Somatization in the Primary Care Setting

The treatment of somatoform disorders exemplifies the "art" of medicine. Because this condition is on a wide-ranging continuum with an unknown cause, it is impossible to apply a strict evidencebased approach to treatment.¹⁷ The acronym CARE MD represents a set of guidelines that can help primary care physicians work with patients who have somatoform disorders (Table 2).

Consultation with a psychiatrist and use of cognitive-behavioral therapy (CBT) has been shown to decrease the intensity and frequency of somatization.^18,19 Kroenke and Swindle²⁰ reviewed 31 controlled studies and concluded that CBT is an effective treatment for patients with somatization type disorders. Group therapy using CBT has also been found to be beneficial.²¹ CBT is generally a short-term psychotherapy (8 to 20 weeks) with the goal that patients will develop skills that last indefinitely. This type of psychotherapy is based on the premise that inaccurate or dysfunctional thoughts are predominant in patients with somatoform disorders. Examples of such thoughts are: "I will always be sick," "No one understands my pain," or "Everyone thinks it's all in my head." Through a variety of mechanisms, patients learn to recognize and reconstruct the dysfunctional thought patterns with resultant decreased somatic complaints. In collaboration with the therapist, primary care physicians can learn to use brief cognitive behavioral techniques during office visits.

Assessing patients on each visit for general medical problems that might explain troublesome physical complaints is important. This is particularly essential for patients who have a long history of somatic preoccupation and present with a new complaint or worsening of existing symptoms. About 25% to 50% of patients with a diagnosis of conversion disorder eventually have an identifiable, nonpsychiatric disease that explains the symptoms.³ It is also important to screen for other common psychiatric conditions. Concurrent mood or anxiety disorders affect 25% to 50% of patients with somatoform disorders.^22,23 The number of unexplained somatic symptoms is highly predictive of comorbid mood and anxiety disorders as well as functional disability. Physicians can use the PRIME-MD scale, which uses a combination of self-reporting and clinician interview, to reliably screen for psychiatric disorders in the primary care setting.

Regular visits with one physician are critical to the management of somatoform disorders. Short, frequent counseling appointments have been shown to decrease outpatient medical costs while maintaining patient satisfaction.13 These encounters should include a brief but focused examination followed by open-ended questions such as: "How are things at home?" "What is the biggest stress for you now?" or if the patient is exposed to CBT, "Tell me about your most frequent dysfunctional thoughts since your last visit." The patient should use this interaction in lieu of inappropriate emergency room visits or frequent calls to the physician's office. Longer, less frequent "noncounseling" visits are reserved for assessment and treatment of all other medical disorders. In sum, spending more that 80% of each "counseling" visit on worrisome psychosocial stressors will provide an outlet for the patient to cope, with less somatic preoccupation as a result.

Empathy, or experiencing the emotional state of the patient, is a key ingredient to forming a healthy therapeutic alliance and optimizing treatment for patients with somatoform disorders. The use of empathy can also minimize negative feelings or countertransference for the treating physician. True empathic remarks such as, "This must be difficult for you" or "I might feel the same way if I were in your situation" are often beneficial, particularly when frustrated family or friends are in the examination room with the patient.

Medicine and psychiatry should interface in the treatment of every patient with somatoform disorders. It is important for patients with somatization to know that emotions and stressors can have a direct effect on the entire body. Many patients are reluctant to accept an explanation such as, "It's all in your head" or "A psychiatrist will have to deal with your symptoms" for their diagnosis. Instead, primary care physicians should provide a diagnosis and, if necessary, arrange for a psychiatric consultation while remaining the primary caregiver. During the short but frequent "counseling" visits, patients should be asked if the unexplained symptoms get worse as the primary stressor worsens or if the symptoms improve as the primary stressor improves. If the answer is yes to both questions, allow the patient to slowly make the connection by asking an openended question like, "Do you have any thoughts on why that is?"

Doing no harm by unneeded consultations or procedures is the most important part of treating patients with chronic somatoform disorders. Primary care physicians should not deviate from normal practice style to appease a patient or minimize frustration. After taking reasonable steps to rule out a general medical condition, the appropriate somatoform diagnosis should be made and treatment should follow accordingly.