Hostname: page-component-7c8c6479df-hgkh8 Total loading time: 0 Render date: 2024-03-29T02:06:38.534Z Has data issue: false hasContentIssue false

Patients who somatize in primary care: a longitudinal study of cognitive and social characteristics

Published online by Cambridge University Press:  09 July 2009

Laurence J. Kirmayer*
Affiliation:
Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry, Sir Mortimer B. Davis – Jewish General Hospital and Division of Social and Transcultural Psychiatry, McGill University, Montreal, Québec, Canada; and Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Arkansas, USA
James M. Robbins
Affiliation:
Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry, Sir Mortimer B. Davis – Jewish General Hospital and Division of Social and Transcultural Psychiatry, McGill University, Montreal, Québec, Canada; and Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Arkansas, USA
*
1Address for correspondence: Dr Laurence J. Kirmayer Institute of Community and Family Psychiatry4333 Chemin de la Cote Ste. CatherineMontréalQuébec H3T 1E4Canada.

Synopsis

We examined the cognitive and sociodemographic characteristics of patients making somatic presentations of depression and anxiety in primary care. Only 15% of patients with depressive symptomatology on self-report, and only 21 % of patients with current major depression or anxiety disorders on diagnostic interview, presented psychosocial symptoms to their GP. The remainder of patients with psychiatric distress presented exclusively somatic symptoms and were divided into three groups - initial, facultative and true somatizers - based on their willingness to offer or endorse a psychosocial cause for their symptoms. Somatizers did not differ markedly from psychologizers in sociodemographic characteristics except for a greater proportion of men among the true somatizers. Compared to psychologizers, somatizers reported lower levels of psychological distress, less introspectiveness and less worry about having an emotional problem. Somatizers were also less likely to attribute common somatic symptoms to psychological causes and more likely to endorse normalizing causes. In the 12 months following their initial visit, somatizers made less use of speciality mental health care and were less likely to present emotional problems to their GP. Somatizers were markedly less likely to talk about personal problems to their GP and reported themselves less likely to seek help for anxiety or sadness. Somatization represents a persistent pattern of illness behaviour in which mental health care is not sought despite easily elicited evidence of emotional distress. Somatization is not, however, associated with higher levels of medical health care utilization than that found among patients with frank depression or anxiety.

Type
Original Articles
Copyright
Copyright © Cambridge University Press 1996

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Angel, R. & Thoits, P. (1987). The impact of culture on the cognitive structure of illness. Culture, Medicine, and Psychiatry 11, 465494.CrossRefGoogle ScholarPubMed
Barrett, J. E., Barrett, J. A., Oxman, T. E. & Gerber, P. D. (1988). The prevalence of psychiatric disorders in a primary care practice. Archives of General Psychiatry 45, 11001106.CrossRefGoogle Scholar
Blacker, C. V. R. & Clare, A. W. (1987). Depressive disorder in primary care. British Journal of Psychiatry 150, 737751.CrossRefGoogle ScholarPubMed
Bridges, K., Goldberg, D., Evans, B. & Sharpe, T. (1991). Determinants of somatization in primary care. Psychological Medicine 21, 473483.CrossRefGoogle ScholarPubMed
Bridges, K. W. & Goldberg, D. P. (1985). Somatic presentation of DSM III psychiatric disorders in primary care. Journal of Psychosomatic Research 29, 563569.CrossRefGoogle ScholarPubMed
Clark, V. A., Aneshensel, C. S., Frerichs, R. R. & Morgan, T. M. (1981). Analysis of effect of sex and age in response to items on the CES-D scale. Psychiatry Research 5, 171181.CrossRefGoogle ScholarPubMed
Coulehan, J. L., Schulberg, H. C., Block, M. R. & Zettler-Segal, M. (1988). Symptom pattern of depression in ambulatory medical and psychiatric patients. Journal of Nervous and Mental Disease 176, 284288.CrossRefGoogle ScholarPubMed
Craig, T. K. J., Boardman, A. P., Mills, K., Daly-Jones, O. & Drake, H. (1993). The South London Somatisation Study. I. Longitudinal course and the influence of early life experiences. British Journal of Psychiatry 163, 579588.CrossRefGoogle Scholar
Craig, T. K. J., Drake, H., Mills, K. & Boardman, A. P. (1994). The South London Somatisation Study. II. Influence of stressful life events, and secondary gain. British Journal of Psychiatry 165, 248258.CrossRefGoogle ScholarPubMed
Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H. & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): a selfreport inventory. Behavioural Science 19, 115.CrossRefGoogle ScholarPubMed
Dohrenwend, B. P. & Chin-Shong, E. (1967). Social status and attitudes toward psychological disorder: the problem of tolerance of deviance. American Sociological Review 32, 417433.CrossRefGoogle ScholarPubMed
Escobar, J. L., Burnam, A., Karao, M., Fosythe, A. & Golding, J. M. (1987). Somatization in the community. Archives of General Psychiatry 44, 713718.CrossRefGoogle ScholarPubMed
Escobar, J. L., Rubio-Stipec, M., Canino, G. & Karno, M. (1989). Somatic Symptom Index (SSI): a new and abridged somatization construct. Journal of Nervous and Mental Disease 177, 140146.CrossRefGoogle ScholarPubMed
Fahy, T. (1974). Pathways of specialist referral of depressed patients from general practice. British Journal of Psychiatry 124, 231239.CrossRefGoogle ScholarPubMed
Fenigstein, A., Scheier, M. F. & Buss, A. H. (1975). Public and private self-consciousness: assessment and theory. Journal of Consulting and Clinical Psychology 43, 522527.CrossRefGoogle Scholar
Goldberg, D. P. & Bridges, K. (1988). Somatic presentations of psychiatric illness in primary care setting. Journal of Psychosomatic Research 32, 137144.CrossRefGoogle ScholarPubMed
Greenley, J. R., Mechanic, D. & Cleary, P. D. (1987). Seeking help for medical problems: applications and extensions. Medical Care 25, 113128.CrossRefGoogle Scholar
Hansell, S. & Mechanic, D. (1985). Introspectiveness, and adolescent symptom reporting. Journal of Human Stress 11, 165176.CrossRefGoogle ScholarPubMed
Hansell, S. & Mechanic, D. (1986). The socialization of introspection and illness behavior. In Illness Behavior (ed. McHugh, S. and Vallis, T. M.), pp. 253260. Plenum Press: New York.CrossRefGoogle Scholar
Helzer, J. E., Spitznagel, E. L. & McEvoy, L. (1987). The predictive validity of lay Diagnostic Interview Schedule diagnoses in the general population. Archives of General Psychiatry 44, 10691077.CrossRefGoogle ScholarPubMed
Horwitz, A. (1977). The pathways into psychiatric treatment: some differences between men and women. Journal of Health and Social Behavior 18, 169178.CrossRefGoogle ScholarPubMed
Katon, W. (1987). The epidemiology of depression in medical care. International Journal of Psychiatry in Medicine 17, 93112.CrossRefGoogle ScholarPubMed
Katon, W., Ries, R. K. & Kleinman, A. (1984). The prevalence of somatization in primary care. Comprehensive Psychiatry 25, 208215.CrossRefGoogle ScholarPubMed
Kirmayer, L. J. (1988). Mind and body as metaphors: hidden values in biomedicine. In Biomedicine Examined (ed. Lock, M. and Gordon, D.), pp. 5792. Kluwer: Dordrecht.CrossRefGoogle Scholar
Kirmayer, L. J. & Robbins, J. M. (1991). Three forms of somatization in primary care: prevalence, co-occurrence and sociodemographic characteristics. Journal of Nervous and Mental Disease 179, 647655.CrossRefGoogle ScholarPubMed
Kirmayer, L. J., Robbins, J. M., Dworkind, M. & Yaffe, M. (1993). Somatization and the recognition of depression and anxiety in primary care. American Journal of Psychiatry 150, 734741.Google ScholarPubMed
Kirmayer, L. J., Robbins, J. M. & Paris, J. (1994 a). Somatoform disorders: personality and the social matrix of somatic distress. Journal of Abnormal Psychology 103, 125136.CrossRefGoogle ScholarPubMed
Kirmayer, L. J., Young, A. & Robbins, J. M. (1994 b). Symptom attribution in cultural perspective. Canadian Journal of Psychiatry 39, 584595.CrossRefGoogle ScholarPubMed
Leaf, P. J., Livingston, M. M., Tischler, G. L., Weissman, M. M., Holzer, C. E. & Myers, J. K. (1985). Contact with health professionals for the treatment of psychiatric and emotional problems. Medical Care 23, 13221337.CrossRefGoogle ScholarPubMed
Mechanic, D. & Hansell, S. (1987). Introspection and illness behavior. Psychiatric Medicine 5, 514.Google ScholarPubMed
Miller, L. C., Murphy, R. & Buss, A. H. (1981). Consciousness of body: public and private. Journal of Personality and Social Psychology 41, 397406.CrossRefGoogle Scholar
Pilowsky, I. & Spence, N. D. (1983). Manual for the Illness Behaviour Questionnaire (IBQ). University of Adelaide: Adelaide, South Australia.Google Scholar
Powell, R., Dolan, R. & Wessely, S. (1990). Attributions and selfesteem in depression and chronic fatigue syndromes. Journal of Psychosomatic Research 34, 665673.CrossRefGoogle ScholarPubMed
Radloff, L. S. (1977). The CES-D: a self-report depression scale for research in the general population. Applied Psychological Measurement 1, 385401.CrossRefGoogle Scholar
Regier, D., Goldberg, I. & Taube, C. (1978). The defacto US mental health service system: a public health perspective. Archives of General Psychiatry 35, 685693.CrossRefGoogle Scholar
Robbins, J. M. & Kirmayer, L. J. (1986). Illness cognition, symptom reporting and somatization in primary care. In Illness Behavior: A Multidisciplinary Model (ed. McHugh, S. and Vallis, T. M.), pp. 283302. Plenum Press: New York.CrossRefGoogle Scholar
Robbins, J. M. & Kirmayer, L. J. (1991 a). Attributions of common somatic symptoms. Psychological Medicine 21, 10291045.CrossRefGoogle ScholarPubMed
Robbins, J. M. & Kirmayer, L. J. (1991 b). Cognitive and social factors in somatization. In Current Concepts of Somatization: Research and Clinical Perspectives (ed. Kirmayer, L. J. and Robbins, J. M.), pp. 107141. American Psychiatric Press: Washington, DC.Google Scholar
Robbins, J. M., Kirmayer, L. J., Cathébras, P., Yaffe, M. & Dworkind, M. (1994). Physician characteristics and the recognition of depression and anxiety in primary care. Medical Care 32, 795812.CrossRefGoogle ScholarPubMed
Roberts, R. E. & Vernon, S. W. (1983). The Center for Epidemiologic Studies Depression scale: its use in a community sample. American Journal of Psychiatry 140, 4146.Google Scholar
Roberts, R. E., Vernon, S. W. & Rhoades, H. M. (1989). Effects of language and ethnic status on reliability and validity of the Center for Epidemiologic Studies-Depression Scale with psychiatric patients. Journal of Nervous and Mental Disease 177, 581592.CrossRefGoogle Scholar
Robins, L. N. & Helzer, J. (1982). Diagnostic Interview Schedule. Archives of General Psychiatry 39, 14421445.CrossRefGoogle Scholar
Robins, L. N. & Regier, D. (1991). Psychiatric Disorders in America: The Epidemiologic Catchment Area Study. Free Press: New York.Google Scholar
Rosenberg, S. J., Hayes, J. R. & Peterson, R. A. (1987). Revising the Seriousness of Illness Rating Scale: modernization and restandardization. International Journal of Psychiatry in Medicine 17, 8592.CrossRefGoogle ScholarPubMed
Ross, C. E. & Mirowsky, J. (1984). Men who cry. Social Psychology Quarterly 47, 138146.CrossRefGoogle Scholar
Sattel, J. W. (1976). The inexpressive male: tragedy or sexual politics. Social Problems 23, 469477.CrossRefGoogle Scholar
Schulberg, H. C. & Burns, B. J. (1988). Mental disorders in primary care: epidemiologic, diagnostic, and treatment research directions. General Hospital Psychiatry 10, 7987.CrossRefGoogle ScholarPubMed
Shapiro, S., Skinner, E. A., Kessler, L. G., Von Korff, M., German, P. S., Tischler, G. L., Leaf, P. J., Benham, L., Cottler, L. & Regier, D. (1984). Utilization of health and mental health services. Archives of General Psychiatry 41, 971978.CrossRefGoogle ScholarPubMed
Shedler, J., Mayman, M. & Manis, M. (1993). The illusion of mental health. American Psychologist 48, 11171131.CrossRefGoogle ScholarPubMed
Shepherd, M. & Wilkinson, G. (1988). Primary care as the middle ground for psychiatric epidemiology. Psychological Medicine 18, 263267.CrossRefGoogle ScholarPubMed
Sireling, L. I., Freeling, P., Paykel, E. & Rao, B. M. (1985). Depression in general practice: clinical features and comparison with outpatients. British Journal of Psychiatry 147, 119126.CrossRefGoogle ScholarPubMed
Spitznagel, E. L. & Helzer, J. E. (1988). The Diagnostic Interview Schedule: its development, evolution, and use. Archives of General Psychiatry 42, 725728.CrossRefGoogle Scholar
Statistics Canada (1988). 1986 Census of Canada. Census Tracts of Montreal: Part 2, Catalogue no. 95–136. Ministry of Supply and Services: Ottawa.Google Scholar
Verbrugge, L. M. (1985). Gender and health: an update on hypotheses and evidence. Journal of Health and Social Behavior 26, 156182.CrossRefGoogle ScholarPubMed
Verhaak, P. F. M. & Tijhuis, M. A. R. (1994). The somatizing patient in general practice. International Journal of Psychiatry in Medicine 24, 157177.CrossRefGoogle ScholarPubMed
Von Korff, M., Shapiro, S., Burke, J. D., Teitlebaum, M., Skinner, E. A., German, P., Turner, R. W., Klein, L. & Burns, B. (1987). Anxiety and depression in a primary care clinic: comparison of Diagnostic Interview Schedule, General Health Questionnaire, and practitioner assessment. Archives of General Psychiatry 44, 152156.CrossRefGoogle Scholar
Warren, L. W. (1983). Male intolerance of depression: a review with implications for psychotherapy. Clinical Psychology Review 3, 147156.CrossRefGoogle Scholar
Widmer, R. B. & Cadoret, R. J. (1978). Depression in primary care: changes in pattern of patient visits and complaints during a developing depression. Journal of Family Practice 7, 293302.Google ScholarPubMed
Widmer, R. B. & Cadoret, R. J. (1979). Depression in family practice: changes in pattern of patient visits and complaints during subsequent developing depressions. Journal of Family Practice 9, 10171021.Google ScholarPubMed