Principles of Psychosomatic Medicine

The term psychosomatic, in common parlance and in the medical community, connotes physical symptoms that are not medically legitimate. At least two national organizations with the term in their titles have given serious consideration to changing it. It implies physical symptoms without organic concomitants, triggered by emotional conflict, exaggerated emotionality, stress, and/or a desire for attention or other personal benefit. It tends to be dismissive; psychosomatic illnesses are thought to consume inordinate amounts of medical attention and are not deemed worthy of that investment. Prejudices such as these belie the intrinsic interrelatedness of 'psyche' and 'soma', deter scientific investigation into a fascinating interface, and ultimately add to the waste of medical resources.^{1, 2}

Psychosomatic medicine poses and addresses critical questions about relationships among 'mind', 'body', the central nervous system, and neuroendocrine functions. It is paradoxical that both medical theory and lay parlance assume that psychologic, neurologic, and somatic functions and symptoms affect one another closely. The same culture that may deride 'psychosomatic' symptoms accepts without question the observation that a person anticipating an examination experiences “butterflies in the stomach”, that someone got so upset he or she “had a heart attack”, and the idea that stress “eats one's heart out”. Physicians are as vulnerable to these positive and negative preconceptions as the rest of the population and must be alert for their unwitting intrusion into medical reasoning and medical care.

Relationships between psychiatric illness and somatic organs were postulated at least as long ago as ancient Greece. Hippocrates attributed unexplained paralyses and other physical symptoms to the wanderings of an unmoored uterus: thus, 'hysteria'. 'Hysteria' went on to acquire a series of related meanings. In the late nineteenth and most of the twentieth century, 'hysteria', for psychiatrists, was a formal diagnostic entity, denoting a deficit in voluntary muscular or special sense function that was caused by an unconscious psychologic conflict. A typical instance cited was the foot soldier whose right arm was suddenly paralyzed in battle because of a long-repressed wish, reactivated by the situation, to harm his father with that same arm. Despite this male example, it was widely, though incorrectly, believed that women predominated among patients with 'hysterical' paralyses, blindness, coughs, and other symptoms. Sigmund Freud, who began his medical career as a neuropathologist and neurologist, was convinced that neurophysiologic mechanisms must underlie physical expressions of psychic conflicts. He theorized that repressed sexual energy was physically transformed into medical symptoms.

A 'hysterical' personality structure, again believed to be most typical, perhaps normative, among women, was characterized by physical vanity, self-involvement, shallow attachments, dramatic expressiveness, and flirtatiousness in the absence of genuine erotic wishes and responsiveness. Most recently, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Edition IV (DSM-IV) (1994), the official reference for psychiatric nosology, describes  a disorder labelled 'histrionic', rather than 'hysterical', personality.³ The diagnosis applies to and is found in both sexes; somatic symptoms do not play a major role in it.

Psychosomatic medicine has not focused exclusively on women or on hysteria. The field of psychiatry received a major impetus from its success in dealing with soldiers who were victims of 'shell shock' in the World Wars. The demobilized military psychiatrists set out in the 1940s and 1950s to discover unconscious psychologic origins for a wide range of serious medical illnesses, including rheumatoid arthritis, duodenal ulcers, colitis, asthma, hypertension, and others.⁴ With the Western world fascinated by the intellectual and clinical power of psychoanalysis, it was exhilarating to explain wheezing as a cry for one's mother, joint inflammation as a reaction to psychologically unacceptable aggressive impulses, and gastrointestinal ulceration as a reaction to unfulfilled oral strivings.⁵

It is easy to poke retrospective fun at these well-intentioned theories, and to deride them for their failure to use modern research methodologies. It took some decades before the cause and effect relationship between the patients' psychodynamics and their physical illnesses was questioned. Because these are all chronic illnesses, it was realized, it is necessary to take into account the effect of the disability, pain, and anxiety on patients' psyches over time. Chronic, painful, disabling illnesses might well make patients understandably angry and emotionally needy. More recent work has also established genetic factors in the occurrence of all or most of these diseases.

What is currently meant by 'psychosomatic' medicine?⁶ The field encompasses all the relationships among physical, psychologic, and social factors in the causation, prognosis, and treatment of illness. It is necessary to distinguish between 'disease', which denotes the presence of visible and/or testable physical pathology, as defined in the medical setting, and 'illness', which is a socially defined condition (the individual becomes a sufferer or an invalid) and denotes acute or chronic symptoms that cause disability and this social reclassification. For example, a person with undiagnosed uterine malignancy has a disease but does not yet have an illness. A woman experiencing menstrual cramps that confine her to bed, but without any hormonal or anatomic derangement, has an illness without a disease.⁷

Broadly and clinically speaking, psychosomatic medicine includes both the psychosocial concomitants of physical disease and the cases in which psychosocial issues are core factors in the etiology of physical complaints and/or disabilities. The subjective experience of physical pathology is profoundly affected by the psychologic and social context within which the disease process occurs. An upper respiratory infection that is extremely annoying will be completely forgotten in the context of a major injury or natural disaster. A soldier in the thick of battle anticipates likely death or disabling injury. Sustaining a wound that is significant but not disabling, and that leads to an honorable evacuation to a safe location, she or he often does not experience the degree of pain that would afflict a civilian incurring the same wound as a bystander in an unanticipated gunfight on the street. A woman who believes that the pain of her labor is related to an obstetric complication reacts with more distress than the woman who understands the natural mechanisms and sensations of childbirth.

When psychosocial issues seem to be compromising a patient's ability to cope with disease, several factors may be involved. One, as illustrated in the cases mentioned just above, is the significance of the disease or injury for the patient's immediate and future circumstances. Does a hysterectomy connote release from repeated failed attempts at contraception, with several unwanted pregnancies, or does it connote the abrupt end to much-desired fertility, and perhaps to a relationship for which fertility is a requisite? Will expressions of suffering in labor evoke respect or dishonor in a woman's significant others and cultural subgroup? Is a woman's failure to comply with a preventive or treatment regimen secondary to life circumstances in which other dramatic priorities overshadow her personal discomforts and health care needs?

A second issue is the meaning the patient attaches to the physical pathology or symptom. Does she believe that suffering in labor is a punishment for original sin, or for some personal, probably sexual, sin of her own? Do the vasomotor changes at menopause connote oncoming decay, ugliness, and death, or release from menstruation and childbearing? Does the patient believe the painful vulvar lump to be a malignancy? Often the patient's misapprehensions are secondary to medical miscommunications. Many patients become extremely anxious when they are told they have “heart failure,” because of the understandable interpretation that a vital organ is about to cease functioning.⁸

Sometimes the psychologic meaning of a disease or a symptom is not so accessible, either to the physician or to the patient herself. Nevertheless, it is the key to diagnosis and treatment. The meaning of a symptom or disability can be ascertained through a comprehensive, psychodynamic, psychiatric evaluation and subsequent psychodynamic psychotherapy. The term psychodynamic refers to the interplay of conflicting, unconscious mental forces and memories. For example, the patient may have an unconscious wish to be dependent, countered by an unconscious prohibition against gratifying this wish. The resultant symptom (e.g. recurrent lower abdominal pain) is the consequence of a compromise between the two unconscious forces. The symptom allows the patient to receive the attentions of others but 'orces her to suffer pain and diminished opportunities for other gratifications in the process. This psychic outcome is termed 'primary gain'. “Secondary gain' consists of reinforcement for the symptom in the behaviors of others in response to it: lessening the patient's normal responsibilities, inquiring anxiously after her health, adapting to her dietary demands, accompanying her on consultations with successive physicians. These gratifying responses secondarily reward the patient for manifesting the symptom and support its maintenance.⁹

Recent developments in psychological analysis and understanding link somatoform disorders to difficulties with the regulation of affect.  Strong feelings that the average person would handle with a soothing or distracting activity, or interaction with friends or relatives, are manifested instead as physical symptoms.¹⁰  Research indicates that people with somatoform disorders have difficulty forming and maintaining relationships.  Of course, those difficulties could be the result, rather than the cause, of physical symptoms.  Chronic or recurrent pain or disability without a discernible cause and treatment could induce either clinginess or a tendency to avoid relationships.¹¹ Somatoform disorders are often associated with symptoms of anxiety and/or depression and can also coexist with diagnosable physical disease.¹²  Investigations of mind–body interrelations have become much more sophisticated than they were in the past.  The central nervous system and the immune system affect, and are affected by, both emotions and the functioning of body organs.¹³

Psychosomatic medicine in gynecology and obstetrics must be considered in the context of social expectations of, and attitudes toward, women's physical symptoms, and the place of physical symptoms in the psychologic and social contexts of women's lives.¹⁴ Assumptions that women are more likely than men to seek care for the same symptom or impairment have not been borne out by more recent studies.¹⁵ However, women do make more visits to health care settings than do men. Women tend to be responsible not only for their own health care, but also for the medical care of family members. They may be either born or socialized to be more sensitive to health concerns than are men.

Western medicine has tended to regard women's normal reproductive phases as pathologic, or, at least, as vulnerable states requiring medical intervention. Examples include the premenstruum, pregnancy and birth, and menopause. Medical texts from the nineteenth century urged that women not participate in higher education, because their delicate systems were fully taxed by the demands of the menstrual cycle. Significant racial and cultural biases were associated with admonitions about women's physical capacities. For example, postpartum care for upper-class women involved lengthy periods of bed rest and convalescence, but it was believed that peasants and women in non-Western societies “gave birth in the fields and went right on with their duties.”

Although women's access to athletic, scholarly, and employment opportunities has waxed and waned, the role of the physician in managing women's reproductive functions has continued to expand. By the mid-twentieth century, a standard obstetrics text noted that, given the emotional lability and dependence of the pregnant, laboring, and postpartum woman, the obstetrician generally had to assume responsibility for the woman's life for the entirety of the childbearing year. The feminist and consumer movements were partially responsive to these sorts of psychosomatic medical approaches to obstetrics and gynecology. Today, no major text would venture such suggestions. However, the widespread practices of episiotomy, hysterectomy, prescription of exogenous hormones at menopause may imply that the traditions of 'management' of women's lives and reproductive functions by the medical profession persist. The increasing knowledge and technical capacities of gynecologists, in the area of fertility enhancement, for example, though used at the behest of eager patients, contribute to this reality and this perception. At the height of the women's liberation movement, women's treatment at the hands of physicians has been frequently and scathingly criticized.¹⁶ Foci of attack have included the frequency of hysterectomy, the use of obstetric interventions, the prescription of exogenous hormones, and the expressed attitudes of physicians toward women and their physical complaints. Equally striking have been both complaints and data indicating that women's physical symptoms tend to be taken less seriously than men's in healthcare settings, with significant consequences in terms of morbidity and mortality, as, for example, from coronary disease. The reasons for this inattention are complex but are likely to include the presumption that women's symptoms are 'psychosomatic'.¹⁷

Although these criticisms are loud, painful, and sometimes well taken, it must be remembered that the majority of female patients are satisfied and/or reasonably compliant with their healthcare. On the other hand, most patients do not feel competent to understand their doctors' reasoning and advice, and are loathe to question or complain. It is likely that some 'psychosomatic' symptoms are the result of unspoken anxieties and discontent with medical interactions in which the patient was neither understood nor helped to understand.¹⁸

Physical, emotional, and sexual abuse and violence have been clearly associated with physical complaints of a 'psychosomatic' nature, and women are much more often than men the victims of these abuses. The American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG) have developed and endorsed programs to enhance the identification and treatment of domestic violence in the healthcare setting. Domestic violence is found in every stratum of society and with all ages of women. In the typical situation, the woman is prevented by her abuser from engaging in contacts outside the household, with the notable exception of the healthcare setting. The possibility of abuse must be actively entertained whenever a woman patient presents with multiple, persistent, and/or unexplained physical complaints. Often the abuser hovers over the patient, ostensibly out of concern for her welfare, but actually out of concern that she will reveal the abuse to healthcare providers. Rape, which may occur within or without the domestic situation, and may be perpetrated by a relative, friend, acquaintance, or stranger, is another common type of abuse suffered differentially by women, and it is also associated with a greatly increased incidence of somatic complaints.

A patient presenting for medical care is unlikely to volunteer a history of abuse, and often has difficulty revealing this history even in response to direct questions. Paradoxically, perhaps, being a victim is experienced as humiliating, and, in fact, society has tended to marginalize, ignore, and blame victims. Many rapes and cases of domestic violence are not reported for this reason. It is nevertheless extremely important to raise the issue. It indicates to the patient that abuse is not an uncommon occurrence, that it is an appropriate subject for medical intervention, and that the physician is open to the subject. The patient may go home to reflect on her situation, and, after several visits to the doctor, work up her courage to reveal the abuse and ask for help. A useful adjunct to the direct doctor–patient interaction is the provision of materials on abuse that the patient can unobtrusively select and take home. Physicians tend to shy away from questions that may evoke revelations of problems that, they fear, will demand time, knowledge, emotions, and resources they do not have. Materials from rape crisis centers and women's shelters can therefore inform and reassure both patients and their physicians.

Until very recently, and in many cases still, the police, courts, and significant others have focused the investigation of an assault on the behavior of the victim rather than on that of the assailant. This tendency is so ingrained that healthcare professionals, too, must take special pains not to overlook this aspect of a patient's past or current history and not to compound the psychologic injury by unthinking behavior or subtly accusatory comments. Careful studies demonstrate that in the overwhelming majority of cases in which women present to healthcare settings with injuries directly caused by battering, the correct diagnosis is neither sought nor established. Whatever explanation the patient offers is automatically accepted, the physical wounds are treated, and the patient is discharged.¹⁹ Such patients are at high risk for 'psychosomatic' symptoms, that is, physical symptoms that result from stress and express inner conflict. It must be emphasized that knowledge of this association should never lead the clinician to dismiss the possibility of organic disease out of hand.

Case Study

A 48-year-old woman was referred for psychotherapy by her internist, who had become convinced, after a comprehensive evaluation, that her gastrointestinal symptoms were psychologically related. She had also undergone a spinal enzyme injection for a slipped disc. During the course of the psychotherapy, her abdominal symptoms abated. She recounted a history of early parent loss, emotional neglect by the relatives who assumed guardianship, and an early first marriage to an abusive husband. She was currently married for the second time, to a reasonably successful professional man whom she described as appreciative and respectful of her, but overly passive both personally and professionally. She was additionally burdened by the ongoing financial and emotional demands of an adult, but very immature, child from her first marriage. She felt imposed upon as a wife and as a mother. One day, as she prepared to leave early in the morning for work, she discovered that her son had left a heavy and valuable object in her car. It was likely that thieves in the neighborhood in which she worked would break into the car and steal it. Although her husband and son were still asleep in the house, and although she had been advised not to life heavy objects after her spinal difficulties, she, fuming again, carried the item into the house. Within hours, she developed immobilizing and excruciating back pain; an ambulance had to be summoned. Although there were clear psychodynamic reasons for her symptoms, and standard examinations revealed no organic pathology, her internist persisted in seeking a somatic answer. She was found to have a localized, acute, and dangerous spinal infection, which responded slowly but surely to intravenous antibiotic therapy. The patient's resentment toward her past and current family members was addressed after her physical recovery, in psychotherapy.

The first, and most important, principle of psychosomatic medicine in clinical practice is the acceptance of interrelated psychologic and physical problems as an intrinsic characteristic of medicine.²⁰ All symptoms are, by definition, subjective, and all disease occurs in, and is influenced by, a psychosocial context. To think otherwise is to reduce medicine to a mechanical discipline. So-called 'psychosomatic' symptoms can lead to as much or more disability and discomfort than diseases with clear physical etiologies.²¹  The clinical practitioner who regards the patient's troublesome feelings and behaviors as an unjustified intrusion on medical care is doomed to experience and cause frustration and to make mistakes in medical judgment. The clinical practitioner who accepts the totality of the patient's presentation as the subject for understanding and interaction, on the other hand, will find intellectual challenge, improved clinical outcomes, and greater professional satisfaction.²²

There are discrete, practical, and proven clinical tools to aid in psychosomatic diagnosis and management.

Interviewing Techniques

1. Ask open-ended questions.
   
2. Allow time for patient to talk freely and uninterruptedly.
   

During the typical doctor–patient interaction, less than 2 minutes elapse from the time the patient begins to explain the reason for her visit to the time she is interrupted by specific, rapid-fire questions from the doctor. It may seem that this is the ideal approach for narrowing down the differential diagnosis, a matter of time efficiency that is increasingly important in modern medical care. However, allowing the patient 5 minutes to explain her concerns, and asking some open-ended, as well as some focused, questions, is an even more effective use of time.

In the ambulatory care setting, over 50% of patients present with symptoms caused by frank psychiatric illness or symptoms complicated by psychosocial factors.²³ These crucial aspects of etiology are very often revealed in the spontaneous utterances of the patient. One extreme, but not rare, example is the patient who is psychotic. She may be perfectly able to give seemingly cogent one-word replies to the physician's questions. Only when she is allowed to speak spontaneously is her thought disorder revealed. She may then volunteer her belief that her symptoms result from a hex, poisoning by a jealous rival, punishment by God for sexual misdeeds or wishes, or sabotage by a government agency. Patients with less severe psychologic impairments often offer information about relationships between episodes of symptomatology and life stressors: “I always get this pain after my mother-in-law comes to visit.” The willingness of the physician to spend a little time just listening enhances the likelihood that the patient will feel trusting enough to reveal highly relevant, but delicate, information, such as domestic violence, sexual difficulties, and substance abuse.  The suggestions below are especially important in cases of multiple visits for unexplained, persistent, or multiple symptoms.

History

1. Inquire about childhood experiences of illness, hospitalization, and other treatments, and the reactions of family members. Were episodes of illness the only times the patient received attention and care?
   
2. What is the patient's lifetime history of symptoms and inability to perform life roles because of illness? Is this the sort of person who focuses on physical complaints or ignores them? What are her baseline and usual levels of functioning? It is highly unlikely that a patient will become more functional after treatment for somatoform illness than she has ever been in the past. Past functioning is the single most useful prognostic indication and therapeutic goal.
   
3. How have the patient's significant others responded to her past and current symptoms? Remember that both 'psychosomatic' and 'real' diseases may result in secondary gain.
   
4. How has the patient typically gone about seeking and using medical care throughout her life? Is this the sort of person who seeks medical attention for every bodily sensation, or who denies problems until they are serious? If the patient complains that she has been successively frustrated or mistreated by one doctor after another, do not delude yourself that she has finally found the expert in you—especially if she says so.
   
5. Has the patient, or have members of her family, been a health professional? Health professionals and members of their families are at increased risk for factitious and other psychosomatic disorders. Their focus on physical health and their knowledge of medical diagnoses and procedures facilitate their adopting, consciously or unconsciously, behaviors that are highly likely to result in serious medical attention.
   
6. Has the patient undergone a number of medical interventions, procedures, or operations without relief of symptoms?
   
7. How has the patient coped with medical illnesses throughout her life? (Does she tend to be incapacitated by relatively minor symptoms, or to cope successfully on her on with relatively major ones?) This simple question can save the physician and the patient from medically and legally disastrous outcomes. It is not enormously useful when the patient has a long history of overreaction to minor diseases. Serious pathology cannot be ruled out on this basis alone. However, the fact that a patient tends to be stoic and to seek medical care only when severely ill is a very important diagnostic warning.²⁴ The differentiation between these two situations must not be made on the basis of assumptions about relationships between gender, race, socioeconomic status, ethnicity, or other factors and reactions to illness, but on the basis of direct questioning of the patient and significant others.
   

Case Study

A married female graduate student was pregnant with her first child. She developed back pain. When she notified her obstetrician, she was told that back pain was a frequent occurrence in pregnancy. After some hours, she was unable to continue her work, and was barely able, with tremendous determination, to make her way home, where she called the doctor again. He said, “If you are still able to get around, it can't be anything serious.” He did not learn that this woman had never left work in her life and had never allowed any physical symptom to interfere with her studies. The diagnosis of a kidney stone with acute and total ureteral blockage was missed.

1. What is the relationship between both the first and subsequent episodes of symptoms and psychologically significant events in the patient's life?
   
2. What does the patient believe is wrong, and what does she expect in the way of treatment? Although many patients insist that the physician must figure out what is wrong with them and advise accordingly, many have private theories about diagnosis and treatment that they do not voice spontaneously for fear of evoking rebuke or revealing their medical ignorance. Unless these private theories are addressed in the medical interaction, they tend to interfere with patient satisfaction and compliance. The patient has not really gotten what she came for. If they are elicited with sensitivity to the patient's vulnerabilities, the physician can compare the patient's expectations with the medical findings and recommendations, and bridge the gap between them: “Your case is not quite like your sister's; the kind of germ causing your infection can't be cured by oral medication. That's why you need to use this vaginal cream.”
   
3. Questions about sexual function and about domestic violence often feel awkward to the physician, more awkward than they feel to the patient. However, both are often related to 'psychosomatic' symptoms. 'Frustrated' sexuality does not lead to physical complaints in the direct manner Freud at first postulated; simplistic conclusions must not be drawn. Domestic violence is highly correlated with otherwise unexplained physical symptoms. Straightforward questions are best: “What is the nature of your sexual activity at this time, and in the past?” “Do people in your house sometimes hurt each other when they are angry?”
   

Given a comprehensive history, physical examination, and appropriate laboratory tests, the nature of the patient's condition often becomes reasonably clear. One stumbling block for many physicians is the decision to slow down, interrupt, or cease the quest for a medical diagnosis. This decision entails considerable anxiety on the part of the physician as well as the patient. The endless quest for a physical basis for a patient's complaints presents a number of risks. These risks include financial burdens for the patient and/or the healthcare system, iatrogenic injuries resulting from ever-more invasive diagnostic procedures, the identification and treatment of findings that don't really contribute to the symptoms, ongoing secondary gain and disability, strains on the patient's significant others, and delay in the treatment of what is actually ailing the patient.²⁵ The patient's role as the passive victim of physical forces is reinforced, and it becomes increasingly the sole responsibility of the physician to remove her symptoms and improve her life.²⁶

This kind of pressure exacerbates the inherent demands of caring for patients with psychosomatic illnesses and can easily result in the physician feeling not only frustrated, but helpless, depressed, resentful, enraged, rejecting, and/or avoidant. There is a powerful message in medical training directing physicians to put all sorts of painful personal feelings aside when providing care, feelings ranging from sexual arousal to disgust and sadness. However, awareness of one's reactions to particular patients is often an extremely useful diagnostic and therapeutic tool. For one thing, it is a clue to the emotions going on in the patient.

For example, a patient may be consciously unaware of, or deny, feelings of depression or anger, yet convey them through her phrasing of complaints, her tone, and her body language and other behaviors. Powerful feelings are highly contagious. Unacknowledged feelings building up in the physician have a tendency to erupt, either abruptly and openly or via countertherapeutic approaches to the patient. When emotional reactions to a patient are recognized, the physician can use those feelings as data, or decide that certain kinds of patients, or certain individual patients, are best referred to a colleague, when that is possible. It is also possible, in many situations, to enlist the support and collaboration of a mental health professional, either to see the patient directly (see below) or to consult as needed.

Over time, each physician can develop a sense of his/her preferences and tolerances for the care of so-called psychosomatic patients. One common danger is the temptation to believe a patient who blames all her difficulties on the diagnostic and therapeutic incompetence, emotional insensitivity, and general neglect of a succession of previous physicians, and declares that the doctor she is now talking to is the first truly intelligent, caring, perceptive physician she has seen. She is certain that the current physician's observations, formulations, and therapeutic plan are ideal. A situation like this first sets the physician up to meet unrealistic expectations, and then to suffer the fate of all the other physicians the patient has seen. Although it can be briefly flattering, it engenders physician resentment and rage at nearly every step.

Sometimes, a particular patient or type of patient elicits problematic emotional responses in the physician for individual, personal reasons. The patient may consciously or unconsciously remind the physician of a troublesome figure in the past or in an ongoing relationship. The physician may be in the midst of a particularly stressful life experience, such as the illness of a loved one, bereavement, divorce, or strife with colleagues or superiors in the healthcare setting. Recognizing an inordinate response to the behaviors of a patient, the physician should stop to reflect on the cause. After reflection, the physician may no longer have a problem with the patient, or may decide, again, that certain clinical situations are best avoided, either until the life situation is resolved, or indefinitely.

In most cases of psychosomatic problems, the relationship between primary care physician and patient will continue. Once the diagnosis of a somatoform, or 'psychosomatic' disorder has been made, however, the physician will have to decide whether to continue ongoing care, attempt a formal psychotherapeutic office or bedside intervention, or make a referral to a mental health professional. This decision will be influenced by the talents, interests, and time schedule of the primary physician, the other resources available, the patient's insight and preferences, and the patient's clinical condition. With patients whose symptoms debilitate themselves and/or their significant others, and patients whose functioning is deteriorating, referral should be considered.²⁷ Many nonpsychiatric physicians dread the prospect of suggesting psychiatric evaluation and care to a patient. Psychiatry, and psychiatrists, are still highly stigmatized. A referral to a mental health professional implies mental instability or, at least, dismissal by the physician because the symptoms are “all in the patient's head.”

Referral Approaches

The following are suggestions for easing mental health referrals. First, the reasons for the referral must be grounded in the patient's own behaviors and concerns: “These pains are disrupting your life and your family's.” Second, they can be based on the stress caused by the physical symptoms, rather than on the symptoms themselves: “It is extremely stressful to endure so many physical problems for so long without any doctor's being able to get to the bottom of the situation.” Third, reassure the patient directly that the referral does not imply that she is insane or deranged. Fourth, introduce the mental health professional as a regular member of the doctor's therapeutic team, one who is familiar with the emotional aspects of conditions like hers.²⁸ Last, make it clear to the patient that the referral is not a way to get rid of her, but rather an additional approach to the relief of her suffering. The most effective way to do this is to make an appointment to see or speak to the patient after her contact with the mental health professional, so that she can report on her view of the interaction and her satisfaction with it.

The choice of mental health professional for referral is a related issue. Some patients are less put off by the idea of a social worker, which has fewer associations with insanity, whereas others associate social work with poverty and social problems they find distasteful. Many physicians are unclear about the distinctions between counselors, social workers, psychologists, and psychiatrists. To complicate matters further, there is a broad range of practitioners and approaches within each of these categories. Counseling is a large umbrella category, with most practitioners at the bachelor's or master's degree level, including marriage and family counselors, rehabilitation counselors, vocational and school counselors, and pastoral counselors. Social workers, most of whom have master's degrees, may specialize in individual, couples, family, and/or group therapy, and in defined areas, including the physically ill. Psychologists may be trained at the masters, PhD, or PsyD (a clinical doctorate) level, and may specialize in testing, research, and/or psychotherapies of various kinds.

Psychiatrists are the only mental health professionals who are fully medically trained. The choice among these categories will be governed by availability, cost (although fee differences may not be as great as is often assumed), third-party coverage and regulations, and the need for medical expertise on the part of the mental health provider. It is extremely useful to develop a relationship with one or more mental health experts for the purposes of collaborative care and mutual education about psychosomatic conditions.

Sometimes referral is not available, not necessary, or refused by the patient. The primary physician may successfully address the psychosocial aspects of the patient's clinical situation, as outlined under the diagnostic categories below.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994), includes a group of conditions, the 'somatoform disorders':  those disorders in which psychologic problems are manifest in physical complaints and disabilities. They include somatization disorder, conversion disorder, hypochondriasis, body dysmorphic disorder, pain disorder, undifferentiated somatoform disorder, and somatoform disorder not otherwise specified. Other formal psychiatric diagnoses closely related to psychosomatic medicine include factitious disorders and psychologic factors affecting medical condition. The distinctions among these disorders lie in the degree to which the patient is consciously aware of producing the symptoms, whether the patient is focused on the symptoms or on her general state of supposed ill-health, the number and persistence of symptoms, and the nature of the symptoms.²⁹  In each case, it is specified that the symptoms must not be secondary to some other psychiatric disorder, such as a delusional depression or generalized anxiety disorder.

Somatization Disorder

Patients with somatization disorder begin to manifest multiple physical complaints no later than their twenties. These complaints persist for years and cause disability in their domestic or workplace functioning and/or visits to the healthcare provider. Either the symptoms cannot be explained by a medical examination, or the patient reacts to a medical condition with symptoms much greater than the usual patient with the condition. To qualify for the diagnosis, the patient must have had at least four pain symptoms, two gastrointestinal symptoms, one symptom related to the reproductive system, and one pseudoneurologic symptom. Pseudoneurologic symptoms include sensory loss or change, loss of consciousness (not fainting), interference with muscle function (skeletal, respiratory, vocal), and difficulty with coordination or balance.

There have been few, if any, reported cures of this chronic condition. The therapeutic goal is to minimize unnecessary and often deleterious medical interventions and to maximize the patient's quality of life. The patient is likely to continue to seek medical care from new providers unless enrolled in an ironclad system that prevents this behavior, and she is unlikely to accept a psychologic explanation for her difficulties. It is sometimes possible to effect a successful referral to a mental health professional by emphasizing the emotional toll the disabilities are taking on the patient, and the role of the mental health professional as an adjunct to the primary care provider.³⁰ The patient may then form a therapeutic attachment to the mental health professional and relinquish some of her demands on the primary provider.³¹

In most cases, however, the primary physician will remain responsible for the whole spectrum of care. It is wise to schedule frequent, brief office visits rather than forcing the patient to produce more complaints in order to obtain contact with the physician. The physician can listen sympathetically for a short time to the most recent complaints, make some common-sense suggestions for the amelioration of symptoms, and then focus on the improvements the patient has made in accomplishing her responsibilities and enjoying her activities and relationships despite her taxing physical condition.³²

Conversion Disorder

A conversion disorder is characterized by the presence of a single sensory or voluntary muscle symptom, other than pain or sexual dysfunction, that resembles a medical or neurologic disorder but is not explained by one. The symptom is not consciously feigned but is associated with psychosocial conflicts or stress. Although the patient does not consciously cause the symptom, the symptom may vary according to the circumstances. It may be more intense when medical staff or family are observing, and it may disappear in an emergency; a psychosomatic lower extremity paralysis is unlikely to prevent the patient from escaping from a fire. Therefore, it may be possible to arrange a situation that reveals the nature of the symptom. However, such maneuvers betray and shame the patient, rupturing the doctor–patient relationship and undermining future attempts at psychiatric referral. Rather, in consultation with a mental health professional, and with the patient's cooperation, the physician and staff can develop a protocol for recovery that saves face for the patient and allows the patient to explore with a psychotherapist at the same time the reasons for the symptom. For example, the paralyzed patient can undergo an abbreviated regimen of physical therapy, be given exercises to perform, and graduate from crutches to a cane to independent ambulation. The patient with difficulty swallowing can progress from clear to thick liquids, to purees, soft foods, and a full diet.

Hypochondriasis

The essence of hypochondriasis is not so much the existence of one or more physical complaints but the patient's reactions to them and beliefs about them. A hypochondriacal patient is preoccupied with the fear or conviction that her bodily sensations are symptoms of a serious medical disorder. She persists in that belief, despite evidence to the contrary, for at least 6 months, and her concerns interfere with her relationships or other personal functioning. The therapeutic approach with such a patient is much the same as with a somatization disorder. The goal is containment of disability and maximization of function, not cure.

Body Dysmorphic Disorder

Patients with body dysmorphic disorder suffer significant distress or disability secondary to a preoccupation with an imagined bodily defect. This disorder is not well understood and is probably best handled by an expert mental health provider. It is most important to avoid acceding to the patient's urgent demands for surgical or other invasive intervention, because these are more likely to lead to litigation and repeated procedures than to patient satisfaction.  These patients willingly undergo one surgical procedure after another.

Pain Disorder

In pain disorder, pain is the focus of the patient's complaints, leads to the pursuit of medical intervention, interferes with the patient's functioning, and is adjudged, on the basis of clinical evidence, to be causally related to psychologic factors. The disorder may be acute or chronic, and may occur independently or in association with a general medical disease.³³ In addition to the suggestions listed for other somatoform disorders, it is important to avoid addicting the patient to analgesics. This concern should never deter physicians from providing adequate analgesia to acutely ill or postoperative patients. There is a great deal of empirical evidence that such patients are widely denied appropriate pain relief. Pain clinics, organized independently and as part of many large medical centers, can be very useful in helping chronic pain patients to reduce the use of pharmacologic agents and to lead productive and gratifying lives.³⁴

Undifferentiated Somatoform Disorder

A patient with this disorder has one or more physical complaints in the absence of, or out of proportion to, a diagnosable medical disease. The complaints last at least 6 months and cause the patient significant impairment or distress.

Somatoform Disorder Not Otherwise Specified

Some somatoform symptoms do not meet the criteria for any of the specific disorders described above. Examples include generalized fatigue or weakness, symptoms or hypochondriacal preoccupations lasting less than 6 months, and pseudocyesis. Pseudocyesis is a woman's false belief that she is pregnant, accompanied by increasing abdominal girth, reduction or elimination of menstrual flow, and other signs and symptoms of pregnancy. The umbilicus does not become everted. Although the disorder is not caused by an endocrine abnormality, there may be endocrine changes similar to those of pregnancy. This disorder is not well understood. It may be helpful to demonstrate ultrasound and other medical findings that disconfirm the pregnancy to the patient, but dramatic unmasking of the absence of pregnancy is not advised. The patients rarely follow through with psychiatric referral.

Two other disorders will be briefly mentioned because they are sometimes confused with somatoform disorders. They are factitious disorder and malingering. Factitious disorders (one variant is so-called Munchausen syndrome) are physical derangements resulting from deliberate misrepresentations and self-injurious behaviors of patients. Parents and other caretakers can also create factitious disorders in children. Patients are often medically sophisticated as a result of medical illness and treatment earlier in life and/or professional exposure. They are knowledgeable about which complaints and symptoms will elicit serious medical attention, hospitalization, and major diagnostic and therapeutic interventions. For example, they claim to have coughed or vomited blood. They inject themselves with nonprescribed insulin or with feces or other toxic or infectious material. Their aim is to receive medical attention and care.

These patients often elicit considerable sympathy at first, followed by tension between members of the medical staff as some begin to suspect, and then dramatic confrontations and elopement when the truth is revealed. Because the patients refuse to undergo psychiatric diagnosis and treatment, only a limited number of cases have been studied, and they cover a wide range of underlying psychiatric diagnoses. The underlying psychodynamics are poorly understood; most normal people will go to considerable lengths to avoid intrusive medical interventions. The United States medical system has largely allowed these patients to proceed from one hospital to another for years without detection. In contrast to these patients, malingerers claim or mimic medical symptoms to achieve ends that are obvious and understandable to everyone, such as avoiding combat duty or jail sentences, or receiving financial compensation.

In summary, somatoform, or 'psychosomatic' disorders have been known to medical science for millennia. They fall into coherent, useful diagnostic categories that have been confirmed by empirical and demographic research. They are common, complex, and costly, often leading clinicians into ever more frustrating, misguided, and counterproductive interactions and interventions.³⁵ Although the treatment of somatoform disorders can be intellectually and emotionally challenging, it is quite possible, with an informed approach, to improve the quality of life of both the physician and the patient.