Managing Somatic Preoccupation

ELISABETH L. RIGHTER, M.D., and RANDY A. SANSONE, M.D.

Wright State University School of Medicine, Dayton, Ohio

Somatically preoccupied patients are a heterogeneous group of persons who have no genuine physical disorder but manifest psychologic conflicts in a somatic fashion; who have a notable psychologic overlay that accompanies or complicates a genuine physical disorder; or who have psychophysiologic symptoms in which psychologic factors play a major role in physiologic symptoms. In the primary care setting, somatic preoccupation is far more prevalent among patients than are the psychiatric disorders collectively referred to as somatoform disorders (e.g., somatization disorder, hypochondriasis). Diagnostic clues include normal results from physical examination and diagnostic tests, multiple unexplained symptoms, high health care utilization patterns and specific factors in the family and the social history. Treatment may include a physician behavior management strategy, antidepressants, psychiatric consultation and cognitive-behavior therapy.

Somatically preoccupied persons have no genuine physical disorder but manifest psychologic conflicts in a somatic fashion. Somatically preoccupied patients with more severe manifestations may meet clinical criteria for bona fide psychiatric diagnoses collectively known as somatoform disorders (i.e., somatization disorder, conversion disorder, pain disorder, hypochondriasis).

See editorial on page 2980.

In the primary care setting, few patients meet strict psychiatric criteria for somatoform disorders because most have subthreshold symptoms or report somatic variations that remain undefined from a psychiatric perspective. These patients can be referred to as "somatically preoccupied." They are a clinical challenge for physicians, generating fundamental questions about the meaning of symptoms and the relationship between mind and body.

Epidemiology

The prevalence of somatic preoccupation among the general patient population is not well defined. Data from the PRIME-MD (Primary Care Evaluation of Mental Disorders) 1000 study¹ indicated that 14 percent of primary care patients met criteria for somatoform disorders, as defined in the Diagnostic and Statistical Manual of Mental Disorders, third editon, revised (DSM-III-R).²

Somatically preoccupied patients include those with somatic expression of psychologic conflicts inadequately manifested to fit the psychiatric diagnosis of somatoform disorder.

In a study using physician ratings, medically unexplainable physical symptoms were identified in 19 percent of primary care patients.³ To underscore the subthreshold phenomenon observed in primary care settings, investigators in one study⁴ found that 26.3 percent of patients met criteria for somatic preoccupation, while only 1 percent met DSM-III-R criteria for somatization disorder.

In addition to prevalence studies, investigators have explored other epidemiologic aspects of somatic disorders. There appears to be a higher prevalence of somatization among Chinese-American,⁵ Asian⁶ and South American patients⁷ than among white patients.

An Australian study⁸ reported that somatizing patients were more likely to be female, a finding supported by other studies. These data suggest that there may be cultural influences (e.g., discouragement of emotional symptoms resulting in a focus on physical symptoms) as well as gender influences that affect the prevalence of somatic preoccupation.

Etiology

The etiology of somatic preoccupation is unclear. This is, in part, because the phenomenon is associated with a variety of psychiatric and nonpsychiatric factors. These associated factors play a meaningful role in the design of a treatment plan and may indicate prognosis (e.g., depression versus personality disorder). Whether these factors are comorbid or causally linked remains unknown.

Psychiatric syndromes appear to be the predominant clinical factors associated with somatically preoccupied patients. Whether these psychiatric syndromes are primary or secondary is unknown. Identified syndromes include both anxiety and depression.

Family members may be role models for somatic preoccupation or reinforce illness behavior.

Early developmental abuse, including sexual and physical abuse,⁹ has also been identified as a psychiatric factor. Experiencing combinations of maltreatment (e.g., sexual, physical or emotional abuse, witnessing violence) may be the element most predictive of subsequent somatic preoccupation in adulthood. Gender differences may exist with regard to the type of abuse. Physical abuse among males and sexual abuse among females are reported as risk factors for the development of adult illness behavior.¹⁰ However, these findings may reflect gender differences in abuse patterns rather than specific types of abuse as risk factors.

Another psychiatric factor associated with somatic preoccupation is the presence of a personality disorder. Somatic preoccupation has been empirically associated with antisocial, passive-dependent, histrionic, narcissistic, avoidant, paranoid, borderline and obsessive-compulsive personality disorders.^11-13

Psychiatric syndromes are commonly associated with somatically preoccupied patients.

Finally, substance abuse has been associated with somatic preoccupation. One study¹⁴ reported that multiple somatic symptoms are so reliably associated with alcohol abuse that somatic symptoms might evidence a high risk for alcohol abuse.

With regard to nonpsychiatric factors, several have been identified. These include genetic factors, which are suggested through adoption studies,¹⁵ and minor physiologic dysfunctions (such as aches and pains, fatigue, dizziness, blackouts, headache and insomnia) that are experienced in childhood.¹⁶ Family factors have also been implicated; family members may function as role models for somatic preoccupation or reinforce illness behavior. Different types of family factors may have greater influence depending on the person's developmental age.

Diagnosis

Among primary care patients with depression and anxiety, up to 85 percent present with exclusively somatic symptoms.

Most somatically preoccupied patients seek evaluation in primary care rather than psychiatric settings.¹⁷ Because the physician is presented with multiple elusive symptoms that must initially be evaluated, diagnosis is often delayed. In addition to normal results from physical examination and diagnostic tests, certain clues in the patient's history suggest somatic preoccupation, including multiple unexplained symptoms, high health care utilization patterns and specific factors in the family, medical and social histories.

Clues From the History
Multiple Unexplained Symptoms. The somatically preoccupied patient may present with medically unexplainable physical symptoms. In a survey¹⁸ of 1,000 adult primary care patients, the 15 most common physical symptoms were assessed. Of the symptoms reported, 16 to 33 percent lacked an adequate physical explanation.

Data from the World Health Organization collaborative study¹⁹ indicate that somatic symptoms cluster into meaningful groups (i.e., gastrointestinal, neurologic/conversion, autonomic, musculoskeletal). Symptoms most likely to be somatoform are fainting, menstrual problems, headache, chest pain, dizziness and palpitations.¹⁸ Unusual types of somatic symptoms, such as functional respiratory disorders (e.g., paroxysmal sneezing, sighing dyspnea, habit cough, vocal cord dysfunction), have been described in children, adolescents and young adults.

As the number of physical symptoms increases, the likelihood of a psychiatric disorder dramatically increases. In patients with zero to one, two to three, four to five, six to eight, and nine or more symptoms, the prevalence of a mood disorder was 2 percent, 12 percent, 23 percent, 44 percent and 60 percent, respectively; the prevalence of an anxiety disorder was 1 percent, 7 percent, 13 percent, 30 percent and 48 percent, respectively.¹⁸ Four symptoms for males and six symptoms for females suggest somatic preoccupation.²⁰

TABLE 1 Symptoms That May Indicate Somatic Preoccupation Stomach pain Back pain Pain in arms, legs or joints (knees, hips, etc.) Menstrual pain or problems Pain or problems during sexual intercourse Headaches Chest pain* Dizziness* Fainting spells* Feeling of a pounding or racing heart* Shortness of breath* Constipation, loose bowels or diarrhea Nausea, gas or indigestion Feeling tired or having low energy levels† Trouble sleeping† A patient with three or more positive responses for symptoms lacking a physical explanation should be assessed by PRIME-MD's second component, a clinician evaluation guide. *--Not classified as somatoform if symptom occurs only during panic attacks. †--Not classified as somatoform if physician decides symptom is due to a mood or anxiety disorder. Adapted with permission from Spitzer RL, Williams JB, Kroenke K, Linzer M, de Gruy FV 3d, Hahn SR, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994;272:1749-56.

High Utilization Patterns
Compared with nonsomatically preoccupied patients, those with somatic preoccupation have a greater number of outpatient visits,^21,22 more frequent hospitalizations²³ and greater overall health care expenditures.²⁴

This high level of service often results in extensive medical records, frequent telephone calls, multiple medications and repetitive subspecialty referrals.²⁵

Associated Medical Problems, and Family and Social History
A past medical history of the following syndromes has been associated with somatic preoccupation: food allergies, vitamin deficiency, factitious disorder, chronic fatigue syndrome, temporomandibular joint syndrome, tinnitus, atypical chest pain, hyperventilation, dyspnea, irritable bowel syndrome, pelvic pain, premenstrual syndrome, low back pain, dizziness, headache, pseudoseizures and closed head injury.^26-28 Somatic preoccupation may manifest as "fashionable" diagnoses such as fibromyalgia, multiple chemical sensitivity or reactive hypoglycemia.²⁹ Finally, a history of multiple surgeries or multiple drug "allergies," including exquisite sensitivity to medication side effects, may indicate somatic preoccupation.

A family history of somatization is a risk factor for somatic preoccupation, especially in first-degree female relatives.³⁰ Social risk factors for somatic preoccupation include single parenthood, living alone, unemployment and urban living.³⁰ Additional associations, as mentioned previously, include ethnicity,^5-7 alcohol or substance abuse,¹⁴ poor nurturing from the family of origin, and physical or sexual abuse.^9,25

Persons who lack skills, fear failure or are trapped in difficult psychosocial situations such as an unsatisfying job or marriage are also at risk.²⁵ Studies of employees in high-tech industries suggest that somatic preoccupation is related, in part, to high perceived mental demands in combination with lack of sufficient skills.³¹

Psychiatric Symptoms
Particular somatic symptoms may suggest a psychiatric syndrome. Among primary care patients with depression and anxiety, up to 85 percent present with exclusively somatic symptoms.³² Somatic presentations of depression often include gastrointestinal disturbances, chronic pain, fatigue and an extensive history of unexplained medical illness.³³

Diagnostic Tools
Two useful diagnostic tools can increase the physician's ability to make an accurate diagnosis of somatoform disorders. First, the PRIME-MD, a psychologic tool that uses a combination of patient self-report and clinician interview, includes two clinician items that inquire about somatic preoccupation.¹ The first item incudes a review of 15 symptoms (Table 1) on a patient questionnaire; a patient who has three or more symptoms that lack a physical explanation fulfills the first of two criteria. The second item allows the physician to query the extent of such symptoms; a patient who has these or other poorly explained symptoms over a period of several years fulfills the second criterion for the diagnosis of a somatoform disorder.

A second tool, the Symptom Checklist-90-Revised (SCL-90-R),³⁴ which is used in primary care and psychiatric research settings, includes a somatization scale. Of the two measures, the PRIME-MD is the more practical one to use in the clinical setting. It is highly sensitive (100 percent) but not specific (37 percent) in diagnosing somatoform disorders.

TABLE 2 Barsky's Suggestions for Managing Patients with Somatic Preoccupation Care rather than cure Do not try to eliminate symptoms completely Focus on coping and functioning Diagnostic and therapeutic conservatism Review old records before ordering tests Respond to requests just as for the nonsomatically preoccupied Schedule frequent visits and physical examinations Once set, try not to alter the frequency of visits Consider benign remedies Validation of distress Do not refute or negate symptoms Do not predicate patient-physician relationship on symptoms Focus on social history Providing a diagnosis Emphasize dysfunction rather than structural pathology Describe amplification process and provide specific example Cautiously reassure Psychiatric consultation Diagnose psychiatric comorbidity Recommend pharmacotherapy options Provide psychotherapy Cognitive/behavior therapy Improve coping Adapted with permission from Barsky AJ. A 37-year-old man with multiple somatic complaints. JAMA 1997;278:673-9.

Treatment

General Management Strategies
A variety of strategies may be helpful in managing the somatically preoccupied patient. Most emphasize regular office visits with the same physician, developing a therapeutic alliance and using behavioral techniques. It is not useful to overtly question the reality of symptoms. One study³⁵ revealed that somatically preoccupied patients perceived doctors as incompetent and inexpert if their explanations questioned the reality of symptoms.

Two studies^36,37 reported improved patient functioning and reduced cost of care with use of the following approaches: (1) schedule regular, brief appointments every four to six weeks (i.e., avoid "as-needed" appointments); (2) perform a brief, focused physical examination at each visit; (3) give physical signs more weight than reported symptoms; (4) avoid procedures and hospitalization unless clearly indicated; (5) understand that symptom development is unconscious; and (6) avoid making remarks to the patient such as "It's all in your head." Along a similar vein, Table 2³⁸ lists management strategies and Table 3²⁵ offers clinical techniques for use in patients with somatic preoccupation.

Antidepressants
When developing a treatment approach to somatically preoccupied patients, the clinician should strongly consider the likelihood of a depressive or anxiety disorder. A trial of antidepressant medication should be considered, with the understanding that the patient may have medication sensitivity or side effects. Prescribing antidepressant medication requires careful patient preparation and education, low initial dosages, slow titration and ongoing reassurance.

Addiction
Patients with longstanding somatic preoccupation (especially chronic pain) may self-medicate and become addicted to analgesics, benzodiazepines, alcohol or nicotine.²⁵ Tolerance and dependence must be addressed, as well as weaning from the substance, when indicated.

Psychiatric Consultation
Psychiatric consultation may be helpful in certain patients. In a study of patients diagnosed with somatization disorder, expenditures were reduced (largely because of decreased hospitalizations) following psychiatric consultation.³⁹ However, not all patients appear to benefit. In a study of random psychiatric consultation among distressed, high-utilizing patients, there was a significant increase in the use of antidepressants,⁴⁰ but there were no significant differences in psychiatric distress, functional disability or utilization of health care at six and 12 months after randomization. The general consensus is that psychiatric consultation can be helpful in assessing a personality disorder, exploring the possibility of other comorbid psychiatric conditions and providing recommendations for psychotropic medications. In some patients with a mood disorder, acute stressors or developmental trauma, psychotherapy may be helpful.

The treatment goal is to improve coping and function rather than to eliminate the symptom completely.

Cognitive-behavior Therapy
Group cognitive-behavior intervention has been helpful in some patients. In one study,⁴¹ patients had two fewer physician visits over a six-month period and less physical discomfort after following a six-week curriculum of relaxation-response training, awareness training and cognitive restructuring to foster a sense of internal control. Another program⁴² incorporated classroom videos, exercises and home study assignments. The 171 participants in this six-week program reported decreases in emotional and physical distress, increases in functional status and high levels of satisfaction, as well as decreases in medical utilization up to 12 months later.

The effectiveness of cognitive-behavior approaches has been replicated in several studies⁴³ among patients with irritable bowel syndrome, chronic idiopathic facial pain and noncardiac chest pain, as well as among children with recurrent abdominal pain (cognitive-behavior family intervention). A potential limitation of this approach is finding capable treatment providers or cognitive-behavior manuals.

Treatment Summary
A "listen more, do less" physician management strategy is the most helpful. Adjunctive interventions include antidepressants, psychiatric consultation when necessary and cognitive-behavior approaches when available.

TABLE 3 Blackwell's Clinical Techniques for Managing the Patient with Somatic Preoccupation Techniques for changing behavior Link symptoms to the patient's life "How is your symptom (pain, fatigue, breathlessness) interfering with your everyday life?" Link symptoms to the patient's feelings "How do you feel when you are having (your symptom)?" Obtain a precise description of the patient's feelings and the behavioral sequence that links symptoms to environmental triggers Link symptoms to everyday hassles The "stress biopsy": the patient selects a typical difficult situation (e.g., arguing with a spouse, confronting the boss), thinks of one word to describe the elicited emotion (e.g., stress, tension, fear, worry, apprehension), notes the predominant bodily sensation (e.g., palpitations, sweating, breathlessness, muscle tension) and chooses whether the emotion or the sensation is more obvious. Techniques to relieve symptoms Use terms such as "symptom sensitivity" and "illness worry" Ask questions such as "Does it feel as if the amplifier is always turned up in your body?" "Do you tend to fear the worst when the alarm bells go off in your body?" Information from Blackwell B, De Morgan NP. The primary care of patients who have bodily concerns. Arch Fam Med 1996;5:457-63.

Outcome

A "listen more, do less" management strategy is the most helpful treatment option.

The area of somatic preoccupation includes few outcome studies. When 100 consecutive patients with medically unexplained symptoms were evaluated 15 months after presentation, 46 percent had improved and 30 percent had recovered,⁴⁴ suggesting spontaneous resolution among some patients. Although 40 percent of patients with unexplained symptoms did not visit their physician in the year after the initial visit, having a high number of symptoms predicted frequent physician contact and poor recovery.⁴⁴ More outcome research is needed, particularly with regard to specific treatment approaches and the impact of somatic preoccupation on the long-term functional and health status of patients.

The authors thank Lori A. Sansone, M.D., for review of the manuscript.

Each year, members of two different medical faculties develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family Medicine at Wright State University School of Medicine, Dayton, Ohio. Guest editors of the series are Cynthia G. Olsen, M.D., and Gordon S. Walbroehl, M.D.

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The Authors

ELISABETH L. RIGHTER, M.D.,
is assistant professor in the Department of Family Medicine at Wright State University School of Medicine in Dayton, Ohio, and associate director of the Dayton Community Family Practice Residency Program. Dr. Righter graduated from Wright State University School of Medicine and completed a residency in family medicine at Grant Medical Center in Columbus, Ohio.

RANDY A. SANSONE, M.D.,
is associate professor in the Department of Psychiatry at Wright State University School of Medicine and director of Psychiatry Education (primary care) at Kettering Medical Center, Dayton. Dr. Sansone graduated from Ohio State University College of Medicine, where he also completed a residency in psychiatry.

Please address all correspondence to Elisabeth L. Righter, M.D., Indian Ripple Family Health Center, 4428 Indian Ripple Rd., Beavercreek, OH 45440. Reprints are not available from the authors.

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