Surgery and medical treatment in persistent somatizing patients.

This study describes the utilization of surgical operations, frequency and outcome of medical and surgical treatment in a group of persistent somatizers compared with a control group of non-somatizers. The study was carried out using the Danish national medical register to identify persons in the general population (age range 17-49 yr) with at least 10 general admissions during an 8-yr period. Persistent somatizers were defined as persons with more than six medically unexplained general hospital admissions in their lifetimes before 1985. Conversely, non-somatizers were patients whose admissions could mainly be ascribed to well-defined somatic disorders. The findings show that persistent somatizers had been exposed to extensive surgery, outnumbering the non-somatizers. Surgical operations were of several categories, with gastrointestinal and gynaecological operations being the most frequent. The physicians used medical and surgical treatment nearly as often for treating persistent somatizers as in the treatment of the non-somatizers. Surgical or medical treatment was used in nearly half of the medically unexplained admissions. The outcome of the surgical treatment of the persistent somatizers was, however, generally unsuccessful in that the effect was unsatisfactory in three quarters of cases. Similarly, two thirds of the medical treatments were judged to be unsuccessful in persistent somatizers. The findings suggest that the costs of somatic diagnostic procedures and fruitless surgical and medical treatment attempts on persistent somatizers are enormous, and only exceeded by the risk of iatrogenic harm. This emphasizes the need for an early diagnosis of somatization and of treating it properly.     

Somatization in patients newly admitted to a neurological department

The incidence of somatization and sociodemographic, clinical and mental factors in 100 consecutive patients newly admitted to a neurological department was investigated. Forty percent of the neurological inpatients were somatizers; they reported higher levels of distress and hypochondriacal concerns and were more often considered as having significant mental disorders by the neurologists. The somatizers were similar to patients with organic symptoms with respect to sociodemographic factors, duration of and number of symptoms, mode of admission and earlier consultations of psychiatric or other specialists. Most of the patients with somatization only believed that psychological factors influenced their somatic symptoms. No sex differences were found except that female somatizers had shorter duration of admission.     

Psychiatric illness and irritable bowel syndrome: a comparison with inflammatory bowel disease

Structured psychiatric interviews and psychological self-report measures were administered to 28 patients with irritable bowel syndrome and 19 patients with inflammatory bowel disease. Significantly more of the patients with irritable bowel syndrome had lifetime diagnoses of major depression, somatization disorder, generalized anxiety disorder, panic disorder, and phobic disorder. They had significantly more medically unexplained somatic symptoms, and most had suffered from psychiatric disorders, particularly anxiety disorders, before the onset of their irritable bowel symptoms.     

Somatization: a spectrum of severity

OBJECTIVE: The DSM-III-R diagnosis of somatization disorder requires that a patient have a specific number of medically unexplained somatic symptoms. This number of symptoms was developed by committee consensus, and it is not clear whether patients with this specific number of symptoms can be differentiated from patients with lower but still substantial numbers of somatic symptoms. METHOD: Fifty-one percent of 767 high utilizers of two primary care clinics were identified as distressed by an elevated SCL anxiety, depression, or somatization scale score or by their primary care physician. The Diagnostic Interview Schedule (DIS) was completed on 119 distressed high utilizers who were randomly assigned to an intervention group in a controlled trial of psychiatric consultation. The 119 distressed high utilizers were separated into four categories according to the number of unexplained somatic symptoms found on the DIS and were compared on demographic, psychiatric distress, disability, medical, and health utilization variables. RESULTS: The data suggest that many clinical and behavioral features of somatization are significantly more common in patients with four to 12 medically unexplained somatic symptoms rather than changing dramatically at the diagnostic threshold for somatization disorder. The data also showed that patients who meet the DSM-III-R criteria for somatization disorder are severely ill and have a high burden of psychiatric illness and disability. CONCLUSIONS: The results suggest that the DSM-IV somatoform disorders section should include somatization disorder, an abridged definition of somatization disorder often associated with anxiety and depression, as well as a type of somatization associated with an adjustment disorder.     

The attribution of somatization in schizophrenia patients: a naturalistic follow-up study

BACKGROUND: Knowledge is limited concerning somatic symptoms that cannot be accounted for by detectable somatic illness among schizophrenia patients. This study aimed to explore the prevalence, correlates, and predictors of somatization among schizophrenia patients. METHOD: Initial data on all consecutively admitted adult patients with DSM-IV schizophrenia, schizoaffective disorder, major depressive disorder, or bipolar disorder were collected between August 1998 and August 2000. Standardized measures of psychopathology, somatization, emotional distress, adverse effects, insight, and stress process-related (psychosocial) variables were administered to 237 schizophrenia patients at admission and at least 12 months thereafter (N = 148). Partial correlation and multiple regression analyses were performed. RESULTS: The frequency of somatization, defined as the presentation of 5 or more medically unexplained somatic symptoms (Somatic Symptom Index-5), among the inpatient population (27%) did not change significantly after at least 12 months (30%; p =.61). Regression analysis showed that somatization scores were best predicted by the combination of scores for emotional distress attributed to psychopathology and side effects, expressed emotion, and insight. This combined model explains at least 40% of the variance in somatization scores. Self-esteem and social support showed negative association with somatization scores. Somatization scores were not associated with gender, age, education, age at onset, observed severity of psychopathology, subtype and duration of illness, number of admissions and treatment settings, or type and dose of antipsychotic agents. CONCLUSIONS: Somatization is a prevalent problem among schizophrenia patients and is associated with emotional distress attributed to psychopathology, side effects of antipsychotic agents, and family members' attitudes toward schizophrenia patients. This study suggests that insight, self-esteem, and social support may protect against somatization in schizophrenia patients.     

Somatic symptoms in children and adolescents referred for emotional and behavioral disorders

Medically unexplained physical symptoms are frequently endorsed by children and adolescents in both clinical and community samples. The aim of this exploratory study is to examine the prevalence of somatic symptoms in a sample of 162 Italian children and adolescents consecutively referred to a Division of Child Neurology and Psychiatry from emotional and/or behavioral disorders. The role of age, gender, and psychiatric status was considered as a variable. Each patient received a DSM-IV assessment, including a diagnostic structured interview (DICA-R). The sample was divided according to gender (96 males, 66 females), age (70 children younger and 92 adolescents older than 12 years), and psychiatric diagnosis (Anxiety, Depression, Depression/Anxiety, Other). The presence of medically unexplained somatic symptoms was based on the responses to the DICA-R. Somatic complaints were reported in 69.2% of the patients. Headache was the most frequent somatic symptom (50.6%). Younger children showed higher rates of abdominal complaints than adolescents. No gender differences in frequency of somatic complaints were reported. Subjects with anxiety and/or depression reported significantly higher rates of somatic complaints, namely headache, than subjects with other mental disorders. No differences in frequency of somatic symptoms were evident between patients with anxiety, depression, and comorbid anxiety-depression. Our data suggest that an unexplained somatic symptom can be often considered as indicative of a neglected anxiety and/or depressive disorder. A collaboration between primary care physicians, pediatricians, and child psychiatrists may promote early diagnoses and timely treatments and prevent negative social and scholastic consequences.     

Neurological disease, emotional disorder, and disability: they are related: a study of 300 consecutive new referrals to a neurology outpatient department

OBJECTIVES: To determine the prevalence of anxiety and depressive disorders in patients referred to general neurology outpatient clinics, to compare disability and number of somatic symptoms in patients with and without emotional disorder, the relation to neurological disease, and assess the need for psychiatric treatment as perceived by patients and doctors. METHODS: A prospective cohort study set in a regional neurology service in Edinburgh, Scotland. The subjects were 300 newly referred consecutive outpatients who were assessed for DSM IV anxiety and depressive disorders (PRIME-MD, and HAD), health status, and disability (SF-36), and patients', GPs' and neurologists' ratings of the need for patient to receive psychiatric or psychological treatment. RESULTS: Of 300 new patients, 140 (47%) met criteria for one or more DSM IV anxiety or depressive diagnosis. Major depression was the most common (27%). A comparison of patients with and without emotional disorder showed that physical function, physical role functioning, bodily pain, and social functioning were worse in patients with emotional disorders (p<0. 0005). The median number of somatic symptoms was greater in patients with emotional disorders (p<0.0005). These differences were independent of the presence of neurological disease. Few patients wished to receive psychiatric or psychological treatments. Both general practitioners and neurologists were more likely to recommend psychiatric treatment when the patients' symptoms were medically unexplained. CONCLUSIONS: Almost half of new referrals to general neurology clinics met criteria for a DSM IV psychiatric diagnosis. These patients were more disabled, and had more somatic symptoms. They expressed little enthusiasm for receiving psychiatric treatment.     

Psychological distress among patients attending a general medical outpatient clinic in Pakistan

It is not known whether the pattern of psychiatric disorders in medical outpatients in Pakistan is similar to that observed in the West. Consecutive medical outpatients completed the Self-Report Questionnaire (SRQ) to detect probable psychiatric disorder. The usual cut-off score of 8/9 was used. One-thousand and sixty-nine patients completed the SRQ (84% response rate) at four half-day clinics. Sixteen percent of men and 58% of women presented with medically unexplained symptoms. In men, 80% of patients with medically unexplained symptoms had an SRQ score of 9 or above (probable depressive disorder) compared to 40% of those with symptoms caused by recognized physical illness (P<.0005). In women, the respective proportions were 55.4% and 49.6% (P=.34). Depressive disorder is probably very common in medical outpatients in Pakistan, especially in men with medically unexplained symptoms. Systematic attempts to initiate antidepressant treatment in this setting should be attempted.     

Somatized mental disorder among primary care arab patients: I. prevalence and clinical and sociodemographic characteristics

The aims of this study were to estimate the prevalence of somatized mental disorder (SMD) in comparison to psychologized mental disorder (PMD) among a sample of primary health care (PHC) Arab patients, and to investigate the clinical and sociodemographic characteristics of SMD. The first stage of study was conducted by general practitioners (GPs), using the 12-item General Health Questionnaire (GHQ-12). The second stage was carried out by a psychiatrist using the Clinical Interview Schedule (CIS) and an inquiry schedule. Specific operational criteria were used to identify SMD and PMD. The estimated prevalence rate of SMD among the total screened sample was 12%. SMD patients constituted 48% of the psychiatric patients identified, whereas, for the PMD group, this figure was 42%. Educational level was significantly lower in the SMD group. Headache, backache, and abdominal pain were the most commonly presented somatic symptoms. The symptoms pursued a chronic and persistent course and most patients experienced multiple symptoms. The most common ICD-10 psychiatric diagnoses among both SMD and PMD patients were mixed anxiety and depressive disorder, generalized anxiety disorder, and mood and adjustment disorders. Recurrent depressive disorder and dysthymia were significantly more prevalent in the PMD group. The severity of psychiatric illness identified was greater among psychologizers than the somatizers of mental disorder.     

Behavioural and psychological management of somatic symptom disorders: An overview

Abstract

The number of patients who seek help at primary and secondary care for somatic symptoms which cannot be explained by any known medical condition is enormous. It has been proposed to rename ‘somatoform disorders’ in DSM-IV as ‘somatic symptom disorders’ in DSM-5. This is supposed to include disorders such as somatization disorder, hypochondriasis, undifferentiated somatoform disorder, pain disorder and factitious disorder. The reason for the renaming and grouping is that all these disorders involve presentation of physical symptoms and/or concern about medical illness. In the literature, there is considerable variation adopted with respect to diagnosis and in the approaches adopted for intervention. However, the common feature of these disorders is the chronicity, social dysfunction, occupational difficulties and the increased healthcare use and high level of dissatisfaction for both the clinician and the patient. A number of behavioural and psychological interventions for somatic symptoms have been carried out at primary, secondary and tertiary care settings and recently there have been more attempts to involve the primary care physicians in the psychological interventions. This review aims at giving an overview of the components of the behavioural and other psychological interventions available for addressing medically unexplained somatic symptoms and to present their efficacy.     

A link between lunar phase and medically unexplained stroke symptoms: an unearthly influence?

OBJECTIVE: Lunar effects on human behaviour and health have been postulated for centuries; associations between phase of the moon and both vascular and psychiatric disease have been reported. We hypothesised that admission with medically unexplained stroke symptoms would be influenced by lunar cycle. METHODS: All admissions to the Western Infirmary Acute Stroke Unit are recorded in a comprehensive database. We analysed admissions between January 1, 1993, and September 30, 2006 (inclusive). Association between admission rate, phase of the moon, and a series of other culturally significant dates was calculated using chi-square testing. RESULTS: There were 7219 admissions during the study period, comprising 167 complete lunar cycles. Stroke admissions were evenly spread throughout lunar phases (P=.72). Admission with medically unexplained stroke symptoms was significantly increased during full moon phases (P=.023). There was no variation in admission rates during other significant dates. CONCLUSION: There was a statistically significant association between admission to the acute stroke unit with a diagnosis of medically unexplained stroke symptoms and lunar phase. The reasons for this observed variation remain elusive; our data do not support a convincing biological or psychosocial aetiology.     

Abnormal illness behavior of patients with functional somatic symptoms: relation to psychiatric disorders.

Functional somatic symptoms are highly associated with hypochondriasis, anxiety, and depressive disorders. Despite the absence of an organic disorder, underlying psychological distress of patients with functional somatic symptoms may result in abnormal illness behavior such as inadequate treatment seeking or overuse of medical services. Using the Illness Behavior Questionnaire (IBQ), we examined the illness behavior of Japanese patients visiting a general medicine clinic whose physical symptoms were considered functional. We used the General Health Questionnaire-30 to classify patients with functional somatic symptoms as those with and without psychological distress. Patients with distress (n=35) reported more physical complaints and higher IBQ scores than did patients without distress (n=22). The IBQ profile of patients with psychological distress was identical to that of patients diagnosed with either hypochondriasis or major depression. The illness behavior of patients without psychological distress was indistinguishable from that of patients whose physical symptoms were attributed to organic disease. These results further support the hypothesis that functional somatic symptoms may be associated with hypochondriasis and major depression, the pathology of which may contribute to the development of abnormal illness behavior.     

Clinical features associated with medically unexplained stroke-like symptoms presenting to an acute stroke unit

In many areas of secondary care, symptoms unexplained by disease account for around one-third of all patients seen. We sought to investigate patients presenting with medically unexplained stroke-like symptoms to identify distinguishing features which may help to identify a non-organic aetiology. Patients given a discharge diagnosis of medically unexplained stroke-like symptoms over the preceding 11 years were identified retrospectively from a prospectively completed stroke unit database. Age- and sex-matched controls with ischaemic or haemorrhagic stroke or transient ischaemic attack were also identified. Clinical features on presentation, ischaemic risk factors, alcohol history, marital status and history of depression or anxiety were examined. Previous or subsequent admissions with medically unexplained syndromes were also examined via record linkage with hospital discharge records. A medically unexplained syndrome was assumed to be present if an International Classification of Diseases 9 discharge code for one or more of the thirteen conditions forming recognized functional syndromes was given. Logistic regression was applied to determine predictors of non-organicity. One hundred and five patients and controls, 1.6% of all stroke unit admissions were identified, 62% (65 patients) were females. Mean age was 50.3 +/- 14.9. Compared with age- and sex-matched controls patients with medically unexplained stroke-like symptoms were significantly more probable to have a headache at presentation (47% vs. 26%, P = 0.0004), have a diagnosis of one or more additional medically unexplained syndromes (24% vs. 11%, P = 0.007) but significantly less probable to present with symptoms of vertebrobasilar dysfunction (32% vs. 61%, P < 0.0001). A history of anxiety or depression, as recorded in the notes, was not found to be associated with a medically unexplained presentation. Medically unexplained stroke-like presentations are common (1.6% of all stroke presentations), they are most strongly predicted by the presence of other functional somatic syndromes, headache and the absence of symptoms of vertebrobasilar dysfunction.     

Illness perceptions and levels of disability in patients with chronic fatigue syndrome and rheumatoid arthritis

OBJECTIVE: To investigate the strength of chronic fatigue syndrome (CFS) patients' negative illness perceptions by comparing illness perceptions and self-reported disability in patients with CFS and rheumatoid arthritis (RA). METHODS: Seventy-four RA patients and 49 CFS patients completed the Illness Perception Questionnaire-Revised and the 36-item Short-Form Health Survey. RESULTS: When compared to the RA group, the CFS group attributed a wider range of everyday somatic symptoms to their illness, perceived the consequences of their illness to be more profound and were more likely to attribute their illness to a virus or immune system dysfunction. Both groups reported equivalent levels of physical disability but the CFS group reported significantly higher levels of role and social disability. CONCLUSION: Although the symptoms of CFS are largely medically unexplained, CFS patients have more negative views about their symptoms and the impact that these have had on their lives than do patients with a clearly defined and potentially disabling medical condition. The data support the cognitive behavioural models of CFS that emphasise the importance of patients' illness perceptions in perpetuating this disorder.     

A primary care perspective on prevailing assumptions about persistent medically unexplained physical symptoms

OBJECTIVE: To re-examine the widespread assumption that medically unexplained physical symptoms represent discrete syndromes resulting from somatization of mental illness. METHOD: Primary care patients (N = 223) with medically unexplained symptoms of at least one year's duration were recruited to a study of exercise therapy. Data gathered from patients, from their general practitioners, and from medical records were used to examine relationships between self-defined disability, symptoms, mental state, and use of health care. RESULTS: Levels of disability and health care use were both raised, but were only weakly correlated. While most patients were depressed and/or anxious, a minority (14 percent) were neither. Although mental state correlated with disability, health care use was unrelated to either. Among a wide range of recorded symptoms, few correlations were found to support the existence of discrete syndromes. Analysis of agreement between patients and their doctors in assigning symptoms to broadly defined "syndromes" appears to reflect collaboration that is largely expedient CONCLUSIONS: In this sample of primary care patients with persistent unexplained physical symptoms, we found little evidence of discrete somatic syndromes. The level of health care use is no indication of mental state or level of disability, and the findings are equally consistent with depression or anxiety being secondary to disability and its consequences as with them being primary. The observed collaboration between patients and their doctors carries the risk of shaping, reinforcing, and legitimizing dubious syndromes.     

Somatized depression in primary care attenders

OBJECTIVE: The aim of this study is to determine, within the context of primary care, the frequency of the various ways in which depression is presented with respect to somatic symptoms and to compare depressed patients who present their distress somatically with those with psychological complaints. METHOD: In the two-phase cross-sectional study, first, we screened 906 consecutive patients, and second, we interviewed in detail 306 selected patients. RESULTS: The prevalence of depression was 16.8% (CI 95%: 13.4-20.2). There were 59 cases with psychological presentation, 45 somatizers and 16 had organic disorders with depressive comorbidity. Somatizers had lower level of education, and somatized depression was less serious and caused less repercussion. Detection, antidepressive treatment and psychiatric care were lower for somatizers than for psychologizers. CONCLUSIONS: Somatization is a frequent way to present depression in primary care. For somatizers, depression is less severe and is associated with less repercussion. Somatization is associated with the under-detection of the underlying psychiatric process.     

An international study comparing the effect of medically explained and unexplained somatic symptoms on psychosocial outcome

OBJECTIVE: Cross-sectional studies show an association between somatic symptoms and psychiatric morbidity in primary care. However, medically explained and unexplained symptoms have been considered separately as distinct and unrelated. In addition, data on outcome in primary care are equivocal. We compare the effect of both constructs (medically explained and unexplained symptoms) on psychiatric morbidity and disability (social and physical) at 1 year follow-up. METHOD: Of 5447 patients presenting for primary care in 14 countries, 3201 participants were followed up (72% compliance). We measured physical, psychiatric, and social status using standardised instruments. RESULTS: Patients with five or more somatic symptoms had increased psychosocial morbidity and physical disability at follow-up, even after controlling for confounders such as sociodemographics and recognition or treatment by general practitioners. There was little difference in outcome between medically explained and unexplained symptoms. CONCLUSIONS: Somatic symptoms-irrespective of aetiology-are associated with adverse psychosocial and functional outcome in diverse cultures.     

Patients with medically unexplained symptoms: DSM-III diagnoses and demographic characteristics

This study reports DSM-III diagnoses and demographic characteristics of 100 patients consecutively referred to a university hospital consultation-liaison service for evaluation of medically unexplained symptoms suggesting physical disorders. Thirty-seven percent of patients received diagnoses of somatoform, dissociative, or factitious disorders, and 14% were felt to have psychologic factors affecting physical conditions. Although black and male patients were less often referred for medically unexplained symptoms, once referred they were more likely than white and female patients to receive diagnoses of somatoform, dissociative, or factitious disorders. Among patients with somatoform disorders, those with conversion disorder and somatization disorder tended to be young women, whereas those with psychogenic pain disorder were older and equally likely to be male or female.     

Somatic Symptom Disorder: An important change in DSM

This paper describes the rationale for the new diagnosis of somatic symptom disorder (SSD) within DSM5. SSD represents a consolidation of a number of previously listed diagnoses. It deemphasizes the centrality of medically unexplained symptoms and defines the disorder on the basis of persistent somatic symptoms associated with disproportionate thoughts, feelings, and behaviors related to these symptoms. Data are presented concerning reliability, validity, and prevalence of SSD, as well as tasks for future research, education, and clinical practice.