The following treatment strategies are not specific to a certain somatic symptom disorder diagnosis. In most cases, it is less important to make a specific psychiatric diagnosis of a somatic symptom disorder than it is to recognize that the patient’s symptoms represent somatization. However, if a psychiatric disorder such as anxiety, depression, or psychosis is present, specific treatments for the identified disorder should be utilized.
Treatments Designed for Primary Care Providers
A management plan with an emphasis on nonsomatic interventions is a useful treatment approach for somatization and the somatic symptom disorders. Patients with somatization symptoms most often present to the primary care setting and are resistant to psychiatric referrals. Techniques are required that are effective, acceptable to primary care clinicians, and useful in busy primary care settings. Finally, the intervention must be congruent with patients’ beliefs about the nature of their illness so that they are willing to engage in the treatment.
The most important aspect of managing patients with somatization is the development of a stable, empathic, trusting relationship. Although it is not easy to form such a relationship with these individuals, establishing a therapeutic alliance is critical to both diagnosis and treatment. It can be helpful to remember that patients with somatization are reacting in the best and, without treatment, only way available to them. Before considering specific therapies for these individuals, it is useful to consider basic techniques for interacting with them.
The practitioner should never challenge the reality of the patient’s physical symptoms. Somatization is an unconscious process, and therefore the somatic complaints are very real to the patient. Further, because most of the symptoms are subjective in nature, there is no means to verify or dispute them. It can be helpful to explicitly acknowledge and validate the patient’s suffering to bolster the therapeutic relationship.
Clinician: I can see how much you’ve suffered with all of these symptoms.
Patient: You’re the only one who seems to understand that.
Medical providers should avoid trying to convince the patient that the symptoms are psychological in origin. They should also avoid the use of psychological labels (e.g., depression, anxiety). Instead, they should try to use easily understandable and mutually acceptable language to discuss symptoms. Each appointment should begin with a discussion of the somatic complaint. The provider can then use descriptive physiologic explanations, which are more acceptable to these individuals, to describe the symptoms (e.g., “abnormally tense muscles in your neck go into painful spasm”). It is important to note that although such descriptors imply a physiologic component to the symptoms, they do not provide an etiology. Over time (often months or years), the patient and clinician may begin to explore possible explanations for the symptoms that integrate somatic and psychosocial aspects of the problem.
Patient: I just don’t get why my neck keeps getting spasms.
Clinician: I have noticed that sometimes you mention this happening after your supervisor criticizes you. Sometimes our muscles react to emotions like anger or stress by tightening up. When this becomes extreme, they can spasm.
Patient: You know that makes some sense. When he comes around I can feel myself grit my teeth and begin to feel stiff.
Another management suggestion is to have the provider evaluate the patient in an appropriate manner to rule out somatic causes of their symptoms. Once somatization is identified, the clinician continues to schedule the individual for brief, regularly spaced intervals. These visits are time contingent; patients need not have new symptoms to be able to meet regularly with their medical practitioner. These visits allow for an initial brief check-in regarding the somatic symptoms followed by discussions of events in the patient’s life and the patient’s emotional well-being and relationships. The clinician can adopt a conservative approach toward new treatments or diagnostic workups when the patient presents with new or worsening symptoms. The goal is to focus patients on behaviors that promote well-being and help them discuss the psychosocial aspects of their life and illness. Patients are redirected from pursuing new therapies or evaluations for their symptoms. At the same time, they are shown that the provider is taking an active interest in their problems. Moreover, patients learn that they will receive this care and attention even without new symptoms or exacerbations of existing symptoms. The clinician may also ask patients when they want to return for the next visit. This provides them with a sense of control, and over time many patients will suggest lengthening the interval between appointments.
Establishing appropriate goals is also important when working with these patients. These disorders, like any chronic disease, are often not curable. However, clinicians often hope that another medication will relieve the symptoms or that one more diagnostic procedure will elucidate the cause of the patient’s problem. However, these beliefs can lead to disappointment for both the patient and the clinician. Rather than aiming for complete resolution of the symptoms, it is better to set more realistic goals. For the primary care practitioner, these might include reducing the number of phone calls and visits with new symptoms, the number of requests for medications or referrals to specialists, and the number of emergency room visits. For patients, these goals might include an increased sense of control in their lives, improved social functioning, better coping with day-to-day symptoms, and overall enhanced functioning.
Clinician: Today I would like to talk about what we should expect from each other in this relationship. From your perspective, I suspect that the best thing I could do would be to figure out what’s causing these symptoms and make them go away completely. Given all of your years of suffering and the many doctors you’ve seen and the limited success of treatments so far, it might be more realistic for us not to focus so much on pursuing a cure but to look at how to improve how you feel and maximize your functioning. What do you think?
Patient: Well, of course I was hoping that you could find a cure. So—does this mean that you can’t help me?
Clinician: No, I didn’t mean to imply that. I do think I can help. First, I’d like to work on helping you learn to cope more effectively with your symptoms. We could also work to improve how you function from day to day. Whether or not we are immediately successful, I’m committed to helping you in the best way I can.
A novel treatment for somatic symptom disorders involves the use of a “written self-disclosure protocol.” This therapy involves having the patient periodically write in a journal format. The clinician convinces the patient to spend 20 minutes one time per week at home writing about distressing experiences in his/her life. The patients do the writing outside of the office visit. They are specifically encouraged to think about experiences involving relationships with others. The patients are also instructed to write about how these experiences have affected them in the past and how they may continue to affect them in the future. The journal may be shared with others if the patient wishes, but it does not have to be shared to have a benefit. This technique has been found to be acceptable by both patients and providers. It has also been found to be helpful, as well as time- and cost-effective. Studies of this management strategy have demonstrated decreases in health care utilization.
Another method for treating patients with somatization symptoms in the primary care setting is designed to help general practitioners teach these patients to reattribute and relate physical symptoms to psychosocial problems. The clinician is encouraged to take a history of the patient’s illness, including related physical, mood, and social factors. The clinician then broadens the view of the problem and the necessary treatment by reframing the complaint using the biopsychosocial information provided by the patient. The practitioner then links the patient’s distress and the physical complaint using a coherent explanation of how psychosocial factors can give rise to and contribute to physical symptoms. This intervention model has been found to be both clinically and cost-effective.
Despite all of these interventions, it may be necessary to refer the patient to a mental health specialist. Many individuals with somatization will resist such a referral. Although this reluctance on the patient’s part can be frustrating, the primary care provider should remember that many of these patients have experienced such a referral as the first step in the termination of the relationship with a health care provider. The primary care clinician can address this concern by making a follow-up appointment with the patient prior to the referral. Once the continuity of the relationship is ensured, the referral can be discussed. Further, a consultation model in which the patient is asked to see the mental health provider for one or a few visits to “advise and help the primary care provider do a better job” is often more acceptable to patients than a referral for ongoing treatment. The consultation can be useful in confirming a diagnosis or in providing advice on the use of psychotropic medications.
Clinician: I’d like to see you in a month. In the meantime, I’d like you to consider seeing Dr. R, the psychiatrist we’ve talked about. I know that you don’t think that your chest pain is caused by your depression. But we’ve both agreed to try to treat the depression. I still don’t know if we’ve found the right antidepressant, and I’d really value Dr. R’s opinion. What do you think?
Cognitive behavioral therapy (CBT) has been studied as a means of addressing the medically unexplained somatic symptoms. This treatment is based on the theory that incorrect beliefs about bodily functioning underlie these symptoms or produce much of the dysfunction. The first task in therapy is to identify these beliefs and behaviors. Next, the patient is encouraged to challenge the beliefs and is taught to formulate more accurate ideas about bodily functioning. This change is paired with adoption of more appropriate behaviors. An analysis of randomized trials of specific treatments for patients with somatic symptom disorders indicated that CBT had the strongest and most consistent evidence of effectiveness. A subsequent review of intervention studies in patients with somatic symptom disorders, functional somatic symptoms, somatization, or medically unexplained symptoms corroborated this finding. Furthermore, a growing body of evidence supports the benefit of mindfulness-based cognitive therapy in treating associated stress, depression, and anxiety in patients with multiple somatic complaints, as well as in patients with medically unexplained symptoms. However, although early results of these studies are promising, there is a need for larger, controlled trials. Overall, this research suggests that CBT approaches are effective in patients with somatic symptom and other related disorders.
Psychodynamic psychotherapy is based on the assumption that the individual is experiencing internal emotional conflicts and that the associated emotions cannot be identified or expressed. As a result, the conflict is manifested through somatic symptoms. The therapy focuses on attempting to uncover and resolve these conflicts by having the patient identify associated emotions and express them openly in the therapy sessions. As the patient does this work, the somatic symptoms become unnecessary and remit. A meta-analysis of short-term therapy for somatic symptom disorders found benefits for subjects in multiple areas, including physical symptom reduction, improvement in social and occupational functioning and psychological symptoms as well as decreases in health care utilization. Unfortunately, many patients with somatization may not be enthusiastic about exploring unconscious conflicts. In general, the psychodynamic psychotherapy is a longer-term, time-intensive approach that requires a referral to a specialist and a significant commitment from the patient.
In family-oriented approaches to therapy, therapists must integrate the biological and psychosocial aspects of the patient’s illness. The care provider must collaborate with the patient and the patient’s family in treating the illness. Further, the clinician must demonstrate true interest in and curiosity about the patient’s symptoms, family, relationships, and life. These therapies attempt to help the patients and their families break down the distinction between physical and psychological and move their thinking from “either–or” (e.g., it is either a physical problem or a mental problem) to “both–and” (e.g., the problem has both physical and mental facets). Relational therapists argue that effective therapy involves validating the illness, involving the family, working closely with the health care team, and enhancing the patient’s curiosity about symptoms. They also emphasize demonstrating interest in the patient’s somatic symptoms, helping the patient to see the relationship between the somatic symptoms and psychosocial stressors, and using physical interventions (e.g., biofeedback and relaxation techniques) to form an alliance with the patient to deal with the illness.
Data on the efficacy of using medications to treat somatic symptom disorders is limited; to date there are few randomized, controlled studies. However, there have been several small, open studies demonstrating the effectiveness of fluoxetine, sertraline, escitalopram, venlafaxine, and mirtazapine in reducing somatic complaints, depressive symptoms, and improving overall assessment of health. Other studies have found similar results with agents that enhance serotonergic transmission in the treatment of patients with body dysmorphic disorder. There is also evidence that St. John’s Wort is effective in treating somatic symptom disorders, with reduction in somatization symptoms and improvement in patients’ self-assessments of health. However, information on the long-term effectiveness of such treatments is yet to be elucidated. Moreover, investigations into the benefits of treatment of comorbid anxiety and depression have yielded mixed results depending on the specific somatic condition, with less success in patients with chronic pain and fibromyalgia.
A summary of recommendations for managing patients with somatization symptoms is found in Table 28-3.
Table 28-3.Management of somatization. ||Download (.pdf) Table 28-3. Management of somatization.
Take a detailed history, perform a physical examination, and order appropriate diagnostic studies.
Screen individuals with multiple somatic complaints for psychiatric disorders.
Integrate the patient’s physical and psychosocial concerns by inquiring not only about somatic symptoms but also about other events in the person’s life.
Develop an empathic relationship.
Never challenge the validity of the patient’s somatic symptoms.
Do not utilize psychological labels for the patient’s symptoms.
Schedule the patient for appointments at regular intervals.
Establish realistic expectations.
Care for yourself.