In 1980. more than 10 billion dollarswere spent on disability payments to American patients with chronic pamproblems13 and disability payments for US postal employees with low-back painalone amounted to 0.8 cents of each 20 cent stamp purchased.Zh

Among traditionally oriented ethnic patients, members of fundamentalist reli-gious sects that disparage the undisguised presentation of negative emotions, andworking class patients, somatization may provide a culturally sanctioned idiom forexpressing personal and interpersonal distress of many types as well as a sociallyeffective means of manipulating limited sources of social power and influencing


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210 KATON, RIES, AND KLEINMAN

maldistribution of available resources. 4~27n interpersonal relationships somatizationis often used out-of-awareness to elicit social support, to avoid intimacy, to expressanger, or to avoid anxiety provoking situations. It is not necessarily maladaptivein that in many families and cultures it is routinely employed as an idiom of distressand may lead to beneficial changes in the family (increased attention, nurturance,or support) or in the community. 28 In the biomedically oriented Western culture,however, it often becomes maladaptive when the somatizing patient interacts withthe medical profession because patients are often diagnosed and treated exclusivelysymptomatically through a biomedical lens. 29 Unnecessary laboratory tests, clinicvisits, hospitalizations, and even surgeries frequently result. Effective handling ofpersonal and interpersonal problems may therefore be delayed and obstructed.Also, what may have started as somatization of a psychiatric disorder or socialstress may develop into a permanent iatrogenically caused physical disability suchas a spinal fusion and distortion from repeated operations for low back pain.

Once somatic symptoms develop, whether secondary to psychological, social orbiomedical problems, there are psychological and social consequences of illness.The patients somatic symptoms can have an effect on family homeostasis, voca-tional adjustment, the patients social network (friends, church) as well as thepatients coping mechanisms. 3oThe patients perception and attribution of a somaticsymptom or group of symptoms is not developed in a vacuum but in the pluralcontexts of his current social environment. People are continually influenced byfeedback from the settings in which they live. Thus a persons perception andcognitive mechanisms are not just the result of past familial, cultural and inter-personal experiences but are due to interpersonal interactions and institutional rolesin the present as well. 3i The psychological unit is not the individual person but theperson within his significant social contexts. This systems model requires the ob-servation of how and to what extent interpersonal transactions and social rolesgovern the patients range of behavior.

The patients perception of his symptoms can be visualized on a continuumbetween amplification and damping. The social systems may reinforce illness be-havior and thus amplification of symptoms by beneficial changes in family structure,disability payments, attention from the medical care system as well as psychoactivemedication that provides a degree of symptom relief. These reinforcers may becomeillness maintenance systems such that somatic symptoms that were initially eitherdue to organic disease or the somatization of psychosocial distress now continueas illness behavior although the physiologic changes of disease or the psychosocialdistress have disappeared. Several studies validate this hypothesis.

Miller determined from his study of insurance actuarial data that persons withthe same type of injury or illness but different disability policies react quite dif-ferently.32 The data from 13 companies were examined covering 138,795 disabilityclaims in which two categories of policies were compared; the first granting benefitsafter an injury primarily for two years and the second to age 65. The study indicatedthat as many as 25% of the persons disabled at least 1 year in the first grouprecovered who would still be asserting their claim for continuous disability benefitsif insured under a long-term or unlimited benefit plan. Hirschfeld et al33 McBride,34and Weinstein35 in three separate reviews have also documented that the disabilitysystem provides strong social reinforcements that seem to prevent recovery fromthe original disease or injury resulting in chronic disabling illness behavior.


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Family therapists have often described some families extreme resistence to changeonce a new system of functioning has been set up, even systems that seem de-monstrably maladaptive to outside observers. Minuchin has published extensivelyon his studies of psychosomatic families in which amplification of a chronic illnesssuch as diabetes mellitus or asthma or the development of anorexia nervosa stabilizesa precarious family equilibrium at the expense of the identified patient. Fordyce3and Hudgens have also shown that family reinforcements, i.e., increased attentionor nurturance, of somatized or actual chronic pain may subsequently bring thepain under operant control such that pain behavior continues in the absence ofphysiologic pain. Both authors mention the social efficacy of the chronic pain infamily interactions as a mechanism to control and manipulate others, justify de-pendency, earn rest, avoid sex, gain attention, punish others, control anger andavoid close relationships.The medical care system also reinforces somatization. Engel has pointed out thatphysicians armed with extensive training in the biomedical model do not evaluatethe psychosocial stress that often underlies somatic complaints. Physicians, byvirtue of their training that is highly technologic, are somatizers. That is, physicianspreferentially look for and treat somatic complaints. The effect on the patientsperception of their illness of the physicians narrow somatic model is that hypo-chondriacal patterns are reinforced by medical concern and substantial workups.The longer the patients perceive themselves to be somatically ill and the longer thephysician focuses on the somatic aspects of illness. the more likely is the patientto develop significant secondary gain for being ill and to accept the sick role as away of life. There is also the the danger of the medical care system becoming asocial support system in itself. In considering the social context of parasuicide aswell as hypochondriacal symptoms, Henderson postulated that there are substantialdeficiencies in the care-giving afforded such patients by others, giving rise to care-eliciting behavior to correct the deficiency in social support.H Balint has pointedout that a significant number of patients in general practice are searching for genuineinterest and empathy from the physician, not relief of physical symptoms. Thesymptoms then are the ticket of admission to see the physician.

Patient maladaptive coping mechanisms may also cause amplification of somaticsymptoms. Dirks et al, in a series of studies, found that two specific coping stylesof chronic asthmatic patients caused significantly higher hospitalization rates afterdischarge from intensive treatment, even among patient groups having similarobjective disease severity. 4o Dirks et al determined that the personality traits as-sociated with subsequent high utilization of health care resources in chronic asth-tnatic patients were reflected by either extremely high scores on the MMPI panic-fear personality scale or extremely low scores on this scale. Patients scoring ex-tremely high on the panic-fear scale were characterized as ambivalent, fearful,emotionally labile, dependent, felt helpless and pessimistic about their illness andoften hyperventillated during asthamatic distress. Patients with extremely low scoresdenied the presence of anxiety, claimed to be unusually calm and self-controlledand typically presented in a rigid, counter-dependent manner.

If somatization is so prevalent in medical care, why have so few studies beer1conducted to ascertain the psychiatric characteristics of these patients? Part of theproblem is that psychiatric nosology has been developed in a partial vacuum fromthe 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 asan illness in which most patients readily focus on their affective and cognitivesymptoms as well as their somatic complaints. Yet Weissman has shown that majordepression is present in 4.3% of the population of an East Coast city, but 66% ofthe patients with depression were not getting any specific treatment for their illness4Two-thirds of these unrecognized, untreated depressives made more than six visitsa year to their primary care physicians for somatic complaints (which was signif-icantly more visits than in the population who were not effected by depression).Thirty-four percent of these people with depression were treated with minor tran-quilizers, 17% were taking sleeping pills whereas only 17% were treated with an-tidepressants. The Weissman finding that patients with depression seek help andare undetected in nonpsychiatric medical settings is consistent with the recentfindings from several surveys of medical inpatient family practice and primarypractice settings in both the United States and Great Britain.42A* Misdiagnosis inmedical outpatients with depression has varied from 50% to 75% and in medicalinpatients as high as 96%.47

The Goldberg8 and Widmer9- studies reported above suggest that the lack ofdetection is due to the fact that patients who seek help for major depression inprimary care often focus on their somatic or vegetative symptoms and minimizeor deny affective and cognitive complaints. Primary care physicians are taughtpsychiatric nosology in psychiatric settings where by and large patients are quiteaware of psychological precipitants and symptoms. They have little training indiagnosing emotional illness in patients who present somatically, i.e., with fatigue,headaches. However patients with emotional illness are utilizing more of their careand timesI7 and often eventually do get labeled nonspecifically as hypochondriacs(or at times pejoratively as crocks or turkeys). This is especially unfortunatebecause major depression has been demonstrated by structured psychiatric interviewto have a prevalence of 5.8% in primary care48 making it the most common overallpsychiatric or medical diagnosis. Hypertension is next at 5.7%. There are also highlyeffective pharmacological treatments for depression.

The term masked depression in psychiatric literature has been used to definepatients who presented with somatic symptoms of depression but minimized ordenied affective and cognitive symptoms. Masked depression has been considereda relatively rare, unusual presentation of depression but in primary care it appearsto be as frequent as depression presenting psychologically.5.7

Thus one of the problems in studying somatization has been the lack of researchdescribing the prevalence, incidence and phenomenology of DSM-III type diagnosesamong primary care patients. Many questionnaire studies utilizing scales like theGHQ, Hopkins checklist, Beck and Zung Depression Rating Scales have demon-strated very high rates of mental illness in primary care.47 Hoeper conducted theonly psychiatric structured interview (SADS) study in primary care and found a26.8% 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 hasfive vegetative and cognitive symptoms.

Another of the major problems in the study of somatization is to define the termso 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 andtreatment are needed despite repeated examinations and laboratory tests with nor-mal results or reassurances from the physician.49

This term has the unfortunate connotation of implying a Cartesian dichotomyto patient symptoms such that the patient complaints are considered to be eitherorganic or psychological. We prefer the broader term of somatization because ofits fit with the biopsychosocial model in which the patients symptoms are consideredidioms of distress in the biological, psychological and/or social parts of the patientslife. Further, patients with chronic medical illness have oscillations of their illnessbetween amplification and damping due to biological, psychological and/or socialstressors. The job of the physician is to weigh each of these factors in determininga diagnosis. In fact the most difficult somatizing patients for primary care physiciansare patients with verifiable organic disease who amplify their symptoms; the phy-sician is trained to react with a biomedical focus in these patients due to the anxietyof missing a physical illness.

CONCLUSIONOur 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 describedabove patients with psychiatric disorders often present somatically (they have beenlabeled the hidden psychiatric morbidity of primary care? and are misdiagnosedand often eventually labeled as hypochondriacs. Studies need to be conducted todescribe the DSM-III psychiatric diagnoses of these patients and our intent in partII will be to present the results of a prospective data based study of IO0 consecutivepsychiatric consultation patients referred from the medical wards because eitherno physiologic pathology was found to explain their somatic complaints or thephysiologic pathology found did not match the extent of complaints. Based on thisstudy a new conceptualization of somatization will be explicated.

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the prevalence of somatization in primary care

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