Handbook of Consultation-Liaison Psychiatry

14. Hypochondriasis and Somatization Disorder

Don R. Lipsitt


14.1 The Concept of Somatization

14.2 Classification

14.2.1 From DSM-I to DSM-III

14.2.2 Case History (Part 1)

14.3 Diagnosis

14.3.1 Hypochondriasis

14.3.2 Somatization Disorder

14.3.3 Case History (Part 2)

14.4 The Consultation-Liaison Psychiatrist's Role in Somatization

14.5 Conclusion

On a busy day in a general physician's office, perhaps 50% or more of the patients with physical complaints will have no definitive explanation for their ailment (Kroenke and Mangelsdorff, 1989). The patients present with distress from fatigue, chest pain, cough, back pain, shortness of breath, and a host of other painful or worrisome bodily concerns. For most, the physician's expressing interest, taking a thorough history, doing a physical examination, and offering reassurance, a modest intervention, or a pharmacologic prescription suffices to assuage the patient's pain, anxiety, and physical distress. But for some, these simple measures fall short of their expected result, marking the beginning of what may become a chronic search for relief, including frequent anxiety-filled visits to more than one physician, and in extreme cases even multiple hospitalizations and possibly surgery.

The longer and more persistently this pattern appears, the more likely it will generate referrals to specialists for expert consultation, greater frustration in both the primary physician and the patient, and ultimately dysfunctional patient physician relationships with inappropriate labeling of the patient as a "problem" or "difficult" patient, and perhaps even worse (Lipsitt, 1970).

This pattern of medical care seeking has been well documented for hundreds of years, accompanied by earnest attempts to understand and describe the phenomenon. Robert Burton's (1621) Anatomy of Melancholy described the melancholic and hypochondriacal person. Crediting Hippocrates, Galen, and others, Burton described hypochondriasis (or "windy melancholy") as an illness that "most commonly [begins with] fear, grief, and some sudden commotion, or perturbation of the mind in such bodies especially as are ill-disposed" (p. 249). The symptoms, he said, are "so ambiguous," that "the most exquisite physicians cannot determine of the part affected" (p. 269).

This difficulty of diagnosis has been reflected through the ages, as one term has been supplanted by another in attempts to quell the discomfort of uncertainty that surrounds patients with multiple recurring physical symptoms; these terms include spinal irritation, hysteria, dissociation, neurasthenia, functional disorder, psychophysiological disorder; psychosocial complication, psychosomatic, unexplained medical disorder, and somatization (Shorter, 1992).

It is this last term, somatization, that has come, not uncontroversially (Martin, 1999; Wessely et al., 1999), to be the most widely applied to patients whose physical symptoms motivate them to seek medical care and to take medications in hopes of finding relief from what distresses them (Lipowski, 1988). An entire spectrum of somatizing (or somatoform) disorders has been enshrined (perhaps temporarily) in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). After a brief review of the concept of somatization, I will address two of the more commonly confused somatoform disorders: hypochondriasis and somatization disorder.

14.1 The Concept of Somatization

Coined first, not, as conventionally thought, by the German psychoanalyst Wilhelm Stekel, but by his translator in 1925 (Marin and Carron, 2002), who was searching for an approximation to the German organsprache (organ-speech), the word somatization at first was close to Freud's concept of conversion. When Stekel (1943) later used the word in an English-language book on dreams, he defined it as the bodily representation of a deep-seated neurosis, the expression of mental conflict through organ language (Kellner, 1991). Freud (1905) had called it "somatic compliance" in his early studies of hysteria, referring to the symbolic representation in particular organs of an otherwise insoluble emotional conflict.

Somatization has since achieved some popularity as a way to comprehend the variety of ways in which mind and body seem to interact. The word helps to establish a bridge between such diverse conditions as hypochondriasis or conversion and irritable bowel syndrome or chronic fatigue syndrome. The term and concept are not universally approved, and indeed there is some early action on redefining somatoform disorders in the next DSM edition.

Theories about somatization are scarce, but at least one group of authors has attributed it to abnormalities of attachment in early life (Waller et al., 2002). A more psychoanalytic explanation is provided by the Viennese psychoanalyst Max Schur (1955), who was also Freud's primary care doctor. Schur's theory provides a developmental model in which the infant's undifferentiated somatic responsiveness to all stimuli gives way, with the development of language and increased ego mastery, to a more de-somatized state with normal emotional adaptation. In the face of trauma or developmental failure, otherwise normal adaptation reverts to a previous somatic state in which physical representation becomes the major response mode.

Given our common developmental heritage, we are all in one sense or another and one time or another somatizers. But it is only those individuals concerned about or distressed enough by their physical reactions to seek medical attention or take medications who earn the name "somatizers." Such individuals tend to attribute their somatic symptoms to signs of physical illness, even in the absence of pathologic medical findings. Consulting a primary care physician often marks the beginning of what, for many, becomes a lifelong quest for relief.

14.2 Classification

Classification is an earmark of science and especially medicine, wherein the recognition of similarities and differences permits manageable groupings for research, communication, and treatment with the greatest parsimony. Major contributions to medicine by the earliest physicians like Hippocrates and Galen addressed this problem in efforts to understand and treat the many symptoms they encountered in their patients. In time, progress is achieved through constantly evolving and, it is hoped, better classifications. In mental illness, classification and "official" recognition of a uniform nomenclature of mental disease is a rather recent enterprise. Beginning with the collection of hospital statistics in 1917, classification gradually paid more attention to diagnosis and treatment, with the first DSM classification established after World War II.

14.2.1 From DSM-I to DSM-III

From the very earliest days of efforts to classify mental disorders, how to characterize somatization clearly presented a very sticky problem. In choosing the subclassification of psychophysiologic autonomic and visceral disorders, the authors of the first edition of the DSM (DSM-I) wrote, "This term is used in preference to `psychosomatic disorders,' since the latter term refers to a point of view on the discipline of medicine as a whole rather than to certain specified conditions. It is preferred to the term `somatization reactions,' which term implies that these disorders are simply another form of psychoneurotic reaction" (American Psychiatric Association, 1952, p. 29). Thus, the place of somatization in the lexicon and theory of psychiatric disorder has had a long and controversial journey.

A large number of practicing psychiatrists and others, in attempts to lend some structure and common language to the vast field of "unexplainable" medical syndromes, finally located the unifying concept of somatization in a separate formal classification. Beginning in 1980, the third edition of the standardized nomenclature (American Psychiatric Association, 1980) introduced the category of somatoform disorders and somatization, replacing the previous catalog of so-called psychophysiological disorders. Although verbally described as distinct entities, the spectrum of somatoform disorders is large, diffuse, and often defying of definitive diagnosis. While sometimes distinguishable one from another, they all share the symptomatic representation of somatization. Sometimes mistaken for a diagnosis itself, somatization is more appropriately acknowledged as merely a descriptive term for a process, much as fever might be for a host of diseases.

Physicians, frustrated by the challenge of accurately diagnosing patients with medically uncertain syndromes, may pejoratively simply characterize such patients as "somatizers" in cases that in previous decades have called forth such epithets as "crock," .. gomer," turkey," or worse (Lipsitt, 1970).

Because most patients with unremitting physical symptoms of uncertain origin are more likely to consult a general physician than a psychiatrist, patients with somatoform disorders are seen infrequently in general psychiatric practice and more frequently by psychiatrists who work closely with nonpsychiatrist colleagues in medical settings. It often falls to the consultation-liaison psychiatrist to treat or manage these patients in the medical setting or to adopt a pedagogical relationship with primary care physicians to help them treat these patients.

A case history helps to elucidate the commonalities of somatizing patients, as well as the diagnostic and therapeutic challenges of sometimes confusing clinical presentations.

14.2.2 Case History (Part 1)

Melissa, an attractive, intelligent black college student, was referred to a psychiatrist at the age of 27 by her primary care physician (PCP) requesting help with "this complex and problematic young woman." He had been seeing her for about a year for complaints of left-sided abdominal as well as pelvic pain and urinary frequency. Having failed to obtain relief with over-the-counter medications, she urgently sought medical help and recommendations. Her physician, a highly skilled and competent young doctor; assiduously pursued an explanation for her symptoms, including referrals to a gastroenterologist, two urologists, and three gynecologists; they added equivocal diagnoses to her history of gastroenteritis, esophageal reflux, irritable bowel syndrome, cervical inflammation, and diverticulosis. Because of a fear of cancer, she also underwent several cystoscopies with vaginal and urethral biopsies, with negative results. Her repeated thorough physical examinations and all laboratory and procedural studies were within normal limits. On verbal referral to the psychiatrist, Melissa's doctor revealed that he was "concerned about the frequency of her visits to a hospital emergency room and to various physicians," and also "about the increasing aggressiveness of the workups she was receiving despite essentially negative data."

The consulting psychiatrist found Melissa to be a willing, if dubious, patient, eager for "anything that will help the pain" and "get my life back on track." He learned that she had experienced a "painful belly" since around age 5, and that both her mother and father, who both had "drinking problems," took her to doctors at a young age. Her father was an advertising executive who had lost his job; her mother worked as a secretary and battled a skin disorder for many years. Melissa revealed little capacity, in spite of her obvious intelligence, for any psychological assessment of her distress or her relationships to family and others. She had been close to a grandfather who died of colon cancer, and she remembers thinking "catastrophic thoughts" when she first began to have crampy periods around the age of 12. Her grandmother had died of diabetes only a few years ago.

In spite of a long-standing struggle with vague pains, Melissa had managed to do her college work reasonably well until she began a sexual relationship with a boyfriend. At that time, all of her pains escalated, with additional throbbing sensations in her urethra, painful intercourse, and painful urinary frequency. As repeated referrals turned up no satisfactory explanation for her symptoms, she became more and more anxious and demanding in seeking medical care. She was reading the medical literature and raising questions about illnesses she thought she might have. Attempts at reassurance by her doctors had fallen on deaf ears. To her doctor, she was also beginning to seem depressed. She had begun to complain of additional symptoms including back and hip pain and constipation.

The psychiatrist recommended to Melissa's physician that he see her on a regular basis, but severely curtail further surgical and medical workups. Although she did not seem a strong candidate for psychotherapy, listening to her story and tolerating her complaints without an urge to "do something" might be of some help. Prescribing an antidepressant (beginning with small doses) could possibly ameliorate both pain and depression, but should not be administered with any optimistic promise of fast (or any) results. He suggested that a stable, continuous patient physician relationship could potentially offer the greatest therapeutic benefit and that definite appointments should be made unrelated to occurrence or intensity of symptoms.

14.3 Diagnosis

14.3.1 Hypochondriasis

To qualify for a diagnosis of hypochondriasis, Melissa would have to fulfill the criteria for that somatoform disorder as outlined in DSM-IV, which include the following: (1) a persisting preoccupation with having a serious disease based on misinterpretation of symptoms, despite normal findings on medical evaluation and reassurance; (2) the preoccupation is not of delusional intensity and is not confined to a circumscribed concern about appearance, as in body dysmorphic disorder; (3) the preoccupation causes significant distress or impairment of function; (4) the duration is at least 6 months; and (5) the preoccupation is not secondary to generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, major depressive episode, separation anxiety, or another somatoform disorder.

Melissa's intense anxiety and depressive accompaniment to her somatic concerns, with her increasing frustration, began to affect her relationships, at least with her recent boyfriend, but it is not clear which comes first concern about pelvic distress worsening her sexual performance, or interpersonal tensions resulting in physical expression. She has not yet shown evidence of psychotic ideation, unreasonable preoccupation with bodily appearance, or significant impairment in her schoolwork. Cancer phobia does seem to have played a part in prompting physicians to repeatedly try to reassure her, with biopsies and other instrumentations, that she is not afflicted with this disease, although she does not feel reassured. And while her major symptoms do appear to be of recent onset, there is clear evidence of long-standing somatic preoccupation, at times even with "catastrophic" fears.

While we might be inclined to accept a diagnosis of hypochondriasis for Melissa, we might gain more clarity by examining other dimensions of this disorder and comparing it later to another somatoform condition-somatization disorder. Clinical Features and Patient Behavior

A physical complaint is the most common entree to a medical care scenario. It is the "bread-and-butter," so to speak, of medical practice, and nothing is considered unusual when a patient first complains of a cough, a backache, fatigue, or dizziness. It is only when such symptoms resist remission with routine or simple measures and interventions that a physician's antennae become attuned for "more than meets the eye." Each physician's threshold for such alertness varies, and some may be tolerant of months or even years of chronic complaint without physical findings before acquiescing to a different view than a strictly biomedical one. Since somatizing patients themselves are not often inclined to use emotional language to describe their distress, their physicians may be dissuaded from exploring this dimension of the patient's experience.

Increasing chronicity often leads to escalating frustration, even restrained anger. Physicians become increasingly aggressive in pursuit of elusive physical etiologies and patients become more and more disappointed in the reports of specialists to whom they are referred for extensive and expensive evaluations. The pinnacle of such dynamics is often a series of dysfunctional patient physician relationships, "doctor-shopping," and resort to marginal remedies of often doubtful worth (Lipsitt, 2001a). If psychiatric referral is regarded an "end-ofthe-line" gesture, it is often made with distorted or inappropriate preparation by the physician and inadequate understanding and resentment by the patient. While this pattern of behavior by itself does not distinguish hypochondriasis from other somatoform disorders, it does begin to characterize the field in which patient and physician will engage one another. Epidemiology and Prevalence

Many individuals manifest a hypochondriacal orientation toward life, but very few actually qualify for a bona fide diagnosis of hypochondriasis. Originally thought to be a disease only of men, it is now recognized as an equal opportunity illness, affecting men and women in similar numbers. Because good epidemiologic studies rely on valid measures of the disease, an illness with such a long, colorful, and changing history does not lend itself easily to such investigation. Recent studies, using such standardized scales as the Whitely Index, the Somatic Symptom Inventory (of the Minnesota Multiphasic Personality Inventory, MMPI), and the Illness Worry Scale, have been able to identify hypochondriasis as a valid distinguishable disorder (Speckens, 2001). Prevalence rates, highly dependent on populations examined, have ranged from 1% to 25%. A worldwide population study, involving 15 sites, established a prevalence rate of 2.2% for hypochondriasis in general populations (Gureje et al., 1997; Simon, Gater et al., 1996). Making fine distinctions among illness phobia, illness fear, bodily preoccupation, and disease conviction is not easy and will alter prevalence rates considerably. Diagnosis

An extremely broad and lengthy spectrum of somatizing primary and secondary disorders makes diagnosis more challenging. Some clinicians prefer simply to describe "hypochondriacal tendencies," or "evidence of somatization" rather than use the specific designation of hypochondriasis, unless the condition almost reaches the threshold of somatic delusion. Of course, consultation and treatment that depend on a specific diagnosis to be eligible for reimbursement by insurance companies will be designated with that formal somatizing disorder that appears most salient in the patient's history and presentation. Controversy prevails among clinicians as to when hypochondriacal behavior represents low-level "illness worry," reasonable attentiveness to physical needs, a personality disorder, or a variant of obsessive-compulsive disorder (Tyrer et al., 1990). Methods of Assessment

The clinician's assessment of patients for hypochondriasis includes a careful review of the prior history, considering all physical investigations and the course of the illness. A good current interview attends to how the patient relates to his or her body, the language used to describe symptoms, and the interactive nature of the encounter as engaged, avoidant, trusting, or doubtful. The past history of the patient-physician relationships sometimes predicts future relationships but should not be exclusively relied on. The patient's capacity for collaborative exploration may define the level of opportunity (or absence) for developing a trusting alliance. A readiness to accept reassurance may anticipate the patient's postexamination response to findings, supportive comments, and suggestions.

Observing patients' reactions of fear, anxiety, or neutrality in discussion of symptoms or diseases, as well as distorted thinking and erroneous knowledge about them, can establish patients' hypochondriacal attitudes toward their symptoms.

While somatizing patients referred for psychiatric assessment may become angry at their primary physician for implying that their physical symptoms are not real, not important, a sign of "craziness," or evidence of desperation in their physician, they may nonetheless be willing to comply with paper and pencil assessments, such as the Structured Diagnostic Interview for Hypochondriasis (SDIH) (Barsky et al., 1992); the Illness Behavior Questionnaire (IBQ) (Pilowsky et al., 1984); the Somatosensory Amplification Scale (SSAS) (Barsky et al., 1990); and the Whitely Index (WI) (Pilowsky, 1967). Illness Attitude Scales (IAS) are available for more extensive assessment (Kellner et al., 1983-4). Inclusion of an assessment of typical coping responses to ordinary (as well as extraordinary) life stresses sheds light on the patient's illness behavior (Pilowsky, 1969).

Of all the above-cited assessments, the Whitely Index is perhaps the most useful and easiest to administer with individual patients. It is available at http://www.uib.no/med/avd/med_a/gastro/wilhelms/whiteley.html. How the elicited data are utilized in either medical or psychiatric practice depends on each physician's individual practice style. Research

There has been increasing interest in researching the etiology, prevalence, and treatment of hypochondriasis. The search for pharmacologic agents that can bring relief to sufferers of hypochondriasis has been especially robust, but, as yet, without adequate random controlled trials that can promote the clinician's confidence in everyday practice (Fallon, 2001). To the extent that hypochondriasis is accompanied by depression, anxiety, or obsessive-compulsive disorder, there is good research evidence that drugs found effective in those conditions will bring some symptomatic relief to hypochondriacal patients without necessarily changing the basic disorder. Other studies have shown that thoughtful application of reassurance can be useful with patients not ordinarily considered amenable to this intervention (Starcevic, 2001). A growing interest in the relative efficacy of cognitive-behavioral treatment, both in groups and individually, has fostered research that validates this approach (Barsky, 2004; Salkovskis and Warwick, 1986; Simon, 2002). A very recent report of the application of interpersonal psychotherapy based on attachment theory premises offers an unsubstantiated promise of effective intervention (Stuart and Noyes, 2006).

In post-Hippocratic days, hypochondriasis was acceptably attributed to disorders of various organs, such as the spleen, liver, stomach, and lungs, until evolving science was able to rule out such etiologies, rendering symptoms "unexplainable." Now, science is also beginning to fill in the blanks of the mysterious leap from mind to body with potentially explanatory findings in neurocircuitry and molecular metabolites (Lipsitt, 2000). Imaging and neuroen- docrinologic research, while exciting and promising, has not yet achieved transferability to the practicing psychiatrist or internist eager to treat somatizing patients. Hypochondriasis and Primary Care

It is the primary care physician who is and will continue to be the mainstay of care for the millions of somatizing patients in the health care system.

Because physicians are trained primarily to detect physical rather than emotional illness (the biomedical approach), inordinate amounts of time can be squandered searching for physical explanations for "mysterious" presenting complaints. The risks include delayed recognition, diagnosis and treatment, high and excessive utilization of medical resources, unreasonable and unnecessary costs, and prolonged suffering before the essential diagnosis and intervention are instituted. Such pitfalls can be avoided with the collaborative assistance of psychiatrists or other mental health professionals (Lipsitt, 1996).

The presentation by the patient of a physical complaint does not automatically put the physician in mind of a somatoform disorder. Nonetheless, with increasing chronicity and a lack of explanatory physical findings, the continuing presence of unexplained physical symptoms should place this category of disorders close to the top of a differential diagnosis list. The entire category of somatoform disorders offers a number of often overlapping options besides hypochondriasis: conversion disorder, pain disorder, somatization disorder, and undifferentiated somatoform disorder. Once symptoms are ruled out as due to a general medical condition, substance use/abuse, body dysmorphic disorder, other mental disorders, and malingering or factitious disorder, the primary care physician is faced with a perplexing choice. And for the PCP, unfamiliar with the nuances of the many subsyndromal somatized presentations, the somatizing patient presents a formidable and ultimately frustrating challenge. A frequent solution to the dilemma is a "seat of the pants" maintenance approach that may either plateau to a tolerable truce or arrive at some critical nodal point where marked change is called for. However, if the predominant clinical picture is one of excessive preoccupation with a fear of having a disease, the PCP might reasonably settle on the diagnosis of hypochondriasis and acceptably maintain the patient, employing recommended management principles (Avia and Ruiz, 2005; Bass and Benjamin, 1993; Lipsitt, 1987; Simon, 2002). The Patient-Physician Relationship in Hypochondriasis

In those instances where a trusting working relationship is not established between the somatizing patient and his or her PCP, the resulting perturbations run the risk of creating a dysfunctional, discordant, or ruptured relationship (Lipsitt, 2001b). Mutual dissatisfaction, distrust, and frustration leading to anger can result in excessive referrals by the physician and futile "doctor-shopping" by the patient. The physician's capacity for empathy may be diminished in such a context, and the propensity for labeling the patient may be invoked. Branding a patient a "problem patient" may unfortunately establish an unwarranted profile that adheres to the patient throughout his or her medical "career." This behavioral characterization does not necessarily distinguish hypochondriasis from other somatoform disorders (Lipsitt, 2001b). Specific Aspects of Treatment

Management and treatment of hypochondriacal patients utilize principles applicable to all somatizing patients: respectful acceptance of the patient's complaints and symptoms; listening with patience to the (usually physical) narrative; thoughtful restraint about psychological interpretation, referral, or prescription; and emphasis on care rather than cure. The judicious use of medication (as yet inadequately proven with good randomized controlled trials) for accompanying anxiety, depression, or obsessive-compulsive tendencies may produce some improvement but not sufficient to terminate treatment. Whether individual or in groups, whether supportive or cognitive-behavioral, all treatment rests on a platform of a trusting patient-physician relationship, and continuity of care with regular appointments at increasingly wider intervals according to the patient's tolerance and agreement.

If there is a distinguishing feature of treating patients with hypochondriasis, it probably resides in the nature of the complaint and persistent presentation of elusive and resistant symptoms that may readily change in nature. This fluctuating pattern may severely test the clinician's tolerance, more than disorders that show greater consistency in symptomatic expression.

Acknowledging Melissa's diagnosis as a somatoform disorder, the next most likely possibility is somatization disorder, formerly known (pre-DSM) as Briquet's syndrome (Guze, 1983).

14.3.2 Somatization Disorder

To qualify for a diagnosis of somatization disorder (SD) by DSM-IV criteria, Melissa would have to fulfill the following criteria: (1) a history of many physical complaints over a period of years, with onset before age 30, with significant impairment for which treatment is sought; (2) at any time during the course of the illness, there must have been (a) four pain symptoms in at least four different sites or functions such as during menstruation or urination; (b) at least two gastrointestinal symptoms; (c) at least one sexual symptom other than pain, e.g., irregular periods or erectile dysfunction; (d) at least one pseudoneurologic symptom not limited to pain, e.g., weakness, blindness, seizures, amnesia; (e) for each of these symptoms, appropriate investigation either fails to reveal a medical disease or substance that fully explains it, or, if a medical disease is found, the symptoms or functional impairment far exceed what might be expected from the disease; and (f) the symptoms are not intentionally produced or feigned, as in factitious disorder or malingering.

Before examining each of these criteria in Melissa's case, a general clinical profile is offered. Clinical Features and Patient Behavior

Patients with SD are likely to attribute their distress to the symptoms themselves rather than, as in the case of hypochondriasis, to their meaning, and to more assertively seek symptom relief. Patients with SD are more likely to be women, often with histrionic coloring in their personality (compared to the more obsessional quality of hypochondriacal patients). They may also present themselves more dramatically in their help-seeking fervor, and rather than reject offers of help, show greater receptivity to whatever might be offered (or not). They may also reveal a stronger family history of personality disorder, alcoholism, or sociopathy. Physicians may be impressed with the multiplicity of prior symptoms, diagnoses, and surgeries beginning at an early age. When patients with suspected SD are asked how long they have been sick, a common response is "all my life." The general picture is one of greater stability than that in hypochondriasis. Epidemiology and Prevalence

Although the incidence of subsyndromal somatization as seen in primary care is quite high, SD in the general community is thought quite rare, according to the Epidemiologic Catchment Area (ECA) Study (Swartz et al., 1990), estimated at 0.13%. Nevertheless, patients referred for psychiatric evaluation from primary care resources have been estimated at 6% (Katon et al., 1984) to 34% (Smith, 1995). Diagnosis

Having derived from an earlier diagnosis of Briquet's syndrome (or hysteria), SD is more likely than hypochondriasis to show a kinship with conversion disorder. Pierre Briquet, a French neurologist, was the first to free the definition of hysteria from its primitive notions of abnormalities of female reproductive organs, namely the "wandering uterus." In 1859, he described a dramatic syndrome with 59 different accompanying symptoms in women, many of which were of a sexual or painful nature. Briquet regarded this illness very seriously and attributed it to a brain defect in "that portion of the encephalon where affective functions are located" (Shorter, 1992, p. 212). Perley and Guze (1962) established the validity and stability of the syndrome, which was subsequently renamed somatization syndrome (Bass, 1990) in the DSM-III.

Because of the cumbersome diagnostic criteria, Briquet's 59 symptoms were reduced to 37, of which 13 were considered sufficient to establish the presence of SD. Even this degree of abbreviation was found unwieldy, heralding an abridged set of criteria showing consistency with DSM-III-R criteria (Smith, 1995). The DSM-IV specifies a requirement of eight symptoms from the criteria as specified above. Escobar and associates (1989) devised the Somatic Symptom Index (SSI), requiring only four symptoms for males and six for females to reach diagnostic significance and concordance with DSM criteria. Syndromes that do not fulfill SD criteria but show other characteristics of the disorder are classified as undifferentiated somatoform disorder. Methods of Assessment

In addition to the usual history, physical examination, and assessment of illness behavior, screening instruments are available (but probably seldom used) for use in primary practice (Othmer and DeSouza, 1985; Swartz et al., 1986). A unique method of assessment and treatment has been developed by Wickramasekera (1989) using tests of hypnotizability and neuroticism to identify the tendency to somatize, then selectively used in a variant of biofeedback treatment; the complexity of this approach, while creative in its implementation, renders it unlikely as a method that can be integrated into primary care practice (Lipsitt, 1998). Research

To date, there is no definitive treatment for SD, although interest in the promise of cognitive-behavioral therapy continues to grow (Allen, 2002; Simon, 2002). Reports indicate some success with noncontrolled educational approaches that help patients reattribute their physical symptoms to psychosocial stressors (Goldberg et al., 1989). The ability of PCPs to effectively follow suggested management guidelines was impressively demonstrated in a randomized controlled study using only a consultation letter to assist physicians in the management of patients with SD (Smith et al., 1986). Patients were managed more effectively, with decreased utilization and a 49% to 53% savings in cost of health care, although physical and emotional characteristics remained essentially unchanged. A replicated study was able to demonstrate emotional and physical changes (Rost et al., 1994). Eight-session group therapy in a randomized controlled trial with 70 SD patients demonstrated lasting physical and emotional improvement 1-year poststudy (Kashner et al., 1995). Regarding targeted pharmacotherapy, anecdotal and case series reports suggest potential benefit from paroxetine (Okugawa et al., 2002), nefazodone (Menza et al., 2001), and other selective serotonin reuptake inhibitor (SSRIs) (Viswanathan and Paradis, 1991), but controlled studies are lacking. Somatization Disorder and Primary Care

Again, as with hypochondriasis, the primary care physician must often resort to "seat of the pants" approaches. The consultation-liaison and primary care literature offer empirical guidelines for the primary practitioner, but most general physicians are either too burdened by competing practice demands or lack the foundation skills and knowledge to support application of recommended interventions. Interest in treating the somatizing patients leans toward the biologic, drug-prescribing side of the interventional spectrum; results often compound the disappointment and frustration of managing SD patients in office practice. Untutored efforts at psychiatric referral may result in aborted attempts to procure specialist advice or care. Some early experience with team or collaborative approaches would appear to show some promise (Lipsitt, 1996; Smith, 1995). The Patient-Physician Relationship in SD

Repeated failures at well-intentioned therapeutic efforts may generate either increasingly aggressive attempts at treatment or resignation and withdrawal from the patient. Either vector is likely to escalate tension in the relationship, to the point of rupture. This end point adds to the patient's history of a succession of failed relationships with physicians; in the meantime, the patient's search goes on for someone who can listen without feeling overwhelmed, who is not impelled to act, and who can hold a middle ground that gives stability, confidence, and quiet reassurance to the patient. Specific Aspects of Treatment and Management

Recommended approaches to treatment are cited in the above sections. But guidelines unfortunately are more general than specific. If there are differences in working with hypochondriacal patients as contrasted with SD patients, they may relate to a difference in entrenchment of patterns of illness behavior and relative time spent in the "sick role." The SD patients have usually had more of a "career" in unremitting illness, disappointment, frustration, and anger, while those with hypochondriasis are more often in the beginning stages of their illness and may even be able to apply a modicum of insight to their plight. In either situation, gratification for the dedicated physician comes slowly, but it is rewarding when some small change occurs. Group approaches, using cognitive behavioral techniques, have found favor partly because of a more economic method and a lower intensity of interaction with therapists (Barsky, 2004; McLeod et al., 1997).

14.3.3 Case History (Part 2)

Is Melissa's diagnosis hypochondriasis or somatization disorder? If we must make a choice at this point for purposes of documentation or therapeutic selection, it is evident that uncertainty reigns. As far as presentation goes, Melissa does manifest multiple symptoms, strong concern that she could have cancer, difficulty being reassured about her negative workups, a history of failed patient-physician relationships, multiple specialist referrals, operative explorations, and an early onset of physical concerns. There is a history of alcoholism in the family as well as an environment of physical illness and death.

The most salient features of hypochondriasis are perhaps the preoccupation with the idea of serious or fatal illness and the inability to be reassured. SD is more characterized by an early persisting history of multiple somatic symptoms. Melissa did complain of lifelong "digestive problems," as well as constipation and other physical problems from the age of 5, and she is not yet 30. She had pain on menstruation, hip and back pain, urethral pain, and a long history of "belly pain." Her nonpainful sexual or reproductive symptoms included urinary frequency and difficult intercourse. There is no evidence that her symptoms represent conversion and would thus cast doubt on a full diagnosis of SD.

We are left with the clinical picture of a woman who most certainly has a somatoform disorder, but clearly defining it as hypochondriasis, somatization disorder, undifferentiated somatoform disorder, or even pain disorder presents a perplexing clinical challenge. At this time in her clinical course, it may be less important to make a definitive diagnosis (other than somatoform disorder) than to apply the general principles of working with somatizing patients of all diagnostic types.

Therefore, how might we be of assistance to Melissa and her concerned, diligent physician?

14.4 The Consultation-Liaison Psychiatrist's Role in Somatization

Because of consultation-liaison (CL) psychiatrists' immersion in medical settings and familiarity with comorbidities, they are well equipped to be of help to both the somatizing patient and the physicians who seek solutions to understanding and treating them. Although their prevalence in the general community is rather rare, they constitute a burdensome challenge to physicians as both in- and outpatients. Whether providing direct therapy or only consultative recommendations and support for the PCP, the CL psychiatrist employs and transmits to the referring physicians those principles of interviewing and management alluded to earlier. The CL psychiatrist is familiar with a biopsychosocial approach, psychodynamic concepts, stress theory, general medicine, and psychopharmacology, permitting a pragmatic, flexible approach.

The CL psychiatrist's ability to conduct a medical-psychiatric interview enables patients to give essential data in an empathic, respectful setting without feeling threatened or rejected, an experience that may seem rather rare for them. Knowing when to withhold or confront patients with psychological interpretations enables the CL psychiatrist to address the patient's worries and fears without puzzling or frightening the patient with emotional (rather than physical) language. The CL psychiatrist has learned to curb therapeutic zeal with these patients, and transmitting this attitude to the PCP has a powerful effect in reducing the PCP's guilt and frustration about poor results. Perhaps most useful of all, the CL psychiatrist can instruct the referring physician in how to create a supportive holding environment for the patient by reducing workups, referrals, and desperate interventions, and instead offering the patient regular (even if infrequent, but definite) appointments.

In the general hospital setting, when somatizing patients are admitted for medical care, the CL psychiatrist can help patients adapt to the sick role, and to endure or minimize pain, fear, and denial. He or she can serve as a "bridge" between the patient and the caregiving staff, who may need help in understanding the patient's illness behavior and minimizing countertransference reactions. Even brief engagement with the somatizing patient and hospital staff can have a profound psychotherapeutic effect (Lipsitt, 2002).

Writing a jargon-free explanatory consultation note with clear recommendations for posthospital management helps the PC psychiatrist maintain the discharged patient; an alliance established in the hospital may carry into the outpatient setting. In the outpatient setting, the CL psychiatrist can make him- or herself available for supportive collaborative assistance on an as-needed basis; this can sometimes be a prelude to easy future referral for more specific combined pharmacotherapy/psychotherapy. Depending on the patient's interest and receptivity, various treatment measures can be suggested, whether cognitive-behavioral therapy, individual, group, and so on.

14.5 Conclusion

Melissa represents a population of patients relatively common in general medical practice. While somatization is nonspecific, it covers a wide spectrum of disorders. There is little definitive treatment and most effective interventions have derived from an abundance of clinical literature describing experience with these patients. The bedrock of any treatment is likely to be a trusting patient physician relationship. A case can be made for Melissa's diagnosis bridging both hypochondriasis and somatization disorder, but diagnosis per se may be less important than recognizing the presence of the somatization process, its impact on the patient's behavior, and its influence on the nature of the patient-physician relationship. The CL psychiatrist can work effectively with primary care clinicians to help many such patients adapt to a lifestyle that will optimize if not totally change their ability to experience satisfaction, pleasure, and gratifying relationships. Not the least is also the likelihood of immeasurably improving the PCP's usual workday. Saving the excessive costs of inappropriate health care utilization is a welcome by-product (Lipsitt, 1992).


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