Primary care patients who present with undifferentiated symptoms are best addressed with a comprehensive approach that includes continuity of care and attention to the physician-patient relationship. “Pathologizing” makes patients feel illegitimate, in itself a major source of distress, and produces stereotypes of patients as “crocks, whiners, or difficult.” Patient characteristics considered as difficult include extensive or exaggerated complaints, nonadherence with treatment recommendations, and behaviors that raise suspicion of seeking drugs. When patients are so labeled, the relevance of the patient’s experience and the potential of partnership between patient and physician are both obviated. A patient-centered method, so important to family practice, becomes impossible. Even without attributions of a mental disorder, SSD presents one of the most difficult challenges in primary care. Uncertainties associated with the diagnosis, the sense that the focus is not medical and therefore the interaction is inappropriate, patient symptom amplification, and the sense that services are being overused inappropriately contribute to the perception that the patient is difficult.
A. General Recommendations
Symptoms of SSD exist on a continuum. Comprehensive, continuous, patient-centered care appropriately addresses most primary care patient presentations. The general recommendations presented in the following paragraphs apply to such an approach.
A therapeutic alliance should be built by a thorough history and physical examination and a review of the patient’s records. The physician should show curiosity and interest in the patient’s complaints and validate the patient’s suffering. Psychogenic attributions should be avoided. To appear puzzled initially is a good strategy. Delivery of a diagnosis is a key treatment step with SSD. Different disorders require different types of information.
The disorder should be treated as a chronic illness, with the focus on functioning rather than cure. Gradual change should be expected, with periods of improvement and relapse. Physicians should try to avoid excessive and/or invasive diagnostics and treatment in order to minimize iatrogenic harm. When procedures or treatments are undertaken, they should be selected only on the basis of objective evidence, not subjective complaints. When new symptoms arise, at least a limited physical examination should be performed to avoid misdiagnosis and assure the patient that his/her concerns are taken seriously. The need for unnecessary tests and procedures can be avoided by having the patient feel “known” by the physician.
3. Management when controlled drugs are involved
Berland et al. (2012) have described a comprehensive approach for managing somatoform pain disorder where patient preferences for opioids complicate treatment. They recommend a structured approach that includes a comprehensive biopsychosocial evaluation and a treatment plan that encourages patients to set and reach functional goals.
Feelings of illegitimacy by patients and common physician attitudes toward patients contribute to power differentials and struggles. Physicians should speak with patients as equals, listen well, ask and answer many questions, explain things understandably, and allow patients to make decisions about their care. A collaborative relationship should be developed in which the physician works together with the patient to understand and manage patient problems. The “common ground” shared by the physician and the patient should be monitored and differences discussed.
Regular, brief appointments should be scheduled, thus avoiding “as-needed” medications and office visits that render medical attention contingent on symptoms. Practical time-related strategies include negotiating and setting the agenda early in the visit, paying attention to the emotional agenda, practicing active listening through appropriate reactions and follow-up questions, soliciting the patient’s attributions for the problems, and communicating empathetically.
Reassurance should be provided to the patient, but not before a thorough exploration of symptoms. Psychosocial questions should be interspersed with biomedical ones to explore all issues: physiologic, anatomic, social, family, and psychological. The physician should inquire about trauma and abuse. As trust builds, the patient should be encouraged to explore psychological issues that may be related to symptoms. In this way, symptoms can be linked to the patient’s life and feelings. Physicians should avoid using the term stress too liberally, as it may be misconstrued as the cause of the patient’s symptoms or an excuse for an incomplete evaluation. Eventually and subtly, patients are likely to reveal their personal issues and concerns.
With the patient’s permission, family members should be invited to participate in patient visits. An occasional family conference can be valuable. Each person’s opinion about the illness and treatment can be solicited, and family members can be asked how family life would differ if the patient were without symptoms. Physicians should solicit and constantly return to the patient’s and family’s strengths and areas of competence.
et al.. Rational use of opioids for management of chronic nonterminal pain. Am Fam Physician. 2012; 86(3):252–258.
Because these patients may be extremely sensitive to side effects, psychopharmacologic agents generally should not be used unless the patient has demonstrated pharmacologically responsive mental disorder such as major depression, generalized anxiety disorder, panic disorder, or obsessive-compulsive disorder. (For further discussion of these disorders, see Chapters 52, 53 and 54.) Selective serotonin reuptake inhibitors (SSRIs), other nontricyclic antidepressants, and benzodiazepines are the medications most frequently used for coexisting psychiatric conditions. Treatment should be initiated at subtherapeutic doses and increased very gradually, as described in Chapters 52, 53 and 54. Exceptions to this general rule are hypochondriasis and body dysmorphic disorders. They are more similar to obsessive-compulsive disorder, and patients with these disorders may benefit from slow increases to higher doses of SSRIs if side effects are tolerated. Those with extreme but transitory dysmorphic concerns may benefit from temporary treatment with an atypical antipsychotic medication.
B. Psychopharmacotherapy of somatic symptoms disorders. Int Rev Psychiatr
C. Consultation or Referral
Involvement of a mental health clinician may be helpful in diagnosing comorbid mental conditions, offer suggestions for psychotropic medications, and engage some patients in psychotherapy. Patients, however, are unlikely to see the value of consultation or may experience referral as an accusation that their symptoms are not authentic. Pressuring the patient to accept a consultation is unlikely to be effective and may render the consultant encounter unproductive. Trust must first be established, and psychological issues must be made a legitimate subject for discussion. The idea of referral can be introduced later. When possible, it can be more effective to see the patient along with the mental health clinician so that a comprehensive approach continues to be emphasized, the patient does not feel abandoned, and worry that the patient’s concerns are not taken seriously are alleviated. Extreme distress or preoccupations worsening to delusional levels may require inpatient hospitalization.
K. Outcome and impact of mental disorders in primary care at 5 years. Psychosom Med
. 2007; 69(3):270–276.
et al.. Differentiation of somatizing patients in primary care: why the effects of treatment are always moderate. J Nerv Ment Dis
. 2005; 193:813.
D. Psychotherapeutic Interventions
Standardized group or individual cognitive behavioral therapies (CBTs) can be an effective treatment for chronic somatoform disorders, reducing somatic symptoms, distress, impairment, and medical care utilization and costs. Cognitive interventions train the patient to identify and restructure dysfunctional beliefs and assumptions about health. Behaviorally, the patient is encouraged to experiment with activities that are counter to usual habits such as avoidance, “doctor shopping,” or excess seeking of reassurance. In addition, patients can learn relaxation and meditation techniques to manage symptoms of anxiety. Patients with high emotional distress respond more rapidly to psychotherapy, and patients able to at least partially attribute symptoms to psychological factors show better therapeutic outcomes than patients who firmly believe that their physical symptoms have a physical cause.
et al.. Specificity and modifiability of cognitive biases in hypochondriasis. J Consult Clin Psychol
. 2013; 81(3):558–565.
MF. Treatment of conversion disorder in the 21st century: have we moved beyond the couch? Curr Treat Options Neurol
M. Behavioural and psychological management of somatic symptom disorders: an overview. Int Rev Psychiatr
. 2013; 25(1):116–124.
E. Complementary and Alternative Therapies
It is to be expected that patients with somatoform symptoms often try alternative treatments such as herbal remedies, mind-body interventions, and other non-Western medical approaches. In these patients, conventional treatments appear to have failed, distrust of physicians may be high, and distress is great. Federal regulations require that label claims and instructions on herbal products and supplements address symptoms only; therefore, there are no specific herbal agents for SSD, per se. Given the plethora of symptoms that can exist in patients with SSD, it is not surprising that there are numerous alternative medications that patients may try.
Patients with pain disorder or primary or comorbid anxiety may benefit from body and mind-body interventions such as massage, movement therapies, manipulations, relaxation, guided imagery, and hypnosis. The placebo effect of various remedies may be helpful, particularly if the agents are largely inert, as bothersome side effects seen in conventional medicines may be avoided. Alternative therapies often include “nonspecific therapeutic effects” that go beyond the placebo effect and can be beneficial. Nonspecific effects include warmth and listening skills of the practitioner, empowerment that comes from legitimization of the patient’s problem, and an egalitarian approach to care. Physicians may wish to recommend alternative treatments and collaborate with alternative practitioners but should also be prepared to protect the patient by cautioning against treatments that are potentially harmful, excessively expensive, or that circumvent conventional treatments that are needed for demonstrated medical conditions.
et al.. Managing lower back pain: you may be doing too much. J Fam Practice
. 2009; 58:180–186.
The American Academy of Family Physicians has developed a patient education page for somatoform disorders. The web address for the page is http://familydoctor.org/familydoctor/en/diseases-conditions/somatoform-disorders.html.