Family physician survey in Mainz: Patients with depression frequently suffer from medically unexplained pain

High frequency of somatoform pain disorder reported from GP practices - significant differences between patients with and without depression


Pain symptoms that cannot be attributed, or at least not fully attributed, to an organic origin are more frequently and more severely experienced by patients with depression than by those without. "It is the case that women are much more frequently affected by depression and also by so-called somatoform pain disorder than men," explains Dirk Frieser, psychologist at the Institute of Psychology at Johannes Gutenberg University Mainz. For the purposes of his doctoral dissertation, Frieser and fellow psychologist Stephanie Körber questioned 308 patients attending two practices of general practitioners in Mainz. Patients were asked about their state of health and their pain symptoms, but also about their anxieties with regard to illness, how they react when ill, what social support they receive, and what psychological stress they experience, together with many other aspects. Subsequently, the pain symptoms reported by the patients were evaluated by their doctors.

Somatoform symptoms, i.e., symptoms that cannot or not fully be explained in medical terms, are an astonishingly widespread phenomenon. According to Frieser "up to 80 percent of the symptoms reported in GP practices are somatoform. However, this does not mean that patients are simply 'imagining' that they have these symptoms." Somatoform symptoms are very real; they impair quality of life, and can also cause clinically relevant disorders that may require psychological treatment, such as cognitive behavioral therapy.

Somatoform disorders, which are often popularly dismissed as 'hypochondria,' frequently not only involve pain symptoms but also other symptoms such as dizziness, sensations of hypersensitivity in various regions of the body, and even fatigue or exhaustion. What is important, according to Frieser, is that not everyone who has somatoform symptoms is diagnosed as having a somatoform disorder. The extent to which a patient's quality of life is impaired and the severity of the psychological problems they experience are the determining factors here.

Taking as their starting point the survey of GP practices in Mainz under the supervision of Professor Wolfgang Hiller of Mainz University, Frieser and Körber decided to investigate what influence depression has on the pain experience of patients and to determine whether this differs if the pain is of clinical origin and if the pain has no medically identifiable cause.

"The results indicate that there is a significantly higher occurrence of somatoform pain in various body regions in patients with existing depression or who suffered depression in the previous 12 months than in patients without depression." According to Frieser then, it is possible that patients who report to their doctors with multiple pain symptoms that cannot be explained in clinical terms are very probably suffering from a depressive disorder requiring treatment. In cases of major depression, the affected patients often exhibit dejection, despair, swings in appetite and body weight, insomnia or an increased need for sleep, tiredness, lack of energy, and psychomotor disturbances. These patients not infrequently also consider committing suicide. Short term mood swings with a duration of less than two weeks are not considered characteristic elements of this disorder.

The results of the GP survey in Mainz underline the importance of the correct classification and evaluation of pain symptoms for healthcare services; the general practitioners concluded that pain was somatoform in 73 percent of cases, and could be fully explained in medical terms in only 27 percent of cases. Where the pain is attributable to an organic cause, it is irrelevant whether the patient has depression or not: The frequency, duration, and the debilitating effect of the pain are roughly equivalent in both patient groups.