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Patients who somatize psychosocial distress commonly present in medical clinical settings. Approximately 25% of patients in primary care demonstrate some degree of somatization, and at least 10% of medical or surgical patients have no evidence of a disease process. Somatizing patients use a disproportionately large amount of medical services and frustrate their physicians, who often do not recognize the true nature of these patients’ underlying problems. Somatizing patients rarely seek help from psychiatrists at their own initiative, and they may resent any implication that their physical distress is related to psychological problems. Despite the psychogenic etiology of their illnesses, these patients continue to seek medical care in nonpsychiatric settings where their somatization is often unrecognized.

Somatization is not an either-or proposition. Rather, many patients have some evidence of biological disease but overrespond to their symptoms or believe themselves to be more disabled than objective evidence would indicate. Medical or surgical patients who have concurrent anxiety or depressive disorders use medical services at a rate two to three times greater than that of persons with the same diseases who do not have a comorbid psychiatric disorder.

Despite the illusion that somatoform disorders are specific entities, as is implied by the use of specific diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), the symptoms most of these patients experience fail to meet the diagnostic criteria of the formal somatoform disorders. Further, over time, patients’ symptoms tend to be fluid, and patients may be best described as having one disorder at one time and another disorder at some other time. Somatization is caused or facilitated by numerous interrelated factors (Table 22–1), and for an individual patient a particular symptom may have multiple etiologies. In other words, these disorders are heterogeneous both in clinical presentation and in etiology.

Table 22–1. Causes of Somatization

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