Diagnosing and Managing SD

Not surprisingly, patients with unexplained physical symptoms are first seen by primary care or nonpsychiatric specialists, who usually make the initial diagnosis. Unfortunately, only about 1 of 4 primary care physicians acknowledge feeling confident about their ability to treat these patients. The percentage of primary care practitioners who report confidence in managing other mental disorders, such as depression or anxiety disorders, is much higher.26

Assisting primary care providers through instructional sessions and manuals or simply by using a consultation letter has proved to be useful.27,28 Referral of these patients to mental health services is generally unsuccessful unless proper bridges between primary and mental health care are built. This requires patient preparation, careful teamwork, and the presence at the primary care site of trained mental health personnel.

 

Because of the high level of discomfort associated with unexplained symptoms, to be told that “there is no physical problem” is disconcerting to many patients. For the provider, however, finding no physical abnormality generally brings a sense of relief. In building a good therapeutic relationship, it is important for the therapist not to downplay the patient’s discomfort at being told “there is no problem” or “your symptoms are all psychological.” As in any other field of medicine, empathy and acknowledging the patient’s distress are essential ingredients for a sound therapeutic relationship. Table 2 provides a stepwise list of suggestions for communicating a diagnosis of SD to the patient.

Table 2 Communicating a diagnosis of somatoform disorder
1. Convey clearly, succinctly, and in a positive, supportive way that the physical examinations and laboratory tests show no physical abnormality
2. Tell the patient that he or she has a relatively common disorder with no clear basis but which may cause severe discomfort and dysfunction
3. Explain that despite the lack of physical findings, the physical symptoms are not intentionally produced and cannot be eliminated by an act of will
4. Let the patient know that there are treatments that can provide relief but require the close collaboration of the patient and all health care providers
5. Do not use psychological or psychodynamic terminology or jargon (eg, denial, resistance) because most of these patients are not psychologically minded

If properly communicated, the diagnosis of SD may offer relief and encouragement to the patient. For example, in a recent study, patients with unexplained symptoms felt that receiving such a diagnosis after a time of worry and uncertainty was an important factor in successfully managing the disorder.29

Regular patient visits should be scheduled (eg, monthly or bimonthly) independent of fluctuations in symptoms. Treatment goals must be concrete, stepwise, and realistic. Do not aim for an all-or-nothing result, but consider a gradual and incremental response. The goal is to progressively decrease emergency visits and calls.

A routine examination is recommended at every visit to reassure the patient and to ensure that there are no physical abnormalities (remember that paranoid people may have real enemies). However, no new tests or consultations should be ordered unless there is a clear indication. Rather than reassuring patients, unwarranted consultations or tests may feed their belief that they have a serious physical illness.

During the visit, the patient can be allowed to play the “sick role.” Allow him or her to verbalize complaints and concerns without entering into needless arguments on issues related to the reported symptoms. The objective is not to negate the symptoms but to improve functionality and well-being. Briefly discuss current stress factors and other important circumstances, and make sure the patient understands that the unexplained symptoms are elements of a biopsychosocial illness. Table 3 presents a list of goals to work toward.


Table 3 Suggested goals in treatment of somatoform disorder
  • Encourage the patient to decrease or (ideally) stop making emergency department visits
  • Address specific psychiatric comorbidities, such as depression, anxiety, alcohol or substance use disorders, and other lifestyle measures (eg, diet, excessive use of stimulants, smoking)
  • Improve sleep with sleep hygiene measures and, if necessary, add a brief course of nonaddictive hypnotic medication
  • Address fatigue with an aerobic exercise program (eg, walking, jogging, biking, swimming) at least 4 days a week but ideally, every day; exercise should be sustained rather than intensive (a half hour walk is better than sprinting or lifting weights for 10 minutes) and should start at a comfortable level for the patient
  • Discourage secondary gains such as missing work or class or avoiding home chores

 

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