Somatizing Patients: Part I. Practical Diagnosis

American Family Physician,  Feb 15, 2000  by David Servan-Schreiber,  N. Randall Kolb,  Gary Tabas

• E-mail
• Print
• Link

The phenomenon of somatization, which results in unexplained physical complaints, is ubiquitous in primary care settings although it often goes unrecognized. Medical training emphasizes the identification and treatment of organic problems and may leave physicians unprepared to recognize and address somatoform complaints. As a process, somatization ranges from mild stress-related symptoms to severe debilitation. Patients at the low end of the spectrum often respond to simple reassurance, but patients who are more impaired require interventions specifically designed to avoid unnecessary exposure to dangerous, costly and frustrating diagnostic procedures and treatments. (Am Fam Physician 2000;61:1073-8.)

In patients with somatoform disorders, emotional distress or difficult life situations are experienced as physical symptoms. Patients who somatize present with persistent physical complaints for which a physiologic explanation cannot be found. Failure to recognize this condition and manage it appropriately may lead to frustrating, costly and potentially dangerous interventions that generally fail to identify occult disease and do not reduce suffering.

Somatization is common.1,2 In one study, no organic cause was found in more than 80 percent of primary care visits scheduled for evaluation of common symptoms such as dizziness, chest pain or fatigue.3 In addition, somatizing patients use inordinate amounts of health care resources. One study4 estimated that patients with somatization disorder (the most severe form of the condition) generated medical costs nine times greater than those of the average medical patient. Despite substantial amounts of medical attention, somatizing patients report high levels of disability and suffering.5 Finally, physicians report that somatizing patients are frustrating to treat.6 Physicians lack a sense of effectiveness when multiple complaints do not fit into usual diagnostic categories or patients do not fit into a typical office schedule.

Traditional medical training is focused on the identification and treatment of organic disorders and leaves most physicians ill prepared for recognizing and managing patients who somatize. This first part of a two-part article provides an approach to diagnosing and understanding the process of somatization that may lead to more effective and satisfying relationships with these often-difficult patients.

Diagnosis of Somatization

Somatization is too often a diagnosis of exclusion. This is a costly and frustrating approach in patients with multiple and chronic complaints. It is much more effective to pursue a positive diagnosis of somatization when the patient presents with typical features. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)7 defines several different somatoform disorders. However, somatization is not a specific disease but rather a process with a spectrum of expression.8-10 Once the process of somatization is identified, management of the different somatoform disorders is based on similar principles.

The low end of the somatization spectrum includes stress-related exaggeration of common symptoms, such as headache, lightheadedness or low back pain in the context of, for example, a divorce, new family member or new job. At the high end, it includes unrelenting problems that can leave patients completely disabled and withdrawn from most aspects of personal and occupational functioning. The primary care physician's emotional response to a patient can serve as an early cue to pursue a somatization diagnosis. A feeling of frustration or anger at the number and complexity of symptoms and the time required to evaluate them in an apparently well person, or a sense of being overwhelmed by a patient who has had numerous evaluations by other physicians, may be a signal to the clinician to consider somatization in the differential diagnosis early in the patient's evaluation. In addition, identifying the physician's emotional reaction to somatizing patients may help prevent deterioration of the physician-patient relationship.

Because the features of somatoform disorders are so variable, establishing specific diagnostic criteria, such as those listed in DSM- IV, can be difficult and may not be very useful. Clinical experience and existing research on diagnostic criteria for the more severe forms of somatization suggest that only two features are necessary to establish a positive diagnosis of somatization in patients in primary care settings: (1) several (more than three) vague or exaggerated symptoms in, often, different organ systems, and (2) a chronic course (i.e., a history of such symptoms for more than two years).9

Table 1 lists many of the symptoms and syndromes affecting patients with somatoform disorders. Most of these symptoms also occur in patients with organic pathology. As isolated symptoms, they would require a full medical work-up. However, somatizing patients have too many symptoms, in too many organ systems, that last too long. The intensity of the symptoms often strikes the physician as being out of proportion to the healthy appearance of the patient. The syndromes listed in Table 1 may be legitimate in many patients but are typically impossible to verify in somatizing patients.