PURPOSE Patients seeking care for medically unexplained physical symptoms pose a major challenge at primary care sites, and there are very few wellaccepted and properly evaluated interventions to manage such patients. METHODSWe tested the effectiveness of a cognitive behavior therapy (CBT)-type intervention delivered in primary care for patients with medically unexplained physical symptoms. Patients were randomly assigned to receive either the intervention plus a consultation letter or usual clinical care plus a consultation letter. Physical and psychiatric symptoms were assessed at baseline, at the end of treatment, and at a 6-month follow-up. All treatments and assessments took place at the same primary care clinic where patients sought care.RESULTS A signifi cantly greater proportion of patients in the intervention group had physical symptoms rated by clinicians as "very much improved" or "much improved" compared with those in the usual care group (60% vs 25.8%; odds ratio = 4.1; 95% confi dence interval, 1.9-8.8; P <.001). The intervention's effect on unexplained physical symptoms was greatest at treatment completion, led to relief of symptoms in more than one-half of the patients, and persisted months after the intervention, although its effectiveness gradually diminished. The intervention also led to signifi cant improvements in patient-reported levels of physical symptoms, patient-rated severity of physical symptoms, and clinician-rated depression, but these effects were no longer noticeable at follow-up.CONCLUSIONS This time-limited, CBT-type intervention signifi cantly ameliorated unexplained physical complaints of patients seen in primary care and offers an alternative for managing these common and problematic complaints in primary care settings.

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Worldwide, patients with common mental disorders, such as depression and anxiety, have a tendency to present first to primary care exhibiting idiopathic physical symptoms. Typically, these symptoms consist of pain and other physical complaints that remain medically unexplained. While in the past, traditional psychopathology emphasized the relevance of somatic presentations for disorders, such as depression, in the last few decades, the “somatic component” has been neglected in the assessment and treatment of psychiatric patients. Medical specialties have come up with a variety of “fashionable” labels to characterize these patients and the new psychiatric nomenclatures, such as the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, attempt to classify these patients into a separate “somatoform disorders” category. These efforts fall short, and revisionists are asking altogether for the elimination of “somatoform disorders” from future nomenclatures.This review emphasizes the importance of idiopathic physical symptoms to the clinical phenomenology of many psychiatric disorders, offers suggestions to the diagnostic conundrum, and provides some hints for the proper assessment and management of patients with these common syndromes.

A history of four or more PNS is common among somatizing patients in primary care and associated with a more severe clinical presentation, even after controlling for other factors known to be associated with severity. Four or more PNS may identify a distinct subgroup of somatization and serve as a clinical indicator for identifying psychiatric disorders in primary care. Future studies should explore the assessment of PNS using briefer measures. Furthermore, PNS should be evaluated with samples more representative of US primary care populations, as well as samples that include adequate representation from other ethnic backgrounds (eg, African-American, Asian, etc.).

Within somatization, unexplained neurological symptoms (UNSs) have been shown to mark a distinct subgroup with greater clinical severity. However, some UNSs resemble ataque de nervios somatic symptoms. This raises questions about cultural factors related to Hispanics with somatization characterized by UNSs. To examine cultural factors, preliminary analyses examined the relationship between Hispanic ethnicity, UNSs, and ataque de nervios. Data were obtained from 127 primary care patients (95 Hispanic, 32 European American) with somatization. The Composite International Diagnostic Interview provided somatization data, whereas the Primary Care Evaluation of Mental Disorders was used for data on Axis I disorders. Ataque de nervios was assessed via a proxy measure. Within each ethnic group, cross-tabs examined the relationship between ataque de nervios and multiple UNSs, and ataque de nervios and selected Axis I disorders. Only among Hispanics, a significant overlap was found between ataque de nervios and having four or more UNSs (p < .001), and ataque de nervios and a diagnosis of panic disorder (p = .05). Although equal percentages of European Americans and Hispanics experience multiple UNSs, these results show that the presentation of UNSs among some Hispanics may be qualitatively different, because it may involve features related to ataque de nervios. A diagnosis of panic disorder also appears to interact with cultural factors.

Socorro was a 35-year-old Venezuelan woman who attempted suicide by overdose. The psychotherapeutic approach relied on identifying the social context, constructs, and working within Socorro's cultural framework. Cultural issues related to immigration, acculturation, and culturally based gender issues were identified. The integration of cognitive-behavioral, feminist, and multicultural approaches helped to identify how migratory stressors oppressed her sense of self. Tenets of multiracial feminism were incorporated to better understand how her social context affected her perception of relationships, how she made choices and interpreted them. Future work with Latinas should address the development of models for treatment that fuse these perspectives.

This case presentation discusses the many variables involved when treating minority women in the United States. The case of Maria portrays a 21-year-old Portuguese woman who was referred to psychotherapy by her mother. On intake, Maria reported anxiety symptoms consistent with Generalized Anxiety Disorder and dysthymic symptoms. Cognitive behavioral as well as behavioral techniques were utilized in the treatment process to increase functioning and coping skills. In addition, issues of acculturation were further explored utilizing an ethnocultural assessment and a genogram. Implications for clinicians are discussed.