by the patient, and appears to be related to psychological stress or conﬂict. The prognosis is directly related to the length of time from onset to diagnosis and treatment (169–172).
Epidemiology Somatization is believed to be among the most common and most difficult psychological conditions in office practice. It is estimated that 60% to 80% of the general population experiences one or more somatic symptoms in a given week, providing an ample substrate for the patient preoccupied with her health (167). Somatization disorder occurs almost exclusively in women; menstrual symptoms may be an early sign. Lifetime prevalence in women is 0.2% to 2.0%. Conversion disorder occurs 2 to 10 times more frequently in women than in men (there is no difference for gender in children), and it is more common in rural and disadvantaged populations with little medical sophistication (167). Cases have become relatively rare. Conversion disorder may develop into somatization disorder. Reported rates of somatization disorder range from 11 to 300 per 100,000. Pain disorder is extremely common in both genders. Hypochondriasis is equally distributed between men and women; prevalence in general medical practice is estimated to be 4% to 9%. There are few statistics about body dysmorphic disorder, but it seems to be equally distributed between men and women, with an average age of onset of about 30 years (167).
Assessment Most somatizing disorders are chronic. The goal of treatment in primary care is not to eliminate all the somatic symptoms but to help the patient cope with them and minimize their effect on her relationships and responsibilities (167). Because patients often seek care simultaneously or sequentially from several physicians, it is crucial to ask about all past and current diagnostic procedures, diagnoses, treatments, and responses. Patients’ level of function over the years is important; prognosis is inversely related to chronicity. Chronicity should not be an excuse for a failure to treat the patient. The impact on the lives of patients and their families can be mitigated even if the condition is not entirely eliminated. For these and most other patients, the gynecologist needs to know what the patient believes is wrong with her and what she believes she needs in the way of diagnostic and therapeutic interventions. When the patient does not receive what she expects or desires, she is unlikely to comply with the recommended course of action, although she may accept it and pretend to be following it so as to avoid criticism from the physician. This behavior is actually very common among patients in general (167).
Management The management of somatizing disorders is focused on the avoidance of unnecessary medical interventions, iatrogenic medical or psychological complications, and disability. It is never possible to rule out all potential medical causes of a symptom. The literature is full of case presentations of patients with multiple sclerosis, brain tumors, and intermittently ﬂaring infections that for years were mislabeled as psychosomatic until a correct diagnosis of the condition was made (167,173). Organic pathology can befall patients with somatizing disorders. Patients who have benign gastrointestinal symptoms for extended periods can get appendicitis. Often a difficult differentiation must be made in each specific case and presentation.
Patients who have a somatizing disorder often approach each new clinician as the one who, “unlike the incompetent and insensitive physicians consulted in the past,” will finally get to the bottom of her troubles and cure her symptoms. The gynecologist must not get caught up in these expectations, but rather remind the patient that symptoms that have resisted diagnosis and treatment for many years are likely to be challenging ones. As with anxious patients, it is important to structure the doctor–patient relationship to avoid giving the patient attention inconsistently and only in response to escalating symptoms and demands (173). It is best to schedule frequent, brief office visits during which the clinician allots a small amount of time to listen to and sympathize with the patient’s somatic symptoms and spends the bulk of the time reinforcing the patient’s efforts to function despite her symptoms. Family members should be encouraged to facilitate functionality rather than invalidism.