Somatization: When to refer to a psychiatrist
How a psychiatrist can help
Typically, patients with somatoform disorders cannot readily find psychiatric treatment because most psychiatrists have little training in assessing or managing these disorders and are not interested in these patients who focus on physical symptoms and for whom treatment is usually slow.
However, psychiatrists can help with somatoform disorders in various ways. They can:
- assess suicide risk, which develops in some patients given the often bleak nature of their lives with unremitting physical symptomatology and the high burden of other psychiatric comorbidity
- give advice about managing treatment-resistant depression or anxiety that may be either the primary issue or a secondary comorbidity with a somatoform disorder
- confirm a diagnosis
Because many psychiatrists are uncomfortable evaluating physical symptoms and medical issues, they may recommend more medical investigations. Sometimes more investigations are appropriate and can find evidence of organicity. At other times, more investigations are a balm for the psychiatrist's anxiety around evaluating physical symptomatology and the psychiatrist may disrupt the primary care provider's attempts to limit investigations.
Preparing the patient for a psychiatric consultation
Preparing patients for a psychiatric consultation is important, given the lingering stigma and misperceptions that continue to exist about psychiatry. Here are some tips to help patients feel more comfortable:
Confirm your concern for the patient. Tell your patient that you want to provide the best care possible, that their symptoms are important and their suffering real, and that your care will be improved and you will feel better if the patient sees an expert in the relevant area (e.g., using medications developed for anxiety and depression that can also manage symptoms the patient is experiencing such as fatigue and sleep problems).
Anticipate that the patient may react negatively to your psychiatric referral. This reaction can happen in the moment, or when the patient goes home and has a chance to think about the referral as evidence that you think it is "all in their head" or that you are trying to "dump them." Ask these patients to remind themselves that the referral is a sign that you want the best for them and are committed to their ongoing management.
Highlight the psychiatrist's experience with physical symptoms. If the psychiatrist sees medically ill patients, add that to your "sell" (e.g., "Dr. X has helped my patients with physical problems, including problems such as you have, and has also helped to improve the quality of life of my patients with cancer and heart disease"). This will help patients to not immediately dismiss the psychiatrist as someone who "won't know anything" about physical symptoms.