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Case Illustration 1

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Ms. A, a 57-year-old woman, makes an appointment with a new clinician. She presents with a 10-year history of multiple unexplained symptoms. She has seen many physicians over the past decade, including several primary care physicians and numerous subspecialists. Her principal complaints today include abdominal pain, chest pain, headache, palpitations, fatigue, and intermittent dizziness. She brings a thick stack of records from some of her prior physicians. These records include multiple laboratory tests and diagnostic procedures, none of which has identified any cause for her symptoms.

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Clinician: How can I help you today, Ms. A?

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Patient (sighing): I don't know. A friend of mine saw you a few months ago and said you were very good. I hope you can help me. I've had these problems for years now, and no one seems to be able to figure them out. Maybe you can. I know there's something wrong. I've been so sick.

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Clinician: Why don't you tell me about your symptoms?

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Patient: Well, it all began about 10 years ago….

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Clinicians are taught that patients will present with symptoms (subjective complaints) and signs (objective findings) that suggest the presence of a pathophysiologic process. They are trained to recognize these presentations and to diagnose the underlying disease so that they may institute the appropriate treatment. Satisfaction for the care provider arises from the ability to perform these tasks proficiently and to see the patient benefit. Patients typically come to the clinician's office seeking an explanation for and relief from their symptoms. Difficulties arise in the relationship when the patient presents with symptoms and the clinician can find no explanation for them. Symptoms that lack discernible physical pathology have been referred to variously as medically unexplained, functional, or somatization.

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The term somatization (as used in this chapter) refers to the experience and reporting of physical symptoms that cause distress but lack a corresponding level of tissue damage or pathology and are linked to psychosocial stress. In contrast to this broad and inclusive view of the process, psychiatrists have developed strict diagnostic criteria that define several distinct disorders, which are collectively referred to as the somatoform disorders. As such, clinicians should be careful to distinguish between somatization, as defined above, and somatization disorder, which is one type of somatoform disorder. In general, these conditions are chronic and reflect an enduring way for the affected individuals to cope with psychosocial stressors. However, it is much more common in the primary care setting to encounter patients who have somatization symptoms but do not meet the full criteria for a psychiatric diagnosis. In many individuals, the somatization might be a transient phenomenon during a particularly stressful period such as divorce consisting of an exaggeration of common physical symptoms such as headache. In other patients, the process may be more persistent and the symptoms may be disabling. The latter ...

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