Somatization Management

See Somatoform Disorder Management Pitfalls
Do not suggest "it's all in your head"
Do not order endless testing without indications
1. Avoid unnecessary invasive tests or medications
2. Avoid over referring to specialists
Do not focus on symptoms (focus on function instead)

Assign a single designated physician
1. Establish long-term empathetic relationship
2. Physician's role is care not cure
3. Patients role is learing to cope
Schedule frequent visits (e.g. 15 minute visit/month)
1. Replaces emergency visits and telephone calls
2. Allows patient attention without a new symptom
3. Not contingent on new complaints
4. Not focused on symptoms
5. See Primary Care Counseling below
Approach
1. Encourage patient to assume active role in their care
2. Focus on function
3. Manage comorbid psychiatric conditions
4. Provider reassurance that serious conditions have been ruled out
  1. Avoid additional lab testing and subspecialist referral
5. Spend most of the encounter listening
  1. Acknowledge that what they are feeling is real
  2. Allow the "sick role"
Consider medications
1. Amitriptyline
2. Fluoxetine (Prozac)
3. St. John's Wort
4. Other agents have not shown benefit

Primary care counseling of psychosocial concerns
1. Use the BATHE Technique
Cognitive Behavioral Therapy
1. Patient's own strategies have not been working
2. Gentle challenging of maladaptive behaviors
Mindfulness-based therapy
Group therapy for Somatization
1. Stress management
2. Problem solving
3. Social skills training
4. Specific interventions
  1. Amplification
  2. Need-to-be sick role