Approach to the Somatizing Patient

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Management

Accurate diagnosis includes a biopsychosocial understanding of the patient. The most important therapeutic process is to help the somatizing patient to understand the disorder and the symptoms. It is only after this process begins that the patient will begin to attribute symptoms to the correct cause. This process occurs slowly over many visits in support of the doctor patient relationship. The indiscriminate use of multiple medications to treat symptoms usually has a paradoxical effect. It iatrogenically reinforces physical illness and increases the risk of medication abuse.

These patients often develop a keen sense of not being treated correctly. If the somatizing patient does not feel understood, or is treated casually or randomly, the symptoms may be reinforced.
If the patient senses that the physician is attempting to "get rid" of him or her, symptoms generally worsen. This increases the risk of iatrogenic harm through doctor shopping and repeated tests, which increases the chance of false-positive test results and unnecessary interventions. For the physician, emerging anger is usually a sign of frustration at not being able to effectively help or cure the patient. Professional impotence can occur in many medical settings but is very prevalent with the somatizing patient. Proper recognition, diagnosis, and management of these patients reduces the frustration. Peer support can help physicians cope with the emotions generated by these difficult medical situations.
Reassurance alone is often helpful in transient, self-limited conditions and acute somatization. The physician's task is to identify precipitating circumstances, allow the patient to ventilate, and provide supportive listening and education about symptoms. This may require a series of brief visits at short intervals. In the long run, this approach is time and cost-effective because it may prevent chronic somatization. Attempts to talk the chronic somatizing patient out of symptoms usually fail and may result in an increase of complaints in order to "persuade" the doctor that he or she is "really" sick.

Psychopharmacologic treatment is effective in most psychiatric syndromes that present with somatic symptoms. Medications are not the primary treatment indicated for personality disorders, voluntary psychogenic syndromes, or somatoform disorders.

When a patient is resistant to treatment, it may be essential to have one or a series of individual or family meetings for education and to come to an agreement on the explanatory model for the symptoms, so that treatment may proceed.

The somatizing patient in primary care is a challenge for the physician in many ways. Making an accurate diagnosis, understanding the patient, and helping the patient feel understood are essential to an effective treatment plan. The physician is well advised to modulate the impulse to "do something" and to remember that offering honest, clear, sincere reassurance and education is doing something and has historically been a mainstay of medical care.

Help patient understand the disorder.

Do not use multiple medications.

Medications may be useful in psychiatric illness.

Resist the impulse to "do something"

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