KEY POINT:

SOMATIZATION----- A Half of the

patients seen

AN OVERVIEW FOR by neurologists

have psychiatric

NEUROLOGISTS illness, and

roughly two
thirds have
Robert M. McCarron, Jae Han, Julie Motosue-Brennan unexplained
somatic
complaints.

ABSTRACT
Neurologists frequently encounter patients with inexplicable, unintentionally pro-
duced somatic complaints, otherwise known as somatoform disorders. Illness with
excessive somatic preoccupation is difficult to diagnose or categorize reliably due
to rigid diagnostic criteria that often overlap with several psychiatric disorders.
Management of patients with dysfunctional somatoform disorders is complex and
challenging, particularly when initiated in a neurology outpatient or inpatient
setting. The acronym CARE-MD represents a comprehensive treatment regimen
that can be used to decrease physician and patient frustration, dramatically
minimize health care overutilization, and improve overall well-being for patients
with somatoform disorders.

INTRODUCTION ing ‘‘antecedent sorrows’’ for both men

Half of the patients seen by neurolo- and woman should be considered when
gists have comorbid psychiatric illness, treating patients with unexplained so-
most commonly somatoform disor- matic complaints (Sadock and Sadock,
ders (Fink et al, 2003). Patients are 2002). Sigmund Freud used the word
often frustrated with troublesome hysteria to describe a condition he
symptoms that are inexplicable and thought was largely based on uncon-
refractory to multiple treatment regi- scious emotional conflict with a related
mens. Neurologists encounter unex- maladaptive somatic response. This
plained and perplexing complaints in term was commonly used until 1980
up to 60% of their patients (Fink et al, when the Diagnostic and Statistical
2005). Because there is variability with Manual of Mental Disorders, Third 87
how patients present and no apparent Edition changed the diagnosis to
physical cause for their illness, this Briquet’s syndrome, in honor of the
clinical situation has historically been work done in this area by the 19th
difficult to conceptualize, categorize, century French physician Paul Briquet.
and treat effectively. Currently, in neurological settings, the
informal diagnosis of ‘‘somatization’’ is
DIAGNOSTIC CONSIDERATIONS broadly used to describe patients with
Ancient Egyptian healers noticed that physical complaints that cannot be
women were affected with inexplicable totally explained by physical examina-
somatic complaints more often than tion and a corresponding diagnostic
men and concluded that a ‘‘floating workup.
uterus’’ was the culprit. The 17th With a focus on the need to ‘‘ex-
century physician Thomas Sydenham clude occult general medical condi-
believed a multifactorial process includ- tions or substance-induced etiologies

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 " SOMATIZATION

KEY POINTS:
for the bodily symptoms,’’ the Diag- matic symptoms. Some common exam-
A Unlike patients
nostic and Statistical Manual of ples include irritable bowel syndrome,
with
malingering or Mental Disorders, Fourth Edition, chronic fatigue syndrome, and fibro-
factitious Text Revision (DSM-IV-TR) (American myalgia. Because many patients do
disorder, those Psychiatric Association, 2000) includes not meet full diagnostic criteria for so-
with a seven diagnoses under the category of matization disorder, Escobar and col-
somatoform somatoform disorders: somatization leagues (1989) introduced the abridged
disorder do not disorder, undifferentiated somatoform somatization disorder as a less restric-
intentionally disorder, conversion disorder, pain dis- tive alternative. This syndrome is based
complain of order, hypochondriasis, body dysmor- on lifetime symptoms and the pres-
symptoms for phic disorder, and somatoform disorder ence of four somatic complaints in
secondary gain.
not otherwise specified (Table 7-1). males and six in females. Several re-
A Because of rigid It is important to note that the group- ports, including the multi-centered
diagnostic ing of these disorders does not neces- World Health Organization Psychologi-
criteria for sarily imply shared pathogenesis. The cal Problems in General Health Care
many of the somatoform disorders are not fully ex- study, indicate high instability of re-
somatoform plained by a general medical condition call when it comes to lifetime symp-
disorders
or another mental disorder and, in toms (Simon and Gureje, 1999). In this
(including
order to meet diagnostic criteria, must study, 61% of unexplained somatic
somatization
cause significant impairment or dis- symptoms reported at baseline were
disorder), other
classifications tress. Also, unlike a diagnosis of malin- not reported 1 year later. Multisomato-
like abridged gering or factitious disorder, patients form disorder is another diagnostic
somatization with a somatoform disorder do not option for primary care patients with
disorder, intentionally produce their symptoms. somatization that addresses this issue
multisomatoform Alternatives to the DSM-IV-TR no- (Kroenke et al, 1997). Multisomato-
disorder, and menclature have been suggested by form disorder is defined as the pres-
undifferentiated some because of the perceived rigid ence of three or more acutely distress-
somatoform diagnostic criteria, frequent overlap in ful, medically unexplained symptoms
disorder are clinical presentation among the somato- from a checklist of 15 common symp-
used as well.
form disorders, and the resultant toms found in the primary care setting
A Conversion impractical application to clinical prac- (developed from the Primary Care
disorder is the tice. For example, in order to establish Evaluation of Mental Disorders or
most prevalent a DSM-IV-TR diagnosis of somatization PRIME-MD). In order to meet full di-
somatoform disorder, one must have four pain symp- agnostic criteria, patients with multi-
disorder toms, two gastrointestinal symptoms, somatoform disorder must have active
88 encountered by
one sexual symptom, and one pseu- symptoms with at least a 2-year history
neurologists.
doneurological symptom during the of somatization.
course of the illness. This somewhat Conversion disorder, one of the
arbitrary combination of symptoms is somatoform disorders encountered
not usually relevant to commonly en- most frequently by neurologists, is a
countered somatization found in the condition in which patients present
neurological clinical setting. Also, peo- with complaints involving the volun-
ple with a diagnosis of somatization tary motor or sensory nervous system.
disorder must have had multiple so- These symptoms cause significant dis-
matic complaints before the age of tress, are not intentionally feigned,
30 (Case 7-1). and are not found to be secondary to
The wide clinical spectrum of so- general medical or neurological pa-
matization has prompted some medi- thology. Unlike many of the other
cal specialties to develop their own somatoform disorders, patients with
system to identify unexplained so- conversion disorder often have a

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TABLE 7-1 Brief Definitions of Commonly Used Somatoform Disorders

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision

Disorder* Definition

Somatization Many unexplained physical complaints with an onset before age 30.
Four pain, two gastrointestinal, one sexual and one pseudoneurological symptom(s).
Rarely encountered in clinical settings.
Undifferentiated One or more unexplained physical complaints.
somatoform Duration of at least 6 months.

Conversion One or more unexplainable, voluntary motor or sensory neurological symptoms

or deficits.
Directly preceded by a psychological stress.
Relatively good prognosis.
More commonly seen by neurologists.
Pain Pain in one or more sites that is largely due to psychological factors.
Can coexist with other pain disorders.
Hypochondriasis Preoccupation with a nonexistent disease despite a thorough medical workup.
Does not meet criteria for a delusion.
Body dysmorphic Preoccupation with an imagined defect in physical appearance.
Somatoform Somatoform symptoms that do not meet criteria for any specific somatoform
disorder.
Not otherwise specified
Non--Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
Abridged Presence of four unexplained somatic complaints in men and six in women.
somatization Long history of physical complaints.

Multisomatoform Three or more unexplained somatic complaints from the PRIME-MD scale.
Two or more years of active symptoms.

*All disorders shown (1) cause significant social/occupational dysfunction; (2) are not due to other medical, neurological, or
psychiatric conditions; and (3) are not intentionally produced or related to secondary gain.
PRIME-MD = Primary Care Evaluation of Mental Disorders.
89
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition, text revision. Washington DC: American
Psychiatric Association, 2000.
Escobar JI, Rubio-Stipec M, Canino G, et al. Somatic symptom index (SSI): a new abridged somatization construct. Prevalence and epidemiological
correlates in two large community samples. J Nerv Ment Dis 1989;177:140--146.
Kroenke K, Spitzer RL, deGruy FV 3rd, et al. Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing
patient in primary care. Arch Gen Psychiatry 1997;54:352--358.

psychosocial stressor that precedes The differential diagnosis for soma-

and is directly associated with and tization is extensive. It is important to
symbolized by somatic complaints. keep in mind that ‘‘inexplicable’’
Fortunately, the majority of patients illness can refer to a general medical
have at least partial resolution of condition that does not exist after a
symptoms within a few weeks of onset complete assessment or a general
(Case 7-2). medical condition that exists and has

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 " SOMATIZATION

Case 7-1 Somatization Disorder

A 43-year-old woman with a history of being ‘‘sickly since childhood’’
and having diet-controlled prehypertension, presents for neurology
consultation with concerns of transient but troublesome left lower
extremity paresis. In addition, the patient has multiple unexplainable
somatic complaints, including persistent nausea, dyspepsia, diarrhea,
abdominal pain, a ‘‘burning sensation’’ on the left side of the face, frontal
headaches, and bilateral wrist pain. The patient has had difficulty
maintaining a relationship for longer than a few months stating, ‘‘I have
no sexual desire and I will be alone forever.’’ She was last employed
10 years ago and is currently on disability.
Collateral history from the primary care practitioner indicates that the
patient frequently presents to the local emergency department and places
numerous calls to her primary care physician and several specialists. On
examination, despite her multiple complaints, there are no abnormal
objective findings. Specifically, her neurological examination is normal.
She states, ‘‘My left leg gets weaker when my boyfriend starts to criticize me.’’
Comment. The numerous somatic complaints involving multiple organ
systems (at least four pain-related symptoms, two gastrointestinal
complaints, one pseudoneurological finding, and one problem relating to
sexual dysfunction) combined with an onset of illness before age 30 is
suspicious for somatization disorder. Empathy or ‘‘becoming the patient’’
for a brief time is critical to the maintenance of a healthy relationship
between the doctor and the patient. Patients with somatoform disorders
struggle with unhealthy coping strategies and, on a mainly unconscious
level, use somatizing as an unhealthy way to function. It is recommended
that patients with this disorder have one treating physician who orders
minimal diagnostic tests and referrals to specialists once the diagnosis
of somatization disorder is made. Short, frequent visits to the primary
provider (in rare cases this may be a neurologist) should be reserved for
discussion of significant stressors and their relationship to the physical
complaints. With the aid of psychiatric consultation, patients with
somatization disorder can slowly learn new ways to deal with stress,
address dysfunctional thought patterns, and minimize overutilization of
the medical system.

90
not been discovered after a compre- somatization disorder a diagnosis of
hensive workup. Lyme disease is an exclusion.
example of the latter. Before Lyme Before establishing a diagnosis of
disease was discovered in 1982, chil- somatization disorder, one must at-
dren and adults alike were presenting tempt to rule out the intentional
with neurological findings such as production of false physical or psy-
cranial/facial palsy and radiculoneuritis chological symptoms. Patients diag-
with no known precipitant or cause. It nosed with malingering fabricate
is beyond the scope of this chapter to illness in an attempt to gain external
discuss a full differential diagnosis for incentives such as monetary compen-
somatization, but it is important to sation, shelter, or escape from military
stress the need to do a complete duty or criminal prosecution. Factitious
diagnostic workup while considering disorder also involves the purposeful

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 KEY POINT:
A When
Case 7-2 Conversion Disorder---Pseudoseizures considering a
A 22-year-old woman with a history of insomnia, generalized fatigue, and differential
increasingly poor concentration is now seen for the third time in 1 week by diagnosis for
the on-call neurologist in the emergency department with the complaint, medically
‘‘My seizures are getting worse.’’ The patient was recently fired from her unexplained
job and reluctantly reports severe depression without suicidal ideation. illness, it is
When asked to recall what happens during a seizure, she states, ‘‘I feel important to do
confused and try to talk to people around me but just keep shaking.’’ a complete
There is no other medical history and no report of illicit drug or alcohol evaluation and
abuse. consider the
Comment. Given the self-description of her seizures, it is unlikely she has somatoform
a true seizure disorder. This young woman has had a recent stressor disorders,
followed by a nonintentional, voluntary motor abnormality and most malingering,
likely has pseudoseizures, which would be classified as conversion disorder. and factitious
Unfortunately, it is often more challenging to differentiate pseudoseizures disorder as
from actual seizures without the use of electroencephalogram monitoring diagnoses of
during or immediately after the abnormal behavior. Up to 30% of exclusion.
patients with pseudoseizures have concomitant documented epilepsy.
Such a high comorbid prevalence illustrates the importance of completing
a thorough examination during each clinical encounter and working
closely with the consulting psychiatrist.
The treatment of her depression with an antidepressant and cognitive
behavioral therapy (CBT) is imperative. Providing the patient with healthier
coping strategies will also decrease the frequency of pseudoseizures. As a
consulting neurologist, it is best to avoid phrases such as ‘‘there is no
neurological problem’’ or ‘‘your problem is strictly psychiatric.’’ One can help
the patient slowly self-discover the connection between increased stress
and the onset of pseudoseizures by acknowledging that the symptoms
experienced by the patient are ‘‘real’’ but are associated with maladaptive
coping mechanisms (eg, conversion disorder).

and sometimes elaborate self-report order, consider each disorder as a diag-

of somatic complaints with the ob- nosis of exclusion (Cases 7-3 and 7-4).
jective of assuming the ‘‘sick role.’’
Common maneuvers associated with
factitious disorder include dilution of CLINICAL SIGNIFICANCE 91
stool to suggest diarrhea, artificial ele- People with somatoform disorders ex-
vation of body temperature used to perience high levels of physical discom-
suggest fever of unknown origin, and fort and tend to be dissatisfied with life
the intentional production of abnor- (Noyes et al, 1995). A retrospective
mal movements that may mimic sei- review of more than 13,000 psychiatric
zure disorder. People with this disorder consultations found that somatization
have no obvious external secondary disorder resulted in more disability and
gain but consciously seek out medical unemployment than any other psy-
care and attention from health care chiatric diagnosis (Thomassen et al,
practitioners. When treating either 2003). It is difficult to establish accu-
condition one must obtain collateral rately the prevalence of somatization
history (particularly from other area because of wide-ranging definitions
hospitals), complete a focused exami- and the patient’s limited ability to ac-
nation, and, as with somatization dis- curately recall symptoms from the

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 " SOMATIZATION

Case 7-3 Malingering

A 33-year-old man with no past medical history is seen in an urgent care center with the
complaint, ‘‘I cannot feel my face. . .I think I’m having a stroke.’’ He is able to talk on the phone
and eat solid foods without difficulty. He does not give permission to obtain collateral history
from his family or friends. A nurse overhears him on the phone say, ‘‘It’s cold out there, and you
better let me back in the house.’’ When confronted, he admits his wife separated from him
recently and that he is essentially homeless. He also laments, ‘‘My face is paralyzed, and I need to
be hospitalized.’’
A complete neurological examination and imaging of the brain are within normal limits. All
laboratory values, including blood alcohol and toxicology screen, are also normal. The patient’s
response to an expressed plan to discharge and reassurance from the consulting neurologist is,
‘‘You better admit me. . .at least for tonight.’’
Comment. In this case, a thorough diagnostic workup was done, and it is likely the patient is
malingering, with shelter as the external secondary gain. Unlike the somatoform disorders,
patients who malinger intentionally report inaccurate information in order to realize a
predetermined goal. Although it is often challenging, practitioners should try to empathize
with patients who are malingering and focus on a solution to the actual problem. Malingering
should always be a diagnosis of exclusion and made only after a complete history and physical
examination are complete.

distant past. Neurological explanations to 0.7% and is 5 times more common

for common somatic complaints like in females (Escobar et al, 1989). Fink
malaise, sensory deficits, and dizziness and colleagues (2003) questioned 198
are found only 15% to 20% of the time consecutive patients referred for the
(Kroenke and Mangelsdorff, 1989). So- first time to a neurologist and found
matization disorder has an estimated that 61.0% had at least one medically
primary care setting prevalence of 0.2% unexplained symptom and 33.8% met

Case 7-4 Factitious Disorder

A 42-year-old woman with history of dyslipidemia, chronic diarrhea, and chronic pain is admitted
to the neurology service with concerns of not being able to ‘‘feel the left side of my body.’’ Upon
presentation to the emergency department, she is found to walk with a slight limp, and she
states that she cannot feel any part of the left side of her body. Imaging of her head is
92 unremarkable. A full neurological examination is normal except for the subjective sensory
finding. The emergency department resident physician does not suspect the patient is having
a cerebral vascular accident but decides to admit the patient for a brief observation.
Comment. No objective findings explain the complaint of left-sided weakness. Moreover, there
is no indication the patient is seeking some type of external secondary gain. After review of
information from local hospitals, the neurology service discovers the patient has a history of
frequent encounters with similar complaints. This patient is intentionally fabricating symptoms in
an attempt to assume the ‘‘sick role’’ and gain medical attention from various health care
practitioners while admitted.
Patients with factitious disorder are often resistant to psychiatric evaluation and psychotherapy
and have a poor prognosis. The most important part of treatment is to recognize the disorder and
do no harm by initiating unnecessary procedures and consultations. These patients should be fully
assessed for general medical, neurological, and highly comorbid psychiatric disorders. Like all
somatoform disorders and malingering, factitious disorder should always be a diagnosis of
exclusion.

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 KEY POINT:
criteria for one of the somatoform they are often called upon to evaluate
A Patients with
disorders. and treat patients with medically
somatization
Patients with somatization have unexplained symptoms. Two recent have more
more than twice the outpatient utili- studies have shown that up to one than twice
zation and overall medical care costs third of new patients referred to the medical
when compared with nonsomatizing neurologists fulfill criteria for a somato- utilization and
patients (Barsky et al, 2005). This of- form disorder (Carson et al, 2000; Fink overall health
ten translates into increased frustra- et al, 2005). Therefore, it is imperative care costs than
tion and low levels of professional that neurologists be aware of effective nonsomatizing
satisfaction for treating physicians management strategies that can be patients.
(Hartz et al, 2000). Part of the problem utilized in consultations to primary
is likely a lack of psychiatric supervi- care providers as well as in their own
sion and instruction during medical practices.
school, residency training, and there- The management of somatoform dis-
after. Sullivan and colleagues (1996) orders consists of psychosocial mea-
surveyed 348 primary care program sures that all primary care providers
directors and found that two thirds and, in many cases, neurologists can
of them believed more psychiatric provide. The acronym CARE-MD, inte-
education (particularly in the area of grates the art and science of medicine
somatoform disorders) was needed to help health care providers effectively
for trainees. Numerous studies have work with patients who have somato-
shown that up to 70% of neurologists form disorders (Table 7-2).
do not recognize common psychiatric
conditions such as the somatoform Consult Psychiatry/Cognitive
disorders (Bridges and Goldberg, 1984; Behavioral Therapy
Fink et al, 2005). Smith and colleagues Consultation with a psychiatrist is in-
(1986) showed that health care utili- dicated for patients with recurring
zation and cost decreased by more symptoms or progressively worsening
than 50% when physicians effectively overall function. Psychiatric consulta-
treated their patients with unex- tion may also be helpful if diagnostic
plained medical symptoms. Increased or treatment questions arise regarding
training for primary care physicians in comorbid psychiatric conditions, in-
this area will likely result in improved cluding mood, anxiety, and personality
job satisfaction and decreased patient disorders. Some patients may actively re-
morbidity. sist psychiatric consultation. Many pa-
tients see a referral to a psychiatrist as 93
TREATMENT an accusation that they are imagining
The treatment of somatoform disor- or fabricating their symptoms or as the
ders exemplifies the ‘‘art of medicine.’’ first step in the referring physician’s
Because this condition is on a wide- withdrawal of involvement in care. It is
ranging continuum with an unknown advisable to schedule a routine follow-
etiology, it is difficult to apply a strict up visit soon after the consultation.
evidenced-based approach to treat- The use of CBT has been shown to
ment (Allen et al, 2002). Physicians decrease the intensity and frequency of
who are trained to use information somatic preoccupation (Speckens et al,
from the medical history and physical 1995; Warwick et al, 1996). Kroenke
examination to guide treatment are and Swindle (2000) reviewed 31 con-
often confronted with apparent ther- trolled studies and concluded that CBT
apeutic failure. Neurologists are fre- is an effective treatment for patients
quently put in this situation because with somatization-type disorders. Group

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 " SOMATIZATION

TABLE 7-2 CARE-MD-----Treatment Guidelines for Somatoform

Disorders

CARE-MD Brief Treatment Plan

Consult psychiatry/ Consult psychiatry with recurrent symptoms or

cognitive behavioral worsening overall function.
therapy
Follow the cognitive behavioral therapy treatment
plan developed by the therapist and patient.
Assess Rule out potential general medical causes for the
somatic complaints.
Treat comorbid psychiatric disorders.
Regular visits Schedule short frequent visits with focused examinations.
Discuss recent stressors and healthy coping strategies.
Patient should agree to stop overutilization of
medical care (eg, frequent emergency department
visits, or excessive calls and pages to the primary
care physician).
Empathy ‘‘Become the patient’’ for a brief time.
During brief visits, spend most of the time listening to
the patient.
Medicine--psychiatry Acknowledge patient-reported discomfort.
interface
Help the patient self-discover the connection between
physical complaints and emotional stressors.
Avoid comments such as, ‘‘Your symptoms are all
psychological’’ or ‘‘There is nothing wrong with you
medically.’’
Do no harm Order no unnecessary diagnostic procedures.
Minimize consultations to medical specialties.
Attempt to obtain collateral history from area medical
centers with complex cases.
Once a reasonable diagnostic workup is negative, feel
94 comfortable with a somatoform-type diagnosis and
initiate treatment.

therapy using CBT with an emphasis on tients with somatoform disorders.

education has also been found to be Examples of such thoughts are ‘‘I will
beneficial (Kashner et al, 1995). Cogni- always be sick,’’ ‘‘No one understands
tive behavioral therapy is generally my pain,’’ or ‘‘Everyone thinks it’s all in
short-term psychotherapy (8 to 20 my head.’’ Through a variety of mech-
weeks) with the goal that patients will anisms, patients learn to recognize and
develop skills that last indefinitely. This reconstruct the dysfunctional thought
type of psychotherapy is based on the patterns with resultant decreased
premise that inaccurate or dysfunc- somatic complaints. In collaboration
tional thoughts are pervasive in pa- with the psychotherapist, physicians

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 KEY POINT:
can learn to use brief cognitive behav- cent to 50% of patients with somato-
A Cognitive
ioral techniques during office visits form disorders have concurrent de-
behavioral
(Case 7-5). pression or anxiety-related disorders therapy is a
(Allen et al, 2001; Kroenke et al, 1994). relatively brief
The number of unexplained somatic treatment that
Assess
symptoms is highly predictive of co- decreases
Assessing patients on each visit for morbid mood and anxiety disorders somatic
general medical or neurological prob- as well as functional disability. Phy- preoccupation
lems that might explain troublesome sicians can use the PRIME-MD, a and associated
physical complaints is important. This screening tool that is a combination dysfunction.
is particularly essential for patients of self-report and clinician interview, At the end
who have a long history of somatic to reliably screen for psychiatric dis- of therapy,
preoccupation and present with a patients have
orders in the primary care setting.
new complaint or worsening of exist- the lifelong skill
ing symptoms. About 30% of patients set to monitor
Regular Visits and improve
diagnosed with conversion disorder
their emotional
eventually have an identifiable, non- Instead of scheduling follow-up visits
well-being.
psychiatric disease that explains the on an as-needed basis, appointments
symptoms (Lazare, 1981). It is also im- should be regular, brief (eg, 15 minutes
portant to screen for other common every 4 to 6 weeks) and not contingent
psychiatric diagnoses. Twenty-five per- on the presence of symptoms. This

Case 7-5 Hypochondriasis

A 31-year-old man with a history of recurrent major depressive disorder is
referred from his primary care doctor to the neurology service with
concerns of a refractory ‘‘tingling and shaking feeling’’ of both hands for
the past 2 years. The patient believes he has Parkinson’s disease and is
asking to be treated before the condition worsens. On examination, he has
no tremor, rigidity, bradykinesia, or postural instability. Inspection of his
hands is within normal limits. All other aspects of his examination are
unremarkable. All laboratory results, including toxic shock syndrome, B12,
rapid plasma reagin, metabolic panel, and complete blood count, are
normal. The patient denies use of illicit drugs or alcohol. With the help of
supportive psychotherapy, his depression is well controlled. Frequent
reassurance and over-the-counter analgesics are minimally helpful.
Because of the discomfort he has recently quit his job and is financially
95
stressed. He is motivated to get better and has no desire to collect
disability.
Comment. This patient is, in a nondelusional way, preoccupied with his
symptoms and the self-diagnosis of Parkinson’s disease. He has significant
occupational dysfunction and related financial concerns. This fixation on a
specific disease and associated impairment, coupled with the inability to
improve with reassurance, is an example of hypochondriasis. Treatment
should begin with a referral to psychiatry for cognitive behavioral therapy
and consideration of an antidepressant. This treatment is effective and,
with the aid of a behavioral plan developed by the psychiatrist and patient,
can be effectively utilized in the primary care and outpatient neurology
settings. There is no reason to think the patient is intentionally feigning
the symptoms for either external (eg, financial) or internal (eg, assuming
the ‘‘sick role’’) secondary gain.

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 " SOMATIZATION

KEY POINT:
allows patients to receive the attention explore emotions and develop effec-
A Patients with
they desire without having to develop tive coping strategies that will mini-
somatization
will benefit new symptoms to obtain it. Each visit mize the use of somatization as a
from short, should begin with an inquiry about any defense against stressful situations.
frequent visits new symptoms and a brief physical An example of such a statement
with the examination looking for objective signs might be: ‘‘The results of my exami-
primary care of illness. The physician then shifts nation and of the tests we conducted
provider away from the patient’s physical symp- show that you do not have a life-
(sometimes a toms to the psychosocial context in threatening illness. However, you do
neurologist). which the symptoms are occurring have a medical condition that is some-
It is essential with open-ended questions such as, what common and obviously causing
always to
‘‘How are things at home?’’ and ‘‘What you significant distress. Curing this
complete a
is the biggest stress for you now?’’ The condition can be difficult and can take
focused
examination
goal with these sessions is to provide some time, but fortunately a number
and screen for an outlet for patients to cope, with less of interventions can help you deal
frequently somatic preoccupation, and in some with the symptoms better than you
comorbid cases to link their symptoms to a have so far.’’ This statement commu-
psychiatric particular psychosocial stressor. nicates the nonlethal nature of symp-
illness. toms but at the same time validates
Empathy the patient’s suffering and reassures
Empathy or ‘‘becoming the patient’’ is the patient that the condition is not
a key ingredient to forming a healthy unusual. Finally, it emphasizes the
therapeutic alliance and optimizing collaborative management of the ill-
treatment for patients with somato- ness symptoms between the physician
form disorders. Explicit acknowledge- and patient.
ment of any emotional or physical Reassuring the patient with an ac-
suffering on the part of the patient is curate diagnosis and treatment plan
critical since patients may believe their involves more than statements such
physician questions the legitimacy of as, ‘‘It’s all in your head and you
medically unexplained symptoms. The should see a therapist’’ or ‘‘There’s
use of empathy can also minimize nothing medically wrong.’’ An ap-
negative feelings or countertransfer- proach that provides accurate informa-
ence for the treating physician. True tion and uses descriptive physiological
empathic remarks like, ‘‘This must be explanations for all symptoms is more
difficult for you’’ or ‘‘I might feel the acceptable. If the patient insists on
96 same way if I were in you situation,’’ a formal diagnosis, the terms func-
are often beneficial particularly when tional weakness or sensory loss can
frustrated family or friends are in the be suggested. This approach does not
examination room with the patient. label a condition as medical, neurologi-
cal, or psychiatric, but, instead, puts
Medicine--Psychiatry Interface the patient at ease by suggesting a
Medicine and psychiatry should inter- holistic association between these and
face in the treatment of every patient other areas.
with somatoform disorders. One way
to accomplish this, while building a Do No Harm
collaborative relationship with the Doing no harm by unneeded consul-
patient, is to develop an easily under- tations or procedures is the most
standable and mutually acceptable important part of treating patients
language to discuss symptoms. This with chronic somatoform disorders.
approach helps the patient safely Neurologists should not deviate from

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normal practice style to appease a common and often frustrating for
patient or minimize frustration. After both physicians and patients as they
taking reasonable steps to rule out a are frequently challenging to manage.
general medical or neurological con- Fortunately, effective CARE-MD man-
dition, the physician is able to make agement strategies are available for
the appropriate somatoform diagnosis patients who are functionally impaired
and treat accordingly. by somatization. These practical strate-
gies emphasize a holistic and collabo-
CONCLUSION rative approach designed to minimize
Disorders relating to somatization in iatrogenic harm and improve overall
the neurological setting are extremely function and well-being.

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99

Copyright @ American Academy of Neurology. Unauthorized reproduction of this article is prohibited.