In general terms, the specialized literature relates non-medically explained symptoms to mental health, more specifically to disorders such as depression and anxiety. At least one-third of patients with somatoform disorders suffer from comorbid anxiety or depressive disorders. In this regard, depression, anxiety, and somatization, with a prevalence rate of 10% each, are identified as the most common mental health disorders in PHCS. These are associated with total functional impairment, increased disability days, and high healthcare costs. Thus, psychometric scales assessing depression, anxiety, and somatization are positively related. This fact would reaffirm the overlap in diagnostic criteria and, consequently, the difficulty of classifying this phenomenon. In India, for example, somatomorphic disorders are conceptualized from CD-10 and DSM IV definitions, known as Functional Somatic Symptoms (FuSS) (9).
Internationally, the most common symptoms found in poly-consultant adults of primary care are fatigue, pain, dizziness, general malaise, gastrointestinal symptoms, abdominal discomfort, diarrhea, and constipation (9). Studies carried out in Southeast Asian countries analyze at a global level the concepts and mechanisms related to medically unexplained symptoms (from now on MUS) and argue that the psychological nature of somatoform disorders is due to the lack of organic origin diseases to explain them. The latter, seen from the predominant, cross-sectional biomedical viewpoint, displaces somatoform disorders to the realm of agent autonomy, where the only people responsible are the patients who suffer from them.
In this direction, research provides exciting characteristics to the hyperfrequent user profile. For example, the older the patient, the higher the healthcare services use. Also, women between 37 and 75 have a worse subjective perception of their health, so they tend to consume higher. In short, the HF patient is characterized as a middle-aged person with a low-level education who belongs to a nuclear family, lives in the nearest central neighborhood, suffers from a chronic disease, and has a psychic dysfunction. This patient makes an average of 15 consultations a year and frequently uses the previous appointment and the scheduled visit by doctor and nurse (21).
In this sense, these studies indicate that creating a definition and clinical delimitation for those patients with hyperfrequency would directly reduce the overuse of Primary Care (PC) (22). Also, they suggest that the patient's type should consider according to whether they have chronic organic or mental pathologies or both. The interventions should be adapted to patient type. Other strategies are those mentioned by Fuertes M, et al. (10), who infer that one of the points for reducing hyperfrequency lies in incorporating non-presence or telephone consultation modalities (telemedicine).
Concerning the overlap between mental health and poly-consultation, studies in Colombia have estimated that 10% of healthcare costs came from consultation overuse (35% and 45% of work absenteeism are due to mental health problems). The somatization disorder prevalence of almost 40% in hyperfrequenters shows that, although they often appear simultaneously, they are not synonymous, making it necessary to distinguish between both terms and search for another kind of cause beyond the disorder itself. 41% of hyperfrequency cases can be considered chronic diseases, 31% to mental disorders, and 15% to acute and chronic stress. Together, these three factors would explain two-thirds of the real phenomenon. In the same sense, when analyzing the most frequent mental disorders present in PC, it could be inferred that they are under-diagnosed in the clinic. This, if we by contrast patients diagnosed with depression, anxiety, or mixed anxiety-depressive disorder records, 5.6% had been diagnosed with depression, 6.3% with anxiety in the clinical history, and 8.5% with mixed anxiety-depressive disorders (23).
However, after conducting a screening survey, it was revealed that 41.9% of the patients had depression symptoms or established depressive syndrome. Anxiety also occurred as a symptom or syndrome in 13.3% of the cases. On this basis, 55.2% of patients tested positive for mental symptoms or syndromes that had not presented in clinical history (23). Clara Han (24), relates this as depression from time to time, thinking from a socio-structural perspective.
The low diagnostic capacity is especially important in the mental health field since several studies suggest that patients with anxiety and depression are twice as likely to be poly-consultants. The explanation given by the studies is that anxiety-depressive disorders can generate physical symptoms, and they may affect the health condition's self-perception. Therefore, random consultations number would increase as a result of this poor self-perception. Therefore, the physician needs to consider research into the mental disorders underlying the reason for consultation (25).
In Chile, research on poly-consultation is scant, and most relate hyperfrequency to somatization disorders. In this matter, the specialized literature estimates that somatic symptoms problem without clinical explanation represents PHC's consultations 15% to 25%, and up to 70% of this consultation type remains unexplained after being evaluated.
What I discovered, however, was a tense entanglement of municipal politics and health services, made even more acute by the fact that it was a municipal election year. Insecurity, fear, resentment, and frustration circulated among the local mental health workers and municipal health officers, affects in which I too became caught (24).
A study by the World Health Organization (WHO) indicates a 17.7% prevalence of this disorder in primary care consultations (Riquelme and Schade, 2013) in Santiago, Chile. There is no poly-consultant patient homogeneous profile. However, several studies agree that poly-consultant users correspond mostly to women who own a home (without formal paid work) , with an average age of 42 years, incomplete primary or average education, married, and with some chronic disease (26).
From the mental health area, national research has addressed the phenomenon as a depression manifestation. This disorder affects 30% of primary health level beneficiaries (7.5% of the general population) (27). In the very same direction, other studies indicate that poly-consultant patients should be treated not only themselves but also their families, since most of them present some family dysfunction, through a family therapy approach from the mental health perspective (28). Alternatively, assuming Clara Han's words assuming "life is by a thread" (29).
From the mental health units from the primary care level centers, various intervention proposals have shown high effectiveness, among which are: cognitive-behavioral therapies, psychodynamic therapies, and group therapies. However, a significant number of these patients refuse to be classified as having mental health problems, attributing the responsibility to the doctor, since he or she does not provide an adequate response to their physical affliction. It means that the doctor-patient relationship is damaged, and patients insist on the need for more evaluations and tests (5) .
The Brief Family Therapy (BFT) approach, whose main characteristics are to be simple, quick, to generate greater user satisfaction and reduce costs, aims to have patients be able to treat their problems in their own homes through objectives set by themselves. BFT seeks to reduce the symptoms and recover the patient's autonomous functioning
With this therapy, the patient stopped using medication and did not request any more complementary examinations, thus saving healthcare costs (30).
The healthcare system provides optimal poly-consultation conditions to be produced and perpetuated since the biomedical approach to providing care, and the Cartesian legacy is still deeply rooted in the given attention. Public health administration does not adequately answer to users' demands by using indicators. Healthcare officials tend to displace the psychosocial component to a secondary concern, producing a rupture between the services offer and poly-consultant population demands, not enabling this problem to diminish (31).
The strains of a clinical category
The somatoform disorder classification is, precisely, the clinical approach to capture a discomfort refractory to the most common organic diagnoses (6). Therefore, the "hyperfrequency," somatizers," or "poly-consultants" status of those users who repeatedly come for a short period (usually six months) is recognized by its name in diagnostic manuals (6) (26) (5). However, this attempt to capture the medical device is quite questionable, as it allows neither an adequate conceptualization nor a practice around this kind of disorder.
Usually, the biomedical approach is summoning because of its limitations (7) (27). This study tries to understand that space where some subjectivity is present (32). It also assumes these critics and mainly focuses on the unspecific psychosocial circumstances.
In this direction, "professionals limit themselves to referring these patients on several occasions, as having "psychosocial problems," seems more to be a new effort to objectify these' subjects' understanding" (32).
Moreover, from clinical experience, physical signs importance and laboratory findings are emphasized to give importance and credibility to patients with non-specific symptoms and subsequent diagnosis. Here we should ask ourselves why this phenomenon is so disregarded by professionals when it leads to a high social and economic burden. It could be explained broadly for the following reasons: 1) The conditions classification in which people develop these non-specific symptoms is diffuse; 2) psychiatrists do not have sufficient experience to be able to deal with these patients; 3) patients with these symptoms do not seek psychiatric help; and 4) general physicians, as well as specialists, do not refer for psychiatric help (33). Precisely, it opens an epistemic problem related to the semiology and clinic exercise (34).
There are models used in primary care to address this problem that allow us to detect, recognize, and manage non-specific symptoms. Still, the literature highlights the importance of developing customized models that meet each center's needs due to their complex and multifactorial nature. Therefore, an exploratory model is proposed for non-psychiatric users in six specific circumstances, each with its considerations when dealing with these users (33).
Based on this, and around a semiological problem, we find an epistemological problem. Specifically, between biomedicine targeting the disease and the condition experienced by the patient:
Sometimes the plaque that makes the body visible shows the doctor that the patient ‘has nothing’ wrong, contrary to what the latter claims, who complains of various aches and pains. The opposition between the ’doctor’s illness and the ’patient’s condition is therefore clear. The objective illness proof was not provided (...), so the pain is imputed to the ’patient’s sickly fantasy. He is an imaginary patient (35).
As Canguilhem points out, instability and irregularity are (...) the vital phenomena essential characteristics, so forcing them into the metric relations rigid framework means denaturing them (36).
While observing interpretative frameworks that make the pathologies exclusively physiomechanical, physical, or biochemical problems, the biomedical view fails. These, specifically to reveal the seriousness that the body's interaction with its environment would have in the' disease's etiology production.
Given this, life is not indifferent to the material and symbolic conditions that make it possible; hence, it is normative activity (36). In other words, life produces installing normative standards that allow it to adapt to a continually changing environment. It is why health manifests itself when the pathological, and the associated pain, impedes the ’individual’s daily life development. The body, then, reveals its health or illness concerning the resistance and adaptation capacity towards the conditions of an environment that forces it to displace its limits. Those processes would explain the proposals for the biomedical model to be modified at different levels, from the bio-psycho-social approach development to the so-called integrative medicine (37) (28) (38) (39) (40) (41).
Problematise the disease and the experience performs an alternative path to research somatoform symptoms, especially if we consider its association with non-specific psychosocial factors.
Social determinants: a critical problematization
Approaches to social determinants proposed by the WHO (15), could be made in a critical path. We consider that this perspective lacks criticism and specificity of the social environment, avoiding topics like how individualizing biomedical features regulates its incorporation (3).
This issue is crucial and related to scientific medicine's social position and its link to the State and the market (42) (43). It is not surprising then that both specialized literature and health institutions recognize a biomedical approach's relative incapacity to face the new challenges in healthcare successfully. We consider that this is directly related to how biomedicine is in society as a technique for managing discomfort, namely: processing social problems on an individual basis.
Indicators for maintenance of healthcare insurances: the dictatorship of numbers
The problem that affects care, diagnosis, and treatment of somatization disorders, must be considered with questions about maintaining and managing neoliberal healthcare.
The literature reports that such benefits generate economic disadvantages with a full agreement-level public care system that is more expensive burdensome, reaching an international prevalence in primary care around 15% to 22% (7) (26). This global observation is particularly sensitive to Chile due to the conditions of its public health system.
Within this framework, extreme resource rationalization and optimization (1) imposes that the recognized burdens that hyperfrequent patients represent for the health system take on particular relevance. Studies said that 30% of users consume 80% of healthcare resources. This is a critical number, considering that unexplained somatic symptoms problem fluctuates around 15% to 25% of total consultations in Primary Health Care (PHC). We consider that it would imply a broad impact of these conditions in the full benefits of primary healthcare services, constituting between 60% and 80% of users' total demand who attend to those centers (26).
Based on international studies, users characterized as hyperfrequent cause twice the cost of any other patient type due to the number of examinations requested and medicines. Considering context, specialized literature agrees on the need to improve the resolution of this sort of disorders, as well as the need to discuss the allopathic, orthodox, scientific, or biomedical medicine limitations (6) (8) (26) (32) (5). In this direction, it is necessary to have a profile that allows us to know who these hyperfrequent patients are beyond the country's limited case studies. A poly-consultant general profile would enable us to rethink, among other things, the management mechanisms of these patients in the public healthcare system.
A way of understanding social relations: collective problems managed as individual problems
A fourth problem overlapping with the previous ones has deserved -and still deserves- an in-depth study that shows its importance in the more or less global matrix of assessment deployment that makes up the connectionist world (44). In this regard, the socio-economic transformations that Chile has undergone in the last 40 years have produced a particular way of understanding social relations (45). This series of reforms contains a new fiscal discipline, macroeconomic stabilization, market liberalization, state enterprises, and social services privatization. Furthermore, the reduction of State intervention in capital markets and the economy in general (46) (47) (45) -, would be at the base of a new institutionality.
The performance of a (neo)liberal revolution is related to generalized privatization that allows the action of free agents as a base element for the management of their lives (3) (48) (49). The first result of Chile's transformations is that, in less than two decades, went from being "a closed economy with a high level of state intervention to being one of the most, if not the most, open and market-based economies in the world" (45), whose main support point is individual modulation. Healthcare is not far from these changes, so FONASA's became a critical example of the process.
Since the 1990s, Chilean governments have not (yet) substantially amended any of these reforms, keeping in line with world trends. On the contrary, the country intensified possibility conditions for individuals exposed to available habitat modification. People also could assume social order as natural, and: renewed society, freedom, political conceptions imposed by the weight of the immutable would appear as utopian. Indeed, modify the public administration's logic and committing individuals to manage their lives based on their projects, quite far from community logic (46) (48).
In this direction, we are currently witnessing a highly individual way of experiencing inter-subjective relations (50) , which has made possible the transition to a new way of understanding the overlap between State, market, and society, and the role that each of these has in the management of social problems. Generalized privatization of social affairs emerges in which freedom of agents operates to manage their environment and their lives, thus transferring the structural inequality burden. Society design demands citizens who must individually manage their precariousness and their lack of certainties (51) (52) (29) .
Crosses over the possible answers to previous points, namely the burden imposed by non-specific somatic consultation and biomedicine's limits in this regard came from the socio-structural perspective. It also conditions the understanding that individuals themselves have of their discomforts and how they deal with them. It is precisely at the intersection of these problems that our research was.