A two-part article on somatization, one part appearing in this issue of American Family Physician1
and the other appearing in the previous issue,2
examines diagnosis and treatment of this illness in primary care. Somatizing patients have symptoms caused by emotional distress rather than physiologic dysfunction. Anne Fadiman's fascinating book The Spirit Catches You and You Fall Down3
tells the true story of the relationship between physicians from a family practice residency in California and a Hmong family. Somatization is a common diagnosis in the Hmong people when they are seen by American physicians. Fadiman sees this as an expression of conflict with what the Hmong perceive to be a hostile American culture. In Fadiman's book, the American physicians report that they dread seeing the Hmong patients because they take a lot of time and then refuse to follow physicians' recommendations.
Somatization is also common among native-born Americans. Many patients struggle within a hostile environment, and many do not have the tools to survive. Suffering with pain that has no obvious pathophysiologic source is one response to a world that is fast-paced and competitive. This psychic pain is real but has no relief.
Where does that leave family physicians? Somatizing patients are difficult. They take a lot of time, they are rarely satisfied with our treatments, they are demanding and they make us feel uncomfortable because we clearly see their suffering but cannot help them. When we are pushed to see as many patients as possible and when capitation creates a disincentive to see patients frequently, it is no wonder that family physicians have little patience with somatizing patients. Like the physicians who dreaded seeing the Hmong patients, we all may be secretly glad when somatizing patients leave to seek care elsewhere.
So what can we do to help these patients? Servan-Schreiber and colleagues1,2
have many good suggestions. We would like to give special emphasis to two of these ideas. The first recommendation is to recognize somatization early in the physician-patient relationship. The authors suggest a process for making a positive diagnosis of somatization, rather than having it become a diagnosis of exclusion after many rounds of unhelpful, frustrating office visits, tests and even invasive procedures. When the diagnosis is made promptly, realistic expectations and appropriate management plans become clear. Then it is possible to begin collaborative work with the patient using approaches that have received mutual agreement from the patient and the physician.2,4,5
The authors' emphasis on less restrictive diagnostic criteria for somatoform disorders than that used for somatization disorder is in keeping with current opinion in primary care.5,6
The second point to emphasize is the importance of developing empathy for these patients. We know that they suffer, and understanding some of the psychologic or cultural stresses in their lives allows us to see their suffering in a context we can understand. Servan-Schreiber and associates1,2
refer to the BATHE technique7
as a structured way of learning about patients' current difficulties in an empathetic but time-sensitive way. If we can understand and know our patients, we often can offer more effective treatment. Also, understanding that patients may be unaware of their effect on physicians is a useful tool for developing the empathy necessary to care for them.
How do we manage ourselves so that we can survive our hectic days yet keep our humanity when treating these difficult patients? Some physicians find that working in teams can be helpful. Because psychodynamic and cognitive-behavioral psychotherapies can be effective for somatizing patients, having a good therapist available to the team can be helpful for the patient and supportive for the family physician. Balint group work8
is specifically geared toward understanding the use of the physician-patient relationship in troublesome interactions such as these. Even referral to a colleague for a short break may be a legitimate alternative. Caring for ourselves allows us the energy to give the compassionate care these patients deserve.