Somatization, heartsink patients, or functional somatic symptoms? Towards a clinical useful classification in primary health care

Abstract

Several definitions of somatization exist and try to deal with the fundamental problem that a large group of patients present with physical symptoms for which a conventional pathology cannot be identified. However, the concept remains somewhat confusing. The prevalence of somatization is high in general practice. Nevertheless, patients do not receive proper treatment and risk iatrogenic somatic fixation and harm, the doctor Á/patient relationship is often negatively affected and the overall healthcare system suffers from high expenditure on unnecessary physical investigations and treatments. During the last decade research has shown that somatization may be treated effectively in specialist care. Little is known about effective treatment in primary care but the Reattribution Model and the Extended Reattribution and Management Model have shown promising results. The development and evaluation of new treatment strategies is, however, hampered by the confusion of definitions and concepts. In this article an overview is presented of the various concepts relevant to the clinical work and research in primary health care. It is important to realize that somatizing patients in primary health care present a broader spectrum of severity than patients seen in a specialist setting. Hence, primary care cannot apply definitions from specialist care directly but needs a definition that also includes the mild cases. We need classifications and agreed definitions applicable in primary health care in order to develop appropriate management strategies, to predict prognosis, and to enable rigorous research concerning the large group of somatizing patients in primary health care.

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“…Belgierne De Gucht & Fischler beskriver de to ulike retninger, som har utviklet seg i somatiseringsfeltet -den klassiske freudianske forståelsen, der symptomene har en psykologisk bakgrunn, til forskjell fra en forståelse, der årsaksforklaringen står helt åpen. Rosendal og medarbeidere betegner den første versjonen som 'normativ' og den andre versjonen som 'deskriptiv' (Rosendal, Fink et al 2005). …”

“…We recommend an approach to clinical care that involves exploring the patient's life context, finding mutually meaningful language to arrive at a name for the illness, normalizing the patient's bodily experience of distress, using a chronic disease model that aEends to functioning, and addressing the physician's need for certainty and efficacy" (Epstein, Quill et al 1999) TERM-modellen inkluderer alle de siste elementene, og den legger stor vekt på å få frem pasientens egen forståelse av sine plager som grunnlag for felles forståelse og samarbeid videre mellom lege og pasient. Denne strategien har også vist seg å endre legenes holdning i retning av større sympati for denne pasientgruppen (Rosendal, Fink et al 2005). Likevel gir reaEribuerings-begrepet i seg selv noen signaler om, at det er pasienten, som tar feil, mens legen har reE.…”

Coping with loss of control in the practice of medicine.

“…However, certain patient behaviors may be more likely to elicit feelings of loss or lack of control for physicians. These include: (a) demanding that doctors "fix" the problem, despite the problem not necessarily being "fixable," or insisting on inappropriate treatment (the "demanding" patient; Strous, Ulman, & Kotner, 2006); (b) becoming overly dependent or reliant upon the practitioner (the "needy" patient); (c) failing to take personal responsibility for their own health care choices; (d) communicating certain emotional states (e.g., anxiety, fear, anger, depression) that the provider is either personally uncomfortable with or finds difficult to address; and (e) having multiple coexisting psychological and medical problems, none of which is easily remediable (predictive of "difficult" clinical interactions) (Rosendal, Fink, Bro, & Olesen, 2005). Relationships with such patients tend to generate negative physician responses (e.g., anger, frustration, discomfort, blame, helplessness), which we relate to loss of control, responses that are likely to adversely affect patient care and create emotional distress in the physician.…”

Improving the Classification of Medically Unexplained Symptoms in Primary Care

“…This definition has been chosen because it is purely descriptive but other names and definitions exist 6,7 .…”