MARK W. KETTERER, PHD CHARLES D. BUCKHOLTZ, no
Somatization disorder (SD) is full complexity of human pathophysiology, as oc- a syndromatic classification that allows a curred prior to the late 1800s.8 physician to identify more easily patients Unfortunately, the same set of beliefs can blind with a lifelong history of chronic subjective practitioners to the role of psychologic processes physical complaints that are unverified by in generating complaints of physical symptoms. objective examinations either at the time of One set of disorders that often confuses mind-brain/ initial presentation or during the body relationships for the primary care physician subsequent five years. The somaticizing are the somatoform disorders. process is believed to be an expression of A patient who chronically reports one or more emotional distress. The most common subjective physical symptoms that cannot be veri- complaints of SD patients include recurrent fied by objective evidence has a somatoform disor- pain (site and quality vary), conversion der. This category includes conversion disorder, so- (pseudoneurologic) symptoms, nervousness matoform pain disorder, hypochondriasis, body or depression (or both), sexual and marital dysmorphic disorder, and somatization disorder.9 discord, and, often, menstrual difficulties. The term somatoform suggests that the patient s Such patients will generally have a history illness has the appearance (or form) of a physical of repeated hospitalization or surgery. disorder. However, the common feature of somato- These symptoms are not perceived as mild form disorders is that there is no demonstrable evi- or unimportant but lead to physician dence of organic dysfunction or no known physi- consultation, prescription drug use, and ologic mechanism for explaining the patient s symp- modification of life-style. Such patients are toms, and that there is a reasonable basis for pre- prone to "doctor-shopping" and self- suming causality by psychologic factors. medication and are at risk for many It must be remembered that unlike the factitious iatrogenic illnesses. Because they generally disorders or malingering, the production of symp- are resistant to psychologic explanations toms is not intentional or conscious. Yet the pro- for their condition, management aimed at duction of symptoms, upon close and detailed scru- protecting them from the consequences of tiny, almost always will appear to be controlled their behavior is important. A heightened or influenced by psychosocial consequences. threshold for instituting aggressive Although not generally classified as somatoform diagnostic and treatment procedures is disorders, traditional psychiatric syndromes, includ- necessary. ing depression and the anxiety disorders, fre- quently will be manifested as physical com- plaints1°,11 and, thus, they arguably can be so cate- Because of medicine s strong biologic orienta- gorized. This is because of the patient s denial (re- tion and its roots in Euro-American culture, dis- pression, suppression, or misattribution) of psycholo- orders that encompass the mind-brain/body dichot- gic problems, the automatization of cognitive and omy can be uniquely problematic in primary care behavioral coping strategies, 7 and the attendant settings.2-4 The mind-brain duality advocated by physical symptoms of these disorders (fatigue and Rene Descartes in the 17th century8,8 still domi- preoccupation with minor pains in depression, or nates the way most educated people conceptualize palpitations, dizziness, dyspnea, or diaphoresis in the relationship between psychologic events and panic attack). physiologic processes, despite powerful evidence The best understood of the somatoform disorders that psychologic phenomena are nothing more, or is somatization disorder (SD).12-14 less, than concomitants of CNS activity.? The Cartesian version of psychoneural relation- Thrminology ships has been heuristic in that it has allowed medi- Because the term hysteria has come to be applied cal science to take on manageable research and clini- to a personality style, 18,18 a personality disorder,9,17 cal tasks rather than being overwhelmed by the an acute emotional state, and a mental disorder,12
Clinical Practice • Ketterer and Buckholtz JAOA • Vol 89 • No 4 • April 1989 • 489 recent empiric studies have begun using more con- head"), and the unconsciously perceived conse- crete criteria and a different terminology to clar- quence (interpersonal confrontation) of acknowl- ify meaning. For example, the personality disor- edging the anger, sadness, or other emotion. der, which is characterized by overly dramatic, re- active, and intensely expressed behavior and dis- Natural history and course turbances in interpersonal relationships, now is The onset of chronic physical complaints and symp- termed "histrionic."9 The mental disorder has come toms generally occurs prior to age 30, most often to be known as Briquet s syndrome (after the phy- in the second decade of life. The course of the ill- sician who first described a polysymptomatic pa- ness generally is either chronic or intermittent. The tient with a complicated medical history who was disorder rarely remits spontaneously; careful his- not objectively ill 18) or SD. tory-taking will reveal that seldom does a year pass without the patient seeking some form of medical Epidemiology and demographics attention. In a severe case, the patient will be an The prevalence of SD among women in the United invalid and will squander her life in a preoccupa- States is 0.2% to 2%.9 Somatization disorder is tion with physicians, medications, and symptoms. rarely diagnosed in men. However, on the basis Psychosocial stressors often appear to be the pre- of one study, 19 SD was a frequent finding in a pri- cipitating event, despite the patient s denial of their mary care outpatient setting. The authors specu- relevance. Interestingly, the disorder does not ap- late that "...for the average physician, this diagno- pear to manifest in childhood. It is unknown sis could be made nearly every day that patients whether such patients display a propensity for are seen." school avoidance or other forms of secondary gain Available data indicate that SD is a familial dis- as children. order. First-degree female relatives of SD patients have a much higher rate of SD (about 10% to 20%) Signs and symptoms than would be expected in the general popula- SD is characterized by recurrent, multiple physi- tion.29-24 Additionally, male relatives of SD patients cal complaints that cannot be objectively verified have much higher rates of antisocial personality but that have led to physician consultation, use of disorder and psychoactive substance abuse than a prescription medication, modification of life-style seen in the general population.29-28 to accommodate the symptom, or a combination of these. While the list of symptoms SD patients will Etiology endorse is endless, most common are recurrent pain The presence of a familial factor in the background (although site and quality vary), conversion (pseu- of SD patients is consistent with both a genetic and doneurologic) symptoms, nervousness or depression environmental etiology. 26 As with the other soma- (or both), sexual and marital discord, and repeated toform disorders, it is presumed that unconscious hospitalization or surgery. secondary gain (the social consequences of being One early study28 listed the astonishing fre- ill, including decreased expectations of others for quency of various signs and symptoms in a group work and increased attention) plays a major role of SD patients (Table 1). A more recent study 29 re- in initiating and maintaining the symptomatic pic- ported that SD patients report more physical symp- ture. That is, patients unknowingly have learned toms than objectively ill patients (with chronic ob- to cope with their own emotional needs (attention, structive pulmonary disease or diabetes) while re- fatigue, loneliness, anger) by becoming "ill"27—a porting only slightly more psychologic symptoms strategy that they likely observed was used by their (Fig 1). mother, sister, aunt, or grandmother. Such a coping strategy allows an individual to Diagnosis obtain something they need without having to take Because of the vague and variable nature of pre- interpersonal responsibility for asking overtly. This sentation, the physician is likely to find history- strategy presumably is adaptive in an interpersonal taking a confusing process with SD patients. A environment with multiple antisocial, personality- straightforward, sequential history of a principal disordered men and multiple "sick" women.? complaint is almost impossible to obtain. Patients The patient, it must be emphasized, is unaware frequently will contradict themselves, and, if con- that her illnesses serve these psychosocial pur- fronted about such inconsistencies, they will con- poses, and she is highly resistant to any such sug- fabulate at least a marginally plausible explana- gestion. The resistance is assumed to be a product tion. of the unconscious nature of the psychologic mecha- In trying to reduce the confusion, many physi- nism,7 fear of stigmatization ("It s all in your cians latch onto a single symptom to guide treat-
490 • JAOA • Vol 89 • No 4 • April 1989 Clinical Practice • Ketterer and Buckholtz TABLE 1. FREQUENCY OF SIGNS AND SYMPTOMS ENDORSED BY SOMATIZATION DISORDER (SD) PATIENTS (ADAPTED FROM PERLEY AND GUZE 28). SD patients SD patients endorsing (%) Sign/symptom endorsing (%) Sign/symptom
92 Nervousness 44 Aphonia 88 Back pain Dysuria Sexual indifference 84 Joint pain Had to quit working because felt bad Extremity pain Dizziness 40 Always sickly (most of life) Fatigue 36 Other bodily pain Weakness Wanted to die 80 Headaches 32 Anesthesia Nausea Vomiting Abodominal pain 28 Lump in throat 72 Dyspnea Weight loss Trouble doing anything because felt bad Burning pains in rectum, vagina, or Chest pain mouth 68 Abdominal bloating Felt life was hopeless Thought of suicide 64 Visual blurring Anxiety attacks 24 Frigidity (absence of orgasm) Constipation 20 Blindness Depressed feelings Fits or convulsions 60 Palpitations Diarrhea Anorexia Vomiting all nine months of pregnancy Crying spells 16 Unconsciousness 56 Fainting Olfactory hallucination Sudden fluctuations in weight 52 Dyspareunia 12 Paralysis 48 Food intolerances Visual hallucination Dysmenorrhea ( other than during preg- Attempted suicide nancy or premarital) Menstrual irregularity 8 Amnesia Excessive menstrual bleeding Urinary retention Phobias Dysmenorrhea (pregnancy only) Thought of dying 4 Deafness Dysmenorrhea (premarital only)
123 General Population Physical Chronically Ill Functioning 1111 Somatization Disorder
Mental Health
0 10 20 30 40 50 60 70 80 90 100
Fig 1. Average mental health and physical functioning scores of 41 SD patients on the Rand Health Status Measures compared to general population norms and a medically ill ( chronic obstructive pulmonary disease and diabetes) sample ( data adapted from Smith and associates29). ment; at best, they are temporarily successful.30-32 testinal symptoms will predominate in the clinical An SD patient will "develop" symptoms in which picture; with a cardiologist, chest pain is a likely the physician shows most interest. For example, complaint. Such patients seem unconsciously, al- if the physician is a gastroenterologist, gastroin- though exquisitely, responsive to the physician s
Clinical Practice • Ketterer and Buckholtz JAOA • Vol 89 • No 4 • April 1989 • 495 nostic utility of SD, five-year follow-up of patients whose condition originally was diagnosed as con- 0 Hysteria 15 version or hysteric reactions revealed that 50% 0 0 later were found to have true medical illness, which probably caused the original symptomatic pic- ture.29,36 By using the original SD criteria,29,34-39
10 0 the probability of such an outcome is reduced to 10%12,35; that is, 90% of patients meeting the origi- nal criteria (82% of those meeting the DSM III cri- 0 Sick control subjects teria) will not have medical illness develop but will remain objectively healthy over the ensuing five 5 years. • ova. The original criteria s required 25 symptoms 4111111W spread across nine of ten body systems. The require- o Healthy control subjects ment for wide systemic spread was based originally 0 10 20 30 40 50 60 on the premise that any true physical disease, even Age in years 21.► if subclinical, most likely would be limited to one or a few systems. But reevaluation of the initial Fig 2. Frequency of operations for SD ( hysteria), medically ill, data has revealed that a higher degree of diagnos- and healthy control subjects as a function of age (data tic sensitivity is accomplished, with no real loss adapted from Cohen and coworkers33). of specificity, by requiring 13 positive symptoms and dropping the requirement of spread across body systems.9 Several checklists40 exist to aid the pri- mary care practitioner in diagnosing the somati- most subtle nonverbal communication of interest. zation disorder. But the currently accepted diag- A good standard question to ask oneself in un- nostic criteria are contained in Table 2.9 derstanding and managing such patients is: "Why The practitioner always must be alert to the pos- this complaint, and why now?" A thorough under- sibility of an organic cause for the patient s dis- standing of the patient s psychosocial history, in- comfort. Other psychologic disorders also must be terpersonal environment, and events temporally re- considered in the differential diagnosis. These in- lated to the onset of the latest symptoms will pro- clude, but are not limited to, anxiety disorders (es- vide the practitioner with the raw data on which pecially those characterized by recurrent panic at- a psychodynamic explanation can be constructed tacks), schizophrenia with multiple somatic delu- and predictions about the future course can be sions, conversion disorders, depression with so- based. matic presentation, and factitious disorder with Because of the physician s well-intentioned at- physical symptoms (Munchausen syndrome). tempts to help, the SD patient is at risk for recur- Two useful axioms for the practitioner to remem- rent multiple exploratory or "therapeutic" surger- ber are that no psychiatric sign or symptom is pa- ies.33 Many will develop "gridiron abdomen" from thognomonic of a psychiatric disorder, and that no the many surgical scars, and many undergo more physical sign or symptom is pathognomonic of a operations than verifiably ill patients (Fig 2). 33 (In medical disorder. The practitioner who can incor- the most dramatic case known to us, a 34-year-old porate these principles into his or her habitual way woman was evaluated at the request of a surgical of conceptualizing patients may prevent the incor- resident. She was undergoing a workup for her 14th rect treatment of medical illnesses as psychologic exploratory laparoscopy in 16 years. The sole rea- disorders and psychologic disorders as medical ail- son for the current laparoscopy was continued un- ments. explained abdominal pain. All laboratory and ra- diologic findings were normal. Consultation with Complications the attending surgeon and referring physician led Many of the most serious complications of SD are to cancellation of the operation. The physician re- iatrogenic. Aggressive, well-intended attempts of ported feeling pressured to "do something" with the multiple physicians to diagnose and treat various patient and therefore referred her for diagnostic symptoms places the patient at risk for the rou- surgery to "reassure" her.) tine complications of surgery (anesthetic-induced Somatization disorder has been demonstrated to sudden death, infection, adhesions) and abuse of be a unique and clinically useful nosologic cate- psychoactive substances (analgesics, soporifics, anx- gory.34•35 In the original studies testing the prog- iolytics, antidepressants). Data indicate that SD
496 • JAOA • Vol 89 • No 4 • April 1989 Clinical Practice • Ketterer and Buckholtz patients expend up to 14 times as much as the gen- TABLE 2. DIAGNOSTIC CRITERIA FOR SOMATIZATION DISORDER eral population on physician services and nine (ADAPTED FROM SPITZER 9). times as much on total health care.19 (A) A history of many physical complaints or a belief that one SD patients generally have chaotic work histo- is sickly, beginning before the age of 30 and persisting for ries45 because they differ with employers about several years. time off from work for bed rest and physician vis- (B) At least 13 symptoms from the list below. To count a its (an average of seven days a month are missed symptom, the following criteria must be met: No organic pathologic findings or, when there is related organic disease, for illness29), abuse of insurance coverage (aver- the complaint or resulting social or occupational impairment age medical bill of $4,700 per year"), and a lesser is grossly in excess of what would be expected from the phys- work load because of weakness, fatigue, and ill- ical findings; the symptom has not occurred only during a panic attack; and the symptom has caused the patient to take ness. Similar conflicts will arise with spouses and medicine (other than over-the-counter pain medication), visit offspring, who alternately feel resentment at or com- a doctor, or alter life-style. passion for the patient s suffering. As the patient s Symptom list history unfolds, significant others come to perceive • Gastrointestinal symptoms: Vomiting (other than during pregnancy) themselves as manipulated or abused by the pa- Abdominal pain (other than when menstruating) tient. Sexual avoidance or dysfunction is common Nausea (other than motion sickness) among these patients and is another source of mari- Bloating (gaseous) tal strain. Diarrhea Intolerance for several different foods Occasionally, SD patients experience depressive • Pain symptoms: symptoms of sufficient severity to cause incapac- Pain in extremities ity. As with any depressed patient, suicidal poten- Back pain tial must be monitored continually. Foreseeable in- Joint pain Pain during urination terpersonal crisis must be the focus of counseling Other pain (excluding headaches) to minimize the probability of suicide attempts. • Cardiopulmonary symptoms: Shortness of breath when not exerting oneself Management and treatment Palpitations Chest pain Somatization disorder patients often evoke frustra- Dizziness tion in physicians because these patients are • Conversion/pseudoneurologic symptoms: viewed as not really sick and therefore in viola- Amnesia tion of the implicit physician-patient social com- Difficulty swallowing Loss of voice pact. lb help protect these patients from their own Deafness harmful proclivities, the primary care physician Double vision must recognize that the behavior is directed en- Blurred vision Blindness tirely unconsciously. Because patients are unable Fainting or loss of consciousness or unwilling to consider psychogenic explanations, Seizure convulsion they can not attribute causality of their distress Trouble walking to psychosocial events. Paralysis or muscle weakness 46 Even the most subtle dis- Urinary retention or difficulty urinating play of frustration or direct challenge to the valid- • Sexual symptoms (for the major part of the patient s life ity (reality) of the patient s illness is counterpro- after the beginning of opportunities for sexual activity): ductive and most likely will lead to the patient seek- Burning sensation in sexual organs or rectum (other than ing help elsewhere. during intercourse) Sexual indifference It is imperative that the physician presents a Pain during intercourse sympathetic demeanor. Regularly scheduled visits Impotence will reduce the patient s need to create symptoms. • Female reproductive symptoms (judged by the patient to Physical examinations can reassure the patient occur more frequently or severely than in most women): Painful menstruation that complaints are being taken seriously. Routine Irregular menstrual periods screening tests (fasting urine glucose tests, serum Excessive menstrual bleeding lipid determinations, Papanicolaou smears, mam- Vomiting throughout pregnancy mograms) conducted when appropriate and when These seven items may be used to screen for SD. The presence of two the patient is most demanding and distressed can or more of these items suggests a high likelihood of the disorder. both reassure the patient of the physician s con- cern and detect malignant conditions in their early acutely talented at detecting physician doubt as phases. well. It may help the physician to keep in mind Not only is it possible for such patients to have Wilder Penfield s maxim: "Assume the pain is real objectively verifiable (real) illnesses develop, but (that is, consciously experienced by the patient such patients are, in fact, suffering, and they are even if not a result of tissue damage) unless you
Clinical Practice • Ketterer and Buckholtz JAOA • Vol 89 • No 4 • April 1989 • 497 have incontrovertible proof that the patient is ma- emotional or mental, somtimes can make counsel- lingering."7 Certainly our current state of igno- ing an acceptable therapy.47,49 In one study47 of a rance regarding mind-brain/body relationships jus- short-term (six to 12 sessions) treatment program tifies such a stance. for Medicaid and Blue Cross abusers (patients who The primary care physician should have an ob- fell into the top 10% of medical charges with no jective medical reason for ordering consultation or verifiable illness), medical costs decreased by 47%. expensive or invasive diagnostic tests for such pa- The practitioner s primary goal with such pa- tients. Such a management strategy reduces health tients should be prevention of iatrogenic harm. By care costs by about 50%.47,48 providing a sympathetic ear and confirmation of In one study,48 a single psychiatric consultation the legitimacy and seriousness of the patient s suf- led to significantly reduced ordering of expensive fering, the physician can avoid having the patient diagnostic tests. Median quarterly total health care "doctor shop." Such physician-shopping eventually charges dropped from $765 to $158, and the an- results in receipt of prescription drugs, drug abuse, nual number of days of hospitalization dropped or aggressive, expensive, and risky diagnostic pro- from 6.4 to 2.4. However, outpatient visits did not cedures.29,48-52 Once this primary goal is accom- decrease, because part of the recommended man- plished, the task of gently suggesting the role of agement protocol was scheduling regular visits at psychologic determinants can be undertaken. four- to six-week intervals. The deliberate avoidance of hospitalizations, di- agnostic procedures, and surgeries may evoke some Summary malpractice anxiety for the primary care physician. Somatization disorder is characterized by a history Once the SD patient s condition is diagnosed, it of multiple somatic complaints that are unverified must be remembered that more care is not neces- by objective evidence. These patients, typically fe- sarily better care. However, new symptoms need male, are prone to doctor-shopping, prescription to be taken seriously for two reasons: (1) to reas- abuse, and multiple, expensive, and unnecessary sure the patient and confirm the validity and seri- workups. Once the diagnosis is made, SD patients ousness of her suffering; and (2) to detect any ob- are best managed by sympathetic primary care phy- jectively verifiable illness that might arise. sicians who are conservative in their pursuit of medi- The use of psychotropic medications for SD pa- cal explanations for the patient s complaints. So- tients requires more caution than usual. SD pa- matization disorder patients generally are resis- tients probably make up a significant proportion tant to psychologic explanations for their problems, of iatrogenic substance abusers. They are prone to but some will accept referral for counseling if it self-medicating and to misinterpreting the signs is presented as adjunctive to medical care and and symptoms of withdrawal from prescribed medi- framed as treatment of "stress" rather than "emo- cations (for example, rebound insomnia following tional" or "mental" problems. withdrawal of soporifics); thus, they remedicate themselves to cope with the absence of the regi- men. 1.Blackwell B: Medical education and modest expectations. Gen Hosp Psychiatry 1985;7:1-3. Repeated admonitions regarding the risks of de- 2. Beaber RJ, Rodney WM: Underdiagnosis of hypochondriasis in fam- veloping a dependence or abuse disorder are help- ily practice. Psychosomatics 1984;25:39-43. ful if such a development is presented as one of 3. Jencks SF: Recognition of mental distress and diagnosis of mental disorder in primary care. JAMA 1985;253:1903-1907. the frequent complications of being sickly. The fact 4. 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498 • JAOA • Vol 89 • No 4 • April 1989 Clinical Practice • Ketterer and Buckholtz 12.Goodwin DW, Guze SB: Psychiatric Diagnosis ed 2. New York, Ox- An assessment of their diagnostic concordance. Arch Gen Psychiatry ford University Press, Inc, 1974. 1984;41:334-336. 13.Gordon E, Kraivhin C, Kelly P, et al: The development of hysteria 45.Zoccolillo M, Cloninger CR: Somatization disorder: Psychologic symp- as a psychiatric concept. Compr Psychiatry 1984;25:532-537. toms, social disability, and diagnosis. Compr Psychiatry 1986;27:65-73. 14.Monson RA, Smith GR Jr: Current concepts in psychiatry: Somati- 46.Ware JE Jr, Manning WG Jr, Duan N, et al: Health status and the zation disorder in primary care. N Engl J Med 1983;308:1464-1465. use of outpatient mental health services. Am Psychol 1984;39:1090- 15.Shapiro D: [Neurotic Styles]. New York, Basic Books, Inc, 1965. 1100. 18. 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