Mrs. M, age 34, was referred for psychiatric evaluation by her primary care physician. She reluctantly agreed to the referral and tells the psychiatrist she “really should be seeing a cardiologist.” Numerous evaluations for chest pain and palpitations—including seven emergency room visits, ECGs and cardiac catheterization—have revealed no medical pathology.
A divorced mother of two children, she says she feels anxious about her “heart condition.” Her father died of a heart attack at age 51. She experiences chest pains at home and at work, particularly when under stress. Sometimes she feels her heart racing and numbness or tingling in her arms.
Although her primary care physician has seen her frequently during the past 6 months, she says the doctor is not taking her complaints seriously. “These chest pains are real,” she says, “so don’t try to tell me they’re all in my head.”
Psychiatrists may be the last doctors patients such as Mrs. M wish to see but the ones best equipped to relieve their suffering. Our experience in treating somatizing patients and the available evidence suggest that cognitive-behavioral therapy (CBT) combined with psychoeducation, reassurance, and sometimes drug therapy is the most effective approach.
Illness worry: When does concern become pathology?
Health-related fear—or “illness worry”—is common, occurring in nearly 10% of adults who responded to a recent community survey.2 When this fear drives individuals to their physicians for evaluation, frequently no organic cause is discovered. Full evaluations are expensive and lead to increased use of health care resources, including potentially dangerous invasive testing.3,4
Defining somatization has been a source of confusion.5,6 Some authors consider somatic complaints to be expressions of suppressed psychosocial stressors. Others label them as medically unexplained complaints, although this definition fails to exclude occult medical problems. Kleinman7 defines somatization as “a somatic idiom of psychosocial distress in a setting of medical health-care seeking.” This useful definition links psychosocial problems with somatic complaints and the behavioral drive to obtain a medical evaluation.
In DSM-IV,8 the defining characteristics of somatoform disorders are somatic complaints or disease fears that are out of proportion with any identifiable somatic cause. Entities include somatization disorder, undifferentiated somatization disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder, and somatoform disorder–not otherwise specified (NOS).
Subthreshold symptoms. Unfortunately, DSM-IV’s categorization of Axis I somatoform disorders does not capture subthreshold presentations, which are common. Patients with less than the required number of somatic complaints are labeled in a wastebasket fashion with “undifferentiated somatoform disorder.”9
Mrs. M’s persistent chest pain of noncardiac origin is a familiar health anxiety, along with functional GI complaints, headaches, chronic fatigue, and lower back pain. Frustrating to their doctors and frustrated themselves, patients with medically unexplained complaints consume an inordinate amount of physicians’ time.1
Without a clear definition of somatization (Box)2-9 or useful clinical guidelines, psychiatrists must rely on the literature for guidance in managing somatization disorders. This article summarizes the evidence and describes how we apply these findings to practice. And when all else fails, we offer last-ditch advice for managing patients who resist your treatment efforts.
IDENTIFYING COMORBIDITIES
Identifying psychiatric comorbidities is the first step in successfully treating patients with somatoform complaints. In an epidemiologic study, 60% of patients with somatoform complaints also had a mood disorder and 48% had an anxiety disorder.10 In a similar study of patients with hypochondriasis, 88% also had one or more Axis I diagnosis.11
If a patient meets criteria for a comorbid psychiatric disorder and is willing to be treated for it, the somatic complaints may resolve along with the underlying disorder. In fact, the presence of an identifiable Axis I disorder order may predict a more positive prognosis.12
Personality disorders. Somatization in patients with a personality disorder poses unique challenges.13 Granted, when making a diagnosis it is difficult to tease apart somatization from personality disorders because somatization itself may be considered a chronic, maladaptive coping style. However, symptoms such as deception, impulsivity, mood lability, and self-injurious behavior introduce treatment complications that exceed the scope of this article.
Posttraumatic stress disorder (PTSD)—particularly childhood sexual and physical abuse—also predisposes some patients to somatization disorders.14,15 Patients with comorbid PTSD and somatization disorder require highly specialized treatment that is beyond the scope of this review.
COGNITIVE-BEHAVIORAL TREATMENT
Cognitive-behavioral therapy (CBT) is the best-studied and most effective treatment for somatoform disorders.16 CBT for somatization relies on both physiologic and cognitive explanations to account for the patient’s experience, without committing to an “either/or” dichotomy. It offers patients an alternate explanation of what is wrong with them—illness anxiety instead of severe physical illness.