Somatization in Family Practice: a Biopsychosocial Approach

Somatization in Family Practice: A Biopsychosocial Approach Gary Rosen, MD, Arthur Kleinman, MD, and Wayne Katon, MD Seattle, Washington The family physician sees many patients who present physical symptoms that have primarily an emotional or psychosocial basis. This paper defines the concept of somatization, reviews its prevalence and consequences, and develops a conceptual model of somatization that includes cultural, childhood, psy chological, and environmental factors. Physicians and the medical care system play a significant role in reinforcing so matization by patients. A biopsychosocial approach to the clin ical assessment, diagnosis, and management of these patients is presented along with case examples that exemplify the util ity of this approach. The patients whose chief complaints are non headache, fatigue, dizziness, malaise). Patients specific physical symptoms and whose biomedical who somatize either have no discernible organic evaluations reveal little or no organic pathology disease and recurrently present with physical are well known to all physicians. Many terms have complaints or have verifiable organic problems but been used to describe these patients, for instance, amplify their symptoms and are frequent users of “the worried well,” “ hypochondriacs,” and physicians’ services. As a group, these patients “crocks.” It is the purpose of this paper to make up a significant proportion of visits to a pri describe more clearly this phenomenon and to mary care physician. This well-known fact is the outline a practical approach to the diagnosis and basis of the adage in family practice that 20 per management of these patients. cent of a practice will take up 50 percent of the physician’s time.1 Somatization is encountered in a wide variety of clinical settings. It is seen in many psychiatric disorders, including depression, anxiety neurosis, Definition and Prevalence Briquet’s syndrome (or somatization disorder, for Somatization can be defined as the articulation merly hysteria), hysterical reaction, factitious ill of emotional problems and psychosocial stress by ness, malingering, and hypochondriasis. It is also way of physical symptomatology (ie, backache, encountered frequently in chronic pain disorders, “psychophysiological reactions,” and as a coping response to stressful life events.2'4 Among tradi tionally oriented ethnic patients, members of fun From the Department of Family Medicine and the Depart ment of Psychiatry and Behavioral Sciences, School of damentalist religious groups, and less educated Medicine, University of Washington, Seattle, Washington. working class members, somatization may provide Requests for reprints should be addressed to Dr. Gary Rosen, Ballard Family Medicine, 1801 NW Market Street, a socially sanctioned cultural idiom for expressing Seattle, WA 98107. personal and interpersonal “troubles” of many 0094-3509/82/030493-10$02.50 5 1982 Appleton-Century-Crofts THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 3: 493-502, 1982 493 SOMATIZATION different types as well as an effective means for percent of his time.16 Studies with chronic pain manipulating social relationships. patients have shown a high incidence of depres While no studies have clearly defined the inci sion despite the lack of depressed mood as a com dence or prevalence of somatization in a primary plaint.17,18 Overall, it has been shown that patients care setting, inferences can be made from a review with mental illness utilize twice as much nonpsy of the literature. Studies have shown that as many chiatric medical care.19 as 50 percent to 75 percent of patients utilizing From these studies it is clear that somatization primary care clinics have psychosocial precipi- is seen frequently as a part of psychiatric disorders tants as opposed to biomedical problems as the in primary care. The prevalence and incidence of main cause of their visit.5'7 Psychiatric disorders chronic pain disorders and psychophysiological make up a significant proportion of problems seen disorders probably well exceed that of affective in primary care. A study in a Wisconsin primary disorders. Thus while the true prevalence of so care clinic found the incidence of mental disorders matization remains unknown, it is of significant to be 26.7 percent in that adult population.8 In the proportions. Virginia study, “Content of Family Practice,” it In order to more fully understand somatization was found that depression and anxiety neurosis and its clinical manifestations, it is necessary to were among the 15 most frequent diagnoses, and look at it from a broader perspective. Somatiza that physical disorder of masked psychogenic ori tion can be viewed as one response by an indi gin ranked number 26.9 In an English study of a vidual to stressful stimuli. These stimuli may be large group of family physicians, only 54 percent external (environmental or social) or internal (psy of the mental illnesses present among their pa chological or physiological). The individual’s re tients was detected.10 These studies add credence sponse to these stimuli is influenced by many to numerous other studies which have estimated factors, including psychological, family, and socio the incidence of mental disorders in primary care cultural variables, as well as the nature of the to be between 15 percent and 50 percent and have stimulus itself (Figure 1). shown that 87 percent of these were affective and psychophysiological disorders (ie, depression, anx iety states).8,11,12 While these studies give some estimate of the Etiologic Factors prevalence of mental disorders, the incidence of somatization is still unclear. An English study Psychological and Personality Factors found that among patients diagnosed with a mental Intrapersonal factors play an important role in disorder, over 50 percent presented with somatic determining how an individual copes with stressful symptoms at the outset.13 Widmer and Cadoret de stimuli. Age and developmental stage are signifi termined in a study of depression in a midwest cant. Children and adolescents have been found family practice that in the seven months prior to somatize frequently;20'23 elderly patients with to the diagnosis of depression, patients had an significant cognitive impairments are likely to so increased number of office visits and hospitaliza matize when faced with stressors,24 as are elder tions, and the subjects presented complaints of ly depressed patients.25 Patients differ markedly three types: (1) ill defined functional complaints, in their degree of “psychological mindedness” ; (2) pain of undetermined origin (ie, head, abdo those with little will often substitute somatic pre men, extremities), and (3) “nervous” com occupation for a dysphoric affect. Personality plaints.1315 In a study of his family practice themes are also important; the somatizing person Collyer discovered a subgroup of high-use families ality has been described as showing three themes: who required 20 percent of physician’s services (1) masochism with chronic guilt and the view of and 32 percent of physician’s time. Depression illness as punishment, (2) hostility with a sense and anxiety were diagnosed in 89 percent of of having been wronged, and (3) excessive inter the families, and “psychosomatic illnesses” were personal dependency and demandingness.26 While present in the vast majority. Practicewide, pa somatization may be seen in any personality type, tients with emotional and “psychosomatic ill it is more common with histrionic, narcissistic, nesses” required 28 percent of his services and 48 dependent, compulsive, and masochistic types. 494 THE JOURNAL OF FAMILY PRACTICE, VOL. 14, NO. 3, 1982 SOMATIZATION Psychological stress indeed is often the precip ones. It is within this social unit that the child itant of the encountered symptomatology. Loss, learns appropriate responses to his environment, separation, and intrapersonal and interpersonal his social world, and his inner feelings. Children conflict can act as potent stressors for the individ are unable to distinguish between physical and ual. Stress causes autonomic hyperactivity, with psychological distress, and it is only through the release of epinephrine and cortisol and internal reaction of adults that this distinction can be monitoring of bodily sensations. Finally, the psy learned.27’28 In many families, somatic ills may chiatric disorders mentioned earlier often have elicit nurturance while emotional ills may elicit somatic complaints as their primary manifestation. little response. In fact, negative sanctions against For example, patients with depression and anxiety expressing emotions may exist. In these families neurosis may experience the associated physical the child quickly learns to utilize somatic com symptoms with little or no psychological compo plaints to seek attention, love, and caring. As a nent. Thus the depressed patient will complain of result, emotional and physical problems become fatigue, aches, decreased energy, and so on, while fused, and a psychological language for internal denying being “ depressed,” and the patient with mood states will not develop. anxiety neurosis will complain of heart pounding, Engel, in his work with “pain-prone” patients, dizziness, sweating, a lump in the throat, and so found that aggression, suffering, and pain played on, while denying being anxious. an important role in the early family relationships of those patients who had (1) physically or verbally abusive parents, (2) parents who

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