Somatization--beyond symptom count

Fibromyalgia Patients Are Not Only Hypersensitive to Painful Stimuli But Also to Acoustic Stimuli

Fibromyalgia is a chronic widespread pain syndrome associated with hypersensitivity to nociceptive stimuli. This increased sensitivity of FM patients has been associated with central sensitization of dorsal horn neurons. Increasing evidence, however, suggests that the mechanisms of FM hypersensitivity not only affect pain but include light, smell, and sound. We hypothesized that supraspinal augmentation of sensory input including sound represent a hallmark of FM. We tested 23 FM patients and 28 healthy controls (HC) for sensory augmentation of nociceptive and non-nociceptive sensations: For assessment of nociceptive augmentation we used sensitivity adjusted mechanical and heat ramp & hold stimuli and for assessment of sound augmentation, we applied wideband noise stimuli using a random-staircase design. Quantitative sensory testing demonstrated increased heat and mechanical pain sensitivity in FM participants (P < .001). The sound pressures needed to report mild, moderate, and intense sound levels were significantly lower in FM compared to HC (P < .001), consistent with auditory augmentation. FM patients are not only augmenting noxious sensations but also sound, suggesting that FM augmentation mechanisms are not only operant in the spinal cord but also in the brain. Whether the central nervous system mechanisms for auditory and nociceptive augmentation are similar, needs to be determined in future studies. PERSPECTIVE: This study presents QST evidence that the hypersensitivity of FM patients is not limited to painful stimuli but also to innocuous stimuli like sound. Our results suggest that abnormal brain mechanisms may be responsible for the increased sensitivity of FM patients.

Evolution of bodily distress disorders

PURPOSE OF REVIEW

The nomenclature and classification of somatoform disorders have undergone revisions in the fifth edition of the Diagnostic and Statistical Manual (DSM 5) and the upcoming eleventh edition of the International Classification of Diseases (ICD-11). The present review describes the changes that have evolved and highlight the possible challenges.

RECENT FINDINGS

Bodily distress disorders replace the term somatoform disorders. The emphasis on the symptoms to be medically unexplained has been removed. The need to have a certain number of symptoms associated with different organ systems has made way to the presence of one or more distressing bodily symptoms. The focus on psychological aspects like excessive attention, thoughts, and behaviors associated with bodily symptoms have been added to make it a more diagnosis of inclusion rather than exclusion. An additional qualifier of severity has been added, which highlights the importance of impairment associated with these symptoms.

SUMMARY

The diagnostic criteria for bodily distress disorders is a step towards making the diagnostic criteria clinically useful and appears to be applicable across the healthcare settings. However, the ability to discern this diagnosis with the newly revised classification of chronic pain and the possibility of over psychologizing the medical disorders need to be researched.

The Theoretical Construction of a Classification of Clinical Somatic Symptoms in Psychosomatic Medicine Theory

Objective

This article adopts the perspective of psychosomatic medicine to present and test a theoretical model of the classification of clinical somatic symptoms. The theoretical model consists of four dimensions: emotional somatic symptoms, biological somatic symptoms, imaginative somatic symptoms, and cognitive somatic symptoms.

Method

A clinical somatic symptom classification scale was developed according to the theoretical model. A total of 542 participants completed the clinical somatic symptoms classification scale. The data were analyzed using exploratory and confirmatory factor analyses.

Results

The results confirmed the theoretical model. The analyses found that the proposed theoretical structure of the scale was good, as indicated by factor loadings and fit indices, and that the scale had good reliability and construct validity.

Conclusions

Based on the interpretation of the clinical symptoms of psychosomatic medicine, the treatment of chronic non-infectious diseases includes at least three dimensions: the first is the etiological treatment, the second is the pathophysiological and pathopsychological dimension, and the third is symptomatic treatment. The unified psychosomatic point of view and diverse clinical thinking modes are aimed at identifying different classes of somatic symptoms and important prerequisites for the treatment of these symptoms. We registered the study with the Chinese Clinical Trial Registry and it was approved by the West China Hospital, Sichuan University ethics committee. Trial registration: The registration number is ChiCTR-OCS-14004632 (time: 2014-05-12).

Do the various categories of somatoform disorders differ from each other in symptom profile and psychological correlates

BACKGROUND

In routine clinical practice, the subcategories of various somatoform disorders are rarely used by the primary care physicians and there is lack of data to suggest any difference in the clinical manifestations of these subcategories.

AIM

To compare the symptom profile, anxiety, depression, alexithymia, somato-sensory amplification and hypochondriasis of patients with persistent somatoform pain disorder with other subtypes of somatoform disorder.

METHOD

A total of 119 patients diagnosed with somatoform disorders according to the International Classification of Diseases-10th Revision (ICD-10) were evaluated for prevalence of somatic symptoms, anxiety, depression, alexithymia, hypochondriacal worry and somato-sensory amplification.

RESULTS

No significant differences were found in the prevalence of various somatic complaints between those with persistent somatoform pain disorder group and those diagnosed with other somatoform disorders. Co-morbid anxiety and depression were seen in two-thirds of the patients, but again there was no difference in the prevalence of the same between the two groups. Similarly, no significant differences were found on alexithymia, hypochondriasis and somato-sensory amplification scales between the persistent somatoform pain disorder group and the group with other somatoform disorders.

CONCLUSION

There are no significant differences between the various subcategories of somatoform disorders with regard to the prevalence of somatic symptoms, anxiety or depression and psychological correlates of alexithymia, hypochondriasis and somato-sensory amplification.

Evaluating new proposals for the psychiatric classification of patients with multiple somatic symptoms

OBJECTIVES

The current DSM-IV classification of somatoform disorders has been criticized, and several new proposals for classification have been suggested (e.g., DSM-V work group: complex somatic symptom disorder [CSSD]). Our aim was to empirically validate and compare new proposals for the classification of people with multiple somatic complaints.

METHODS

Three hundred twenty-one participants were selected from a general population sample of more than 2500; half were selected from a subgroup with increased somatization scores (Patient Health Questionnaire 15-item somatic symptom subscale). Clinical and psychological variables and health care use were assessed with interviews and self-ratings to validate the new proposals. In addition, a high-risk group was defined to check whether new classification proposals could identify people in this a priori defined group; criteria for this high-risk group were disabling medically unexplained somatic symptoms and increased health care use. To analyze the stability of the syndromes, participants were recontacted 1 year later (completion rate, 76%).

RESULTS

The DSM-V proposal for CSSD shows good validity in the identification of people with disability and people requiring medical treatment. It is still restrictive but to a much lesser degree than the current somatization disorder: 29% of our a priori high-risk group was identified, whereas none of the participants fulfilled criteria for somatization disorder. For most proposals, the temporal stability is satisfactory yet substantially lower than expected for clinical samples. Classification criteria that include psychological features are advantageous in identifying people with health care needs.

CONCLUSIONS

Whereas some validation criteria for the new proposals (including CSSD) are satisfactory, most of the new proposals are still restrictive.

Empirical foundations for the diagnosis of somatization: implications for DSM-5

BACKGROUND

The aim of this study was to develop empirically validated criteria for the diagnoses of clinically relevant somatization.

METHOD

This study was performed in a population-representative cohort consisting of 461 males (47.8%) and 503 females (52.2%), with an average age of 55.8 years (s.d.=11.1). Somatization, anxiety and depression were derived from the Composite International Diagnostic Interview. Mplus was used to perform confirmative factor analyses on the current DSM-IV symptom groups; on alternative symptom clusters previously suggested; and to perform latent class analysis in order to define an empirically derived cut-off for somatization.

RESULTS

The existence of symptom groups as described in DSM-IV was not supported by our data, whereas a differentiation between cardiopulmonary, musculoskeletal, gastrointestinal and general somatic symptoms did fit our data. Latent class analysis revealed two classes characterized by few (n=859) and many (n=105) symptoms. The class of subjects could be approached by a simple cut-off of four functional symptoms (sensitivity 79%, specificity 98%, positive predictive value 82%, negative predictive value 97%) regardless of the number of organ systems involved.

CONCLUSIONS

This study in a large population-representative cohort suggests that a simple symptom count can be used as a dimensional diagnosis of somatization. In those instances in which a categorical diagnosis is preferred, a simple cut-off of four out of 43 functional symptoms best fitted our data. We did not find any added value for incorporating the number of symptom clusters into the diagnostic criteria.

Are psychological features useful in classifying patients with somatic symptoms?

OBJECTIVE

To evaluate psychological characteristics that could be used for the classification of somatic syndromes requesting medical care. Positive psychological classification criteria are needed to justify the classification of somatic syndromes as Diagnostic and Statistical Manual of Mental Disorders- or International Classification of Diseases-10 section F/mental disorders diagnosis.

METHODS

From a population-based sample of 2510 people, subsamples reporting high scores for somatic symptoms (SOM+; n = 154) versus average scores for somatic symptoms (SOM-; n = 167) were defined. Telephone interviews (e.g., structured interviews for diagnoses, healthcare use, symptom history, possible psychological characteristics), self-rating scales (e.g., Pain Disability Index, depression scale Patient Health Questionnaire-9), and general practitioners reports were collected for these subsamples. In addition to somatic symptoms, we used healthcare use and disability as major external validation criteria.

RESULTS

There was strong evidence for ten of the 28 binary coded psychological variables to identify those people with somatic symptoms who needed medical help and/or were seriously disabled. These variables included "avoidance of physical activities," "bias for somatic illness attributions," "self-concept of being physically weak," and "desperation because of somatic symptoms." The relevance of these psychological characteristics was partially further confirmed by stepwise regression analyses, which showed incremental validity compared with variables like somatic symptoms and depression.

CONCLUSIONS

This study identified several psychological characteristics of people with somatic complaints who need medical care. These features can be assessed, using binary variables that are more feasible for classification processes. These psychological criteria should be included in classification rules for people with somatic syndromes (e.g., somatoform disorders).

[Stress, coping and craniomandibular disorders - a longitudinal study]

OBJECTIVES

Stress is widely accepted as an etiologic factor of craniomandibular disorders (CMD). There is, however, a lack of studies evaluating the significance of interindividual differences of stress and coping for the development of CMD.

METHODS

99 volunteers (33 male, 66 female) were observed over a period of 24 months. The clinical examination at the beginning and end of the observation time were carried out according to the protocol of the Research Diagnostic Criteria for Temporomandibular Disorders (Dworkin 1992). Data concerning stress and general body complaints were evaluated twice by questionnaires, and data on coping methods were collected at the beginning of the study.

RESULTS

Stress, coping methods and general body complaints correlate with clinical functional parameters. Stress and body complaints proved to be significant predictors via linear regression analyses.

CONCLUSIONS

Stress and general somatic complaints are predictors of the development of craniomandibular disorders.

Revising the Classification of Somatoform Disorders: Key Questions and Preliminary Recommendations

As the DSM-V process unfolds, Somatoform Disorders are a diagnostic category for which major revisions seem warranted. The Conceptual Issues in Somatoform and Similar Disorders (CISSD) project recently convened three workshops, involving 24 experts. The CISSD identified key questions related to stakeholders; terminology; appropriate axis (I versus III); medically unexplained criteria; status of functional somatic syndromes; and symptom counts, grouping, lifetime recall, and checklists. Preliminary recommendations include substantial revision of the category of Somatization Disorder, elimination of Undifferentiated Somatoform Disorder and Pain Disorder, terminology changes, and potential shifting of certain disorders to different DSM categories or axes.

Are somatoform disorders 'mental disorders'? A contribution to the current debate

PURPOSE OF REVIEW

During the last 2 years, a debate has started over whether the somatoform symptoms/medically unexplained symptoms are wrongly placed under the category of mental disorders (section F in International classification of diseases-10 and in Diagnostic and statistical manual for mental disorders-IV).

RECENT FINDINGS

Most experts on medically unexplained symptoms agree that there is a substantial need for revision of the diagnoses of somatoform disorders. While some authors suggest moving the somatoform disorders from axis I to axis III, others suggest improving the classification of these syndromes on axis I, such as by using empirically derived criteria and by introducing psychological descriptors which justify the categorization as a mental disorder. In contrast to the situation when the last version of Diagnostic and statistical manual for mental disorders was published, new empirical data has shown some psychological and behavioural characteristics of patients with somatoform symptoms. These and other empirically founded approaches can be landmarks for the revision of this section in Diagnostic and statistical manual for mental disorders-V and International classification of diseases-11.

SUMMARY

The classification of somatoform disorders as 'mental disorders' could be justified if empirically founded psychological and behavioural characteristics are included into the classification process. Attention focusing, symptom catastrophizing, and symptom expectation are outlined as possible examples of involved psychological processes.

Somatization, somatosensory amplification, attribution styles and illness behaviour: a review

Somatic symptoms have been conceptualized in many different ways in literature. Current classifications mainly focus on the numbers of symptoms, with relative neglect of the underlying psychopathology. Researchers have emphasized the importance of a number of experiential, perceptual and cognitive-behavioural aspects of somatization. This review focuses on existing literature on the role of somatosensory amplification, attribution styles, and illness behaviour in somatization. Evidence suggests that somatosensory amplification is neither sensitive nor specific to somatizing states, and that other factors like anxiety, depression, neuroticism, alexithymia may also have an influence. Attribution research supports the existence of multiple causal attributions, which are related to the numbers of somatic symptoms. While somatizing patients have more organic attributions, depressed patients have more psychological attributions. A global somatic attribution style is associated with the number of obscure somatic symptoms, while a psychological attribution style is associated with both--psychological and somatic-- symptoms of depression and anxiety. There are conflicting findings with respect to the role of normalizing attributions in reducing physician recognition of anxiety and depression. Specific symptom attributions appear to explain physician recognition of psychological distress, but global attribution styles do not appear to explain any further variance in physician recognition beyond that explained by specific causal attributions. Illness behaviour has been studied in two distinct ways in literature. Research focusing on attendance rates as a form of illness behaviour suggests that somatization is associated with high levels of health care utilization. There is also some evidence that health care utilization, amplification and attributions styles may be interrelated among somatizing patients. More structured ways to assess illness behaviour have found high levels of abnormal illness behaviour in this population. Overall, research appears to suggest a complex (and as yet unclear) relationship between somatic symptoms and underlying cognitions/illness behaviours. While it is clear that somatization is closely related to a number of perceptual and cognitive-behavioural factors, the precise nature of these relationships are yet to be elucidated.

Classification of somatization and functional somatic symptoms in primary care

OBJECTIVE

A substantial proportion of patients found in primary care complain of physical symptoms not attributable to any known conventionally defined disorder, that is, medically unexplained or functional somatic symptoms. The objective of this paper is to outline the problems with the current classification and propose a classification more suitable for primary health care.

METHOD

We refer to and discuss relevant literature including papers on our own research on the topic in the light of our experiences from major projects on somatizing patients in primary health care.

RESULTS

Functional somatic symptoms may impose severe suffering on the patient and are costly for society because of high health-care utilization, lost working years and social expenses. At present, studies on functional somatic symptoms and disorders and their treatment are hampered by lack of a valid and reliable diagnostic classification. The diagnostic categories of somatoform disorders are overlapping. Thus, the present situation is that patients with identical symptoms and clinical pictures may receive different diagnostic labels depending on the focus of interests of the assessing physician. A particular problem in primary care is that the somatoform diagnostic categories only include persistent cases and do not offer the opportunity for classification of the patients with short-symptom duration found in this setting. We present a framework for a new descriptive classification of functional somatic symptoms and unfounded illness worrying, and outline a new classification that covers the whole spectrum of severity seen in clinical practice.

CONCLUSION

A precondition for an appropriate management of patients with functional somatic symptoms is a valid taxonomy common for all medical specialties facilitating cooperative care. Classification systems as outlined in this paper may be a candidate for such a system, but it should be subject to further evaluation in research.

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

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-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.

Subjective health complaints, sensitization, and sustained cognitive activation (stress)

INTRODUCTION

This review argues that "subjective health complaints" is a better and neutral term for "unexplained medical symptoms." The most common complaints are musculoskeletal pain, gastrointestinal complaints and "pseudoneurology" (tiredness, sleep problems, fatigue, and mood changes). These complaints are common in the general population, but for some these complaints reach a level that requires care and assistance.

THEORETICAL ASSUMPTIONS

We suggest that these complaints are based on sensations from what in most people are normal physiological processes. In some individuals these sensations become intolerable. In some cases it may signal somatic disease, in most cases not. Cases without somatic disease, or with minimal somatic findings, occur under diagnoses like burnout, epidemic fatigue, multiple chemical sensitivity, chronic musculoskeletal pain, chronic low back pain, chronic fatigue syndrome, and fibromyalgia. These complaints are particularly common in individuals with low coping and high levels of helplessness and hopelessness.

CONCLUSION

The psychobiological mechanisms for this is suggested to be sensitization in neural loops maintained by sustained attention and arousal.

Effektivität einer stationären Gruppentherapie für Patienten mit multiplem somatoformen Syndrom:

Zusammenfassung. Theoretischer Hintergrund: Obwohl somatoformen Störungen eine erhebliche klinische und sozioökonomische Relevanz zukommt, liegen bislang nur wenige kontrolliert-randomisierte Therapiestudien vor. Fragestellung: Wir untersuchten daher a.) die kurz- und langfristige Effektivität eines stationären verhaltensmedizinischen Behandlungsprogramms und überprüften b.) die differentielle Wirksamkeit einer begleitenden kognitiv-behavioralen Gruppentherapie für Patienten mit multiplem somatoformen Syndrom. Methode: In einer psychosomatischen Fachklinik wurden 191 Patienten mit multiplem somatoformen Syndrom randomisiert den Interventionen (1) Standardbehandlung plus Gruppentherapie Somatisierung oder (2) Standardbehandlung plus Entspannungstraining zugewiesen. Eine Warte-Kontrollgruppe von 34 Patienten wurde bei Anmeldung untersucht. Ergebnisse: In beiden Interventionsgruppen zeigten sich trotz ausgeprägter Schwere der Symptomatik langfristig stabile Behandlungseffekte bezüglich Symptomanzahl, gesundheitsbezogener Lebensqualität, allgemeiner Psychopathologie, dysfunktionaler Kognitionen und Inanspruchnahmeverhalten. Die additive Gruppentherapie erwies sich dem Entspannungstraining bezüglich der Reduktion von Inanspruchnahmeverhalten und störungsspezifischen Kognitionen als überlegen. Schlussfolgerungen: Die Ergebnisse sind Beleg für die Effektivität des stationären Behandlungsprogramms, das durch eine störungsspezifische Gruppentherapie optimiert werden kann.

Clinical characteristics of somatization in dental practice

OBJECTIVES

This study was a first attempt to derive an estimate of the likely incidence of somatization-specific behaviour in a dental setting and its relationship with both somatic symptoms and symptoms of depression.

METHODS

Somatization-specific behaviour was operationalized as reporting of inexplicable dental symptoms (eg pain), remarkable frequent attendance at a dental surgery, inexplicably high treatment use or unreasonable requests with regard to treatment.

RESULTS

Of the 309 patients surveyed, 8.7%o fulfilled one or more of the criteria for somatization-specific behaviour. This was particularly manifested by a high attendance rate (6.8%). Women exhibited somatization-specific behaviour significantly more often (73%) than men (27%9). Support was found for the hypothesis that individuals exhibiting characteristics of somatization-specific behaviour would present themselves to dentists more often with dental complaints and would suffer more from symptoms of depression than patients that did not display these characteristics.

CONCLUSIONS

The results suggest that somatization is a factor in dental practice.

Specific somatoform disorder in the general population

The authors assessed the validity of the recently proposed diagnosis for specific somatoform disorder in the general population. German versions of the DSM-IV adapted Composite International Diagnostic Interview were administered to a representative sample of 4075 individuals. Multivariate analyses were used to compare impairment, life satisfaction, and use of health care. A total of 803 of 4075 subjects (19.7%) with undifferentiated somatization disorder were identified, which included 51 subjects (1.3%) who met criteria for specific somatoform disorder. Subjects with specific somatoform disorder were more impaired, had lower life satisfaction, and had higher use of health care than subjects with undifferentiated somatization disorder only. The proposed diagnosis of specific somatoform disorder demonstrated a high validity independent of comorbid depressive and anxiety disorders.

Somatization: a critical review of conceptual and methodological issues

Despite its apparent clinical importance and the extensive research that has been conducted in the past decades, somatization remains a complex concept. Two distinct ways of looking at somatization can be distinguished: somatization as a phenomenon that is secondary to psychological distress (presenting somatization) and somatization as a primary phenomenon characterized by medically unexplained symptoms (functional somatization). The literature was analyzed in terms of this distinction and a selective review was conducted, focusing on a critical analysis of conceptual and methodological issues related to presenting and functional somatization. A number of measurement issues related to somatization in general were also highlighted. On the basis of the available data, the strengths and weaknesses of different concepts are pointed out. Conclusions are formulated regarding which concepts or approaches might be useful both clinically and from a research perspective. Finally, a number of suggestions for future research are offered.

Is "somatisation" a defense against the acknowledgment of psychiatric disorder?

OBJECTIVE

To determine whether experiencing physical symptoms is associated with a denial of psychological distress in individuals with probable psychiatric disorder.

METHODS

A nested case-control study was performed using data from a national birth cohort study. All subjects who scored above threshold on a case-finding questionnaire of psychiatric disorder were identified. Those who in a separate question endorsed the presence of psychiatric disorder ("acknowledgers") were compared with those who did not.

RESULTS

Acknowledgers were more likely to be female, better educated and have more severe current and past psychiatric disorder. They were also more likely to report multiple physical symptoms, even when potential confounders and severity of psychiatric disorder were controlled.

CONCLUSION

There is no evidence that experiencing multiple physical symptoms helps the individual deny the presence of psychiatric disorder.

Toward empirically based criteria for the classification of somatoform disorders

There is a major need for an empirical evaluation of classification criteria for somatoform disorders. The present study analyzes psychometric properties of the existing criteria for somatization disorder. The full sample consisted of 324 patients seeking help because of "psychosomatic problems." Data from a subsample of carefully diagnosed patients with somatization syndrome (n = 76) and a clinical comparison group (n = 32) permitted the analysis of the discriminative power of items. Twenty-one somatic symptoms adopted from DSM-IV and ICD-10 criteria did not exhibit the necessary psychometric characteristics (item probability, item-total correlation, etc.). Thirty-two somatic symptoms showed a satisfactory psychometric performance. A cut-off of seven or more symptoms yielded the best discrimination between low and high disability. New criteria for somatization syndrome ("polysymptomatic somatoform disorder") are proposed taking into account for the strong association of somatization and abnormal illness behavior.

Patients with medically unexplained symptoms: sources of patients' authority and implications for demands on medical care

Lay and medical beliefs are not separate systems. The beliefs of somatizing patients, in particular, incorporate medical understanding and it has been argued that this increases the power that such patients exert in seeking treatment from doctors. To understand the nature and use of this power requires investigation of (i) how patients use medical ideas and language to explain their symptoms and (ii) how this process influences patients' expectations and evaluations of their doctors. We interviewed 68 patients, in whom no physical cause had been found for persistent physical symptoms. Their accounts of symptoms and of their experience of doctors were subjected to qualitative thematic analysis. As expected, patients used medical terms to explain their symptoms. However, these depicted explanatory themes which have long been familiar in traditional lay models: disease as a malign entity and imbalance between bodily forces. Patients' sense of authority over doctors derived, not from facility with medical language and ideas but from contrasting their own sensory, and therefore infallible, experience of symptoms with doctors' indirect and fallible knowledge. By providing explanations that questioned the reality of symptoms, doctors were perceived as incompetent and inexpert. Patients used their authority, not to seek treatment, but to secure naming of, and collaboration against, the disorder. Although these patients saw the doctors' role as limited and inexpert by comparison with their own, our analysis suggests ways in which doctors might more effectively engage with persistent somatizing patients.