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A CLINICAL PROTOCOL FOR ADVANCED PRACTICE NURSES
TO IDENTIFY CHRONIC SOMATIZATION
AMONG FREQUENT ATTENDERS IN PRIMARY CARE

By

Joan M. Clark-McHale

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTERS OF SCIENCE IN NURSING

College of Nursing

1999

ABSTRACT

A CLINICAL PROTOCOL FOR ADVANCED PRACTICE NURSES
TO IDENTIFY CHRONIC SOMATIZATION
AMONG FREQUENT ATTENDERS IN PRIMARY CARE

By
Joan M. Clark-McHale

The purpose of this project is to develop an assessment protocol to efficiently
identify chronic somatization among patients who frequently attend primary care
settings. Recognizing chronic somatization in the primary care setting is a clinical
challenge. A multistage screening protocol is advised for advanced practice nurses
(APN‘s) in primary care beginning with administration of the Patient Health
Questionnaire (PHQ), a brief screening questionnaire for diagnosing somatization
and other mental disorders commonly found in primary care. This is followed by the
evaluation of selected measures to validate the diagnosis of somatization among
those who screen positive on the PHQ. It is proposed that this strategy will be an
efficient and effective way of identifying primary care patients with somatization in
need of clinical attention. Once somatizers are identified and treated, their health
care utilization and treatment costs may be reduced and patient-provider satisfaction
improved. This systematic screening and identification of patients who frequently
attend primary care will encourage APN‘s to be more mindful of the hidden presence
of chronic somatizers in their nonpsychiatric settings. The High Risk Model of
Threat Perception (HRMTP) was the conceptual model chosen to highlight the
cognitive styles of chronic somatizers and further serves to validate the recognition
and diagnosis of somatization. Additional implications for research, education, and

practice are discussed.

DEDICATION

To Mom, whose lifetime love and generosity has been an enabler of all things good
and great, who demonstrated to each of her twelve children, the importance of
family and how to keep life’s priorities in order.

iii

ACKNOWLEDGEMENTS

This project has been a collaborative effort and I have been fortunate to work
with a remarkable group of professionals who represent my committee; Kate Lein,
chairperson, Linda Spence, and Celia Wills. As author, I am immensely grateful for
their contributions as I tried to produce a comprehensive, authoritative piece of
work. They have been graciously patient with my efforts to give this paper a unified
structure and consistent style. I also owe a special debt of gratitude to my husband,
Jim, and four children, Dana, Carly, Natalie, and Brian, for their love, patience, and

support during preparation of this project.

iv

TABLE OF CONTENTS

LIST OF FIGURES ..................................................................................................... vi

1. INTRODUCTION .................................................................................................. 1
1. Statement of the Problem
2. Purpose of the Project
3. Conceptual Definitions

11. CONCEPTUAL FRAMEWORK ........................................................................... 7
1. Theoretical Perspectives
2. The High Risk Model of Threat Perception (HRMTP)
3. Clinical Applications for the HRMTP

III. LITERATURE REVIEW ...................................................................................... 18
Definitions of Somatization

Prevalence

Patient Profile

Frequent Attenders, High Utilization, and Costs

Patient-Provider Dissatisfaction

Diagnosis and Treatment

P‘S‘PP’NE‘

IV. PROJECT DEVELOPMENT ............................................................................ 38
1. Recommendations for implementing clinical protocol
2. Discussion

V. IMPLICATIONS FOR RESEARCH, EDUCATION, AND PRACTICE .......... 49
V]. CONCLUSIONS ................................................................................................. 55
APPENDICES ............................................................................................................ 56

Appendix A: Somatization: Spectrum of Severity

Appendix B: Multistage Assessment Protocol for Chronic Somatizers
Appendix C: Patient Health Questionnaire

Appendix D: Cognitions About Body And Health Questionnaire
Appendix B: General Wellbeing Survey

Appendix F: The Difficult Doctor-Patient Relationship Questionnaire

LIST OF REFERENCES ............................................................................................ 75

LIST OF FIGURES

Figure l. The High Risk Model of Threat Perception
Figure 2. Diagnostic Criteria for Multisomatoform Disorder

Figure 3. Seven-Symptom Screening Test for Somatization Disorder

Figure 4. Target Population for Chronic Somatization

vi

INTRODUCTION

Somatization disorder is a chronic, multi-symptomatic psychiatric syndrome that
results in significant disability and generally shows poor response to conventional
approaches to care (Escobar, Bumham, Karno, Forsythe, & Golding, 1987; Fink,
1992; Kroenke, Arrington, & Manglesdorff, 1990). Medical causes of the symptoms
are carefully ruled out before a diagnosis of somatization is considered. Often,
organic disease is not found (Smith, Monson & Ray, 1986; Wilkie and Wesseley,
1994). When medical causes of symptoms are established, the physical complaints,
the use of health care services, and social and occupational impairment are in excess
of what would be expected from the medical findings (Katon, Reis, & Kleinman,
1984). Patients are at risk of having multiple diagnostic evaluations, invasive
procedures, and surgical operations (Katon, Lin, & VanKorff, 1991; Kroenke, et al.,
1990). Somatization disorder is most commonly seen in psychiatric settings (DSM-
IV, 1994).

Most of these patients seen in primary care are characterized as having a
subsyndromal form of somatization associated with higher rates of seeking health
care, but at an intermediate level between the general population and psychiatrically
diagnosed patients with somatization disorder. Swartz, et a1., (1991) found that
approximately 11.6% of the general population met the criteria for this
subsyndromal form of somatization. Another community study (Kirmayer and
Robbins, 1991) describes a larger subgroup of people who have multiple,
unexplained somatic symptoms but fall short of meeting the criteria for a formal
diagnosis of somatization disorder.

It follows then that, somatization disorder, as labeled and defined by the
Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV),

represents only 'a tip of the iceberg’ of true somatizers. Somatic presentation of

l

psychosocial distress is common and in one sense could be viewed as normal. These
somatizers attribute physical causes for their somatic symptoms (Benjamin and
Bridges, 1994), they are less likely to be recognized as suffering from a
psychological disorder by the primary care provider, and it is these chronic
somatizers who are likely to be referred to secondary care (Weich, et al., 1995).
Chronic somatizers are the focus of this project.
Statememoflhefimblem

Somatization is an important problem in primary care and a source of frustration
and challenge for primary care providers and their patients (Barsky, Wyshak,
Latham, & Klerman, 1991; Lin, Katon, & VanKorff, 1991; Lipowski, 1988).
Physical symptoms are very prevalent, generating an estimated 400 million clinic
visits each year in the United States, or 57% of all outpatient encounters (Schappert,
1992). At least one quarter to one third of these physical symptoms are somatoform
(Kellner, 1985; Kroenke, et al., 1993; Kroenke, et al., 1990). Somatization is
estimated to affect fi'om 25% to 75% of the population, upwards of forty percent of
primary care patients (Katon, et al., 1987; Schappert, 1992). Somatization causes
substantial patient disability (Escobar, RubioStipec, Canino, & Kamo, 1989; Katon,
et al., 1991; Kroenke, et al., 1993; Smith, Monson, & Ray, 1986), excess health care
use, increased costs (Escobar, et al., 1989; Katon, et al., 1991; Smith, et al., 1986),
physician frustration (Katon, et al., 1991; Hahn, Thompson, Wills, Stern, Budner,
1994), and poor response to therapy (Kroenke, Arrington, & Mangelsdorff, 1990).
Somatization has been a difficult and confusing diagnosis to make because, in the
past, the term has had several meanings, patients present with ill-defined complaints,
and they often change doctors (Beaber and Rodney, 1984).

Frequently, the diagnosis of somatization is missed, ignored or not even
considered. Although this is a disease that is psychologically based, somatizers

usually present in the primary care setting, thus hampering recognition (Borus,

2

Howes, Devins, Rosenberg, Livingston, 1988; Katon, et al., 1995). Physical rather
than emotional symptoms are the predominant complaints in patients with
psychological disorders who seek care in the primary care setting (Ormel, et al.,
1991).

Physical symptoms are pervasive in primary care and their potential relationship
to somatization is analyzed here. The numerous labels created across disciplines to
designate patients who are somatizers, the frustrations that these patients bring to the
primary care provider, the dissatisfaction with care and treatment, and the fact that
the majority of these patients use primary care services rather than psychiatric
services have challenged the course of treatment and outcomes. Given the
magnitude of this problem and concerns about cost in the era of managed care, early
recognition is crucial.

Given the utilization patterns of somatizing patients, the controversies about their
proper management, and the mounting costs in caring for them, it is imperative to
screen for these patients in the primary care setting using established assessment
criteria. The complex network connecting physical illness, psychiatric distress,
somatization, and overall life-situation of those who frequently attend the primary
care setting has been addressed in the literature. Efforts to recognize and describe
these frequent attenders is the first premise on which this project is based.

Psychiatric problems are usually not treated in the mental health specialty care
system. Primary care is considered the ”middle ground" for psychiatric care
(Bridges and Goldberg, 1985; Kroenke and Mangelsdorff, 1989). It is recognized as
a "central avenue” for the delivery of care to patients with psychiatric disorders
(Bridges and Goldberg, 1985). General practitioners ofien have long-lasting
relationships with their patients, see them fairly regularly for different reasons, and
see family members as well. Of all providers, the APN, as a family practitioner, is

in good position to detect somatization. The APN is responsible for the diagnosis

3

and treatment of a great variety of physical and psychological disorders in the
ambulatory patient. This is the second premise on which this project is based.

Lipowski (1988) calls somatization "the borderland between medicine and
psychiatry." Somatization, the presence of many symptoms that suggest physical
disease but which remain unexplained after medical and laboratory assessments, is
one of the most puzzling and fi'ustrating problems in primary care. Frustrations are
related to the difficulty experienced in recognizing somatizers, their deceptive mode
of presentation, use of multiple providers, lack of awareness in medical circles,
family dysfunction, associated psychiatric illnesses, problems with communication
during the medical encounter, poor response to therapy, and a lack of research on
effective approaches to work with these patients in the primary care setting (Barsky,
Wyshak, Latham, & Klerman, 1991; Lin, Katon, & VanKorff, 1991).
West

The overall objective of this project is to develop a clinical assessment protocol
for identifying somatizers in the clinical area before costly medical care is incurred.
A multidimensional approach to assessment will be described Patients who
frequently attend primary care clinics will be identified, followed by a brief
somatoforrn screener, and further assessment of contributing risk factors that
independently predict somatization. Specifically, the psychosocial characteristics of
somatizers will be uncovered. This assessment protocol will raise "red flags" if an
undiagnosed somatizer presents to primary care.

The specific aim of this protocol is to profile chronic somatizers so that APN‘s
can detect and treat these patients in the primary care setting. The outcome will be
early recognition and effective management leading to decreased utilization rates,
reduced health care costs, fewer iatrogenic illnesses, decreased functional

impairment, and improved patient-provider satisfaction.

This paper further explores the definitions and clinical features of somatization
and the cognitive styles of somatizers. Emphasis is placed on the importance of
routine screening for chronic somatization among frequent attenders in primary care.

Management principles will be briefly reviewed, but are not a major thrust of the

paper.
2 l I: E . .

Advance Practice Nurse (APN). APN‘s are registered nurses who have advanced
education and clinical training in a health care specialty area. They work with
people of all ages and their families, providing information people need to make
informed decisions about their health care and lifestyle choices. APN‘s serve as
regular health care providers for children and adults during health and illness. They
practice under the rules and regulations of the Nurse Practice Act of the state in
which they work and are nationally certified in their specialty area.

Primary Care. Broadly defined, primary health care is basic, initial health care
for general complaints, frequently given in an ambulatory setting such as an office or
clinic, and usually representing a person's first contact with the health care system.

Clinical Protocol. For this project, a multistage screening process that highlights
the range of cognitive and social factors that may contribute to somatization in
primary care.

Physical symptom. Any physical symptom reported by a patient, including both
symptoms that have an adequate explanation as well as those that are unexplained
(i.e., somatoform).

Frequent attenders. For this project, frequent attenders are defined as a patient
who has made 8 or more visits to a provider dming the previous twelve months or
those whose utilization places them in the top 20% of the number of ambulatory

health care visits for their age and sex groups.

Chronic somatization Chronic somatization, for this project, is defined
according to the PRIME-MD/PHQ multisomatoforrn disorder. It will be based on a
positive response on the subscale of the PHQ that measures somatization. A positive
response is 3 or more current unexplained symptoms with a history of at least
several years of unexplained multiple physical symptoms. Chronic somatizing
patients are distinguished from patients with entirely physical illness and patients
with clear psychiatric illness as defined by the PHQ, patient interview, and chart
review.

Use of medical services. For this project, use of medical services is based on
patients report of whether, within the previous twelve months, they have visited (a)
an emergency room, (b) another doctor‘s office, (c) any outpatient department, ((1) a
specialist, (e) a mental health clinic, (f) chiropracter, and (g) alternative healer", or
have received services such as (h) hospitalizations (i) surgeries (j) physical therapy

(k) laboratory and diagnostic tests.

CONCEPTUAL FRAMEWORK
I] . l P. .

The cause of chronic somatization is unknown, however, there are many theories
about the etiology of somatic symptoms. The reasons why a person might employ
somatization as a means of communication or as a coping strategy include a range of
possibilities. Somatizers may use the health care system as a social support system
if they are socially isolated (Falkner, Fatovich, & Winkler, 1987). The sick role may
be used to provide rationalizations for failures in social role responsibilities (Quill,
Lipkin, & Greenland, 1988). Illness may be a means to seek nurturance (Feldman
and Ford, 1994) or may be used to manipulate interpersonal relations and create
power in those who have little control over others (Sullivan and Katon, 1993).
Somatic symptoms may provide a cry for help and other forms of communication
when verbal skills, psychological sophistication, or education are limited and the
expression of one’s distress is impaired (Ford & Folks, 1985; Hollender, 1972). The
somatic symptoms of psychological disorders may be misattributed to physical
disease (Mathew, Weinman, & Minabi, 1981) and certain symptoms may have
significant personal meanings, for example, a middle-aged man whose father
recently died of a myocardial infarction is likely to respond to chest pain differently
than a teenage girl. Often psychiatric illness is misperceived as reflecting a weak
character, therefore, stigrnatization can be avoided by reinterpreting psychological
symptoms as due to physical causes. Overattention to bodily sensations may reflect
learned behavior (Craig, et al., 1994; Whitehead, Crowell, Heller, Robinson,
Schuster, & Horn, 1994). Similiarily, providers may reinforce abnormal illness
behavior through numerous diagnostic evaluations of unexplained physical
symptoms (Devries, Berg, & Lipkin, 1982). Bodily sensations may be amplified or
regarded as more troubling, noxious, or frightening (Barsky and Wyshak, 1990).

There are also identifiable gains to many‘illnesses, such as, resolving anger, eliciting
sympathy from others, and release from responsibilities (Dansak, 1973 ). Finally, the
experience of trauma, particularly during childhood, appears to predispose one to
somatization (Symes, 1995).

Personality and personality disorders are implicated as causes for somatizing.
Craig, et al., (1994) found that somatizers, when compared to psychologizers, are
less likely to develop coping efforts that neutalize their response to life events.
Children who somatize their emotional distress may develop more enduring
personality traits into adulthood Battaglia, et al., (1995) demonstrated that around a
quarter of those with personality disorder also had somatization disorder. Stern, et
al., (1993) found 72% of patients with somatization disorder met criteria for
personality disorders, compared to 36% of the psychiatric control group. This may
not be surprising given the fact that somatization disorder, like personality disorders,
is present from a relatively early age and is a chronic condition.

Of all these postulations, there is growing theoretical support for the cognitive-
behavioral theory of somatization (Greenwald, 1992; Kihlstrom, 1991). A cognitive
style of somatosensory amplification is described by Barsky, etal., (1990), and in
another study by Barsky, et al., (1991), hypochondriacal patients believed good
health to be relatively symptom fi'ee and considered symptoms to be equal to
sickness. Thus, it has been proposed that among somatizers an inadequate concept
of health could contribute to a perceptual and cognitive style of somatosensory
amplification (Clark, et al., 1997). A formal model of threat perception that
captures the cognitive styles of somatizing patients will be the conceptual
framework for this project
IIH'IE'IIIIIEI] E .

The conceptual model chosen for this project is The High Risk Model of Threat
Perception (HRMTP), proposed by Wickramasekera (1995). Wickramasekera

8

(1995) defines this as a ”multidimensional model that identifies three predisposing
factors (hypnotic ability, catastrophizing, and negative affectivity) that amplify the
probability that two triggering variables (major life change and minor hassles) will
generate psychological or somatic symptoms unless the impact of the triggers and
predisposers are buffered (by social support and coping skills)" (Figure 1). These
mechanisms can underlie the perception of threat that can lead to psychopathology
and pathophysiology. The perception of threat causes fear, which in turn, increases
the perception of pain. The HRMTP predicts that these risk factors a) amplify
somatic symptoms or b) transduce threat perception into somatic symptoms
(Wickramasekera, 1994).

 

Fig. 1. High risk model of threat perception (Wickramasekera, 1979, 1995)

 

Factors that W stress (threat perception)

' 1. High Social Support
BUFFERS 2. High Sau'sfaction with Social Support
3. High Coping Skills

 

 

Density of:
Psychological
TRIGGERS 1) Major Life Changes and/or
and/or Somatic
2) Minor Hassles Symptoms
Factors that m stress (threat perception)
I. High or Low Hypnotic Ability
AMPLIFIERS 2. High Catastrophizing

3. High Neuroticism a Negative Afl'ectivity
4. High Lie Score

 

Enedispnsem
Hypnotic Ability. Hypnosis is defined as a way to process information in which
attention and critical analytic cognition is suspended and can involuntarily cause

major changes in perception, memory, and mood (Wickramasekera, 1995). Those

high in hypnotic abilities are prone to less self control when information is processed
verbally. A person with high hypnotic ability is at risk for threat-related diseases
because when they enter the hypnotic mode, their perception of fear and pain is
amplified and they see meaning in events that are otherwise insignificant to others
(Dantzer, 1991). These "meanings" are viewed as threatening and come with
physical consequences (Kihlstrom, 1987). Those with high hypnotic ability are also
prone to "surplus empathy" or "permeable membranes." When they feel personally
threatened they absorb the pain, fear, and negative affect of others (Crowson, et al.,
1991)

People with low hypnotic ability have difficulty expressing feelings in words.
This too is considered an amplifying variable that potentiates the perception of
threat. They may repress or deny psychological causes of threat and prefer surgical
or medicinal solutions to their problems. Perceived threats are responded to with
excessive motor behavior rather than verbal responses (Frankel, et al., 1977).

Absorption is a trait related to hypnotic susceptibility (Tellegen, 1982) and may
clarify the term 'hypnotic ability.’ Absorption is not a concept within the HRMTP.
Absorption has been defined as "a characteristic of the individual that involves an
openness to experience emotional and cognitive alterations across a variety of
situations" (Roche and McConkey, 1990). Like people who are both high and low in
hypnotic ability, people who are both high and low in absorption ability will be at
greater risk for threat-related disorders (Wickramasekera, 1994). Absorption is
considered to be a good measure of hypnotic ability (Woody, et al., 1992).
Absorption is highly correlated with "openness" (Glisky, et al., 1991). Individuals
with low absorption (openness) are conventional and conservative (Costa and
Mche, 1986), reality oriented, pragmatic, and have little imagination
(Wickramasekera, 1994). Sperry (1980) and Wickramasekera (1994) hypothesized
that individuals with low absorption are predisposed to a strictly biomedical

10

 

approach toward their own bodies. Consistent with the predictions from the
HRMTP, people low in absorption may use behavioral coping with threat perception
through excessive eating and/or drinking.

The HRMTP predicts that hypersensitivity to the perception of threat places
individuals with high hypnotic ability at risk for stress- or threat-related
psychological and somatic symptoms (Wickramasekera, 1995). Correlations
between high hypnotizability and acute and chronic pain, phobias, negative moods,
PT SD, nightmares, insomnia, substance abuse, bulimia, and nausea have been
reported by many authors (Belicki and Belicki, 1986; Crowson, et al., 1991;
Wickramasekera, 1994).

Catastrophizing. The second personality variable that is hypothesized to amplify
threat perception is a fairly conscious verbal behavior where the individual verbally
catastrophizes (Wickramasekera, 1995). A catastrophizer becomes intensely
absorbed in negative events by talking to oneself about the event. They use negative
catastrophizing statements that amplify their misery. Catastrophizers are the
opposite of "copers" who are defined as individuals who use pleasant or positive
thoughts to distract their response to unpleasant events. Catastrophizers make "a
mountain out of a mole hill." High castastrophizing is common among those who
use analgesics and psychotropic medications (Wickramasekera, 1994).

Negative Aflectivity or Neuroticism. The third personality variable is negative
affectivity (NA) or neuroticism (Wickramasekera, 1994, 1995). These terms are
used interchangeably. High neuroticism or NA (Costa and Mche, 1986) is the
high probability of experiencing a variety of negative emotions like anxiety across
situations and time (Watson and Clark, 1984). Amplification is very similiar to the
concept of negative affectivity (NA). NA is an amplifying risk factor when it
becomes high overt NA and high covert (repressed) NA. NA is believed to be
genetically based (Tellegan, et al., 1988) and is found in individuals who report

11

negative emotions and distress independent of objective stress (Clark and Watson,
1991; Costa and McCrae, 1986). This negative bias in perception, mood, and
memory is related to a number of somatic complaints independent of age and
pathophysiology (Costa and McCrae, 1985). NA is a highly stable trait. There is
evidence that NA is stable across 20 years (Clark and Watson, 1991; Costa and
McCrae, 1986).

It is believed that high overt and covert NA is a risk factor for threat-related
disorders because this chronic negative bias in perception and memory may alter the
hypothalamic-pituitary—adrenal axis and immune function (Wickramasekera, 1995).
An interaction between hypnotic ability and NA is hypothesized to dysregulate the
autonomic nervous system (ANS) driving clinical symptoms (Wickramasekera,
1994).

Eysenck (1983) claims that neuroticism or NA is closely related to changes in the
ANS. The lability of the ANS is an important component of the HRMTP and is
theorized to interact with hypnotic ability and catastrophizing. to predipose a person
to enhanced threat perception and to generate psychological and somatic symptoms.
Individuals with high neuroticism show signs of ANS reactivity and a delay in
returning to baseline afier stressful stimulation. A strong relationship has been noted
between coronary artery disease and neuroticism. Individuals who show maximum
reactivity in the cardiovascular system may be at high risk for angina pectoris,
myocardial infarction, or stroke, whereas those who show strongest response on an
electromyogram measure may be at greatest risk of tension headache or low back
pain.

According to the HRMTP, additional risk factors for somatization are
hypersensitivity to threatening perceptions and memories as measured by high
neuroticism or NA (Eysenck, 1983). People with high NA have enhanced memory

for threatening or stressful events and experience high levels of anxiety

12

(Wickramasekera, 1995). Also at risk for somatization are people who are low on
NA but who also score high on the Lie Score, perhaps because they overuse
repression or denial mechanisms (Wickramasekera, 1995).

Iziggm.

Life Change and Hassles. These two triggering variables may be a large number
of major life changes over 1 year and/or a large number of minor chronic hassles.
Major life changes (a new job, a divorce, the birth of a new child, etc.) can be potent
sources of psychosocial stress and precursors of somatic illness. Major life changes
are not nearly as predictive for somatic disease as hassles (Rabkin and Struening,
1976; Stembach, 1986). Hassles are the irritating, fi'ustrating, distressing demands
that to some degree characterize everyday transactions with the environment. They
include annoying practical problems such as losing things, traffic jams, inclement
weather, arguments, disappointments, and financial and family concerns. Hassles
are more frequent than major life changes and are related to other indicators of
health status (Wickramasekera, 1995).

Bum

Social Support and Coping Skills. The two variables that buffer a person's
perception of threat are number and degree of satisfaction with social support
(House, et al., 1988) and coping skills (Lazarus and Folkman, 1984). It is well
established that social support is associated with less morbidity (House, et al., 1988)
and that coping skills affect health outcomes (Lazarus and Folkrnan, 1984). Social
support is the comfort, help, and information that one gets through formal and
informal enduring contact with individuals or groups. Support systems are
essentially psychological resources (spouse, siblings, psychotherapist, church,
friends) on which the patient can lean and with whom one can rely on to cushion the
impact of stressors (Wickramasekera, 1994). Coping skills (religion, projection,

intellectualization, humor, sublimation, escape through fantasy or reading, work,

13

jogging, recreation, relaxation, meditation, etc.) can also be used to distract the
patient, change or reframe the aversive meaning of events, and lower the level of
physiological arousal during both the acute and chronic phases of the stressors

impact. Patients who lack coping skills are at much higher risk of clinical symptoms

(Wickramasekera, 1994).

14

21"!!!" EIIIEIIIF.
The constructs of the HRMTP are high risk factors that underlie the perception of

threat and interact to either amplify symptoms or transduce threat into symptoms.
The predisposers are personality variables or cognitive styles (hypnotic ability,
catastrophizing, or neuroticism) that amplify the probability that two triggering
variables (major life changes or minor hassles) will generate symptoms unless the
impact of the triggers and predisposers is buffered by the individual's social system
and/or coping skills (Perceived threat--->Fear--—->Increased perception of pain).
Cognitive styles have an effect on the way an individual perceives threat. This
project aims to identify these cognitive styles using the Cognitions about Body and
Health Questionnaire (CABAH).

The HRMTP offers the APN a useful, short-term intervention for patients who
present with symptoms of anxiety, depression, high stress, somatization, chronic
pain, insomnia, and/or family dysfunction. This model is applicable to the goals of
this project because it specifically addresses the assessment of psychosocial factors
that contribute to somatic symptoms. The HRMTP hypothesizes that somatizers
have psychosocial conflicts and perceptions of threat that become unconsciously
converted into somatic symptoms. It collectively identifies eight risk factors that
can independently drive somatic symptoms and may have profound implications for
recognition, diagnosis, treatment, and the prevention of somatization in primary care
settings.

Clinically, as predicted by the HRMTP, one would expect the bulk of the people
with chronic physical symptoms without physical findings to have either low or high
hypnotic ability. Those with high hypnotic ability will make both physical and
psychological symptom presentations in either medical or psychiatric settings, but
those with low hypnotic ability will make mainly physical presentations and almost

exclusively in medical settings. Furthermore, individuals with high hypnotic ability

15

and high negative affectivity will respond most strongly and recover more slowly
from stressful stimulation (Wickramasekera, 1994).

The impact of multiple major life changes or multiple minor hassles will depend
not only on cognitive styles but also on the patient’s access to and effective use of
social support systems and personal c0ping skills. The patient at greatest risk for
chronic somatization is the one who is positive for all prediposing features, is
deficient in support systems and coping skills, and has experienced a massing of
multiple major life changes and chronic hassles (Wickramasekera, 1994).

Somatization is diagnosed by exclusion, that is, making a diagnosis by the
absence of disease. Inappropriate and expensive tests and procedures are often
needed to exclude identifiable pathophysiology. This model emphasizes the need to
avoid making a diagnosis by exclusion. Diagnosis by inclusion requires the
exclusion of pathophysiology but also the recognition of psychosocial factors that
may amplify (Barsky and Klerman, 1983) somatic symptoms. The HRMTP provides
an approach to diagnosis by inclusion (Wickramasekera, 1994) because it identifies
specific high risk psychosocial factors in threat perception that are believed to
amplify or cause somatic symptoms. APN‘s are trained in this biopsychosocial
model of health care making the HRMTP an easy model to apply.

Use of the HRMTP may provide information about specific cognitive styles that
predisposes one to somatization allowing APN‘s to identify treatments related to
individual cognitive styles. The model provides broad targets for therapy in general,
for example, increase or decrease hypnotic ability, decrease catastrophizing, or
increase coping skills and support systems. The model accounts for the observation
that some people with clear physical findings who get specific medical help continue
to have symptoms. The risk factors may someday be the focus of primary

prevention efforts starting in childhood or adolescence.

l6

The HRMTP offers several advantages over other models in directing the goal of
this project. As a cognitive model, this model offers the latest foundation for
somatic-like illnesses. The HRMTP has concepts that have been developed for over
twenty years. The high risk factors in this model are measurable and are based on a
systems approach to care. The HRMTP is an assessment intervention model which
is the focus of this project. This model assesses psychosocial factors that contribute
to somatization and serves as an easy model for APN‘s to apply because APN‘s are
aware of the importance of psychological issues on the body. The HRMTP further
serves as a prevention model, that is, APN‘s who know the risk factors identified in
this model can help predict individuals who may be somatizers and intervene early.
It is important to screen for these cognitive styles and other risk factors because
somatizers show no overt psychopathology. Unlike other conceptual models, the
HRMTP brings together seven risk factors for chronic somatization. Together, these
risk factors are potent predictors for somatization and recognize the complexity of
mind-body interactions in real clinical situations. The HRMTP is based on the
premise that somatizers cannot be reduced to an either/or category of medical versus
psychiatric illness. Knowledge of these risk factors may serve to prevent APN's
from submitting the patient to multiple tests, surgeries, and iatrogenic illnesses, and
may further help APN‘s to differentiate between a somatizer and a nonsomatizer

since these cognitive traits are somatizing traits.

17

LITERATURE REVIEW

Somatization has been defined in a variety of ways. Somatizers straddle the fence
between physical and psychological health problems and therefore are perceived
differently by the provider oriented in the biomedical aspects of illness and the
provider who may be more prepared to consider psychosocial aspects of illness
(Katon, et al., 1984). Somatization has been viewed from a number of different
perspectives (Katon, et al., 1991; Kinnayer and Robbins, 1991). There are
definitions that emphasize the presence of multiple complaints in different areas of
the body (Escobar, et al., 1987; Escobar, et al., 1989; Mai and Merkey, 1980).
Another definition stresses fear of having a serious physical disorder in the absence
of disease (Barsky and Klerman, 1983), yet another definition views physical
complaints as a manifestation of hidden psychiatric morbidity (Bridges and
Goldberg, 1985). With such diversity in the way the phenomenon of somatization is
conceptualized, it is not surprising to find conflicting research findings. Some
reports suggest that somatization is a defense against the awareness or expression of
psychological distress (Katon, et al., 1982). Some suggest that these symptoms are
common expressions of distress rather than defenses against the awareness of
distress (Escobar, et al., 1987; Simon and Gureje, 1999). In addition, while some
authors have claimed that less sophisticated subjects are more likely to be
somatizers, Bridges and Goldberg (1985) noted a lack of distinguishing social and
educational factors between somatizers and "psychologizers."

Historically, the behavior of somatizing was termed hysteria or Briquet's
syndrome. Presently, somatization is conceptualized as a "chronic syndrome of
recurring, multiple symptoms that are not explainable medically and are associated

with psychosocial distress and medical help-seeking" (Barsky, et al., 1997).

18

Along the way, a variety of definitions of somatization have been developed in
medical settings that emphasize etiology rather than the defining characteristics used
in DSM-IV. Rosen, et al., (1982), for instance, defined somatization as "the
articulation of emotional problems and psychosocial stress by way of physical
symptomatology." They divided somatizers into several clinical subtypes: 1) "the
acute"-the patient responding to an acute psychosocial stressor with somatic
complaints; 2) "the subacute"-the person whose symptoms are present for 2
months or more and whose problems are due to a treatable psychiatric or social
problem; and 3) "the chronic-«he person who presents a long-term coping style or
personality disorder that involves somatization (Rosen, et al., 1982). Others define
somatization in more general terms that incorporate all of the subtypes noted above.
Barsky and Klerman (1983) define somatization as "... the expression of emotional
discomfort and psychosocial stressors in the physical language of bodily symptoms."
Smith (1995) defines somatization as "an alternative way (somatic) to express
psychiatric disease or psychological stress when a patient is unable to use the
emotional route of expression." Somatization is defined by Katon, et a1. (1984) as
an expression of distress in which patients with psychosocial and emotional
problems articulate their distress primarily through physical symptomatology.

There are definitions that seem to describe more of the chronic disorder,
potentially including some patients who meet the DSM-IV criteria for somatization.
Somatization is defined by Lipowski (1988) as "the tendency to experience and
report somatic symptoms that have no pathological basis, to misattrrbute them to
disease, and to seek medical attention for them." Another definition, "a longstanding
pattern of seeking medical intervention for vague, multi system symptoms often

without a physical cause" was proposed by Quill (1985).

19

The common thread to all of these definitions is the patient's experience of
symptoms when psychological or social problems are present and when there is no
organic disease to explain the symptoms.

The four most prominent and formal terms found in the literature, most of which
have been operationalized in research studies, include 1) somatization disorder 2)
undifferentiated somatoform disorder 3) abridged somatization disorder (also known
as Somatic Symptom Index (SS1) or somatization syndrome) and 4)
multisomatoform disorder. A description of each of these constructs follows a brief
review of the classification of all somatoform disorders.

Psychiatric disorders are classified in the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV, 1994). Somatization disorder is one of
the current somatoform diagnosis included in the DSM-IV. DSM-IV diagnostic
criteria for somatization disorder include at least: (1) four different pain symptoms
(e.g., headache; back, joint, extremity, or chest pain; painful urination, intercourse,
or menstruation); (2) two gastrointestinal symptoms (e. g., nausea, bloating, diarrhea,
and food intolerance); (3) one sexual symptom (e.g., menstrual symptoms, erectile
or ejaculatory dysfunction, or sexual indifference); (4) one pseudoneurological
symptom, other than pan (e.g., deafness, paralysis, lump in the throat, phonia,
fainting, anesthesia, or blindness). The symptoms are severe enough to seek medical
attention. There is evidence of significant role impairment. Finally, the symptoms
are disproportionate to demonstrable medical disease (DSM—IV, 1994).

The diagnostic criteria for somatization disorder are quite restrictive. Most
somatizers do not meet the stringent criteria for somatization disorder. Prior to
DSM-IV, these patients were previously diagnosed as somatoform disorder not
otherwise specified. DSM-IV now includes the entity undiflerentiated somatoform
disorder. This diagnosis requires one or more physical symptoms that persists for at

least six months and are otherwise medically unexplained. Although this may prove

20

to be a more popular diagnosis, little is known empirically about patients placed in
this category (Kirmayer and Robbins, 1996).

Several researchers have sought to define a more inclusive classification that
requires fewer somatic complaints than are required for somatization disorder but
that nonetheless identifies patients who have the clinical and behavioral features
characteristic of the disorder. Research has shown that patients with four to six
somatoform symptoms have significant levels of disability, psychological
impairment, elevated rates of psychiatric comorbidity, and manifest maladaptive
illness behaviors such as undue use of medical care (Escobar, et al., 1989; Kroenke,
et al., 1997 ).

Based on this observation and the fact that full somatization disorder as defined
by DSM-IV is rare in the primary care setting, Escobar and colleagues (1987) have
proposed an abridged somatic construct, also known as the Somatic Symptom Index
(581) and "somatization syndrome." This less restrictively defined form of
somatization is the more common variant of somatization found in primary care
settings. To meet the criteria for 881, male subjects are required to have 4 medically
unexplained somatic symptoms, while female subjects are required to have six.

Recently, a new somatoform disorder called multisomatoform disorder,
developed by Kroenke and colleagues (1997), was derived from the Primary Care
Evaluation of Mental Disorders (PRIME-MD). The PRIME-MD is a validated
diagnostic interview that consists of a 26-item, self-administered patient
questionnaire that assesses for the presence of mood, anxiety, somatofornr, alcohol,
and eating disorders. Chronic somatizers, for this project, will be defined according
to the criteria of multisomatoform disorder. Multisomatoform disorder is defined as
3 or more current somatoform symptoms reported from a 15 symptom checklist
along with at least a 2-year history of somatoform symptoms (Figure 2). This

checklist includes 15 symptoms or symptom groups: stomach pain, back pain,

21

headache, chest pain, dizziness, fainting, palpitations, shortness of breath, bowel
complaints (ie, constipation or diarrhea), dyspeptic complaints (ie, nasuea, gas, or
indigestion), fatigue, trouble sleeping, pain in the joints or limbs, menstrual pain or
problems, and pain or problems during sexual intercourse. The criteria for
multisomatoform disorder were tested for validity in the PRIME-MD 1000 Study
(Kroenke, et al., 1997).

 

Figure 2. Diagnostic Criteria for Multisomatoform Disorder

 

A. Three or more somatoform symptoms currently present (ie,
within the past month).

B. A somatoform symptom meets either criterion 1 or 2:

1. After appropriate investigation, the symptom cannot be
fully explained by a known general medical condition or
thedirectefi‘ectsofa substance(eg,adrugofabuse

or a medication).

2. When there is a related general medical condition, the
physical complaint or resulting social or occupational
impairment is in excess of what would be expected hour
the history, physical examination, or laboratory findings.

C. The symptoms caused clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.

D. Althoughspecificsymptansmaycomeandgo,thepersonhas
hadonea'moresmnatoform symptoms, formoredays thannot,
for at least two years.

E. Criteria for somatization disorder are not met nor are the
symptomspanofthe diagnostic criteria foramental
disorder that is currently present (eg, fatigue or insomnia
in a patient with depressive disorder or chest pain and
diuinessthatonlyoccmdmingapanicattackinapatient
with panic disorder).

F. The symptoms are not intentionally produced or feigned
(as in factitious disorder or malingering).

 

Multisomatoform disorder differs from undifferentiated somatoform disorder in
three ways. It has a higher symptom count (ie, 3 instead of 1), longer duration (ie, 2
years instead of 6 months), and fewer psychiatric diagnoses to exclude. Counting
three symptoms was judged to be clinically important (Kroenke, et al., 1997). It was

associated with impairment in quality of life, excess health care use, and excessive

22

disability days and clinic visits that exceeded that of any mood or anxiety disorder
(Kroenke, et al., 1997). The requirement for a two-year hisory of unexplained
symptoms recognizes the often chronic course of somatization. Kroenke, et al.,
(1997) do not support the hierarchical rule for undifferentiated somatoform disorder,
whereby the latter is not diagnosed if unexplained physical symptoms are better
accounted for by another mental disorder. The authors propose that excluding a
diagnosis of somatization because the symptoms could be attributed to a psychiatric
disorder involves considerable clinician judgement, uncertainty, and bias.
Multisomatoform disorder does not count physical symptoms when they are part of a
diagnostic criteria for a current mood or anxiety disorder. However, symptoms such
as fatigue or insomnia are included in the symptom count of patients who do not
have a concurrent mood or anxiety disorder. There is evidence that it is not the
specific type of somatoform disorder but the number of symptoms that determines
the severity of functional impairment and psychiatric comorbidity (Kroenke, et al.,
1993).

Both somatization syndrome (S81) and multisomatoform disorder have been
shown to be associated with excess functional impairment and health care use
(Escobar, et al., 1989; Katon, et al., 1991; Kinnayer and Robbins, 1991; Smith, et
al., 1995; Swartz, et al., 1991).

Aside from these definitions, it is useful to view somatization as a continuum
(Appendix A) on which increasing levels of somatic symptoms indicate increasing
distress, disability, and maladaptive illness behavior (Katon, et al., 1991). Katon and
colleague's (1991) data on distressed high users of primary care suggests that many
clinical and behavioral features associated with somatization were evident before
patients met the diagnostic threshold for somatization disorder. Moreover, physical
symptoms, disability, and medical utilization increased linearly with the number of

somatic symptoms. Patients who somatized were reported as having worse mental

23

health and amplifying physical symptoms, as well as being significantly more
fi'ustrating patients than patients with low level of somatization. This data suggests
that rather than a discrete cutoff point for somatization, one or more categories of
less severe types of somatization presently included in the DSM-IV should be
utilized when a diagnosis is needed Patients who did not meet the diagnostic
criteria for somatization disorder, were found to be almost as severely disabled as
those who did meet the diagnostic criteria for somatization. These less severe forms
of somatization disorder are more applicable to the clinical realities of primary care
practice, where somatization associated with social stress, anxiety, depression, and
functional disability is much more common than somatization disorder (Katon, et
al., 1991).

Based on the premise that somatization is viewed as having a spectrum of
severity, somatizers, for this project, are not defined predominantly or exclusively by
somatic clinical presentation of somatization disorder as defined by DSM—IV. While
abridged somatization disorder has practical utility for clinical studies and has
demonstrated a high prevalence in primary care studies, this construct was not
chosen because the primary care provider must inquire about a patient's lifetime
experience with a long list of 37 symptoms. This is impractical in a busy primary
care setting. More importantly, errors in recall might affect the outcome of the
project. Rather, this project will support multisomatoform disorder as a working
definition for chronic somatization and as an alternative to the rather vague DSM-IV
category of undifferentiated somatoform disorder. The diversity of these definitions
is reflected on the prevalence and correlates of somatization in different populations.
Prudence

Much of primary care resources are devoted to the care of somatizing patients
who are symptomatic but not seriously ill. The high prevalence of somatization is

well documented. Only 16% of the fourteen most common somatic symptoms found

24

in 1000 primary care settings were shown to have an organic cause (Kroenke and
Mangelsdorff, 1989). In 25-50% of all primary care visits, no serious medical cause
is found to explain the patients presenting symptoms, and psychological factors
appear to play a role in prompting the visit (Bridges and Goldberg, 1985; Katon,
Reis, & Kleinman, 1984; Kroenke, et al., 1990).

Research has shown that the most severe form of chronic somatization as defined
by DSM-IIIR or DSM-IV, has a relatively low occurrence rate (Gureje, et al., 1997;
Escobar, et al., 1987), but that subthreshold somatization is very common (Bridges
and Goldberg, 1985; Kirmayer and Robbins, 1991). The Epidemiologic Catchment
Area Study (ECA) measured prevalence rates of somatization. The formal disorder
was very rare, occurring in only 0.05% to 0.38% of the adult population (Swartz, et
al., 1991 ). In a primary care study by the World Health Organization (WHO),
somatization disorder was relatively infrequent with a prevalence of 2.8% (Gureje,
et al., 1997). Other sources have reported a slightly higher rate of occurrence among
patients with the full disorder. A prevalence rate of 5-8% has been noted in
outpatient settings (Barsky, et al., 1995; deGruy, et al., 1987; Escobar, et al., 1989
and a 9% prevalence among inpatient settings (deGruy, et al., 1987). It is the fourth
most common diagnosis among medical outpatients (deGruy, et al., 1987; Katon and
Russo, 1989), and the second most common diagnosis among medical inpatients
(deGruy, et al., 1987).

However, chronic somatization, as defined in this project, is common. It has an
estimated prevalence rate of 33% among outpatients (Smith, et al., 1986). The ECA
survey reported a prevalence of between 9% to 20% using the abridged form of
somatization disorder as defined by Escobar and colleagues (1989). Another study
confirmed a prevalence of 20% using the same definition (Gureje, et al., 1997).
Kirmayer and Robbins (1991) estimate that one quarter of primary care patients are

somatizers.

25

Chronic somatizers, for this project, will be defined as having multisomatoform
disorder which has been previously described. Multisomatoform disorder is
considered as prevalent as and highly correlated with abridged somatization.
Eatienthfile

Gender, Age, and Education. Cultural factors seem to influence the type of
presentation. Patients who are nonwhite, less educated, and from nonurban
communities are more likely to somatize repeatedly in response to stress (Swartz, et
al., 1991; Escobar, et al., 1989). Although somatization has been reported in both
sexes, it is commonly held that it occurs more often in females than males.
However, there are data that does not support this common belief. Piccinelli and
Simon (1997) found that somatic symptoms and emotional distress are strongly
associated among frequent attenders in primary care with few differences between
the sexes. According to Escobar, et al., (1989) the common somatizer shows no
gender bias. DSM-IV (1994) reports a prevalence in women to be ten times that in
men for somatization disorder. According to Swartz, et al., (1991) it is more
common in females than males. Others also support the notion that the association
between somatization and the female sex applies to the more severe forms of the
disorder (Katon, et al., 1991; Gureje, et al., 1997). Gender differences remain
unclear and inconclusive due to inconsistencies across studies (Wool and Barsky,
1994)

Since somatization represents a lifelong way of handling psychological
difficulties, most patients begin to complain of multiple physical symptoms by the
age of 30 years (DSM—IV, 1994). According to Gureje, et al., (1997) patients with
somatization disorder were not much diffferent from chronic somatizers with respect
to mean age (43.3 years and 42.6 years, respectively). The majority (55%)
experienced their first somatic symptom before 15 years of age, and remission of

symptoms was rare (Swartz, et al., 1991).

26

There is only modest support for the notion that somatization may represent the
mode of expression of psychologically impaired or less sophisticated people. Gureje
(1997) found that somatizers had fewer years of formal education than
nonsomatizers, but does not postulate that lack of formal education was a strong
correlate of somatization Swartz, et al., (1991) found that somatization was more
common among those who did not graduate from high school.

Functional impairment and disability. Patients with multiple unexplained
symptoms have been found to have high rates of functional impairment (Gureje, et
al., 1997). Chronic somatizers had greater functional disability on 3 measures of
health status: physical functioning, general health perceptions, and mental health,
when compared to the general population and to the chronically ill population.
Somatizers spent an average of 7 days in bed every month compared to 0.5 day in
the general population and 83% no longer work because of their illness (Smith, et
al., 1986). Another study found that somatizers were three times more likely to
report current disability compared to nonsomatizers (Escobar, et al., 1989, Escobar
and Canino, 1989, Escobar, et al., 1987). The amount of impairment in functioning
and quality of life is comparable to mood and anxiety disorders (Katon, Lin, &
VanKorff, 1991).

The paradox is that this impairment is intensified as providers continue to
evaluate and treat somatizers for physical diseases that do not exist. They are
exposed to unnecessary diagnostic tests (Ford, 1985; Shaw and Creed, 1991;
Zoccolillo and Cloninger, 1986; Wickramasekera, 1994), hospitalizations (Cherkin
and Deyo, 1993; Smith, et al., 1986; Zoccolillo and Cloninger, 1986) and surgery
(Deyo, et al., 1993; Fink, 1992; Hoffman, et al., 1993; Katon, et al., 1983; Zoccolillo
and Cloninger, 1986), all of which lead to high iatrogenic complications (Barsky &
Borus, 1995; Katon, et al., 1984; Smith, et al., 1986; Wickramaserkera, 1994). In

addition, trial treatments with antibiotics and corticosteroids and the indiscriminate

27

use of addicting and other medications make patients worse (Deyo, et al., 1993;
Katon, et al., 1984; Lightfoot, et al., 1993).

Finally, joblessness is a problem among somatizers. Somatizers reported being
unemployed for six months or longer in the preceding five years. Half of these were
patients with somatization disorder, one-third of these patients were common
somatizers, and one-fifth of those were not classified as somatizers (Escobar, et al.,
1989; Escobar and Canino, 1989).

Overall, chronic somatizers do not feel well and find it difficult to function daily
and at work. Thus, they limit their activities, spend time in bed, and miss work.
Somatization contributes greatly to lost productivity and disability (Robbins and
Kinnayer, 1991).

Childhood abuse. Many studies have confirmed the association between
somatoform disorders and childhood abuse (Farley and Keaney, 1997; Kinzl, et al.,
1995; Walker, et al., 1995). In general, persons with somatoform disorders have
been found to have experienced higher rates of childhood abuse. Specific aspects of
this association are presented here.

Persons with somatization often have chaotic and stressful childhoods and
adulthoods, with unstable families and considerable psychosocial stress. Morrison
(1989) reported that 55% of 60 women with somatization disorder had a history of
molestation compared to only 16% of 31 women with a primary affective disorder.
Similarly, adult survivors of sexual abuse have high rates of somatization disorder.
Somatization disorder has a lifetime prevalence rate of 16% in adult survivors of
incest, compared to the general population prevalence of less than 1% (Portegij s, et
al., 1996). Kinzl, et al., (1995), confirmed that severe or repeated childhood
victimization and a familial deficiency syndrome in childhood may be important in

the pathogenesis of somatization.

28

Farley and Keaney (1997); Atlas, et al., (1995); Probor, et al., (1993); and Walker,
et al., (1995) investigated the relation between history of sexual abuse, somatization,
and dissociation. Dissociation and somatization were positively correlated in
subjects who had a history of sexual abuse, but this relation did not occur in subjects
who reported no history of sexual abuse. Farley and Keaney (1997) further reported
that the more perpetrators a subject reported, the greater the number of reported
chronic physical symptoms. As the age of onset of abuse neared puberty, the more
the subjects reported childbirth complications. Recent literature has implicated
childhood sexual abuse as a specific risk factor for chronic pelvic pain (Fry, et al.,
1997; Rosenthal, 1997).

Salmon and Calderbank (1996) compared history of sexual and physical abuse in
childhood and health care utilization, somatization, and hypochondriasis as an adult.
Both types of abuse were followed by a greater number of hospital admissions and
surgical procedures in adulthood

Associations of sexual assault history with multiple measures of physical health
were examined by Golding (1994). Sexually assaulted women were more likely than
nonassaulted women to report poor health perceptions, fimctional limitation, several
chronic diseases, medically explained and unexplained somatic symptoms.
Kimerling and Calhoun (1994) further clarified the relationship between the
experience of sexual assault and physical health. They found that women who
experienced sexual assault reported more somatic complaints, poorer perceptions of
physical health, greater psychological distress, and increased use of medical
services.

The contribution of childhood abuse to adult illness behavior and psychiatric
problems has sparked the interest of researchers in the last 10-15 years. This survey
of research findings clearly demonstrates that a history of sexual abuse in childhood

is reported more often by somatizing patients.

29

Psychiatric co-morbidities. Chronic somatizers have high levels of psychiatric
co-morbidity. Psychiatric disorders are found in 75% of these patients and the most
common are affective disorders, anxiety, and alcohol abuse (Kaplan, et al., 1988).
Epidemiological studies in primary care have determined that 25% to 35% of
primary care patients have a mental illness as defined by the Diagnostic and
Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) (Katon,
1991). Moreover, these studies have found that 50% to 70% of patients with a
mental illness initially present with a somatic symptom such as headache, back pain,
or fatigue (Goldberg and Bridges, 1988; Kinnayer and Robbins, 1991). Researchers
have found a high rate of misdiagnosis in patients who have somatic symptoms as an
expression of psychosocial distress (Bridges and Goldberg, 1985; Kirmayer and
Robbins, 1991).

It is often reported that depression is a commonly somatized disorder (Escobar, et
al, 1987; Simon and VanKorff, 1991; Gureje and Obikoya, 1992). Depression is one
of the most common disorders underlying somatization in primary care (Katon,
1984) with lifetime rates reported at 80% to 90% (Katon, et al., 1991; Liskow, et al.,
1986). It is the most common mental disorder in the general population after
substance abuse and anxiety (Regier, et al., 1984). Smith (1992) estimated
prevalence rates for major depression among somatizers to range from 48% to 94%.
Depression with somatoform complaints is far more common than somatoform
disorder (Barsky, et al., 1991). Depressed patients may selectively focus on the
somatic manifestation of their disease and ignore, or not experience affective or
mood disturbance (Katon, et al., 1995). Lacking the symptoms of depressed affect,
these patients often present to primary care providers with the classic depressive
somatic complaints, such as chest pain, gastrointestinal complaints, and localized
pain. Major depression is often accompanied by other somatic symptoms, such as,

insomnia, fatique, anorexia, and weight loss. Functional somatic complaints like

30

aches, pains and dizziness often mask the presence of depression. Unlike the
somatoform disorder patient, depressed patients feel they are not worth treating and
do not deserve to feel better. In addition, depressed patients are hopeless about
improvement. Major depression in the presence of somatic symptoms must be
treated first. Both affective and functional symptoms may improve with treatment,
although, sometimes functional somatic symptoms continue to be a problem as the
affective illness remits (Simon and Gureje, 1999).

Anxiety disorders are also frequently found in patients with chronic somatization.
Liskow, et al., (1986) found that of patients with somatization disorder, 27% met
criteria for obsessive-compulsive disorder, 45% met criteria for phobic disorder, and
45% met criteria for panic disorder. Smith (1990) reported that patients with
somatization disorder had the following anxiety disorders: generalized anxiety
disorder (34%), obsessive-compulsive disorder (18%), and panic disorder (26%).

Symptoms of anxiety effect functional somatic symptoms. Anxiety distorts one's
attention toward dangerous and threatening perceptions, and the cognitive appraisal
of somatic symptoms, causing unwarranted alarm. Anxious patients tend to
exaggerate normal physiologic sensations and trivial ailments. Many of the
symptoms of panic disorder are somatic: dyspnea, palpitations, chest pain, choking,
dizziness, paresthesia, hot and cold flashes, sweating, faintness, and trembling
(Kaplan, et al., 1988). Although anxiety is more obvious to clinicians than
depression, panic disorder often goes unrecognized. Panic disorder is far more
prevalent among somatizers than was once thought (Kaplan, et al., 1988).

Anxiety is also a common feature of major depression. Anxiety in the presence of
pain can dramatically lower the pain threshold, causing the provider to misinterpret
the significant discrepancy between the complaints of pain and the objective
findings. This is common in the more malignant forms of somatizing (drug abuse

and personality disorder). Diagnosis is delayed and the provider and patient become

31

frustrated because many of the patients cannot distinguish anxiety from pain
(Kaplan, et al., 1988).

The risk for having a current depressive illness or an anxiety disorder for patients
with chronic somatization is significant. Gureje (1997) found that 40% of chronic
somatizers also met the criteria for either depression or generalized anxiety disorder.
Sirniliar data is reported by Simon and Gureje (1999), who found that 50% of those
with five or more somatic symptoms met the criteria for current psychiatric
diagnosis.

Alcohol abuse appears to occur with increased frequency in patients with
somatization disorder, affecting 15% to 30% of patients (Smith, 1990). Reif, et al.,
(1996) evaluated possible risk factors for somatic syndromes, and found that
somatizing patients reported a higher rate of partners with regular alcohol
consumption than other patients. Tier, et al., (1998) hypothesized that somatic
symptoms might be associated with alcohol use and concluded that self-reported
somatization symptoms may be indicators of current or future alcohol use. He also
concluded that alcoholism was associated with somatization while Simon and
Gureje (1999) confirmed that there is an association between full somatic disorder
and alcoholism.

When one views somatizers, the somatoform disorders may be the obvious
diagnostic category, but the psychiatric diagnoses identified above need to be
considered Once these psychiatric disorders remit, the somatic symptoms usually
subside.

E g l H'llll' . I:

Persistent somatizers are very high utilizers of both outpatient and inpatient health
care services. They are hopitalized more often, see more physicians, have more
clinic visits, are exposed to more diagnostic tests, and take more medication

(deGruy, et al., 1987; Katon et al., 1991; Smith, Monson, & Ray, 1986). There are

32

numerous studies that demonstrate the impact somatization has on excessive
utilization among chronic somatizers (Katon, et al., 1990; Lloyd and Pender, 1992;
Smith, 1994; Zoccolillo and Cloninger, 1986).

Somatization has been shown to have a very high prevalence among patients who
frequently attend primary care clinics (Katon, et al., 1990). In this study of high
utilizers, he determined that 10% of these patients account for almost one-third of
ambulatory visits and one half of inpatient hospital days. Approximately one half of
these patients were psychologically distressed, and among these distressed high
utilizers, one fifth had somatization disorder and three fourths met an abridged
definition of somatization (Katon, et al., 1990). In these days of escalating medical
costs, researchers have found that patients with mental illness use two to three times
as many outpatient visits as nondistressed control subjects (Katon, 1991).

Patients with multiple unexplained physical complaints have sometimes been
labeled the "worried well," implying an absence of disease and an inappropriate use
of services. Not all patients who experience common symptoms actually report
them to a health care provider. Factors that precipitate a clinic visit include
persistent symptoms, perceived seriousness, functional impairment, expectations for
medications, testing, and referrals, and psychological distress, such as anxiety,
depression, and stress (Barsky, Goodson, Lane, & Cleary, 1988; Marple, Luay,
Kroenke, et al., 1993). The uncertainty and suffering related to these factors cannot
be dismissed

Somatizing patients are disproportionately high users of medical services,
laboratory tests, and surgical procedures ( Kroenke, et al., 1990; Katon, Lin, &
VanKorff, 1991). Chronic physical illness explains part of the problem; more
importantly, factors include mental illness, substance abuse, and particularly
somatization (Fink, 1992). Somatization imposes a serious burden on patients

themselves as well as the health care system (Fink, 1992).

33

The ECA study established that severe somatizers used medical inpatient services
four times more than nonsomatizers, and common somatizers used these services
two times more than nonsomatizers. In terms of outpatient care, severe somatizers
were two times as likely to use the services compared to nonsomatizers and common
somatizers were 1.5 times more likely to use these services compared to
nonsomatizers (Escobar, et al., 1989; Escobar and Canino, 1989).

The cost of health care for somatizing patients is very high. Studies report health
care costs from six (Smith, et al., 1986) to thirteen (Labott, et al., 1995) times higher
when comparing the use of services by somatizing patients with the expenditures
incurred by the average patient. In the past, patients with somatization disorder
consumed nine times the average health care expenditures (Smith, et al., 1986).
More recent data on costs show only a threefold increase in costs among patients
with somatization disorder. This is likely due to the impact that DRG's have had
upon hospitalization rates (Rost, et al., 1994). Smith and colleagues also reported an
average annual cost of $4700 in a group of patients with unexplained symptoms
compared to $543 for the general population, and the American Academy of Family
Physicians reported that from $20 to $30 billion is spent annually on unnecessary
bills for somatizing patients (Ford and Folks, 1985). Chronic low back pain is one
type of somatization that afflicts approximately 40 to 70 million Americans, with
costs of care escalating to $57 billion from lost production, medications, and health
care services (Brena and Chapman, 1983). Numerous other studies showing high
cost in somatizing patients support the above findings (Katon, et al., 1991; Shaw and
Creed, 1991; Simon, 1992; Smith, 1994).

E . CE . l 1. . E .

Despite heavy use of health care services, somatizers are often unhappy with their

care and they are a source of frustration for providers (Escobar and Canino, 1989;

Escobar, Golding, Hough, et al., 1987; Noyes, Kathol, Fisher, et al., 1993). Hall

34

(1998) concluded that patients in better health received more social conversation,
which in tum, implies that the provider was more responsive to their psychosocial
needs. Patients in poorer health received little social conversation, which in turn,
meant the patient lost regard for the provider. Overall, poorer health meant less
patient satisfaction either because dissatisfaction had a negative impact on health or
health led to the degree of satisfaction. Chronic somatizers are unrewarding because
they are so difficult and they are often blamed for their health. The negative feelings
of the provider are often leaked to the patient through verbal and nonverbal cues
(Hall, 1998).
Diagnrrsimdlreannem

Primary care providers seldom recognize somatization (Barsky, 1995 ; Bridges, et
al., 1985; deGruy, 1987) and this complicates the high prevalence rate and
overutilization of professional services. A wealth of literature on somatization
suggests that most patients with psychological disorders seen in primary care present
with physical rather than emotional complaints (Katon, Reis, & Kleinman, 1982;
Keller, 1985; Kirmayer & Robbins, 1991). This somatic presentation decreases the
likelihood that health care providers recognize the patient's psychiatric distress
(Kirmayer and Robbins, 1996), further complicating the diagnostic process among
those who frequently seek care for their symptoms. Chronic somatization may be
difficult to detect because these patients may also have several physical illnesses.
Furthermore, providers' attitudes toward psychosocial problems may be a central
factor in determining whether somatization is recognized

Utilizing the DSM-IV can be cumbersome for the busy clinician. Othmer and
DeSouza (1985) developed an abbreviated list of seven symptoms that can be used
to screen for the disorder. There is a high likelihood of somatization disorder if two

or more of the symptoms in their clever mnemonic are present (Figure 3). The

35

presence of three symptoms accurately identified 91% of the patients with

somatization disorder.

 

Figure 3. Seven-Symptom Screening Test for Somatization Disorder

 

 

Mnemonic Symptom System
Somatization Shortness of Breath Respiratory
Disorder Dysmenorrhea Female reproductive
Besets Burning in Sex Organ Psychosexual
Ladies Lump in throat (difliculty swallowing) Pseudoneurologic
and Amnesia Pseudoneurologic
Vexes Vomiting Gastrointestinal
Physicians Painful Extremities Skeletal Muscle

 

From Othmer E, DeSouza 0: American Journal of Psychiatry 142:1146-1149

 

Diagnosing and treating chronic somatizing patients is difficult. The key to
diagnosis is recognition and this is the first obvious step. Once diagnosed, extensive
work-ups at the initial phase of diagnosis are almost always needed to exclude
organic diseases (Barsky, 1989; Smith, 1991; Smith, et a], 1990).

Although somatizing patients are difficult to manage, there is consensus about the
approach health care providers should take (Bass and Benjamin, 1993). Patients
with chronic somatization require a unique treatment plan. Treatment
recommendations suggested by Smith, Monson, and Ray (1986) included regularly
scheduled appointments (e.g., every four to six weeks); a focused physical exam
performed at each visit to look for true disease; advise to avoid hospitalization,
diagnostic procedures, surgery, and the use of laboratory assessments, unless clearly
indicated; and to avoid telling patients "it's all in your head." This intervention was
reported to reduce quarterly health care charges by 53%, largely as a result of
decreases in hospitalization. Neither the health of the patient nor their satisfaction

with care was compromised.

36

Smith (1999) in an unpublished and on-going study proposes a four-point
treatment intervention that establishes contact with the health provider on a regular
basis even if the patient is asymptomatic. The four points describe a cognitive-
behavioral approach conducted in the context of a positive primary care provider-
patient relationship that involves goal setting, achieving patient understanding, a
commitment to treatment, and negotiating a specific treatment plan.

However, treatment will not be initiated unless these patients are identified
Thus, the purpose of this project was to develop a clinical protocol to identify
chronic somatizers. A comprehensive assessment is suggested for use in the primary
care setting to expedite recognition and treatment and to avoid expensive diagnostic
testing in the care of these patients. If primary care providers have a protocol to
identify chronic somatizers, they can begin appropriate interventions to reduce high
utilization, costs, and frequent attendance, in addition to, improving patient-provider

satisfaction.

37

PROJECT DEVELOPMENT

Given the magnitude of this problem, efforts to recognize and diagnose the
somatizer merits scrutiny. One approach to understanding the origin of somatic
complaints has been to identify cognitive styles and other factors in these patients‘
histories that distinguish them from the general population or from patients who
complain of similiar symptoms but with clear organic basis. An assessment protocol
is needed to enhance recognition of somatizers. Therefore, a comprehensive,
multistage and multidimensional assessment protocol (Appendix B) is proposed for
identifying chronic somatizing patients in the primary care setting.

This assessment process is based on identifiable risk factors for somatization
present in the literature. An efficient approach for identifying samples of severe
somatizers will begin with identifying frequent attenders, followed by a screening
procedure for mental disorders, and a final evaluation of selected identifying
measures for the somatic population through self-administered questionnaires, a
structured patient-provider interview, and a chart audit. Upon completion of this
four-step assessment intervention, a definitive diagnosis of somatization could be
made based on a positive PHQ screening result for somatization and the presence of
any of the following measures: psychiatric diagnosis for anxiety or mood disorders,
excessive number of clinic visits in the preceding 12 months, use of multiple
providers and health care facilities, numerous diagnostic tests and procedures that
yield no organic disease, exorbitant cost of care, difficult patient-provider
relationship, functional disability or role dysfirnction, and lack of social support An
evaluation of these measures will support and validate a positive screen for
somatization disorder on the PHQ.

In addition to the conceptual definitions, the following are important terms

related to identifying and distinguishing characteristics of chronic somatizers.

38

Somatoform symptom. A physical symptom that lacks an adequate physiological
explanation.

Multisomatoform disorder. Current history of 3 somatoform symptoms, fiom the
PHQ list of 13 physical symptoms, for 2 or more years.

Psychiatric health status. Psychiatric health status or comorbidity will be
determined by the subscales of the PHQ that measures anxiety, depression, panic
disorder, eating disorder and alcohol abuse. Patients will be categorized as (a) well,
(b) subthreshold psychiatric disorder, and (c) potential psychiatric disorder.

Cognitive Styles of Somatizers. Cognitive styles of somatizers are derived fi'om
the HRMTP and defined as hypnotic ability, catastrophizing, and negative affectivity
or neuroticism. These terms were operationalized using the revised version of the
CABAH questionnaire.

Reason for the visit. Reason for the visit will be determined by the patient based
on their belief of the origin of the presenting complaint or meaning of the symptom
for that day. The response options include (a) emotional, (b) physical, or (c) stress-
related

Self-reported chronic diseases. Chronic diseases will be defined, for this project,
as any of the following seven chronic medical conditions: hypertension, diabetes,
arthritis, heart disease, bronchitis or emphysema, stomach disorder, and cancer. A
single item question will address the presence of chronic diseases. In addition, a
stem question will be asked to determine the presence of any other serious physical
diseases.

Self—reported overall health status. Health status will be defined as an overall
sense of wellbeing and the extent to which the symptoms they experience disrupt
their ability to function or interfere in some significant fashion with their life

activities (Mechanic, 1982). Self-reported overall health will be defined by a single

39

item question and responded to as (a) excellent, (b) very good, (c) good, (d) fair, or
(6)130“-

Role Dysfunction. Role dysfunction will be assessed with a brief three part social
disability assessment that will determine the risk of the somatizing patient to have
occupational role dysfunction, days of functional impairment at home, and
relationship problems. Impaired occupational role functioning will be answered as
(a) none, (b) mild, (c) moderate, and (d) severe. Number of disability days will be
dichotomized as none versus one or more. Difficulting maintaining satisfying
relationships is responded to as (a) not difficult at all, (h) somewhat difficult, (c)
very difficult, or (d) extremely difficult. Disability may also be measured using the
final question on the PHQ which addresses problems related to ability to perform
role fimctions.

Patient satisfaction. Patient satisfaction will be determined by a single-item
question with response choices ranging from very satisfied to not satisfied

Provider satisfaction. Provider satisfaction with the encounter for that day will
be determined by the Difficult Doctor-Patient Relationship Questionnaire-Ten Item
Version (DDPRQ-lO) (Hahn, Kroenke, Spitzer, Brody, Williams, et al., 1996)

Provider-rated physical health status. Provider-rated physical health status will
be defined by a single-item question and responded to as either as (a) completely
healthy, (b) some symptoms but not ill (subclinical), (c) mildly ill, (d) moderately ill,
and (e) severely ill.

PRIME-MD Patient Health Questionnaire (PHQ) (Spitzer, Williams, & Kroenke,
1994) The PRIME-MD (an acronym for the Primary Care Evaluation of Mental
Disorders) is an instrument developed by Drs. R. Spitzer and J. Williams for the
diagnosis and management of mental disorders in the primary care setting. It
evaluates five groups of mental disorders most commonly encountered in the

primary care settings and the general population. The PHQ (Appendix C) is the new

40

self-report version of the PRIME-MD (R.L. Spitzer, MD, personal communication,
March 12, 1999) and is estimated to take approximately three minutes to complete.
It is designed to facilitate prompt recognition and diagnosis of the most common
mental disorders in primary care patients (mood, anxiety, somatoform, and alcohol)
and eating disorders, which has been shown to be common in the general population.
The portion of the PHQ that identifies somatoform disorder identifies eleven
symptoms or symptom clusters most commonly experienced in the last 4 weeks.
Responses for each item include: not bothered at all, bothered a little, bothered alot
Somatoforrn disorder is diagnosed if at least 3 of the symptoms or symptom clusters
are answered as "bothered a lot" and lack a biological explanation (Spitzer,
Williams, Kroenke, 1994).

The PHQ was chosen for its ability to screen for somatizers. The PHQ has the
advantage over the original PRIME—MD in that it can be completed entirely by the
patient. If the patient, for any reason, cannot read or complete the questionnaire, it
can be administered as an interview by the APN or some other personnel. If the
PHQ is completed by the patient, the health provider need only to scan the
questionnaire and confirm positive responses with the patient. Thus, instead of
taking 5-8 minutes of provider time for the average pateint as was the case with the
original PRIME-MD the provider time with the PHQ is generally less than a minute,
allowing for more time to be spent discussing management and treatment options.
Like the original PRIME-MD, the PHQ contains skip-outs so that if the initial
criteria for a disorder are not met, the patient is directed to skip to questions about
the next disorder that is evaluated The formal DSM-IV diagnostic evaluations of
the PRIME-MD are simplified in the PHQ. The PHQ diagnoses are considered
"subthreshold" because the criteria encompass fewer symptoms than are required for
any specific DSM-IV diagnosis. These subthreshold diagnoses are important
because psychiatric symptoms below diagnostic threshold in these areas are

41

associated with significant functional impairment and because patients with these
disorders benefit fi'om monitoring and treatment early in the disease process. The
PHQ identifies chronic somatizers who are below the diagnostic threshold of
somatization disorder as defined by DSM-IV. The PHQ also screens for common
disorders associated with somatoform disorders, such as, depression, anxiety,
alcohol abuse, and eating problems. The validity and scoring procedure for the PHQ
is available for review in Appendix C.

Cognitions About Body and Health Questionnaire (CABAH) (Rief, Hiller, &
Margraf, 1998) (Appendix D). A modified version of the original CABAH is being
used for this project to determine cognitive styles of chronic somatizers. This
particular questionnaire has been used at the Roseneck Center for Behavioral
Medicine, a German inpatient treatment unit that specializes in a high-risk group for
somatization syndromes. The original version consisted of 68 items that were
answered on a 4-point scale as follows: 3 (completely right), 2 (mostly right), 1
(mostly wrong), and 0 (completely wrong). High internal consistency of all items
(.90) was confirmed across many studies (Reif, Hiller, & Margraf, 1998). The
selected items concern interpretation of body signals, perception of minor body
events, attitudes about body and health, and health habits (Reif, Hiller, & Margraf,
1998). The principle aim of this tool selection was to find possible cognitive
features for somatizing patients as defined by the conceptual model chosen for this
project, the High Risk Model of Threat Perception (HRMTP). Item selection
depended on whether there were parallels of cognitive styles (hypnotic ability,
catastrophizing, and negative affectivity) as defined on the HRMTP. The naming of
factors have been reinterpreted as corresponding to the HRMTP. Factor 1
(catastrophizing) describes the tendency to interpret body signals in a catastrophizing
manner. Factor 2 (hypnotic ability) included minor bodily sensations of the

autonomic nervous system that are typically not perceived but which are perceived

42

by those who focus their attention on them. Factor 3 (negative affectivity) included
a negative self-concept of being weak, feeling exhausted, or not tolerating any stress.
Factor 4 (negative affectivity) is rated high for those who do not tolerate bodily
complaints, aches, and pains. Factor 5 (coping skills) describes typical habits of
people who want to live healthy. It was determined that the dimensions of the
CABAH reflect specific cognitive concerns of patients with somatization as defined
by the HRMTP.

General Wellbeing Survey (Appendix E). This survey will be completed by the
patient to assess functional abilities, patient's perception of the cause for the current
symptoms, overall health status, satisfaction with care, social support, presence of
medical conditions, and utilization of other health care services in the past year.

The Diflicult Doctor-Patient Relationship Questionnaire- Ten Item Version
(DDPRQ-IO) (Hahn, Kroenke, Spitzer, Brody, Williams, et al., 1996) (Appendix F).
This questionnaire will be utilized to assess the relationship between the provider
and patient. It consists of 10 liken-type questions with a 6-point response scale with
0 meaning ‘not at all' to 5 meaning 'always'. It requires less than one minute to
complete. An additional question assesses the provider’s evaluation of the patient's
overall health and is not formally a part of the DDPRQ-lO. Briefly, the DDPRQ-IO
has an validity of .96 with the original instrument, and an internal consistency
reliability of .88 in the current study of 627 participants (Hahn, Kroenke, Spitzer,
Brody, Williams, et al., 1996). The original instrument (DDPRQ-30) had an internal
consistency reliability of 9.6, factor analysis demonstrated five factors with high
face-validity, and construct validity was demonstrated by strong associations with
psychopathology, personality pathology, and somatization (Hahn, Kroenke, Spitzer,
Brody, Williams, et al., 1996).

43

E l . E I l . :1. . l E 1
Initially, the institutional review board should be introduced to the project. The

implications that this project has for cost savings, patient care, and patient and
provider satisfaction needs to be emphasized, as discussed in the literature. A brief
inservice for all staff is conducted to enlist their support and c00peration for this
project. Questions need to be addressed thoroughly before the project begins.

A health care assistant generates a list of frequent attenders based on patient
records from a primary care clinic during the months of January, February, and
March. Somatization has been found to be very prevalent among those who
frequently attend primary care (Katon, et al., 1984). The target population (Figure 4)
includes patients between the ages of 18 years and 55 years. Charts need to be
flagged as a signal to initiate the assessment protocol for identifying somatization

during the patient's next clinic visit.

 

Figure 4. Target Population for Somatization Screening: X=target population

 

+ screening on PHQ?

 

 

Y N
Frequent Y X
Primary Care
Attender N

 

 

 

 

Next, patients are given three brief questionnaires by the exam room nurse.
These can be completed in the privacy of the exam room prior to the patient's office
visit. The first questionnaire to be completed is the PHQ. If the patient screens

positive for somatization on the PHQ, an evaluation of their cognitive style will be

44

 

done with a second questionnaire. This questionnaire is called the Cognitions about
80052 and Health Questionnaire and can be completed in two to three minutes.

The third questionnaire, the General Wellbeing Survey can then be completed by the
patient and is estimated to take approximately one minute. Age, gender, education,
and employment are also verified on this form.

Once these three questionnaires are completed by the patient, a structured patient-
provider interview is conducted to validate findings on the PHQ, CABAH, and
General Wellbeing Survey. After having met the patient during this interview
process and identifying that a relationship with the patient had been initiated during
previous encormters, the provider completes the DDPRQ. Following this step, a full
review of the charts of patient's clinic visits can substantiate the above data as well
as identify somatizers from nonsomatizers or those with organic disease. Also of
interest is the cost impact of somatic patients. Therefore, this chart review can
determine costs of care among somatizers for clinic visits, laboratory tests,
consultations, emergency visits, and hospitalizations.

The information from this project could be analyzed using descriptive charts and
tables. The following data on the frequent attenders could be compiled: prevalence
of chronic somatizers in a primary care setting; association of somatization with age,
gender, and education in a primary care setting; association of somatization with
health ratings in a primary care setting; association of somatization with role
dysfunction in a primary care setting; association of somatization with anxiety and
depression in a primary care setting; percentage of catastrophizing scores in a
chronic somatizing group; percentage of high neuroticism (NA) in a chronic
somatizing group; and the association between mental disorders and the likelihood
of being experienced as difficult.

45

Discussion

Medically unexplained symptoms are a common problem in primary care, and
undoubtedly worthy of ftnther research. When compared with scores on the self-
report questionnaire (PHQ) for somatization, recognizing this type of problem in the
primary care setting will probably be unlikely as evidenced by lack of
documentation that indicates a probable or definitive diagnosis of somatization prior
to administration of the PHQ. It is presumed that primary care providers may be
more likely to recognize patients with anxiety and depression than somatization
disorder and differentiating patients with anxiety and mood disorders fi'om those
with multiple physical symptoms may be difficult.

Further analysis may indicate that patients who met the criteria for somatization
using the PHQ survey had an increased risk of one or more chronic physical diseases
than those who did not. These patients may be significantly more likely to rate their
own health as poor. Among these same patients, physical health status as
determined by the provider may be rated as good

It is presmned that difficult patients may be much more likely than non-difficult
patients to have mental disorders, more functional impairment, higher health care
utilization, and lower satisfaction with care, whereas demographic characteristics
and chronic diseases will not be associated with difficulty. Among the mental
disorders, particularly strong associations with difficulty would be multisomatoform
disorder and alcohol abuse or dependence. Furthermore, the presence of mental
disorders may accormt for a substantial proportion of the excess functional
impairment and dissatisfaction in difficult patients. Finally, provider characteristics
may have an effect on the likelihood of a patient being experienced as difficult.
These include provider familiarity with the patient, gender, age, years of training,
type of training, and interest in psychiatric diagnoses.

46

The Cognitions about Body and Health Questionnaire will identify various types
of cognitions that appear to be broadly characteristic of somatizers. There are also
cognitive features that distinguish hypochondriasis from somatization groups. This
is particularily true for the cognitive variable, Intolerance of Bodily Complaints.

This item has high relevance for hypochondriasis. A most striking and significant
cognitive aspect of patients with somatization is a self-concept of being weak, of not
being able to tolerate physical effort, and of not being able to imagine that physical
exercise could be useful. Therefore, this cognitive style may help to explain a
patient's inactivity or measure of disability.

The literature clearly relates that somatization burdens the health care system.
There is less discussion in the literature concerning the serious burden this disorder
may have on the patients themselves. The main purpose of the General Wellbeing
Survey is to assess social role functions and the potential limitations the process of
somatization may have on patients. Another outcome measure is the SF-36 Health
Survey, a well validated instrument for assessing physical and mental components of
health. SF-36 includes one multi-item scale measuring eight health concepts: 1)
physical functioning; 2) role limitations because of physical health problems; 3)
bodily pain; 4) social functioning; 5) general mental health (psychological distress
and psychological well-being); 6) role limitations because of emotional problems; 7)
vitality; and 8) general health perceptions (Ware and Sherbourne, 1992).

The High Risk Model of Threat Perception is an appropriate theoretical
framework for the chronic somatizer because it clearly detects the cognitive styles of
chronic somatizers in primary care. As predicted by this model, there should be high
negative affectivity, high or low hypnotizability, and high catastrophizing scores
occuring among chronic somatizers.

It is possible that respondents may feel burdened by three questionnaires,

however, the time it takes to complete each questionnaire is under three minutes.

47

Patients may readily comply when informed of the benefits related to accurate
diagnosis and apppropriate treatment.

Clearly, prompt recognition of somatization disorder and its subsyndromal
divisions is needed. The primary project goal is to create an assessment protocol for

APN‘s to screen for chronic somatizers in the primary care setting.

48

IMPLICATIONS FOR RESEARCH, EDUCATION, AND PRACTICE

Research

Research implications for this project are numerous. The following research
questions could be asked: Is somatization associated with the cognitive style of
catastrophizing? Can differences in somatization between patients with anxiety or
depressed mood and controls (if any) be attributed to differences in catastrophizing?
What cognitive styles (hypnotizability, catastrophizing, and neuroticism or negative
affectivity) are present among chronic somatizers in primary care? Is somatization
less prevalent among those with adequate social support and c0ping skills? Is
somatization correlated with anxiety and depression among the subsets of the PHQ?
What proportion of chronic somatizers are experienced by their physicians as
"difficult" and is there an association between difficulty and physical and mental
disorders, ftmctional impairment, health care utilization, and patient satisfaction
with care?

This project suggests that it should be feasible to utilize simple screening
procedures for use in primary care, which could eventually be valuable for further
research on treatment approaches and outcome studies. The diagnosis for
somatization disorder could be categorized based on severity. A subdivision of these
patients into those with and without physical disease, anxiety, and depression may
help in exploring the hypothesis that somatization disorder varies between
individuals, and that management can be enhanced by attention to mood disorders
and health beliefs as well as physical disease and functional limitations.

49

Education

One main concern of this project is that health care providers are responsible for
managing the spectrum of psychological and psychiatric problems without the
necessary skills. Health care providers need more comprehensive, longitudinal
training in psychosocial aspects of practice. In addition, educational programs in
communication skills can make a difference in caring for difficult patients.
Continuing educational programs have an important role in maintaining and
improving standards. One of the most important reasons for the deficiencies in
recognition of somatization is inadequate training. Higher education institutions
should mandate psychosocial training and also require assessment programs that can
assure minimal competence.
Practice

This assessment protocol to identify potential somatizers has important
implications for APN‘s in practice. The literature gives evidence that primary care
providers are ineffective in recognizing and facilitating treatment of psychosocial
distress. Thus, providers often fail to recognize subsyndromal, yet clincially
significant, somatoform disorders and distress. They may be reluctant to address
psychosocial factors in their patients presentation, and when they do, treatment is
often not timely or appropriate. Furthermore, somatic presentations hamper the
recognition of psychiatric disorders in primary care. The psychological and social
aspects of every patients' illness needs to be evaluated and should influence the total
medical management to promote the patient as a psychobiological person. A holistic
approach is needed in the evaluation and care of somatizers and APN's are trained to
use a biopsychosocial approach to the delivery of health care.

As a clinician caring for chronic somatizers, a standard thorough history and
physical examination should include personal and family psychiatric history,

psychosocial history, medical history, current medications, and results of recent

50

laboratory and diagnostic tests. Even when dealing with functional somatic
complaints, APN's must always ask what organic disease could account for the
symptoms because such symptoms can occur in the context of serious medical
disease. A thorough chart review is important.

The provider-patient relationship cannot be overemphasized As counselor,
APN‘s must provide a trusting relationship to communicate emotional problems.
This will allow for identification of psychiatric problems, and as collaborator, the
need for psychiatric referrals may be more readily discussed Therapeutic progress
is dependent on a patient's basic trust in the provider and the belief that the provider
is capable of helping them.

As patient educator, it is important to convey to patients that stresses can be a
source of their physical symptoms. The stress caused by these conflicts is
transformed or translated into physical symptoms that are easier to acknowledge
than the psychological issues. Many people experience physical illnesses that are
worsened by stress and emotional conflict, but somatizers have a less common
problem. Their physical problems are almost always psychological in origin.
Without challenging a patient's belief that they are having medical problems,
patients can be encouraged to begin talking about their issues.

A clinical tool that identifies the psychosocial attributes of somatizers may assist
APN‘s in prevention-oriented interventions. Knowledge and identification of risk
factors will facilitate prompt recognition of potential somatizers and a greater
understanding of the patients' clinical problems. The strength of this assessment
process is that it focuses on the form of the complaint (eg, medically tmexplained),
and not just the content (eg., abdominal pain). Thus, it is expected that in the
absence of recognition and hence treatment, complaints of somatization, anxiety,
and depression will remain fairly stable overtime. Once treatment begins,

significant decreases in distress will be maintained, with levels of somatization,

51

anxiety, depression, and physical symptoms remaining lower than before the
assessment and intervention.

Sociocultural factors have an effect on how a patient communicates their
symptoms to the provider. The manner in which a patient complains influences the
diagnosis. The provider may block or reject the patients specific complaints.
Patients tend to report only what they believe providers expect, i.e., primarily
physical complaints. Psychosocial distress is rarely conveyed to providers. This
skewed communication is one source of diagnostic error and mismanagement. As
client advocates and counselors, APN‘s can show patients how to become active
participmts in managing their physical well-being by acknowledging mind-body
interactions and by encouraging discussion of life stressors.

The link between somatization disorder and childhood abuse may be a
parodoxical pattern of hiding feelings and distrusting caregivers, while also seeking
acknowledgemnt for suffering. As assessors, APN's need to explore these patient
experiences with sensitivity when assessing and treating patients with somatization
disorder and a history of childhood abuse. Furthermore, APN‘s need to recognize
that patients who suffer childhood abuse, Mculary sexual abuse, may carry the
emotional scars into adulthood and mask them with somatic symptoms. The
somatic symptoms are a "ticket of admission" to the health care provider. This care-
elicitng behavior of somatizers may be an unconscious or tmintentional attempt to
correct the deficiency in social support. Many patients really desire genuine interest
and empathy from the provider, not relief of physical symptoms. This may lead to
improved understanding and management by APN‘s. Of further significance,
somatization can be a marker for unrecognized abuse. Many somatizers describe
additional violence during adulthood. As APN‘s, it may be important to consider

ongoing abuse.

52

A major shortcoming of this problem is that the only way we can currently
measure childhood abuse in our adult patients is retrospectively. Patients may
exhibit symptoms related to previous abuse and may be misdiagnosed due to lack of
knowledge of the abuse history. As assessors, APN‘s can play an integral part in
preventing the emotional scars of childhood abuse by routinely inquiring about
childhood abuse and by identifying the familial factors that predisposes one to
abuse, and subsequently, somatic symptoms. As educators, APN‘s can teach young
patients and families about childhood abuse. Although most agree on the
importance of assessment, most providers do not assess for a history of childhood
abuse. As planner, knowing the abuse history of a patient, APN‘s can gain greater
understanding of the patients clinical problems and facilitate appropriate planning of
care. Providers that do not routinely assess psychosocial factors may not be meeting
the patients' needs. The irnplications of actively asking if our patients have
experienced significant childhood trauma is evident.

As coordinator, patients with somatization disorder do best under the care of a
single provider. If specialists are involved, APN‘s should coordinate all aspects of
the patient's care. The managed care environment that encourages primary care
providers to act as gatekeepers for specialist care is a beneficial arrangement in this
regard

The information presented here suggests that APN's come into contact with a
sizable population of patients with mental health problems in the primary care
setting. It appears that the utility of DSM-IV somatization disorder in the primary
care setting is limited. It represents the extreme end of the somatization spectrum
and so is useful only in settings where the most severely impaired of somatizing
patients can be found.

The PHQ is a cost—effective, simple-to—take, easy-to-score measure of

psychological disorders that can assist APN‘s in the assessment, diagnosis, refenals,

53

and treatment for mental health problems in the primary care setting. There has
been rapid proliferation of instruments to assess somatization disorder over the past
decade. This project concentrates on utilizing existing instruments to identify
patients somatizing in primary care. Systematic efforts to utilize existing tools will
enhance the APN‘s understanding of somatization and allow APN's to compare the
predictors of somatization across different studies and to compare the effectiveness
of both assessment and treatment interventions. This project is a step to move APN‘s
in the direction of combining their role as clinician and researcher. Furthermore, to
the extent that measurement tools are not utilized, so too is our understanding of
somatization disorder and our ability to improve the lives of people who experience

it.

54

CONCLUSIONS

Somatizing patients are characterized by abnormal illness behavior (eg, failure to
respond to treatment, excessive utilization of care) and psychological distress (eg,
depressive symptoms, anxiety, psychosocial stressors). Recognition requires
alertness to characteristic features and skillful assessment techniques. Successful
management begins by legitimizing symptoms. Restraint should be used in
performing workups and assigning diagnoses to somatizing patients. Treatment
goals should be clarified and regular visits scheduled. Also, behaviors that threaten
the provider-patient relationship should be dealt with. Depression and anxiety
should be treated when present. Caring for rather than curing somatizing patients is
the goal of therapy. Provider expectations focus on management of symptoms and
improvement in function rather than resolving physical problems.

In drawing together assessment strategies for somatization disorder, this project
provides a valuable and creative stimulus for primary care APN‘s to study, prevent,
and predict the prevalence of somatization. By using standardized tools, such as the
PHQ and CABAH, this project provides a unique and comprehensive protocol that
will guide APN‘s in identifying chronic somatizers in primary care. It is critical that
APN's identify and utilize a sensitive approach to measurement when assessing

chronic somatizers in the primary care setting.

55

Appendices

56

Appendix A

57

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Appendix B

59

lll' : E If :1 .5 .

Stage I. Computerized Audit to Identify Frequent Attenders

Stage H. Administration of Screening Tools
a) Patient Health Questionnaire (PHQ)
b) Cognitions About Body and Health Questionnaire (CABAH)

c) General Wellbeing Survey

Stage III. Structured Patient-Provider Interview
"' Includes Completion of Difficult Doctor-Patient Relationship

Questionnaire (DDPRQ-10) and Provider-Rated Physical Health Status
Question

Stage IV. Chart Review for Use of Medical Services and Cost of Care Analysis

Frequent attenders

l

PHQ

Positive screen for somatization

Negative screen for somatization

CABAH
General Wellbeing Survey

Provider-------- Structured patient-provider interview

I

DDPRQ Initiate treatment plan

Chart review

60

Appendix C

61

 

 

i i Patient.Health?Q'Lieéti‘dflhaire7

 

 

This questionnaire is an important part of providing you with the best health care possible. Your
answers will help in understanding problems that you may have. Please answer every question to the
best of your ability unless you are requested to skip over a question.

 

 

 

TODAY'S DATE NAME AGE__ sex: [I Female [3 Male
Not
1. During the last 4 weeks, how much have you been bothered bothered Bothered Bothered
by any of the following problems? at all a little a lot
a Stomach pain ....................................................... . D D D
b Back pain ............................................................. D D D
c. Pain in your arms, legs, orjoints (knees, hips, etc)... D D D
d Menstrual cramps or other problems with your
periods D D D
e. Pain or problems during sexual intercourse......... D D D
f. Headaches ............................................................ D D D
9. Chest pain ............................................................. D D D
h. Dizziness ............................................................. . D D D
i. Fainting spells ....................................................... D D D
j. Feeling your heart pound or race ........................... D D D
k. Shortness of breath .............................................. D D D
I. Constipation, loose bowels, or diarrhea .................. D D D
m. Nausea, gas, or indigestion ................................... D D D
2. Over the last 2 weeks, how often have you been bothered by More Nearly
any of the following problems? Several than ha” every

Not at all days the days day

a. Little interest or pleasure in doing things ...................... D D D D
b. Feeling down, depressed, or hopeless..................... .. D D D D
0. Trouble falling or staying asleep, or sleeping too

much ......................................................................... D D D D
(1. Feeling tired or having little energy ............................. D D D D
e. Poor appetite or overeating ........................................ D D D D
f. Feeling bad about yourself — or that you are a failure or

have let yourself or yourfamily down D D D D
9. Trouble concentrating on things, such as reading the

newspaper orwatching television............................. D D D D
h. Moving or speaking so slowly that other people could

have noticed? Or the opposite — being so fidgety or

restless that you have been moving around a lot more

than usual ............................................................. [j E) D E]
i. Thoughts that you would be better off dead or of hurting

yourself in some way D D D D

 

FOR OFFICE CODING: Som Dis if at least 3 of #1a-m are "a lot“ and lack an adequate biol explanation.
Maj Dep Syn if #2a or b and 5 or more of #Za-i are at least “more than half the days" (count #2i if present at all) .
Other Dep Syn if #2a or b ant 7. 3, or 4 of #2a-l are at least 'more than half the days” (count #2i if present at all) 1

3. Questions about anxiety.

 

 

a. In the last 4 weeks, have you had an anxiety attack— NO YES
suddenly feeling fear or panic? D D
[ If you checked “NO", go to question #5. I
b. Has this ever happened before?........................... D D

c. Do some of these attacks come suddenlv out of the blue —
that is, in situations where you don’t expect to be nervous or

 

 

uncomfortable7........................... D D
d. Do these attacks bother you a lot or are you worried about
having another attack? D D
4. Think about your last bad anxiety attack. NO YES
a. Were you short of breath? D D
b. Did your heart race, pound, or skip? D D
0. Did you have chest pain or pressure?............... D D
(1. Did you sweat? D D
e. Did you feel as if you were choking?............................. D D
f. Did you have hot flashes or chills? D D
Q. Did you have nausea or an upset stomach, or the feeling
that you were going to have diarrhea?........................... D D
h. Did you feel dizzy, unsteady, orfaint?................ D D
i. Did you have tingling or numbness in parts of your body?... D D
j. Did you tremble or shake? D D
k. Were you afraid you were dying? D D
More than
5. Over the last 4 weeks, how often have you been bothered by Several half the
any of the following problems? Not at all days days
a. Feeling nervous, anxious, on edge, or worrying a lot
about different things D D D
[ If you checked “Not at all”, go to question #6. I
b. Feeling restless so that it is hard to sit still... D [:1 D
0. Getting tired very easrly D D D
d. Muscle tension, aches. or soreness........................ D D D
e. Trouble falling asleep or staying asleep................... D D D
f. Trouble concentrating on things, such as reading a
book orwatching TV D D D
g. Becoming easily annoyed or irritable.......... D D D

 

FOR OFFICE CODING: Pan Syn If all of #3a-d are ‘Y' and 4 or more of #4a-k are 'Y'.
Other Anx Syn if #53 and answers to 3 or more of #Sb-g are 'more than half the days‘. 2
‘-—_

6. Questions about eating.

a. Do you often feel that you can ‘t controlw what or how much NO YES
you eat?.. ... . D D

b. Do you ofteri eat, within any m2- hgur period, what most
people would regard as an unusually large amount of

food?... ... . ... .. D D
[If you checked ‘NO’ to either #a or #b, 90 to question #9. ]

0. Has this been as often, on average, as twice a week for the

 

 

last3months? D D
7. In the last 3 months have you often done any of the
following in order to avoid gaining weight? NO YES
a. Made yourselfvomit?.. .. . D D
b. Took more than twice the recommended dose of
laxatives?................................................... D D
c. Fasted — not eaten anything at all for at least 24
hours?” .. D
d. Exercised for more than an hour specifically to
avoid gaining weight after binge eating?... D D
8. If you checked ‘ YES’ to any of these ways of avoiding gaining NO YES
weight, were any as often, on average, as twice a week? ............... D D
NO YES
9. Do you ever drink alcohol (including beer or wine)?... D D
[If you checked “NO" go to question #11. J

 

10. Have any of the following happened to you
more than once in the lgst 6 months? NO YES

a. You drank alcohol even though a doctor suggested that you
stop drinking because of a problem with your health ..........

b. You drank alcohol, were high from alcohol, or hung over
while you were working, going to school, or taking care of
children or other responsibilities..................

c. You missed or were late for work school, or other activities
because you were drinking or hung over”

(I. You had a problem getting along with other people while you
were drinking.

e. You drove a car after having several drinks or after drinking
too much”

C]
C]

DUDE]
DUDE]

11. If you checked off any problems on this questionnaire, how difficult have these problems made
it for you to do your work, take care of things at home, or get along with other people?

 

Not difficult Somewhat Very Extremely
at all difficult difficult difficult
E] El

 

FOR OFFICE CODING: Bul Ner if #63,b, and-c and #8 are all 'Y’; Bln Eat Die the same but #8 either 'N' or left blank.
Alc Abu if any of #10a-e are ‘Y'.
h.

 

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues with an unrestricted educational grant from Pfizer
Inc. For information contact Dr. Spitzer at Unit 60, 1051 Riverside Drive, NY NY 10032 3

Quick Guide to PRIME-MD Patient Health Questionnaire

Purpose. The Patient Health Questionnaire (PHQ) is designed to facilitate the recognition
and diagnosis of the most common mental disorders in primary care patients. For patients with a
depressive disorder, a PHQ Depression Severity Index score can be calculated and repeated
over time to monitor change.

Who Should Take the PHQ. Ideally, the PHQ should be used with all new patients, all
patients who have not completed the questionnaire in the last year, and all patients suspected of
having a mental disorder.

Making a Diagnosis. Since the questionnaire relies on patient self-report, definitive
diagnoses must be verified by the clinician, taking into account how well the patient understood
the questions in the questionnaire, as well as other relevant information from the patient, his or
her family or other sources.

Interpreting the PHQ. To facilitate interpretation of patient responses, all clinically
significant responses are found in the column farthest to the right. (The only exception is for
suicidal ideation when diagnosing a depressive syndrome.) At the bottom of each page,
beginning with “FOR OFFICE CODING", in small type, are criteria for diagnostic judgments for
summarizing the responses on that page. The names of the categories are abbreviated, e.g.,
Major Depressive Syndrome is Maj Dep Syn.

For experience in applying the PHQ diagnostic criteria for mood, anxiety, eating, alcohol
and somatoform disorders, see the Patient Health Questionnaire (PHQ) Case Simulations, ten
hypothetical cases with PHQ responses.

 

 

Page 1

Somatoform Disorder if at least 3 of #1 a-m bother the patient “a lot" and lack an adequate biological
explanation.

Major Depressive Syndrome if #2a or band 5 or more of #2a-i are at least “more than half the days" (count
#2i if present at all) .

Other Depressive Syndrome if #2a or b and 2, 3 or 4 of #Za-i are at least “more than half the days" (count
#Zi if present at all).

Note: the diagnoses of Major Depressive Disorder and Other Depressive Disorder requires ruling out

normal bereavement (mild symptoms, duration less than 2 months), a history of a manic episode
(Bipolar Disorder) and a physical disorder, medication or other drug as the biological cause of the
depressive symptoms.

Page 2

Panic Syndrome if #Ba-d are all ‘Yes' and 4 or more of #4a-k are ‘Yes'.
Other Anxiety Syndrome if #5a and answers to 3 or more of #5b—g are “more than half the days".

Note: The diagnoses of Panic Disorder and Other Anxiety Disorder require ruling out a physical disorder,
medication or other drug as the biological cause of the anxiety symptoms.

Page 3

Bulimia Nervosa if #Sah, and c and #8 are ‘Yes'; Binge Eating Disorder the same but #8 is either 'NO' or
left blank.

Alcohol abuse if any of #10a-e are “Yes".

 

Additional Clinical Considerations. After making a provisional diagnosis with the PHQ.
there are additional clinical considerations that may affect decisions about management and
treatment.

Have current symptoms been triggered by psychosocial stressor(s)?

What is the duration of the current disturbance and has the patient received any treatment for it?
To what extent are the patient's symptoms impairing his or her usual work and activities?

Is there a history of similar episodes, and were they treated?

Is there a family history of similar conditions?

 

Validation of the Patient Health Questionnaire (PHQ),
A Selfireport Version of PRIME-MD

Robert L. Spitzer, M.D., Janet B.W. Williams, D.S.W (New York State Psychiatric institute) and Kurt
Kroenke, MD. (Regenstrief Institute for Health Care, Indianapolis, Indiana)

Purpose: PRIME-MD, a two-stage assessment procedure for diagnosing mental disorders in primary
care, was introduced in 1994, and has been widely used in primary care research. However, the main
obstacle to its use in clinical practice is the physician time required to administer the structured interview
guide for patients screened positive on the patient screening questionnaire (X=8.5 minutes). The PHQ
is a three page self-report questionnaire that gathers most of the information obtained by the “classic”
PRIME-MD. The task of the physician is merely to confirm positive questionnaire responses and apply
simple diagnostic algorithms. The purpose of this study was to determine if the self-report PHQ has the
same validity as “classic” PRIME-MD.

Methods: 3000 patients from 4 family practice and 3 lntemai medicine sites completed the PHQ, which
were then reviewed by their physician. On a subset of patients (N=585) a mental health professional did
a blind telephone diagnostic assessment.

Results: The agreement between the mental health professional and the PHQ diagnosis is presented,
as well as the comparable agreement with diagnoses using the classic clinician administered PRIME-
MD (PRIME-MD 1000 study).

Operating Characteristics of the Self-administered (PHQ) Compared to the Clinician-administered (CA)
PRIME-MD using Mental Health Professional's Diagnoses as the Criterion Standard'

PRIME-MD PHQ n=585; PRIME-MD CA n=431

 

 

 

Sensitivity, % Specificity, °/o Overall Accuracy Kappa
Rate, %
PHQ CA PHQ CA PHQ CA PHQ CA
Any PRIME-MD 75 83 90 88 85 86 0.85 0.71
psychiatric diagnosis
Any mood disorder 61 67 94 92 88 84 0.58 0.61
Major depressive 73 57 98 94 93 92 0.54 0.61
disorder
Any anxiety disorder 63 69 97 90 T 91 88 . 0.65 0.55
Panic disorder 81 57 99 99 98 96 0.84 0.60 T
Probable alcohol 62 81 97 98 95 98 0.60 0.71
abuse/dependence
Any eating disorder 89 73 96 99 T 96 98 0.61 0.73

 

 

 

 

' PRIME-MD indicates Primary Care Evaluation of Mental Disorders; PHQ indicates Patient Health
Questionnaire.

T The only differences are higher specificity CA>PHQ for any anxiety disorder (p<.001), specificity
PHQ>CA for any eating disorder (p<.02) and kappa PHQ>CA for panic disorder (p<.05).

Conclusions: Over 90% of patients can complete the PHQ unassisted. The PHQ provides comparable
information to that obtained by a clinician using the PRIME-MD interview. Because the PHQ is less
demanding of physician time, there is a greater likelihood that it will be used by the busy primary care or
ob/gyn physician.

 

 

Appendix D

67

10.

ll.

12.

13.

14.

 

Questions are answered on a 4-point scale as follows:

3=completly right
2=mostly right
1=mostly wrong
0=completely wrong

WWW (14 item)

A suddenly appearing joint pain can be a sign
of a beginning paralysis.

I'm healthy when 1 don't have any bodily sensations.

My doctor and I must be capable of finding an
explanation for all bodily complaints.

When suffering from constipation, one should consult
an expert immediately to be certain that one doesn't
have intestinal cancer.

. The most serious diseases develop unnoticed and then

break out at some time or another.
Bodily complaints are always a sign of disease.
Red blotches on the skin are always a sign of skin cancer.

When sufl‘ering from joint pain, one should always take
good care of oneself.

When one sweats alot, it can be due to an overburdened
heart.

The most common reason for discomfort is a serious illness.

Ifa doctor refers me for further examination, then he is
convinced that there is a serious problem

Only persons who do not exert themselves physically stay
healthy in the long run.

A healthy body doesn‘t cause complaints.

A tingling senation in the legs can be a serious sign
of a nerve disorder.

68

3210

3210

3210

3210

3210

15.

16

17.

18.

19.

20.

21.

22.

23.

24

25.

26.

27.

28.

29.

30.

31.

WW (4 item)

I can sometimes hear my pulse or my heartbeat throbbing
in my ear. 3 2 1 0
. When I take a bath I ofien feel how my heart is beating. 3 2 1 0
I hate to be too hot or too cold. 3 2 1 0
I often feel my heart beating because my circulatory
system is very sensitive. 3 2 1 0
W (6 item)
I can‘t take much physical exertion as my ability to
perform is slowly decreasing. 3 2 l 0
I‘m not as healthy as most of my friends or acquaintances. 3 2 1 0
After physical exertion I often have a feeling of being
weak. 3 2 1 O
I have to avoid physical exertion in order to save my
strength. 3 2 1 0
I'm physically rather weak and sensitive. 3 2 1 0
. My body can tolerate a lot of strain. 3 2 1 0

WW (4 itemS)

Ifsomething is wrong with my bodily sensations,
it upsets me at once. 3 2 1 0

I consult a doctor as soon as possible when I have
bodily complaints. 3 2 l 0

If] don‘t observe my body often, I could become
seriously ill without noticing it. 3 2 1 0

If I have sudden bodily complaints, I first wait
andseewhathappens. 3 210

W (3 itemS)
I‘m always careful to live really healthily. 3 2 l 0
Imakesurethatleathealthily. 3210

HI feel physically weak, I get some fresh
air to recuperate. 3 2 1 0

69

Appendix E

70

WWW

Age __ Gender __ Employed: Yes __ No __ Occupation
Last completed level of formal education (1-12) Years in
college

 

 

M 1' IC l'l'

Do you have any of the following medical conditions?

High Blood pressure __ Diabetes __ Arthritis __ Heart Disease _
Bronchitis or Emphysema __ Stomach Disorder _ Cancer _

Wakes

Did you receive medical or other health care services during the past year other than
at this facility? Yes __ No _ If yes, describe the purpose and type of treatment.

 

 

 

 

 

 

Purpose of treatment Type of treatment

Purpose of treatment Type of treatment

Purpose of treatment Type of treatment
B fl I I , 1:. 'I

Is your visit today for evaluation of an emotional problem, physical problem, or
stress-related problem?

Emotional _ Physical _ Stress-related _
Wm

Overall, how would you say your health is?

Excellent __ Very Good __ Good __ Fair __ Poor

Sl'l'i |° 'IIC

Overall, how satisfied are you with your medical care over the last year?

Very satisfied _ Satisfied _ Fairly satisfied _ Not satisfied __

71

Wm
(continued)

SmiaLSJlnmn
How would you rate the support of family and friends?

Excellent __ Very Good _ Good _ Fair __ Poor __

D I IS 'ID' l'l'l ! |
A. Occupational Role Dysfunction

How much do your symptoms impair your ability to accomplish the usual tasks at
work?

None __ Mild __ Moderate __ Severe __
B. Family Role Dysfunction

How many days per month do your symptoms impair your ability to accomplish the
usual tasks at home?

None __ One or more __
C. Social Role Dysfunction
How difficult is it to maintain satisfying relationships with others?

None _ Mild __ Moderate __ Severe _

72

Appendix F

73

 

Questions are answered on a 6-point likert scale as follows:

5=always
4=most of the time
=sometimes
2=not too often
1=rarely
O=not at all
1. How much are you looking forward to this patient's next
visit after seeing this patient today? 5 4 3 2 1
2. How ”frustrating" do you find this patient? 5 4 3 2 l
3. How manipulative is this patient? 5 4 3 2 l
4. How difficult is it to communicate with this patient? 5 4 3 2 1

5. To what extent are you fiustrated by this patient's
vague complaints? 5 4 3 2 l

6. How self-destructive is this patient? 5 4 3 2 l

7. Do you find yourself secretly hoping that this patient
will not return? 5 4 3 2 l

8. How at ease did you feel when you were with this

patient today? 5 4 3 2 1
9. How time-consuming is caring for this patient? 5 4 3 2 l
10. How enthusiatic do you feel about caring for this patient? 5 4 3 2 l

 

Each item is scored on a five-point scale as noted above.
The DDPRQ-10 score equals the sum of the 10 items.
Items 1. 8, and 10 are scored in reverse direction.
Difficult was based on a DDPRQ score of at least 25.

 

E '1 -B|IEI . IH IIISII
Overall, how would you rate this patient's health?

Completely healthy _ Some symptoms but not ill _
Mildly ill __ Moderatly ill _ Severely ill __

74

LIST OF REFERENCES

American Psychiatric Association (1994). magngstmistafisfigalmm
memmwmm American Psychiatric Association,
Washington D. C.

Barsky, A. & Klerman, G. (1983). Overview: hypochondriasis, bodily complaints
and somatic styles. AmeficanlonmaLostychiahLJAQ. 273-283

Barsky, A. J. & Wyshak, G. (1990). Hypochondriasis and somatosensory
amplification. W404-409

Barsky, A. J. ,Wyshak, G., Latham, K. S. ,& Klerman, G I (1991).
Hypochondriacal patients, their physicians and their medical care. lmnnalgf

GenemllntemalMedrcrneA4l3-4l9

Bass C. & Benjamin, S. (1993) The management of chronic somatization.
WWZ-flo

Beaber, R. & Rodney, W. (1984). Underdiagnosis of hypochondriasis in family
practice. MW 39-46-

Belicki, K. & Belicki, D. (1986). Predisposition for nightmares: A study of
hypnotic ability and absorption. WW 714-781.

Borus, J. ,Howes, M, Devins, N. ,Rosenberg, R., & Livingston, W. (1988).
Primary health care providers recognition and diagnosis of mental disorders 1n their

Patients fienemlflcspimLBsxchiathfl. 317-321

Bridges, K. W. & Golberg, D. P. (1985). Somatic presentation of DSM—III

psychiatric disorders in primary care. qumaloffisychcsomancReseamLZQ. 563-
569.

Clark, D. et al. (1.997) Misinterpretation of body sensations in panic disorder.
lmunalnffinnsulnngandflrmcalfisycholow 2 203-213

Costa, P. & McCrae, R. (1986). Personality, stability, and its implications for
clinical psychology. WM 407-423.

Craig, T.K., Boardman, A.P., Mills, K., Daly-Jones, 0., & Drake, H. (1993). The
South London somatization study, I: longitudinal course and the influence of early

life experiences. Bflfimlmmsxchimlfil. 579-5 88.

75

Craig, T. K., Drake, H., Mills, K. ,& Boardman, A. P. (1994). The South London
somatization study, H: Influence of stressful life events and secondary gain. British

WM 248-258

Crowson, J. Conroy, A. ,& Chester, T. (1991). Hypnotizability as related to
visually induced affective reactivity. Intemafignallgumalmmgal
Hypnomahflimlfl. 3,140-144

Dansak, D. (1973). On the tertiary gain of illness. WW
532-534.

Dantzer, R. (1991). Stress and disease. WWWJL 205-
210.

Devries, N., Berg, R., & Lipkin, M. (1982). W. New
York, NY: Praeger Publishers.

Escobar, J. I. ,,Burnham A. ,,Kamo M. ,Forsythe, A. ,&Golding,J. M. (1987).
Somatization 1n the community. WW 713-718.

Escobar, J..I & Canine, G. (1989). Unexplained physical complaints:

psychOpathology and epidemiological correlates. MW
4, 24-27.

Escobar, J. I. ,Golding, J. M. ,Hough, R. L. ,,Kamo M. ,,Bumham M. A. ,& Wells,
K. B. (1987). Somatization 1n the community: relationship to disability and use of

services. AmencanloumachflnhlicHeahhll. 837-840

Escobar, J. L., Ribio-Stipec, M., Canine, G., & Karno, M. (1989). Somatic
symptom index (881): A new and abridged somatization construct. .[QmmLQf
NemasandMentalflmfll. 140-146-

Eysenck, H. (1983). Psychophysiology and personality. In A. Gale and J. Edward
(Eds.,) Physiclogicalmnelatesoflmmanmhardot London: Academic Press

Farley, M. & Keaney, J. (1997). Physical symptoms, somatization, and
dissociation in women survivors of childhood sexual assault. WM
33-45.

Faulkner, T. ,Fatovich, B. ,& Winkler, R. (1987). Social networks of high

attenders at a low 1ncome area suburban general practice. W
101- 106.

Feldman, M. D. & Ford, C. V. (1994) WWW
worldnflactitiousdisordcrs. New York: Wiley

76

Fink, P. (1992). Physical complaints and symptoms of somatizing patients.
loumalnffisychcscmanckescarchalé. 125-136

Ford, C. & Folks, D. (1985). Conversion disorders: an overview. Bsychgsgmatics,
26, 371-378.

Frankel, F. ,,Apfel R. ,Neimmh, J. ,& Sifneos, P. ,.(1977) The relationship

between hypnotizability and alexithymia. W 172-
178.

Fry, R. ,Crisp, A. ,& Beard, R. (1997). Sociopsychological factors 1n chronic
pelvic pain. WWI 1- 15

Glisky, M. ,Tataryn, D. ,& Tobias, B. (1991). Absorption, openness to

experience and hypnotizability WM
263- 272.

Goldberg, D. P. & Bridges K. (1988). Somatic presentations of psychiatric illness
in Primary care setting leumalcfiBsychchmaucResearchJZ. 137-144

Greenwald, A. (1992). Unconscious cognition reclaimed. Ammcanfisxchnlcgy.
41, 766-779.

Hahn, S. R. ,Kroenke, K. ”Spitzer R. ,Brody, D. ,et a1. (1996). The Difficult
Patient: Prevalence, Psychopathology, amd Functional Impairment. lonmalpf
fienerallntemalMedicineiL 1 8

Hahn, S. R. ,Tho.mpson,K Wills, T., et al. (1994). The difficult doctor patient
relationship. somatization, personality, and psychopathology. .[Qumalgflllinical
Epidemiclcatfl. 647-657

Hall, J ., Milburn, M.A., Roter, D., Daltroy, L.H. (1998). Why are sicker patients
less satisfied with their medical care? Tests of two explanatory models. Health

W 70-75.

Hollender, M. (1972). Conversion Hysteria: a post Freudian reinterpretation of
19th century psychosocial data. Amhiyesntfmnemlfisychimlc. 311-314.

House, J ., Landis, K., & Umberson, D. (1988). Social relationships and health.
Salem 540-545.

Kaplan, C., Lipkin, M. Jr., & Gordon, G. H. (1988). Somatization in primary
care: Patients with unexplained and vexing medical complaints. Lmnnamffieneral
W 177-190-

77

Katon, W. ,Lin, E. ,VonKorff, M. ,et al. (.1991) Somatization: a spectrum of
severity. AmencanlorunalcflisychiamaflhMAO

Katon, W., Ries, R. K. ,& Kleinman, A. (1984). The prevalence of somatization
in primary care. W 203-215

Katon, W. ,Vitalianno, W. ,,Russo J. ,et al. (1987). Panic disorder: Spectrum of
severity and somatization W 12-18

Kellner, R. (1985). Functional somatic symptoms and hypochondriasis. Amhiyes
WM 821-833.

Kihlstrom, J. (1987). The cognitive unconscious. M 1445-1452.

Kinnayer, L. J. & Robbins, J. M. (1996). Patients who somatize in primary care: a

longitudinal study of cognitive and social characteristics. MW
26, 937-951.

Kinnayer, L.J. & Robbins, J .M. (1991). Three forms of somatization in primary
care prevalence, co-occurrence, sociodemographic characteristics. Ionmalgf

NemrundMentalDisordersm 647-655.

Kroenke, K. ,Arrington, M. E ,& Mangelsdorff, A D. (1990). The prevalence of
symptoms in medical outpatients and the adequacy of therapy. Amhryespflntemal
MedrcmeJiO. 1685- 1689

Kroenke, K., Lucas C.A., Rosenberg, M.L., Scherokman, B.J., & Herbers, J .E.,
(1993 ). Psychiatric disorders and functional impairment in patients with persistent
dizziness. WW3. 530-535.

Kroenke, K. & Mangelsdorff, A. D. (1989). Common symptoms in ambulatory

care: incidence, evaluation, therapy, and outcome. AmeficmlgumalgfiMedieine,
86, 262-266

Kroenke, K., Spitzer, R.L., deGruy, F.V., et al. (1997). Multisomatoform
disorder: an alternative to undifferentiated somatoform disorder for the somatizing

patient in primary care. Archivesoffienemlisxchimi 352-358.

Lazarus, R., & Folkrnan, S. (1984). W. New York:
Stringer.

Lin, B, Katon, W., & VonKorff, M (1991). Frustrating patients: physician and

patient perspectives among high users of medical services. JonmathGeneral
IntemalMedicineA 241-246.

78

Lipowski, Z. J. (1988). Somatization. The concept and its clinical application.
AmencanlmimalnffisychianLléi. 1358-1368

Mathew, R. ,Weinman, M. ,& Minabi, M. (1981) Physical symptoms of
depression W293-296

Noyes, R. ,Kathol, R. ,Fisher, M. ,Phillips,B., Suelzer, M., &Holt, C. (1993).

The validity of DSM-IIIR hypochondriasis. MW 96]-
970.

Orrnel, J. ,,Koeter M., VandenBrink, W. & VandeWillige, G. (1.991)
Recognition, management, and course of anxiety and depression 1n general practice.

AmhivesofifieneralfisxchiatryAfi. 700-706

Othmer, E. & DeSouza, C. (1985). A screening test for somatization disorder.
AmeucmlcumalnfflsychMJfiz. 10 1146-1149

Pilowsky, J. ,Smith, Q P. ,& Katsikitis, M. (1987). Illness behavior and general

practice utilization. a prospective study. MW
177-1 83.

Quill, T. (1985). Somatization disorder-one of medicine' 5 blind spots. loumalgf
theAmencanMedicalAschiaticmzfl. 3075-3079

Quill, T. ,Lipkin, M. ,.&Greenland,P (1988). The medicalization of normal

variants, the case of mitral valve prolapse. lonmalflenexallntemflmm
267-276.

Rabkin, J. & Struening, E., (1986). Life events, stress, and illness. M
1013-1020.

Rief, W. & Hiller, W. (1998). Cognitive aspects of hypochondriasis and the
somatization syndrome. loumalnflAbncnnalBsychologicJDl. 4, 587-595.

Robbins, J.M.& Kinnayer, L.J. (1991). Wm
summizamm In: Kirmayer L.J., Robbins, J .M., eds. Current concepts of

somatization: Research and Clinical Perspectives, Washington DC: American
Psychiatric Press; 107-141.

Roche, S. M. & McConkey, M. (1990). Absorption. W
W 91- 101

Rosen, G., Kleinman, A. ,& Katon, W. (1982). Somatization 1n family practice: a
biopsychosocial approach. W493-502.

79

Salmon, P. & Calderbank, S. (1996). The relationship of childhood physical and

sexual abuse to adult illness behavior. MW 329-
336.

Schappert, S. (.1992) National ambulatory medical care survey. W
Stansticm; 210-211

Simon, G. & Gureje, O. (1999). Stability of somatization disorder and
somatization symptoms among primary care patients. Amhiyemffieneml
Esychiamic. 90-94.

Smith, G. R. ,Monson, R. A. ,& Ray, D. C. (1986). Patients with multiple
unexplained symptoms. their characteristics, functional health, and health care

utilization. W69‘72
Speny, R. (1980). Mind-brain interaction. W5. 195-206.

Spitzer, R ,,Williams J., Kroenke, K. et al. (1994). Utility of a new procedure for
diagnosing mental disorders 1n primary care: The PRIME- MD 1000 Study. Journal

enheAmcncanMedrcalAssmranonle. 1749-1756
Stembach, R. (1986). Pain and hassles in the United States. EainJZ, 69-80.

Sullivan, M. & Katon, W. (1993). Somatization: the path between distress and
somatic symptoms. WWW 141-149.

Swartz, M., Landennan, R., George, L., et al. (1991). Wander, In:
Robbins, L., Regier, D., Eds. Psychiatric Disorders in America, New York, NY:
Free Press, 220-257.

Symes, L. (1995). Posttraumatic stress disorder: an evolving concept. Archivesjn
WM 4,195-202

Watson, D. & Clark, L. A. (1984). Negative Affectivity: The Disposition to
Experience Aversive Emotional States. Bsychglggigalfinumfié, 3, 465-490.

Weich, S., Lewis, G. ,,Donmall R. ,& Mann, A. (1995). Somatic presentation of

psychiatric morbidity 1n general practice. BunmlmlmalnffienemMfimfii.
143-147.

Weinberger, M., Hiner, S., & Tierney, W. (1985). In support of hassles as a

measurement of stress in predicting outcomes. loumflnfiBehanmaLMedrcmeJfl.
1,19-31.

80

 

Whitehead, W. ,,Crowell M ,,Heller B. ,Robinson, J., Schuster, M. ,& Horn, S.
(1994). Modeling and reinforcemnt of the sick role during childhood predicts adult

illness behavior. PsychosomangMemgingjfi, 541-.550

Wickramasekera,]. (1995). Somatization: concepts, data, and predictions from
the high risk model of threat perception. WW
DiseaseJfiIi. 1 15- 22

Wickramasekera, I. (1.994) Psychophysiological and clinical implications of the
coincidence of high hypnotic ability and high neuroticism during threat perception in

somatization disorders Amerrcanlcumalcflflhmcalflypnosrsll. 1 22- 29

Wilkie, A. & Wessely, S. (1994) Patients with medically unexplained symptoms.
BritishioumaLofiHospitalMedicineil. 421-427

Zocolillo, M. ,& Cloninger, C. R. (1986). Somatization disorder. psychologic
symptoms, social disability, and diagnosis. Cgmprehensmeflsychjmzlfi-B.

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