Elsevier

General Hospital Psychiatry

Volume 25, Issue 1, January–February 2003, Pages 1-7
General Hospital Psychiatry

Psychiatry and primary care
The somatization in primary care study: a tale of three diagnoses

https://doi.org/10.1016/S0163-8343(02)00247-5Get rights and content

Abstract

Somatization is a common phenomenon that has been defined in many ways. The two most widely used diagnoses, Somatization Disorder (SD) and Abridged Somatization Disorder (ASD), are based on lifetime unexplained symptoms. However, reports indicate instability in lifetime symptom recall among somatizing patients. Multisomatoform disorder (MSD) is a new diagnosis based on current unexplained symptoms. To understand how knowledge about SD and ASD translates to MSD, we examined the diagnostic concordance, impairment and health care utilization of these groups in a sample from the Somatization in Primary Care Study. The diagnostic concordance was high between MSD and SD, but lower between MSD and ASD. All three groups reported considerable physical impairment (measured using the PCS subscale of the SF-36). The mental health (MCS) scores for the three groups were only slightly lower than those of the general population. Over the course of one year, physical functioning fell significantly for all three groups. Mental functioning did not change significantly for any of the three groups over this period. Utilization patterns were very similar for the three groups. The high prevalence, serious impairment, and worsening physical functioning over the course of one year suggest the importance of developing interventions in primary care to alleviate the impaired physical functioning and reduce utilization in somatizing patients. MSD should be a useful diagnosis for targeting these interventions because it identifies a sizable cohort of somatizing patients reporting impairment of comparable severity to full SD, using a more efficient diagnostic algorithm based on current symptoms.

Introduction

Somatization has been defined in multiple ways, [1], [2], [3], [4], [5], [6], [7], [8], [9] but generally is understood to mean the occurrence of clinically significant physical symptoms that cannot be entirely explained by physical disease. Somatization occurs frequently in primary care, where up to half of all primary care visits are for somatic complaints and one-third remain unexplained. [10], [11], [12], [13], [14] The diagnosis of somatization disorder (SD) evolved out of the earlier concepts of neurasthenia, hysteria and Briquet’s syndrome. SD was first defined in the DSM-III, based on a lifetime history of unexplained symptoms. [15] The DSM-IIIR modified the criteria to require 13 of a list of 35 lifetime unexplained physical symptoms. [16] The DSM-IV defined a complex algorithm requiring unexplained symptoms from several different categories. [3] Reported prevalence of SD ranges from 0.1% to 16% in various populations, typically about 1–5% in primary care patients. [13], [17], [18] Because many patients who somatize do not meet criteria for full somatization disorder, Escobar proposed and validated a less severe form of somatization called abridged somatization disorder (ASD). [4], [19] ASD is also based on patient recall of lifetime symptoms, requiring at least six unexplained symptoms in women and four in men. Studies report prevalence of ASD ranging from 8 to 37%. [4], [6], [13], [17]

The diagnoses of SD and ASD are made on the basis of lifetime unexplained symptoms. However, the WHO Study of Psychological Problems in Primary Care suggested that recall of lifetime somatic symptoms among somatizing patients is unstable. [20] Although another study indicated that the overall tendency of patients to somatize is a more stable phenomenon, [21] these reports have cast some doubt on the reliability of diagnoses based on recall of lifetime somatic symptoms. Recent investigators have explored the validity of multisomatoform disorder (MSD), which is based on current unexplained symptoms [22], [23]. MSD requires the presence of three or more unexplained symptoms within the past two weeks out of a list of 15, along with a two-year history of somatization. Reported prevalence of MSD in primary care ranges from 4% to 18% [22], [23]. To better understand how the newer diagnosis based on current symptoms relates to older diagnoses based on lifetime symptoms, we examined the diagnostic concordance, impairment, and health care utilization of subjects with SD, ASD, and MSD using data from the Somatization in Primary Care Study, a longitudinal investigation of somatization treatment in a representative population of primary care patients.

Section snippets

Study design

The Somatization in Primary Care Study is a five-year NIMH-funded study conducted in three family practices in or near Mobile, Alabama, USA. Practice sites were selected to achieve geographic and socioeconomic diversity, with one urban practice that serves a racially and economically diverse population, and one suburban practice and one rural practice that both serve higher socioeconomic populations.

The results reported are part of a large randomized controlled trial evaluating the impact of a

Results

A total of 2,902 primary care patients were screened. Fourteen percent of the patients screened were unavailable for enrollment, 6.7% due to refusal and the remainder due to inability to contact or other difficulties. In the enrollment sample of 280 subjects, the estimated prevalence of ASD was 23.0%, MSD was 19.0%, and SD was 5.4%.

Discussion

The Somatization in Primary Care study provides important insights about the overlap among three commonly used somatization diagnoses: full (lifetime) somatization disorder, abridged (lifetime) somatization and (current) multisomatoform disorder. This study demonstrates that the majority of patients who meet diagnostic criteria for MSD also meet criteria for ASD or SD, although the extent of MSD overlap with SD is higher than with ASD. Thus, knowledge of somatization and its treatment derived

Acknowledgements

This work was supported in part by grant MH45441 and MH63651 from the National Institute of Mental Health, Bethesda, MD.

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