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Medical Symptoms without Identified Pathology: Relationship to Psychiatric Disorders, Childhood and Adult Trauma, and Personality Traits

Wayne Katon, MD; Mark Sullivan, MD, PhD; and Ed Walker, MD
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From University of Washington Medical School, Seattle, Washington. Note: This article is one of a series of articles comprising an Annals of Internal Medicine supplement entitled “ Investigating Symptoms: Frontiers in Primary Care Research—Perspectives from The Seventh Regenstrief Conference ” To see a complete list of the articles included in this supplement, please view its Table of Contents.

Copyright ©2004 by the American College of Physicians

Grant Support: By grant MH-01643 from the National Institute of Mental Health (Dr. Katon).

Requests for Single Reprints: Wayne Katon, MD, Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Box 356560, 1959 NE Pacific Street, Seattle, WA 98195-6560; e-mail, wkaton@u.washington.edu.

Current Author Addresses: Drs. Katon, Sullivan, and Walker: Department of Psychiatry and Behavioral Sciences, University of Washington Medical School, Box 356560, 1959 NE Pacific Street, Seattle, WA 98195-6560.

Ann Intern Med. 2001;134(9_Part_2):917-925. doi:10.7326/0003-4819-134-9_Part_2-200105011-00017
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Community studies have shown that stressful life events, psychological distress, and depressive and anxiety disorders are associated with 1) a range of medical symptoms without identified pathology, 2) increased health care utilization, and 3) increased costs. In both primary care and medical specialty samples, patients who have syndromes with ill-defined pathologic mechanisms (such as the irritable bowel syndrome and fibromyalgia) have been shown to have significantly higher rates of anxiety and depressive disorders than do patients with comparable, well-defined medical diseases and similar symptoms. Other studies show that after adjustment for severity of medical illness, patients with depression or anxiety and comorbid medical disease have significantly more medical symptoms without identified pathology than do patients with a similar medical disease alone. Both childhood maltreatment and psychological trauma in adulthood have been associated with increased vulnerability to psychiatric illness and more medical symptoms. The substantial functional impairment, distress, and costs associated with medical symptoms without identified pathology suggest that research studies promoting a better understanding of the biopsychosocial cause of these symptoms may yield pragmatic, cost-effective approaches to treatment in medical settings.


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Figure 1.
The association of current panic disorder with medical syndromes without identified pathology.white barsgray bars*

The figure compares 1-month prevalence of panic disorder in patients with medically unexplained symptoms ( ) and in controls with a well-defined medical illness ( ). On angiography. CAD = coronary artery disease; RA = rheumatoid arthritis; Pheo = pheochromocytoma.

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Figure 2.
Association of depression with number of somatic symptoms in patients with chronic medical illness.Diagnostic and Statistical Manual of Mental Disorders

White bars represent patients with current depressive or anxiety disorders according to , fourth edition, criteria; gray bars represent patients without such disorders. IBD = inflammatory bowel disease.

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