Somatic distress syndromes in later life: the need for paradigm change.

Somatic distress syndromes, which include somatoform disorders and syndromes of chronic fatigue such as neurasthenia but not somatic presentations of anxiety and depression, are one of the common expressions of distress in primary care (Ormel et al. 1994) and general hospital settings (Hemert et al. 1993). They are of considerable importance cross-culturally (Ono et al. 1999), and often lie at the interface of psychiatry and medicine (Hickie, 1999). They are associated with significant disability (Ormel et al. 1994; Andrews, 2000) and health-care utilization (Escobar et al. 1991). Old-age psychiatry arose in response to the epidemiological imperative of dementia (Kay et al. 1964). While late-onset schizophrenia and depression have been the subject of research interest since, the neurotic disorders, in particular somatoform disorders, have tended to be relatively neglected (Jorm, 1998). The contention that preoccupation with body function is characteristic of older age has been accepted on the basis of received wisdom (Pitt, 1982) and limited research on hypochondriacal symptoms in late life depression (Brown et al. 1984). Conceptual confusion about the somatic distress syndromes in general (Hickie et al. 1998; Wessely et al. 1998; Jablensky, 1999) may have also inhibited further exploration of this area. However, the study of somatoform disorders in older people would seem important for a number of reasons. People aged 65 years and over account for up to 25% of primary care consultations (Commonwealth Department of Health and Family Services, 1996). The presence of medical illness is a risk factor for somatic distress, a fact which has tended to be overlooked (Lipowski, 1988). It would also complement the preliminary literature, which has suggested a decline in vulnerability to affective and anxiety disorders with age (Flint, 1994; Henderson, 1994; Krasucki et al. 1998; Jorm, 2000), and thereby clarify how neurotic disorders may vary in presentation with age. Therefore, the issues pertinent to this paper include whether the traditional conceptualization of somatic distress syndromes are appropriate to older people and those with medical illness, whether prevalence rates vary with age and medical illness, and if so, possible explanations for any differences. Medline and PsycLit databases were studied for the years 1989 to 1999. We reviewed community and primary care studies that reported rates of at least one DSM or ICD somatoform disorder or relevant somatic distress syndrome in adults across the age span and included subjects aged at least 60 years. Studies of somatic distress syndromes in medical settings were also used. Other key terms, such as somatization, were searched. A secondary manual search of references from retrieved papers was then made.