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International Journal of Methods in Psychiatric Research logoLink to International Journal of Methods in Psychiatric Research
. 2006 Mar 24;12(1):34–43. doi: 10.1002/mpr.140

Patients presenting with somatic complaints: epidemiology, psychiatric co‐morbidity and management

Kurt Kroenke 1,✉
PMCID: PMC6878426  PMID: 12830308

Abstract

Somatic symptoms are the leading cause of outpatient medical visits and also the predominant reason why patients with common mental disorders such as depression and anxiety initially present in primary care. At least 33% of somatic symptoms are medically unexplained, and these symptoms are chronic or recurrent in 20% to 25% of patients. Unexplained or multiple somatic symptoms are strongly associated with coexisting depressive and anxiety disorders. Other predictors of psychiatric co‐morbidity include recent stress, lower self‐rated health and higher somatic symptom severity, as well as high healthcare utilization, difficult patient encounters as perceived by the physician, and chronic medical disorders. Antidepressants and cognitive‐behavioural therapy are both effective for treatment of somatic symptoms, as well as for functional somatic syndromes such as irritable bowel syndrome, fibromyalgia, pain disorders, and chronic headache. A stepped care approach is described, which consists of three phases that may be useful in the care of patients with somatic symptoms. Copyright © 2003 Whurr Publishers Ltd.

Keywords: somatic symptoms, co‐morbidity, depression, anxiety disorder

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References

  1. Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 2001; 134: 868–81. [DOI] [PubMed] [Google Scholar]
  2. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130: 910–21. [DOI] [PubMed] [Google Scholar]
  3. Barsky AJ, Saintfort R, Rogers MP, Borus JF. Nonspecific medication side effects and the nocebo phenomenon. JAMA 2002; 287: 622–7. [DOI] [PubMed] [Google Scholar]
  4. Brody DS, Miller SM, Lerman CE, Smith DG, Caputo GC. Patient perception of involvement in medical care: relationship to illness attitudes and outcomes. J Gen Intern Med 1989; 4: 506–11. [DOI] [PubMed] [Google Scholar]
  5. Cassem EH. Depressive disorders in the medically ill: an overview. Psychosomatics 1995; 36: S2–S10. [DOI] [PubMed] [Google Scholar]
  6. Ekstrand J, O'Malley PG, Labutta R, Jackson JL. Mental disorders in a neurology clinic setting. J Gen Intern Med 2000; 15(1, suppl): 112. [Google Scholar]
  7. Gardner JW, Gibbons RV, Hooper TI, Cunnion SO, Kroenke K, Gackstetter GD. Identifying new diseases and their causes: the dilemma of illnesses in Gulf War veterans. Milit Med (in press). [PubMed] [Google Scholar]
  8. Green LA, Fryer GE, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001; 344: 2021–5. [DOI] [PubMed] [Google Scholar]
  9. Gureje O, Simon GE. The natural history of somatization in primary care. Psychol Med 1999; 29: 669–76. [DOI] [PubMed] [Google Scholar]
  10. Hahn SR. Physical symptoms and physician‐experienced difficulty in the physician‐patient relationship. Ann Intern Med 2001; 134: 897–904. [DOI] [PubMed] [Google Scholar]
  11. Hahn SR, Kroenke K, Spitzer RL, et al. The difficult patient in primary care: prevalence, psychopathology and impairment. J Gen Intern Med 1996; 11: 1–8. [DOI] [PubMed] [Google Scholar]
  12. Henningsen P, Zimmermann T, Sarrel H. Medically unexplained physical symptoms, anxiety and depression: a meta‐analytic review. Psycho Med (in press). [DOI] [PubMed] [Google Scholar]
  13. Jackson JL, Houston JS, Hanling SR, Terhaar KA, Yun JS. Clinical predictors of mental disorders among medical outpatients. Arch Intern Med 2001; 161: 875–9. [DOI] [PubMed] [Google Scholar]
  14. Jackson JL, Kroenke K. Difficult patient encounters in the ambulatory clinic: clinical predictors and outcomes. Arch Intern Med 1999; 159: 1069–75. [DOI] [PubMed] [Google Scholar]
  15. Jackson JL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms. Ann Intern Med 2001; 134: 889–97. [DOI] [PubMed] [Google Scholar]
  16. Jackson JL, Kroenke K, Chamberlin J. Effects of physician awareness of symptom‐related expectations and mental disorders: a controlled trial. Arch Fam Med 1999; 8: 135–42. [DOI] [PubMed] [Google Scholar]
  17. Jackson JL, O'Malley PG, Kroenke K. Clinical predictors of mental disorders among outpatients: validation of the ‘S4’ model. Psychosomatics 1998; 39: 431–6. [DOI] [PubMed] [Google Scholar]
  18. Jackson JL, O'Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta‐analysis. Am J Med 2000; 108: 65–72. [DOI] [PubMed] [Google Scholar]
  19. Jackson JL, Passamonti ML. Symptoms in primary care: outcomes at five years. J.Gen.Intern.Med 2001; 16(1, suppl): 142 (abstract). [Google Scholar]
  20. Jailwala J, Imperiale T, Kroenke K. Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials. Ann Intern Med 2000; 133: 136–47. [DOI] [PubMed] [Google Scholar]
  21. Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med 2001; 134: 917–25. [DOI] [PubMed] [Google Scholar]
  22. Khan AA, Khan A, Kroenke K. Symptoms in primary care: etiology and outcome. J Gen Intern Med 2000; 15 (1, suppl.): 76–7. [Google Scholar]
  23. Klinkman MS. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry 1997; 19: 98–111. [DOI] [PubMed] [Google Scholar]
  24. Kroenke K. Symptoms and science: the frontiers of primary care research. J Gen Intern Med 1997; 12: 509–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Kroenke K. Studying symptoms: sampling and measurement issues. Ann Intern Med 2001; 134: 844–55. [DOI] [PubMed] [Google Scholar]
  26. Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med 1990; 150: 1685–9. [DOI] [PubMed] [Google Scholar]
  27. Kroenke K, Jackson JL. Outcome in general medical patients presenting with common symptoms: a prospective study with a two‐week and a three‐month follow‐up. Fam Pract 1998; 15: 398–403. [DOI] [PubMed] [Google Scholar]
  28. Kroenke K, Jackson JL, Chamberlin J. Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med 1997; 103: 339–47. [DOI] [PubMed] [Google Scholar]
  29. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989; 86: 262–6. [DOI] [PubMed] [Google Scholar]
  30. Kroenke K, Price RK. Symptoms in the community: prevalence, classification, and psychiatric comorbidity. Arch Intern Med 1993; 153: 2474–80. [PubMed] [Google Scholar]
  31. Kroenke K, Spitzer RL, Williams JBW, et al. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994; 3: 774–9. [DOI] [PubMed] [Google Scholar]
  32. Kroenke K, Spitzer RL, Williams JBW. The PHQ‐9: Validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Kroenke K, Swindle R. Cognitive‐behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom 2000; 69: 205–15. [DOI] [PubMed] [Google Scholar]
  34. Leventhal LJ. Management of fibromyalgia. Ann Intern Med 1999; 131: 850–8. [DOI] [PubMed] [Google Scholar]
  35. Marple RL, Kroenke K, Lucey CR, et al. Concerns and expectations in patients presenting with physical complaints: frequency, physician perceptions and actions, and two‐week outcome. Arch Intern Med 1997; 157: 1482–8. [PubMed] [Google Scholar]
  36. Mulrow CD, Williams JW Jr, Gerety MB, Ramirez G, Montiel OM, Kerber C. Case‐finding instruments for depression in primary care settings. Ann Intern Med 1995; 122: 913–21. [DOI] [PubMed] [Google Scholar]
  37. O'Malley PG, Balden E, Tomkins G, Santoro J, Kroenke K, Jackson JL. Treatment of fibromyalgia with antidepressants. A meta‐analysis. J Gen Intern Med 2000; 15: 659–66. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. O'Malley PG, Jackson JL, Kroenke K, Yoon K, Hornstein E, Dennis GL. The value of screening for psychiatric disorders in rheumatology referrals. Arch Intern Med 1998b; 158: 2357–62. [DOI] [PubMed] [Google Scholar]
  39. O'Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999; 48: 980–90. [PubMed] [Google Scholar]
  40. O'Malley PG, Wong PWK, Kroenke K, Roy MJ, Wong RKH. The value of screening for psychiatric disorders prior to upper endoscopy. J Psychosom Res 1998a; 44: 279–87. [DOI] [PubMed] [Google Scholar]
  41. Rao JK, Weinberger M, Kroenke K. Visit‐specific expectations and patient‐centered outcomes: a literature review. Arch Fam Med 2000; 9: 1148–55. [DOI] [PubMed] [Google Scholar]
  42. Reid S, Wessely S, Crayford T, Hotopf M. Medically unexplained symptoms in frequent attenders of secondary health care: retrospective cohort study. BMJ 2001; 322: 767. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Reidenberg MM, Lowenthal DT. Adverse nondrug reactions. N Engl J Med 1968; 279: 678–9. [DOI] [PubMed] [Google Scholar]
  44. Salerno SM, Browning R, Jackson JL. The effect of antidepressant treatment on chronic back pain: a meta‐analysis. Arch Intern Med 2002; 162: 19–24. [DOI] [PubMed] [Google Scholar]
  45. Schappert SM. National Ambulatory Medical Care Survey: 1989 summary. National Center for Health Statistics. Vital Health Stat 1992; 13(110): 1–80. [PubMed] [Google Scholar]
  46. Simon GE, Von Korff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999; 341: 1329–35. [DOI] [PubMed] [Google Scholar]
  47. Speckens AEM, Van Hemert AM, Bolk JH, Rooijmans HGM, Hengeveld MW. Unexplained physical symptoms: outcome, utilization of medical care and associated factors. Psychol Med 1996; 26: 745–52. [DOI] [PubMed] [Google Scholar]
  48. Spitzer RL, Kroenke K, Williams JBW, and the Patient Health Questionnaire Study Group . Validation and utility of a self‐report version of PRIME‐MD: The PHQ Primary Care Study. JAMA 1999; 282: 1737–44. [DOI] [PubMed] [Google Scholar]
  49. Thomas KB. General practice consultations: is there any point in being positive? Br Med J (Clin Res Ed) 1987; 294: 1200–2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Tomkins G, Jackson JL, O'Malley PG, Balden E, Santoro J. Treatment of chronic headache with antidepressants: a meta‐analysis. Am J Med 2001; 111: 54–63. [DOI] [PubMed] [Google Scholar]
  51. US Preventive Services Task Force . Screening for depression: recommendations and rationale. Ann Intern Med 2002; 136: 760–4. [DOI] [PubMed] [Google Scholar]
  52. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999; 354: 936–9. [DOI] [PubMed] [Google Scholar]
  53. Wetterneck TB, Linzer M, McMurray JE, et al. Worklife and satisfaction of general internists. Arch Intern Med 2002; 162: 649–56. [DOI] [PubMed] [Google Scholar]
  54. Whooley MA, Avins AL, Miranda J, Browner WS. Case‐finding instruments for depression: two questions are as good as many. J Gen Intern Med 1997; 12: 439–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Williams JW Jr. Competing demands: does care for depression fit in primary care? J Gen Intern Med 1998; 13: 137–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Williams JW, Mulrow CD, Kroenke K, et al. Case‐finding for depression improves patient outcomes: a randomized trial. Am J Med 1999; 106: 36–43. [DOI] [PubMed] [Google Scholar]
  57. Williams JW Jr, Noel PH, Cordes JA, Ramirez G, Pignone M. Is this patient clinically depressed? JAMA 2002; 287: 1160–70. [DOI] [PubMed] [Google Scholar]

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