- Email: [email protected]
Patterns of referral in patients with medically unexplained motor symptoms
Journal of Psychosomatic Research 49 (2000) 217 ± 219
Short report
Patterns of referral in patients with medically unexplained motor symptoms Helen L. Crimliska, Kailash P. Bhatiaa, Helen Copeb, Anthony S. Davidb, David Marsdena, Maria A. Rona,* a
Neuropsychiatry Section, Department of Clinical Neurology, Institute of Neurology, Queen Square, London WC1N 3BG, UK b Institute of Psychiatry, London, UK Received 2 March 1999; accepted 27 July 1999
Abstract Objective: To investigate the pattern and reasons for referrals in 64 patients with a stable diagnosis of motor conversion symptoms who had been assessed at the National Hospital for Neurology and Neurosurgery (NHNN). Method: Patients were interviewed on average 6 years after their original admission to the NHNN. Hospital notes and GP records were consulted. Results: Psychiatrists at the NHNN saw 75% of patients. Treatment was initiated in 60% of these. During the 6-year follow up, many patients continued to be referred to neurologists and other specialists, but subsequent psychiatric referral was rare. Many changed their GP
after discharge from the NHNN and a disproportionate number of re-referrals was made by GPs who had known their patients for less than 6 months. Psychological attribution of symptoms was rare and did not appear to be related to the pattern of referrals. Conclusion: The pattern of care of these patients was inconsistent and many felt dissatisfied with the treatment they received. This led to further referrals, unnecessary use of valuable resources and unnecessary exposure to iatrogenic damage. Further studies should aim to assist GPs and other clinicians in deciding when referral is likely to be beneficial. D 2000 Elsevier Science Inc. All rights reserved.
Keywords: Conversion disorder; Referrals; Symptom attribution
Introduction
Methods
Unexplained physical symptoms are a common presentation of psychiatric disorder in primary care [1]. Such patients are perceived as difficult to help [2] but are often referred for multiple consultations and use a disproportionate amount of health resources [3,4]. We studied a group of patients with neurologically unexplained motor symptoms and found evidence that the diagnosis of conversion disorder is stable over time [5], but the patients studied continued to be referred for costly and unnecessary investigations. We have examined here the pattern of referrals in a sample of previously reported patients with unexplained motor symptoms in whom the diagnosis of conversion disorder remained stable 6 years later [5]. We have investigated some of the factors leading to new consultations and examined the role of illness attribution on referral patterns.
Sixty-four subjects (33 men and 31 women) were included in the study. The three patients from our original study [5] who had developed neurological disorders at follow up were excluded. During the 6-year follow up, subjects underwent a semistructured interview and were reassessed by a neurologist. Data were collected from hospital and GP records. The patients' attribution of symptoms was graded into three categories: (1) psychological factors brought on symptoms; (2) psychological factors may have played a part; (3) psychological factors were not important.
* Corresponding author. Tel.: +44-171-837-3611; fax: +44-171-8131189. E-mail address: [email protected] (M. Ron).
Results Source and reasons for initial referral Forty-one (64%) had been referred to the NHNN by their GP, 19 (30%) by a neurologist, and four (6%) by
0022-3999/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 1 6 7 - 7
218
H.L. Crimlisk et al. / Journal of Psychosomatic Research 49 (2000) 217±219
another specialist. Over half (56%) of the referrals by GPs were for a ``second opinion.'' The referral letter made it clear that in 39 (61%), the diagnosis was thought to be entirely or predominantly non-organic. Fourteen (22%) referral letters expressed concern about an organic disorder, and in the remaining 11 (17%), no mention was made of the possible aetiology. Pattern of management before admission The mean age of patients was 37 years (SD = 12.7), and the duration of motor conversion symptoms ranged from 1 to 140 months (median 18, SD 26.6). The majority had previously been investigated for these symptomsÐ31 (48%) by a neurologist, 17 (27%) by another specialist. A total of 42 (66%) had been admitted to hospital (number of admissions ranged from 0 to11). In contrast, only 14 (22%) had seen a psychiatrist for assessment or treatment of their motor symptoms. Of these, five had been seen once and told there was ``nothing wrong psychologically''. Two had received cognitive behaviour therapy and four (6%) had antidepressants. On admission to the NHNN, 25 (39%) had a history of organic neurological disorder (e.g. prolapsed disc, peripheral nerve palsy, migraine, epilepsy and mild mental handicap), but only in eight patients did the unexplained motor symptoms resemble those of previous illness. The original neurological symptoms had improved in most patients when seen 6 years later. The mean length of admission was 8 days (range 2 ±32, SD 3). All patients had routine blood tests, 52 (81%) had other blood tests, 39 (61%) EEG, EMG and other electrophysiological tests, 34 (53%) imaging (CT, MRI), 20 (31%) a lumbar puncture and 16 (25%) psychometry. Forty-eight (75%) were referred for a psychiatric opinion while at the NHNN. Referral was not significantly associated with age, gender, chronicity, suspicion of psychological aetiology in the initial referral or concurrent psychiatric morbidity. In eight (12.5%), no treatment was suggested, 16 (25%) received cognitive behavioural therapy, 14 (22%) antidepressants and in 10 (16%), referral to local psychiatric services was suggested. The eight patients who did not receive treatment had more chronic symptoms (c2 = 5.03, p < 0.03) and fitted the criteria for somatisation disorder (c2 = 3.98, p < 0.05) more often than the rest. Referrals after discharge from the NHNN Thirty-three subjects (51%) were subsequently referred to neurologists, and 27 (42%) had further admissions. In 28%, referrals were for further opinions on the same symptoms. Only 10 patients (16%) had been under neurological care throughout the follow-up period, in most cases to monitor pre-existing organic conditions (e.g. epilepsy, migraine), rather than the motor conversion symptoms.
In addition to the 30 patients (47%) treated by psychiatrists at the NHNN and the 10 (16%) referred to local psychiatrists, a further 10 (16%) new psychiatric referrals were subsequently made. Of these, five (8%) received no treatment and five (8%) received antidepressants and/or psychotherapy. Eighteen (28%) had counseling arranged by the GP and six (9%) had alternative therapies. Only nine patients (14%) were under psychiatric care at follow up. Twenty-two patients (34%) had been referred to rheumatologists, general physicians and specialists in infectious diseases (mostly to those with an interest in ``myalgic encephalomyelitis''), orthopaedics and immunology. The total number of referrals was 48, and some patients were referred more than once. GPs initiated the majority of these referrals. Thirty-nine patients (61%) had changed GP during the follow-up period, some more than once (range 1 ±5, mean 1.8). The patients almost always initiated these changes and few were related to change of address. New GPs were particularly likely to make new referrals shortly after having taken over the care of the patient. See Table 1. Patients with no subsequent referrals Thirteen patients had not been referred elsewhere during the follow-up period. Of these, three had short-lived symptoms, two had received psychiatric treatment at the NHNN and a further six had remained under the care of a psychiatrist (three at the NHNN) and were managed in conjunction with the GP. Their GPs alone had managed the remaining four, and the NHNN diagnosis had been accepted as the ``final'' opinion. Subjects who had not been referred elsewhere were less likely to have changed GP (c2 = 6.23, p = 0.02) and were more likely to have improved (c2 = 6.17, p = 0.03). Age and gender were not significantly related to further referrals. Symptom attribution Only three (5%) patients believed that psychological factors were important in causing their symptoms. Fourteen Table 1 Referrals for ``second opinions'' on motor conversion symptoms Referrals within 6 months of changing GP
Referrals Specialty
No.
(%)
No.
(%)
Neurology Psychiatry Rheumatology General medicine Infectious diseases Orthopaedics Immunology Other Total
18 10 12 10 6 6 4 10 76
(28) (16) (19) (16) (9) (9) (6) (16)
12 6 10 5 5 3 3 5
(67) (60) (83) (50) (83) (50) (75) (50)
H.L. Crimlisk et al. / Journal of Psychosomatic Research 49 (2000) 217±219
(22%) implied that psychological factors had played a part, often using the model of ``stress,'' e.g. ``I was under a lot of pressureÐmy body just couldn't cope with the stress.'' The majority (47, or 73%), however, thought psychological factors were irrelevant and interpreted coexistent psychiatric disturbances as caused by the somatic symptoms. Psychological attribution of symptoms was not related to subsequent referrals. When asked at follow up, most believed that doctors had been puzzled by their symptoms and could not give a name to their diagnosis. Only four patients (6%) used terms such as ``conversion'' or ``non-organic,'' 12 (19%) reported that they had ``chronic fatigue syndrome'' or ``ME'', and nine (14%) gave as their diagnosis a disorder that had been specifically excluded or that did not account for their symptoms (e.g. multiple sclerosis, arthritis). Discussion The aim of this study was to examine the patterns of referral in patients with medically unexplained motor symptoms and the possible factors leading to multiple consultations. As previously reported [5], 6 years after admission to the NHNN, the presenting symptoms had improved in half of our patients and very few had acquired new neurological or psychiatric diagnosis. Most patients had previously been extensively investigated by neurologists and other specialists and conversion disorder was often suspected before admission to the NHNN. Those who referred the patients were looking for a ``final opinion,'' but admission to the NHNN proved far from final for many. Very few patients had been referred to psychiatrists before admission to the NHNN, even when somatisation was suspected. This reflects the attitudes of doctors and patients to psychiatry and that of some psychiatrists to patients with conversion disorders. Some doctors feared that psychiatric referral would be unacceptable and some patients reported that psychiatrists had been unsympathetic or had sent them back to neurologists or GPs with a ``clean bill of psychological health'' without attempting to address the unexplained symptoms. The reasons for seeking a psychiatric opinion during the NHNN admission were often unclear. Some neurologists tended to refer whenever unexplained symptoms were present, while others saw their brief as excluding organic disease leaving further management to the referring doctor. The effectiveness of psychiatric intervention is also difficult to judge as treatment was not standardised and was often determined by the logistics of future attendance to the NHNN and availability of local services. In this cohort,
219
psychiatric treatment did not result in drastic changes in the pattern of subsequent referrals. Many of our subjects changed GPs after discharge and the referring behaviour of new GPs is of particular concern, although it is easy to understand the temptation to give ``the benefit of the doubt'' to a new patient about whose previous history there is little information. The fact that the majority of patients did not consider psychological factors to be relevant and were keen to get a physical diagnosis is also likely to have played a role. Perhaps the most striking finding of the study is that few of these patients had a consistent pattern of care during the follow-up period despite the chronicity and severity of their symptoms. Doctors may perceive them as too difficult to help and/or as ``wasting valuable time,'' while patients feel dissatisfied with their treatment. This vicious circle leads to further referrals, unnecessary use of valuable resources and exposure to iatrogenic damage. In those with chronic symptoms, improvement tends to be modest [5,6] and management should focus on reducing iatrogenic damage and unnecessary costs. These views are supported by a few studies showing that training GPs in the management of patients with unexplained symptoms is cost effective [7], and that psychiatric consultation followed by clear management advice can reduced costs by 20 ±30% and improve levels of function [3,8]. Finally, GPs and specialists need to see these patients as a rewarding challenge worthy of their best efforts. References [1] Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care settings. J Psychosom Res 1988;32:137 ± 44. [2] Sharpe M, Mayou R, Seagroatt V, Surawy C, Warwick H, Bulstrode C, Dawber R, Lane D. Why do doctors find some patients difficult to help? Q J Med 1994;87(3):187 ± 93. [3] Smith GR Jr, Ross K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52:238 ± 43. [4] Shaw J, Creed F. The cost of somatisation. J Psychosom Res 1991; 35:307 ± 12. [5] Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up of patients with medically unexplained motor symptoms. Br Med J 1998;316:582 ± 6. [6] Mace CJ, Trimble MR. 10-year prognosis of conversion disorder. Br J Psychiatry 1996;169:282 ± 8. [7] Morriss R, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Leese B, Goldberg D. Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Fam Pract 1998;15(2):119 ± 25. [8] Rost K, Kashner TM, Smith RG Jr. Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs. Gen Hosp Psychiatry 1994;16:381 ± 7.
Short report
Patterns of referral in patients with medically unexplained motor symptoms Helen L. Crimliska, Kailash P. Bhatiaa, Helen Copeb, Anthony S. Davidb, David Marsdena, Maria A. Rona,* a
Neuropsychiatry Section, Department of Clinical Neurology, Institute of Neurology, Queen Square, London WC1N 3BG, UK b Institute of Psychiatry, London, UK Received 2 March 1999; accepted 27 July 1999
Abstract Objective: To investigate the pattern and reasons for referrals in 64 patients with a stable diagnosis of motor conversion symptoms who had been assessed at the National Hospital for Neurology and Neurosurgery (NHNN). Method: Patients were interviewed on average 6 years after their original admission to the NHNN. Hospital notes and GP records were consulted. Results: Psychiatrists at the NHNN saw 75% of patients. Treatment was initiated in 60% of these. During the 6-year follow up, many patients continued to be referred to neurologists and other specialists, but subsequent psychiatric referral was rare. Many changed their GP
after discharge from the NHNN and a disproportionate number of re-referrals was made by GPs who had known their patients for less than 6 months. Psychological attribution of symptoms was rare and did not appear to be related to the pattern of referrals. Conclusion: The pattern of care of these patients was inconsistent and many felt dissatisfied with the treatment they received. This led to further referrals, unnecessary use of valuable resources and unnecessary exposure to iatrogenic damage. Further studies should aim to assist GPs and other clinicians in deciding when referral is likely to be beneficial. D 2000 Elsevier Science Inc. All rights reserved.
Keywords: Conversion disorder; Referrals; Symptom attribution
Introduction
Methods
Unexplained physical symptoms are a common presentation of psychiatric disorder in primary care [1]. Such patients are perceived as difficult to help [2] but are often referred for multiple consultations and use a disproportionate amount of health resources [3,4]. We studied a group of patients with neurologically unexplained motor symptoms and found evidence that the diagnosis of conversion disorder is stable over time [5], but the patients studied continued to be referred for costly and unnecessary investigations. We have examined here the pattern of referrals in a sample of previously reported patients with unexplained motor symptoms in whom the diagnosis of conversion disorder remained stable 6 years later [5]. We have investigated some of the factors leading to new consultations and examined the role of illness attribution on referral patterns.
Sixty-four subjects (33 men and 31 women) were included in the study. The three patients from our original study [5] who had developed neurological disorders at follow up were excluded. During the 6-year follow up, subjects underwent a semistructured interview and were reassessed by a neurologist. Data were collected from hospital and GP records. The patients' attribution of symptoms was graded into three categories: (1) psychological factors brought on symptoms; (2) psychological factors may have played a part; (3) psychological factors were not important.
* Corresponding author. Tel.: +44-171-837-3611; fax: +44-171-8131189. E-mail address: [email protected] (M. Ron).
Results Source and reasons for initial referral Forty-one (64%) had been referred to the NHNN by their GP, 19 (30%) by a neurologist, and four (6%) by
0022-3999/00/$ ± see front matter D 2000 Elsevier Science Inc. All rights reserved. PII: S 0 0 2 2 - 3 9 9 9 ( 0 0 ) 0 0 1 6 7 - 7
218
H.L. Crimlisk et al. / Journal of Psychosomatic Research 49 (2000) 217±219
another specialist. Over half (56%) of the referrals by GPs were for a ``second opinion.'' The referral letter made it clear that in 39 (61%), the diagnosis was thought to be entirely or predominantly non-organic. Fourteen (22%) referral letters expressed concern about an organic disorder, and in the remaining 11 (17%), no mention was made of the possible aetiology. Pattern of management before admission The mean age of patients was 37 years (SD = 12.7), and the duration of motor conversion symptoms ranged from 1 to 140 months (median 18, SD 26.6). The majority had previously been investigated for these symptomsÐ31 (48%) by a neurologist, 17 (27%) by another specialist. A total of 42 (66%) had been admitted to hospital (number of admissions ranged from 0 to11). In contrast, only 14 (22%) had seen a psychiatrist for assessment or treatment of their motor symptoms. Of these, five had been seen once and told there was ``nothing wrong psychologically''. Two had received cognitive behaviour therapy and four (6%) had antidepressants. On admission to the NHNN, 25 (39%) had a history of organic neurological disorder (e.g. prolapsed disc, peripheral nerve palsy, migraine, epilepsy and mild mental handicap), but only in eight patients did the unexplained motor symptoms resemble those of previous illness. The original neurological symptoms had improved in most patients when seen 6 years later. The mean length of admission was 8 days (range 2 ±32, SD 3). All patients had routine blood tests, 52 (81%) had other blood tests, 39 (61%) EEG, EMG and other electrophysiological tests, 34 (53%) imaging (CT, MRI), 20 (31%) a lumbar puncture and 16 (25%) psychometry. Forty-eight (75%) were referred for a psychiatric opinion while at the NHNN. Referral was not significantly associated with age, gender, chronicity, suspicion of psychological aetiology in the initial referral or concurrent psychiatric morbidity. In eight (12.5%), no treatment was suggested, 16 (25%) received cognitive behavioural therapy, 14 (22%) antidepressants and in 10 (16%), referral to local psychiatric services was suggested. The eight patients who did not receive treatment had more chronic symptoms (c2 = 5.03, p < 0.03) and fitted the criteria for somatisation disorder (c2 = 3.98, p < 0.05) more often than the rest. Referrals after discharge from the NHNN Thirty-three subjects (51%) were subsequently referred to neurologists, and 27 (42%) had further admissions. In 28%, referrals were for further opinions on the same symptoms. Only 10 patients (16%) had been under neurological care throughout the follow-up period, in most cases to monitor pre-existing organic conditions (e.g. epilepsy, migraine), rather than the motor conversion symptoms.
In addition to the 30 patients (47%) treated by psychiatrists at the NHNN and the 10 (16%) referred to local psychiatrists, a further 10 (16%) new psychiatric referrals were subsequently made. Of these, five (8%) received no treatment and five (8%) received antidepressants and/or psychotherapy. Eighteen (28%) had counseling arranged by the GP and six (9%) had alternative therapies. Only nine patients (14%) were under psychiatric care at follow up. Twenty-two patients (34%) had been referred to rheumatologists, general physicians and specialists in infectious diseases (mostly to those with an interest in ``myalgic encephalomyelitis''), orthopaedics and immunology. The total number of referrals was 48, and some patients were referred more than once. GPs initiated the majority of these referrals. Thirty-nine patients (61%) had changed GP during the follow-up period, some more than once (range 1 ±5, mean 1.8). The patients almost always initiated these changes and few were related to change of address. New GPs were particularly likely to make new referrals shortly after having taken over the care of the patient. See Table 1. Patients with no subsequent referrals Thirteen patients had not been referred elsewhere during the follow-up period. Of these, three had short-lived symptoms, two had received psychiatric treatment at the NHNN and a further six had remained under the care of a psychiatrist (three at the NHNN) and were managed in conjunction with the GP. Their GPs alone had managed the remaining four, and the NHNN diagnosis had been accepted as the ``final'' opinion. Subjects who had not been referred elsewhere were less likely to have changed GP (c2 = 6.23, p = 0.02) and were more likely to have improved (c2 = 6.17, p = 0.03). Age and gender were not significantly related to further referrals. Symptom attribution Only three (5%) patients believed that psychological factors were important in causing their symptoms. Fourteen Table 1 Referrals for ``second opinions'' on motor conversion symptoms Referrals within 6 months of changing GP
Referrals Specialty
No.
(%)
No.
(%)
Neurology Psychiatry Rheumatology General medicine Infectious diseases Orthopaedics Immunology Other Total
18 10 12 10 6 6 4 10 76
(28) (16) (19) (16) (9) (9) (6) (16)
12 6 10 5 5 3 3 5
(67) (60) (83) (50) (83) (50) (75) (50)
H.L. Crimlisk et al. / Journal of Psychosomatic Research 49 (2000) 217±219
(22%) implied that psychological factors had played a part, often using the model of ``stress,'' e.g. ``I was under a lot of pressureÐmy body just couldn't cope with the stress.'' The majority (47, or 73%), however, thought psychological factors were irrelevant and interpreted coexistent psychiatric disturbances as caused by the somatic symptoms. Psychological attribution of symptoms was not related to subsequent referrals. When asked at follow up, most believed that doctors had been puzzled by their symptoms and could not give a name to their diagnosis. Only four patients (6%) used terms such as ``conversion'' or ``non-organic,'' 12 (19%) reported that they had ``chronic fatigue syndrome'' or ``ME'', and nine (14%) gave as their diagnosis a disorder that had been specifically excluded or that did not account for their symptoms (e.g. multiple sclerosis, arthritis). Discussion The aim of this study was to examine the patterns of referral in patients with medically unexplained motor symptoms and the possible factors leading to multiple consultations. As previously reported [5], 6 years after admission to the NHNN, the presenting symptoms had improved in half of our patients and very few had acquired new neurological or psychiatric diagnosis. Most patients had previously been extensively investigated by neurologists and other specialists and conversion disorder was often suspected before admission to the NHNN. Those who referred the patients were looking for a ``final opinion,'' but admission to the NHNN proved far from final for many. Very few patients had been referred to psychiatrists before admission to the NHNN, even when somatisation was suspected. This reflects the attitudes of doctors and patients to psychiatry and that of some psychiatrists to patients with conversion disorders. Some doctors feared that psychiatric referral would be unacceptable and some patients reported that psychiatrists had been unsympathetic or had sent them back to neurologists or GPs with a ``clean bill of psychological health'' without attempting to address the unexplained symptoms. The reasons for seeking a psychiatric opinion during the NHNN admission were often unclear. Some neurologists tended to refer whenever unexplained symptoms were present, while others saw their brief as excluding organic disease leaving further management to the referring doctor. The effectiveness of psychiatric intervention is also difficult to judge as treatment was not standardised and was often determined by the logistics of future attendance to the NHNN and availability of local services. In this cohort,
219
psychiatric treatment did not result in drastic changes in the pattern of subsequent referrals. Many of our subjects changed GPs after discharge and the referring behaviour of new GPs is of particular concern, although it is easy to understand the temptation to give ``the benefit of the doubt'' to a new patient about whose previous history there is little information. The fact that the majority of patients did not consider psychological factors to be relevant and were keen to get a physical diagnosis is also likely to have played a role. Perhaps the most striking finding of the study is that few of these patients had a consistent pattern of care during the follow-up period despite the chronicity and severity of their symptoms. Doctors may perceive them as too difficult to help and/or as ``wasting valuable time,'' while patients feel dissatisfied with their treatment. This vicious circle leads to further referrals, unnecessary use of valuable resources and exposure to iatrogenic damage. In those with chronic symptoms, improvement tends to be modest [5,6] and management should focus on reducing iatrogenic damage and unnecessary costs. These views are supported by a few studies showing that training GPs in the management of patients with unexplained symptoms is cost effective [7], and that psychiatric consultation followed by clear management advice can reduced costs by 20 ±30% and improve levels of function [3,8]. Finally, GPs and specialists need to see these patients as a rewarding challenge worthy of their best efforts. References [1] Goldberg DP, Bridges K. Somatic presentations of psychiatric illness in primary care settings. J Psychosom Res 1988;32:137 ± 44. [2] Sharpe M, Mayou R, Seagroatt V, Surawy C, Warwick H, Bulstrode C, Dawber R, Lane D. Why do doctors find some patients difficult to help? Q J Med 1994;87(3):187 ± 93. [3] Smith GR Jr, Ross K, Kashner TM. A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somatizing patients. Arch Gen Psychiatry 1995;52:238 ± 43. [4] Shaw J, Creed F. The cost of somatisation. J Psychosom Res 1991; 35:307 ± 12. [5] Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up of patients with medically unexplained motor symptoms. Br Med J 1998;316:582 ± 6. [6] Mace CJ, Trimble MR. 10-year prognosis of conversion disorder. Br J Psychiatry 1996;169:282 ± 8. [7] Morriss R, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Leese B, Goldberg D. Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Fam Pract 1998;15(2):119 ± 25. [8] Rost K, Kashner TM, Smith RG Jr. Effectiveness of psychiatric intervention with somatization disorder patients: improved outcomes at reduced costs. Gen Hosp Psychiatry 1994;16:381 ± 7.