Psychiatric consultation in somatization disorder. A randomized controlled study

The changing faces of somatization

The prevalence of several diseases popularized by the media is examined in a group of 50 consecutive patients allegedly suffering from environmental hypersensitivity disorder. Ninety percent of patients reported suffering from at least one other "fashionable" condition, including food allergies that cause psychological symptoms, postinfectious neuromyasthenia, candidiasis hypersensitivity, and severe premenstrual syndrome. Each of the conditions named above was endorsed by at least 50% of patients. Multiple endorsements were common, and the patients' attribution of the etiology of their symptoms varied with time. Physicians must become adept at identifying and managing somatizing patients, and the public must be educated about somatization and provided with reliable information about "fashionable" illnesses.

Screening indexes in DSM-III-R somatization disorder

A sample of 196 general medical patients with multiple unexplained somatic complaints was used to compare the performance (sensitivity and specificity) and positive and negative predictive values for the published screening indexes for somatization disorder. This study shows similar performances for both the DSM-III-R and the Swartz et al. screening indexes for somatization disorder with use of DSM-III-R diagnostic criteria. By use of Receiver Operating Characteristic (ROC) curve analysis, graphs of achievable sensitivity and specificity through the range of possible symptom thresholds allow for a more informed decision to be made concerning which screening index to use at a given symptom threshold. Positive predictive values for screening indexes ranged from 68% to 79%, and negative predictive values ranged from 72% to 81%. Use of a screening index is suggested in medical patients with unexplained complaints and in patients seen in the consultation-liaison (CL) setting.

The low yield of physical examinations and laboratory investigations of patients with chronic fatigue

Fatigue is a common symptom but guidelines for its appropriate evaluation are lacking. The authors prospectively studied 100 adults with a chief complaint of fatigue lasting at least 1 month in order to determine the diagnostic contribution of physical examinations and laboratory investigations. The evaluations were performed in the specialized clinic of a faculty practice. Physical examinations produced diagnostic information in 2% of patients, and laboratory investigations elucidated the cause of fatigue in 5% of patients. Structured follow-up evaluations after an average interval of 10 months failed to reveal any new organic causes for the fatigue symptom. Minor laboratory abnormalities were relatively common but did not contribute to the diagnostic process and did not seem to influence the clinical outcome. The authors conclude that the traditional medical evaluation of patients complaining of chronic fatigue has a low yield in discovering treatable physical disorders.

Non-institutional treatment of chronic pain by field management: an outcome study with comparison group

Field management, through the use of specially trained field consultants, is a mechanism by which interdisciplinary interventions can be implemented in non-institutional settings. Management of the real environmental determinants (home, work, social) of pain and disability should improve the effectiveness of behaviorally based interventions and make these treatments more accessible. Over a 6 year period, 261 patients having various chronic somatic complaints (e.g., pain, fatigue, gastrointestinal complaints) underwent interdisciplinary outpatient treatment based on medical and behavioral sciences. Comparison of patients having field management with patients receiving office-based treatment found a significantly greater reduction in disability with field management. 84% of field managed patients had a successful outcome as defined by: (a) return to regular work, or (b) reduced limitations on work, exercise, and daily living activities, depending on functional status at assessment. Only 61% of patients with office-based treatment were successful. Compliance, defined as the frequency with which treatment was mutually terminated, was significantly higher with field management. The availability of long-term disability benefits was highly predictive of a poorer outcome. However, field management remained effective for improving functional status regardless of the availability of benefits. Finally, determination of the cost of non-institutional treatment indicated that field management is a cost-effective modality. Implications of these findings for the treatment of disability in chronic pain and other chronic illness syndromes are discussed.

Teaching humanistic and psychosocial aspects of care: current practices and attitudes

OBJECTIVE

To assess current practices and attitudes toward teaching humanistic and psychosocial aspects of care in internal medicine residency programs.

DESIGN AND PARTICIPANTS

Survey questionnaires were sent to residency directors at all 434 internal medicine residency programs accredited in 1985-1986. Response rate for two mailings was 71%.

MEASUREMENTS AND MAIN RESULTS

78% OF RESIDENCY DIRECTORS and 70% of department chairpersons had high or moderately high levels of commitment to teaching humanistic/psychosocial aspects of care, but only 44% of responding programs offered mandatory training, and only 18% offered elective training in these areas. Obstacles to expanded teaching of the humanistic/psychosocial aspects rated high or moderately high by residency directors included insufficient curriculum time (51%), lack of trained faculty (44%), and pressures to reduce both training costs (40%) and patient-care costs (37%).

CONCLUSIONS

Most of the training that does occur in the humanistic/psychosocial aspects of care probably happens informally via mentoring and role modeling. Appeals to expand teaching in these areas raise questions regarding what to include in medical training and the proper scope of internal medicine. Sustainable change will depend on the politics of resource distribution and the influence of general internal medicine and primary care on traditional training.

The general health questionnaire (GHQ) as a predictor of hospital care and mortality in the non-institutionalized elderly

The general health questionnaire (GHQ) and its relation to hospital care and risk of death were studied prospectively in the total elderly population living in a community in northern Finland. Of the eligible elderly, 982 or 85% took part in the study, returning the GHQ. A high score on the questionnaire was considered an indicator of minor psychiatric illness. It was found that the average number of hospital days, calculated per person-years, was twice as high in the high scorers than in the low scorers. When the effects of age and certain diseases were controlled for, the high scoring men and women had a significantly higher risk of being hospitalized for at least ten days over a five-year period than the 0-1 scorers. The risk ratio was 1.6 and 1.4 for men and women, respectively. The ten-year mortality was significantly higher in the high scoring men and women than in the low scorers, when the effects of age and certain diseases were controlled for. The risk ratios for both men and women were 1.4. The GHQ was found to predict hospital care, physician visits, home services and mortality in a representative group of rural elderly people.

Clinical assessment and interpretation of abnormal illness behaviour in low back pain

Patients with chronic low back pain present with a mixture of symptoms and signs. Some are a direct consequence of physical pathology whereas others are attributable to associated and appropriate psychological and behavioural changes. At times the latter may be out of keeping with the degree of physical pathology and thus have specific significance in terms of the affective and cognitive disturbances that are also present and which may be the basis for abnormal illness behaviour. In an attempt to demonstrate more clearly the relationship between physical, psychological and behavioural components of illness, this paper draws on two data sets in patients with low back pain. The first explores the relationship between behavioural symptoms and signs, objective physical impairment, pain and disability and psychometric measures of distress together with scales making up the illness behaviour questionnaire (IBQ) of Pilowsky and Spence. A second data set is used to assess the value of the IBQ in understanding how psychological distress and behavioural signs and symptoms are related to the outcome of surgical treatment. The results gained reveal that behavioural symptoms and signs are directly related to the physical severity of low back disorder, the patient's report of pain and disability and the outcome of surgical treatment. Scores on the IBQ were strongly related to measures of affective disturbance and psychological distress. More specifically the disease affirmation scale of the IBQ, incorporating scales for disease conviction and psychological versus somatic focussing was an important dimension in relation to the behavioural symptoms and signs, thereby confirming results gained by other workers. Disease conviction and lack of response to clinicians' reassurances regarding illness - a situation in which abnormal illness behaviour is often deemed to exist - should not be seen simply as a function of the disease process, but more as a psychological coping mechanism for certain individuals under stress. The significance of this observation is discussed in relation to decisions regarding the overall assessment of chronic pain patients and their treatment.

Beneficial effects of psychiatric intervention on recovery after coronary artery bypass graft surgery

The effects of perioperative psychiatric intervention were studied in 33 patients undergoing coronary artery bypass graft (CABG) surgery. All patients were evaluated preoperatively using the Mini-Mental State Exam and the Psychological Adjustment to Illness Scale-Self-Report. Participants in the study group (N = 16) had a structured psychiatric interview prior to surgery and were followed daily with supportive psychotherapy throughout their hospitalization. The number of medical complications was higher in the control group. No significant differences were found in neurologic or psychologic complications. The study group used significantly more oxycodone-acetaminophen (Percocet), but less morphine-sulfate or benzodiazepine on postoperative days 3, 4, and 6. The mean length of stay was 3 days shorter for patients in the study group. In the current era of escalating health care costs and high technology, clinical protocols and research studies that evaluate the cost effectiveness and efficacy of psychiatric intervention in medically ill patients should be pursued.

A proposed value matrix for the evaluation of psychiatric consultations in the general hospital

A strategy of determining the value of psychiatric consultation services in the general hospital is presented. Value analysis, a theoretically driven model for establishing the worth of mental health services from multiple perspectives, is used to propose a value matrix for consultation psychiatry. Based on an integration of decision theory and evaluation science, the goal of value analysis is to establish a range of outcomes that might be viewed as important from various perspectives. This hypothesized matrix of economic and clinical values for patients, families, medical staff, providers, payors, and society provides a framework for evaluating outcomes of psychiatric consultation services.

Functional somatic complaints in adolescents: relationship to negative life events, self-concept, and family characteristics

While recurrent somatic complaints are commonly encountered in children and adolescents, occult organic disease is rarely found in patients with these complaints. Recent studies have confirmed the clinical impression that a relationship exists between functional somatic complaints and negative life events in adolescents. Our goal was to investigate additional psychosocial characteristics that may be associated with functional complaints. One hundred fifteen adolescents coming for the first time to an adolescent medicine clinic completed standard measures of negative life events, psychophysiologic symptoms, self-esteem, peer social comparison, and family functioning before an independent evaluation by a physician. Patients with functional somatic complaints (chest pain, recurrent abdominal pain, limb pain, and hyperventilation syndrome) reported significantly more negative life events, lower self-esteem, more psychophysiologic symptoms and a lower self-evaluation than did patients coming for physical examination or routine health maintenance. Functional somatic complaints in adolescents may be associated with poor psychosocial adjustment and reaction to negative life events. In addition to ruling out organic disease, physicians dealing with these patients should evaluate other areas, including stressful life events, peer relations, and self-esteem.

Erratum: Human Gene Therapy Test

In the first paragaph on page 1005 of the article "A molecular basis for MHC class II-associated autoimmunity" by John A. Todd et al. (20 May, p. 1003), invention of the polymerase chain reaction amplification method was incorrectly attributed to "Erlich and colleagues." The method was invented by Kary Mullis at the Cetus Corporation and developed by Erlich's group.

Psychiatric consultations in two Israeli general hospitals

Data were gathered on 479 inpatients of two Israeli general hospitals for whom psychiatric consultations were requested over a 1-year period. The data presented here include age and sex of referred patients, source of referral, reason for referral, psychiatric and physical diagnoses, and consultant's recommendation. Emergency ward consultations are included. Additional data were collected on patients transferred to psychiatric wards. Our findings are similar in general to those reported from other countries, although such comparisons are limited by the lack of uniformity in the classifications used by the various workers.

Psychiatric co-morbidities and patients with head and spinal cord trauma. Effects on acute hospital care

Three hundred twenty-one patients with traumatic head and spinal cord injuries were studied. Forty-two of these patients (13.1%) received psychiatric consultation services. Two types of consultation patients were identified--one receiving psychiatric consultation services in the acute-care hospital and one receiving psychiatric services in the post-acute care, long-term rehabilitation center. In order to assess the impact of psychiatric co-morbidities on hospital length of stay and charges, 40 consultation patients (23 acute and 17 rehabilitation) were matched to 87 control patients who received no psychiatric services. Matching was done on severity of injury, age, and sex. Psychiatric consultation cases had significantly longer stays than did matched controls. There were no differences on total charges.

Long term follow-up of factitious anaemia

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An inpatient programme for persistent somatizers

Somatization, defined as a transient or persistent tendency to experience and communicate psychological distress in the form of somatic symptoms and to seek medical help for them, represents a common problem in clinical practice. A comprehensive inpatient rehabilitation program for somatizing patients has been developed at the Clarke Institute in Toronto and is described in detail. It involves concurrent application of psychiatric, psychological, social, and medical therapies.

Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions

An extensive series of investigations over the past 2 decades clearly demonstrate that mental disorders are present in approximately 25% of primary care patients and that physicians underdiagnose these illnesses. The factors producing this bias are poorly understood and should be focused upon in future research. Also requiring much more study is the efficacy of pharmacologic and psychosocial treatments initially validated with psychiatric populations. Clinical trials should determine whether standardized interventions can be utilized with medical patients whose symptom profiles and organic comorbidity may differ from those of psychiatric populations.

Somatization in primary care: patients with unexplained and vexing medical complaints

Somatizing patients experience or express emotional discomfort and psychosocial distress as physical symptoms. Somatization occurs in a broad spectrum of illnesses, in association with a wide variety of mental disorders, including depression, anxiety, and the somatoform disorders. Primary care providers must detect and treat these patients. Diagnosis is based on positive criteria. Care rests upon conservative medical management and evaluation; a physician-patient relationship based on acceptance, caring, and trust; reinforcement of positive behaviors and elimination of destructive ones; and the gradual use of the relationship to promote healthy relating in the patient.

Interventions in consultation-liaison psychiatry: the development of a schema and a checklist for operationalized interventions

A literature review and pilot investigations reveal that (ward-) management consultation-liaison (C/L) psychiatry recommendations are infrequent and unsystematically used. Furthermore, the communication with the operational group as defined by Meyer and Mendelson is not sufficiently activated. The major focus of the consultation is the first contact, but follow-up is infrequent. With the exception of biologic recommendations and disposition, chart notes by psychiatric consultants do not sufficiently specify the actions to be taken by the ward staff in a general hospital. A schema for the systematic organization of the intervention was developed. A checklist of operationalized C/L interventions is reported. This combination provides a tool for the systematic use of strategic ward management and discharge recommendations. Its basic structure is currently integrated in MICRO CARES [Hammer et al, SCAMC]. The impact on clinical care, education, and research is described.

Screening emergency room patients with atypical chest pain for depression and panic disorder

In response to recent reports relating atypical chest pain to normal coronary arteries and to various types of psychopathology, we developed a pilot study to investigate 1) the prevalence of depression and panic disorder among patients presenting to an emergency room with atypical chest pain, and 2) what the likelihood is of an emergency room physician recognizing the psychosocial factor. Of forty-nine subjects screened, 39 percent scored positively for depressive syndrome on the Center for Epidemiological Studies-Depression rating scale, 43 percent met criteria for panic attack and 16 percent met criteria for panic disorder by DSM-III. Although thirty subjects (61%) screened positively for depression or panic attack, only one received a psychiatric diagnosis of any kind. This pilot study suggests: 1) that the relationship between chest pain and psychopathology in emergency room patients deserves further rigorous study; 2) that depression and panic attacks in association with atypical chest pain may be underdiagnosed by the emergency room physician; and 3) that self-report screening measures as an aid to diagnosis in this population need to be more closely investigated.

The 'tired person' syndrome. Understanding the pathologic factors in these 'problem' patients

Many "problem" patients seen in primary care settings cannot be easily classified as "masked depressives" or seekers of secondary gain. Rather, they fit into a third category--those with the "tired person" syndrome. The essential feature of this syndrome is the decrease in self-esteem that follows the real or perceived loss of the ability to work productively. The decrease in self-esteem triggers anxiety, which may be so severe as to approach a panic state. The patient then becomes increasingly disabled or has increasing physical symptoms and enters a vicious cycle culminating in debility. Treatment is aimed at the physician's accepting and legitimizing the very real loss that the patient perceives in order to help him or her become comfortably dependent.

Ambulatory mental health liaison research: a review and preview

Mental health liaison in primary care is a complex technology requiring scientific study and validation if we are to know when, where, and how to utilize it. Earlier studies have raised as many questions as they have resolved. Recommendations for future research are presented in relation to such issues as: How should mental health consultation/liaison be defined? How should consultation/liaison studies be prioritized? What aspects of consultation/liaison should be studied? What methodologies are appropriate?

The effectiveness of mental health consultation and referral in ambulatory primary care: a research lacuna

This article reviews the research literature on referral to and consultation with mental health specialists for patients in ambulatory medical settings. Very few controlled trials measuring the efficacy of such liaison could be located. They were mainly from the British literature, usually involved psychologists, and (with the exception of one study) tested only the model of referral to the mental health specialist for treatment. More research needs to be done in this important area. Methodologic issues and topics for further study are discussed.