Turning Illness into a Way of Life

By Anastasia Toufexis

A new study says somatizers and doctors have a lot in common

In public, doctors call them hypochondriacs, malingerers and hysterics. In private, physicians have been known to describe some of them as turkeys, hospital hobos and GOMERs (an acronym for Get Out of My Emergency Room). By whatever name, they are doctors' least-loved patients, individuals who use imaginary or self-inflicted physical illnesses to gain attention and manipulate others. The hostility displayed by physicians to these patients, known clinically as somatizers, is usually attributed to irritation and frustration. Now Psychiatrist Charles Ford of the Vanderbilt University School of Medicine offers a more startling explanation for the rancor: physicians and somatizers have a lot in common. The attraction of many doctors to medicine, he suggests, is a kind of somatization: a fear of disease and death.

Ford puts forth the provocative hypothesis in a new book, The Somatizing Disorders: Illness as a Way of Life (Elsevier Science Publishing Co., Inc.; $29.95). Somatizers (from the Greek soma for body) are patients whose maladies result from stress, unexpressed emotions or the need for attention. Explains Ford: "They turn psychological issues into body issues." He cites one of his patients as typical: a housewife torn between a desire to work and a desire to be pampered. For two years, she had been complaining of terrible pain in her abdomen whenever she sat down. Her symptom, Ford says, was caused by her conflicting needs: "If she had a pain, she had to be taken care of, but the pain was also punishment for not working."

According to Ford, somatizing disorders take many forms, including hysteria, malingering, chronic pain and hypochondriasis. The hypochondriac is preoccupied with the fear of having a serious disease. Some doctors refer to the treatment of hypochondriacs, or "crocks," as "psychoceramic medicine" and the recitation of their histories as "organ recitals." Other somatizers sometimes deliberately fake illness, going so far, for example, as to rub a thermometer on a bedsheet to produce a fever, lacerate the skin to create lesions, or overuse laxatives to disrupt the gastrointestinal tract. In the bizarre Munchausen syndrome, which, according to one estimate, affects 4,000 U.S. patients, ailments are feigned so that the individual can enter the hospital. One man was so skillful at complaining about his abdominal pain, vomiting and seizures that he was hospitalized more than 400 times and submitted to 102 gastrointestinal tests.

Ford estimates conservatively that 10% of the patients seen by internists and family practitioners have no physical basis for their ailments. Some doctors, he says, put their case loads of somatizers as high as 40%. Even the low figure, says Ford, means that $20 billion a year in medical care is spent on people with no organic disease.

Part of the problem in dealing with somatizers, notes Ford, is that "physicians on the whole have no training in the identification, diagnosis and treatment of these patients. Typically, the patient's complaint is taken at face value." Physical test after test follows with uniformly negative findings, though, warns Ford, "enough tests and, sooner or later, the patient will have a real disease caused by the process of diagnosing and treating." Doctors must be taught to recognize the hidden meaning behind many physical complaints, says Ford: "It's like two languages being spoken."

But another factor in the poor handling of somatizers, he suggests, is that these patients tap into the physicians' own conflicts. Doctors, Ford argues, see a reflection of themselves in their somatizing patients. Citing studies, plus his own research, he says that many doctors and many somatizers tend to be emotionally inhibited, with high rates of sexual and marital difficulties and a high incidence of drug abuse. As children, both groups frequently lacked close, affectionate relationships with their parents. Their childhoods were commonly marked by a death or serious illness in the family that left them with anxieties about disease and dying. Such experiences, says Ford, lead both groups to make illness a way of life. Somatizers try to allay their fears by repeatedly seeking medical help; physicians strive to overcome their dread by "devoting themselves to conquering disease."

Faced with somatizing patients, says Ford, physicians are uncomfortably reminded, often unconsciously, of their own inadequacies. As a result, a doctor may reject a patient outright. For example, a physician who is depressed and abusing liquor will tend to shy away from a patient who is an alcoholic. Conversely, the doctor may become overly solicitous, a tactic that backfires. Ford believes the words "You're fine; come back and see me if something develops" are a virtual invitation to create new symptoms.

Patricia Bloom, an internist at New York City's Montefiore Hospital, thinks Ford's position on the similarities between somatizers and doctors may have some validity but is "skeptical that the doctor is fearful for the same reason that the patient is." Arthur Barsky, a psychiatrist at Boston's Massachusetts General Hospital, believes Ford's views are difficult to substantiate. Says he: "The way you treat somebody has a lot to do with the way you think about yourself. That phenomenon is there. Beyond that, it's inference."

Barsky feels that no one really knows how to manage somatizers. Referrals to psychiatrists and psychologists would seem to be in order, but the patients themselves are offended by such referrals, believing that the doctors are not taking them seriously. That often leads patients to shop for a doctor. "Clinical experience," Barsky says, "indicates that they do not want to be cured, although a long-term supportive relationship with a physician often stabilizes them."

Ford agrees about the need for a perdurable relationship, advocating periodic 15-minute visits to the physician by somatizers. "After doing doctor-type things, you ask the patients about their feelings," he says. "Ask about their families and give the patients a chance to talk. The doctor is really practicing medicine when sitting and listening to patients.''

--By Anastasia Toufexis. Reported by Val Castronovo/New York

With reporting by Val Castronovo This file is automatically generated by a robot program, so viewer discretion is required.