In their article on somatically preoccupied patients in this issue of American Family Physician,1 Righter and Sansone point out that patients who have multiple, physically unexplainable symptoms are a heterogeneous group presenting great challenge and, sometimes, frustration to physicians. Such patients have long been described in the medical literature. In recent years, interest in the somatoform spectrum disorders seems to have been growing, as indicated in part by increased attention in medical textbooks2,3 and in the medical literature noted in the reference list of the Righter and Sansone article.1 The diagnostic approach described by Righter and Sansone, however, would provide many more patients with a diagnosis of somatic preoccupation than would the use of diagnostic criteria for the better defined somatoform disorders.4 The question can be reasonably posed: Is this diagnostic approach too broad and over-inclusive?
Righter and Sansone state that, in the primary care setting, few patients meet the full criteria for a somatoform disorder.1 While it is true that few patients have medical records that actually bear the written diagnosis of somatization disorder, or hypochondriasis, some studies show that somatoform disorders are common in primary care. Certain authors have estimated that 25 to 75 percent of visits to primary care physicians are related to psychosocial problems with somatic presentations.5–7 These patients may consume nearly one half of a family physician's time. Ten years ago, somatization disorder alone was called the fourth most common problem seen in family practice, although another diagnostic label was usually used.7 In addition, 10 to 15 percent of adults per year in the United States have disability from pain disorder with back pain alone.4 Regardless of the estimates of fully recognized somatoform disorders, far more patients have unexplained symptoms and do not meet the full criteria for one of the somatoform disorders. Will the formal recognition of patients with a diagnosis of somatic preoccupation benefit anyone, particularly those patients?
As early as 1986, controlled studies demonstrated that psychiatric consultation in the care of patients who had somatization disorder reduced health care costs and improved their health status.8 This same beneficial effect was demonstrated again, with a broader range of somatizing patients, in a 1995 study.9 Another brief six-week behavioral medicine intervention was shown to benefit a broad range of somatizing patients.10 The somatoform disorders have been recognized as a spectrum of disorders in which the patient may appear at different times to have somatization disorder, pain disorder or hypochondriasis, or to have insufficient diagnostic criteria to fit neatly into any one of those categories.3,11
Righter and Sansone1 suggest that physicians should recognize these patients and develop a plan of management similar to that of the other somatoform spectrum disorders. This suggestion is consistent with those of other authors who have referred to this group of patients as having “subsyndromal somatization disorder,”10 “abridged somatization disorder”11 or “multisomatoform disorder.”12 These patients are now classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as having “undifferentiated somatoform disorder.”4
Other psychiatric diagnoses have been similarly viewed and defined in their “subsyndromal” forms, and treatment of patients with milder symptoms has been shown to be beneficial. These diagnoses include “subsyndromal panic disorder,”13 “subsyndromal depression”14 and “subsyndromal (mixed) anxiety-depression.”15 Recognizing the patient who does not meet the full criteria for one of the better defined somatoform disorders allows the physician to develop a management plan that will help the patient achieve and maintain his or her optimal health outcome. Using this perspective in practice is also consistent with the conceptualization of other common conditions, such as depression, panic disorder and other anxiety disorders.
Whatever label is used to define patients with multiple, physically unexplained symptoms, the management approach is similar. Righter and Sansone also provide an important reminder that, as the number of physical symptoms increases, so does the probability that the patient has a mood disorder or an anxiety disorder.1 After the patient's symptoms are evaluated and no general medical or psychiatric disorder is found that needs treatment, the management described by Righter and Sansone1 and the tables presented with the article represent an approach that is most likely to help these patients. The proposed treatment approach is also cost-effective, empathic and the most personally rewarding approach for the physicians who care for these challenging patients.