Leicester Royal Infirmary, 1Harplands Hospital, Newcastle-under-Lyme, 2North Staffordshire Hospital, Stoke-on-Trent, 3Staffordshire Rheumatology Centre, Stoke-on-Trent, UK
Correspondence to: A. Kinder, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK. E-mail: alisonkinder{at}dsl.pipex.com
SIR, Patients with somatization disorder are high users of health care and often receive expensive, unnecessary tests and treatments. Current society expects doctors to diagnose and cure specific pathology. A failure to achieve this creates a psychological pressure of failure upon clinicians. We present one case that illustrates a common approach to a common condition with benign pathology which often presents to rheumatology out-patient departments.
This lady initially presented at the age of fourteen to ear, nose and throat surgeons with recurrent sore throats and underwent a tonsillectomy. Five years later during pregnancy she developed recurrent abdominal pain and despite extensive investigations no cause was found. She had a normal delivery of a healthy child. Since this time she has been referred to 16 different hospital specialities and undergone investigations for chest pain, breast pain, facial pain, ear pain, nasal stuffiness, irritable bowel disease, menorrhagia, urinary problems and dyspareunia. She has been referred to the rheumatology department on three occasions with back pain or multiple joint pains. Her symptoms have not improved despite surgery. A retrospective 30-yr review of her hospital case notes revealed she has had 29 operations requiring general anaesthetic, 10 MRI scans, three CT scans and 25 ultrasound examinations. She attended out-patients on 204 occasions with 52 in-patient stays totalling 411 days (Table 1). She is now 44 yr old and under the care of neurologists, physicians and urologists.
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We evaluated the hospital costs of this patient to the NHS by current reference costs for private patients at the trust in terms of out-patient visits, in-patient stays, procedures and investigations. The total cost came to £209 000. This does not take account of other potential costs such as primary care consultations, prescription costs, accident and emergency visits and attendances outside this trust. We are aware that she has had two consultations at other hospitals.
This patient fulfilled the diagnostic criteria for somatization disorder, which includes:
Patients with somatization disorder have multiple somatic complaints for which no biomedical abnormality has been demonstrated. The current theory is that this is due to underlying emotional conflict the patient is unable to face [3, 4]. The lifetime prevalence of somatization disorder is 0.10.2% but symptoms of part of this disorder are 100 times more common [5].
This disorder needs to be recognized by all specialities and emphasized during training. It should be diagnosed at a relatively early stage before the illness becomes chronic and intractable [6]. Extensive investigation only increases the burden of physical and psychosocial disability on patients and their relatives and is costly to the NHS, as demonstrated by this patient [7].
The management of these patients should be consistent and unambiguous and coordinated by one speciality such as the chronic pain management team, psychiatrist or psychologist with involvement of the general practitioner. A programme should be agreed with the general practitioner that limits investigations and patients access to specialists. Cognitive behavioural psychotherapy and short-term intensive psychotherapy may help the patient understand the underlying conflicts and thereby reduce the symptoms and recurrent presentations. Pharmacological therapy such as antidepressants or anxiolytic medication may be helpful in some patients [8].
This case demonstrates two learning points:
Signed consent from the patient was obtained for publication.
The authors have declared no conflicts of interest.
References