The Prevalence of Somatization in Primary Care

Wayne Katon, Richard K. Ries, and Arthur Kleinman

ABSTRACT

The authors define somatization as an idiom of distress in which patients with psychosocial and
emotional problems articulate their distress primarily through physical symptomatology. Studies
are then reviewed to demonstrate the inordinate amount of time and energy these patients cost
the health care practitioner as well as the frequency of misdiagnosis. latrogenic harm is a common
problem in somatizing patients due to unnecessary tests, hospitalizations, surgeries as well as
the development of chronic illness behavior. It is essential that psychiatrists working in consultation-
liaison begin to develop research in the area of somatization especially at the primary care level.

A LTHOUGH several studies have described the diagnoses of patients referred

to a psychiatric consultation service in a general hospital,i,2 none have spe-
cifically reported the psychiatric diagnoses of patients who somatize, i.e., patients
with psychosocial distress and emotional problems who articulate their distress
primarily through physical symptomatology. These patients either do not have
discernable organic pathology or amplify their verifiable physiologic changes. They
have been shown to be high frequency utilizers of physician services3 and, when
somatization is part of chronic medical disorders, to represent a major challenge
for health care systems worldwide.4
Few descriptive’studies have focused on the somatizing patient yet these patients
take up an inordinate amount of time and energy of the medical practitioner as
well as a disproportionate share of the health care dollar. Collyer’s study of so-
matizing patients in his primary care practice revealed that 28% of his patient
contacts involved emotional illness and that these consultations took up 48% of
the physician’s time.’ Overall, 3.6% of the families in his general practice accounted
for 32% of his time. Nearly all of these high use families had one member diagnosed
as depressed and often several family members were presenting to the physician
with vague somatic complaints. Regier has shown that 60% of patients with mental
illness are being seen by primary care physician9 and Hankin and Oktay have
demonstrated that patients with psychiatric diagnoses tend to utilize more than
two to four times as much non-psychiatric medical care.’ Goldberg reported in a
large English primary care population that over 50% of the patients with psychiatric
problems presented initially with somatic complaints.*
Widmer’s studies of primary care patients revealed that in the 7 months prior
to the diagnosis of major depression being made these patients presented with (1)
an increase in the number of patient initiated office and home visits, (2) an increased
incidence of hospitalizations, and (3) an increased number of presenting complaints
of three types: (a) ill-defined functional complaints, (b) pain of undetermined etiol-
ogy in a wide variety of sites such as the head, chest, abdomen, and extremities,

From the Division of Consultation-Liaison Psychiatry, Department of Psychiatry and Behavioral Sciences,
University of Washington: and the Harvard Medical School and The Cambridge Hospital.
Address reprint requests to Wayne Katon, M.D., Dept. of Psychiatry, RP-IO, University of Washington,
Seattle, Washington 98195.
@ I984 by Grune & Stratton, Inc. 0010-440X/84/2502-09$01.00/0

208 Comprehensive Psychiatry, Vol. 25, No. 2, (March/April) 1984

SOMATIZATION IN PRIMARY CARE 209

(c) and nervous complaints, mainly increased tension and feelings of anxiety.“,‘”
Widmer also demonstrated that family members of these depressed patients also
had ill-defined somatic complaints and increased visits to the clinic in the same
time period.” Once the depressed patient’s affective illness was successfully treated
both the patient and his family’s clinic visits decreased to baseline levels. Sheehan
found, in a study of agoraphobic patients who suffered from panic attacks, that
70% of the patients had visited more than ten different physicians with somatic
complaints before they received accurate diagnosis and treatment.‘? Overall. it
appears that 25% to 75% of patient visits to primary care physicians are primarily
due to psychosocial distress but patients usually present with somatic complaints.”
Is In fact, studies from health maintenance organizations like Kaiser-Permanente
have revealed that as many as 60% of primary care patients recurrently present
with somatic symptoms that are an expression of psychosocial distress.J,‘n,” Further,
the Kaiser studies have revealed that when these patients are referred to short-term
psychotherapy their pattern of overutilization of primary care physicians decreased
significantly.‘6,‘x In a review of these health maintenance organization studies. Cum-
mings concluded that the failure to provide mental health services has the potential
of bankrupting the health care financing system due to the overutilization of primary
care physicians by somatizing patients.’
From another perspective, many patients who do visit physicians regularly are
without serious medical illness. Analyses of the content of general medical practice
have shown that 68% to 92% of patients are without serious physical disorder.“‘.‘”
Only 41%3 of identified problems of patients are clear somatic diagnoses?’ and the
most common single diagnosis in general practice is nonsickness.?’ Ten to 60”; of
patients with each of the five most common medical complaints have been found
without structural disease responsible for their symptoms.?’
Somatization occurs in a wide variety of clinical settings. Psychiatrically, it I\
often found in patients with depression, panic disorder, somatization disorder,
histrionic personality disorder, borderline personality disorder, grief syndrome.
posttraumatic stress disorder, factitious disorder, hypochondriasis, and malinger-
ing.lj It is also encountered in psychophysiologic disorders, and as a coping response
to stressful life events. But oscilations between amplification and damping of symp-
toms occur routinely in chronic medical disorders, in which somatization owing to
psychosocial and cultural contexts is a common source of clinical management
problems.
The most common form of somatization in American society is the chronic pain
syndrome-defined as affecting an individual when he or she has suffered more
than 6 months of pain in one or several bodily sites of a disabling kind that
significantly interferes with life activities. In 1980. more than 10 billion dollars
were spent on disability payments to American patients with chronic pam
problems13 and disability payments for US postal employees with low-back pain
alone amounted to 0.8 cents of each 20 cent stamp purchased.Zh
Among traditionally oriented ethnic patients, members of fundamentalist reli-
gious sects that disparage the undisguised presentation of “negative” emotions, and
working class patients, somatization may provide a culturally sanctioned idiom for
expressing personal and interpersonal distress of many types as well as a socially
effective means of manipulating limited sources of social power and influencing
210 KATON, RIES, AND KLEINMAN

maldistribution of available resources. 4~27 In interpersonal relationships somatization

is often used out-of-awareness to elicit social support, to avoid intimacy, to express
anger, or to avoid anxiety provoking situations. It is not necessarily maladaptive
in that in many families and cultures it is routinely employed as an idiom of distress
and may lead to beneficial changes in the family (increased attention, nurturance,
or support) or in the community. 28 In the biomedically oriented Western culture,
however, it often becomes maladaptive when the somatizing patient interacts with
the medical profession because patients are often diagnosed and treated exclusively
symptomatically through a biomedical lens. 29 Unnecessary laboratory tests, clinic
visits, hospitalizations, and even surgeries frequently result. Effective handling of
personal and interpersonal problems may therefore be delayed and obstructed.
Also, what may have started as somatization of a psychiatric disorder or social
stress may develop into a permanent iatrogenically caused physical disability such
as a spinal fusion and distortion from repeated operations for “low back pain”.
Once somatic symptoms develop, whether secondary to psychological, social or
biomedical problems, there are psychological and social consequences of illness.
The patient’s somatic symptoms can have an effect on family homeostasis, voca-
tional adjustment, the patient’s social network (friends, church) as well as the
patient’s coping mechanisms. 3oThe patient’s perception and attribution of a somatic
symptom or group of symptoms is not developed in a vacuum but in the plural
contexts of his current social environment. People are continually influenced by
feedback from the settings in which they live. Thus a person’s perception and
cognitive mechanisms are not just the result of past familial, cultural and inter-
personal experiences but are due to interpersonal interactions and institutional roles
in the present as well. 3i The psychological unit is not the individual person but the
person within his significant social contexts. This systems model requires the ob-
servation of how and to what extent interpersonal transactions and social roles
govern the patient’s range of behavior.
The patients perception of his symptoms can be visualized on a continuum
between amplification and damping. The social systems may reinforce illness be-
havior and thus amplification of symptoms by beneficial changes in family structure,
disability payments, attention from the medical care system as well as psychoactive
medication that provides a degree of symptom relief. These reinforcers may become
illness maintenance systems such that somatic symptoms that were initially either
due to organic disease or the somatization of psychosocial distress now continue
as illness behavior although the physiologic changes of disease or the psychosocial
distress have disappeared. Several studies validate this hypothesis.
Miller determined from his study of insurance actuarial data that persons with
the same type of injury or illness but different disability policies react quite dif-
ferently.32 The data from 13 companies were examined covering 138,795 disability
claims in which two categories of policies were compared; the first granting benefits
after an injury primarily for two years and the second to age 65. The study indicated
that as many as 25% of the persons disabled at least 1 year in the first group
recovered who would still be asserting their claim for continuous disability benefits
if insured under a long-term or unlimited benefit plan. Hirschfeld et al33 McBride,34
and Weinstein35 in three separate reviews have also documented that the disability
system provides strong social reinforcements that seem to prevent recovery from
the original disease or injury resulting in chronic disabling illness behavior.
SOMATIZATION IN PRIMARY CARE 211

Family therapists have often described some families’ extreme resistence to change
once a new system of functioning has been set up, even systems that seem de-
monstrably maladaptive to outside observers. Minuchin has published extensively
on his studies of psychosomatic families in which amplification of a chronic illness
such as diabetes mellitus or asthma or the development of anorexia nervosa stabilizes
a precarious family equilibrium at the expense of the identified patient.” Fordyce3”
and Hudgens” have also shown that family reinforcements, i.e., increased attention
or nurturance, of somatized or actual chronic pain may subsequently bring the
pain under operant control such that pain behavior continues in the absence of
physiologic pain. Both authors mention the social efficacy of the chronic pain in
family interactions as a mechanism to control and manipulate others, justify de-
pendency, earn rest, avoid sex, gain attention, punish others, control anger and
avoid close relationships.
The medical care system also reinforces somatization. Engel has pointed out that
physicians armed with extensive training in the biomedical model do not evaluate
the psychosocial stress that often underlies somatic complaints.” Physicians, by
virtue of their training that is highly technologic, are somatizers. That is, physicians
preferentially look for and treat somatic complaints. The effect on the patients’
perception of their illness of the physicians narrow somatic model is that hypo-
chondriacal patterns are reinforced by medical concern and substantial workups.
The longer the patients perceive themselves to be somatically ill and the longer the
physician focuses on the somatic aspects of illness. the more likely is the patient
to develop significant secondary gain for being ill and to accept the sick role as a
way of life. There is also the the danger of the medical care system becoming a
social support system in itself. In considering the social context of parasuicide as
well as hypochondriacal symptoms, Henderson postulated that there are substantial
deficiencies in the care-giving afforded such patients by others, giving rise to care-
eliciting behavior to correct the deficiency in social support.‘H Balint has pointed
out that a significant number of patients in general practice are searching for genuine
interest and empathy from the physician, not relief of physical symptoms.“’ The
symptoms then are the “ticket of admission” to see the physician.
Patient maladaptive coping mechanisms may also cause amplification of somatic
symptoms. Dirks et al, in a series of studies, found that two specific coping styles
of chronic asthmatic patients caused significantly higher hospitalization rates after
discharge from intensive treatment, even among patient groups having similar
objective disease severity. 4o Dirks et al determined that the personality traits as-
sociated with subsequent high utilization of health care resources in chronic asth-
tnatic patients were reflected by either extremely high scores on the MMPI panic-
fear personality scale or extremely low scores on this scale. Patients scoring ex-
tremely high on the panic-fear scale were characterized as ambivalent, fearful,
emotionally labile, dependent, felt helpless and pessimistic about their illness and
often hyperventillated during asthamatic distress. Patients with extremely low scores
denied the presence of anxiety, claimed to be unusually calm and self-controlled
and typically presented in a rigid, counter-dependent manner.
If somatization is so prevalent in medical care, why have so few studies beer1
conducted to ascertain the psychiatric characteristics of these patients‘? Part of the
problem is that psychiatric nosology has been developed in a partial vacuum from
the rest of medicine. The most lucid example is the description of the phenomenolog!;
212 KATON, RIES, AND KLEINMAN

of major depression. In the psychiatric literature major depression is described as

an illness in which most patients readily focus on their affective and cognitive
symptoms as well as their somatic complaints. Yet Weissman has shown that major
depression is present in 4.3% of the population of an East Coast city, but 66% of
the patients with depression were not getting any specific treatment for their illness4’
Two-thirds of these unrecognized, untreated depressives made more than six visits
a year to their primary care physicians for somatic complaints (which was signif-
icantly more visits than in the population who were not effected by depression).
Thirty-four percent of these people with depression were treated with minor tran-
quilizers, 17% were taking sleeping pills whereas only 17% were treated with an-
tidepressants. The Weissman finding that patients with depression seek help and
are undetected in nonpsychiatric medical settings is consistent with the recent
findings from several surveys of medical inpatient family practice and primary
practice settings in both the United States and Great Britain.42A* Misdiagnosis in
medical outpatients with depression has varied from 50% to 75% and in medical
inpatients as high as 96%.47
The Goldberg8 and Widmer9-” studies reported above suggest that the lack of
detection is due to the fact that patients who seek help for major depression in
primary care often focus on their somatic or vegetative symptoms and minimize
or deny affective and cognitive complaints. Primary care physicians are taught
psychiatric nosology in psychiatric settings where by and large patients are quite
aware of psychological precipitants and symptoms. They have little training in
diagnosing emotional illness in patients who present somatically, i.e., with fatigue,
headaches. However patients with emotional illness are utilizing more of their care
and timesI7 and often eventually do get labeled nonspecifically as hypochondriacs
(or at times pejoratively as “crocks” or turkeys”). This is especially unfortunate
because major depression has been demonstrated by structured psychiatric interview
to have a prevalence of 5.8% in primary care48 making it the most common overall
psychiatric or medical diagnosis. Hypertension is next at 5.7%. There are also highly
effective pharmacological treatments for depression.
The term masked depression in psychiatric literature has been used to define
patients who presented with somatic symptoms of depression but minimized or
denied affective and cognitive symptoms. Masked depression has been considered
a relatively rare, unusual presentation of depression but in primary care it appears
to be as frequent as depression presenting psychologically.5.7
Thus one of the problems in studying somatization has been the lack of research
describing the prevalence, incidence and phenomenology of DSM-III type diagnoses
among primary care patients. Many questionnaire studies utilizing scales like the
GHQ, Hopkins checklist, Beck and Zung Depression Rating Scales have demon-
strated very high rates of mental illness in primary care.47 Hoeper conducted the
only psychiatric structured interview (SADS) study in primary care and found a
26.8% rate of mental illness by RDC criteria. 4* It is unclear in this study, however,
whether specific attention was focused on the diagnosis of somatizing patients, i.e.,
the patient presenting with back pain or headaches who denies depression but has
five vegetative and cognitive symptoms.
Another of the major problems in the study of somatization is to define the term
so that two psychiatrists seeing the same patient have operational criteria upon
SOMATIZATION IN PRIMARY CARE 213

which to base diagnoses. The old terminology for somatization was hypochondriasis.
which was defined as the belief one has a disease for which medical diagnosis and
treatment are needed despite repeated examinations and laboratory tests with nor-
mal results or reassurances from the physician.49
This term has the unfortunate connotation of implying a Cartesian dichotomy
to patient symptoms such that the patient complaints are considered to be either
organic or psychological. We prefer the broader term of somatization because of
its fit with the biopsychosocial model in which the patients symptoms are considered
idioms of distress in the biological, psychological and/or social parts of the patients
life. Further, patients with chronic medical illness have oscillations of their illness
between amplification and damping due to biological, psychological and/or social
stressors. The job of the physician is to weigh each of these factors in determining
a diagnosis. In fact the most difficult somatizing patients for primary care physicians
are patients with verifiable organic disease who amplify their symptoms; the phy-
sician is trained to react with a biomedical focus in these patients due to the anxiety
of missing a physical illness.

CONCLUSION

Our intent in the first of this two part series was to review the data base describing
the known prevalence of somatization in medical clinics and wards. As described
above patients with psychiatric disorders often present somatically (they have been
labeled the “hidden psychiatric morbidity of primary care’? and are misdiagnosed
and often eventually labeled as hypochondriacs. Studies need to be conducted to
describe the DSM-III psychiatric diagnoses of these patients and our intent in part
II will be to present the results of a prospective data based study of IO0 consecutive
psychiatric consultation patients referred from the medical wards because either
no physiologic pathology was found to explain their somatic complaints or the
physiologic pathology found did not match the extent of complaints. Based on this
study a new conceptualization of somatization will be explicated.

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