Among the more challenging clinical situations seen in the primary care setting are patients who are recurrently distressed and present with multiple physical complaints and symptoms that do not fit a clearly definable syndrome or diagnosis — a clinical presentation that presents the provider with no target for definitive medical intervention. Categorized as Somatoform Disorders in the current DSM—there are seven subtypes—these patients can present as quite frustrating individuals to help as their complaints are inexplicable and refractory to routine care.
The conundrum facing the practitioner is dual— 1) How do you convince yourself that you’re not missing a diagnosis? and, 2) Absent a definable physical illness/ailment, how do you proceed with care and intervention to optimally manage the patient’s distress? This is one arena where the medical intersects with the psychological and where appreciation of the various somatization disorders may be warranted. Physicians managing patients with these presentations often identify these cases as among the more frustrating and unrewarding of their professional work. The guidelines discussed below can help finesse some of these challenges and help to achieve more favorable clinical outcomes.
The starting point, of course, is to proceed with due diligence in evaluating the presenting complaints, carefully exploring both the physical health and psychosocial status of the patient. Step one is to conduct a complete assessment with a careful history and physical, complemented with reasonable and appropriate laboratory tests and relevant tests. Attention to the chronicity (one of the diagnostic criteria for a somatization disorder) and the degree of consistency of the patient’s complaints (typically there are multiple ones) is important. In this phase of involvement, it is helpful to project an empathic and engaged approach to seeking resolution (or simply improvement) of the patient’s condition. It can be helpful in establishing an effective alliance with the patient to note the chronicity of their problem and to frame your involvement as a partnership with the patient to “see what we can to do to get you some relief”. Promising cure or even suggesting certainty of finding a definitive diagnosis can lead to challenges down the line.
For about upwards of 25-50% of patients who present with a somatization profile, a relevant diagnosis of a physical ailment will actually be achieved over time, so ongoing engagement with the patient is of obvious importance and consideration of a variety of diagnoses over time (e.g., Lyme disease, auto-immune disorders, etc., etc.) should be part of the clinical process— as sometimes “Time does tell”. But for the majority, roughly 50-75%, our best hope is to be able to manage the complaints to minimize distress and dysfunction and it is important to see this as a viable and acceptable outcome. Promising a patient more is a recipe for disappointment, so a modest and collaborative approach is recommended. For many patients, this empathic and modest approach is appreciated and accepted, but both for diagnostic reasons and as a vehicle for providing ongoing support for the patient, a referral to a colleague or a specialist may be helpful, even if the anticipated outcome is not one of finding “the answer or cure”. Excessively aggressive consultative referrals or intrusive diagnostic procedures without clear indications can be both costly and may exacerbate the patient’s situation as the disappointment of an unproductive intervention may reinforce the patient’s distress and even exacerbate the presenting symptom(s).
Somatoform disorders are more common in females by a scale of five times greater than in males. The disorder can be diagnosed in children where it frequently presents as abdominal pain, nausea, headaches or fatigue—family dynamics are an important element in these cases. In older patients it might be underdiagnosed since providers and their patients are often acculturated to believe that these complaints are “just part of normal aging”.
While not a panacea, gingerly approaching the patient with psychological, psychosocial and behavioral health considerations in mind can be quite helpful. Many patients with the disorder have underlying mood problems and/or significant psychosocial stressors and supportive and empathic attention to these issues should be a part of general care. Inquiring about “How things are going?” or “How is life treating you?” can open the door for patient’s to discuss their concerns and for some may pivot their focus from their experience of physical distress to an exploration of their emotional state, allowing for potential referral for supportive intervention in those arenas of hurt and distress. A variety of psychotherapeutic interventions have been found to be beneficial for patients who accept referral – this might take the form of a consultation with a mental health provider, involvement in group cognitive behavioral therapy (CBT), ‘mindfulness’ psychotherapy approaches, or even treatment with an antidepressant medication.
Referrals to behavioral health services, however, can be difficult to make as the somatic patient may experience the referral as an indication that their physical symptoms are being dismissed and as implying that you do not accept their health concern as real— that you are seeing the problem as being all “in their head” and not where they experience their hurt. As such, their interpretation may be that you no longer want to be part of their support system. Approaches that assure the patient of continuity of care (“I want to continue to meet with you regularly to see how things progress and see what we can accomplish,…”) while encouraging attention to psychological and psychosocial issues (…but I do think you should consider a referral to XYZ as many folks with ongoing symptoms like yours, really benefit from exploring their coping strategies and learn new techniques to reduce the impact of their physical symptoms.”) can be of value to your patient and a source of relief as well for you their primary care health provider.
References:
- Treating Somatization: A Cognitive-Behavioral Approach, 1st ed, Lesley A. Allen, Robert L. Woolfolk
- “The Somatization in Primary Care Study: a tale of three diagnoses” WP Dickinson, General Hospital Psychiatry vol 25, Issue 1, Jan-Feb 2003, p1-7
- Managing Somatization Medically Unexplained Should Not Mean Medically Ignored Jeffrey Jacks MD MPH, Kurt Kroenke MD . J: General Intern Med 2006 July; 21 (7): 797-799
- Somatization in The Primary Care Setting Psychiatric Times May 2006, M. Mccarron DO