High utilizers of medical care: A crucial subgroup among somatizing patients
Introduction
Patients with somatoform disorders (SFD) are bothered by physical complaints for which no sufficient medical explanations can be found. Despite negative medical tests, many of these patients continue to believe that their symptoms are caused by organic dysfunction or disease [1]. They therefore tend to visit additional physicians and specialists, demand further medical investigations, and undergo treatments that are often not clearly indicated. This pattern of behavior has been termed inadequate illness behavior [2] because patients adopt a sick role despite the absence of a medical disease. From a socioeconomical perspective, illness behavior is likely to lead to increased utilization of healthcare services and unnecessary expenditures [3].
A few studies have indeed indicated an association between SFD and healthcare overutilization [4], [5], [6]. We have recently demonstrated that adequate treatment may lead to cost reductions [7]. However, high utilization is not an unavoidable characteristic of SFD. It may develop if patients persistently hold false beliefs about the nature of their symptoms and unrealistic expectations about treatment effects. Illness behavior may also develop from inadequate clinical management strategies in primary care [8]. Thus, while only a subgroup of somatizing patients develops a pattern of high utilization behavior, it is not known how well this subgroup can be differentiated from SFD patients with normal healthcare utilization. This question has been addressed by the research presented here. We compared high- and average-utilizing patients and attempted to identify clinical characteristics that are able to differentiate both groups. Since this study was conducted in an inpatient treatment unit, we also analyzed whether both groups differed with respect to their treatment improvements.
Section snippets
Method
We studied 95 patients fulfilling the diagnostic criteria of SFD according to DSM-IV [9]. All patients were investigated at the Roseneck Center for Behavioral Medicine in Prien, Germany, as part of a larger study evaluating the efficacy and cost effectiveness of cognitive–behavioral treatment for SFD. The study period was from 1995 to 2000. The major results and details of the methods were described in a recently published article [7]. Only a short description will be given here.
Differences between high and average utilizers
We analyzed on which measures high- and average-utilizing SFD patients were different. Table 3 lists those variables for which statistically significant group differences were obtained, ordered according to their strength of group differentiation as indicated by the amount of explained variance. The data displayed in Table 3 were assessed at admission to the hospital. The largest differences were found for utilization-related variables such as costs, hospitalization, and work disability
Discussion
Socioeconomical perspectives play an increasing role in the discussion of how mental and psychophysiological disorders should be treated. It will be important to identify clinical groups who are likely to overuse the medical system. One crucial group is the SFD. Because somatizing patients develop bodily complaints, which are not due to organic pathology, the value of usual medical treatment is limited. If psychosocial factors are not recognized, inadequate utilization of medical services over
References (20)
- et al.
Illness behavior and somatization in general practice
J Psychosom Res
(1996) - et al.
The cost of somatization
J Psychosom Res
(1991) - et al.
Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition
Psychosomatics
(1999) - et al.
A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost-effectiveness
J Psychosom Res
(2003) - et al.
How disabled are patients with somatoform disorders?
Gen Hosp Psych
(1997) - et al.
Screening for somatizing patients in the pulmonary subspecialty clinic
Psychosomatics
(1996) - et al.
Psychological distress as a predictor of frequent attendance in family practice: a cohort study
Psychosomatics
(2001) - et al.
Causal attributions about common somatic sensations among frequent general practice attenders
Psychol Med
(1996) - et al.
Patients with multiple unexplained symptoms. Their characteristics, functional health, and health care utilization
Arch Intern Med
(1986) - et al.
Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment
Arch Fam Med
(1994)
Cited by (57)
Association between frequency of primary care provider visits and evidence-based statin prescribing and statin adherence: Findings from the Veterans Affairs system
2020, American Heart JournalCitation Excerpt :This observation can likely be attributed to several factors. Previous analyses have shown that patients with medically unexplained physical symptoms, social barriers, and somatoform disorders are often frequent primary care users.24,25 Hence, we suspect that a proportion of patients with ≥5 PCP visits within our cohort may likely represent a similar population (i.e. with higher number of somatoform complaints), thereby accruing a large number of PCP visits without incremental benefit in statin prescribing.
Excess costs from functional somatic syndromes in Germany — An analysis using entropy balancing
2017, Journal of Psychosomatic ResearchCitation Excerpt :Associations between FSS and direct as well as indirect costs have been analysed in some studies, although evidence from Germany is rare [5,6]. Two studies compared costs in FSS patients to costs in patients with different mental disorders as well as to average per capita expenditures of German public health insurance companies [4,7]. In a previous study, we estimated overall costs of somatoform disorders in patients with mild, moderate and severe somatic symptom severity (SSS) according to the PHQ-15 [8].
Association of costs with somatic symptom severity in patients with medically unexplained symptoms
2013, Journal of Psychosomatic ResearchA high physical symptom count reduces the effectiveness of treatment for depression, independently of chronic medical conditions
2013, Journal of Psychosomatic ResearchThe implicit health-related self-concept in somatoform disorders
2013, Journal of Behavior Therapy and Experimental PsychiatryCitation Excerpt :Besides a highly focused attention to bodily processes and catastrophizing interpretations of minor bodily misconceptions, they found that patients with somatization syndrome tend to hold overexclusive beliefs about good health and communicate a self-concept of being weak and intolerant of stress. Hiller and Fichter (2004) reported that the strongest differences in SFD patients with medically unexplained symptoms that distinguish between high and average utilizers of healthcare systems were found on scales measuring illness behavior, psychosocial disabilities, and the self-perception of being bodily weak, whereas this last cognitive variable was the only one differentiating between high (healthcare costs ≥ € 2500 during the past 2 years) and extreme utilizers (healthcare costs ≥ € 5000 during the past 2 years). Thus, having a self-concept reflecting physical weakness is one of the most important factors that distinguishes a problematic SFD subgroup, which is characterized by frequent doctor visits and increased disability, from an unproblematic subgroup of people with SFDs who cope better with somatic symptoms (Rief, Mewes, Martin, Glaesmer, & Braehler, 2010).