Somatization: Screening, assessment and diagnosis
Plan to assess patients over a minimum of several sessions. If possible, schedule an extended appointment for the assessment.
The basic assessment includes:
- a history of the presenting complaint
- a focused physical examination and relevant investigations
When no organic basis is found for the symptom, do a psychiatric review of systems to rule out the common major psychiatric disorders presenting with prominent bodily complaints. If a major psychiatric disorder is present, focus on treating that disorder with the hope that it will also address the physical symptoms.
If the patient does not have a common major psychiatric disorder, consider various somatic symptom and related disorders diagnoses.
Patients with medically unexplained symptoms
Broadly speaking, there are two groups of patients with medically unexplained symptoms: patients you know, and patients who are new to your practice.
Patients you know
The "thick chart"
The patient with a "thick chart" has had many medically unexplained symptoms with multiple past investigations and is well known to you.
Rule out an organic cause and a current major psychiatric disorder.
Persistent, medically unexplained somatic complaints
For a patient with persistent somatic complaints for which you can find no medical base, check out recent psychosocial stressors without implying that the patient is responsible for the stressor, or that the stressor is "causing" the symptom. Ask the patient:
- "Having symptoms like you are describing is really difficult and makes it harder to put up with other stress in your life. Are your symptoms making it difficult to cope with other stresses right now?"
Medically unexplained symptoms may have developed in response to high stress, particularly a major medical illness in a partner, family or friends.
A patient preoccupied with her bowel function over the last few months. When asked how her disturbed bowel function is affecting other stresses in her life, the patient replies that it is very difficult because she is the executor for her uncle's estate. When asked what the uncle died of, the patient responds "colon cancer."
It is likely that these patients have a major psychiatric disorder other than a somatic symptom or related disorder, which accounts for their presentation. Do a careful review of psychiatric symptomatology, especially depression and anxiety.
Patients who are new to your practice
- Do not assume that you will make a rapid assessment.
- Try to get at least some past medical records for more information.
- Start with ruling out organic pathology, then turn to ruling out a major psychiatric diagnosis. Finally, see if you can rule in a somatic symptom or rlated disorder diagnosis.
Ruling out organic pathology
Ruling out organic pathology is important for several reasons:
You do not want to miss a treatable illness. If patients have a somatic symptom or related disorder diagnosis or medically unexplained symptoms, you must be comfortable managing them. You need to be able to calmly reassure yourself that they do not have a treatable illness when they present with multiple complaints.
Patients need to know you are taking them seriously. Patients who are somatizing typically need some initial investigations as evidence that you have taken them seriously. Doing minimal but relevant investigations then opens the door for you to subsequently refuse other investigations unless medically indicated.
While it may seem wasteful to do "medically unnecessary investigations," doing so often pays off because it helps to settle patients and makes them more likely to follow your advice and not make unnecessary visits elsewhere. The health care dollars spent on initial investigations are likely to save many more health care dollars in patients' pursuit of a health care professional who "takes them seriously." Draw the line at investigations that carry significant risk of harm.
What investigations do I order?
Start with baseline investigations indicated by the clinical complaint. Consider ordering second-line or more expensive investigations such as a CT scan if there are clinical indications to do so or if you sense that the patient will not settle without having them done and there is a very low risk of harm.
Be reasonable. Medical training focuses on the axiom "common things are common." Therefore, clinicians have been encouraged to think of horses when they hear hoofbeats. But our training also emphasizes the possibility of zebras. Our own anxiety, our concerns about medico-legal risk and our sincere desire to do the best for our patients make it hard to know when to stop investigating unexplained somatic complaints.
Usually, the best strategy is to do good baseline investigations and then to keep your ears open for a change in symptoms or further development of symptoms that sets off alarm bells and warrants further investigation.