Review Article The Recognition and Management of Somatization What Is Needed in Primary Care Training RICHARD

J.

GOLDBERG, M.D., DENNIS

H.

NOVACK, M.D.

LINDA GASK, M.B., CH.B., M.Sc., M.R.C.PSYCH.

This article addresses the medical education issues associated with teaching primary care residents about somatization. SpeCific training designed to recognize and manage somatization involves a hierarchical series offive knowledge domains with associated discrete skills. As a foundation , a biopsychosocial model must be embraced by the medicalleadership ofthe training program. Second, because psychosocial stresses playa critical etiologic role in somatization, the ability to identify relevant psychosocial issues during medical interviewing is afundamental skill. Third, basic psychiatric diagnostic areas (depression and anxiety) must be mastered as a prerequisite for identifying somatization. Specific interviewing and management techniques are reviewed, along with two current programmatic approaches. Finally, the concept ofphysician countertransference also must be explicitly addressed as part ofthe curriculum. Without assuring that these building blocks are in place, residents are likely to become overwhelmed by the management of somatizing patients and continue the pattern offrustration associated with these patients.

S

omatization, the manifestation of psychological stress in somatic symptoms, is a universal phenomenon.' When somatizing is persistent and associated with repeated medical help-seeking behaviors, it can create both clinical and economic difficulties. v The topic of somatization has a fairly substantial associated literature,4-7 although consolidation of the literature is greatly hampered by variance in terminology. The phenomena of somatization encompass terms including Briquet's syndrome, conversion disorder, somatization disorder. hypochondriasis, somatoform disorders, psychogenic pain disorder, and functional somatic symptoms. Because of research establishing the reliability and validity of the diagnosis of somatization disorder,S much of the recent literature has foVOLUME 33· NUMBER 1 • WINTER 1992

cused on this disorder, including reports of its prevalence in the community9-I' and in general practice. 12 . 13 However, somatization disorder, as defined by DSM-III-R, is a restricted (limited prevalence) subset of more prevalent and clinically relevant somatization behaviors that confront primary care physicians. ' 4-'9 Received September 18, 1990; revised January 29, 1991; accepted March IS, 1991. From the Rhode Island Hospital and Women and Infants Hospital, Providence; the Departments of Psychiatry and Human Behavior, Medicine, and Community Health, Brown University, Providence; the Division of General Internal Medicine, Rhode Island Hospital, Providence; and the University of Sheffield, England. Address reprint requests to Dr. Goldberg, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903. Copyright © 1992 The Academy of Psychosomatic Medicine. 55

Somatization and Primary Care Training

This article addresses the medical education issues associated with teaching primary care residents about somatization. Specifically, it addresses teaching about functional somatic symptoms (which are defined as short-tenn somatic manifestations of distress and designated in DSM-III-R as adjustment disorder with physical complaints) and about hypochondriasis and somatization disorder (which are defined in DSM-III-R as chronic disorders). Because somatization represents a significant component of medical care. there should be specific training designed to recognize and manage it. To accomplish this, a hierarchical series of knowledge domains with associated discrete skills in the context of a particular conceptual framework is required (Table I). THE BIOPSYCHOSOCIAL MODEL The foundation of any medical training program for understanding and managing somatizing must be the conceptual framework of an integrated biopsychosocial model. Being comfortable with an interactive systems model of health and illness 20 is fundamental to comprehending the concept of somatization. 21 -2.1 A biopsychosocial model must be embraced by the medical leadership of the training program; it should be manifested in role modeling and included in curriculum content. This commitment can be assessed by a review of the content of a written TABLE I. Curricutum hierarchy for somatization in primary care Curriculum Issue Integrated model of care Managing countenransference Interviewing and mangemenl skills Clarifying terminology and psychiatric diagnosis Psychosocial review of systems Biopsychosocial model

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Examples of Curriculum Markers Multidisciplinary facuhy Resident (individual or group) case supervision Somatization-teaching clinic or video/role-play Depression. anxiety. somalization seminars Objective review of resident interviews Written curriculum and review of faculty inlerviewing

behavioral science/psychiatry curriculum/ 4 as well as by content reviews of faculty interviews with methods developed for resident assessment. 25 THE PSYCHOSOCIAL REVIEW OF SYSTEMS Because psychosocial stresses playa critical etiologic role in somatization,26 the ability to identify relevant psychosocial issues during medical interviewing is a fundamental skill. Further, somatization patients are often unaware of their stressors and affects in relation to their symptoms. Using some medical curricula, teachers, despite good intentions, often have problems teaching residents to assess the psychosocial component of patient care. 27 .2N However, in the United Kingdom, Maguire et al. 29 taught medical students psychosocial assessment skills by providing their trainees with a clear checklist of areas to cover in the interview and with video feedback of their consultations. Similar work based on the model of problem-based interviewing'lO has demonstrated that psychosocial assessment skills also can be successfully taught to primary care trainees.)' There remains a lack of consensus about the most relevant psychosocial variables and a lack of agreement about the evaluation instruments that should be used to measure trainee performance in this area. Programs trying to teach about somatization could benefit from a more systematic method of presenting and evaluating psychosocial issues. One possible resource is the "Psychosocial Review of Systems," a document that provides a summary of the major psychosocial dimensions relevant to medical care (RJ. Goldberg, D. Novack, P. Gardner, unpublished manuscript, 1991). The areas covered by this instrument include the content of the "Psychosocial Review of Systems," which currently is also being developed as an interview assessment instrument. Unless a program can assure itself that residents understand the importance of somatization and can obtain appropriate psychosocial infonnation, teaching about somatizing will be hampered. PSYCHOSOMATICS

Goldberg et al.

CLARIFYING TERMINOLOGY AND DIFFERENTIAL DIAGNOSIS The current nosology of somatoform disorders has been difficult to integrate into medical practice. Terminology is confounded by both semantic and nosological issues. 26.32.33 The somatization disorder category of DSM-III-R, while an important subset, is often too narrow for primary care physicians. For example, what is probably the most common somatization phenomenon in primary care comprises a residual category: undifferentiated somatoform disorder. 19 The history of multiple psychodynamic and psychosomatic frameworks used to explain somatization also contributes to conceptual confusion. J4 A teacher in this area needs to familiarize stud~nts with current DSM-III-R terms, creating a perspective while simplifying terminology. Moreover, both the consolidation and clarification of terminology need to be developed by field trials of less restrictive clinical syndromes in primary care settings. In the classroom it is probably most practical to begin with two areas: I) functional (stress-induced) somatic symptoms and 2) more chronic forms of somatization (even those that do not meet research criteria). Basic psychiatric diagnostic areas also must be mastered as prerequisites for identifying somatization. Not all medically unexplained symptoms represent a primary somatization process. Common disorders producing medically unexplained symptoms include affective and anxiety disorders and concurrent substance abuse. 3s - 37 Unfortunately, primary care physicians frequently fail to detect these disorders. 38-40 In addition, issues of compensation (malingering) and the possibility of the co-occurrence of somatization with another medical or psychiatric disorder need to be explained. INTERVIEWING AND MANAGEMENT ISSUES Once somatization is recognized and described, specific interviewing and management techniques can be employed for optimal management. VOLUME 33· NUMBER I • WINTER 1992

Acute Somatic Symptoms Acute somatic symptoms are conceptualized as acute manifestations of current psychosocial distress. In general, these patients have a high level of premorbid function. They generally respond to management consisting of the following: I. Identification of the relevant distress issues (e.g., current psychosocial stressors, fears about illness) 2. Brief physical evaluation to assure the patient that a medical problem is not being overlooked 3. A model that links the distress to the symptom 4. Reassurance that there is no disease requiring medical treatment 5. An approach that addresses the underlying distress Chronic Somatic Symptoms When working with chronic somatizing patients, physicians find that the management techniques helpful for acute somatic symptoms do not work. What is helpful often seems counter-intuitive and contrary to the interpersonal processes that develop with these patients. A summary of management recommendations for chronic somatization I4 .41-46 indicates general agreement on the following issues: I. Reassurance that nothing is wrong does not help. 2. The patient does not want symptom relief, but, rather, a relationship and understanding. 3. What the patient wants is physician willingness to agree that he or she is sick. The physician should avoid challenging the patient, agree there is a problem, and show a willingness to help identify it. The physician should acknowledge the patient's plight. 4. Little is gained by a premature explanation that the symptoms are emotional. Such an explanation must be presented in such a 57

Somatization and Primary Care Training

5.

6.

7. 8.

way that the patient does not experience it as rejection. Stress education should be introduced gradually. A positive organic diagnosis will not cure the patient. The emphasis should be on function, not symptoms. and assessment of the patient's coping resources and responses is required. Regularly scheduled appointments are required so that the patient does not have to manifest symptoms to seek help. The physician should operantly reinforce nonillness behaviors and communications. Diagnostic tests should be limited. Some focused examination can be helpful. with reliance more on signs than symptoms.

Virtually all of these management guidelines were included in a paper written over 40 years ago. 43 More recently. there has been some introduction of other approaches. Some of these have included specialized psychiatric inpatient programsl~ in addition to cognitive and behavioral techniques. 47 .48 One approach to teaching these interactional techniques involves a faculty supervision clinic that emphasizes the biopsychosocial assessment of somatizing patients and the need to supervise interviewing.49 This clinic emphasizes attaining an understanding of symptoms in light of the patient's development. personality, current psychosocial situation. and primary and secondary gains. This understanding usually can be achieved in a I-hour interview. The patient is presented with a model of the symptoms as a logical result of past and present conflicts. This approach is similar to Viederman and Perry's psychodynamic life narrative.~o The clinician points out attitudes. conflicts. and social situations that need attention. Appropriate medications are prescribed for depressive and anxiety disorders and. if necessary. appropriate mental health referrals are made. The referring physician receives a report outlining the assessment and treatment strategies. There also may be some discussion with the referring physician about any countertransference issues that need resolution. 58

In this teaching experience, the residents are introduced to the concepts of guilt and shame. the psychodynamics and psychophysiology of conversion and pain. and the implications ofdifferent personality types in medical management and behavioral therapeutic strategies. Another approach involves a structured roleplay and video-feedback technique that aims to teach trainees the skills necessary to manage patients with acute and subacute somatization. A three-stage model for the consultation has been developed and the component skills demonstrated in a teaching videotape. ~I The three stages are labeled "feeling understood." "changing the agenda." and "making the link." Trainees are first videotaped in a role-played consultation with an actor prior to viewing the first part of the teaching tape and then have the opportunity to practice the microskills of the model by role-playing their responses to a second interactive part of the teaching videotape. This session is followed up by further sessions in which the trainees are given feedback on both their role-played and real consultations with somatizing patients in a group setting. Evaluation of the course has demonstrated that the component skills of the model can be successfully taught.~2 COUNTERTRANSFERENCE The management of somatizing patients is often complicated by physician countertransference.~354 Therefore, this concept must be explicitly taught and addressed through some mechanism as part of the curriculum.5~.56 To address issues of countertransference (and transference) there may be no other teaching method than the individual longitudinal case supervision method commonly provided in psychiatry training programs. This method unfortunately is timeand labor-intensive. and it requires resources that are generally not available (without significant cost) to primary care programs. Some primary care programs have addressed this problem by the use of Balint groups. However. such groups may be unacceptable to many physicians.~7 An alternative is to provide longitudinal supervision for the treatment of a difficult PSYCHOSOMATICS

Goldberg et al.

patient in a group setting where video or audiotapes can be reviewed over a period of 3 or 4 months. In such a setting, countertransference issues can be addressed in a manner that seems clinically meaningful to the primary care trainee, who experiences the support of peers, the resurgence of hope, and the opportunity to learn and try out new strategies, with the patient under close supervision. STRUCTURAL ISSUES IN MEDICAL CARE The problems of somatizing patients are reinforced by a fragmented model of medical care. The specialization of services has highlighted the gap between the psychosocial and biomedical. A more comprehensive and integrated behavioral/psychiatric curriculum in primary care training is one obvious step toward reintegrating medical care. Each of the curriculum issues presented here is addressed in some specific way in the program developed by Novack et al. at Rhode Island Hospital. 58 However, it is unlikel.y that training as it is now offered in most programs will be sufficient to address the challenge of somatizing patients. Even the best planned curriculum faces time constraints and what seem to be irreconcilable training priorities. There may not be enough time in a 3-year program to address the complex and sophisticated issues involved in this area. Further, it may be that not all physicians are suited temperamentally to manage chronic somatizing patients. Finally, there likely will remain somatizing patients who, because of their complexity, are better managed conjointly with psychiatric or other behavioral specialists. As an additional barrier, the primary care reimbursement structure does not support adequate payment for psychosocial interventions by

the primary care physician. At the same time, some systems create disincentives for referrals to behavioral providers, even though there is some evidence that such referral can have a positive impact on reducing excessive health care costs. 3 There are also significant nonfinancial problems with referral to psychiatry. How can referrals best be made without the patient feeling rejected or neglected? How can referrals be made for the patient who refuses to accept any hints that the symptoms are "emotional"? Some of these problems can, no doubt, be overcome by more careful communication with the patient about referral. 59 However, there is also a need to integrate behavioral specialists more fully into medical student teaching as well as into the primary care setting, creating opportunities to interact with and influence other medical faculty. SUMMARY Somatization is a highly complex phenomenon, the recognition and management of which require a synthesis of a number of more fundamental knowledge domains and skills. Training programs systematically should address their commitment to a biopsychosocial model, incorporate some systematic teaching of psychosocial data gathering, clarify terminology and provide adequate teaching about depression and anxiety, and set up supervised interviewing experiences supplemented by opportunities for residents to address their countertransference issues. Without assuring that these building blocks are in place, residents are likely to become overwhelmed with the management of somatizing patients and reinforced with negative experiences, thereby continuing the long tradition of frustration associated with these patients.

References I. Lipowski ZJ: Somatization: the concept and its clinical

application. Am] Psychiatry 145:1358-1367. 1988 2. Smith GR Jr, Monson RA. Ray DC: Patients with multiple unexplained symptoms: their characteristics, functional health and health care utilization. Arch Intern Med 146:69-72, 1986

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3. Smith GR, Monson RA, Ray DC: Psychiatric consultation in somatization disorder: a randomized controlled study. N Engl] Med 314:1407-1413,1986 4. Ford CV: The Somatizing Disorders: Illness as a Way of Life. New York. Elsevier. 1983 5. Kellner R: Somatization and Hypochondriasis. New

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York. Praeger. 1986 6. Goldberg DP. Bridges K: Somatic presentations of psychiatric illness in primary care settings. J Psychosom Res 32:137-144.1988 7. Grol R (ed): To Heal or to Harm: the Prevention of Somatic Fixation in General Practice. London. Royal College of General Practitioners. 1988 8. Guze SB: The validity and significance of the clinical diagnosis of hysteria (Briquet's syndrome). AmJ Psychiatry 132: 138-141. 1975 9. Swanz M. Blazer D. George L. et al: Somatization disorder in a community population. Am 1 Psychiatry 143:1403-1408.1986 10. Swanz M. Landerman R. Blazer D. et al: Somatization symptoms in the community: a ruraVurban comparison. Psychosomatics 30:44-53. 1989 II. Escobar 11. Burnam A. Karno M. et al: Somatization in the community. Arch Gen Psychiatry 44:713-718. 1987 12. Katon W. Ries RK. Kleinman A: The prevalence of somatization in primary care. Compr Psychiatry 25:208215.1984 13. DeGruy F. Columbia L. Dickinson P: Somatization disorder in a family practice. J Fam Pract 25:45-51. 1987 14. Kaplan C. Lipkin M Jr. Gordon GH: Somatization in primary care: patients with unexplained and vexing medical complaints. J Gen Intern Med 3: 177-190. 1988 15. Lipowski ZJ: An inpatient programme for persistent somatizers. Can J Psychiatry 33:275-278. 1988 16. Paisson N: Functional somatic symptoms and hypochondriasis among general practice patients: a pilot study. Acta Psychiatr Scand 78:191-197.1988 17. Pilowsky I: Dimensions of hypochondriasis. Br J Psychiatry 113:89-93. 1967 18. Stinnett JL: The functional somatic symptom. Psychiatr Clin North Am 10: 19-33. 1987 19. Escobar JI. Rubio-Stipec M. Canino G. et al: Somatic Symptom Index (SS1): a new and abridged somatization construct. 1 Nerl' Ment Dis 177: 140-146.1989 20. Engel GL: The clinical application of the biopsychosocial model AmJ Psychiatry 137:535-544. 1980 21. Barsky AJ. Goodson JD. Lane RS. et al: The amplification of somatic symptoms. Psychosom Med 50:510-519. 1988 22. Drossman DA: The problem patient. Ann Intern Med 88:366-372.1978 23. Schwanz MA. Wiggins OP: Systems and the structuring of meaning: contribution to a biopsychosocial medicine. AmJ Psychiatry 143:1213-1221. 1986 24. Goldberg RJ. Novack D. Fulton J. et al: A survey of psychiatry and behavioral science curricula in primary care residency training. Journal of Psychiatric Education 9:3-11.1985 25. Stillman PL. Swanson DB. Smee S. et al: Assessing clinical skills of residents with standardized patients. Ann Intern Med 105:762-771. 1986 26. Brodsky C: Sociocultural and interactional influences on somatization. Psychosomatics 25:673-680. 1984 27. Goldberg RJ. Wallace S. Rothney J. et al: Medical clinic

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referrals to psychiatric social work: review of 100 cases. Gen Hosp Psychiatry 6: 147-152. 1984 28. Thompson TL. Stoudemire A. Mitchell WD. et al: Underrecognition of patients' psychosocial distress in a university hospital medical clinic. Am J Psychiatry 140:158-161.1983 29. Maguire P. Roe P. Goldberg D. et al: The value of feedback in teaching interviewing skills to medical students. Psychol Med8:695-704. 1978 30. Lesser A: Problem based interviewing in general practice: a model. Med Educ 19:299-304. 1985 31. Cask L. Goldberg DP. Lesser AL. et al: Improving the psychiatric skills of the general practice trainee: an evaluation of a group training course. Med Educ 22: 132-138. 1988 32. Kellner R: Functional somatic symptoms and hypochondriasis. Arch Gen Psychiatry 42:821-833.1985 33. Lipowski ZJ: Somatization: medicine's unsolved problem. Psychosomatics 28:296-297. 1987 34. Barsky AJ. Klerman GL: Overview: hypochondriasis. bodily complaints. and somatic styles. Am 1 Psychiatry 140:273-283.1983 35. Orenstein H: Briquet's syndrome in association with depression and panic: a reconceptualization of Briquet's syndrome. Am J Psychiatry 146:334-338. 1989 36. Lipowski ZJ: Somatization and depression. Psychosomatics 31: 13-21.1990 37. Pilowsky I: Primary and secondary hypochondriasis: Acta Psychiatr Scand 46:273-285. 1970 38. Jencks SF: Recognition of mental distress and diagnosis of mental disorder in primary care, JAMA 253:19031907.1985 39. Borus JF. Howes MJ. Devins NP. et al: Primary health care providers' recognition and diagnosis of mental disorders in their patients. Gen Hosp Psychiatry 10:317321.1988 40. Wells KB. Hays RD. Burnam A. et al: Detection of depressive disorder for patients receiving prepaid or fee-for-service care. lAMA 262:3298-3302.1989 41. Smith RC: A clinical approach to the somatizing patient. 1 Fam Pract 21:294-301.1985 42. Rasmussen NH. Avant RF: Somatization disorder in family practice. American Family Physician 40:206214.1989 43. Lyon JM: On the treatment of hypochondriasis. American Practice and Digest ofTreatment 3:545-549. 19481949 44. AdlerG: The physician and the hypochondriacal patient. N Engl J Med 304:1394--1396.1981 45. Walker JI: How to help your hypochondriac patients. Behav Med. pp 30-32. February. 1978 46. Quill TE: Somatization disorder: one of medicine 's blind spots. lAMA 254:3075-3079. 1985 47. Barsky AJ. Geringer E. Wool CA: A cognitive-educational treatment for hypochondriasis. Gen Hosp Psychiatry 10:322-327. 1988 48. Salkovskis PM. Warwick HMC: Morbid preoccupations. health anxiety and reassurance: a cognitive-behav-

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The recognition and management of somatization. What is needed in primary care training.

This article addresses the medical education issues associated with teaching primary care residents about somatization. Specific training designed to ...
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