| |
In
conclusion, research in which symptoms are a primary or secondary
outcome must take into account the high symptom burden in individuals
with cancer and other chronic illnesses, hospitalized populations,
the palliative care setting, and, in general, patients with medical
or psychiatric comorbidity.
The default
presumption is (and should be) that a discrete pathological lesion
or agent that can be reasonably linked to a physical symptom is
indeed the likely cause (e.g. back pain in a patient with vertebral
compression fracture, dyspnea in a patient with extensive pulmonary
metastases, constipation in a patient on high doses of narcotics).
However, when
symptoms are more general in nature or less definitively connected
to a specific physical cause, greater in number, or poorly responsive
to specific treatments, the possibility of coexisting somatization
should be entertained.
There are
several reasons that studying the prevalence and impact of somatization
in palliative care is important. First, 10% of ambulatory care
patients have at least a moderate level of somatization; since
many of these patients will eventually develop serious disorders
later in life (if not earlier), it would be clinically useful
to know how they respond to structural disease in terms of the
number and severity of symptoms reported. Second, medical and
psychosocial stress itself can trigger somatization even in individuals
who have previously not been somatizing patients. Thus, persistent,
multiple somatic symptoms unresponsive to medical interventions
in some patients with a terminal illness may be due to pre-existing
or incident somatization as well as to the advanced physical disorder.
Examples of
research questions include:
- Do patients
with pre-existing somatization respond differently to serious
structural disease in terms of symptom reporting than nonsomatizing
patients?
- What do
psychological disorders (depression and anxiety), unaddressed
patient concerns and expectations, coping style, and other factors
separate from the structural disease itself contribute to symptom
reporting and response to treatment?
- What is
the longitudinal course of symptom reporting (including number
and severity of symptoms and related impairment) in various
stages of a disease like cancer, such as pretreatment, remission,
recurrence, and refractory progression?
- In patients
with advanced illness and symptoms that are responding inadequately
to medical interventions, does the addition of psychological
treatments (e.g. antidepressants or brief cognitive-behavioral
therapy) benefit some individuals?
- What are
the similarities and differences in physical symptom reporting
among patients with different types of serious conditions, such
as cancer, HIV disease, and advanced cardiopulmonary disease?
Other recommendations for research are published elsewhere (Breitbart
et al, 1995).
|