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Psychosomatics 41:481-489, December 2000
© 2000 The Academy of Psychosomatic Medicine

Consultation-Liaison Psychiatrists' Management of Somatoform Disorders

Graeme C. Smith, MBBS, M.D., DPM, FRANZCP, FAPM, David M. Clarke, MBBS, MPM, Ph.D., FRACGP, FRANZCP, Dennis Handrinos, MBBS, MPM, FRANZCP, Astrid Dunsis, MBBS, FRANZCP, DPM, DCH, and Dean P. McKenzie, B.A. (Hons.), FRSS

Received February 2, 2000; revised April 3, 1999; accepted June 19, 2000. From Consultation-Liaison Psychiatry Research Unit, Monash University Department of Psychological Medicine and Southern Healthcare Network, Melbourne, Australia. Address correspondence and reprint requests to Dr. Smith, Monash University Department of Psychological Medicine, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia; e-mail: graeme.smith{at}med.monash.edu.au


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
The authors studied interventions recommended by consultation-liaison (C-L) psychiatrists when they diagnosed somatoform disorder prospectively in a cohort of 4,401 consecutive inpatients referred to the C-L psychiatry service of a general teaching hospital, using standardized MICRO- CARES methodology. A DSM-III-R somatoform disorder was diagnosed in 2.9%, somatoform pain disorder in 1.4%, conversion disorder in 0.7%, hypochondriasis or somatization disorder undifferentiated/not otherwise specified in 0.6%, and somatization disorder in 0.2%. In 3.4%, somatoform disorder was considered a differential diagnosis. Psychiatric comorbidity included mood disorder (39%), personality disorder (37%), and psychoactive substance use disorder (19%). Recommendations were made about antidepressants in 40% of the patients, anxiolytics in 18%, sedatives in 18%, and antipsychotics in 10%. Psychiatrists recommended the following: more laboratory tests for 14%; additional medical/surgical consultations for 11%; an increase in the vigor of medical treatment for 13%; and psychological treatment for 76%; also they stressed an earlier discharge of 16%. Psychiatrists were more likely to request a prolongation of inpatient stay for patients with comorbid somatoform, mood, anxiety, and personality disorder. Differences in characteristics and treatment of the subgroups tended to be consistent with their constructs and comorbid psychiatric diagnoses.

Key Words: Somatoform Disorders

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Somatization is a phenomenon encountered in much of inpatient consultation-liaison (C-L) psychiatry work. Lipowski1 originally postulated a continuum of somatization reactions from the "conversion and hypochondriacal disorders" to the "psychophysiological disorders." The somatic components of anxiety disorders, depression, sleep disorders, eating disorders, and sexual function all came within Lipowski's concept of somatization, as did factitious disorders. Data derived from studies in primary care confirm the validity of this broad conceptualization. Somatic symptoms are the most common presentation of psychiatric distress in primary care, and this appears to be independent of physical health status.2 Somatic symptoms, irrespective of etiology, have a strong association with psychiatric morbidity.3 The DSM-III-R classification,4 used in this study, does not adequately address the high prevalence, complexity, and functional importance of somatization,5 nor does the DSM-IV. The DSM classifications allow identification of pure somatizers but not those who somatize their presentations of anxiety and depression. These are distinct populations.6 The DSM classifications do not contain the category "neurasthenia" and provide only in the most general way for the construct of "medically unexplained symptoms." These are important constructs in the international conceptualization of somatization.3

Somatization as a phenomenon is extremely important for primary care doctors and C-L psychiatrists alike, far beyond the disorders so narrowly defined in the DSM classification. Up to 17% of primary care patients have impairing, subsyndromal somatoform disorder.5,6 Barsky et al.,7 based on their 5-year follow-up, concluded that hypochondriasis carries a very substantial long-term burden of morbidity, functional impairment, and personal distress. Perhaps as a result of the inadequacy of definition and conceptualization of patients with somatization, there is little to guide its management except consensus opinion. There are no formal practice guidelines for a somatoform disorder, except as implied in those for the management of cancer pain published by the Agency for U.S. Health Care Policy and Research8 and for chronic pain published by The American Society of Anesthesiologists.9

The Quality Assurance Project of the Royal Australian and New Zealand College of Psychiatrists10 established some preliminary treatment outlines for the management of somatoform disorders, using the following three sources of information: the treatment outcome literature, the opinions of a sample of practicing psychiatrists, and the views of a panel of nominated experts. The recommendations were as follows: for hypochondriasis—brief dynamic psychotherapy, family therapy, and excellent medical consultation; for somatization disorder—limited supportive psychotherapy and good medical consultation; and for psychogenic pain disorder—symptom relief, psychotherapeutic support, and meticulous collaboration with physicians. Those working on the project stated that physiotherapy to improve physical functioning and patient education to facilitate the distinction between normal symptoms and abnormal illness behaviors are important in all three conditions.

The few controlled trials of psychotherapy that have been reported subsequently begin to provide the basis for substantial guidelines. These have concerned cognitive therapy for medically unexplained symptoms,11 for chronic fatigue syndrome,12–15 for hypochondriasis,16,17 and for noncardiac chest pain.18 They also include dynamic interpersonal psychotherapy for irritable bowel syndrome19 and group therapy for somatization disorder20 and for irritable bowel syndrome.21 Trials of medication in fibromyalgia22 and of systemic intervention23,24 have been reported. Further views of experts have been published.25–27

Our study is an example of the third type of data gathering used by the Quality Assurance Project, a sampling of psychiatrists' practice, which is important in providing valuable information about what psychiatrists do when they make specific diagnoses.28 Reliable documentation of the types of diagnoses made and interventions recommended when experienced C-L psychiatrists diagnose somatoform disorders will be an important part of the process of developing guidelines in this field. Here we report such data, as we have done previously for organic mental disorder,29 depression,30 and adjustment disorder.31

The purpose of our study is to describe the interventions recommended by C-L psychiatrists when they make a diagnosis of somatoform disorder in referred inpatients. We also seek to determine whether or not the constructs of the DSM classification of this disorder are validated by usage in the field. We hypothesized that diagnosis of somatoform disorder comorbidly with other psychiatric diagnoses would significantly affect the treatment recommendations and the hospital process variables (e.g., length of stay, lagtime in referral, and time spent).32


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
We studied prospectively 4,401 consecutive inpatient referrals to the adult C-L psychiatry services of two metropolitan general teaching hospitals affiliated with Monash University, Melbourne, Australia, over a 5-year period (the "referred cohort"). At each hospital, consultant psychiatrists and psychiatry trainees rotate through the C-L psychiatry service, work in a mixture of liaison and consultation mode, and see referrals from medical, surgical, and specialty units including obstetrics and gynecology. Each hospital used the MICRO-CARES clinical database system routinely.33,34 Training and quality assurance processes to help ensure intrahospital reliability were common to each hospital, and interhospital reliability was addressed by having one of the authors (GCS) supervise the process in each hospital.34

We collected the following data: 1) demographics; 2) reasons for referral and relevant problems as stated by the consultee (referring doctor) and by the consultant (psychiatrist)—up to 5 reasons/problems per patient; 3) DSM-III- R Axis I & II terminal diagnoses for the admission episode—up to 6 diagnoses per patient, confirmed (meets DSM-III-R criteria) or rule out (considered likely but does not reach criteria because of insufficient data, confounded by physical factors, or subthreshold status); 4) ICD-9CM physical diagnoses for the admission episode—up to 3 diagnoses; 5) rating scales—DSM-III-R Axis V (GAF), Global Psychiatric Assessment, Karnofsky score; 6) interventions—nondrug and drug; 7) hospital process—referring unit, length of stay, lagtime in referral, urgency of referral, time spent on referral, total visits, total supervision time, administrative action, and discharge location.

From the referred patients cohort we created a cohort of those with a DSM-III-R somatoform disorder and divided it into four mutually exclusive subgroups: conversion disorder, 300.11; somatization disorder, 300.81; somatoform pain disorder, 307.80; and hypochondriasis, 300.70. Unfortunately, the code 300.70 is also assigned to body dysmorphic disorder, undifferentiated somatoform specified disorder, and somatoform disorder, not otherwise specific. It was not possible to distinguish these diagnoses, making this category a mixture of mainly chronic conditions. The MICRO-CARES data collection system permits diagnosis at two levels of certainty: confirmed (meets DSM criteria) and rule out (does not meet criteria but is under active consideration). Although the main body of data reported concerns only confirmed diagnoses, we have used differential (rule out) diagnoses in several analyses to study the diagnostic pattern and intervention practice of C-L psychiatrists across a wider spectrum of somatization.5

Statistical Analyses
We performed a comparison between groups using ANOVA and t-tests for continuous variables and chi- squared analysis for categorical variables, using the SPSS for Windows package.35 We assessed the magnitude of effects using eta-squared36 and phi-squared37 coefficients for continuous and categorical variables, respectively. The larger the value of eta-square and phi-square, the greater the amount of variance in the dependent variable is accounted for by a particular independent variable. In the advent of a significant (P<0.01) ANOVA or chi-squared test, we used KnowledgeSEEKER38 to form homogeneous clusters and exploratory decision-tree analysis, as previously applied to psychiatric data.29


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
A confirmed diagnosis of somatoform disorder was made for 127 (2.9%) of the referred patients cohort; conversion disorder in 30 (0.7%); hypochondriasis in 27 (0.6%); somatization disorder in 10 (0.2%); and somatoform pain disorder in 60 (1.4%). Another 148 patients (3.4%) had a rule- out somatoform disorder as their only diagnosis. A somatoform disorder diagnosis (rule-out or confirmed) was made as a comorbid diagnosis with another confirmed Axis I or II diagnosis in 3.6% of referrals.

Demographics, Referral, Clinical, and Hospital Process Data
Demographics, referral, clinical, and hospital process data for those patients given a confirmed somatoform disorder diagnosis are shown in Table 1. Of interest in the demographic data is the majority of women (76%), the very low rate of employment (16%), and the fact that the patients were almost exclusively White (96%). Sixty-seven percent had had a serious physical illness in the previous 12 months and 28% a psychiatric illness. Referral for resolution of a diagnostic problem was the most common reason given (60%), and 25% were recognized by the consultee as having depression. The mean GAF score for highest level of functioning in the past 12 months was 62, and the mean Karnofsky score for highest level of physical functioning in the past month was 65. There was a high prevalence of comorbid mood disorder (39%), personality disorder (37%), and psychoactive substance use disorder (19%). Ill-defined symptoms were the most frequent physical diagnosis on Axis III (32%). Psychiatric staff spent a mean of 3.5 hours and a mean of 3.4 visits for a mean length of stay of 12 days.


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TABLE 1. Demographic, diagnostic, intervention, and hospital process data for patients with a confirmed somatoform disorder diagnosis (n=127)



Treatment Recommendations
The complete treatment recommendations are shown in Table 1. Of interest were the psychiatrists' recommendations to decrease the rate of investigation or treatment: medical treatment (11%), laboratory investigations (2%), and medical/surgical consults (1%). They recommended an early discharge date in 16% of cases.

Subgroups of Somatoform Disorder
Variables that distinguish the four subgroups of somatoform disorder are shown in Table 2. Significant differences (P<0.05) were observed for only one of the demographic variables—marital status; those with conversion or somatization disorder were less likely to be presently married. Those with somatization and somatoform pain disorder were more likely to have had a serious physical illness in the previous 12 months. Those with conversion disorder were more likely to have had a family member with serious physical illness. Referral for "strange behavior" distinguished those with conversion disorder, and referral for pain distinguished those with somatoform pain disorder as the diagnosis. There were high rates (66%– 84%) of referral for "diagnosis—suspected psychological component" for all except those diagnosed with somatoform pain disorder. Axis I psychoactive substance use disorder and mood disorder were more frequent in those diagnosed with somatoform pain disorder. Those with somatization and somatoform pain disorder had the lowest Karnofsky scores. A recommendation for increased physical activity distinguished those with conversion disorder. There was a high rate of recommendations about anxiolytics for those with somatoform pain disorder and about antidepressants for those with somatization and somatoform pain disorder.


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TABLE 2. Variables that distinguish subgroups of confirmed somatoform disorder cohort (n=127).



Comorbidity With Other Axis I Diagnoses
We explored the effect on management of other Axis I disorders that somatoform disorder as a comorbid diagnosis made. As mood disorder was the most prevalent comorbidity, we confined that analysis to the cohort with major depression (Table 3). Patients with comorbid major depression and somatoform disorder were younger, more likely to be women, and had more comorbidity with anxiety disorder and personality disorder than did those with major depression without somatoform disorder. They were more likely to be referred because of problems of diagnostic uncertainty and more likely to be recommended for a delay in discharge, perhaps reflecting their diagnostic difficulty. There were no other treatment differences.


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TABLE 3. Comparison of patients with major depression with and without somatoform disorder comorbidity; significant variables




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Prevalence
The prevalence of a confirmed DSM-III-R diagnosis of somatoform disorder in this cohort of inpatients referred to C-L psychiatry was 2.9%, comparable with the 2.6% reported for a similar cohort by Snyder and Strain.39 Somatoform disorder was considered as a differential diagnosis in 3.4% of patients. It is likely that there was underreferral of somatizing patients. In our study of a sample of the total inpatient population of the same general hospital scoring above 20 on the 36-item General Health Questionnaire, the prevalence of somatizing disorders was 39%.40 The prevalence of somatoform pain disorder in that study was 5.6%, considerably higher than that of 1.4% reported in the current study. The reasons for underreferral require further investigation.

The combined prevalence of 6.3% represents the extent to which C-L psychiatrists have to deal with somatoform disorder as defined by DSM criteria in a referred inpatient population. But C-L psychiatrists deal with somatoform disorder in its other forms, somatization of depression and anxiety, and subsyndromal somatization, to a much greater extent. Although not measured here, some idea of the prevalence of subsyndromal somatization can be gleaned from a comparable population that presents to primary care physicians. In the World Health Organization (WHO) Collaborative Study on Psychological Problems in General Health Care, the prevalence of ICD-10 neurasthenia was 5.5%.41 The symptoms of neurasthenia are predominantly those of somatization; this disorder was not included in DSM-III-R or DSM-IV. Up to 17% of patients in primary care have subsyndromal somatization disorder.5,6,42–45 Patients with subsyndromal disorders were found to be as impaired as those with formal ICD-10 somatization disorders.42,43 These data are consistent with the current view that the DSM-IV and ICD-10 criteria for somatization disorder are too restrictive. It is true that DSM- IV has two nonspecific categories; undifferentiated somatoform disorder and somatoform disorder NOS. However, the criteria for undifferentiated somatoform disorder and somatoform disorder NOS are so minimal that they could be used to label any unexplained physical symptom, which does not help the process of refining the diagnostic category. DSM-IV perpetuates the coding problem by allocating the same code to somatization disorder and these nonspecific codes.

Characteristics of Somatoform Disorder Cohort
The somatoform disorder cohort contained two-thirds of patients with a chronic physical illness or an episode of physical illness other than that causing their current admission in the past 12 months. However, only one-third of patients had a psychiatric illness in the past 12 months. The patients in the current study had functioned only moderately well over the past month, both psychiatrically and physically.

Gureje et al.42,43 noted that hypochondriasis was associated with considerable functional disability. Kroenke et al.46 reported similar findings. Comorbidity on Axes I and II was high: mood disorder (39%), psychoactive substance use disorder (19%), and personality disorder (37%). This is similar to the findings of Snyder and Strain.39 Gureje et al.42,43 noted high levels of comorbidity in the WHO study on hypochondriasis and somatization disorder in primary care. Numerous other authors have stressed the importance of recognizing such comorbidity.3,5,32 Patients with hypochondriasis and somatoform disorder posed a major diagnostic problem for referring doctors; in 60% of cases the diagnostic problem was cited as the reason for referral. There is abundant evidence of the problems that non-psychiatrist doctors have in conceptualizing and diagnosing somatizing patients47—comorbidity is just one of the reasons.

What Did the C-L Psychiatrists Do?
The psychiatrists recommended further investigations (e.g., laboratory tests, psychometric tests, or medical/surgical consults) for 1 in 7 patients. This is a marker of their continuing uncertainty about the extent to which organic factors were contributing to the presentation. Only occasionally did C-L psychiatrists urge a decrease in investigations, but they recommended a decrease in the amount of active medical treatment for 1 in 10 patients, bringing forward the discharge date in 16% of cases. This degree of involvement in decisions about the extent of investigation and active medical treatment of somatoform disorders is consistent with guidelines.8–10,26,48 It reflects the extent to which C-L psychiatrists are prepared to intervene to help ensure that such patients are not overinvestigated and overtreated.

C-L psychiatrists asked for more information, from nonmedical personnel and external sources, in the majority of cases, illustrating the need for extensive corroborative data and for a multidisciplinary approach in management of somatoform disorder. Only 6% were admitted to a psychiatric unit, which is consistent with the observation that as inpatient psychiatric units and their staff become more focused on psychotic disorders, they have less capacity to manage patients with somatoform disorders.47 The management of unexplained physical symptoms requires meticulous collaboration between physician and psychiatrist.24 If all management is to be carried out in medical and surgical wards in the future, there are major implications for organization and training of psychiatry, internal medicine, and surgery staff as well as for patients.

Psychological treatment was the mainstay in 76% of patients, and an increase in social support was recommended in 41%. This is consistent with the fact that there is emerging evidence for the efficacy of psychological interventions in somatoform disorders: cognitive therapy,15 dynamic interpersonal psychotherapy,19 and group therapy.20,21 A recommendation for increased physical activity was made for 1 in 5 patients, which is indicative of the importance placed on attending to both the physical and psychological symptoms of the somatizing patient as well as to their functional capacity.

In general, the prescription of antidepressants paralleled the prevalence of comorbid mood disorder. However, for somatization disorder, where only 30% had mood disorder, 50% were prescribed antidepressants. This may reflect their use as analgesics, but it may also represent expression of the hypothesis that somatization can be a form of masked depression. The prevalence of recommendations about anxiolytics (17.5%) greatly exceeds the prevalence of anxiety disorder (7%). This reflects the fact that many patients were on anxiolytics when seen, and although withdrawal from them may have been recommended, this was not performed during their admission. Evidence for the efficacy of antidepressants in somatoform disorders without comorbid mood disorder is limited.22

Hospital Process Variables
The length of stay was twice that of the general hospital population but similar to that of other referred patients in these hospitals.30 We have shown in other studies that referral to C-L psychiatry is a marker of prolonged length of stay.49,50 There were no significant differences between groups.

Somatoform Disorder as a Comorbidity
Patients with comorbid somatoform disorder and major depression were younger, more often referred as a diagnostic problem, and more likely to be recommended for a delay in discharge than patients without major depression. In addition they were more likely to be given the comorbid diagnoses of anxiety and personality disorder. Clearly patients with somatoform disorder and these comorbid diagnoses constitute a major diagnostic and management problem for consultees and psychiatrists alike.32

To What Extent Are the DSM Constructs for Somatoform Disorder Validated by the C-L Psychiatrists' Practice?
The DSM-III-R classification is regarded as largely inadequate for use in cases of physical/psychiatric comorbidity, and there is concern that this issue has not been addressed well enough in DSM-IV.46,51 Here we examined the characteristics of patients, the referral behavior, and the practice of C-L psychiatrists in the field to see whether the data support the validity of the DSM constructs in any way. Some support was given as follows: conversion disorder patients were less likely to be married; patients with somatoform pain disorder were most often referred for management of pain and least often for diagnostic issues; conversion disorder patients were most often referred because of "strange behavior."

Limitations of the Study
This was a practice sampling study. It did not use structured interviews but rather attempted to capture the normal clinical diagnostic and management practice of a group of experienced C-L psychiatrists. The validity of this approach is well supported,28 and it complements data from other methods—the validity of which has a different quality. The reliability of the data was enhanced by the use of a standardized database, a manual, the training procedures, the checking of data from the record randomly and for completion, and the prospective nature of the data collection. However, caution should be used in generalizing the findings to nonreferred populations because of the referral bias. The allocation, in DSM-III-R, of the same code to hypochondriasis, body dysmorphic disorder, undifferentiated somatoform disorder, and somatoform disorder NOS meant that the specificity of the data for these disorders was diluted.


  CONCLUSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
In summary, C-L psychiatrists in these hospitals were considering a somatoform disorder diagnosis in 6.3% of referred patients, though only in 2.9% was a confirmed diagnosis of such a disorder made. There was considerable psychiatric comorbidity, and the drug recommendations tended to reflect this. The differences in patient characteristics, reasons for referral, and treatment recommendations were consistent with the constructs of the subgroups to some extent. C-L psychiatrists were vigorous in their recommendations about physical investigation and medical treatment, especially in recommending a slowing down of such interventions. One particular group with comorbid diagnoses of somatoform, mood, anxiety, and personality disorder seems to pose major assessment and management difficulties. There is a dearth of data that would serve as a research basis for guidelines about how to deal with physical/psychiatric comorbidity of this type; at present we must rely on guidelines produced by consensus review, so which the findings reported here contribute. A shift from inpatient psychiatric units to medical and surgical units as the site for treatment poses a challenge to C-L psychiatry organization and training.


  ACKNOWLEDGMENTS

 
The authors thank the psychiatry trainees and their consultant supervisors who faithfully contributed to the database and participated in the quality control training and auditing. This work was supported by SmithKline Beecham (Australia) Pty Ltd and the Buckland Foundation.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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