Annals of Clinical Psychiatry, Vol. 11, No. 2, 1999

Psychiatric Symptoms Endorsed by Somatization DisorderPatients in a Psychiatric Clinic

Eric J. Lenze, M.D.,1 Anthony R. Miller, M.D.,1 Zeelaf B. Munir, M.D.,1 ChanvitPornnoppadol, M.D.,1 and Carol S. North, M.D.1,2

Patients with somatization disorder (SD) endorse high rates of psychiatric symptoms. How-ever, prior studies have not addressed whether these endorsed symptoms reflect underlyingpsychiatric illness or whether they represent symptom overendorsement mirroring somaticcomplaints in patients with SD. Thirty-two female outpatients with SD and 101 with otherpsychiatric disorders completed a checklist of current and lifetime psychiatric symptoms.These findings were analyzed with respect to the diagnoses given by their treating psychia-trists. Patients with SD displayed significantly more current and lifetime psychiatric symptomsthan did patients without either SD or cluster B personality disorder. Patients with SDendorsed a large number of psychotic, manic, depressive, and anxiety symptoms; however,they endorsed few alcohol use disorder symptoms. Psychotic and manic symptoms endorsedby patients with SD did not reflect their clinical diagnoses: only two patients with SD carriedan additional clinician diagnosis of either schizophrenia or bipolar disorder, despite highrates of endorsed symptoms by the group. Patients with cluster B personality disorders butwithout SD showed a symptom profile similar to that of patients with SD. Psychiatric outpa-tients with SD endorse many more psychiatric symptoms than do other psychiatric patients.Patients with SD in the psychiatric treatment setting may mimic other psychiatric illnesses;therefore, SD should be considered in the differential diagnosis for a wide variety of psychiat-ric illness, including psychotic and mood disorders.

INTRODUCTION

Somatization disorder (SD) is a clinical syn-drome characterized by multiple medically unex-plained physical symptoms of many years' duration,beginning before age 30(1). Patients with SD oftenhave a great deal of disability associated with theirillness in terms of days missed from work or otheractivities, in addition to increased hospitalizations,medical tests, surgical procedures, medications, andiatrogenic illness. The current definition of SD wasderived from Briquet's syndrome, originally a re-

1Department of Psychiatry, Washington University School of Med-icine, St. Louis, Missouri.

2To whom correspondence should be addressed at WashingtonUniversity School of Medicine, Department of Psychiatry, 4940Children's Place, Box 8134, St. Louis, Missouri 63110.

search diagnosis which included 59 physical and psy-chiatric symptoms, with 25 symptoms required fordiagnosis (2). Briquet's syndrome is a stable diagnosisover time, with a high interrater reliability and famil-ial aggregation. The same can be said for SD, asprevious research has demonstrated a high concor-dance with Briquet's syndrome (3, 4). Previous au-thors have addressed the importance of diagnosingSD in primary care and other medical settings, aspatients with SD generate considerable medical ex-penditures from hospitalizations, medications, proce-dures, and physician visits (5-7). Previous studieshave described the prevalence and presentation ofSD in medicine or specialty clinics and the value ofpsychiatric consultation in reducing expenditures andiatrogenic illness (8-10).

SD has received less study in psychiatric patient

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1040-1237/99/0600-0073$16.00/l © 1999 American Academy of Clinical Psychiatrists

KEY WORDS: Somatization disorder; somatoform; psychoform; psychiatric symptoms.

74 Lenze, Miller, Munir, Pornnoppadol, and North

populations. However, the disorder is prevalent ingeneral psychiatric settings. DeSouza's group identi-fied SD in 96 out of 2800 patients, or 3%, in a univer-sity psychiatric clinic (11), and Guze and colleaguesobserved a 6% prevalence of Briquet's syndrome ina similar clinic (12). These rates are comparable tothe 5-6% rates of SD reported in family practiceclinics (13, 14), suggesting that SD is prevalent inpsychiatric settings as well as in general medical set-tings.

Studies have shown that psychiatric symptomsmay be quite prevalent in SD. In the Piedmont sec-tion of the Epidemiologic Catchment Area Study(15), subjects who met SD criteria also reported highrates of current and lifetime depressive, anxiety, andpsychotic symptoms. As a result, 78% met criteriafor at least one other DSM-III diagnosis, including65% with major depression, 38% with schizophrenia,38% with panic disorder, and 35% with bipolar disor-der. Liskow and colleagues (16) also found high ratesof psychiatric symptom endorsement among psychi-atric inpatients with Briquet's syndrome, with a meanof 3.7 additional DSM-III diagnoses, more than twiceas many as for a comparison group of inpatients;94% met criteria for major depression, 38% forschizophrenia, and 38% for bipolar disorder. In an-other study (17), psychiatric outpatients with Bri-quet's syndrome were found to qualify for an averageof 3.3 additional psychiatric diagnoses. Two MMPIstudies have documented a wide variety of psycho-pathological complaints among patients with Bri-quet's syndrome, including elevations in the paranoiaand schizophrenia scales compared to other psychiat-rically ill groups (16, 18).

Thus, it is well documented that patients withSD endorse many psychiatric symptoms. Reflectingthis tendency, SD has been labeled a "psychoform"as well as a somatoform illness (18,19). Although SDis considered in the differential diagnosis of medicalillnesses, it is not usually in the differential of psychi-atric syndromes. For example, the authors have ob-served that the diagnosis of SD is often overlookedin patients presenting with psychotic or manic symp-toms. This may be partly because SD is not a formalpart of DSM-IV exclusion criteria for schizophreniaor mania (1) and because screening for SD is notroutine in general psychiatric practice. Therefore,when a patient endorses psychotic or manic symp-toms, the usual differential does not include SD. Fur-ther, if a patient with psychiatric symptoms is diag-nosed with SD, it is often considered "comorbid"to the psychiatric symptoms, rather than the source.

About this issue, Martin has written (20), "Inabilityto recognize excessive complaints as part of a patternmay greatly compromise effective management."This report further addresses the presentation of psy-chiatric symptoms by SD patients in a psychiatrictreatment setting by systematically examining en-dorsements of a variety of psychiatric symptoms andcomparing them with the clinical judgment of theirpsychiatrists.

METHODS

Subjects were recruited by residents who weretheir treating psychiatrists at the Washington Univer-sity psychiatric clinic, which serves primarily Medic-aid and Medicare patients. Criteria for inclusion werefemale patients between 18 and 65 years of age withno intellectual, cognitive, or language barriers visitingthe clinic within the 6-month time period for thestudy. Only female patients were selected because ofthe rarity of SD in males (21). All patients enteredin the study were screened systematically for SD.Because screening and entry into the study were rou-tinely accomplished during the clinic visit, time con-straints dictated that not all possible patients couldbe entered. The screening procedure for SD mostlikely resulted in higher recruitment rates for SDpatients than for patients with other disorders.

Study subjects were asked to fill out a self-reportquestionnaire. The questionnaire was specifically de-signed by the authors for this study. Using phraseol-ogy borrowed from the Diagnostic Interview Sched-ule (22), it inquired about the current (i.e., in thelast month) and lifetime occurrence of psychiatricsymptoms derived from DSM-IV criteria for schizo-phrenia, bipolar disorder, major depression, panicdisorder, obsessive-compulsive disorder, and alcoholuse disorders. The questionnaire included a totalof 82 psychiatric symptoms, represented in the fol-lowing categories: delusions (13 symptoms), halluci-nations (9 symptoms), mania (11 symptoms), depres-sion (11 symptoms), panic (14 symptoms),generalized anxiety (7 symptoms), obsessions andcompulsions (4 symptoms), and alcohol use (13symptoms). Prior to the inception of this study,approval from this institution's Human StudiesCommittee was obtained. Following a completedescription of the study to the subjects, writteninformed consent was obtained.

Diagnoses for this study were provided by sub-jects' psychiatrists who generated a complete list of

Psychiatric Symptoms of Somatization Disorder Patients 75

their participating patients' current psychiatric diag-noses. Diagnoses were made with careful adherenceto DSM-IV criteria. At the Washington Universitypsychiatry clinic, patient charts are reviewed by full-time board-certified psychiatric faculty, with particu-lar attention to whether the diagnosis given by thepsychiatric resident is supported by DSM-IV criteria.In addition, patients routinely are followed over time,providing longitudinal confirmation of diagnosis.

For this study, patients were categorized intofour comparison groups: definite SD, suspected SD(in cases where the psychiatrist responsible for thepatient's care had a strong clinical suspicion of SDand the patient met most criteria but not the fulldiagnostic criteria), cluster B personality disorder di-agnosis without definite or suspected SD, and psy-chotic and nonpsychotic diagnoses without either SDor cluster B personality disorder.

Symptom data are presented as means and stan-dard deviations, and t tests were used to determinedifferences between groups. Fisher's exact tests wereused in analyses of categorical variables. Statisticalsignificance was set at a < 0.05.

RESULTS

Of 145 female psychiatric patients determinedto be eligible for this study, 12 refused and 133 com-pleted the questionnaire, for a participation rate of92%. The 12 patients who refused were significantlydifferent from participants only in that all were black(p = 0.004). Table 1 shows that, of the women en-rolled in the study, 32 (24.1%) met DSM-IV criteriafor somatization disorder. An additional eight cases(6.0%) had suspected SD but did not meet the fulldiagnostic criteria. In nine (6.8%) other cases, thepatient had a principal diagnosis of a cluster B per-sonality disorder but did not meet the criteria forsomatization disorder. Diagnoses of the women with-out confirmed or suspected somatization disorder orcluster B personality disorder included schizophreniain 24 (18.0% of the total sample), other psychoticdisorders (schizoaffective disorder, psychotic depres-sion, bipolar disorder with psychotic features, or psy-chotic disorder—not otherwise specified) in 13(9.8%), bipolar disorder without psychotic featuresin 11 (8.3%), unipolar depression without psychoticfeatures (major depressive disorder or depressive dis-order—not otherwise specified) in 30 (22.6%), alco-hol abuse or dependence in 9 (6.8%), other substanceuse disorders in 4 (3.0%), panic disorder in 7 (5.3%),

generalized anxiety disorder in 5 (3.8%), and obses-sive compulsive disorder in 1 (0.8%).

As shown in Table 2, women with confirmed SDreported significantly more current symptoms thanwomen with suspected SD and more lifetime andcurrent symptoms than other women (without clusterB personality disorder). Patients with cluster B per-sonality diagnoses not meeting criteria for somatiza-tion disorder had symptom counts similar to thoseof patients with somatization disorder, and their rateswere significantly higher than other patients (p =0.0019 for lifetime symptoms, p = 0.013 for currentsymptoms).

Table 3 shows that SD patients endorsed asmany lifetime and current hallucinations, delusions,and overall psychotic symptoms as schizophrenia pa-tients and significantly more than patients without apsychotic disorder. Patients with cluster B personalitydisorder had rates of psychotic symptoms similar tothose of SD patients.

As shown in Table 4, SD patients reported asmany lifetime and current manic symptoms as pa-tients with bipolar disorder and significantly morethan patients with unipolar depression or schizophre-nia. SD patients reported significantly more lifetimeand current depressive symptoms than patients witheither unipolar or bipolar mood disorders. Rates ofmanic and depressive symptoms in cluster B person-ality disorder patients were similar to rates in SD pa-tients.

Contrary to our general findings that SD patientsendorsed at least as many criterion symptoms of agiven syndrome as those with that primary diagnosis,Table 5 shows that they endorsed fewer lifetime alco-hol use disorder symptoms than patients with diagno-ses of alcohol abuse or dependence.

DISCUSSION

These data demonstrate that patients with SDendorse significantly more psychiatric symptoms onself-report than either psychotic or nonpsychotic pa-tients without a diagnosis of SD or cluster B personal-ity disorder. This is true for both current and lifetimesymptoms and for symptoms of a range of psychiatricdisorders. SD patients as a group are indistinguish-able from patients with schizophrenia in numbers ofpsychotic symptoms reported and from patients withbipolar disorder in number of manic symptoms re-ported. They report significantly more symptoms ofdepression, both current and lifetime, than do pa-

76 Lenze, Miller, Munir, Pornnoppadol, and North

Table 1. Demographics and Diagnoses of the Study Sample

N(%)Age, years (±SD)

RaceBlack (%)White (%)Other (%)

Mean number of DSM-IVdiagnoses (±SD)

No. (%) with a diagnosis ofSchizophreniaSchizoaffective disorderBipolar disorder

With a history of psychosisDepression

With a history of psychosisObsessive-compulsive disorderPanic disorderGeneralized anxiety disorderAlcohol abuse or dependenceCluster B personality disorder

SomatizationDisorder

32 (24.1)42.6

(±11.0)

19 (59.4)13 (40.6)

0

(±0.9)

1 (3.1)0

1 (3.1)0

19 (59.4)1 (3.1)1 (3.1)4 (12.5)1 (3.1)6 (18.8)1 (12.5)

ProbableSomatization

Disorder

8 (6.0)51.6

(±6.5)

4 (50.0)4 (50.0)

0

(±0.5)

1 (12.5)0

2 (25.0)1 (12.5)4 (50.0)

0000

2 (25.0)2 (25.0)

Cluster BPersonalityDisordera

9 (6.8)42.1

(±11.8)

3 (33.3)5 (55.6)1 (11.1)

(±0.7)

01 (11.1)

00

7 (77.8)00

1 (11.1)1(11.1)2 (22.2)9 (100.0)

Subjects withPsychoticDisorders'

37 (27.8)45.0

(±11.5)

25 (67.6)12 (32.4)

0

(±0.6)

24 (64.4)1 (2.7)6 (16.2)6 (16.2)7 (18.9)6 (16.2)1 (2.7)1 (2.7)2 (5.4)5 (13.5)

0

Subjects withNo History

ofPsychosis"

47 (35.3)41.5

(±13.0)

22 (46.8)24 (51.1)1 (2.1)

(±0.6)

00

11 (23.4)11 (23.4)30 (63.8)

00

6 (12.8)3 (6.4)4 (8.5)

0aExcluding somatization disorder (definite or probable).bExcluding somatization disorder (definite or probable) and cluster B personality disorders.

Table 3. Psychoti

Diagnosis Group

Somatization disorder (N = 32)Schizophrenia (N = 24)a

Nonpsychotic (N = 47)a

Cluster B personality disorder (N = 9)b

c Symptoms by Diagnosis Grc

Number ofHallucinations(mean ± SD)

Lifetime

3.8 ± 2.63.2 ± 2.21.1 ± 1.6***2.3 ± 1.9

Current

2.3 ± 2.41.8 ± 2.20.5 ± 1.1***1.2 ± 2.0

iup

Number ofDelusions

(mean ± SD)

Lifetime

3.6 ± 3.93.6 ± 2.21.2 ± 2.1**2.7 ± 2.5

Current

1.6 ± 2.22.0 ± 2.80.4 ± 1.2*1.0 ± 1.9

Total PsychoticSymptoms

(mean ± SD)

Lifetime

7.4 ± 6.26.8 ± 4.92.2 ± 3.3***5.0 ± 3.5

Current

3.9 ± 4.13.8 ± 4.51.0 ± 2.1***2.2 ± 3.4

aExcluding somatization disorder (definite or probable) and cluster B personality disorders.bExcluding somatization disorder (definite or probable).*p < 0.05 compared to patients with somatization disorder.**p< 0.001 compared to patients with somatization disorder.***p < 0.0001 compared to patients with somatization disorder.

Table 2. Total Psychiatric Symptom Count by Diagnosis Group

Diagnosis Group

Somatization disorder (N = 32)Probable somatization disorder (N = 8)Cluster B personality disorder (N = 9)a

Other subjects (N = 84)

Number of Symptoms(mean ± SD)

Lifetime

40.4 ± 15.933.3 ± 15.039.0 ±11.723.1 ± 14.4**

Current

26.1 ± 14.314.8 ± 8.6*22.0 ± 14.011.5 ± 11.1**

aExcluding somatization disorder (definite or probable).*p s 0.05 compared to patients with somatization disorder.**p < 0.0001 compared to patients with somatization disorder.

Psychiatric Symptoms of Somatization Disorder Patients 77

Table 4. Mood Symptoms by Diagnosis Group

Diagnosis Group

Somatization disorder (N = 32)Bipolar disorder (N = 17)a

Unipolar depression (N = 37)a

Schizophrenia (N = 24)a

Cluster B personality disorder (N = 9)b

Number of ManicSymptoms

(mean ± SD)

Lifetime

5.1 ± 2.74.9 ± 4.02.7 ± 1.9***2.3 ± 2.4**6.4 ± 2.0

Current

3.1 ± 2.41.7 ± 2.71.7 ± 1.6*1.0 ± 1.2**3.6 ± 2.6

Number of DepressiveSymptoms

(mean ± SD)

Lifetime

8.8 ± 2.56.7 ± 4.3*7.3 ± 3.0*2.9 ± 2.9***7.8 ± 1.9

Current

5.8 ± 3.42.6 ± 3.2*4.1 ± 3.5*1.1 ± 1.6***5.6 ± 2.5

aExcluding Somatization disorder (definite or probable) and cluster B personality disorders.'Excluding Somatization disorder (definite or probable).*p < 0.05 compared to patients with Somatization disorder.**p <0.001 compared to patients with Somatization disorder.***p s 0.0001 compared to patients with Somatization disorder.

tients with depression. Alcohol abuse or dependencewas notably different: SD patients did not endorsemore alcohol use disorder symptoms than other pa-tients.

There are three potential explanations for thefinding of high rates of psychiatric symptoms en-dorsed by SD patients compared to other patients.First, SD patients may actually have prevalent andsevere psychiatric comorbidity. Evidence against thispossibility is that SD patients endorse many morediagnosis-specific symptoms than severely ill patientswith these disorders (i.e., schizophrenia or psychoticmood disorders), and they also report many symp-toms of multiple diagnoses rather than a concentra-tion of many symptoms of one diagnosis. Second, SDpatients also endorsed not only more current but alsomore lifetime symptoms, suggesting that the high rateof reported symptoms was not just due to resistantillness or untreated illness. Most importantly, the psy-chiatrists' clinical judgments did not support the pres-ence of actual comorbidity as an explanation for thehigh symptom rates: only 2 of the 32 patients with SDalso received a diagnosis of schizophrenia or bipolar

disorder. It might be questioned whether a psychiat-ric resident's diagnosis represents an adequate "goldstandard" for clinical judgment; however, the pa-tients were diagnosed according to DSM-IV and werefollowed longitudinally; also, the residents were su-pervised by faculty. Ultimately, this question mustbe addressed by longitudinal follow-up of SD patientswho endorse symptom criteria for major depression,schizophrenia, and bipolar disorder. If SD patientsindeed have these other conditions as well, theircourse would be expected to follow that of their com-orbid disorders.

A second possibility is that patients with SD tendto endorse or give "yes" responses to all questionsabout symptomatology. To address this possibility,questions referring to alcohol use were included; thefact that patients with SD did not endorse these symp-toms suggests that these patients "choose" whichtypes of symptoms they endorse. This low reportingof alcohol use symptoms is a likely reason for theunexpectedly low rate of alcohol use disorders foundin patients with SD in this study, compared to priorstudies (16, 23).

Table 5. Alcohol Use Symptoms by Diagnosis Group

Diagnosis Group

Somatization disorder (N = 32)Cluster B personality disorders (N = 9)a

Alcohol abuse or dependence (N = 9)b

Other subjects (N = 75)b

Number of Symptoms(mean ± SD)

Lifetime

1.4 ± 3.12.6 ± 4.45.6 ± 4.2*0.9 ± 2.2

Current

0.1 ± 0.41.3 ± 4.00.3 ± 1.00.3 ± 1.2

aExcluding Somatization disorder (definite or probable).bExcluding Somatization disorder (definite or probable) and cluster B personal-ity disorders.

*p s 0.005 compared to patients with Somatization disorder.

78 Lenze, Miller, Munir, Pornnoppadol, and North

A third possibility, which the authors feel is mostlikely, is that patients with SD in a psychiatric settingendorse a multitude of psychiatric or psychologicalcomplaints, just as in an internal medicine or surgicalsetting they endorse a variety of physical complaints.These data suggest this scenario because they didnot focus on one symptom group (e.g., depressivesymptoms) but endorsed symptoms from all majorpsychiatric syndromes, with the exception of alcoholuse disorders. This pattern of general symptom over-endorsement has been reported in previous studies ofpsychiatric inpatients and outpatients with Briquet'ssyndrome who also endorsed a wide variety of psychi-atric symptoms and met the criteria by symptomcount for many psychiatric diagnoses (16, 17).

IMPLICATIONS

It is already known that SD is prevalent in psy-chiatric settings. Failure to recognize patients withSD in internal medicine and surgical settings (re-sulting in inappropriate tests, diagnoses, medications,surgeries, hospitalizations) may also occur in the psy-chiatric setting (resulting in inappropriate diagnoses,medications, ECT, hospitalizations). This oversightis much more likely to occur in settings where initialinterviews are restricted by time constraints. Physi-cians and other mental health professionals in high-demand settings may be more likely to focus on onlya few diagnoses, and on symptom checklists or non-physician assessments, rather than assessing a"greater picture" which includes understandingsymptoms based on the patient's longitudinal statusand typicality of presentation as well as a completemedical history obtained by a physician.

These findings suggest that SD should be consid-ered in the differential diagnosis of a wide range ofpsychiatric illnesses including psychosis (where it isnot intuitively considered). This has important treat-ment implications, as it does for somatizing patientsin other medical settings. For example, SD patientspresenting to an internal medicine clinic complainingof chest pain with negative medical workups wouldbe best treated by reassurance unless the chest painpresentation is classic for angina. Similarly, in consid-ering psychiatric medication for SD patients in a psy-chiatry clinic, one should consider that the targetedsymptoms are psychoform and exercise caution be-fore beginning a course of pharmacotherapy, espe-cially potentially harmful medications such as neuro-leptics. Additionally, acting on endorsed psychoform

symptoms with medication could lead psychiatrictreatment away from appropriate therapy for the so-matization disorder itself (24).

The group of nine patients with cluster B person-ality disorder but without confirmed or suspected SDwas analyzed as a separate category. This was donebecause the authors hypothesized that these patientswould exhibit a symptom profile similar to patientswith SD. This is suggested by prior studies whichindicate a considerable overlap between cluster Bpersonality disorder and SD (25,26). It was thereforehypothesized that patients with cluster B personalitydisorders would endorse symptoms in a similar man-ner as patients with SD. As the results showed, thesepatients did exhibit the same presentation of psychi-atric symptoms as SD patients. Therefore, patientswith cluster B personality disorders may present asimilar potential for misdiagnosis in a psychiatric set-ting. However, the small size of this group (nine pa-tients) suggests that this finding should be replicatedwith a larger sample size to be more conclusive.

Future areas of needed investigation arisingfrom this line of study include the prevalence of SDin various inpatient and outpatient psychiatric set-tings and how psychiatric symptoms stemming fromoverendorsement in SD can best be differentiatedfrom those of other psychiatric illness. Also, the fre-quency at which patients with SD are misdiagnosed(e.g., with schizophrenia or bipolar disorder) shouldbe investigated. Further study is needed to determinewhether patients with SD endorse similar psychiatricsymptoms in other medical settings or are distinctfrom patients with SD who also seek treatment forpsychiatric symptoms. One study suggests that theyare not distinct (27): patients with SD in a primarycare setting were interviewed with the DIS. Theyreported high rates of major depression (55%), gener-alized anxiety disorder (34%), and schizophrenia(10%) and a low rate of mania (4%). However, ofthe 11 patients diagnosed with schizophrenia by theDIS who had psychiatric records, only 2 had a chartdiagnosis of schizophrenia or schizoaffective disor-der; the authors of that study concluded that theDIS overdiagnoses schizophrenia in patients with SD.Hence, this conclusion is similar to the findings ofthe present study using questions derived from theDIS. As the present study used an instrument notpreviously validated, the results should be replicated,possibly using the DIS as the study above did.

This study found that patients with SD endorseda wide variety of psychiatric symptoms but not alco-hol use symptoms, which they may have perceived

Psychiatric Symptoms of Somatization Disorder Patients 79

as socially undesirable. The inference from this isthat patients with SD selectively endorse certainsymptoms, rather than nonspecifically overendorsing.Along these lines, some authors have suggested thatSD patients tend to have "diseases of fashion" (28,29), for example, chronic fatigue syndrome, seasonalaffective disorder, and multiple personality disorder(19). Therefore, a more thorough examination of spe-cific psychiatric syndromes or clusters of symptomsmost endorsed by SD patients could elucidate ascreen for SD in the psychiatric setting; currently SDis very difficult to adequately screen for, becauseof both the relatively cumbersome criteria and thepatients' own tendency to be unreliable historians.Eventually, improvement in the recognition of SD isneeded to avoid problems of psychiatric misdiag-nosis.

ACKNOWLEDGMENTS

The authors would like to acknowledge the fol-lowing people for their help with this study: DarrinFriesen, M.D., Debra Gusnard, M.D., MatthewsJohn, M.D., and Dan Reising, M.D.

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