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August 27, 1997, Vol 278, No. 8 >
ARTICLE | August 27, 1997

A 37-Year-Old Man With Multiple Somatic Complaints FREE

Arthur J. Barsky, MD
[+] Author Affiliations

This conference took place at the Medicine Grand Rounds of the Beth Israel Deaconess Medical Center, West Campus, Boston, Mass, on March 18, 1997.

Reprints: Erin E. Hartman, MS, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, East Campus, 330 Brookline Ave, LY318, Boston, MA 02215.

Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and edited by Thomas L. Delbanco, MD, and Jennifer Daley, MD; Erin E. Hartman, MS, is managing editor. Clinical Crossroads section editor: Margaret A. Winker, MD, Senior Editor, JAMA.


JAMA. 1997;278(8):673-679. doi:10.1001/jama.1997.03550080083044
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References

DrDelbanco:  Mr H is a 37-year-old man who has had multiple physical complaints for years without a clear medical diagnosis. An immigrant from Colombia to the United States, he is selfemployed, and works as an educator for the young in the inner city. He is covered by a commercial managed care insurance plan and is cared for by a medical resident in primary care practice at the Beth Israel Deaconess Medical Center.His multiple physical complaints began during adolescence with nausea and vomiting without weight change In recent years, he has suffered from periodic pruritus ani, legs that become "weak" at times, and allergic symptoms including hay fever, allergy to cats, and recurrent itchiness around the eyes. He notes a frequent rectal discharge and had 1 episode of bleeding, evaluated by colonoscopy, which was normal. Liver function tests were mildly elevated in the past. He has experienced pain and numbness

REFERENCES

1 +
Lipowski ZJ.  Somatization: the concept and its clinical application . Am J Psychiatry . 1988;;145:1358-1368.
2 +
Bridges KW, Goldberg DP.  Somatic presentation of DSM III psychiatric disorders in primary care . J Psychosom Res . 1985;;29:563-569.
3 +
Kroenke K, Arrington ME, Mangelsdorff AD.  The prevalence of symptoms in medical outpatients and the adequacy of therapy . Arch Intern Med . 1990;;150:1685-1690.
4 +
Katon W, Ries RK, Kleinman A.  The prevalence of somatization in primary care . Compr Psychiatry . 1984;;25:208-215.
5 +
van der Gagg J, van de Ven W.  The demand for primary health care . Med Care . 1978;;26:299-312.
6 +
Pilowsky I, Smith QP, Katsikitis M.  Illness behavior and general practice utilization: a prospective study . J Psychosom Res . 1987;;31:177-183.
7 +
Kroenke K, Spitzer RL, Williams JBW, et al.  Physical symptoms in primary care . Arch Fam Med . 1994;;3:774-779.
8 +
Kroenke K, Mangelsdorff AD.  Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome . Am J Med . 1989;;86:262-266.
9 +
Craig TKJ, Boardman AP, Mills K, Daley-Jones 0, Drake H.  The South London Somatization Study, I . Br J Psychiatry . 1993;;163:579-588.
10 +
Escobar JI, Golding JM, Hough RL, Karno M, Burnham MA, Wells KB.  Somatization in the community . Am J Public Health . 1987;;77:837-840.
11 +
Lipowski ZJ.  Somatization . Can Med Assoc J . 1986;;135:609-613.
12 +
Bass C. Somatization: Physical Symptoms and Psychological Illness . Oxford, England: Blackwell Scientific Publications; 1990;.
13 +
deGruy F, Columbia L, Dickinson P.  Somatization disorder in a family practice . J Fam Pract . 1987;;25:45-51.
14 +
Swartz M, Blazer D, George L, Landerman R.  Somatization disorder in a community population . Am J Psychiatry . 1986;;143:1403-1408.
15 +
Zoccolillo MS, Cloninger CR.  Excess medical care of women with somatization disorder . South Med J . 1986;;79:532-535.
16 +
Barsky AJ, Wyshak G, Latham KS, Klerman GL.  Hypochondriacal patients, their physicians, and their medical care . J Gen Intern Med . 1991;;6:413-419.
17 +
Fink P.  The use of hospitalizations by somatizing patients . Psychol Med . 1992;;22:173-180.
18 +
Smith GR, Monson RA, Ray DC.  Patients with multiple unexplained symptoms . Arch Intern Med . 1986;;146:69-72.
19 +
Fink P.  Surgery and medical treatment in persistent somatizing patients . J Psychosom Res . 1992;;36:439-447.
20 +
Ford CV. The Somatizing Disorders: Illness as a Way of Life . New York, NY: Elsevier Biomedical; 1983;.
21 +
Kellner R. Somatization and Hypochondriasis . New York, NY: Praeger; 1986;.
22 +
Cassem NH, Barsky AJ.  Functional somatic symptoms and somatoform disorders . In: Cassem NH, ed. Massachusetts General Hospital Handbook of General Hospital Psychiatry . St Louis, Mo: Mosby-Year Book Inc; 1991;:131-158.
23 +
Russo J, Katon W, Sullivan M, Clark M, Buchwald D.  Severity of somatization and its relationship to psychiatric disorders and personality . Psychosomatics . 1994;;35:546-556.
24 +
Dworkin SF, Von Korff M, Le Resche.  Multiple pains and psychiatric disturbance; on epidemiologic investigation . Arch Gen Psychiatry . 1990;;47:239-244.
25 +
Katon W, Lin E, Von Korff M, et al.  Somatization: a spectrum of severity . Am J Psychiatry . 1991;;148:34-40.
26 +
Brown FW, Golding JM, Smith R.  Psychiatric comorbidity in primary care somatization disorder . Psychosom Med . 1990;;52:445-451.
27 +
Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ.  Somatization and the recognition of depression and anxiety in primary care . Am J Psychiatry . 1993;;150:734-741.
28 +
Oxman TE, Harrigan J, Kues J.  Diagnostic patterns of family physicians for somatoform, depressive, and anxiety disorders . J Fam Pract . 1983;;17:439-446.
29 +
Ormel J, Van Den Brink W, Koeter MWJ, et al.  Recognition, management and outcome of psychological disorders in primary care: a naturalistic follow-up study . Psychol Med . 1990;;20:909-923.
30 +
Strain JJ, Hammer JS, Fulop G.  APM Task Force on Psychosocial Interventions in the General Hospital Inpatient Setting . Psychosomatics . 1994;;35:253-262.
31 +
Simon G, Ormel J, Von Korff M, Barlow M.  Health care costs associated with depressive and anxiety disorders in primary care . Am J Psychiatry . 1995;;152:352-357.
32 +
Barsky AJ, Wyshak G.  Hypochondriasis and somatosensory amplification . Br J Psychiatry . 1990;;157:404-409.
33 +
Barsky AJ, Klerman GL.  Overview: hypochondriasis, bodily complaints, and somatic styles . Am J Psychiatry . 1983;;140:273-283.
34 +
Barsky AJ.  Amplification, somatization and the somatoform disorders . Psychosomatics . 1992;;33:28-34.
35 +
Pennebaker JW. The Psychology of Physical Symptoms . New York, NY: Springer-Verlag; 1982;.
36 +
Pennebaker JW, Epstein D. Implicit psychophysiology.J Personality . 1983;;51:468-496.
37 +
Pennebaker JW, Watson D.  The psychology of somatic symptoms . In: Kirmayer LJ, Robbins JM, ed. Current Concepts of Somatization: Research and Clinical Perspectives . Washington, DC: American Psychiatric Association Press; 1991;:24-35.
38 +
Robbins PR, Meyersburg HA, Tanck RH.  Interpersonal stress and physical complaints . J Pers Assess . 1974;;38:578-585.
39 +
Mechanic D.  Effects of psychological distress on perceptions of physical health and use of medical and psychiatric facilities . J Human Stress . 1978;;4:26-32.
40 +
Speckens AEM, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooijmans HGM.  Cognitive behavioural therapy for medically unexplained physical symptoms: a randomized controlled trial . BMJ . 1995;;311:1328-1332.
41 +
Barsky AJ.  Hypochondriasis: medical management and psychiatric treatment . Psychosomatics . 1996;;37:48-56.
42 +
Sharpe M, Peveler R, Mayou R.  The psychological treatment of patients with functional somatic symptoms . J Psychosom Res . 1992;;36:515-529.
43 +
Warwick HMC, Marks IM.  Behavioural treatment of patients with functional somatic symptoms: a practical guide . Br J Psychiatry . 1988;;152:239.
44 +
Salkovskis PM.  Somatic problems . In: Hawton K, Salkovskis PM, Kirk JW, Clark DM, eds. Cognitive-Behavioral Approaches to Adult Psychiatric Disorders: A Practical Guide . Oxford, England: Oxford University Press; 1989;:235-276.
45 +
Bass C, Benjamin S.  The management of chronic somatisation . Br J Psychiatry . 1993;;162:472-480.
46 +
DeGuire S, Gevirtz R, Kawahara Y, Maguire W.  Hyperventilation syndrome and the assessment of treatment for functional cardiac symptoms . Am J Cardiol . 1992;;70:673-677.
47 +
van Dulmen AM, Fennis JFM, Bleijenberg G.  Cognitive-behavioral group therapy for irritable bowel syndrome . Psychosom Med . 1996;;58:508-514.
48 +
Deale A, Chalder T, Marks I, Wessely S.  Cognitive behavior therapy for chronic fatigue syndrome . Am J Psychiatry . 1997;;54:408-414.
49 +
Caudill M, Schnabel R, Zuttermeister P, et al.  Decreased clinic use by chronic pain patients . Psychosom Med . 1995;;57:234-244.
50 +
Buckelew SP.  Fibromyalgia: a rehabilitation approach . Am J Phys Med Rehab . 1989;;68:37-42.
51 +
Martin PR, Nathan PR, Milech D, van Keppel M.  Cognitive therapy vs self-management training in the treatment of chronic headaches . Br J Clin Psychol . 1989;;28:347-361.
52 +
Sharpe M.  Cognitive behavioural therapies in the treatment of functional somatic symptoms . In: Mayou R, Bass C, Sharpe M, eds. Treatment of Functional Somatic Symptoms . Oxford, England: Oxford University Press; 1995;: 122-143.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Lipowski ZJ.  Somatization: the concept and its clinical application . Am J Psychiatry . 1988;;145:1358-1368.
2 +
Bridges KW, Goldberg DP.  Somatic presentation of DSM III psychiatric disorders in primary care . J Psychosom Res . 1985;;29:563-569.
3 +
Kroenke K, Arrington ME, Mangelsdorff AD.  The prevalence of symptoms in medical outpatients and the adequacy of therapy . Arch Intern Med . 1990;;150:1685-1690.
4 +
Katon W, Ries RK, Kleinman A.  The prevalence of somatization in primary care . Compr Psychiatry . 1984;;25:208-215.
5 +
van der Gagg J, van de Ven W.  The demand for primary health care . Med Care . 1978;;26:299-312.
6 +
Pilowsky I, Smith QP, Katsikitis M.  Illness behavior and general practice utilization: a prospective study . J Psychosom Res . 1987;;31:177-183.
7 +
Kroenke K, Spitzer RL, Williams JBW, et al.  Physical symptoms in primary care . Arch Fam Med . 1994;;3:774-779.
8 +
Kroenke K, Mangelsdorff AD.  Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome . Am J Med . 1989;;86:262-266.
9 +
Craig TKJ, Boardman AP, Mills K, Daley-Jones 0, Drake H.  The South London Somatization Study, I . Br J Psychiatry . 1993;;163:579-588.
10 +
Escobar JI, Golding JM, Hough RL, Karno M, Burnham MA, Wells KB.  Somatization in the community . Am J Public Health . 1987;;77:837-840.
11 +
Lipowski ZJ.  Somatization . Can Med Assoc J . 1986;;135:609-613.
12 +
Bass C. Somatization: Physical Symptoms and Psychological Illness . Oxford, England: Blackwell Scientific Publications; 1990;.
13 +
deGruy F, Columbia L, Dickinson P.  Somatization disorder in a family practice . J Fam Pract . 1987;;25:45-51.
14 +
Swartz M, Blazer D, George L, Landerman R.  Somatization disorder in a community population . Am J Psychiatry . 1986;;143:1403-1408.
15 +
Zoccolillo MS, Cloninger CR.  Excess medical care of women with somatization disorder . South Med J . 1986;;79:532-535.
16 +
Barsky AJ, Wyshak G, Latham KS, Klerman GL.  Hypochondriacal patients, their physicians, and their medical care . J Gen Intern Med . 1991;;6:413-419.
17 +
Fink P.  The use of hospitalizations by somatizing patients . Psychol Med . 1992;;22:173-180.
18 +
Smith GR, Monson RA, Ray DC.  Patients with multiple unexplained symptoms . Arch Intern Med . 1986;;146:69-72.
19 +
Fink P.  Surgery and medical treatment in persistent somatizing patients . J Psychosom Res . 1992;;36:439-447.
20 +
Ford CV. The Somatizing Disorders: Illness as a Way of Life . New York, NY: Elsevier Biomedical; 1983;.
21 +
Kellner R. Somatization and Hypochondriasis . New York, NY: Praeger; 1986;.
22 +
Cassem NH, Barsky AJ.  Functional somatic symptoms and somatoform disorders . In: Cassem NH, ed. Massachusetts General Hospital Handbook of General Hospital Psychiatry . St Louis, Mo: Mosby-Year Book Inc; 1991;:131-158.
23 +
Russo J, Katon W, Sullivan M, Clark M, Buchwald D.  Severity of somatization and its relationship to psychiatric disorders and personality . Psychosomatics . 1994;;35:546-556.
24 +
Dworkin SF, Von Korff M, Le Resche.  Multiple pains and psychiatric disturbance; on epidemiologic investigation . Arch Gen Psychiatry . 1990;;47:239-244.
25 +
Katon W, Lin E, Von Korff M, et al.  Somatization: a spectrum of severity . Am J Psychiatry . 1991;;148:34-40.
26 +
Brown FW, Golding JM, Smith R.  Psychiatric comorbidity in primary care somatization disorder . Psychosom Med . 1990;;52:445-451.
27 +
Kirmayer LJ, Robbins JM, Dworkind M, Yaffe MJ.  Somatization and the recognition of depression and anxiety in primary care . Am J Psychiatry . 1993;;150:734-741.
28 +
Oxman TE, Harrigan J, Kues J.  Diagnostic patterns of family physicians for somatoform, depressive, and anxiety disorders . J Fam Pract . 1983;;17:439-446.
29 +
Ormel J, Van Den Brink W, Koeter MWJ, et al.  Recognition, management and outcome of psychological disorders in primary care: a naturalistic follow-up study . Psychol Med . 1990;;20:909-923.
30 +
Strain JJ, Hammer JS, Fulop G.  APM Task Force on Psychosocial Interventions in the General Hospital Inpatient Setting . Psychosomatics . 1994;;35:253-262.
31 +
Simon G, Ormel J, Von Korff M, Barlow M.  Health care costs associated with depressive and anxiety disorders in primary care . Am J Psychiatry . 1995;;152:352-357.
32 +
Barsky AJ, Wyshak G.  Hypochondriasis and somatosensory amplification . Br J Psychiatry . 1990;;157:404-409.
33 +
Barsky AJ, Klerman GL.  Overview: hypochondriasis, bodily complaints, and somatic styles . Am J Psychiatry . 1983;;140:273-283.
34 +
Barsky AJ.  Amplification, somatization and the somatoform disorders . Psychosomatics . 1992;;33:28-34.
35 +
Pennebaker JW. The Psychology of Physical Symptoms . New York, NY: Springer-Verlag; 1982;.
36 +
Pennebaker JW, Epstein D. Implicit psychophysiology.J Personality . 1983;;51:468-496.
37 +
Pennebaker JW, Watson D.  The psychology of somatic symptoms . In: Kirmayer LJ, Robbins JM, ed. Current Concepts of Somatization: Research and Clinical Perspectives . Washington, DC: American Psychiatric Association Press; 1991;:24-35.
38 +
Robbins PR, Meyersburg HA, Tanck RH.  Interpersonal stress and physical complaints . J Pers Assess . 1974;;38:578-585.
39 +
Mechanic D.  Effects of psychological distress on perceptions of physical health and use of medical and psychiatric facilities . J Human Stress . 1978;;4:26-32.
40 +
Speckens AEM, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooijmans HGM.  Cognitive behavioural therapy for medically unexplained physical symptoms: a randomized controlled trial . BMJ . 1995;;311:1328-1332.
41 +
Barsky AJ.  Hypochondriasis: medical management and psychiatric treatment . Psychosomatics . 1996;;37:48-56.
42 +
Sharpe M, Peveler R, Mayou R.  The psychological treatment of patients with functional somatic symptoms . J Psychosom Res . 1992;;36:515-529.
43 +
Warwick HMC, Marks IM.  Behavioural treatment of patients with functional somatic symptoms: a practical guide . Br J Psychiatry . 1988;;152:239.
44 +
Salkovskis PM.  Somatic problems . In: Hawton K, Salkovskis PM, Kirk JW, Clark DM, eds. Cognitive-Behavioral Approaches to Adult Psychiatric Disorders: A Practical Guide . Oxford, England: Oxford University Press; 1989;:235-276.
45 +
Bass C, Benjamin S.  The management of chronic somatisation . Br J Psychiatry . 1993;;162:472-480.
46 +
DeGuire S, Gevirtz R, Kawahara Y, Maguire W.  Hyperventilation syndrome and the assessment of treatment for functional cardiac symptoms . Am J Cardiol . 1992;;70:673-677.
47 +
van Dulmen AM, Fennis JFM, Bleijenberg G.  Cognitive-behavioral group therapy for irritable bowel syndrome . Psychosom Med . 1996;;58:508-514.
48 +
Deale A, Chalder T, Marks I, Wessely S.  Cognitive behavior therapy for chronic fatigue syndrome . Am J Psychiatry . 1997;;54:408-414.
49 +
Caudill M, Schnabel R, Zuttermeister P, et al.  Decreased clinic use by chronic pain patients . Psychosom Med . 1995;;57:234-244.
50 +
Buckelew SP.  Fibromyalgia: a rehabilitation approach . Am J Phys Med Rehab . 1989;;68:37-42.
51 +
Martin PR, Nathan PR, Milech D, van Keppel M.  Cognitive therapy vs self-management training in the treatment of chronic headaches . Br J Clin Psychol . 1989;;28:347-361.
52 +
Sharpe M.  Cognitive behavioural therapies in the treatment of functional somatic symptoms . In: Mayou R, Bass C, Sharpe M, eds. Treatment of Functional Somatic Symptoms . Oxford, England: Oxford University Press; 1995;: 122-143.

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