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Editor's Correspondence
August 9/23, 1999

More Thoughts on Somatization

Arch Intern Med. 1999;159(15):1811-1817. doi:

While I greatly enjoyed the recently published thoughtful analysis of somatization in the ARCHIVES by Epstein et al,1 I have 3 distinct concerns about their proposals. The first is that they stigmatize as pejorative such labels as "amplifying" when, in fact, they are useful in establishing individualized therapeutic strategies and goals. For example, in my practice of adult rheumatology, most patients with rheumatoid arthritis rate their average pain between 4 and 6 on a 0- to 10-point verbal analog scale. Some, however, report pain levels of 8 or greater even when their disease appears mild by criteria such as the number of tender or swollen joints or acute-phase reactants. Effective analgesia may be a greater priority for these "pain amplifying" patients than "control of their disease." I realize that their pain report is higher than expected without having to affix a label, but my colleagues in primary care may not. Conversely, other patients report pain levels of 0 or l and seek medical attention only after years of joint destruction have led either to unacceptable (albeit painless) loss of function or to deformities obvious enough to provoke pressure from relatives. Analgesia is not a concern for these "pain minimizers," and their few complaints may mask the severity of their disease to some physicians. The adaptive value of amplification suggested by Epstein et al may exceed that of minimization by bringing disease to medical attention early, or the reverse may hold if amplification makes iatrogenic misadventure more likely. These possibilities are appropriate targets for further research; in the meantime, useful labels should not be arbitrarily dropped because some misuse them pejoratively.