Cluster C Anxious Fearful

1. Dependent

Indecisive; lacks initiative; submissive; helpless; dependent; fears abandonment

2. Obsessive-compulsive

Perfectionism; inflexibility; preoccupation with details; wishes to control others; stingy; overconscientiousness; excessive morality or ethics

3. Avoidant

Easily hurt; timid, fearful; social discomfort; avoids interpersonal interactions

From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC, APA, 2000.

*DSM-IV-TR abridged criteria, 2000.

tFrom APA. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed revised. Washington, DC, APA, 1986.

way, as described throughout this text. In about one third of patients, however, the symptoms are causing impairment and no physical explanation can be found; alternatively the symptom is out of proportion to the supposed explanatory finding; these patients are somatic. At the more severe end of the continuum, somatic symptoms cluster into discrete diagnostic categories: the somatoform disorders, including somatization disorder, conversion disorder, somatoform pain disorder, hypochondriasis, factitious disorder, malingering, and body dysmorphic disorder. Primary care physicians tend not to pursue diagnoses to the level of these categories, because it is a time-consuming process not yet shown to improve patient outcomes. However, these categories have promising implications for managing the difficult clinical relationship, particularly in the context of personality types and disorders.

About 15% of primary care encounters are experienced by physicians as "difficult," as determined by the self-administered DDPRQ (Hahn et al., 1996). Patients classified as difficult are not distinguished by the usual demographic categories (age, gender, race, social status) but rather by the presence of somatoform complaints; other DSM Axis I conditions, particularly depression and anxiety disorders; and unique personality styles, up to and including DSM Axis II personality disorders. There is extensive overlap among these symptom clusters, particularly at the less severe end of the spectrum.

Unexplained physical symptoms are often benign and transitory, and only 3% of patients with these symptoms see a physician. Somatic complaints are described by patients within all domains of the traditional review of symptoms. Somatoform disorders are a group of severe psychiatric conditions that present with physical symptoms that suggest a medical condition but that cannot be adequately explained by a medical condition. Patients can have both a medical condition and unexplained physical symptoms that meet criteria for a somatoform condition. Box 46-2 describes somatoform disorders (DSM-IV-TR classification). Social or occupational impairment in these patients exceeds what would be expected based on physical complaints.

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