Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Somatization

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Somatization - Key Features

1. In patients with recurrent physical symptoms, diagnose somatization only after an adequate work-up to rule out any medical or psychiatric condition (e.g., depression).

2. Do not assume that somatization is the cause of new or ongoing symptoms in patients previously diagnosed as somatizers. Periodically reassess the need to extend/repeat the work-up in these patients.

3. Acknowledge the illness experience of patients who somatize, and strive to find common ground with them concerning their diagnosis and management, including investigations. This is usually a long-term project, and should be planned as such.

4. In patients who somatize, inquire about the use of and suggest therapies that may provide symptomatic relief, and/or help them cope with their symptoms (e.g., with biofeedback, acupuncture, or naturopathy).

Definition: Patients with somatization disorder experience their emotional distress or difficult life situation through physical symptoms, where no physiologic explanation can be found

The DSM-IV-TR diagnostic criteria are:

• A history of somatic complaints over several years, starting prior to the age of 30.
• At least four different sites of pain on the body, AND at least two gastrointestinal problems, AND one sexual dysfunction, AND one pseudoneurological symptom.
• Such symptoms cannot be fully explained by a general medical condition or substance use OR, when there is an associated medical condition, the impairments due to the somatic symptoms are more severe than generally expected.
• Complaints are not feigned as in malingering or factitious disorder

Diagnostic Features Suggesting Somatization
Multiple symptoms, often occurring in different organ systems (KEY FEATURE)
Symptoms that are vague or that exceed objective findings
Chronic course (KEY FEATURE)
Presence of a psychiatric disorder
History of extensive diagnostic testing
Rejection of previous physicians

• Perform a comprehensive physical examination to rule out physical causes for the patient's somatic complaints. A detailed focus on specific systems, ie, neurological, may be necessary; this is based on the specific complaint.
• Order appropriate blood work and or imaging to rule out organic disease
• Include a full mental status examination. A patient with somatoform disorder displays the following on an examination.

o Appearance - Normal
o Attitude and behavior - Attitude is appropriate and behavior demonstrates a preoccupation with physical symptoms and complaints.
o Mood - Mildly anxious and depressed
o Affect - Full range and appropriate
o Thought disorder - None, although thoughts are limited to issues around physical symptoms.
o Hallucinations - None
o Delusions - None
o Obsessions - None
o Compulsions - None
o Attention - Within normal range
o Memory - Within normal range
o Concentration - Within normal range
o Orientation - Patient is oriented to time, place, and person.
o Insight and judgment - Insight appears limited in that nonmedical causes of symptoms are not considered. Judgment appears unimpaired.
o Suicidal and homicidal ideation - No evidence of such

-No definitive causes for most of the somatoform disorders have been established.
-Genetic and environmental influences appear to contribute to somatization.
-Children raised in homes with a high degree of parental somatization may model somatization.
-Sexual abuse may be associated with an increased risk of somatization later in life.
-Poor ability to express emotions (alexithymia) may result in somatization

Psychiatric comorbidity
-Alcohol and drug abuse are common in patients with somatoform disorders. Patients may attempt to treat their somatic pain with alcohol or other drugs.
-Additionally, alcohol or drug intoxication or withdrawal may induce somatic symptoms of unclear etiology, unless the physician considers the potential role of substances.
-Anxiety disorders and mood disorders commonly include physical symptoms as part of the presentation. Ruling out a primary anxiety disorder or mood disorder is key before reviewing the role of somatoform disorders.

-->coexisting depression (up to 60 percent), anxiety disorders such as panic or obsessive-compulsive disorder (up to 50 percent), personality disorders (up to 60 percent) or a substance abuse disorder

Patient Management
- Key patient educational issues include the following:

• The physician acknowledges the patient's symptoms and suffering.
• The physician takes on the role of evaluation and monitoring of symptoms.
• Not all symptoms indicate evidence of a pathological disease.
• The patient should attempt to maintain interpersonal function despite symptoms.
• Physical symptoms not due to a defined disease often remit spontaneously.
• Identifying key life stressors and sources of anxiety can be important.
• Stress reduction may produce improvement in physical symptoms.
• Aggressive surgical approaches should be used cautiously and only with the approval of a primary care physician who knows the patient well.

Family Education
- Family education is often crucial for the successful management of somatoform disorders. For the patient's family members, this education should include the following:

• Discuss the somatoform diagnosis.
• Expect the patient to improve and return to normal function.
• Direct the patient to discuss any somatic symptoms with the primary care provider. Patients should not seek assistance from family members in assessing the seriousness of their symptoms or the diagnosis relating to their symptoms
• The primary care provider should direct any need for subspecialty evaluation.
• Family members should spend time with and pay attention to the patient when symptoms are absent. For the patient, this reinforces the idea that their symptoms do not bring special attention from others.
• Family members may help by providing distraction activities if somatic symptoms are present, eg, going for a walk or going out to a movie

Practice Management Strategies for Somatoform Disorders
-Accept that patients can have distressing, real physical symptoms and medical conditions with coexisting psychiatric disturbance without malingering or feigning symptoms
-Consider and discuss the possibility of somatoform disorders with the patient early in the work-up, if suspected, and make a psychiatric diagnosis only when all criteria are met
-Once the diagnosis is confirmed, provide patient education on the individual disorder using empathy and avoiding confrontation
-Avoid unnecessary medical tests and specialty referrals, and be cautious when pursuing new symptoms with new tests and referrals
-Focus treatment on function, not symptom, and on management of the disorder, not cure
-Address lifestyle modifications and stress reduction, and include the patient's family if appropriate and possible
-Treat comorbid psychiatric disorders with appropriate interventions
-Use medications sparingly and always for an identified cause
-Schedule regular, brief follow-up office visits with the patient (five minutes each month may be sufficient) to provide attention and reassurance while limiting frequent telephone calls and “urgent” visits
-Collaborate with mental health professionals as necessary to assist with the initial diagnosis or to provide treatment, including CBT, which has been found to be an effective treatment for somatization disorder

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