A Randomized Clinical Trial of a Care Recommendation Letter Intervention for Somatization in Primary Care

W. Perry Dickinson; L. Miriam Dickinson; Frank V. deGruy; Deborah S. Main; Lucy M. Candib; Kathryn Rost

doi:10.1370/afm.5

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What about the doctor?
Glenn H Griffin

Published on: 02 December 2003
Somatisation or somatic fixation?
Aya Biderman

Published on: 27 November 2003
Alternate Explanations For Findings
David A Katerndahl

Published on: 27 November 2003
Addressing the process of change
Lawrence Fisher

Published on: 27 November 2003
Somatization
Ronald M. Epstein

Published on: 27 November 2003

Published on: (2 December 2003)
Page navigation anchor for What about the doctor?
What about the doctor?
Glenn H Griffin, Al Ain, United Arab Emirates
Dear Authors: I read with pleasure your article on a care recommendation letter intervention for somatization in primary care. You have documented some evidence of improvement for the patient. Having had significant experience in the management of somatizing patients as their physician, I wondered whether this letter might have also improved the quality of life of the physician and whether anyone had studied that aspec...
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Dear Authors: I read with pleasure your article on a care recommendation letter intervention for somatization in primary care. You have documented some evidence of improvement for the patient. Having had significant experience in the management of somatizing patients as their physician, I wondered whether this letter might have also improved the quality of life of the physician and whether anyone had studied that aspect of this intervention.
It would be my hypothesis that, since these patients are challenging and physicians frequently do not know what to do with them, a care recommendation letter would improve the lot of the physician at least as much as that of the patient! Cheers GG
Competing interests: None declared
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Competing Interests: None declared.
Published on: (27 November 2003)
Page navigation anchor for Somatisation or somatic fixation?
Somatisation or somatic fixation?
Aya Biderman, Meitar, Israel
I enjoyed reading your article. I think it strengthens the idea that we, physicians, have an important role in making our patients "somatizers", and therefore, I believe that the term "somatic fixation" is more suitable for this phenomenon. The fact that changing a doctor's behaviour has changed the patients' self-rated health status, without any other direct intervention, supports the notion that physicians can enhance...
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I enjoyed reading your article. I think it strengthens the idea that we, physicians, have an important role in making our patients "somatizers", and therefore, I believe that the term "somatic fixation" is more suitable for this phenomenon. The fact that changing a doctor's behaviour has changed the patients' self-rated health status, without any other direct intervention, supports the notion that physicians can enhance the process of patients' somatization, and it is not only the patient's character, trait, or disorder. It is ours, too!
Another point is that physicians can learn this and change their somatizing behaviours, which is an optimistic view of the problem. This implies to our training programs both for residents in family medicine and in other medical specialties.
Ref: 1. Yeheskel A,Biderman A, Borkan J, Herman J. Acourse for teaching Patient-centered Medicine to Family Medicine Residents. Academic Medicine 2000;75(5):494-497.
2. Biderman A, Yeheskel A, Herman J. Somatic fixation: the harm of healing. Soc Sci Med 2003;56(5):1135-8.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (27 November 2003)
Page navigation anchor for Alternate Explanations For Findings
Alternate Explanations For Findings
David A Katerndahl, San Antonio, Texas
There is a desperate need for studies on somatization among primary care patients. This study represents sound research and provides a possible intervention, as far as it goes. However, I would like to suggest possible alternate explanations for some of the findings.
For example, the observation that patients with at least 1 chronic physical disease responded better to the intervention may reflect the effect...
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There is a desperate need for studies on somatization among primary care patients. This study represents sound research and provides a possible intervention, as far as it goes. However, I would like to suggest possible alternate explanations for some of the findings.
For example, the observation that patients with at least 1 chronic physical disease responded better to the intervention may reflect the effect of increased frequency of visits, enabling the physician to detect complications of the physical disease earlier and preserve functional status.
In addition, although the decline in functional status after 1 year may indicate the need for a "booster", it may also reflect a rejection by the patient of the physician's explanation for their continuing symptoms. Starcevic et al (1992) found that hypochondriacal panic disorder patients wanted explanations more than treatment for their attacks. If, after a year, they perceive that the explanation is not correct, they may reject it and their functional status may decline.
Future research may need longer follow-ups and a trial of "boosters" to the intervention.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (27 November 2003)
Page navigation anchor for Addressing the process of change
Addressing the process of change
Lawrence Fisher, San Francisco, USA
Other Contributors:
The paper by Dickinson, et al. on somatization raises a number of interesting issues, both practical and theoretical. I would be interested to learn how others view several issues that emerge from this report.
First, I am surprised that the intervention led to a change in a relatively subjective patient self-report measure of physical health, rather than from a “harder” measure of, say, primary care visits or...
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The paper by Dickinson, et al. on somatization raises a number of interesting issues, both practical and theoretical. I would be interested to learn how others view several issues that emerge from this report.
First, I am surprised that the intervention led to a change in a relatively subjective patient self-report measure of physical health, rather than from a “harder” measure of, say, primary care visits or number of physical complaints to the PCP. Somehow, patients must have detected a change in response by the PCP and reacted accordingly. Since these patients tend to be physically hypervigilant, it does not surprise me that no change in emotional functioning was reported. If this is the case, I wonder if there are any data on how PCP behavior changed in this or in similar studies? After all, the intervention was somewhat unstructured and PCPs could apply this new information in any of a number of ways. In other words, what did they do with this new information that was different, and, by inference, what led to the recorded effect?
Second, there are some theoretical views that suggest that patients who somatisize tend to translate poorly managed life stresses into physical presentations. If changes in PCP behavior leads to a stabilization or reduction of this process, would one now suggest that these patients would express these stresses in other ways? Should we predict an increase in family conflict, smoking or drinking, etc.? The stress remains, but the vehicle for its expression now becomes uncertain if the PCP no longer responds in the same way. Or perhaps these patient concerns remain and are experienced but are simply not presented to PCPs because PCPs do not respond to them? I wonder what others’ experience is with the effect of this kind of change and other evidence about what happens to patients?
Last, the fall-off in positive reports of physical functioning among patients in the immediate intervention group after 12 months suggests that some kind of ongoing strategy for managing these patients is required. Following the care recommendation letter, I wonder what kinds of “booster” strategies have been tried in the past to sustain the initial effect? Also, whom do we boost: the patient or the PCP?
This very well-documented, simple and cost-effective intervention highlights how small changes in primary care practice can lead to big changes in patient behavior and cost efficiency. Furthermore, it informs me yet again how an easily used screening measure identifies a subset of patients whose diagnosable disorder affects their primary care treatment. Perhaps a further study of the process of the effect will help generate more refined interventions for a variety of biobehavioral problems seen in primary care.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (27 November 2003)
Page navigation anchor for Somatization
Somatization
Ronald M. Epstein, Rochester, NY, USA
There are several problems with the construct of somatization.1 What we know is this: Physicians cannot explain the majority of symptoms that patients experience. Most of these symptoms resolve spontaneously. These patients are not malingering. And, all symptoms, regardless of whether they are explained or unexplained, physical or psychological, tend to improve if patients feel understood, reassured, exculpated and tru...
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There are several problems with the construct of somatization.1 What we know is this: Physicians cannot explain the majority of symptoms that patients experience. Most of these symptoms resolve spontaneously. These patients are not malingering. And, all symptoms, regardless of whether they are explained or unexplained, physical or psychological, tend to improve if patients feel understood, reassured, exculpated and trusted by their physician.
The consultation letter developed by Smith et al, and reported by Dickinson, et al. contains the elements described above. It instructs physicians not to blame patients for their own distress, which helps to avoid or defuse conflict. It fosters reassurance; when the physician’s predictions are verified by experience, patients become more self- confident and trusting. It recognizes that patients not only seek relief from symptoms, but also need to be understood as people.
What is lacking, still, is an adequate theory of somatization. This may be because so-called somatizers are a heterogeneous group. Some suggest that the diagnosis of somatization is only invoked when there is conflict between physician and patient about the cause of the patient’s distress.2 This conflict does not have to persist indefinitely. For example, depression often presents with somatic symptoms,3 but most patients accept a psychological explanatory model if their physician suggests it.4
A significant minority of patients with disabling and unexplained symptoms display no clear signs of depression or anxiety, and seem to have a worse prognosis.5 Many of suggestions in the letter would likely benefit these patients as well as those chronic physical illness who have no unexplained symptoms; the success may be due to a non-specific effect of acceptance, reassurance and naming. I wonder if it would be equally successful with patients with chronic disease who would not be considered “somatizers”.
I also have to wonder if the intervention really reduces uncertainty, as the authors suggest, or, rather, creates the illusion of certainty. Illusions may be calming for both physician and patient, and, may help to focus on mutual understanding rather than on conflict over causality. If we believe that this “certainty” is illusory yet salubrious, it creates an ethical dilemma for physicians, for to deconstruct the diagnosis may undermine the therapeutic effect.
The most honest response to uncertainty is “I don’t know.” But, facing uncertainty can be frightening. Future interventions might also provide guidance on how to provide reassurance to the patient while accepting that there are intrinsic uncertainties that always result from imperfect knowledge.
Reference List
1. Epstein RM, Quill TE, McWhinney IR. Somatization reconsidered: Incorporating the patient's experience of illness. Archives of Internal Medicine. 1999;159:215-222.
2. Fabrega H, Jr. Somatization in cultural and historical perspective. In: Kirmayer LJ, Robbins JM, eds. Current concepts of somatization: Research and clinical perspectives. Washington, DC: American Psychiatric Press, Inc.; 1991:181-199.
3. Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care setting. Journal of Psychosomatic Research. 1988;32:137-44.
4. Kirmayer LJ, Robbins JM. Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics. Psychological Medicine. 1996;26:937-951.
5. Kirmayer LJ, Robbins JM. Three forms of somatization in primary care: prevalence, co- occurrence, and sociodemographic characteristics. Journal of Nervous & Mental Disease. 1991;179:647-655.
Competing interests: None declared
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Competing Interests: None declared.