Somatization, distress and chronic pain

The two defining features of somatization are numerous self-reported physical symptoms and excessive health care seeking. This may be due to a lowered perceptual threshold for perceiving and reporting bodily symptoms, amplification or misinterpretation of those symptoms, or underlying psychiatric disturbance. Recurrent pain is the most common somatic symptom reported. True somatization disorder is very rare (<1%) and=" requires=" a=" dsm-iii-r=" diagnosis=" of=" at=" least=" 13=" different=" physical=" symptoms=" which=" cannot=" be=" explained=" by,=" or=" are=" in=" gross=" excess=" of=" physical=" findings,=" and=" have=" caused=" the=" patients=" to=" seek=" health=" care=" or=" alter=" their=" lifestyles.=" however,=" researchers=" have=" argued=" that=" a=" spectrum=" of=" severity=" for=" somatization=" exists,=" and=" this=" is=" supported=" by=" epidemiological=" research.=" available=" data=" also=" indicate=" that=" behavioural=" interventions=" may=" show=" long-term=" cost-effectiveness=" in=" the=" management=" of=" chronic=" pain.=" chronic=" pain=" dysfunction=" appears=" to=" place=" a=" disproportionate=" burden=" on=" overall=" health=" care=" expenditure=" for=" chronic=" pain=">     

A preliminary study of the clinical differences between dissociative and nondissociative depression in Hong Kong: implications for mental health practice

Depression is a serious public health issue, but not all patients with depression respond well to pharmaceutical treatments. Some scholars suggested that dissociation could be a marker indicating the types of patients with depression that may benefit more from psychosocial interventions than from pharmaceutical treatments. This study explored the possibility to differentiate dissociative depression and nondissociative depression in a clinical sample (N = 68) in the Chinese context, and discusses the potential implications for treatment considerations. Compared with the nondissociative group, the dissociative group reported higher occurrences of psychosocial etiological risk factors (e.g., childhood physical abuse, lack of help from family) and psychosocial-related symptoms (e.g., unstable relations, fear of abandonment, trauma-related flashbacks, somatization symptoms). Our initial findings revealed that patients with dissociative depression appeared to have distinct clinical features and might require more psychosocial interventions. Implications for health care research and practice are discussed.     

Impact of chronic pain on health care seeking, self care, and medication. Results from a population-based Swedish study

STUDY OBJECTIVE: To explore individual and social factors that could predict health care utilisation and medication among people with chronic pain in an unselected population. DESIGN: A mailed survey with questions about pain and mental symptoms, disability, self care action, visits to health care providers, and medication. SETTING: General populations in two Swedish primary health care (PHC) districts. Medical care was given in a state health system. PARTICIPANTS: A random sample (from the population register) of 15% of the population aged 25-74 (n = 1806). MAIN RESULTS: Among people reporting chronic pain 45.7% (compared with 29.8 of non-chronic pain persons, p < 0.05) consulted a physician and 7.2% (compared with 1.2%, p < 0.05) a physiotherapist during three months. Primary health care was the most frequent care provider. High pain intensity, aging, depression, ethnicity, and socioeconomic level had the greatest impact on physician consultations. Alternative care, used by 5.9%, was associated with high pain intensity and self care. Use of self care was influenced by high pain intensity, regular physical activity, and ethnicity. Alternative care and self care did not imply lower use of conventional health care. Women reporting chronic pain consumed more analgesics and sedatives than corresponding men. Besides female gender, high pain intensity, insomnia, physician consultation, social network, and self care action helped to explain medication with analgesics. Use of herbal remedies and ointments correlated to self care action, visit to an alternative therapist, high pain intensity, and socioeconomic level. CONCLUSIONS: The presence of chronic pain has an impressive impact on primary health care and medication. Various therapeutic actions are common and are partly overlapping. The use of health care among people with chronic pain depends above all on pain perception and intensity of pain but is also affected by ethnicity, age, socioeconomic level, and depressive symptoms. Among people with chronic pain use of analgesics is common in contrast with other types of pain relief (acupuncture, physiotherapy) suitable for treating chronic pain symptoms.     

Psychological assessment and treatment of somatization: adolescents with medically unexplained neurologic symptoms

Adolescent patients who report physical symptoms that are unexplained by physical disease or pathophysiologic processes are prevalent in health care settings. Physical symptoms with no notable physical pathology are often referred to as medically unexplained symptoms (MUS). Common MUS found in adolescent populations include headaches, abdominal pain, back pain, fatigue, dizziness, numbness and tingling sensations in the limbs, and gastrointestinal symptoms. The most important diagnostic concern is the exclusion of neurologic and other general medical conditions. Failure to diagnose real physical pathology appropriately can have serious, deleterious consequences. However, it is also important for physicians to address psychological and other psychosocial factors that may play a role in the etiology or maintenance of MUS. The onus often falls on the primary care physician to screen for such problems and to make cost-effective and appropriate referrals. This article reviews some alternative treatment guidelines for physicians to assist in the assessment, intervention, and referral process for adolescent patients with MUS. The advantages of integrating psychological screening practices into the evaluation process and present recommendations regarding the management of such patients are discussed.     

Medically unexplained symptoms--GPs' attitudes towards their cause and management

BACKGROUND: Medically unexplained physical symptoms present one of the most common problems in modern medical practice but often prove difficult to manage. The central position of the GP in the care of patients with medically unexplained symptoms has been emphasized repeatedly, but little is known about the attitudes of GPs to this role. Understanding how GPs view these patients may inform the development of effective strategies for management. OBJECTIVE: Our aim was to survey the attitudes of UK GPs towards medically unexplained symptoms (MUS) and somatization. METHODS: A random sample of 400 GPs in the South Thames (West) region were surveyed using a postal questionnaire. Respondents' attitudes toward the cause and management of MUS were recorded. RESULTS: A total of 284 completed questionnaires were returned (22 returned incomplete), giving an adjusted response rate of 75%. Although it was broadly felt that patients with MUS are difficult to manage, most GPs felt that patients with MUS should be managed in primary care. Providing reassurance, counselling and acting as a 'gatekeeper' to prevent inappropriate investigations were considered important roles for GP management. A majority felt that patients with MUS have personality problems or psychiatric illness. Fewer than half of the respondents felt that there are effective treatments available for somatization. CONCLUSION: GPs consider the management of patients with MUS to be an important part of their workload, but there is a perception that effective management strategies are lacking. Psychiatrists need to offer greater support and training for GPs in this area of health care.     

Domestic violence among Druze women in Israel as reflected by health status and somatization level

Women with a history of physical or emotional abuse demonstrate a higher incidence of medical disorders but may be reluctant to disclose the abuse to health care providers. The present study explored whether measures of health status may serve as an indication of violence against women. Sixty-two Druze women (18-50 years old) completed health status (SF-36 survey), somatization (Brief Symptom Inventory-BSI), and abuse (the Abuse Assessment Screen-AAS) questionnaires during a visit to the family physician in the community primary care clinic. Higher somatization symptoms and diminished health status were associated with severity of violence. Results attest to the value of these measures as an additional indirect device for screening victims of domestic violence in general and among traditional societies in particular.     

Pain intensity is associated with both performance-based disability and self-reported disability in a sample of older adults attending primary health care centers

BackgroundOlder adults' function level can be used as a predictor of future detrimental events, such as disability, reliance on others, risk of institutionalization and likelihood of death. The assessment of function at the primary health care centers using self-reported and/or performance based measures is of prime importance.ObjectiveTo determine whether personal factors, pain, depression and physical activity are associated with self-reported and performance based disability for older adults aged ≥60 years attending primary health care centers, as measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) and Short Physical Performance Battery (SPPB), respectively.MethodsParticipants (196 females and 55 males; mean age ± SD = 70.87 ± 7.76) had their pain, self-reported disability, performance, physical activity levels and depressive symptoms assessed. Regression analyses were performed with self-reported and performance-based disability as the dependent variable and age, sex, education, chronic conditions, depression, physical activity and pain characteristics as dependent variables.ResultsMean (SD) results for SPPB were 8.45 (2.86) and 20.06 (8.21) for WHODAS. Pain intensity, depression, pain frequency, number of chronic conditions and level of physical activity explained 44% of the self-reported disability variance. Pain intensity, age, level of physical activity, years of formal education and chronic conditions explained 37% of the performance variance. Pain intensity alone explained 27% and 18% of the self-reported and performance based disability, respectively.ConclusionFindings indicate that primary health care interventions should target pain intensity, depressive symptoms and physical activity as a means to preventing or decreasing both self-reported and performance based disability.     

A clinical approach to the somatizing patient

Patients with chronic, unexplained physical complaints are evaluated diagnostically in two steps in primary care: (1) brief consideration of three specific, but rare, disorders (somatic delusion, conversion, and malingering); and (2) extensive consideration of the remaining three common but overlapping disorders (somatization disorder, hypochondriasis, and psychogenic pain). Because of frequent confusion in differentiating among the common somatizing disorders and because the treatment is similar for all, the family physician can be content with the general designation of "common somatization syndrome" when unable to distinguish among them. This diagnosis can be easily established by a good history and physical examination. Psychiatric referral is required for the rare somatizing disorders. The primary physician can manage the majority of the common somatizing patients by observing the following principles: develop a good physician-patient relationship, apply techniques of behavior modification, engage the patient at the somatic level but extend it to include associated life stresses, strategically use symptomatic measures, treat depression with full doses of antidepressants, and accept the importance of ongoing contact with the patient irrespective of symptoms. When these therapeutic principles are employed, decreased morbidity, medical utilization, and cost can be expected to follow.     

Comparison of symptoms in Japanese and American depressed primary care patients.

BACKGROUND: Depression is a highly prevalent, worldwide problem with multiple social and health consequences. It often presents in primary care with physical symptoms. Little research has been done on cross-cultural expression of depression in primary care. This paper examines the hypothesis that depressed Japanese patients present with more and with more distinct somatic complaints than depressed American patients. METHODS: Data were collected by chart audit for patients with a diagnosis of depression at two sites: Minamikawachi Tochigi, Japan and Cleveland, Ohio, USA. Patient demographics and type and number of presenting symptoms in the two populations were compared. Logistic regression was used to determine whether there were differences between countries in physical symptoms and to adjust for relevant demographic characteristics. RESULTS: Japanese family physicians charted more somatic complaints from patients diagnosed as depressed than did American family physicians. Specific physical symptoms differed by country: Japanese patients had more abdominal distress, headaches, and neck pain. These symptoms have strong cultural significance for Japanese patients. CONCLUSIONS: This study clearly indicates the prominence and importance of physical symptoms in the presentation of depression in Japanese primary care patients. Their physicians must be alerted to the possibility of depression, especially when patient complaints include abdominal, neck or head pain.     

The content of a low-income,uninsured primary care population: including the patient agenda

BACKGROUND: Poor and uninsured people have increased risk of medical and psychiatric illness, but they might be more reluctant to seek care than those with higher incomes. Little information exists about the biopsychosocial problems and concerns of this population in primary care. METHODS: We surveyed 500 consecutive patients (aged 18 to 64 years) in a primary care clinic serving only uninsured, low-income patients. We used self-report questions about why patients were coming to the clinic, a chronic illness questionnaire, the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, and items from the Childhood Trauma Questionnaire. Providers completed a questionnaire naming problems elicited from patients. RESULTS: Patients reported their most common chronic medical problems to be headaches, chronic back problems, and arthritis. The most common concerns patients wanted to discuss with providers and that providers elicited from patients were problems with mood. Compared with patients without current major mental illness, patients with a current major mental illness reported significantly (P <.001) more concerns, chronic illnesses, stressors, forms of maltreatment and physical symptoms. CONCLUSION: The illness content of this uninsured, low-income population is dominated by emotional distress and physical pain. These needs place a serious burden on providers and can complicate management of chronic medical illnesses. Recommendations for specialized interview training and integrating mental health services are discussed.     

Caring for children with physical disability in Kenya: potential links between caregiving and carers' physical health

Background The health of a carer is a key factor which can affect the well‐being of the child with disabilities for whom they care. In low‐income countries, many carers of children with disabilities contend with poverty, limited public services and lack assistive devices. In these situations caregiving may require more physical work than in high‐income countries and so carry greater risk of physical injury or health problems. There is some evidence that poverty and limited access to health care and equipment may affect the physical health of those who care for children with disabilities. This study seeks to understand this relationship more clearly. Methods A mixed methods study design was used to identify the potential physical health effects of caring for a child with moderate‐severe motor impairments in Kilifi, Kenya. Qualitative data from in‐depth interviews were thematically analysed and triangulated with data collected during structured physiotherapy assessment. Results Carers commonly reported chronic spinal pain of moderate to severe intensity, which affected essential activities. However, carers differed in how they perceived their physical health to be affected by caregiving, also reporting positive benefits or denying detrimental effects. Carers focussed on support in two key areas; the provision of simple equipment and support for their children to physically access and attend school. Conclusions Carers of children with moderate‐severe motor impairments live with their own physical health challenges. While routine assessments lead to diagnosis of simple musculoskeletal pain syndromes, the overall health status and situation of carers may be more complex. As a consequence, the role of rehabilitation therapists may need to be expanded to effectively evaluate and support carers' health needs. The provision of equipment to improve their child's mobility, respite care or transport to enable school attendance is likely to be helpful to carers and children alike.     

Health-related quality of life and associated psychosocial factors in irritable bowel syndrome: A review

Irritable Bowel Syndrome (IBS) is a chronic recurring disorder with variable illness episodes that may continue for many years. Diagnosis is based on symptoms such as abdominal pain and irregular bowel habits. These symptoms, plus the influence of psychological factors and extraintestinal symptoms, adversely affect the health-related quality of life (HRQoL) of individuals with IBS. This paper summarizes publications relating to the characteristics of IBS and associated HRQoL. Significantly lower scores on both the physical and mental health scales of the Short Form-36 are reported for individuals with IBS symptoms as compared with asymptomatic controls and US norms. IBS negatively affects general health, vitality, social functioning, bodily pain, diet, sexual function, sleep, and is associated with lost time from work. IBS-specific instruments that incorporate many of these domains have recently become available. HRQoL appears to correlate with IBS symptom severity and influences decisions to seek medical care. Psychosocial problems are also linked with IBS in relation to health care utilization. However, the full burden of this painful illness is still unknown since only 25–60% of individuals suffering from IBS symptoms see a physician for their illness.     

Unexplained physical symptoms: a widespread problem but still low-profile in training programs and guidelines

Unexplained physical symptoms or functional somatic syndromes that cannot be explained in terms of a defined medical disease are common. If persistent, they can cause significant distress and disability, and lead to absenteeism and social isolation as well as major health-care costs. Unexplained physical symptoms form a spectrum from transient unexplained mild physical symptoms to chronic severe somatoform disorders. Various functional somatic syndromes overlap one another substantially in symptomatology and are often resistant to conventional medical therapy. The 'Vereniging Nederlands Tijdschrift voor Geneeskunde' (Dutch Journal of Medicine Association) recently held a special conference on unexplained physical symptoms. The conclusions were: (a) patients are reluctant to accept the diagnosis of unexplained physical symptoms, because physicians do not have sufficient knowledge, expertise, and skill to diagnose and treat them, (b) patients with unexplained physical symptoms do not necessarily need to be treated by a psychiatrist except in cases of chronic and serious somatoform disorder. Patients with unexplained physical symptoms, who often have multiple and complex problems, are best treated by a team of physicians and allied paramedical professionals; (c) patients with unexplained physical symptoms can be treated effectively by specialists using cognitive behaviour therapy. Different cognitive models are available; the 're-attribution model' focuses on the re-establishment of a liveable life, while 'the consequence model' is directed at reducing the consequences of the unexplained physical symptoms. Management using the attribution model may be followed up by the consequence model approach; (d) the development of a practice guideline for the diagnosis and treatment of patients with both acute and chronic unexplained physical symptoms would improve the quality of patient care, reduce disability, increase the possibility of reintegration, and stimulate scientific research; (e) both theoretical and practical training in the diagnosing and managing of unexplained physical symptoms is inadequate in both university curriculums and postgraduate training programmes for medical specialists. Scientific research for the development of an evidence-based practice guideline is urgently needed.     

A somaticizing adolescent: an approach to evaluation and therapy

Adolescents may chronically somatize as part of the symptoms of an underlying psychological disorder. Unless the underlying psychological disorder. Unless the underlying psychopathology is recognized by the treating physician, chronic somatization may result in high cost to the health care system due to frequent use and unnecessary biochemical and radiographic evaluation. The case presented is illustrative of the differential diagnosis and management of such a patient.     

Disabling musculoskeletal pain and its relation to somatization: a community-based postal survey

BACKGROUND: Somatization (a tendency to report distress from somatic symptoms) is a little studied, but potentially important, confounder and effect modifier in occupational studies of musculoskeletal disease. AIMS: To assess the role of somatization as a risk factor for disabling regional pain. METHODS: A questionnaire was mailed to 4998 subjects of working age. Questions were asked about chronic and disabling pain in the past 12 months affecting the arm, low back, knee or combinations of these sites. Distress from physical symptoms was assessed using elements of the Brief Symptom Inventory and mental well-being was assessed using the short-form 36 (SF-36). Associations were examined by modified Cox regression and expressed as hazard ratios (HRs) with 95% confidence intervals (CI). RESULTS: Among 2632 responders, 24% reported chronic pain and 25% disabling pain at one or several sites. Risk of chronic or disabling pain increased strongly according to the number of somatic symptoms reported as bothersome. For example, the HR for chronic upper limb pain in those distressed by > or =2 somatic symptoms in the past 7 days versus none was 3.9 (95% CI 2.9-5.3), and that of disabling upper limb pain was 5.8 (95% CI 4.1-8.3). Similar patterns were found for the low back and knee, and there was a gradient of increasing risk according to the number of sites with disabling pain. In comparison, associations with SF-36 mental well-being score were weaker. CONCLUSION: Somatizing tendency should be evaluated as a possible confounder or effect modifier in studies of occupational risk factors for musculoskeletal pain.     

New directions in the understanding and management of pain

Control of pain and the suffering that it causes still eludes us. Despite impressive progress in the prevention and cure of disease and in care of the trauma victim, pain is still a frontier in medical research. It accompanies surgery, various diagnostic procedures and dental care as well as acute injury and disease. For a significant number of patients it persists after injury or illness into a chronic state. Chronic pain is recognized to be the most frequent cause of disability in the United States and many industrialized nations today, and is a major cost to society in both work hours lost and medical expenses. In addition to its social importance, pain is an intimate cause of personal concern for every human being throughout life. The progress, or lack of progress, achieved by medical research in pain control is of interest to us all. Pain disorders may be usefully classified in two categories: acute and chronic. The etiology, physiopathology, symptomatology, diagnosis and therapy of these two types of pain are quite different and require separate consideration. Acute pain is that which arises from an acute injury or disease process and persists only as long as the tissue pathology itself. If acute pain problems are not effectively treated, they may progress to chronic states. Chronic pain is that: (1) associated with chronic tissue pathology; or (2) which persists beyond the normal healing period for an acute injury or disease. There are unique challenges for health care providers associated with each of these two categories of problems, and failure to distinguish between these types of pain has led to a widespread, ongoing mismanagement of patients that can be prevented if strong efforts are made to better educate health care professionals about pain and its therapy. This paper presents an overview of current understanding about the nature of pain and its management. The physiology and psychology of pain are reviewed against a background of the concepts and information taught 25 years ago. Some common acute and chronic pain problems are reviewed and discussed. Finally, several new directions in pain control are described.     

Somatization disorder, a cause of difficult pain: a case report

Presented is a case report of a 55-year-old man with a suspected diagnosis of pancreatic malignancy who was referred for pain management to the pain and palliative care clinic. A diagnosis of pain originating from a malignancy was later ruled out. The patient was referred for psychiatric evaluation, where his pain symptoms were confirmed to be somatoform in origin. This case highlights the importance of ruling out somatization as the cause of symptoms in difficult pain patients.