Psychosomatics 42:261-268, June 2001
© 2001 The Academy of Psychosomatic Medicine
Medically Unexplained Symptoms in an Urban General Medicine Practice
Adriana Feder, M.D.,
Mark Olfson, M.D., M.P.H. ,
Marc Gameroff, M.A.,
Milton Fuentes, Psy.D. ,
Steven Shea, M.D.,
Rafael A. Lantigua, M.D., and
Myrna M. Weissman, Ph.D.
Received August 25, 2000; accepted December 5, 2000. From the Division of Clinical and Genetic Epidemiology, Department of Psychiatry, and the Division of General Medicine, Department of Internal Medicine, College of Physicians and Surgeons; Joseph L. Mailman School of Public Health, Columbia University; New York State Psychiatric Institute, New York, New York; and Psychology Department, Montclair State University, Upper Montclair, New Jersey. Address correspondence Dr. Feder, Division of Clinical and Genetic Epidemiology, Department of Psychiatry, Columbia University, 1051 Riverside Drive — Unit 24, New York, NY 10032; e-mail: af286{at}columbia.edu
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ABSTRACT
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The authors investigated the prevalence of multiple medically unexplained symptoms (MMUS) as identified by primary care physicians (PCPs) in a systematic sample of 172 patients. Patients were from a university-affiliated urban primary care practice serving a low-income population. Patients with a history of MMUS were older (mean: 57.2 vs. 53.0 years), more likely to be female (90.5% vs. 72.3%), and less likely to be married or living with a partner (14.4% vs. 36.2%) than those without MMUS. Patients with MMUS had over twice the rate of any current psychiatric disorder, almost two-and-a-half times the rate of any current anxiety disorder, and greater functional impairment. These data suggest that patients with MMUS are as common in urban primary care clinics as in more affluent clinics and reinforce the need for PCPs to screen these patients for common and treatable psychiatric conditions.
Key Words: Medically Unexplained Symptoms • Primary Care Physicians • Urban Clinics
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INTRODUCTION
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Patients commonly present to their primary care physician complaining of physical symptoms. More often than not, appropriate medical work-up fails to reveal a clear underlying physical etiology.1–3 Although many of these symptoms remit spontaneously and patients do not come back seeking further help, a significant number of patients present with multiple medically unexplained symptoms (MMUS) that persist over time. Unlike full-blown somatization disorder, with a prevalence of only 1%–5% in primary care settings,4–6 the prevalence of medically unexplained symptoms that are multiple, chronic, and associated with medical help-seeking—but do not meet full criteria for a DSM-IV somatization disorder diagnosis—is much higher. Previous research has shown that 19.7%–22% of primary care patients meet abridged somatization criteria, that is, at least four persistent and impairing medically unexplained symptoms in men and at least six such symptoms in women.7–10
Patients with MMUS appear to share many of the characteristics of patients with the more severe somatization disorder, including functional impairment and overutilization of health care resources.2,6,11–15 Studies have also shown that patients with these symptoms have higher rates of comorbid psychiatric disorders, especially depressive and anxiety disorders.1,8,11,16,17 As demonstrated by Smith et al.,13 a psychiatric consultation tailored for patients with MMUS can reduce annual medical care charges while improving patients' functioning.
Although increased attention has recently been devoted to medically unexplained symptoms in the primary care setting, previous research has focused almost exclusively on middle class, privately insured populations. Relatively little is known about the prevalence of these symptoms or about associated mental health problems and functional impairment in low-income, urban primary care populations. The World Health Organization (WHO) international primary care study included several sites with low-income populations in other countries and found significant rates of somatization using the Somatic Symptom Index, averaging 20%, with no clear differences between centers from more- and less-developed countries.9,18 Another study found a significant percentage of somatizers in a convenience sample of urban primary care patients that excluded illiterate patients.19 Patients from low-income groups in urban primary care practices are an important group to study because there is evidence that individuals from socioeconomically disadvantaged populations have higher rates of psychiatric disorders20,21 and higher levels of unmet need for mental health services than their more affluent counterparts.22,23 Further information about medically unexplained symptoms in this setting would assist primary care physicians in identifying and treating patients in this at-risk population. In addition, the growing economic importance of prepaid arrangements under Medicaid managed care places renewed emphasis on maximizing efficient delivery of medical care.
The present study sought to determine the prevalence of MMUS, defined as physical symptoms in excess of those expected from the patients' medical conditions, in a university-affiliated urban primary care practice serving a low-income population. MMUS status was identified by primary care physicians. This study investigates the association between MMUS and sociodemographic factors, relative risk for several DSM-IV psychiatric disorders, and level of functional impairment.
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METHODS
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Subjects
These data come from a study that was conducted at the Associates in Internal Medicine (AIM) practice, the faculty and resident group practice of the Division of General Medicine at the New York Presbyterian Hospital (Columbia Presbyterian Medical Center). The clinic provides approximately 54,000 medical visits annually to 18,000 patients from an ethnically and racially diverse community.
The study was carried out in two phases. In Phase I, described in detail elsewhere,24,25 a systematic sample of consecutive adult primary care patients with scheduled appointments who presented to the clinic waiting room were invited to participate in the study. Eligible patients were between 18 and 70 years of age, had made at least one previous visit to the practice, could speak and understand Spanish or English, and were scheduled for face-to-face contact with their primary care physician. Patients were excluded from the study if their current general health status prohibited completion of the survey forms.
A total of 1,266 patients met study eligibility criteria, and 1,007 (80%) consented to participate. Consenters were slightly younger than nonconsenters but did not differ in gender or ethnicity. A random subsample (n=271) of participating patients was invited to participate in Phase II. Those selected and not selected did not differ significantly in their sociodemographic characteristics. Consenters (82%) did not differ from nonconsenters in terms of age, gender, racial/ethnic distribution, or household income, but consenters were somewhat more educated.
Measures
At study intake, patients completed a patient history form to assess age, gender, race/ethnicity, marital status, family income, and educational achievement. Psychiatric diagnoses were assessed in Phase II patients with the Composite International Diagnostic Interview (CIDI) version 2.1,26 which uses DSM-IV criteria. The CIDI was administered by a team of experienced bilingual mental health professionals. The following sections of the CIDI were administered: mood disorders (major depressive disorder, dysthymic disorder, and bipolar disorder); anxiety disorders (panic disorder, generalized anxiety disorder, social phobia, and specific phobia); and alcohol use disorder and substance use disorders. Patients also completed the Medical Outcomes Study Short Form-36 Health Survey (SF-36), the Social Adjustment Scale-Self-Report (SAS-SR), and the symptom checklist from the PRIME-MD PHQ, which inquires about the presence or absence of 15 physical symptoms during the past month.27 All assessments not previously available in Spanish were translated and back translated by a bilingual team of mental health professionals. Patients' language of choice in completing the interviews and questionnaires was recorded.
Primary care physicians (PCPs) of Phase II patients were asked to complete a physician encounter form immediately after seeing the patient. The presence of a history of MMUS was determined by the physicians' response to the following yes/no question: "Does this patient have a history of many physical complaints that are in excess of what would be expected from the patient's medical (nonpsychiatric) diagnoses, physical examination, or laboratory findings?" The questionnaire also asked PCPs to rate their patient's current physical and emotional health on a five-point scale (5=Excellent, 1=Poor). PCPs were also asked to describe their proficiency in Spanish ("native speaker or fluent," "fairly proficient," or "limited Spanish"). When a patient's primary language was Spanish, if their PCP answered "native speaker or fluent," the PCP-patient pair was classified as language concordant; if their PCP answered "fairly proficient" or "limited Spanish," the pair was classified as language discordant. When a patient's primary language was English, the PCP-patient pair was classified as language concordant.
Complete physician encounter forms were available for 172 (82%) Phase II patients. These are the patients included in the analyses below. These 172 patients did not differ significantly from the remainder of the 211 (n=39) Phase II patients with respect to age, gender, race/ethnicity, education, or household income.
Statistical Analyses
The 172 patients were divided into two groups: those with and without physician-identified MMUS. For categorical variables (language concordance, race/ethnicity, and marital status), the two groups were compared using chi-square analysis. Continuous variables (age and number of symptoms) were compared by means of a t-test. Results for mean number of symptoms were adjusted for age, gender, and marital status, the three sociodemographic characteristics that differed significantly between the two groups. Education and household income in the two groups were compared using the Mann-Whitney test.
Logistic regressions were used to compare the proportions of the five most commonly reported symptoms (in the past month) by patients in the MMUS group, and the odds ratios (OR) with 95% confidence intervals (CI) for DSM-IV psychiatric disorders, adjusted for age, gender, and marital status. Multiple regression was used to examine associations between MMUS status and general health status (SF-36), social adjustment (SAS-SR), and physician-rated physical and emotional health, again controlling for age, gender, and marital status, and also for number of DSM-IV disorders (1, 2, or  3). Number of DSM-IV disorders was added to the model already containing age, gender, and marital status. For 12 patients, some DSM-IV diagnostic categories could not be determined due to missing information, so these patients were excluded from the analyses that involved number of DSM-IV psychiatric disorders.
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RESULTS
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Background Characteristics
The sample was of low socioeconomic status and had little formal education. Most patients (83.1%) reported an annual family income of less than $12,000. Many (37.2%) reported family incomes of less than $6,000 per year. About half (50.6%) of the patients had not completed high school and a substantial number (34.3%) had an 8th grade or lower level of education.
The sample was composed primarily of women (76.7%), and the mean age was 54 years (SD=12.2). Only a minority (30.8%) reported being married or living with a partner at the time of the study. Over two-thirds of the sample (69.2%, n=119) identified themselves as Hispanic. Among Hispanic patients, the most common country of origin was the Dominican Republic (76.5%), followed by Puerto Rico (17.6%). Spanish was the primary language for 59.9% of the sample.
Multiple Medically Unexplained Symptoms
Primary care physicians identified 24.4% (n=42) of their patients as having a history of MMUS. Physicians who did not speak a patient's primary language (language discordant pairs) were equally likely to identify their patient as having MMUS as physicians who spoke the patient's language (language concordant pairs) (22.2% vs. 25.7%, respectively, P=0.61).
Table 1 shows the sociodemographic characteristics of patients with and without a history of MMUS. Patients with MMUS were slightly older, more likely to be female, and less likely to be married or living with a partner. The racial/ ethnic composition of the groups was nearly identical. Patients with MMUS tended to have somewhat lower education and yearly household income, but these differences were not statistically significant. Patients with MMUS were not more likely to be born outside of the United States than patients without MMUS; this remained true when considering only patients without any DSM-IV psychiatric diagnoses as measured by the CIDI (not shown).
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TABLE 1. Sociodemographic characteristics of patients with and without a history of multiple medically unexplained symptoms (MMUS)
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Common Physical Symptoms
Patients with MMUS reported a greater number of symptoms in the past month than patients without MMUS on the 15-item PHQ symptom checklist (mean 7.3 vs. 4.6 symptoms; P<0.0001). Sixty-two percent of patients with MMUS endorsed 7 or more symptoms on the 15-item PHQ symptom checklist, compared with 25% of patients without MMUS. The five most commonly reported symptoms by patients in the MMUS group were, in decreasing order of frequency, limb pain, back pain, trouble sleeping, feeling tired/having low energy, and nausea/gas/indigestion. The frequencies of back pain, trouble sleeping, and nausea/gas/ indigestion were significantly higher in patients with MMUS than in patients without MMUS, after adjusting for age, gender and marital status (not shown).
Associated Mental Disorders
Table 2 shows the rates of current DSM-IV psychiatric disorders in patients with and without a history of MMUS. Patients with MMUS had significantly higher rates of any psychiatric disorder, any mood disorder, major depressive disorder, any anxiety disorder, and specific phobia. Within the specific phobia category, animal and natural environment phobias were significantly more common in patients with MMUS (not shown). After adjusting for age, gender, and marital status, the rates of any psychiatric disorder, any anxiety disorder, and specific phobia remained significantly higher in patients with MMUS. The rates of lifetime psychiatric disorders (not shown) were very similar to the rates of current psychiatric disorders.
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TABLE 2. Rate per 100 patients of current DSM-IV psychiatric disorders in patients with and without a history of multiple medically unexplained symptoms (MMUS)
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Health-Related Quality of Life and Functional Impairment
Table 3 shows the level of functional impairment in patients with and without a history of MMUS. On self-report measures, patients with MMUS showed significantly greater overall emotional impairment but not overall physical impairment. The SF-36 Mental Component Summary score (MCS) was lower for patients with MMUS, indicating more impairment, a difference that persisted after adjusting for age, gender, and marital status. The SF-36 Physical Component Summary score (PCS) was not significantly different in the two groups. Patients with MMUS showed significantly higher impairment in their total SAS-SR score, before and after adjusting for sociodemographic characteristics.
Five SF-36 subscale scores remained significantly more impaired in patients with MMUS after adjusting for age, gender, and marital status: the bodily pain (25.7 vs. 44.0, respectively, P=0.005), the vitality (40.2 vs. 56.7, P=0.012), the social functioning (59.2 vs.72.6, P=0.039), the role-emotional (38.1 vs. 70.6, P=0.0001), and the mental health (50.7 vs. 69.3, P=0.001) subscale scores (unadjusted means, adjusted P-values). After also adjusting for number of current DSM-IV psychiatric diagnoses, the MCS score and the bodily pain and role-emotional subscale scores remained significantly lower in patients with MMUS. In the SAS-SR, two subscale scores remained significantly higher (indicating more impairment) in patients with MMUS after adjusting for age, gender, and marital status: the extended family role (1.8 vs. 1.5, respectively, P=0.007) and the marital role (3.0 vs. 1.9, P=0.001) subscale scores (unadjusted means, adjusted P-values). After also adjusting for number of current DSM-IV psychiatric diagnoses, these differences were no longer significant.
PCPs rated the emotional health of patients with MMUS as significantly poorer than that of patients without MMUS. This difference persisted after adjusting for age, gender, and marital status (Table 3) and even after additionally adjusting for number of current DSM-IV psychiatric diagnoses. PCPs rated patients with MMUS as having somewhat poorer physical health but after adjusting for age, gender, and marital status, this difference was no longer significant (Table 3). However, when comparing PCP ratings for the two groups on the subsample of patients for whom complete information on number of current DSM-IV psychiatric diagnoses was available (n=159), PCP ratings for physical health remained significantly lower for patients with MMUS than control subjects, after adjusting for age, gender, and marital status (2.8 vs. 3.2, respectively, P=0.019) and additionally adjusting for number of current DSM-IV psychiatric diagnoses (P=0.033).
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DISCUSSION
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The findings from this study suggest that patients with MMUS are as common in primary care clinics that serve low-income, urban, immigrant patients as in clinics serving more economically advantaged patients. In our sample, patients with MMUS were more likely to be women who were not living with a partner, and had over twice the rate of any current psychiatric disorder and almost two-and-a-half times the rate of any anxiety disorder, after adjusting for sociodemographic characteristics.
Although defined somewhat differently in each study, the percentage of patients with MMUS in this sample (24%) is similar, at the higher end of the range, to that reported in previous studies of physician-identified patients with unexplained physical symptoms28 or of patients formerly called the "worried well" (7%–25%).29 The percentage of patients in this study with MMUS is also similar to the prevalence of somatization syndrome in primary care studies using Escobar's abridged somatization construct.8,9 In addition, 62% of patients with MMUS endorsed seven or more symptoms, a threshold that was found to identify patients at higher risk for multisomatoform disorder, a proposed diagnosis that is more severe than abridged somatization.27
In our study, a history of MMUS was more common in women. However, although studies have shown that full-blown somatization disorder is much more common in women,30 this is not necessarily the case for abridged somatization. Although earlier studies appeared to show that women somatize more than men, some of these studies were found to be flawed.31 Gender differences may also depend on the way somatization is defined. More recently, one study found more frequent somatoform symptoms in women,32 whereas another found equivalent rates of MMUS meeting criteria for abridged somatization in both genders.9,18 Of note, it has been suggested that physicians are more likely to identify women than men as somatizers.33,34 Thus, in our sample, a history of MMUS may be more common in women because MMUS were identified by PCPs instead of being assessed by an independent interviewer.
The prevalence of MMUS in this sample did not differ by race/ethnicity. Although several studies have found a higher frequency of medically unexplained symptoms among Hispanics,7,9,35 this is not a consistent finding across studies. After controlling for demographic factors, Escobar et al.8 found no difference in the overall rates of somatization across ethnic groups but did find that immigrant groups were more likely to have somatization without coexisting psychiatric disorders.8 In our study, the rates of MMUS were similar for immigrants and patients born in the U.S. It may be that in our sample, poverty and its associated psychosocial stressors are more important determinants of somatization than cultural factors. Other studies also identified a modest tendency for somatization to be more common in individuals with lower education and income.9 In our study, although patients with MMUS tended to have somewhat lower education and yearly household income, these differences were not statistically significant. This may be due to small sample size and narrow range of education and income in our urban sample.
Patients with MMUS reported lower vitality and higher bodily pain but not significantly lower overall physical functioning, unlike in previous studies where somatizing patients reported both lower emotional and physical functioning.8,9 Our findings suggest that in an urban primary care population, MMUS may actually be stronger indicators of emotional distress than of perceived physical impairment, but this finding needs further study. PCPs did rate the physical health of patients with MMUS as somewhat poorer, although this difference did not reach statistical significance. The WHO international study previously found that in some sites, but not all, physicians rated the physical health of somatizers as lower.9 Of note, in our study PCPs were asked to state whether patients had a history of many physical complaints that were in excess of what would be expected from the patient's medical problems. It is thus possible that some of the patients with MMUS in our study had additional medical problems that led PCPs to rate their physical health as somewhat lower.
In our sample, a history of MMUS was frequently associated with psychiatric disorders, suggesting that global physician judgments of MMUS have some face validity. The prevalence of a current psychiatric disorder was over twice as high in patients with MMUS and that of anxiety disorders was almost two-and-a-half times as high. These results suggest that, in urban primary care populations as well, MMUS can serve as indicators of underlying psychiatric disorders and impaired functioning. As has been pointed out before,6 this is a very different picture from that suggested by the term "worried well" previously used to refer to these patients, and these findings reinforce the need for PCPs to screen all patients with MMUS for anxiety and mood disorders.
Patients with MMUS were less likely to be married or living with a partner and reported poorer social adjustment and more difficulties in their relationships. As has been suggested by other researchers,36,37 it may be that medically unexplained symptoms represent, at least for some patients, a means of seeking care and understanding from their primary care doctor in the face of otherwise poor social supports. Alternatively, individuals with a naturally lower threshold for experiencing physical symptoms or pain when under stress may then focus their attention on their symptoms and become less emotionally available for relationships with others, leading to interpersonal problems or isolation.
The fact that in our study many patients with MMUS readily acknowledged mental health and social adjustment problems once again dispels the common belief among some physicians that most somatizing patients will deny psychological distress. In addition, PCPs did recognize that patients with MMUS had significantly poorer emotional health. Both findings are consistent with those of previous studies by Kirmayer et al.,38,39 who found that most of these patients do admit to emotional distress if openly asked and that the presence of medically unexplained symptoms aids in the recognition of mood and anxiety disorders by PCPs. Because patients seem to acknowledge emotional problems and are therefore likely to be amenable to treatment, and PCPs do seem to recognize the existence of these problems, continued efforts should be directed at providing PCPs with efficient ways to evaluate and treat common psychiatric disorders in the face of time constraints and competing clinical demands. Several published reviews summarize useful treatment recommendations, including finding a shared language with the patient, regular brief follow-up appointments, a rehabilitation approach, minimizing the potential for iatrogenic complications, and the use of antidepressants when appropriate.40–42
This study is limited by several factors. First, its relatively small sample size limited our ability to perform more analyses on certain subgroups. Second, although physician-identified MMUS correlated with higher numbers of physical symptoms reported by patients, we did not assess which of these symptoms were in fact medically unexplained or how many patients met criteria for an actual somatoform disorder. Third, although the study refusal rate was low, the two-step study design resulted in a significant selection rate of participation. Fourth, since patients were sampled from the clinic waiting room, frequent attenders may have been oversampled. Finally, our findings may not be generalizable to patients and physicians in other settings.
Our findings suggest that in urban primary care settings, just as in more affluent clinics, when patients present with a history of MMUS, the physician should carefully evaluate these patients' emotional well-being and functioning and screen for a number of common and treatable psychiatric conditions. Future studies should examine the effect of treating these psychiatric conditions on the clinical course and health care utilization pattern of patients with MMUS.
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ACKNOWLEDGMENTS
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The authors thank Carlos Blanco, M.D., Renee Goodwin, Ph.D., Raz Gross, M.D. and Daniel J. Pilowsky, M.D. for their helpful comments during the preparation of this manuscript.
This research was supported by investigator-initiated grants from Eli Lilly & Co. and Pharmacia-Upjohn and by NIMH Grant P30-AG15294 (SS and RAL).
This study was presented in part at the Academy of Psychosomatic Medicine annual meeting, November 1999, New Orleans. Abstract with preliminary results published in Psychosomatics 2000;41(2):186–187.
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A. J. Barsky, E. J. Orav, and D. W. Bates
Somatization Increases Medical Utilization and Costs Independent of Psychiatric and Medical Comorbidity
Arch Gen Psychiatry,
August 1, 2005;
62(8):
903 - 910.
[Abstract]
[Full Text]
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B. van den Berg, L. Grievink, J. Yzermans, and E. Lebret
Medically Unexplained Physical Symptoms in the Aftermath of Disasters
Epidemiol. Rev.,
July 1, 2005;
27(1):
92 - 106.
[Full Text]
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D. J.H. Deeg, A. C. Huizink, H. C. Comijs, and T. Smid
Disaster and associated changes in physical and mental health in older residents
Eur J Public Health,
April 1, 2005;
15(2):
170 - 174.
[Abstract]
[Full Text]
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L. B. Mauksch, W. J. Katon, J. Russo, S. M. Tucker, E. Walker, and J. Cameron
The Content of a Low-income, Uninsured Primary Care Population: Including the Patient Agenda
J Am Board Fam Med,
July 1, 2003;
16(4):
278 - 289.
[Abstract]
[Full Text]
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G. Schneider, M. Wachter, G. Driesch, A. Kruse, H.-G. Nehen, and G. Heuft
Subjective Body Complaints as an Indicator of Somatization in Elderly Patients
Psychosomatics,
April 1, 2003;
44(2):
91 - 99.
[Abstract]
[Full Text]
[PDF]
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ABSTRACT
INTRODUCTION
