JET pe = w TEN ETT National Institute of Mental Health Disorder in the Medical Setting U8. DEPOSITORY | Lo ¢ AUG 13 1990 bo : U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration Lela ASE EF = Doma bh oe a Cle Disorder in the Medical Setting G. Richard Smith, Jr., M.D. Departments of Psychiatry and Medicine University of Arkansas for Medical Sciences U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute of Mental Health 5600 Fishers Lane Rockville, Maryland 20857 This report was developed under contract number 88-MO-305008-01D from the National Institute of Mental Health. Douglas B. Kamerow, M.D., served as the initial NIMH project officer. Ann A. Hohmann, Ph.D., M.P.H., and David B. Larson, M.D., M.S.P.H., assumed that responsibility during the course of the study. The opinions expressed herein are the views of the author and do not necessarily reflect the official position of the National Institute of Mental Health or any other part of the U.S. Department of Health and Human Services. All material contained in this volume (except quoted passages from copyrighted sources and the tables on pages 34-36) is in the public domain and may be used or reproduced without permission from the Institute or the author. Citation of the source is appreciated. Suggested Citation National Institute of Mental Health. Somatization Disorder in the Medical Setting, by Smith, G.R., Jr. DHHS Pub. No. (ADM)90- 1631. Washington, DC: Supt. of Docs., U.S. Govt. Print Off., 1990. DHHS Publication No. (ADM) 90-1631 Printed 1990 AC 55% HE sed 2015 FOREWORD Lewis L. Judd, M.D. People with somatization disorder are encountered frequently in primary care practices. A study by DeGruy and colleagues (1987a) suggests that as many as 5 percent of those seen in primary practice settings may suffer from this mental disorder, which occurs as frequently as diabetes and urinary tract infections in these settings. Despite its frequency, somatization disorder is often not recognized at all in primary care practice or is difficult to recognize as a mental disorder, since many of its somatic symptoms resemble those of a number of prevalent physical illnesses. Because of this underrecognition, many patients receive general medical care that is inappropriate and ineffective instead of the mental health treatment they require. During the past decade, important research strides have been made in specifying empirically based diagnostic criteria for somatization disorder, elucidating the role of co-occurring psychiatric and substance abuse disorders, and developing effective treatments for this disorder. Effective approaches to treatment now include mental health counseling, the use of more specialized treatments such as group therapy to improve coping or socialization skills (Ford 1984), and the use of consultations by mental health specialists. All of these treatment approaches can help knowledgeable primary care physicians improve the course of this once-confusing and difficult-to-treat disorder. Many primary care practitioners, especially those trained before these developments took place, have had little opportunity to stay abreast of the recent advances. Little of the available psychiatric research literature pertaining to the accurate recognition and effective treatment of somatization disorder has been translated into practical clinical advice for primary care physicians. This volume was written to fill this knowledge gap by providing busy primary care practitioners with practical, state-of-the-art assessment, treat- ment, and management techniques for somatization disorder. It is intended to aid clinicians in more effectively recognizing and treating patients with this common mental disorder and in identifying when psychiatric consultation or referral is required. This publication includes up-to-date information on the history and epidemiology of somatization disorder, its co-morbidity with medi- cal, psychiatric, and substance use disorders, and the health care utilization patterns of patients with this disorder. Foreword The volume’s author, G. Richard Smith, M.D., has studied somatization disorder, its presentation in primary care settings, and its management. Publi- cations from his research have appeared in many clinical fields, including psychiatry, internal medicine, family practice, and obstetrics-gynecology. Using helpful illustrative case histories, Dr. Smith clearly discusses the challenge of diagnosing somatization disorder, the medical and psychiatric illnesses associated with it, the problems raised by neglecting to recognize it, and the bases for making the differential diagnosis. In addition, he suggests effective clinical means to treat and to manage primary care patients who suffer from this disorder. Finally, he offers guidelines on making a psychiatric referral. For the National Institute of Mental Health, which sponsored the develop- ment of this volume, it represents an important aspect of our research mission: closing the gap between the findings of research and the clinician’s office. Because primary care practitioners are a key resource in both recognizing and providing care for those with mental disorders, we are eager to ensure that clinically relevant results of mental health research, as found in this volume, reach clinicians quickly, in a form that will be accessible and applicable in their day-to-day practice. I believe that these goals are successfully met in this document. Acknowledgments This publication benefited from the critical review of several experts in the mental health field: Charles V. Ford, M.D., and Frederick G. Guggenheim, M.D., Department of Psychiatry, University of Arkansas for Medical Sciences; Peter R. Lichstien, M.D., Department of Medicine, School of Medicine, East Carolina University; Mack Lipkin, M.D., and Sarah Williams, M.D., Depart- ment of Medicine, New York University Medical Center; Z.J. Lipowski, M.D., F.R.C.P., Psychosomatic Medicine Unit, Clarke Institute of Psychiatry, Toron- to; Gerald T. Perkoff, M.D., School of Medicine, University of Missouri— Columbia; Stephen Snyder, M.D., and James J. Strain, M.D., Division of Behavioral Medicine and Consultation Psychiatry, Mount Sinai School of Medicine; and Ann A. Hohmann, Ph.D., M.P.H., Kelly J. Kelleher, M.D., M.P.H, David B. Larson, M.D., M.S.P.H., and Jack D. Maser, Ph.D., National Institute of Mental Health. The Institute gratefully acknowledges their reviews and comments. The manuscript also benefitted from the editorial management and assis- tance of Mrs. Sally A. Barrett, who generously provided continued input after her departure from the Division of Biometry and Applied Sciences. Bh mT ES em Fem PS Eg Re AS ST . u ; . = v - B - : ) ) iL oo - a i i u B n ®, n i - = hb = = a ~ . = 2 ; { * » 1 ; . as ‘ > = FR % % i ' . ) j = : . _ ] ) = ) . of ’ ‘ - » - . = ih - - : 5 ) o " . 4 oo 3 - . ) x - Lm B & mT, . + Syl ik K oo - - 5 v =" E - . hm * - . i - b « N N a . = wy . - . . i n ) En a -l } of tL A I 3 hg .- B . Ep we ) . h - «Tong lon ait RE a - . ma rt pr, or a ae, Fr 3 . . nn B ak ha Ek a. CR, nih 3 i : = ps a E [I } 3 : ) 3 x A ad a a 3 4 =a, 9 a » . “y = ie . ga - k 1 ) rp Fo IB? saan tt ashl Wes ER Bh 4 . i Fir bs . ° . i F & un BN - ir £ a! ) . T i | - o nt H Fs a $e B : « % - z . ) Bn - 4 * | - 3 in " Ei. & = E a «fi . oo A - oo x aT A ® - - i "= . = “ fy wl we he, - = - ro x La t ' Lo ~ “ a : B 3 " i ~ Rx a . r - i = — Contents page Boreword ....:.::ircssiasmasmvuin@numnsinkmnigss iii ACKNOWICBZMIEALS . . « ; sv vss ss stv ern mss nape onse wy v IMroduetion . : : « «och ves cps RR ER FRM IER ERE REE 0 1 How ToUse ThisBook ........................ 1 TeAOlOgY : cs wes v sav umsn amen sns dss son nslshs 2 Chapter 1. Who Are These Patients? .................. 5 Chapter 2. Historical Perspective . ................... 9 Early History of These Disorders . . . ................ 9 Contemporary History of Hysteria . . ................ 11 MeCHAfiSIE vss: err anasrvr ons sass sssssnssnms 13 Psychosocial Mechanisms . . . .................. 13 Pathophysiological Mechanisms . . . .............. 14 GeneticMechanisms . ...................... 15 Chapter3. Prevalence ........................... 17 Mental Health Care in Primary Care Settings ............ 17 Somatization Disorder « . . oo cc ai css icv meas ns 19 Health Care Utilization . ....................... 22 Chapter 4. Course ofthe Disorder . ................... 25 Conderand Age srr nnivriitanscamnssdans sae 25 Untreated Course of the Disorder . . ................ 27 Psychiatric Comorbidity - - - «cc ves mv ns env oan ass ans 29 Chapter. Diagnosis . ...........ccoveuermnncnss 33 DSM-III-R Criteria . . . . o.oo vite ieee ieee enn 33 Sereening . : ccc s crassa sRsa ERA a raw HEE 33 SOMAtiZers . . . . «oi eee 37 Differentiating Somatization Disorder . . .............. 38 Somatized Anxiety . . ...... iii 38 Somatized Depression . . . . ..... iii. 39 PamiCINSOrder « « c:uncsnnsssnvssnss mans sss 39 Hypochondriasis . ............. uuu... .. 40 Conversion Disorder . . ..................... 41 Contents SomatoformPainDisorder . . .................. Factitious Disorders . ........ viii i ener. MedicalProblems . ............ 00 een.. Chapter 6. Treatment of Somatization Disorder in Primary Care Managing the Chronic Condition . .................. Conservative Treatment of Selected Symptoms . . ......... IDEPTEEEIOI 5. + fos 45 4 bl 30 8180 30 oh 52 oo sh 8 0 eo AnXIRtY visser esse rrr n tant ana e Comorbid Medical Conditions . . ................ 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MechahiSiig: ... +s ov sons sa mrsnns or mnss meses Mental Health Care in Primary Settings . ........... Somatization Disorder . . . ................... Health Care Utilization ..................... Genderand Age ...........ciiiieunenn... Untreated Course of the Disorder . .............. Paychisttic COMO . «os 2 0 vo vo muse mavnisn es Diagnosisand Screening. . .................. BOMAIZEIS od sie nis wh Be maa Differentiating Somatization Disorder . . ........... Managing the Chronic Condition . . . ............. Conservative Treatment of Selected Symptoms . . . ..... SpecialzBd Cate. «oc vv as sno vrs spon sn omens Indications for Consultation and/or Joint Care . . ...... IndicationsforReferral ............. 000... page 8 13 15 18 21 8 &ERER 42 52 54 55 57 . v 7 | x f +n pa | i . a t . x w . > I ee 3 ail . Pe) . , ‘ . » P32 2 3 2 . > . oo ® ve “ i} 4 . Bo ¢ r * 2 i = . = ‘ v Go. ¥ i 3 o oh air 3 - ! ye 1 4 3 "Ak 2 by wa of : 1p = = @ W of a w i . . i 4 N ' hp gE Ty x 3 = Lu oo . : . Te =a i Wo E § a we rar — 7 an, . 5 TT 5 . i . ? « . * E v » 3 "a ‘ - 3 “ “ wy a - RE = rr {4 . - J - % + i te 7 pe i Le ‘ 5 32) B 4 Je a : 5 . . ) . =k =. Tas = < s . t = + 3 EAT « Introduction The goal of this monograph is to provide primary care physicians and mental health consultants with current research findings on the recognition, diagnosis, and management of patients with somatization disorder. Somati- zation disorder is a recently described, chronic, relapsing psychiatric condition characterized by multiple unexplained somatic complaints. It is not the intent of this monograph to present a thorough discussion of the process of somatization, which has been well described elsewhere, but rather to directly address the relatively homogenous group of patients diag- nosed with somatization disorder. Management principles are also included for patients who do not specifically meet the diagnosis of somatization disorder but who appear to be diagnostically very similar. How To Use This Book Since primary care physicians and mental health consultants require dif- ferent degrees of knowledge about this disorder, the monograph has been organized to be read at three different levels. The first level is as a quick reference guide to particular aspects of recognition, diagnosis, and manage- ment of these patients. In daily practice, a primary care physician can quickly pull this book from the shelf while the patient is in the office and obtain very specific, brief management suggestions to facilitate the care of the difficult patient. For example, when faced with the differential diagnosis between soma- tization disorder and hypochondriasis, the physician can look up “Differ- entiating Somatization Disorder” under “Diagnosis” in the contents, turn to the pages cited, and read the boxed summaries at the end of the appropriate sections. The primary care physician who wants a quick overview of all aspects of somatization disorder can read only the boxed summaries at the end of each section plus the entire section on treatment. In this way, the entire field of somatization disorder can be covered in 20 to 30 minutes. The physician should probably read the material at least once in this manner to become generally !See, for example, Chodoff 1974; Ford 1983, 1984, 1987; Kaplan et al. 1988; Katon 1985; Katon et al. 1982, 1984a, b; Lipowski 1986, 1987a, b; Lloyd 1986; Merskey 1986; Smith 1985, 1988; Snyder and Pitts 1986; Westermeyer et al. 1989. Introduction familiar with it and subsequently use the monograph as a quick reference guide for management. For the mental health consultant who works in a primary care setting and the interested primary care physician, this monograph provides (1) a thorough review of the research literature available on somatization disorder and (2) a topically directed annotated bibliography of the research literature. Consult- ants who need to be thoroughly grounded on somatization disorder, so they may serve as “experts” on these perplexing patients, should read the book in its entirety. The sections are designed to be neither inordinately laborious nor painful. Terminology The terminology in this field is confusing. Multiple terms are used to represent the same concept, while different concepts are referred to by the same name. Further, relatively subtle differences in terms (somatization vs. somatiza- tion disorder) have very specific meanings to those actively involved in the field, but at first glance, mean little to those not involved in the area. The following glossary is provided to help the reader understand better the material in this monograph. BRIQUET’S SYNDROME: The eponym given to the disorder now called somatization disorder. It was initially proposed to avoid confusion associated with the term hysteria. CHRONIC HYSTERIA: A term used in the past to describe the syndrome that eventually became referred to as somatization disorder. CONVERSION: A psychological process whereby a physical symptom is sub- stituted for an intrapsychic conflict or distress. This substitution often involves the temporary loss of physical functioning of a body part. CONVERSION DISORDER: A psychiatric disorder characterized by conver- sion symptom(s). CONVERSION SYMPTOM: A symptom, usually somatic, thought to be secondary to the process of conversion. Conversion symptoms are not pathognomonic of a particular disorder. Rather, they may occur in healthy people and as part of several disorders including somatization disorder and conversion disorder. HYSTERIA: A centuries-old term replete with numerous meanings. For this reason, it is generally avoided except in historical discussions. This was the first name given to somatization disorder. SOMATIZATION: A process whereby psychological distress is expressed in physical symptoms. SOMATIZATION DISORDER: A chronic, relapsing psychiatric disorder characterized by at least 13 unexplained medical symptoms from a list of 37 criteria, with at least one such symptom occurring before the age of 30. SOMATIZERS: Persons who have 6 to 12 unexplained medical symptoms in their lifetimes, with at least one such symptom occurring before the age of 30. SOMATOFORM: A group of disorders with somatic symptoms that suggest a physical disorder, but for which no organic etiology can be demon- strated. There is presumptive evidence of a psychological basis for the disorder. These disorders are listed in DSM-III (APA 1980) and DSM-III-R (APA 1987). aw 1 = . ; } . NR J We ce LE A : a + tl. 5 rr 3 ¥. ay 18 won ve ow el aft hs » T . V . - ; x 7 “ : a - x s % v4" 5 lh a ' ' ¥ - . - oe : ’ - T ~ . * ‘ A Fed . ” : 2 RAE “A ‘ “2 i a . 5 ’ . z . . . - . . a Ri - + we “ . y ei oF “pa . at a . Chapter 1 Who Are These Patients? Somatization disorder patients as a group are well known to most primary care physicians. To further aid the reader in identifying who these patients are, three brief case examples are presented. Mrs. A. is a 47-year-old white female who presents to your office 2 weeks after she was eligible to see you under the new preferred provider plan that has just become available at the steel mill where her husband is employed as a laborer. She states that she has chosen you to be her primary care physician because of your reputation as a “thorough” physician in the community and because she has become quite disenchanted with many of the “careless” physicians in the community. Today she complains of chest pain and bloating that has bothered her for the past 6 months. Her chest pain is constant throughout the day. It keeps her from doing many of her usual activities, such as housecleaning; however, it does not keep her from bowling in her league. She describes her pain as sharp in quality and at times accom- panied by a throbbing sensation. On your new patient information sheet, she has indicated that she is bothered frequently or occasionally by 42 of the 67 possible symptoms of your review of systems. Under history of family medical problems, she writes that she is the last child of six children, and that she has been sickly since birth. She reports that she has had eight operations. These included a cholecystectomy, an exploratory laparotomy where adhesions were found, a breast biopsy, a total abdominal hysterectomy at age 26 for pain and fibroids, a hemorrhoidectomy, and three D & Cs, one of which followed a miscarriage during which, she reports, she almost bled to death. She takes four medications on a daily basis — one for low energy, quinine tablets for leg cramps, a nonsteroidal antiinflammatory agent for her arthritis, and diazepam for her nerves. She notes parenthetically that she has just run out of her diazepam and will need a new prescrip- tion from you. Who Are These Patients? Given all of the above, her physical examination is unremarkable except for mild obesity and appropriate abdominal scars for her listed procedures. Her resting electrocardiogram is normal. Readers should note their subjective responses to this case. Usually, primary care physicians will wish that they had not been so fortunate as to have been considered “thorough” but can also usually resist the impulse to refer Mrs. A. to another physician. Ms. B. is a 34-year-old mother of three children who is married to an attorney who has a senior position in one of the State’s regulatory agencies. She is referred by her cardiologist because he believes she needs a primary care physician more than his treatment. She has been cared for by three cardiologists for her mitral valve prolapse and currently takes a low dose of a beta blocker for this condition. When she sees you, she states that she is looking forward to getting to know you. As an aside, she adds that the last primary care physician she saw was not sufficiently attentive and understanding, so she decided not to go back. She has no real problems today other than her mitral valve prolapse and ringing in her ears, the latter of which she has been told by other physicians is because of her excessive use of aspirin to treat her headaches. While it is also time for her every-3-months breast exam (an exam recommended to her by a previous physician because of her fibrocytic disease), the main reason she has scheduled this visit is to develop a relationship with you so that when she does become sick, you will be able to help her. While Ms. B. does not work outside the home, she states that caring for three children is plenty of work. She is active in various community affairs including working in a literacy program. Her past history reveals three Cesarean sections, two breast biop- sies, and a cardiac catheterization. She states she was admitted to the hospital on two occasions for evaluation of her chest pain, one of which required the catheterization. Ms. B. also states that she has had quite a few medical problems since early childhood — more, in fact, than most people her age. These problems began at age 7 when she was hospitalized for the evaluation of urinary retention. Ms. B. states that “they never could figure out what caused that.” She is dressed attractively in a red, tight-fitting silk dress that is stylishly short in length. She wears white hose and matching red shoes with 4-inch heels. She has three rings on one hand, two on another, and four gold bracelets on one wrist. Who Are These Patients? Her physical examination is within normal limits. She does have some mild nodularity in her breasts that appears to be fibrocystic disease. From this presentation, you might expect that the primary care physician would initially feel flattered that an esteemed colleague had referred a prominent citizen to you for care. On the other hand, the astute physician might also wonder what lies ahead in the long-term management of this patient, especially considering the relatively extensive health care this woman has received for her age and her somewhat flamboyant clothing. Ms. C. is a 48-year-old white female who is referred to your practice by a neurologist. She states that she has been completely disabled by her medical condition. Previously, she had been employed as a masseuse. Ms. C. goes on to say that her neurologist, whom she had been seeing for shoulder pain, neck pain, and dizziness, had recently con- ceded that she “had too many medical problems” to be seen only by a neurologist and had, therefore, referred her to you. In addition to shoulder pain, neck pain, and dizziness, Ms. C. also complains of bloating and diarrhea, which have been intermittent for the last 3 months. Ms. C. has had seven operations, including chest surgery when she was 6 months old; an appendectomy 18 years ago; two carpel tunnel releases; a hysterectomy; a gastric bypass; and a procedure for a perirectal abscess. She has been hospitalized both at the local teaching hospital and at another private hospital. Ms. Cs citing of the physicians with whom she has consulted is equally impressive. In the last 2 years, she has seen four physicians in a local multispecialty group, a primary care physician in a nearby city, and another neurologist. On examination she is an obese white female wearing a black top, black slacks, and bright pink terry house shoes. Her hair is in rollers with a scarf covering the rollers. She tells you that she is just “too sick” to dress for the appointment. She is extremely slow moving to and from the examining room and appears to be overtly cooperative but covertly resistant. Her speech is tangential, diffuse, and at times, rambling. She appears to be mildly depressed. Her physical examination reveals the scars of her surgery and, except for her obesity and moderate external hemorrhoids, is within normal limits. At the end of the examination, Ms. C. states that she would like to sign arelease of information so that you could forward copies of today’s visit to her attorney who is assisting her in obtaining her disability income. Who Are These Patients? Ms. C. certainly has the capacity to develop into a difficult patient. Many physicians might feel inclined to schedule her next visit for 1 year later or simply suggest that she come back to see them only when she needs to. If either of these routes is taken, she is likely to be back in a week or two. These three patients are all quite different. Two things, however, are common to each of these cases. First, the experienced primary care physician will probably intuitively sense that this person is going to be a difficult patient. Second, each of these patients has somatization disorder, which is a chronic relapsing psychiatric condition characterized by the presentation of multiple unexplained somatic complaints. Fortunately, all three patients can probably be managed in a similar way — to the benefit of the patients and to the relief of the primary care physician. 1 Are These Patients? : ith: somatization disorder are typically i soa intuitiv ysicians sense almost i imme Chapter 2 Historical Perspective The history of somatization disorder is confusing. Essentially, two syndromes have been described over the centuries: monosymptomatic and polysymptomatic. The monosymptomatic syndrome is currently recognized as conversion disorder, while the polysymptomatic syndrome has become known as somatization disorder. Historically, these two disorders have often been interrelated and commingled. Early History of These Disorders Somatization disorder has had many names and many antecedents. One such predecessor was the complex syndrome of hysteria, first recognized by the ancient Egyptians. The Kahun Papyrus, an Egyptian writing that dates from 1900 B.C, refers to many of the manifestations that today occur in patients with somatization disorder. An illustrative quote is a “woman aching in all her limbs with pain to the sockets of her eyes” (Veith 1977). The Egyptians believed that hysteria was caused by upward dislocation of the uterus and displacement of other organs. The migration of the uterus throughout the body was the basis for the multiple symptoms developed by these patients. Typically, they used one of two treatments for the wandering uterus. One treatment involved fumigating with precious and sweet-smelling substances to attempt to attract the uterus back to the womb. The alternative treatment involved inhaling or ingesting evil or foul-tasting substances to repel the uterus away from the upper part of the body where it had wandered. The Greeks held fast to the Egyptian view of hysteria, as evidenced in some of Hippocrates’ writings that mention the wandering uterus causing problems. The Greeks first used the term “hysterical” as an adjective to refer to a particular symptom. For example, they called the displacement of the uterus in the throat globus hystericus. Treatment for this symptom involved the application of foul-smelling substances around the neck, strongly perfumed wine in the mouth, and aromatic fumigations to the vagina. The wandering uterus concept remained well in force throughout the Middle Ages and into the Renaissance, where writers continued to espouse the 9 Historical Perspective uterine etiology of hysteria. Richard Mead (1673-1754), probably one of the most successful English physicians of his time, stated that “no disease is so vexatious” as hysteria. He noted that it was common in maids, wives, and widows, and that “. . . while it may not be attended with great danger, it is frequently terrifying.” For treatment, he recommended blood letting, applying cupping glasses to the groins and hips, inhaling fetid smells into the nostrils, and rubbing the thighs and legs (Veith 1977). Doubts about the uterine origin of hysteria began in the 17th century with two prominent physicians, Charles Le Pois (Carlous Piso) and Thomas Syden- ham, also famous for his discourses on gout and chorea. Sydenham not only dissociated hysteria from the uterus but associated it with the psychological disturbance known at that time as “antecedent sorrows,” therein recognizing the emotional origin of the disorder. Further, Sydenham was the first to recog- nize the disorder in males. However, his important essay on the topic of hysteria was largely ignored. Cotton Mather, a student of Sydenham and infamous for the Salem Witch Trials, wrote the first colonial medical text, The Angel Of Bethesda. In it he, too, recognized hysteria, and as a loyal student of Sydenham, subscribed to a very similar formulation. The French work on hysteria came not from private medical offices, as it had in England, but from large public institutions. Two public insane asylums, Le Bicetre and La Salpetrier, were the centers of this research. Phillipe Pinel, best known for striking the chains of patients at the Salpetrier in the true spirit of the French Revolution, placed hysteria under neurotic disorders in his disease classification published in 1813. Pierre Briquet (1859) formulated a substantially different idea about hysteria. His report of the 430 cases he observed in the Hospital de la Charite in Paris described a polysymptomatic disease. Unlike the prior emphasis on a single symptom, he emphasized the multisymptomatic patient with a protracted course. However, his treatise on hysteria, published in 1859, went largely unnoticed. Briquet also recognized the disorder in men as had Sydenham before him. Briquet attributed the disorder to emotional causes and developed appropriate diagnostic criteria. His name was eventually attached to subsequent versions of the diagnosis because of the significance of his work. Some time later at La Salpetrier, Jean-Martin Charcot, a famous neurol- ogist who also held a professorship at the University of Paris, devoted himself to the study of neurosis, hysteria, and hypnotism. Famous for his clinic where Freud observed the use of hypnosis in hysterical patients, Charcot emphasized single-symptom hysterical phenomena at the expense of the multisymptomatic patient. Like Briquet, Charcot, too, recognized the disorder in men, but because La Salpetrier was for women, he worked exclusively with women. Another French physician, Pierre Janet, recognized that hysteria was a general disease that affected the whole organism. He was a student of Charcot 10 Historical Perspective and presented many of his thoughts in his book, The Mental States of Hystericals, published in 1901. Sigmund Freud is widely associated with hysteria. His early work with Josef Breuer led to two works — a preliminary communication on the practical mech- anism of hysterical phenomenon, published in 1893, and one on his studies on hysteria, published in 1895. Freud’s discussion of Breuer’s patient, Miss Anna O., was a landmark case that marked the beginning of the study of hysteria in psychoanalysis. Freud continued the movement away from the multisymptomatic patient and focused on monosymptomatic hysteria. He considered the psychic mechanisms involved in the development of hysteria as etiological. He eventually described a per- sonality style or personality disorder that was associated with physical symp- toms, but lacked the multisymptomatic focus. Contemporary History of Hysteria A landmark series of papers was published between 1951 and 1953 by Purtell, Robbins, and Cohen, who were later joined by Altmann and Reid (Purtell et al. 1951; Robins et al. 1952; Cohen et al. 1953; Robins and O’Neal 1953). These papers presented the first modern conceptualization of the mul- tisymptomatic concept of hysteria. They studied 50 patients with a diagnosis of hysteria using a systematic diagnostic process and reexamined them 4 or more months later (Purtell et al. 1951). They concluded that hysteria is a definable clinical syndrome with a characteristic clinical picture that begins before the age of 35. While noting the similarities of their work to Briquet’s, they deviated somewhat from the latter’s theories by suggesting that men did not have the disorder. Further, they reported a finding that has often gone unrecognized — that the prevalence of this multisymptomatic disorder in the general hospital is 2.2 percent of all admissions. Followup work by Cohen et al. (1953) included a study of surgical proce- dures on 50 women with multisymptomatic hysteria. They noted the excessive number of operations —3.8 procedures compared to 1.9 procedures for the control group — and, by implication, the serious health care utilization problems of these patients. The same group undertook an extensive search for men with somatization disorder in Boston area hospitals. Except for one case report that was published as an addendum, they found no cases of the multisymptomatic disorder in men that they had previously described in women. They concluded that somatization disorder is rare in men (Robins et al. 1952). Published work in the modern era of hysteria ceased for a decade until two companion papers by Perley and Guze appeared. The first (Perley and Guze 1962) reported a followup study that confirmed the findings of Purtell et al. with respect to a definable clinical syndrome. It further demonstrated the diagnostic 11 Historical Perspective stability of the multisymptomatic concept of hysteria. Perley and Guze noted that patients had a 90-percent probability of meeting diagnostic criteria 6 to 8 years later. Their second paper (Guze and Perley 1963) reported that patients with multisymptomatic hysteria had a uniform clinical course that formed a chronic recognizable disorder with few, if any, remissions. Guze went on to lead an extremely productive group of investigators who developed the contemporary diagnosis of multisymptomatic hysteria. The majority of these studies were conducted at Washington University in St. Louis. Guze set the course for the development of research concerning hysteria by noting that the medical model is the sine qua non for progress in research and treatment of psychiatric conditions (Guze 1975). He argued that the medical model was built on diagnostic validity, which required a clear descrip- tion of the disorder. This description could then be supported by demonstrating a common etiology or similar pathogenesis, which in psychiatry is always difficult. Two avenues could support diagnostic validity: (1) followup studies demonstrating a uniform course and (2) family studies demonstrating an in- creased prevalence in close relatives. These two particular types of studies were pursued with vigor over the ensuing 25 years. It should be stressed that while Guze had numerous collaborators on all of the aforementioned projects, he was the person primarily responsible for conceptualizing and validating multi- symptomatic hysteria as we know it today. The term “hysteria,” with its ancient heritage, was further confused during and immediately after Frued’s lifetime when the term took on new and more complex meanings that called into play various psychodynamic and psycho- analytic implications. For some, the term “hysteria” carried substantial pejora- tive connotations. In 1970, Guze proposed that the eponym, Briquet’s syndrome or Briquet’s disease, be used to denote multisymptomatic hysteria. The disorder was known as Briquet’s syndrome until the publication (APA 1980) of the Diagnostic and Statistical Manual of Mental Disorders - Third Edition (DSM-III). Ironically, after the decision was made to incorporate Briquet’s syndrome as part of the new standard diagnostic nomenclature for American psychiatry, another sepa- rate, unrelated decision was made to drop all eponyms. Going back to the proverbial drawing board, a new name was created — somatization disorder. In DSM-III, an attempt was made to simplify the diagnosis. Prior to that time, various diagnostic criteria had required 25 symptoms to be present, distributed over 10 symptom groups from a list of 60 possible symptoms — clear- ly, a cumbersome diagnostic schema (DeSouza and Othmer 1984). DSM-III streamlined the criteria to 14 positive lifetime symptoms in women (12 in men) from a list of 37 symptoms; moreover, the symptom group requirement was dropped. With the advent of DSM-III-R (APA 1987), the revised edition of DSM-III, the criteria were again modified, and the number of symptoms required for men and women were both changed to 13. There are those who question whether somatization disorder is a single disorder. Some contend that the presence of other psychiatric disorders (psy- 12 Historical Perspective chiatric comorbidity) indicates a heterogeneous disorder (Liskow et al. 19864). Others contend that there is a spectrum of disorders without clear demarcation between them (Ford 1983). While these arguments have merit, the currently available data argue for considering the disorder as a relatively discrete, homo- geneous entity. ummary — Historical Perspective here The p of this work was recognized by indloding the disorder i in the DSM-III nomenclature, where it became known as somat Mechanisms Psychosocial Mechanisms Numerous theories abound concerning the psychosocial mechanisms in- volved in the process of somatization. By contrast, few theories have been proposed to account for the psychological basis of somatization disorder. Some people would argue that somatization disorder is simply the process of somat- ization carried to an extreme; they would submit that theories relevant to the process of somatization are relevant to somatization disorder. Without entering into the debate, it is still appropriate to briefly discuss three areas relevant to this monograph: somatization as a social communication, as an emotional communication, and as a result of an intrapsychic dynamic. Ford (1983, 1984; Ford and Long 1977) has discussed somatization as a social communication. Examples include the use of bodily symptoms to manipu- late or control relationships —such as an adolescent girl’s developing unex- plained abdominal pain to prevent her parents from going away for the weekend. Similarly, somatization may be used to maintain relationships — as in the woman who receives nurturing from her husband only when she is ill. Other 13 Historical Perspective social uses of somatization include using it to gain disability or to divert attention. For example, a child develops or maintains a symptom to divert attention away from the conflict generated by the father’s alcoholism. Somatization may also be used to serve an emotional need or as an emo- tional communication. These, too, are well described by Ford (1983, 1984; Ford and Long 1977). Some patients may be unable to verbally express their emo- tions; therefore, they use symptoms to express their emotional state. Symptoms may also be used to symbolically communicate emotions, as they are in conver- sion disorders. Some patients use medical complaints as a coping device to deal with environmental stress. Finally, physical symptoms may be used as a solution to an intrapsychic conflict, again as in conversion symptoms. Classical psychoanalytic theory has held that hysteria (conversion) repre- sents a substitution of somatic symptoms for repressed instinctual impulses (Chodoff 1974). Freud postulated that the conflict was a phallic-oedipal one; however, more recent work has emphasized a pregenital conflict as well. Pathophysiological Mechanisms Some data are available on other explanations for somatization disorder. Neuropsychological testing by Flor-Henry et al. (1981) revealed equal bifrontal impairment of the cerebral hemispheres and nondominant hemispheric dys- function in patients with somatization disorder. The authors suggested that dominant hemisphere dysfunction is fundamentally related to the disorder. Abnormal psychological testing has also been noted in patients with somat- ization disorder (Liskow et al. 1986b). Compared to controls, these patients have significantly more scale elevations on the Minnesota Multiphasic Per- sonality Inventory (MMPI). The authors suggest an MMPI screening scale for the disorder. Preliminary evidence from Gordon and colleagues (19864, b) indicated that patients with somatization disorder may have an abnormality in cortical func- tioning as evidenced by abnormal auditory-evoked potentials. In subsequent studies, the authors found that these patients responded more similarly than controls to both relevant and irrelevant stimuli. Hence, they had an impairment in attention (James et al. 1987, 1989). Other preliminary data indicate that somatization disorder patients may have electroencephalogram frequency ab- normalities in the right frontal region (Drake et al. 1988). These data require much more extensive work. Others have advocated that somatization disorder arises as a consequence of other disorders. Sheehan and Sheehan (1982) suggested that somatization disorder is a result of panic disorder. Orenstein (1989) proposed that somatiza- tion disorder is a sequela of a common diathesis that is shared by panic disorder and major depression. More data are needed to evaluate those proposals. 14 Historical Perspective Genetic Mechanisms Considerable evidence now demonstrates familial and/or genetic associa- tions with somatization disorder. Patients with somatization disorder have been noted in several studies to have a higher than expected prevalence of antisocial personality disorder or, at the very least, manifest antisocial personality traits (Liskow et al. 1986a, b; Zoccolillo and Cloninger 1985; Lilienfeld et al. 1986; Guze et al. 1971; Cloninger and Guze 1970b). These data were derived primarily from patients seen in general psychiatric settings and in prisons. Some of the author’s unpublished data appears to contradict these findings, possibly be- cause our patients were not obtained from psychiatric settings but rather from primary care settings. In any event, the association with antisocial personality disorder occurs in only a relatively small percentage of cases in the general medical setting. Thus the association between somatization disorder and anti- social personality disorder is likely to be of only limited significance in the primary care setting. Other work has shown that women with somatization disorder may selec- tively choose to mate with men with antisocial personality disorder (Woerner and Guze 1968; Cloninger and Guze 1975; Zoccolillo and Cloninger 1985). Here again, the association is only greater than random chance, not that-a majority of patients with somatization disorder have spouses with antisocial personality disorder. One interesting theory holds that antisocial personality disorder and somatization disorder may have a common genetic background, somatization disorder being the female expression of this genetic tendency and antisocial personality disorder being the male expression (Guze 1983; Lilienfeld et al. 1986; Cloninger et al. 1975). Work evaluating Swedish adoptees has shown that in the population, there are two types of somatization. One type, similar to somatization disorder, is associated with criminality in the biological parents (Cloninger et al. 1986b). While some evidence supports this theory, it remains theoretical. Morrison (1983) indicated that patients with-somatization disorder have a nonrandom birth order. This would indicate that factors other than genetics, e.g., the environment, play a substantial role in the disorder. A random birth order would be expected if a disorder were purely genetic. Accordingly, these findings would argue that somatization disorder is more the result of environ- mental rather than genetic influences. Brown and Smith (1989) contradict this finding. We found a completely random birth order in 143 patients with somatization disorder. Therefore, at present, it is unclear which conclusion the reader should draw. Summary — Mechanisms Historical Perspective 16 Chapter 3 Prevalence Mental Health Care in Primary Care Settings As recently as 1986, findings from the Epidemiology Catchment Area (ECA) project conducted by the National Institute of Mental Health (NIMH) indicated that approximately one in every three Americans has or has had an acute psychiatric disorder in need of treatment (Robins et al. 1984). Further, 19 percent of Americans have a currently active psychiatric problem in need of treatment (Myers et al. 1984). When these somewhat surprising figures are combined with data on psychiatric manpower, it becomes very clear that speciality mental health services cannot possibly meet the service demand for these problems (Kamerow et al. 1986). By implication, the major locus for psychiatric services is quite likely to be primary health care settings and, unless our organization of care changes drastically, such services will be provided by the primary care physician. This contention is further supported by empirical estimates that almost 60 percent of the care for mental illness episodes is provided by general medical providers (Schurman et al. 1985; Schulberg and Burns 1988). Recent studies have also demonstrated that patients with psychiatric dis- orders are overrepresented in primary health care settings. Community-based estimates are in the 15- to 20-percent range for psychiatric disorders, while in ambulatory medical patients, the prevalence is 25-30 percent (Schulberg and Burns 1988). In patients with chronic medical conditions, Wells et al. (1988) reported a prevalence of psychiatric conditions in the 25- to 42-percent range. Not only is the prevalence of psychiatric disorders in primary health care settings high, but these disorders frequently go unrecognized (Jencks 1985). Boruset al. (1988) found that practitioners in a health maintenance organization failed to recognize 66 percent of the psychiatric disorders present in their patients. This underrecognition can cause obvious problems since a patient cannot be properly treated until the correct diagnosis is made. Recent advances in psychiatric treatment provide exceptionally effective means for treating many of the disorders seen in primary health care settings. For example, mood disorders can almost always be effectively treated, and 17 Prevalence prophylaxes can often be given as followup preventive measures. Significant advances in the effective treatment of panic disorder have also been made during the last decade (Katon 1989). Unfortunately, the psychiatric care provided in primary care settings is at times inappropriate. As a result, patients are incorrectly diagnosed and treated, and primary care physicians become frustrated because their patients do not improve. For example, Callies and Popkin (1987) showed that antidepressant dosages for the treatment of mood disorders in primary care settings are insufficient and that the duration of the treatment is often inappropriate. Further, analgesics, antianxiety agents such as benezodiazepines, and similar psychotropic compounds are prescribed frequently in primary health care settings. While no clear evidence or statistics exists to indicate the exact mag- nitude of the problem, the prescribing of these drugs is undoubtedly excessive. Such factors work together to produce (1) patients who do not have the best outcome and are therefore likely to be dissatisfied with their health care and (2) physicians who desperately want good outcomes from their patients but often end up frustrated. ry — _ Mental Health Care in Primary Settings One of the most common categories of disorders seen in general healt I psychiatric disorders, which affect approximately one ive Americans. a up to this time, numerous factors ‘hav Other Tetons compliae the pions Frequently, peyelistle disorder - are unrecognized in a en care settings, SO they: remain untreated. 18 Prevalence Somatization Disorder According to the ECA project, an estimated 0.13 percent of the general population, or one person in a 1,000, has somatization disorder (Swartz et al. 1990). One group of ECA investigators at Duke University used a somewhat different methodology and found the prevalence in the Piedmont region of North Carolina to be approximately 0.4 percent (Swartz et al. 1988). Estimates prior to the ECA study had been in the range of 0.4-2 percent of the population (Farley et al. 1968; Woodruff et al. 1971; Weissman et al 1978). The ECA data probably underestimate the true prevalence of somatization disorder because of the limitations of the Diagnostic Interview Schedule (DIS), which was used for all the diagnoses in these studies. Recent data indicate that the DIS may underdiagnose somatization dis- order by as much as 31 percent compared to a careful clinical examination (author’s unpublished data). This means that between 1 and 4-5 people per 1,000 in the community may meet the full diagnostic criteria for somatization disorder. Other findings from the ECA project indicate that somatizers — people who have histories of multiple unexplained somatic symptoms but whose symptoms are not severe enough to meet diagnostic criteria— are relatively numerous in the population. Escobar and colleagues (1987b) estimated that 4.4 percent of the population studied at the Los Angeles site met an abridged construct of somatization. In Puerto Rico, Escobar et al. (1989) estimated that 18-20 percent met this abridged construct. Again, these estimates are likely to be affected by the systematic underestimation resulting from the DIS. When somatizers are combined with somatization disorder patients, an appropriate estimate would be at least 5 percent, meaning S or more people per hundred in the general population may be somatizers. In fact, Swartz et al. (1990), who reported a subsyndromal form of somatization that they call somatization syndrome, estimated that 11.6 percent of the general population could be so classified. While physicians in primary care settings see patients from the general population, they see a selected sample of the general population. This is evidenced by the number of patients with somatization disorder or multiple unexplained somatic complaints who present in primary care settings. Since patients with somatization disorder believe themselves to be medi- cally ill, one would assume they congregate in physicians’ offices. Deighton and Nicol (1985) indicated that in a large group practice, 0.2 percent of the women between 16 and 25 years old possibly had somatization disorder. DeGruy and colleagues (1987a) provided a much higher estimate. Their work indicated that as many as 5 percent of the patients seen in an academic family practice setting may have somatization disorder. If this is the case, then in a practice in which primary care physicians see 50 patients per day, 2 or 3 patients would probably have somatization disorder. Even if this estimate is 19 Prevalence high, the study clearly points out that patients with somatization disorder are overrepresented in primary care settings. Somatization disorder easily falls in the range of diseases such as diabetes mellitus and urinary tract infections in terms of the frequency with which it is seen in physicians’ offices. Early work by Woodruff (1967) and colleagues revealed that 1in 50 women admitted to a medical ward had somatization disorder. DeGruy and colleagues (1987p) did similar work in the general hospital setting. They estimate that 9 of every 100 patients admitted to general medical/surgical services in the general hospital setting have somatization disorder. Another estimate based on their work placed the figure in the 3-percent range (Smith 1987). These figures indicate that somatization disorder is a major clinical entity in the general hospital setting. Patients with somatization disorder are overrepresented among patients with certain disorders or with specific procedures. For example, 27 percent of women receiving non-cancer-related hysterectomies had somatization disorder (Martin et al. 1980). Two other studies reported an increased prevalence of 17 percent (Liss et al. 1973) and 28 percent (Young et al. 1976) in patients with irritable bowel syndrome. In another study, 13 percent of patients with polycys- tic ovary disease had somatization disorder (Orenstein and Raskind 1983; Orenstein et al. 1986), and 12 percent of chronic pain patients had somatization disorder (Reich et al. 1983). Folks et al. (1984) found that patients with conversion symptoms have a high probability (34 percent) of having somatiza- tion disorder. Good data are not available concerning the prevalence of somatization disorder patients in subspecialty medical practices. However, anecdotal data and clinical wisdom indicate that somatization disorder patients are seen with substantial regularity in subspecialty practice. In a typical scenario, a patient with somatization disorder presents to the primary care physician with a new symptom. The primary care physician evaluates the symptom and believes that there is nothing medically wrong, overlooking the possible diagnosis of somat- ization disorder. In an effort to provide good care and not “miss” a diagnosis, he refers the patient to a subspecialist for an evaluation. The onus is now on the subspecialist. A trusted colleague has referred a patient for an “expert” opinion. The subspecialist, wanting to be thorough and complete, performs various, often invasive, diagnostic tests. Indirect evidence from health care utilization patterns of somatization disorder patients indicates that this or some similar scenario must be operative since these patients undergo an excessive number of diagnostic procedures. Presumably, medical specialists, particularly surgically oriented specialists, see somatization disorder patients quite frequently. Many of these patients undergo exploratory surgery or surgery for some type of symptom relief. The expected relief rarely occurs. Given the number of symptoms that these patients will present during their lifetimes, there is a high probability of a chance association of some symptom and the presence of a false positive laboratory or diagnostic finding. For 20 Prevalence example, a 45-year-old man may be referred to a urologist for evaluation of dysuria. The patient may, in fact, have an enlarged prostate and when asked to describe symptoms, will describe characteristics of hesitancy and urgency. It appears to the urologist that a transurethral resection of the prostate is indi- cated. What was overlooked in this scenario was the fact that the dysuria was not a symptom of benign prostatic hypertrophy but rather a symptom of somatization disorder. It is, therefore, extremely important to identify patients with somatization disorder prior to surgery, because they frequently do not have the expected surgical outcome. Surgical, laboratory, and diagnostic procedures should be performed only when indicated by new signs of disease, not by symptoms (Monson and Smith 1983). In psychiatric clinical settings, somatization disorder may be both under- represented and unrecognized. Slavney and Teitelbaum (1985) found that 8 percent of patients with medically unexplained symptoms referred for psychia- tric consultation had somatization disorder. Several small studies have es- timated the prevalence of psychiatric patients with somatization disorder, but the rates varied widely (Saxena et al. 1988; Weller et al. 1983; Kroll et al. 1979). The underrepresentation is likely due to the enormous resistance these patients have to understanding their disorder as a psychiatric problem rather than as a true medical illness. While these patients can eventually be referred and treated in psychiatric settings, the process requires skill, persistence, and time on the part of both the primary care physician and the psychiatrist. Anecdotally, it appears that somatization disorder patients are underdiag- nosed by psychiatrists to approximately the same degree that they are undiag- nosed in general medical settings. Many psychiatrists do not even consider the diagnosis, so the diagnosis is rarely made. Summary — Somatization Disorder tients with somatization disorder and those who have multiple unex as 2 or 3 of every 50 patients seen in a primary care e practi atization disorder or near somatization disorder. These patient : inappropriate care from li and subspecialists, which results excessive diagnostic evaluations and surgical procedures. 21 Prevalence Health Care Utilization Changing physicians frequently or consulting new physicians —a phenom- enon sometimes known as “doctor-hopping” —seems to be characteristic of patients with somatization disorder. While no definitive data exist on the number of physicians a patient with somatization disorder consults or the repetitiveness with which changes are made, these patients do see an inordinate number of physicians and change doctors quite frequently. This doctor-hopping confounds the management of somatization disorder patients since one of the prerequisites for successful management of the disorder appears to be a long- term relationship with one physician. Excessive surgery was reported in patients with hysteria as early as 1953 by Cohen and associates. They found that patients with hysteria averaged 3.8 surgical procedures, while hospitalized ill control subjects had 1.9. Zoccolillo and Cloninger (19864) compared surgical procedures in patients with somatiza- tion disorder and those with major depression and found that the somatization patients had three times more operations than the depressed patients. Morrison and Herbstein (1988) found that somatization disorder patients reported an average of 5.4 operations, while mood disorder patients reported 1.6 operations. Lilienfeld and associates (1986) reported that somatization disorder patients had 4.3 surgical procedures per patient. Finally, in the author’s un- published study, patients with somatization disorder reported 5.2 surgical procedures with a range from 0-23. While no control subjects were evaluated for these latter two series, the general population is unlikely to have quite this many surgical procedures. Frequently, patients and/or their physicians attribute these procedures to some particular indication, such as a patient who reports that she had an exploratory laparotomy for adhesions. However, rarely does a careful review of the physician’s records show that any signs of obstruction were noted. Whether the physician directly tells the patient or implies to the patient that adhesions are present or whether the patient infers it is unclear. Whatever the case, patients with somatization disorder appear to have excessive surgery. It is fairly easy to understand how this can happen. Typically, the patient presents to a physician who is unaware of the patient’s somatization disorder. The physician evaluates the symptom with diagnostic tests. The tests are normal. But the patient continues to complain, so the physician escalates the invasiveness of the diagnostic procedures. The symptoms continue un- abated. In desperation, the physician may perform or refer for exploratory surgery to make a diagnosis. Alternatively, in the dogged pursuit of organic pathology, physicians may discover abnormal, benign physical findings. If the physicians are not aware of the somatization disorder and only aware of the symptoms, they might mistaken- ly combine the symptom with the benign physical finding and believe that surgery is indicated. 22 Prevalence An example of this phenomenon is a patient who complains of lower abdominal pain. If by chance she has tender, enlarged ovaries, the gynecologist may decide that surgery is indicated when typically, without the symptom of pain and only the finding of a slightly enlarged tender ovary on routine examination, no surgery would be performed. This type of surgery, of course, does not improve the symptom in the patient with somatization disorder. It may distract her for a period of time, but in most situations, the surgery is unnecessary, unhelpful, and places the patient at increased risk of surgical complications. Such excessive surgery can be substantially reduced with appropriate manage- ment. Because of the excessive number of operations and outpatient visits, patients with somatization disorder have extraordinary health care utilization. Data from the ECA project indicated that patients with somatization disorder as diagnosed by the DIS had 6.1 outpatient visits per 6-month period (Swartz et al. 1987). Ninety-five percent of these patients had seen health care providers in the previous 6 months versus 56 percent of the general population (Swartz et al. 1990). Of somatization disorder patients, 45 percent were hospitalized in the previous year compared to 12 percent of the general population (Swartz et al. 1990). In addition to general medical service, patients with somatization disorder also use an abundance of psychiatric services. Seventeen percent of those in the ECA study were hospitalized on psychiatric services within the past year compared to only 0.5 percent of the general population; 56 percent were seen in psychiatric outpatient settings versus 7.5 percent of the general population in the previous 6 months (Swartz et al. 1990). When hospitalized, these patients rarely receive the diagnosis of somati- zation disorder despite the high frequency of negative medical evaluations in somatization disorder patients (74 percent) compared to general hospital patients (21 percent) (deGruy et al. 1987b). In outpatient primary care settings, somatization disorder patients have been found to have 0.58 visits per month compared to 0.41 visits per month for outpatients without somatization dis- order, and charges that were twice as much (deGruy et al. 1987a). Patients with somatization disorder have been shown to average 7.6 stays in the hospital per year and average 13.0 outpatient visits (Smith et al. 19864, b). Smith et al. (19864) found that the total health care charges for patients with somatization disorder in 1980 dollars were $4,700 per year or nine times the U.S. per capita personal health care expenditure. Fewer data are available about the health care utilization of somatizers; however, some findings do exist from the ECA study. Men who somatize are more likely to use health care than men who do not somatize, while women who somatize are more likely to use general health care for mental health problems (Escobar et al. 1987b). Seventy-five percent of the patients who somatize have seen health care providers within the last 6 months compared to 56 percent of the general population, and 25 percent have been hospitalized in the last year versus 12 percent of the general population (Swartz et al. 1990). 23 Prevalence Patients who somatize also use psychiatric outpatient services. Thirty-four percent were seen in outpatient settings during the last 6 months compared to 7.5 percent of the general population. They also require inpatient psychiatric hospitalization at the rate of 2 percent per year versus 0.5 percent of the general population (Swartz et al. 1990). 24 Chapter 4 Course of the Disorder Gender and Age Somatization disorder was originally described in women (Purtell et al. 1951) and early reports stated that it was found exclusively in women (Robins et al. 1952). However, it is now recognized that somatization disorder does afflict men, but it is much less common in men than in women (APA 1987; deGruy et al. 1987b; Cloninger et al. 1986a; Kaminsky and Slavney 1976; De Figueiredo et al. 1980; Rounsaville et al. 1979; Smith 1987; Oxman and Barrett 1985; Maany 1981; Pittman and Moffett 1981). Guze (1983) stated that fewer than 5 percent of the somatization disorder patients seen by his group are men. Data from the ECA study indicated that the female/male ratio is 10 to 1 (Swartz et al. 1990). In a series of patients referred from primary care settings for a study of somatization disorder, the female to male ratio was 5 to 1 (Smith un- published). Thus, it is important to at least consider the diagnosis of somati- zation disorder in men with multiple unexplained somatic complaints. By definition, somatization disorder must begin prior to the age of 30. This does not mean that the patient must present prior to age 30. It simply means that the patient must have at least one unexplained somatic complaint prior to this age. Data from the author’s series of 126 patients with somatization disorder yielded an age range of 21 to 73 years with a mean age of 43 and a standard deviation of 11 years. In an attempt to find patients who met the criterion of 13 symptoms but with an age of onset later than 30 years, 151 patients with unexplained multiple somatic complaints were examined, and only two met this criterion. The ECA data indicated that somatization disorder is just as prevalent among people under 45 years of age as among those over 45 (Swartz et al. 1990). Simply getting older does not affect the likelihood of having enough symptoms to qualify for the diagnosis. The diagnosis is more difficult to make in a geriatric patient than in a younger patient. By definition, somatization disorder patients have a certain number of unexplained physical complaints. As the patient ages, it is increas- ingly difficult to attribute certain pain symptoms to a nonorganic origin. For 25 Course of the Disorder example, if a 75-year-old female patient complains of joint pain, it is easier to attribute her affliction to some demonstrable joint pathology than it would be if she were 25 years old. In the ECA study, the age of onset was under 10 years for 40 percent of the patients, and under 15 years for 55 percent. In women, the age of onset is usually at the time of menarche when they complain of dysmenorrhea and excessive bleeding (Swartz et al. 1990). While there have been several small series on children with somatization disorder (Robins and O’Neal 1953; Livingston and Martin-Cannici 1985; Kriechman 1987), adolescents are more likely to have the disorder (Weller et al. 1983). By implication, the diagnosis of somatization disorder is rarely made before puberty. There are now some indications that somatization disorder runs in families and that children of women with multiple unexplained complaints have children who also have multiple somatic complaints. Studies are currently underway to fully explain this relationship. Coryell and Norten (1981) and Morrison (1989) noted that women with somatization disorder are more likely to be sexually abused as children com- pared to women with mood disorders. Morrison reported that 55 percent of the women with somatization disorder reported being molested as children while 16 percent of the mood disorder controls reported being molested. : Summary — Gender and Age Somatization disorder is far more prevalent in women than men. It does occur in ‘men, however, and should be considered | in the differ the age of 30. The usual age of onset in women is at menarche Th diagnosis can be made at any age. Because of the development of ; medical problems, the diagnosis is more difficult | to make i ina geriatric : patient than i ina younger patient. . Ca Somatization disorder appears torunin families. Children of patients with : the disorder may develop unexplained somatic complaints that represe; the onset of the disorder. Usually, however, the children do not h ~ enough positive symptoms to qualify for ihe diagnosis. Some evidenc - sexually molested as children, 26 Course of the Disorder Untreated Course of the Disorder By definition, somatization disorder is a chronic relapsing condition. The etiology is unknown, and no cure for the disorder has been found. Proper management of this chronic condition is the treatment of choice. In its untreated course, the disorder usually begins in middle to late adolescence, but may start as late as the third decade. Typically, patients develop a new symptom or symptoms during times of emotional distress. No data are available as to how long an episode of illness (relapse) lasts; it is the author’s impression that a typical episode lasts 6 to 9 months. Quiescent periods (remission) may last 9 months to a year. However, it is unlikely that patients with somatization disorder will go more than a year without developing a new symptom or seeking some type of health care. As one indication of the course of the disorder, the ECA study showed that 95 percent of the patients with somatization disorder had visited a health care provider in the last 6 months (Swartz et al. 19884), while only 56 percent of the other community respondents had seen a provider during the same period. Occasionally, patients in their 40s, 50s, or 60s become so frustrated with the physician’s efforts to help them and with the medical profession in general, that they completely abandon visits to physicians. However, even during these times, patients probably remain symptomatic at a similar level of severity. Periods of distress seem to coincide either with the onset of new symptoms or withincreased health care-seeking behavior associated with some preexisting symptom. While no data exist on whether stress precipitates the relapse, there does seem to be an association. This association is especially problematic since patients with somatization disorder are known for their chaotic social lives, often reflected in multiple divorces and remarriage, work disability, and marked interpersonal difficulties. Accordingly, they have an inordinate number of distressing situations. If many of these situations are associated with illness relapse, one can easily understand why relapses are so frequent. In the author’s series of patients with somatization disorder, 50 percent had been divorced at least once; those divorced had 1.4 divorces per patient. Several interesting reports have suggested that patients with somatization disorder engage in assortive mating (Woerner and Guze 1968; Cloninger and Guze 1975; Zoccolillo and Cloninger 1985), that is, they specifically choose a certain type of individual with which to marry and/or have children. Moreover, it appears that women with somatization disorder selectively choose alcoholics or men with antisocial personality disorder as their mates. This was confirmed in a recent study where primary care somatization disorder patients were inter- viewed about their husbands’ alcohol consumption. The husbands were found to have a rate of alcoholism or alcohol abuse fourfold higher than the U.S. male population (Cook et al. unpublished). 27 Course of the Disorder As any physician who has treated patients with somatization disorder knows, these patients typically report poor health statuses. When standard measures for health status assessment are applied to patients with somatization disorder, these patients report that all aspects of their health — physical, social, and mental — as well as their general health perceptions are severely impaired, When patients with chronic medical conditions such as hypertension, rheumatoid arthritis, chronic obstructive pulmonary disease, and insulin-de- pendent diabetes mellitus are compared to patients with somatization disorder, the somatization disorder patients report worse health than do those with chronic medical conditions (Smith et al. 19864). In other words, patients with somatization disorder perceive themselves as “sicker than the sick.” This perception may be a helpful tool for primary care physicians to increase their index of suspicion for somatization disorder. When patients profess that they are substantially more ill than they actually are, somatization disorder should at least enter the differential diagnosis. Thus, while this concept is quite nonspecific, it may still serve as a useful clinical sign. Further, since somatization disorder patients perceive themselves to be severely ill, it is not at all incongruous that they also usually deem themselves disabled from work. As evidence, Smith et al. (1986a) reported that 86 percent of the patients said they were disabled from work. With respect to full-time employment, three-fourths of the somatization disorder patients in the ECA study were not employed full time, compared to one-third of the patients without the diagnosis (Swartz et al. 1990). Course of the Disorder Psychiatric Comorbidity Somatization disorder patients have much higher levels of depression than seen in the general population. In the somatization patients seen in psychiatric inpatient or outpatient settings, depression — including major depressive epi- sodes — was manifest in 80-90 percent of the patients (Liskow et al. 19864, b; Bibb and Guze 1972; Morrison and Herbstein 1988). These findings are amaz- ingly consistent. Patients with somatization disorder from primary care settings may be less likely to have depression; however, depression is still quite common in this group. In the author’s current study, 92 percent acknowledged a history of depression. And yet, when these same patients were administered the DIS, only 40 percent had lifetime histories of a major depressive episode. An additional 9 percent had histories of dysthymia independent of a major depressive episode. Still, these lifetime prevalences are six times higher than would be expected in a general population (Robins et al. 1984). Clinical wisdom indicates that patients with somatization disorder also have substantial problems with anxiety (Sheehan and Sheehan 1982). Cloninger and Guze (1970a) noted increased anxiety in female criminals with somatization disorder. Another study revealed that 28 of 41 patients with somatization disorder from primary care settings had a history of anxiety disorders (Smith et al. 1986a). Liskow et al. (19864) reported on the systematic evaluation of 78 psychiatric outpatients who had somatization disorder. They found that 27 percent met criteria for obsessive/compulsive disorder, 39 percent had phobic disorders, and 45 percent met criteria for panic disorder. In the author’s unpublished series, 34 percent of patients with somatization disorder had generalized anxiety disorder, 18 percent had obsessive compulsive disorder, and 26 percent had panic disorder. In total, 66 percent had a diagnosable anxiety disorder (excluding simple and social phobias). These data provide support for most writers’ clinical observations that patients with somatization disorder have substantial comorbidity with anxiety disorders. Patients with somatization disorder may have an increased prevalence of alcoholism compared to the general population. In studies of psychiatric patients, 15-31 percent of somatization disorder patients had alcoholism (Lis- kow et al. 19864, b; Bibb and Guze 1972; Martin et al. 1982). Sigvardsson et al. (1986) found that men with a somatization disorder-like illness had an increased prevalence of alcoholism. Several studies have noted that first-degree male relatives and husbands of patients with somatization disorder also have high rates of alcoholism (Woerner and Guze 1968; Arkonac and Guze 1963; Routh and Ernst 1984). Of the author’s subjects, 23 percent were noted to have a lifetime history of alcohol abuse and/or dependence; 1.6 percent of the subjects abused all other substances. This compares with approximately 16-percent prevalence of alcohol 29 Course of the Disorder abuse and/or dependence seen in the general population. These data indicate an increased prevalence of alcohol problems but not of drug abuse. Drug abuse, especially prescription drug abuse, has been deemed a com- plication of somatization disorder. Empirical evidence to support this is only moderate (Liskow et al. 19864, b; Bibb and Guze 1972; Martin et al. 1982). The scenario used to explain prescription drug abuse is relatively easy to understand. Patients complain of a symptom. In an effort to relieve the symptom, the physician prescribes an analgesic, a hypnotic, or a tranquilizer. This medication improves the patients’ symptom only moderately. They then present again. The physician either increases the dose or prescribes a more potent and possibly more abusable drug. Personality disorders are longstanding patterns of maladaptive behavior that usually result in substantial interpersonal difficulties. Both histrionic per- sonality traits and histrionic personality disorder are associated with somati- zation disorder (Lilienfeld et al. 1986; Kaminsky and Slavney 1983; Kimble et al. 1975). There is likewise an association of somatization disorder and antiso- cial personality disorder or antisocial behavior in men and women who are psychiatric patients or criminals (Liskow et al. 1986a, b; Guze 1964, 1983; Zoccolillo and Cloninger 1985; Cloninger and Guze 19704, b; Lilienfeld et al. 1986; Guze et al. 1971; Spalt 1980; Guze et al. 1967). In the author’s study, 70 patients were administered the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID II) (Spitzer et al. 1988). While no population norms are available for this instrument, 47 percent of the patients had evidence of at least one personality disorder. Specifically, 17 percent had histrionic personality disorder and only 4.3 percent had antisocial personality disorder. The most prevalent personality disorder in this group was avoidant personality disorder (28 percent) followed by paranoid personality disorder (24 percent). Of note is that while 47 percent had one or more personality disorders diagnosed, 34 percent had two or more, 13 percent three or more, and 13 percent had four or more personality disorders diagnosed. Many of these subjects, therefore, can be considered to be severely disabled by their per- sonality disorders, which are only diagnosed in the face of longstanding mal- adaptive patterns of behavior. The 26-percent prevalence of avoidant personality disorder may explain the severe social isolation apparent in soma- tization disorder paiems. Summary - Psychiatric Comorbidity a hisory of ro n, 30 Course of the Disorder 31 ny STS [ES IT SE Ar re ES =e ay . ¥ h - . } oy . ) b a a i 7 go i . } . 4 grhecs on oo a yb Rt Re B - ™y, ny jl 4 : » a 3 ot - . i I Ca - ' 4 ) B = he i Ch = vd - = . Sn La B k- B Fe . B Pow > a ) 1 1 i 2 . . . eas - =4 z 2 3 = - . r 4 - 4 oo . =" 1 = * - . CTL, 2 - Pm = 25? Bh #7 v0 1 “yt i Ra ER. . Ce ob = edt DR Ne. wf y 3 1a SI i - a A » I afihp ry ® pls x ) 3 - . : 5 } LN Bh } i F - . Co Lr oo oh Da CR] pe f } Su Hirer ) ; . gl ee » Eu ty el, han = most w go. LE wy ea . Bath J dF ee at EE - . oo ] t, mph ane Amal ae ng PIL OE I rE : & ‘i t B a. Zhi = a = ) B b Medgar tw BL ERLE n . @ . ) © ani ry “ 2 £ - Bh a Ek) . Eat # 0 SHER 24 SF Lp ES 1 a 2¢ So oT CERES ee BL eo Sy oo A i “1 A ) - . ii " “ay i 5 f Miya D 49 Lr ame pf CS | ° ill oi G N = a # 3 E FRE «0 Rte i Fil a 1 fl 2 Eg. [Ee § - a ; # . on - ol i y wn lx Eo ¥ ¥ a A PT n - : = 5 . : ; by % ) EL Eine. ) = -» 1 = - = n k } Pr - ot . "ey Be "z In Ay BE oo - wv, "FL Few B mh = . ig co. . ¥ T } ) k hy £5 2 — h x - Fat wf 0 on Gri a FE Ey Eos Eigse, : oe p) - o ) rd - . } g [. 4 - . . : roll god) re . eae. wt Le er oro Caf. TR INL | J . Chapter 5 Diagnosis DSM-III-R Criteria Somatization disorder should be diagnosed according to the DSM-III-R criteria (table 1). These criteria were published as part of DSM-III-R in 1987 and will serve at least until the issue of DSM-IV in the mid 1990s. The essential feature of the disorder is recurrent and multiple somatic complaints of several years’ duration for which medical attention has been sought, but which ap- parently are not due to any physical disorder. The diagnosis requires a lifetime history of 13 unexplained somatic symp- toms from a list of 37 possible symptoms, the first of which must have developed before the age of 30. These symptoms must be of sufficient severity to require patients to consult a physician, take medicine, or change their lifestyle. It is important to note that the physician need not be convinced that the symptom is real or has actually occurred. Patients’ reports that they have the symptom is sufficient as long as the symptom meets the severity criteria. Since the disorder frequently begins during adolescence or young adult- hood, it is especially important to determine in women whether dysmenorrhea or excessive bleeding occurred around the time of menarche. This is a frequent time of onset for adolescent girls. A patient can have somatization disorder even if a current or presenting symptom did not begin before the age of 30. A careful review of the earliest onset of any of the 37 symptoms for which the patient has had problems is necessary to make the diagnosis. While it may seem especially time-consuming and somewhat unnecessary for the busy clinician, it is well worth the investment because of the time saved in the long-term management of these patients. Screening It would help the physician in the clinical practice setting to have a tool for diagnosing somatization disorder, especially since the interviews required for such determination often take 45 minutes to an hour. Screening can be very helpful to the physician simply because once the diagnosis is recognized, 33 Diagnosis Table 1. Symptom list for somatization disorder Gastrointestinal symptoms 1. Vomiting (other than during pregnancy) 2. Abdominal pain (other than when menstruating) 3. Nausea (other than motion sickness) 4. Bloating (gassy) 5. Diarrhea 6. Intolerance of (gets sick from) several different foods Pain symptoms 7. Pain in extremities 8. Back pain 9. Joint pain 10. Pain during urination 11. Other pain (excluding headaches) Cardiopulmonary symptoms 12. Shortness of breath when not exerting oneself 13. Palpitations 14. Chest pain 15. Dizziness Conversion or psuedoneurologic symptoms: 16. Amnesia 17. Difficulty swallowing 18. Loss of voice 19. Deafness 20. Double vision 21. Blurred vision 22. Blindness 23. Fainting or loss of consciousness 24. Seizure or convulsion 25. Trouble walking 26. Paralysis or muscle weakness 27. Urinary retention or difficulty urinating Sexual symptoms for the major part of the person’s life after opportunities for sexual activities 28. Burning sensation in sexual organs or rectum (other than during intercourse) 29. Sexual indifference 30. Pain during intercourse 31. Impotence 34 Diagnosis Table 1. (Continued) Female reproductive symptoms judged by the person to occur more frequently or severely than in most women 32. Painful menstruation 33. Irregular menstrual periods 34. Excessive menstrual bleeding 35. Vomiting throughout pregnancy Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised. Copyright 1987 American Psychiatric Association. NOTE: These 35 items represent 37 symptoms since numbers 26 and 27 are both listed as “or” for items that are not synonymous. considerable management time is saved. In fact, deGruy (deGruy et al. 1987a), an advocate of screening who is himself a primary care physician, suggests that all primary care patients can be effectively screened for somatization disorder. Several attempts have been made to develop screening indices for somat- ization disorder (Woodruff et al. 1973; Reveley et al. 1977). Currently, three published screening indices are in clinical use: one developed by Othmer and DeSouza (1985), another by Swartz et al. (1986), and finally, a modification of Othmer’s and DeSouza’s screening index, published in DSM-III-R (APA 1987). In one published comparison of these indices, a sample of 151 patients were studied who were referred from primary care settings because of multiple unexplained somatic complaints (Smith and Brown in press). The Othmer and DeSouza index resulted in a sensitivity of 83 percent and a specificity of 69 percent. The Swartz et al. and DSM-III-R indices performed in very similar fashion, with approximately 95-percent sensitivities and specificities in the 35- to 40-percent range. The DSM-III-R index is recommended since the Swartz index requires 5 positive symptoms from a list of 11 possible symptoms, whereas the DSM-III-R only requires 2 positive symptoms from a list of 7. All three indices are listed in table 2. If the DSM-III-R index is used, a positive screen in a patient with multiple unexplained somatic complaints indicates that the patient has a 69-percent chance of having somatization disorder (positive predictive value). Similarly, such a patient with a negative screen has an 81-percent chance of not having somatization disorder (negative predictive value) (Smith and Brown in press). If patients have a positive screen, they require an evaluation for the dis- order. This usually involves an extended return appointment with the primary care physician for assessment of all 37 symptoms from the criteria list. Psychi- atric consultation may be sought to assist with making the diagnosis. 35 Diagnosis Table 2. Screening indices for somatization disorder currently in use Othmer/DeSouza (1985) Swartz et al. (1986) Threshold: 3/7 Threshold: 5/11 Amnesia Abdominal gas Burning in sex organs Abdominal pain Dysmenorrhea Chest pain Lump in throat Diarrhea Painful extremities Dizziness Shortness of breath Fainting spells Vomiting Feels sickly DSM-III-R (APA 1987) Nausea (Othmer/DeSouza) Pain in extremities Threshold: 2/7 Vomiting Amnesia Weakness Burning in sex organs Dysmenorrhea Lump in throat Painful extremities Shortness of breath Vomiting Diagnosis Somatizers Unless the reader is familiar with the work of Guze and his colleagues, it will seem quite arbitrary that a patient with 13 unexplained medical symptoms beginning before the age of 30 has somatization disorder while a patient with 12 unexplained somatic symptoms beginning before the age of 30 does not have somatization disorder. This has very practical applications in primary care since the patient who somatizes, that is, has 6-12 unexplained somatic complaints, is probably common in the primary care setting. Guze and colleagues attempted to be quite rigorous in defining a disorder that has a uniform clinical course. Their work indicated that when the symptom number threshold is reduced, patients who have an atypical clinical course inappropriately receive the diagnosis. As a problem in psychiatric nosology, the above information is quite interesting; however, for the busy practicing primary care physician, the issue is somewhat arcane or even irrelevant. In the primary care setting, the more pointed questions asked are “What is wrong with the patient with multiple but less than 13 unexplained complaints?” and “How should that person be man- aged?” The answers to those questions are simply not known. However, some research data, while indirectly relevant, provide some clinical wisdom that may be of help in management. For the purpose of this discussion, patients with 6-12 unexplained medical complaints beginning before the age of 30 are defined as somatizers. Clinically, these patients present in nearly identical fashion to patients with somatization disorder. Like somatization disorder patients, somatizers focus much more on their symptoms than they do on any given disease. Similarly, they see multiple physicians and have had numerous surgical procedures, some of which are for questionable indications. Data from the ECA researchers (Escobar et al. 19874; Swartz et al. 1990) indicated that in a community-based sampling, those patients who somatize have increased health care-secking behavior but are at an intermediate level between the general population and patients with somatization disorder. Com- munity-based prevalence estimates are available for subsyndromal somati- zation, in this case defined as having between 4 and 12 unexplained somatic complaints. In all the ECA sites combined, 11.6 percent of the population had subsyndromal somatization (Swartz et al. 1990). While these data indirectly indicate that somatizers are similar to somatization disorder patients, the study is by no means conclusive nor does it prove that somatizers and somatization disorder patients have similar courses. Through their clinical experiences, numerous writers have suggested man- aging somatizers with the same approach used with patients with somatization disorder. The implication is that these somatizers have a similar course and, therefore, may be managed in a similar way. No data are available concerning the course of somatizers. While specific management recommendations for 37 Diagnosis somatizers are addressed in the following sections, it is important for the reader to understand that no empirical data are available to lend support to the above implied contention. to those who clearly ave somatization disorder. Differentiating Somatization Disorder Animportant aspect of successfully managing the patient with somatization disorder is making the correct diagnosis. Since numerous psychiatric and medical problems present with similar symptoms, careful attention to the differential diagnoses of these common syndromes is very important. Without proper diagnosis, proper management cannot be instituted. Somatized Anxiety A frequent problem seen in the primary care setting is somatized anxiety. This condition may result in psychic anxiety being transformed into muscle tension. For example, a new and somewhat insecure certified public accountant (CPA) may present to the physician’s office complaining of the new onset of shoulder and neck pain. The CPA may have unconsciously converted his psychic anxiety to muscle tension in his neck and shoulders, thereby creating discomfort or pain. The same situation could be true if the CPA presented with a new onset of headaches. Similarly, the anxiety could produce abdominal pain with symp- toms similar to irritable bowel syndrome. Several aspects of the differential diagnosis are important to distinguish somatized anxiety from somatization disorder. Patients with somatized anxiety usually do not have a lifetime history of multiple unexplained somatic symptoms. Rather, they may have one or two symptoms that could have begun at any age. Second, somatized anxiety usually takes the form of musculoskeletal, sym- pathetic cardiovascular, or gastrointestinal symptoms. Usually, the patient has only two or three symptoms associated with the anxiety as opposed to the many symptoms manifested in the patient with somatization disorder. 38 Diagnosis Moreover, patients with somatized anxiety either have a chronic anxiety condition such as generalized anxiety disorder or have a situation in their life that produces the anxiety. This is not characteristic of a patient with somati- zation disorder, who may or may not have anxiety symptoms and who almost always is experiencing multiple distressing situations. Often, the patient with somatized anxiety has time-limited symptoms around the stressful life event. Finally, patients with somatized anxiety often have a symptom complex specific to that individual, such as the CPA who usually develops shoulder or neck pain during times of emotional distress or the high school student who develops crampy abdominal pain around examinations. Somatized Depression Depression is, unarguably, one of the most (if not the most) common psychiatric conditions seen in primary care settings. Typically, depressed patients present with persistently blue moods and some associated features of depression such as decreased appetite, decreased libido, insomnia, and loss of the ability to perceive pleasure. Sometimes, however, depression may present as a somatized symptom. For example, a 62-year-old school teacher may present with diffuse mild abdominal pain that has lasted 4 to 6 weeks. She does not have a history of multiple unexplained somatic complaints, but she does have a sad facial expression and when initially questioned, acknowledges that she has difficulty experiencing pleasure. When questioned further, she admits that she has been increasingly despondent since her granddaughter moved to another State 6 months ago, adding that her granddaughter had been the center of her life while they lived in the same town. Several points in this differential are important. The depressed patient usually does not have a lifelong history of multisystemic unexplained complaints. While numerous somatic symptoms may accompany depression, a history of unexplained somatic complaints beginning before the age of 30 suggests soma- tization disorder rather than depression per se. Depression may often be episodic in that patients may have had similar symptoms at a previous time when they were depressed. When the patient over 50 presents with a new, obviously unexplained physical complaint, it is especially important to differentiate depression from the onset of a new somatic disease. In this situation, somatization disorder can be easily ruled out by simply taking a history of unexplained somatic complaints. Panic Disorder Panic disorder is another psychiatric condition that is seen with consid- erable regularity in primary care settings (Katon 1989). While some authors contend that the clinical picture of somatization disorder is often a sequela of panic disorder, only limited empirical evidence is available to support this 39 Diagnosis contention (Sheehan and Sheehan 1982). Orenstein (1989) suggested a common substrate from which panic disorder, agoraphobia, major depression, and somatization disorder all develop. Further work in the area is necessary to adequately evaluate this contention. Panic disorder is an anxiety condition in which patients develop very intense, acute episodes of anxiety lasting 3 to 5 minutes. These episodes are extremely uncomfortable and of such intensity that the patients often believe that they are dying or having a psychotic episode. This anxiety is accompanied by very characteristic somatic manifestations of anxiety, specifically tachycar- dia, palpitations, hyperventilation, and diaphoresis. The differentiation from somatization disorder relies on the fact that these somatic symptoms of anxiety are expressly due to the panic disorder and its accompanying intense but short-lived anxiety. In contrast, somatization dis- order is a chronic relapsing condition involving multiple systems with numerous complaints. Patients with panic disorder do not have a history of multisystemic unexplained problems. Panic disorder may begin at any age whereas somatization disorder by definition always begins before the age of 30. Patients with panic disorder are more likely to present in the emergency room shortly after a panic attack. Rarely are they seen during a panic episode. On the other hand, patients with somati- zation disorder often have the symptom while they are being examined by the physician, and no associated anxiety or fear of a panic attack is evident. Hypochondriasis Hypochondriasis is a somatoform disorder whose essential feature is a preoccupation with the fear of having (or the belief that one has) a serious disease based on the person’s interpretation of physical signs or sensations. Reviewed extensively by Barsky and Klerman (1983) as well as by Kellner (1987), hypochondriasis is essentially anxiety about having a particular disease or diseases. It is often thought of as psychic anxiety that is actually focused on normal somatic functioning, which is then interpreted as pathological. Note that hypochondriacal patients present with concern that they have a particular disease, such as cancer. They may also have several symptoms. When asked if they are concerned about having a particular disease, they reply that they are very concerned. Their distress is not around a symptom but around the implication of the symptom, namely, a particular disease. Patients with hypochondriasis may present over time with a series of worries. Nevertheless, this is noticeably different from the patient with somati- zation disorder who complains of various symptoms over time. Somatization disorder patients are almost indifferent to the possibility of their symptoms representing a diseased state. To reiterate, the patient with hypochondriasis is disease focused; the patient with somatization disorder is symptom focused. And, while hypochondriasis may begin at any time, somatization disorder typically begins in adolescence. 40 Diagnosis Conversion Disorder Conversion disorder is a psychiatric syndrome characterized by the pres- ence of a conversion symptom (Ford and Folks 1985). A conversion symptom is a loss of function, presumably based on an intrapsychic conflict. As anisolated symptom, the conversion symptom is probably prevalent in the general popula- tion. Conversion disorder is simply the diagnosis made when a conversion symptom is present. Conversion symptoms may be a part of somatization disorder. Symptoms such as aphonia, paralysis, and blindness are conversion symptoms used to make the diagnosis of somatization disorder. In a series of patients with conversion symptoms in a general hospital, 34 percent had somatization disorder (Folks et al. 1984). However, somatization disorder differs from conversion disorder in that it is multisymptomatic and chronic beginning before the age of 30. Numerous studies demonstrate that the clinical course of patients diag- nosed as only having conversion disorder is extremely varied. In patients with multiple conversion symptoms, it is important to search diligently for’ the diagnosis of somatization disorder. If somatization disorder is correctly diag- nosed, the clinician may have increased confidence that the patient will have a highly predictable course. Somatoform Pain Disorder Somatoform pain disorder is a psychiatric condition characterized by a preoccupation with pain in the absence of adequate physical findings that could account for the pain or its intensity. In this syndrome, previously known as psychogenic pain disorder, pain is the central focus, and psychological mecha- nisms are presumed to be of etiological significance or to contribute substan- tially to the patient’s disability. As with a conversion symptom, a somatoform pain such as chest pain may be a component of somatization disorder. However, the patient with somati- zation disorder has multiple symptoms. This assures the clinician of a much more uniform course than could be accounted for solely by the presence of somatoform pain disorder. Factitious Disorders Several disorders can be classified as factitious disorders whereby patients present with fabricated physical or psychological disorders. These disorders have been given various names such as Munchausen Syndrome, Hospital Hobo, and so forth. Patients who present with factitious disorders are thought to be malin- gerers, that is, they make conscious attempts to manipulate society for some overt gain. While Ford (1983) contends that patients with factitious disorder are quite similar to somatization disorder patients, to the author, factitious 41 Diagnosis patients are quite different in that patients with somatization disorder do not make a conscious attempt to delude the physician. On the contrary, patients with somatization disorder genuinely believe they are medically ill. When the differential diagnosis of factitious disorder or malingering is considered, psy- chiatric consultants should almost always be considered to assist with the diagnosis, since the implications for the patient are substantial. Medical Problems Several medical conditions may initially be mistaken for somatization disorder because they are characterized by perplexing symptom complexes. These include multiple sclerosis, systemic lupus erythematosus, and sometimes, hyperparathyroidism. Multiple sclerosis often presents with a perplexing picture of various neurological symptoms that are present for awhile and then remit. Classical features of multiple sclerosis include impaired vision, nystagmus, dysarthria, intention tremor, ataxia, impaired position and vibratory sense, and bladder dysfunction. Most, if not all, of the above are signs of disease rather than symptoms — signs with which patients with multiple sclerosis present. Also, notably absent from the presentation of multiple sclerosis is the complaint of pain, which occurs frequently in somatization disorder patients. Systemic lupus erythematosus (SLE) is another disease with a confusing presenting picture. Arthritis, arthalgias, fever, and central nervous system manifestations are common. SLE also has signs such as nephritis, pleurisy, pericarditism, anemia, leukopenia, and thrombocytopenia. These signs enable the physician to effectively differentiate it from somatization disorder. Further, SLE rarely presents with a loss of function, which may be one of the symptoms that appear in somatization disorder. Hyperparathyroidism may present with nonspecific symptoms of the cen- tral nervous system, abnormal neuromuscular function, gastrointestinal symp- toms, and pain in the joints and soft tissue. Hyperparathyroidism is, however, usually associated with recurrent kidney stones and/or signs of osteitis fibrosa as well as abnormalities in calcium metabolism. : Summary - we Differentiating Somatization Disorder “The physician should be aware of three psychiatric problems that are . frequently seen in primary settings and that may present as somatized "yom. anxiety, depression, and panic disorder. oo : Ani ty typically presents as muscle tension, cardiovascular sympto- . sociated with overt signs of anxiety or stressful psychosocial situations in os the patient’ s life. Depression usually presents with only a few symptoms 42 Diagnosis A conversion n symptom 1 may | whe a part of somatization a Sn it one . aspect. If only a conversion Sympioi is present, then 43 EET oT a Ee RR FRE TTT EET TT TE TTR . | | - - - ? CEE : | a B a ar . at } J t ¥ : i oo - . . ) | “ s | | we > - Bh " 2 . ’ oo tm - & a“ " » a . i" w - wi . ay - . Bl . oo us 1 . a p - " B . = Bh } oo ; = } = fF . =" - - - E= N : =f oo : | § No, ‘i vos - cw ) } . } his 8c TE oo | ) : | . i Ha No Pi ar a 0 = - a .! | | f oo ) ) oo re : oe 0 . 2 P N 3 7 rw dg SE J Ra oo | | [3 2 a = oo . . LF a ty k " YC fa * : I oo | oo fin ) Fr te » " B > | = 5 EE CA TS . . . a hag WA i Zan A a at oo ay % EE " i ‘ ‘ oo # Rd a n - oo : - Es Ee Sets 1 2 di ER me geht te, : a TE - “and oo St ou wd ES 2 4 + 2p oy 3 wn rs a ) oo hs gr be ) hi a a = I - . wt ah he Ee id Thy TE I § wih 4 ie Ae el Fit] fof I = Tams: a ME ry 0 sir - ~{eliey FATA vis de for. = = 4 - - = date NN " a Fol lad fe - a =. LS ats } i. ] : A oo] Chapter 6 Treatment of Somatization Disorder in Primary Care Once the correct diagnosis of somatization disorder is made, appropriate treatment can be implemented. Since the etiology of somatization disorder is unknown, and no treatment, either curative or ameliorative, has been found, it is probably more accurate to talk about the management of a patient with somatization disorder. Very few treatment or management studies exist for somatization disorder patients, but there is a broad general consensus concern- ing appropriate management strategies. Managing somatization disorder patients involves three levels of approach: (1) providing general management of a chronic condition, (2) conservatively treating certain symptoms for symptomatic relief, and (3) providing specialized care in specialized settings. Experimental data are available concerning man- agement of the chronic condition, and some limited data exist on providing specialized care, but little or no research has been done on providing conser- vative treatment for symptomatic relief. Managing the Chronic Condition Management of the chronic condition known as somatization disorder has only been tested empirically in one study known to the author. Smith, Monson, and Ray (1986b) reported the results of a randomized, controlled crossover study of 41 patients with somatization disorder. This study tested the specific management recommendations detailed below. To date, the study has not been replicated, although a trial is currently underway. 1 Abbey and Lipowski 1987; Cloninger and Guze 1975; Cohen 1986; Ford 1984, 1986; Goodyer and Taylor 1985; Haberkern et al. 1985; Hyler and Sussman 1984; Katon 1985; Lichstein 1986; Lipowski 1986, 1988; Monson and Smith 1983; Morrison 1980; Murphy 1982; Oken 1984; Quality Assurance Project 1985; Ritvo and Thompson 1986; Smith 1985, 1988; Smith et al. 1986a; Woodruff et al. 1982; Zoccolillo and Cloninger 1986b. 45 Treatment of Somatization Disorder in Primary Care Their findings revealed that when certain management strategies were undertaken by the primary care physician, the patients with somatization dis- order maintained a constant health status. Simultaneously, their health care utilization decreased dramatically, and their satisfaction with their care im- proved over time. The study’s management approach includes (1) having the physician at- tempt to become the patient’s main, and if possible, only physician; (2) setting up regularly scheduled outpatient visits at relatively frequent intervals (every 4-6 weeks); (3) conducting brief visits so that this management can fit into a busy primary care practice; and (4) during each visit, performing at least a partial physical exam of the organ system in which the patient has complaints. Other important considerations in managing somatization disorder include understanding the symptom as an emotional communication rather than as the harbinger of new disease; looking for signs of disease instead of being symptom focused; and avoiding diagnostic tests, laboratory evaluation, and operative procedures unless clearly indicated. Finally, though this was not tested in the study, a goal of primary care management should be to get selected patients “referral ready” so that they are open to receiving care in the mental health sector. The cornerstone for successful management of the somatization disorder patient is establishing a trusting relationship with the patient whereby one physician is the main and hopefully only physician that the patient sees. The constant “doctor-hopping” that frequently occurs in somatization disorder patients is countertherapeutic. In the author’s experience, this typically occurs when the patient and physician are both frustrated with the unsuccessful management of the disorder. Without a coordinated management approach, these patients do extremely poorly. Also, while it is possible to provide coordinated management with several physicians, it is much more cumbersome and probably much more work for primary care physicians than if they alone manage the patient. Regularly scheduled visits are very important, especially in the first year of managing a new patient or in the period following an exacerbation of the disorder. In an effort to conserve health care resources and possibly avoid seeing difficult patients, physicians inadvertently contribute to their own man- agement problems with these patients by telling them, “Nothing is wrong; come back and see me only if you need to.” This advice creates a situation whereby the patient must develop a new symptom to see the physician. Since seeing the physician is terribly important to the patient, physicians who attempt to manage patients with somatization disorder in this manner are likely to create many more problems for themselves than if they scheduled routine visits. By logical extension, primary care physi- cians who can capitalize on the patient’s desire to see the physician actually expedite their management strategy for that patient. The optimal interval between visits is unknown. The interval recommended in the study cited above was 4-6 weeks. Clinically, this seems to be appropriate. 46 Treatment of Somatization Disorder in Primary Care Once patients are stabilized, they may then look forward to the next visit and contain any new complaints until the next regularly scheduled appointment. When establishing a new patient/physician relationship, during relapse, and during periods of psychosocial distress, 4-6 weeks is too long between visits. The interval needs to be shortened so the patient does not make extra visits or go to the emergency room. On these patient-initiated visits, the patient usually presents new symptoms. New symptoms require more diagnostic effort and more of the physician’s time. During periods of new symptomatology, intervals of 1 or 2 weeks may be required before patients begin to feel secure enough to stop initiating visits. Once the patient-initiated visits stop, the primary care physician should not lengthen the interval for several weeks or possibly months. Then, the time may be gradually lengthened. Also, during the first year of management, it is generally not wise to lengthen the interval past 6 weeks, unless the patient suggests it. When the patient presents with a new symptom, it is important to physically examine at least the organ system of which the patient complains. This examina- tion serves two purposes: (1) it reassures the physician that no signs of organic disease are present and (2) patients receive real comfort from the examination. This examination may harken back to the symbolic gesture of laying on of hands. After obtaining a brief history of the symptom and physically examining the appropriate part of the body, physicians should then reassure their patients that they can find nothing seriously wrong, but that they are interested in both the patient and the symptom and want to follow the patient closely to make sure that the symptom resolves. This maneuver serves to reassure the patients and to teach them that the physician will provide ongoing care, doing what is necessary for the patients and their symptoms. It is important that the physician communicate concern for the patient and the symptom. Further, it is best to avoid any suggestion that the symptom does not exist or that the symptom is not substantial. The patient actually hurts and does have the symptom. Suggestions to the contrary only serve to weaken the relationship and complicate the management. The physician should understand that a new symptom is an emotional communication — that the patient is saying “I hurt” or “I am in distress.” New symptoms presented by patients with somatization disorder are not the har- bingers of new disease in the vast majority of cases. Several authors suggest that when a symptom represents a new disease, the patient often presents in a qualitatively different manner, thereby cuing the physician to approach the problem differently. Since the physician is diligently examining the patient at each visit, looking for signs of disease, rarely, if ever, will an important new disease onset be missed. Avoiding diagnostic procedures, laboratory tests, and surgical procedures unless clearly indicated serves three purposes. By deliberately refraining from using these procedures, the physician can (1) contain the health care utilization of patients who are extraordinary health care utilizers, (2) decrease the ex- 47 Treatment of Somatization Disorder in Primary Care posure to iatrogenic complications in patients who would normally receive an inordinate amount of procedures, and (3) decrease false positive laboratory tests in patients who have no real indication for the test. The interpretations of laboratory and diagnostic procedures are based on set sensitivities and specificities (true positive and true negative rates) in patients who have appropriate indications for these tests. The criteria for a positive result established for patients with appropriate indications are not applicable to those without appropriate indications. One possible resulting problem for clinicians is that they may be confronted with a patient who has a symptom (from somatization disorder) and a false positive laboratory test that appears to relate to the symptom but in actuality does not. This poses a very difficult management dilemma, usually forcing further diagnostic interventions, all of which will probably be for naught. Most patients benefit from mental health care. With somatization disorder patients, this is much easier said than done. Willingness on the patient’s part usually only grows out of a long-term patient/physician relationship — gradually and over time at that. Primary care physicians may, in a gentle, empathetic way, tell their patients that they understand the distress that the disorder must be causing. Physicians may then suggest that it might reduce the patients’ distress to have someone who could spend more time with them than busy primary care physicians can. In the author’s experience, the above scenario works with a substantial number of patients with somatization disorder but should not be attempted before the physician/patient relationship is well established. It is very important that the patients not perceive that the primary care physician is abandoning them, but rather, that the physician still wants to follow the patient and will continue to be available as before. referral ea status to receive carei in 1 the mental health : patient toa‘r 48 Treatment of Somatization Disorder in Primary Care Conservative Treatment of Selected Symptoms Several symptoms may need to be specifically treated in the somatization disorder patient. Typically, these are comorbid psychiatric and medical condi- tions. Since the patient needs a unified management approach, the proper management of these problems is important to the overall outcome of the patient. The specific problems addressed in this section are depression, anxiety, comorbid medical conditions, and disability. Depression Depression is the most common comorbid condition in somatization dis- order patients. Depressed mood has long been recognized as an associated feature of somatization disorder. Depressed mood alone, however, is not an indication for psychotropic drug treatment since depressed mood in and of itself is not responsive to pharmacologic interventions. Syndromes of depression, that is, constellations of signs and symptoms that together make up a discrete, clinical entity, should be treated in the somatization disorder patient. In the author’s study of psychiatric comorbidity in somati- zation disorder patients, 9 percent were noted to have dysthymic disorder, and 40 percent had lifetime histories of major depressive episodes, “a depressed mood or loss of interest or pleasure in almost all activities for a period of 2 weeks” (APA 1987). Regardless of the particular depressive disorder, the primary care physi- cian should look for a persistently pervasive blue mood and the associated symptoms of depression — insomnia, anorexia, decreased libido, and anhedonia (the inability to experience pleasure). When this constellation of signs is present, aggressive psychopharmacologic management is indicated. The drugs of choice for treating the depression syndrome are the tricyclic antidepressants. There are a wide variety of antidepressants to choose from; moreover, the clinician should remember to ensure that adequate doses are achieved for an adequate length of time and that the symptoms do resolve. It is rare today for depression to be unsuccessfully treated. Therefore, if after aggressive management by the primary care physician, the depressive syndrome does not resolve, the patient should be referred for psychiatric consultation and treatment. Anxiety The symptom of anxiety is very common among somatization disorder patients; many report chronic problems with anxiety. Much of this can be attributed to their inability to deal with the world and their poor social skills. Treatments for anxiety vary depending upon the specific anxiety disorder. Both panic disorder and agoraphobia, a condition that at times can result from 49 Treatment of Somatization Disorder in Primary Care panic disorder, should be treated aggressively since combined pharmacologic and behavioral regimens provide superior results. The diagnosis and treatment of panic disorder are covered in a monograph by Katon (1989) in which specific treatment recommendations are provided. Social and simple phobias are quite prevalent in the population (Kirmayer et al. 1988). In the author’s unpublished series, they are even more prevalent in patients with somatization disorder. Unless the phobia hinders the patient in some substantial way, treatment is not usually indicated. When treatment is elected, the patient should be referred to a mental health professional. Of all the anxiety disorders, the most difficult symptom that confronts the primary care physician, as well as the patient, is the chronic persistent anxiety as seen in generalized anxiety disorder. While the symptom of anxiety may be an associated feature of somatization disorder, usually the anxiety itself is severe enough to meet diagnostic criteria for generalized anxiety disorder. For several reasons, this specific pairing of somatization disorder and anxiety can give rise to very problematic and difficult considerations in terms of primary care. The first difficulty is that only symptomatic treatment is available for generalized anxiety disorder. The benzodiazepines provide quite impressive symptomatic relief. Unfortunately, the very effectiveness of the benzodiaze- pines tends to undermine the treatment approach in the long-term management of patients with generalized anxiety disorder. As almost every primary care physician knows, because these drugs are so effective and because anxiety is so uncomfortable, patients often are reluctant to discontinue their medication. A new type of pharmacologic agent — buspirone — that is felt to be specific for generalized anxiety disorder and does not lead to tolerance or withdrawal symptoms, is now marketed in the United States. This drug has yet to stand the test of time. Hopefully, however, in several years the drug can be recommended as an appropriate treatment for anxiety associated with somatization disorder. At present, the first line of treatment of generalized anxiety disorder in the somatization disorder patient is to encourage the patient to simply tolerate the symptoms. While encouraging tolerance or encouraging suffering of symptoms is not conscionable with the current direction of American medicine, few, if any, proven alternatives exist. The next line of treatment is regular visits with an ample amount of emotional support. Emotional support can be surprisingly therapeutic. Another possible line of treatment involves the use of biofeedback or some form of relaxation therapy such as systematic relaxation. Normally, these ther- apies need to be administered by a mental health professional. While their technologies are relatively straightforward, they are time-consuming and usual- ly require special training. As an absolute last resort, an extremely conservative, judicial use of an- tianxiety agents may be prescribed. As always with antianxiety agents, physicians should be relatively certain that they are the main physician that the patient is seeing. Prescriptions should be carefully monitored so that the dosage does not slowly increase over time. The patient should not be given multiple refills but 50 Treatment of Somatization Disorder in Primary Care should be required to return to the physician frequently for monitoring. And finally, by all means, the lowest possible dose should be used. Comorbid Medical Conditions Comorbid medical conditions also need to be treated and managed in the most conservative manner possible. In all cases, invasive diagnostic or thera- peutic procedures should only be undertaken as a last resort, since these patients usually have poor outcomes. The physician should be aware that patients with somatization disorder have what Barsky and Klerman (1983) described as amplified somatic styles. This means that they overrespond to almost any symptom. Therefore, the physician should exercise as much prudence as possible in the management of comorbid conditions, relying on frequent contact with the patient when the situation is serious. Providing reassurance is extremely important when dealing with any patient who has a chronic condition. This is especially so in patients with somatization disorder. The somatization disorder patient does not respond well to a complete description of all the various side effects of a medication. In this particular situation, it is much more important that the primary care physician tell the patient that the course of the condition will be relatively straightforward. For example, in patients who develop moderate essential hypertension, a disease that can be easily controlled with medication, the physician should tell patients that the medication will control their blood pressure. It is unlikely that they will develop other symptoms or have other complications if the blood pressure is controlled. By having the physician check the blood pressure on a regular basis, both the physician and the patient are assured that the patient is doing well. Disability For most people, work provides structure for their lives, income for their families, and incentives for being healthy, the last of which many disability plans discourage. Unfortunately for patients with somatization disorder, disability from work is a very problematic issue. These patients are often quite in- capacitated by their symptoms and often have a very limited capacity with which to deal with their world. In one series of 43 patients with somatization disorder (Smith et al 19864), 86 percent said they were disabled from work. Zoccolillo and Cloninger (1986b) found that 26 percent had work disability compared to 4 percent of the control group. Considering the enormous societal costs that are incurred for disabled workers, work disability is a major complication of somatization disorder. Just as work adds meaning and structure to healthy lives, work is equally important to patients with somatization disorder, and they should be en- 51 Treatment of Somatization Disorder in Primary Care couraged strongly and repetitively to continue working. When that is no longer an option, the patient should be assisted in finding other, less distressing employment. Efforts in this direction could involve vocational counselors and probably rehabilitative services. Rehabilitative services can be particularly helpful after a patient has been through numerous efforts to maintain employment. It is the author’s usual practice to assist the patient in obtaining some form of disability payment. Treatment of Somatization Disorder in Primary Care Specialized Care Group Treatment Several authors have noted that group treatment for somatization disorder patients may be helpful 2 Similar to suggestions for medical management, the authors are relatively uniform in their recommendations. Most suggest directed, time-limited group therapy where the emphasis is on ways to improve patients’ socialization skills and ability to cope. Typically, these therapy groups are run by mental health professionals rather than physicians. While the solo primary care physician may lack a sufficient number of patients to form a group, moderately sized group practices probably have enough patients with somati- zation disorder or enough patients who somatize to form regular groups. One moderately successful approach this author has used to encourage patients to attend group meetings is to say that their purpose is to learn from one another ways in which they may better cope with their multiple medical problems. The physician should continue to see the patient on a regular basis, at least initially, and encourage the patient to continue in the group. Advocating ongoing group psychotherapy is not likely to be a successful approach to treating the patient with somatization disorder, especially if the recommendation is offered early in the doctor/patient relationship. Patients usually become offended that the physician would suggest that their problem might be a psychiatric disorder instead of multiple medical problems. In addi- tion, few somatization disorder patients are sufficiently psychologically minded for insight-oriented group therapy. Other Specialized Treatment The only other treatment approach mentioned in the literature is a trial of electrosleep in patients with somatization disorder. Electrosleep, now in disuse, is a form of central electrical stimulation at a subseizure threshold level. Scallet et al. (1976) found that specialized somatic therapies had no advantage over more traditional treatment approaches. 2 Ford 1984; Mally and Ogston 1964; Ford and Long 1977; Schoenberg and Senescu 1966; Schreter 1980; Valko 1976; Corbin et al. 1988. These reports, however, did not result from experimentally designed tests of group treatment. Corbin et al. (1988) did report a 33-percent reduction in office visits during the period of group treatment and the following 3 months. 53 Treatment of Somatization Disorder in Primary Care Indications for Consultation and/or Joint Care Consultation with a mental health provider is often appropriate in making the initial diagnosis of somatization disorder. Since management of somati- zation disorder involves the long-term treatment of a chronic disorder, it is usually helpful to the primary physician to have another professional confirm the diagnosis. Such consultation tends to lower the physicians’ anxiety about missing some esoteric diagnosis, thereby enabling them to more closely adhere to appropriate management guidelines. Another indication for consultation or joint care is the presence of specific subspecialty problems. These fall into three categories: psychiatric, specific chronic conditions, and diagnostic questions. Joint care with a psychiatrist or other mental health professional is impor- tant when other comorbid psychiatric conditions such as major depressive episode are present. Joint care facilitates an appropriate, prompt treatment of the comorbid condition, a condition that without fail adds to the disability of the somatization disorder patient. When specific chronic conditions are present, the primary physician should care for the patient jointly with the subspecialist. In this situation, it is imperative that the primary care physician alert the subspecialist to the patient’s somati- zation disorder and outline a conservative management plan with which the subspecialist should cooperate. 54 Treatment of Somatization Disorder in Primary Care It is clearly unwise to ask subspecialist colleagues for consultation concern- ing a somatization disorder patient without alerting them to the patient’s propensity for developing symptoms and complaining profusely about them. Unfortunately, the following scenario is more common than not: upon referral from the primary care physician, the somatization disorder patient sees a subspecialist. Unsuspecting and, what’s worse, uninformed, the subspecialists unwittingly disrupt a carefully designed management approach because they believe that the referring primary care physician wants a symptom thoroughly evaluated and aggressively treated. As is usual with patients with somatization disorder, the symptom does not improve. The end result is increased health care utilization, a disrupted management plan, and a frustrated subspecialist. Difficult diagnostic dilemmas can sometimes arise in patients with somati- zation disorder. In such a situation, the subspecialist who is assisting in the diagnostic evaluation should be alerted to the patient’s somatization disorder and the need for a careful, conservative approach. Specific indications should be present before diagnostic procedures are instituted. Again, abnormal physical signs rather than symptoms should be relied on to avoid unhelpful and possibly harmful procedures. a id ny Iti is very important for the primary care ns n ee alert : the subspecialist to the presence of somatization disorder and to describe : the Specific management approach the primary care Physician is taking, 55 Treatment of Somatization Disorder in Primary Care Indications for Referral Many physicians believe that the simplest solution to the dilemma posed by somatization disorder is for that patient to go see another physician and never return to the primary care physician’s office. This way of thinking is neither in the patient’s nor probably in the primary care physician’s best interest. By contrast, it is usually in everyone’s best interest for the primary care physician to make the appropriate diagnosis and embark on an effective long- term management plan for this difficult multisymptomatic patient. Two indica- tions, however, when present, warrant referral. The first indicates a physician’s successful management of the patient with somatization disorder. After a long-term relationship has been established and the patient has been responding successfully to the management plan, the somatization disorder patient will likely be ready for referral to a psychiatrist or other mental health professional. In this situation, however, primary care physicians should still reassure the patient that they will continue to be available and will see the patient on a regular basis. Nevertheless, at this stage, the primary care physician can consider the management of the patient very successful, especially once the patient becomes successfully involved in treatment with the mental health professional. A second indication for referral is when the negative feelings of the primary care physician toward the patient become so intense that it is no longer in the patient’s best interest to continue receiving care from that particular physician. This situation occasionally occurs; when it does, the decision to refer should be made consciously rather than unconsciously. The referral should be made in a direct manner. If at all possible, direct communication should occur between the referring physician and the accepting physician to make sure that continuity of care is maintained and that the patient is at least accepting of the referral. 56 Treatment of Somatization Disorder in Primary Care 57 Chapter 7 Case Studies From Primary Care These case studies are presented to assist the primary care physician in the recognition, diagnosis, and management of patients with somatization disorder. Case studies are used because medical education is often more enjoyable and effective when it is clinically based. Several introductory comments are appropriate. The patients’ clothes are described in more detail than is typical for medical audiences; the author and others have observed that many patients with somatization disorder dress noticeably differently from typical patients seeing their physician. While clothes are not generally pathognomonic, unusual dress may serve as a clinical sign for the physician to at least wonder about somatization disorder. Similarly, in several studies the patient’s behavior is described since behavior, too, may be a clinical hint for the disorder. Case #1 Ms. H. is a 38-year-old white female from a rural community 30 miles from the city. She has been married for 20 years to the same man who works for a public utility. She has an 11th grade education and is disabled from her work as a hairdresser. She has been receiving her care from a publicly supported primary care clinic near her home. When her previous physician moved to another State, Dr. D., the new family practitioner assigned to her case, noted that her outpatient chart was 5 inches thick. However, the problem list did not include a single major chronic medical problem. She had reported 14 operations: a tubal ligation, five breast operations (four for fibrocystic disease and a fifth for reconstruction and breast implants), a cholecystectomy that included an appendectomy; a hysterec- tomy, bladder repair, an intestinal bypass, a stomach resection, and three D & Cs. During the past 2 years she received care not only from the clinic but also from a cardiologist, a psychiatrist, and a medical school teaching outpatient program. She was hospitalized at two different private general hospitals. On her first visit to Dr. D., Ms. H. complained of shoulder pains. Since she was only scheduled for a 15-minute visit and the exam of her shoulder was within normal limits, Dr. D. rescheduled her for a more extensive return visit. On her 59 Case Studies From Primary Care second visit, for a followup of her shoulder pain, the pain was somewhat improved but still troublesome. Dr. D. administered the screening index for somatization disorder. She was positive for five of the seven symptoms. A third visit was scheduled in 2 weeks as an extended visit to obtain a careful history and physical examination. On her third visit, she was noted to be positive for 20 of the 37 DSM-III-R symptoms with an age of onset of 12 years. On physical examination, she was noted to be an obese white female wearing a bright canary-yellow pants suit and black high-top tennis shoes. She also carried a 2-quart insulated pitcher of water with a straw, saying that her mouth frequently became dry. Except for her obesity and her abdominal scars, her physical examination was within normal limits. During this third visit, Dr. D. said that he would like to have another physician see her, assisting him with making a correct diagnosis. She readily agreed and was seen on two occasions by a consulting psychiatrist who con- firmed Dr. D.’s diagnosis of somatization disorder and made recommendations similar to those presented in this monograph. On Dr. D.’s fourth visit with her, he began the management approach outlined herein, seeing her every 4 weeks. On her fifth visit to the clinic, Dr. D. noted that she continued to make emergency room visits once or twice monthly and called the clinic to come in for extra appointments about three times a month. At this point, he reduced the interval to every 2 weeks. Six weeks later, Dr. D. still noted too many emergency room visits and reduced the interval between her appointments to once a week. Over the next month there were no calls to the office and no emergency room visits. After 3 months of weekly office visits, the interval was extended to every 2 weeks — a change to which the patient readily agreed. She continued to save her complaints for her regularly scheduled visit and made no emergency room visits or calls to the office. After 3 months of every other week visits, Dr. D. increased the interval to every 4 weeks. This pattern was maintained for an additional 18 months with only two smergency room visits and an occasional call to the office. At the end of this time, Ms. H.’s husband’s employer changed their health insurance plan to a managed care plan. This required her to stop seeing Dr. D. and choose a physician from a panel of participating physicians. Even with Dr. D.’s and the consulting psychiatrist’s help with phone calls and letters to arrange a physician who would be understanding of her problems, Ms. H. was unable to find a physician who would see her on a regular basis. Most indicated that they thought nothing was wrong with her and that she should only call them on an as-needed basis. About this time numerous emergency room visits began again as well as a plethora of telephone calls. Comment: This case study illustrates that a high-quality patient/physician relationship is the backbone of successful management of these patients. When that relationship is disrupted for whatever reason, the patient’s progress is likely to deteriorate, and the patient starts to backslide. This case also demonstrates how important it is to decrease the interval between regularly scheduled visits 60 Case Studies From Primary Care until the patient has no need to call the office for an extra appointment or go to the emergency room. While at first glance, this approach may appear to be an invitation to excessive use of medical care, it is by far the superior choice. The patient receives care on a regular basis, the physician can allocate time for a brief office visit, and the need for emergency room and urgent visits is dramatically reduced. All in all, the effectiveness of the care as well as its cost effectiveness is substantially improved. Case #2 Mrs. LM. is a 54-year-old white female from a very rural area who was referred to a general internist in the city for evaluation of persistent back pain and multiple other complaints. The internist, Dr. S., hospitalized her. She noted that the patient was disabled from her job as a machine operator at a shoe factory. Mrs. M. gave a history of 10 operations: removal of a tumor from her right wrist, a D & C, a hysterectomy, three abdominal gastric operations, three breast biopsies, and leg surgery. She had received care from five different hospitals and seven different physicians in the last 2 years. On physical examination, Mrs. M. was an obese, chronically ill-appearing woman who came to the hospital wearing her transcutaneous electrical nerve stimulation unit. She was cooperative and showed her various scars with a certain amount of enthusiasm. The remainder of her physical examination was within normal limits except for a decreased range of motion in the area of her lumbar spine and local muscle guarding with some tenderness in that area as well. Spine films did reveal some degeneration of vertebral bodies L2-L5. Disallowing all back-related symptoms, Mrs. M. was positive for 16 soma- tization disorder symptoms with an age of onset of 26 years. Dr. S. made the diagnosis but asked for consultation with a psychiatrist to confirm the diagnosis. Dr. S. discussed the management cf Mrs. M. with the referring physician as well as providing him with reading material concerning the management of somatization disorder patients. Because of various circumstances, Dr. S. felt that the subsequent management by the referring physician was unlikely to go well. During the ensuing 12 months, Mrs. M. reported that she had been in bed 21 days, had made seven office visits to four physicians, and had been hospi- talized for a total of 52 days. Comment: Mrs. M.’s case illustrates that the diagnosis of somatization disorder can and should be made in the presence of comorbid medical condi- tions. Patients with somatization disorder do become ill, and their problems need to be appropriately diagnosed and treated. However, the management of somatization disorder should continue unchanged. 61 Case Studies From Primary Care Case #3 Ms. ALP. is a 36-year-old white female who is a teacher in one of the local public school systems. She has been divorced but has been remarried now for a year. Her previous husband beat her, which she believes to be the origin of her problems. In addition, she was sexually abused as a child by her father. For the last 3 years, she has been seeing Dr. M.,, a general internist in private practice. Dr. M. had attempted to treat Mrs. P. for depression with a tricyclic antidepressant without success because she stopped taking the medication because it caused a dry mouth. Ms. P. was referred for psychiatric consultation and for management recommendations. When seen for consultation, she described three psychiatric admissions for depression. During one of the admissions, she was encouraged to return to school by one of the nurses. She entered psychotherapy and began to deal appropriately with the abuse dealt to her by her father and husband. She later divorced her husband and began making what she calls rapid progress. Since that time, she reports that her physical symptomatology has been substan- tially reduced. She was positive for 13 DSM-III-R symptoms, with an age of onset of 10 years. She had a history of six operations: the removal of a cyst from the bladder, a hysterectomy, bilateral oophorectomy, a cesarean section, exploratory laparotomy, cholecystectomy, and a tonsillectomy as a child. Her physical examination, as reported by Dr. M., was within normal limits. On mental status examination, she appeared to be a well-groomed white female looking her stated age. She was wearing a floral print jacket, navy skirt, cotton blouse with a large scarf, and moderately high heels. She was cooperative during the interview and fairly eager to be of help. She had some psychomotor slowing, her mood was blue, and her affect was appropriate to her mood. The remainder of her mental status examination was within normal limits. By making a diagnosis of somatization disorder, Dr. M. was less likely to employ diagnostic procedures in the care of Ms. P. He was already seeing her on a relatively routine basis. Comment: This case illustrates that depression is the most common comor- bid psychiatric condition seen in patients with somatization disorder. At times, the depression is simply dysphoric mood; however, at other times, patients have major depressive episodes that require aggressive treatment. It further calls attention to the social chaos (abusive husband) that is common in many of these patients. Similarly, the history of childhood sexual abuse has also been reported to be prevalent in patients with somatization disorder. Case #4 Mrs. V.H. is a 32-year-old white female who lives in a metropolitan area. She is a patient of the general medicine teaching service at a university hospital. 62 Case Studies From Primary Care She presented to the emergency room of the hospital complaining of a severe headache. She was evaluated in the emergency room, given pain medication, observed for 4 hours, and 2 days later, was scheduled for an appointment to the group practice where she received her care. In reviewing Mrs. H.’s record, Dr. W. noted an average of two emergency room visits per month for the last year. Within the last 2 years she had received care from two different emergency rooms, two different hospitals, a physician in another community, and another physician in a nearby suburb. She reported nine operations: a cholecystectomy, a D & C, three abortions, a tonsillectomy, two knee operations, and an appendectomy. When Dr. W. saw her, her headache had resolved, but she complained of chest pain that was sharp in nature, nonradiating, not associated with exertion, and had been bothering her for about 4 months. On physical examination, she was a casually groomed white female wearing ared and black sweater, blue jeans, and loafers and was carrying a bright yellow jacket. She had long blond hair. Her physical examination was within normal limits. On mental status examination, she was cooperative and pleasant, and her behavior was somewhat seductive. There was no pressure or eccentricities in her speech. She showed little hesitation in discussing intimate details of her life. Her mood was euthymic; her affect was appropriate to mood but possibly alittle shallow. The remainder of her mental status examination was within normal limits. She was scheduled 2 weeks later for a followup appointment. At this appointment she was positive for 13 DSM-III-R somatization symptoms. Her age of onset was 16. She was vague about the details of her life saying she was a part-time student and worked part time as a singer. Dr. W. referred her for diagnostic confirmation. When seen in consultation, it became apparent that her primary livelihood was as a prostitute. Further, she had a history of passing bad checks; there had been periods of her life when she did not have a place to live; and as an adult, she had been in physical fights. A substantial stress in her life was that at times she had so many somatic symptoms that she had difficulty working as a prostitute. Comment: This case illustrates the association between somatization dis- order and antisocial behavior and antisocial personality disorder. While this type of association is not present in the majority of somatization disorder patients, it is present in a higher proportion of the patients than would be expected by chance alone. Case #5 Ms. D. was self-referred to an academic physician whose work with patients with multiple somatic complaints had recently been publicized. A 43-year-old 63 Case Studies From Primary Care white female, Ms. D. worked as a guidance counselor in a local high school. She normally went to a primary care physician in private practice in her community. In her consultation with the academic physician, Ms. D. reported a history of four operations: a hysterectomy, an exploratory laparotomy, and two thyroid surgeries. In the past 2 years, she had received health care from three hospitals, two different otolaryngologists, and a general surgeon. On mental status examination, Ms. D. was well groomed, wearing a grey silk blouse, a grey skirt, and grey leather walking shoes. Her silver hair, which was dramatically coiffured, gave her a strikingly matron-like appearance. Her speech was somewhat tangential and circumstantial. Her behavior was coopera- tive, particularly since she handed the examiner a three-page, single-spaced typed medical history that she had prepared on the morning of the consultation. Her mood was euthymic; her affect was appropriate to mood but somewhat schizoid and shallow. The remainder of her mental status was within normal limits. Ms. D. was positive for 25 DSM-III-R symptoms with an age of onset of 12. Comment: This patient recognized herself as a patient with a somatization disorder-like illness after having watched a 2-minute news story about the author’s work on a local TV news station. Her responsive action underscores the fact that some patients with somatization disorder can evidence amazing insight concerning their condition as long as the descriptions of the disorder in the patient are not done in a pejorative manner. Particularly to be avoided are phrases like “It’s all in your head” and “I don’t find anything wrong with you.” Case #6 Mr. N. is a 42-year-old white male who was referred by his primary care physician for evaluation as part of a study of patients with multiple unexplained symptoms. An insurance underwriter, Mr. N. is married and has three children. In the past several years, he has been through numerous evaluations for inner ear difficulties. He has also had seven operations: tonsillectomy, eye surgery, three ear operations, septoplasty, and the removal of alipoma. In the last 2 years, he was hospitalized on four occasions, one of which was a psychiatric hospi- talization. He has seen at least 10 different physicians in the last 2 years. On mental status examination, he was reluctantly cooperative and wore sunglasses throughout the interview. When asked about the sunglasses, he stated that they were his regular glasses and that he preferred tinted lenses. His speech was not spontaneous and was circumstantial. He reported his mood as euthymic while his affect was constricted and moderately flattened. He was well oriented. He denied a history of hallucinations and ideas of reference. No delusions were apparent during the interview; however, his hospital records indicated paranoid delusions had been present. During the interview, his judgment was noted to be overly cautious and suspicious. His insight was limited. 64 Case Studies From Primary Care When evaluated for somatization disorder, Mr. N. was positive for 16 DSM-III-R symptoms with an age of onset of 19 years. These 16 symptoms excluded any symptoms remotely related to his inner ear problem. Comment: This case illustrates three points. The first is that men do have the disorder, and somatization should be considered in a differential diagnosis of men with unexplained somatic symptoms. Second, the diagnosis can be made in the presence of comorbid medical conditions. Finally, psychiatric comor- bidity is probably higher in men with the disorder than in women. Chapter 8 Clinical Scripts Screening and Diagnostic Questions DOCTOR: Ms. M., I would like to ask you some questions about some common symptoms you might have had at one time or another during your life. These symptoms do not have to be present currently but could have occurred at any time. For a symptom to be positive, it must have caused you to take medicine, see a doctor, or change your lifestyle. For example, if I asked you about headaches, and you had some, as most people have, but yours had not been severe enough to cause you to take medicine, see a doctor, or change your lifestyle, then your answer would be “no.” Have you ever been bothered by chest pain? PATIENT: Yes. DOCTOR: Have you ever told a doctor about this? PATIENT: Yes. DOCTOR: What did the doctor say was causing your chest pain? PATIENT: She did not know, she said it might be my nerves. DOCTOR: When did you have this chest pain? PATIENT: When I was in high school. (This would constitute a positive symptom for somatization disorder.) DOCTOR: Have you ever had shortness of breath? PATIENT: Yes. DOCTOR: Did you see a doctor about your shortness of breath? PATIENT: Yes. DOCTOR: What did the doctor say was causing your shortness of breath? PATIENT: My asthma. 67 Clinical Scripts DOCTOR: Have you had shortness of breath at any other time except when you had asthma? PATIENT: No. (This would be a negative response.) Discussion About Becoming the Patient’s Main Physician When initiating the management of patients with somatization disorder, it is important to become the patient’s main physician to reduce that patient’s propensity toward doctor-hopping. The discussion might go something like this: “Ms. M., as we both know, you have a lot of symptoms and usually see a great number of doctors. I think it would be better for you to see only one physician as your main doctor. That way all of your care could be coordinated. You would then know that one person was attempting to understand your problems, and you would avoid the frustration of dealing with many doctors. “I would like to be your main doctor. I believe we can work out a way to communicate so that you know I understand your problems, and you can feel assured that I am working with you in helping you feel better. Further, by following you closely, I can help evaluate any new symptoms you may develop to be sure that they do not represent something serious.” Referral for Mental Health Services After the patient has been under your care for a prolonged period, areferral for mental health services may be appropriate. This should only occur after the relationship with you has been well established and the patient trusts you. “Ms. N., I know that these numerous symptoms are distressing to you and that sometimes you must get discouraged by them. I wonder if it would be helpful for you to have someone to talk to about this distress — someone who has more time than I do and who may be better able to help you cope with these problems. This does not mean that I will stop seeing you. I will continue to see you just as before unless we both agree that it is not helpful — and if that becomes the case, I will still be available to you if you need me.” If the patient refuses, you should offer to help her arrange it in the future if she would like. Disability Request Work is an important aspect of life. Patients with somatization disorder should be kept in the work force as long as possible. Frequently, the physician 68 Clinical Scripts is approached to assist in obtaining disability payments. This should be dis- couraged as long as possible. One approach might be: “Ms. O., I understand that you are having difficulty working, especially with your many medical symptoms. While I know that to you it seems like things would be easier if you did not have to work, I think that is the wrong decision. In my experience, the longer you work, the better off you are. 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Wells, K.B.; Golding, J.M.; and Burnam, M.A. Psychiatric disorder in a sample of the general population with and without chronic medical conditions. American Journal of Psychiatry 145:976-981, 1988. Westermeyer, J.; Bouafuely, M.; Neider, J.; and Callies, A. Somatization among refugees: An epidemiologic study. Psychosomatics 30(1):34-43, 1989. Woerner, P.I., and Guze, S.B. A family and marital study of hysteria. British Journal of Psychiatry 114:161-168, 1968. Woodruff, R.A., Jr. Hysteria: An evaluation of objective diagnostic criteria by the study of women with chronic medical illnesses. British Journal of Psychiatry 114:1115-1119, 1967. 78 References Woodruff, R.A, Jr.; Clayton, P.J.; and Guze, S.B. Hysteria — Studies of diag- nosis, outcome, and prevalence. JAMA 215:425-428, 1971. Woodruff, R.A., Jr.; Robins, L.N.; Taibleson, M.; Reich, T.; Schwin, R.; and Frost, N. A computer assisted derivation of a screening interview for hysteria. Archives of General Psychiatry 29:450-454, 1973. Woodruff, R.A., Jr.; Goodwin, D.W.; and Guze, S.B. Hysteria (Briquet’s syn- drome). In: Roy, A., ed. Hysteria. New York: John Wiley & Sons, 1982. pp. 117-129. Young, S.J.; Alpers, D.H.; Norland, C.C.; and Woodruff, R.A., Jr. Psychiatric illness and the irritable bowel syndrome. Gastroenterology 70:162-166, 1976. Zoccolillo, M.S., and Cloninger, C.R. Parental breakdown associated with somatisation disorder (hysteria). British Journal of Psychiatry 147:443-445, 1985. Zoccolillo, M.S., and Cloninger, C.R. Excess medical care of women with somatization disorder. Southern Medical Journal 79:532-535, 19864. Zoccolillo,M.S., and Cloninger, C.R. Somatization disorder: Psychologic symp- toms, social disability, and diagnosis. Comprehensive Psychiatry 27:65-73, 1986b. 79 om rg TE — m= rms sm smi 3 -F RU TR tr Ste Tg a ow i 3 B B i } i ) oF 3 . 3 pw LE rf. B . - cs cog hg . BN = oT El p a ty Fate AE iF da Ep Sa at i wh : . ) . 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EEE UR fi . = Doh ah wR dey 2a TEE I " TA * noo - a w - ~ » Fe '= a = : ’ ) . - - B a N - a . a - 2 ) x - : ¥ be °n . EE Annotated Bibliography Each reference in this bibliography is listed only once, even though it may be relevant to several topics. Children Ernst, AR; Routh, D.K,; and Harper, D.C. Abdominal pain in children and symptoms of somatization disorder. Journal of Pediatric Psychology 9:77-86, 1984. A study from a multispeciality primary care setting that supports the development of a childhood disorder similar to somatization disorder. Kriechman, A.M. Siblings with somatoform disorders in childhood and adoles- cence. Journal of the American Academy of Child and Adolescent Psychiatry 26:226-231, 1987. A study of the first-degree relatives of 12 children with somatoform disorders demonstrating the high prevalence of somatization disorder in the women and alcoholism and sociopathy in the men. Livingston, R., and Martin-Cannici, C. Multiple somatic complaints and pos- sible somatization disorder in prepubertal children. Journal of the American Academy of Child Psychiatry 24:603-607, 1985. A report on five prepubertal children with multiple unexplained com- plaints. Morrison, J. Childhood sexual histories of women with somatization disorder. American Journal of Psychiatry 146:239-241, 1989. A study of 60 female psychiatric patients with somatization disorder and 31 women with primary mood disorders showed that childhood sexual histories were similar for the two groups except that women with somatization were significantly more likely to have been sexually abused as a child (55 percent vs. 16 percent). 81 Annotated Bibliography Robins, E., and O’Neal, P. Clinical features of hysteria in children, with a note on prognosis. A two to seventeen year follow-up study of 41 patients. The Nervous Child 10:246-271, 1953. An early study of somatization disorder in children demonstrating the reliability of the multisymptomatic form of hysteria. Routh, D.K., and Ernst, A.R. Somatization disorder in relatives of children and adolescents with functional abdominal pain. Journal of Pediatric Psychology 9:427-437, 1984. A study of 20 children with functional abdominal pain and controls found that 10 of the 20 children had one or more relatives with somatization disorder. Zoccolillo, M.S., and Cloninger, C.R. Parental breakdown associated with somatization disorder (hysteria). British Journal of Psychiatry 147:443-445, 1985. A study of 30 patients with somatization disorder compared to controls with major depression indicating parenting problems in patients with somatization disorder. Comorbidity Katon, W.; Kleinman, A.; and Rosen, G. Depression and somatization: A review. American Journal of Medicine 72:127-135, 1982. A two-part review that thoroughly addresses the relationship between the process of somatization and depression, especially as it relates to primary care. Lilienfeld, S.0.; VanValkenburg, C.; Larntz, K.; and Akiskal, H.S. The relation- ship of histrionic personality disorder to antisocial personality and somatization disorder. American Journal of Psychiatry 143:718-722, 1986. A study demonstrating the association between somatization disorder, antisocial personality disorder, and histrionic personality disorder in somatization disorder patients and their first-degree relatives. The study proposes that somatization disorder may be the female manifes- tation and antisocial personality the male manifestation of the same underlying disorder, in this case, histrionic personality disorder. 82 Annotated Bibliography Liskow, B.; Othmer, E.; Penick, E.C.; DeSouza, C.; and Gabrielli, W. Is Briquet’s syndrome a heterogeneous disorder? American Journal of Psychiatry 143:626-69, 1986. A study of the comorbidity of 78 psychiatric outpatients diagnosed with somatization disorder, demonstrating the high prevalence of addition- al diagnoses in the patients. Conversion Coryell, W., and House, D. The validity of broadly defined hysteria and DSM-III conversion disorder: Outcome, family history, and mortality. Journal of Clinical Psychiatry 45:252-256, 1984. A followup study of patients with somatization disorder, hysteria but not somatization disorder, and conversion disorder demonstrates that somatization disorder is different from conversion disorder and that somatization disorder has a lower mortality rate than depression. Farley, J.; Woodruff, R.A, Jr.; and Guze, S.B. The prevalence of hysteria and conversion symptoms. British Journal of Psychiatry 114:1121-1125, 1968. In postpartum women, the prevalence estimates of hysteria were 1-2 percent. Data demonstrate difference of those with somatization dis- order from those with conversion disorder. Folks, D.G.; Ford, C.V.; and Regan, W.M. Conversion symptoms in a general hospital. Psychosomatics 25:285-291, 1984. Analysis of 1,000 consecutive psychiatric consultations that showed a S-percent prevalence of conversion symptoms. Of those 50 patients with a conversion symptom, 34 percent had somatization disorder. Ford, C.V., and Folks, D.G. Conversion disorders: An overview. Psycho- somatics 26:371-378, 1985. A comprehensive review of conversion disorders with special attention to conversion symptoms. The authors conclude that conversion should be evaluated as a symptom rather that as a syndrome. Guze, S.; Woodruff, R.A; and Clayton, P.J. A study of conversion symptoms in psychiatric outpatients. American Journal of Psychiatry 128:643-646, 1971. Another study that supports the hypothesis that somatization disorder and antisocial personality may share a common etiology. 83 Annotated Bibliography Woodruff, R.A.; Clayton, P.J.; and Guze, S.B. Hysteria: An evaluation of specific diagnostic criteria by the study of randomly selected psychiatric clinic patients. British Journal of Psychiatry 115:1243-1248, 1969. A study of 100 psychiatric outpatients in which conversion was found in patients of various diagnosis. Little overlap was found between somatization disorder and other psychiatric illnesses. Course Coryell, W., and Norten, S.G. Briquet’s syndrome (somatization disorder) and primary depression: Comparison of background and outcome. Comprehensive Psychiatry 22:249-256, 1981. A followup study of psychiatric patients with somatization disorder compared to primary depression shows that somatization disorder patients have a more chronic course and are less likely to recover. Guze, S.B. The diagnosis of hysteria: What are we trying to do? American Journal of Psychiatry 124:491-498, 1967. An earlyreview of work toward establishing the validity of somatization disorder with special focus on followup and family studies. Guze, S.B.; Cloninger, C.R.; Martin, R.L.; and Clayton, P.J. A follow-up and family study of Briquet’s syndrome. British Journal of Psychiatry 149:17-23, 1986. A followup study of 36 cases of somatization disorder and 26 probable cases drawn from a population of psychiatric outpatients. Also in- cludes the study of their first-degree relatives. Demonstrates diagnos- tic consistency over many years. Female first-degree relatives have increased risk for somatization disorder and antisocial personality while male relatives have increased risk for antisocial personality. Guze, S.B., and Perley, M.J. Observations on the natural history of hysteria. American Journal of Psychiatry 119:960-965, 1963. A 6- to 8-year followup study of 25 patients with hysteria (somatization disorder) showing that it is a distinct, recognizable multisymptomatic illness with a chronic course. There were few, if any, remissions. Perley, M.J., and Guze, S.B. Hysteria — The stability and usefulness of clinical criteria. New England Journal of Medicine 266:421-426, 1962. Followup study confirmed findings by Cohen et al. that there was diagnostic stability using the criteria in multisymptomatic patients with 84 Annotated Bibliography somatization disorder. Patients meeting specific criteria have a 90-per- cent probability of meeting the criteria in 6-8 years. Woodruff, R.A., Jr; Goodwin, D.W.; and Guze, S.B. Hysteria (Briquet’s syndrome). In: Roy, A., ed. Hysteria. New York: John Wiley & Sons, 1982. pp. 117-129. A review of studies about somatization disorder with emphasis on evaluation of the concept of the disorder and its management. Depression Bibb, R.C., and Guze, S.B. Hysteria (Briquet’s syndrome) in a psychiatric hospital: The significance of secondary depression. American Journal of Psychi- atry 129:224-228, 1972. Study of women on a psychiatry inpatient service indicating that 10 percent of the admissions have somatization disorder. Depression, substance abuse, and suicide threats are common in these patients. Maany, I. Treatment of depression associated with Briquet’s syndrome. American Journal of Psychiatry 138:373-376, 1981. Presentation of two cases of somatization disorder complicated by depression. Morrison, J., and Herbstein, J. Secondary affective disorder in women with somatization disorder. Comprehensive Psychiatry 29:433-440, 1988. Sixty women with somatization disorder were compared with 29 women with either unipolar or bipolar depression. Of the patients with somatization disorder, 54 (90 percent) had a lifetime history of a major depressive episode. The somatization disorder patients generally reported more severe depressive episodes and more psychiatric read- missions. Orenstein, H. Briquet’s syndrome in association with depression and panic: A reconceptialization of Briquet’s syndrome. American Journal of Psychiatry 146:334-338, 1989. In a consecutive sample of psychiatric patients, somatization disorder was significantly more common in patients who had both major depres- sion and panic than in patients who had either alone. The author suggests a common etiological diathesis for these disorders. 85 Annotated Bibliography Oxman, T.E., and Barrett, J. Depression and hypochondriasis in family practice patients with somatization disorder. General Hospital Psychiatry 7:321-329, 1985. Thirteen primary care patients were studied for the presence of hypochondriasis and depression. Data suggest the separation of hypochondriasis from somatization disorder and the need for better definitions of depression in these patients. Diagnosis Ford, C.V. The somatizing disorders. Psychosomatics 27:327-337, 1986. An excellent review of all of the somatization disorders. Diagnostic and management considerations are discussed. Ford, C.V. Somatization. In: Soreff, S.M., and McNeil, G.N., eds. Handbook of Psychiatric Differential Diagnosis. Littleton, MA: PSG, 1987. pp. 195-235. A review of the differential diagnosis of the somatoform disorders with an excellent section on somatization disorder. Guze, S.B. The validity and significance of the clinical diagnosis of hysteria (Briquet’s syndrome). American Journal of Psychiatry 132:138-141, 1975. The author outlines diagnostic validity as essential for progress in psychiatric research. Diagnostic validity includes a clear description, common etiology, uniform course, and increased prevalence in family members. These are then related to hysteria. Katon, W.; Ries, R.K.; and Kleinman, A. Part II: A prospective DSM-III study of 100 consecutive somatization patients. Comprehensive Psychiatry 25:305-314, 1984. A prospective study of 100 patients from primary care who were referred for psychiatric consultation because of the amount of somati- zation. A variety of psychiatric diagnoses were found, but only 6 percent met criteria for somatization disorder. Smith, R.C. A clinical approach to the somatizing patient. Journal of Family Practice 21:294-301, 1985. A review of the diagnosis and management of somatizing patients in primary care. 86 Annotated Bibliography Swartz, M.; Hughes; D.; Blazer, D.; and George, L. Somatization disorder in the community— A study of diagnostic concordance among three diagnostic systems. Journal of Nervous and Mental Disease 175:26-33, 1987. A study of the diagnostic concordance in a general population survey showing that the various criteria for somatization disorder identify roughly the same people. Disability Zoccolillo, M.S., and Cloninger, C.R. Somatization disorder: Psychologic symptoms, social disability, and diagnosis. Comprehensive Psychiatry 27:65-73, 1986. A study of 50 psychiatric outpatients with somatization disorder and controls with major depression. Patients with somatization disorder were greatly disabled in work, social activities, and parenting. Epidemiology Cloninger, C.R.; Martin, R.L.; Guze, S.B.; and Clayton, P.J. A prospective follow-up and family study of somatization in men and women. American Journal of Psychiatry 143:873-878, 1986. A prospective followup study of psychiatric outpatients. Prevalence of somatization disorder in psychiatric outpatients was 22 percent. Soma- tization was very rare in men. Clear familial aggregation in women who met Briquet’s syndrome criteria was found. deGruy, F.; Columbia, L.; and Dickinson, P. Somatization disorder in a family practice. Journal of Family Practice 25:45-51, 1987. A study of somatization disorder in a primary care setting indicating that 5 percent of the patients had somatization disorder. These patients had 50-percent greater health care utilization and lower socioeconomic status. deGruy, F.; Crider, J.; Hashimi, D.K.; Dickinson, P.; Mullins, H.C.; and Tron- cale, J. Somatization disorder in a university hospital. Journal of Family Practice 25:579-584, 1987. A study of patients from medical and surgical services of a general hospital demonstrates that 9 percent of these patients had somatization disorder. Fourteen percent of the women had somatization disorder and 3 percent of the men had the diagnosis. 87 Annotated Bibliography DeSouza, C., and Othmer, E. Somatization disorder and Briquet’s syndrome: An assessment of their diagnostic concordance. Archives of General Psychiatry 41:334-336, 1984. A comparison of somatization disorder and Briquet’s criteria provid- ing data that they represent similar patients. They show that the prevalence in psychiatric outpatients is 5.7 percent. Escobar, J.I.; Brunham, A.; Karno, M.; Forsythe, A.; and Golding, J.M. Soma- tization in the community. Archives of General Psychiatry 44:713-718, 1987. The results from one of the ECA sites which showed that only 0.03 percent of the community sample had somatization disorder. However, 4.4 percent of the sample were somatizers. Escobar, J.1.; Golding, J.M.; Hough, R.L.; Karno, M.; Burnam, M.A.; and Wells, K.B. Somatization in the community: Relationship to disability and use of services. American Journal of Public Health 77:837-840, 1987. A study that used six unexplained symptoms for women and four for men to define somatizers found that 4.4 percent of the general poplula- tion meet criteria for trait. The study also found that somatizers had more health care utilization, reported poorer health status, and preferentially used more medical care services compared to other psychiatric patients. Escobar, J.I.; Rubio-Stipec, M.; Canino, G.; and Karno, M. Somatic symptom index (SSI): A new and abridged somatization construct. Journal of Nervous and Mental Disease 177:140-146, 1989. Data from two community studies demonstrate that an abridged con- struct of somatization is very prevalent and related to demographic variables. Kessler, L.G.; Cleary, P.D.; and Burke, J.D., Jr. Psychiatric disorders in primary care. Archives of General Psychiatry 42:583-590, 1985. An epidemiological study of primary care patients indicating that 4 percent have somatization disorder. This is a low rate compared to other primary care studies. Martin, R.L.; Roberts, W.V.; and Clayton, P.J. Psychiatric status after hysterec- tomy. JAMA 244:350-353, 1980. A study of 49 patients who had noncancer hysterectomies. The study found that 27 percent of these women had somatization disorder. 88 Annotated Bibliography Purtell, J.J; Robins, E.; and Cohen, M.E. Observations on clinical aspects of hysteria— A quantitative study of 50 hysteria patients and 156 control subjects. JAMA 146:902-909, 1951. First modern study of multisymptomatic patients with hysteria. Ob- served 50 patients at diagnosis and 4 or more months later. Suggested that men do not have hysteria. Prevalence in a general hospital: 2.2 percent. Noted similarity to Briquet’s work. Reich, J.; Tupin, J.P; and Abramowitz, S.I. Psychiatric diagnosis of chronic pain patients. American Journal of Psychiatry 140:1495-1498, 1983. Twelve percent of chronic pain patients had somatization disorder. Swartz, M.; Blazer, D.; George, L.; and Landerman, R. Somatization disorder in a community population. American Journal of Psychiatry 143:1403-1408, 1988. A report from a large epidemiology study of the general population indicating the prevalence of somatization disorder is at 0.38 percent. Swartz, M.; Landerman, R.; George, L.; Blazer, D.; and Escobar, J. Somati- zation disorder. In: Robins, L.N., and Regier, D. eds. Psychiatric Disorders In America. New York: Free Press, 1990. A thorough presentation of Epidemiology Catchment Area project’s findings concerning somatization disorder. Young, S.J; Alpers, D.H.; Norland, C.C.; and Woodruff, R.A., Jr. Psychiatric illness and the irritable bowel syndrome. Gastroenterology 70:162-166, 1976. A study of psychiatric diagnoses in patients with irritable bowel syndrome. They found that 17 percent had somatization disorder. Family Arkonac, O., and Guze, S.B. A family study of hysteria. New England Journal of Medicine 268:239-242, 1963. A study of 172 first-degree relatives of patients with somatization disorder indicating an increased prevalence of somatization disorder in female relatives and alcoholism and possibly antisocial personality in the men. 89 Annotated Bibliography Cloninger, C.R., and Guze, S.B. Hysteria and parental psychiatric illness. Psychological Medicine 5:27-31, 1975. A two-generation study of 46 families of convicted women showed that the daughters of sociopathic fathers had a significantly higher preva- lence of hysteria than did the daughters of other fathers. The differ- ences were for daughters with hysteria plus sociopathy and for hysteria without sociopathy. The association was of assortive mating between sociopathic men and women with hysteria or sociopathy. Cloninger, C.R.; Martin, R.L.; Guze, S.B.; and Clayton, P.J. A prospective follow-up and family study of somatization in men and women. American Journal of Psychiatry 143:873-878, 1986. A prospective followup study of psychiatric outpatients. Prevalence of somatization disorder in psychiatric outpatients was 22 percent. Soma- tization was very rare in men. Clear familial aggregation in women who met Briquet’s syndrome criteria was found. Cloninger, C.R.; Reich, T.; and Guze, S.B. The multifactorial model of disease transmission. III: Familial relationship between sociopathy and hysteria (Briquet’s syndrome). British Journal of Psychiatry 127:23-32, 1975. A study that provides further evidence of somatization disorder and antisocial personality clustering in families. This study argues that the two disorders are manifestations of the same process. Coryell, W. A blind family history study of Briquet’s syndrome. Archives of General Psychiatry 37:1266-1269, 1980. A followup chart study of 49 patients with somatization disorder that supports the validity of the syndrome. Guze, S.B. Studies in hysteria. Canadian Journal of Psychiatry 28:434-437, 1983. An historical and scientific account of somatization disorder as it has evolved, by the researcher primarily responsible for most of the work, Samuel B. Guze, M.D. The account argues for increased prevalence of somatization disorder in female first-degree relatives of somati- zation disorder patients and of antisocial personality and alcoholism in male relatives. Guze, S.B.; Cloninger, C.R.; Martin, R.L.; and Clayton, P.J. A follow-up and family study of Briquet’s syndrome. British Journal of Psychiatry 149:17-23, 1986. A followup study of 36 cases of somatization disorder and 26 probable cases drawn from a population of psychiatric outpatients. Also in- cludes the study of their first-degree relatives. Demonstrates diagnos- 90 Annotated Bibliography tic consistency over many years. Female first-degree relatives have increased risk for somatization disorder and antisocial personality while male relatives have increased risk for antisocial personality. Group Treatment Corbin, L.; Hanson, R.; Hopp, S.; and Whitley, A. Somatoform disorders — How to reduce overutilization of health care services. Journal of Psychosocial Nursing 26:31-34, 1988. Preliminary report of a group treatment approach for patients who are “overutilizers” of health care; in this case, most had a somatoform disorder. The authors report a reduction in unscheduled visits after the group intervention. Ford, C.V. Somatizing disorders. In: Roback, H.B., ed. Helping Patients and Their Families Cope with Medical Problems. San Francisco: Jossey-Bass, 1984. pp. 39-59. Treatment of somatization is reviewed with special emphasis on group treatment. The efficency of group treatment is discussed. Ford, C.V., and Long, K.D. Group psychotherapy of somatizing patients. Psychotherapy and Psychosomatics 28:294-304, 1977. A review of group treatment with somatizing patients that is applicable to somatization disorder. Mally, M.A, and Ogston, W.D. Treatment of the “untreatables.” International Journal of Group Psychotherapy 14:369-374, 1964. A study describing a group treatment approach for patients seen in a medical setting who somatize. Schoenberg, B., and Senescu, R. Group psychotherapy for patients with chronic multiple somatic complaints. Journal of Chronic Diseases 19:649-657, 1966. A report of an 18-month analytically oriented group treatment of patients with multiple somatic complaints. At a 5-year followup, their health care utilization was substantially reduced. Schreter, R.K. Treating the untreatables: A group experience with somaticizing borderline patients. International Journal of Psychiatry in Medicine 10:205-215, 1980. A report of a 2-year group treatment of patients with chronic somatic complaints. 91 Annotated Bibliography Valko, R.J. Group therapy for patients with hysteria (Briquet’s disorder). Diseases of the Nervous System 37:484-487, 1976. A report of a group therapy intervention with somatization disorder patients that reduced their outpatient visits and number of medica- tions. Health Care Utilization Smith, G.R., Jr.; Monson, R.A; and Ray, D.C. Patients with multiple unex- plained symptoms. Archives of Internal Medicine 146:69-72, 1986. A series of 41 patients with somatization disorder from a primary care setting were studied. They were found to have nine times the U.S. per capita health care expenditure. Zoccolillo, M.S., and Cloninger, C.R. Excess medical care of women with somatization disorder. Southern Medical Journal 79:532-535, 1986. A study of 50 patients with somatization disorder indicating their excess health care utilization and surgery. History Mai, F.M. Pierre Briquet: 19th century savant with 20th century ideas. Canadian Journal of Psychiatry 28:418-421, 1983. An historical account of what is known of Pierre Briquet, the French physician who first described somatization disorder. Mai, F.M,, and Merskey, H. Briquet’s treatise on hysteria: A synopsis and commentary. Archives of General Psychiatry 37:1401-1405, 1980. A synopsis of Paul Briquet’s treatise describing 430 cases of hysteria. The treatise clearly noted the polysymptomatic presentation and the fact that men have the disorder. Merskey, H. Hysteria: The history of an idea. Canadian Journal of Psychiatry 28:428-433, 1983. A review of the history of hysteria. 92 Annotated Bibliography Management Abbey, S.E., and Lipowski, N.J. Comprehensive management of persistent somatization: An innovative inpatient program. Psychotherapy and Psycho- somatics 48:110-115, 1987. The authors outline an inpatient program designed to interrupt the cycle of somatization and improve the persistent somatizers’ level of social and occupational functioning. The approach is multidisciplinary and involves four phases: preadmission consultation and screening, comprehensive assessment, multifactorial treatment, and discharge planning and followup. Cohen, S.I. Somatoform disorders — Symptoms and psychiatric implications. Hospital Practice 165-198, 1986. Author reviews the presentation, diagnosis, and management of somatoform disorders. Kaplan, C.; Lipkin, M., Jr.; and, Gordon, G.H. Somatization in primary care: Patients with unexplained and vexing medical complaints. Journal of General Internal Medicine 3:177-190, 1988. A comprehensive review of the process of somatization in primary care. Kellner, R. Somatization and Hypochondriasis. New York: Praeger, 1986. The author discusses the process of somatization, especially as it relates to hypochondriasis. Lichstein, P.R. Caring for the patient with multiple somatic complaints. Southern Medical Journal 79:310-314, 1986. An excellent review of management approaches for the primary care patient with somatization. Lipowski, Z.J. Somatization: The concept and its clinical application. American Journal of Psychiatry 145:1358-1368, 1988. The process and somatization disorder itself are both discussed in this review of the concept, its implications for medicine, and its manage- ment. 93 Annotated Bibliography Lipowski, Z.J. An inpatient programme for persistent somatizers. Canadian Journal of Psychiatry 33:275-278, 1988. A paper describing a successful treatment program for patients who somatize in a general hospital setting, Monson, R.A., and Smith, G.R., Jr. Current concepts in psychiatry: Somati- zation disorder in primary care. New England Journal of Medicine 308:1464- 1465, 1983. A brief review of somatization disorder as seen in primary care. Morrison, J.R. Management of Briquet’s syndrome (hysteria). Western Journal of Medicine 128:482-487, 1978. A review of various management approaches for the patient with somatization disorder, including working with the family. Murphy, G.E. The clinical management of hysteria. JAMA 247:2559-2564, 1982. A clinically oriented review of management approaches with very helpful personal suggestions. Oken, D. The management of the somatizer. Psychiatria Fennica 15:53-62, 1984. A thorough review of the management of various somatizing disorders, especially useful in a primary care setting. Quill, T.E. Somatization disorder—One of medicine’s blind spots. JAMA 254:3075-3079, 1985. A review of management of somatization disorder in primary care settings. Ritvo, J.H., and Thompson, T.L., II. A 49-year-old clinic for chronically ill somatizers. Hospital and Community Psychiatry 37:631-633, 1986. Describes a clinic in a general medical setting for patients who somatize. Smith, G.R., Jr.; Miller, L.M.; and Monson, R.A. Consultation-liaison interven- tion in somatization disorder. Hospital and Community Psychiatry 37:1207-1210, 1986. A summary of work testing a consultation intervention in somatization disorder. A case report of a successfully managed patient is presented. 94 Annotated Bibliography Smith, G.R., Jr.; Monson, R.A.; and Ray, D.C. Psychiatric consultation in somatization disorder. New England Journal of Medicine 314:1407-1413, 1986. A randomized, controlled crossover trial of primary care patients with somatization disorder indicating that a psychiatric consultation ad- vocating a specific management approach was cost-effective. The Quality Assurance Project. Treatment outlines for the management of the somatoform disorders. Australia and New Zealand Journal of Psychiatry 19:397- 407, 1985. An outline of management recommendations for the somatoform disorders, including somatization disorder. Woodruff, R.A., Jr.; Goodwin, D.W.; and Guze, S.B. Hysteria (Briquet’s syndrome). In: Roy, A., ed. Hysteria. New York: John Wiley & Sons, 1982. pp. 117-129. A review of studies about somatization disorder with emphasis on the evaluation of the concept of the disorder and its management. Mechanisms Drake, M.E.; Padamadan, H.; and Pakainis, A. EEG frequency analysis in conversion and somatoform disorder. Clinical Electroencephalography 19:123- 128, 1988. Preliminary study that showed no difference in spectral EEG analysis between somatization disorder patients and controls. There were dif- ferences between somatization disorder patients and patients with conversion disorder. Gordon, E.; Kraiuhin, C.; Kelly, P.; Meares, R.; and Howson, A. A neurophysiological study of somatization disorder. Comprehensive Psychiatry 27:295-301, 1986. Some evidence for a neuropsychological dysfunction in somatization disorder patients. Gordon, E.; Kraiuhin, C.; Meares, R.; and Howson, A. Auditory evoked response potentials in somatization disorder. Journal of Psychiatric Research 20:237-248, 1986. Preliminary evidence of an abnormality in cortical function as evidenced by auditory evoked potentials in somatization disorder. 95 Annotated Bibliography James, L.; Gordon, E.; Kraiuhin, C.; and Meares, R. Selective attention and auditory event-related potentials in somatization disorder. Comprehensive Psy- chiatry 30:84-89, 1989. Patients with somatization disorder were shown to be physiologically less able to discriminate background (irrevalent) from target (relevant) stimuli. This finding supports Janet’s hypothesis of a neurological basis for hysteria. James, L.; Singer, A.; Zurnyski, Y.; Gordon, E.; Kraiuhin, C.; Harris, A.; Howson, A., and Meares, R. Evoked response potentials and regional cerebral blood flow in somatization disorder. Psychotherapy and Psychosomatics 47:190- 196, 1987. A study of 14 somatization disorder patients and 14 controls using auditory evoked potentials and regional cerebral blood flow. They found less mismatched negativity in the somatization disorder patients, which suggests that these patients are less capable of distinguishing between relevant and irrelevant stimuli. Further, the blood flow ratio study showed higher right to left hemisphere flow and possibly a hyperactive right posterior region. Both experiments suggests that somatization disorder patients may attend differently to afferent stimuli. Orenstein, H. Briquet’s syndrome in association with depression and panic: A reconceptualization of Briquet’s syndrome. American Journal of Psychiatry 146:334-338, 1989. In a consecutive sample of psychiatric patients, somatization disorder was significantly more common in patients who had both major depres- sion and panic than in patients who had either alone. The author suggests a common etiological diathesis for these disorders. Men Cloninger, C.R.; von Knorring, A.L.; Sigvardsson, S.; and Bohman, M. Symptom patterns and causes of somatization in men: II. Genetic and environmental independence from somatization in women. Genetics and Epidemiology 3:171- 185, 1986. A study that provides evidence that men and women who somatize are fundamentally different and that somatization in men and women may have different causes. 96 Annotated Bibliography Robins, E.; Purtell, JJ.; and Cohen, M.E. “Hysteria” in men. New England Journal of Medicine 246:677-685, 1952. A report of early attempts to find men with somatization disorder. All cases of somatization disorder in this series were found to be attempts to seek compensation. Smith, G.R., Jr.; Monson, R.A.; and Livingston, R.: Somatization disorder in men. General Hospital Psychiatry 7:4-8, 1985. Report of a series of new cases of somatization disorder in men indicating that the diagnosis needs to be considered in men with multiple recurrent unexplained somatic complaints. Screening Othmer, E., and DeSouza, C. A screening test for somatization disorder (hysteria). American Journal of Psychiatry 142:1146-1149, 1985. Reports the development of two screening indexes for somatization disorder, one of which was incorporated into DSM-III. Paisson, N., and Kaij, L. Development of a screening method for probable somatizing syndromes. Acta Psychiatrica Scandinavica 72:69-73, 1985. A study of the process of somatization in 50 primary care patients. Proposes a questionnaire as a screening index. Reveley, M.A.; Woodruff, R.A., Jr.; Robins, L.N.; Taibleson, M.; Reich, T.; and Helzer, J. Evaluation of a screening interview for Briquet’s syndrome (hysteria) by the study of medically ill women. Archives of General Psychiatry 34:145-149, 1977. Reports on a test of a previously described screening interview for somatization disorder in women who were medically ill. Swartz, M.; Hughes, D.; George, L.; Blazer, D.; Landerman, R.; and Bucholz, K. Developing a screening index for community studies of somatization dis- order. Journal of Psychiatric Research 20:335-343, 1986. A study relating the development of an 11-item screening index for somatization disorder. This instrument works very well in the general population. 97 Annotated Bibliography Woodruff, R.A.; Robins, L.N.; Taibleson, M.; Reich, T.; Schwin, R.; and Frost, N. A computer assisted derivation of a screening interview for hysteria. Archives of General Psychiatry 29:450-454, 1973. Report on the development of a screening interview for somatization disorder. Substance Abuse Liskow, B.; Penick, E.C.; Powell, B.J.; Hacfele, W.F.; and Campbell, J.L. Inpatients with Briquet’s syndrome: Presence of additional psychiatric syndromes and MMPI results. Comprehensive Psychiatry 27:461-470, 1986. A study of 16 patients with somatization disorder and 32 controls demonstrating the presence of comorbid conditions such as al- coholism, substance abuse, antisocial personality, and schizophrenia. The authors also suggest an MMPI screening scale for somatization disorder. Martin, R.L.; Cloninger, C.R.; and Guze, S.B. The natural history of somati- zation and substance abuse in women criminals: A six year follow-up. Com- prehensive Psychiatry 23:528-536, 1982. A 6-year followup of 66 female felons; 41 percent qualified for a diagnosis of somatization disorder. Shows the association of somati- zation disorder and antisocial personality and, to a lesser extent, substance abuse. 98 PUBLIC HEALTH LIBRARY NOV 211980 © ERE ; ic Health Service Alcohol, Drug Abuse, and Mental Health Administration Rockville MD 20857 Official Business Penalty for Private Use $300 a on Fa Lag pboaipte dl 5 - DHHS Publication No. (ADM) 90-1631 Alcohol, Drug Abuse, and Mental Health Administration Printed 1990 U.C. BERKELEY LIBRARIES IE, i 35 (022371595