treatment overview​

General management strategies

Follow these strategies to manage patients who are somatizing:

• Reassure patients that you are not dismissing their symptoms and that you do not see the problem as "all in their head." Emphasize that you understand that they have distressing symptoms in their body and need relief, and that you are trying to help them.
• Explain the results of medical investigations (there is an art to doing this with these patients) and emphasize the importance of improving functional status and quality of life in spite of symptoms.
• Let patients know that the investigations have reassured you that there is no evidence of a sinister condition or a biological abnormality requiring correction through a medication, specific treatment or surgery.
• Empathize with patients that it is frustrating that at this point in the 21st century modern medicine cannot measure or image the symptoms they are experiencing.
• Emphasize that a negative test finding does not mean the patient is "faking" or the symptom is "all in their head." Remind patients that you take their symptoms seriously and that the distress they are experiencing is real and debilitating. The idea of their symptoms being a disorder of function rather than structure is often helpful.
• Reassure patients that you will continue to follow them and work with them to decrease the level of their distress and improve their functioning.
• Tell patients that you will only do further investigations if they describe a symptom complex that raises a "red flag" or "sets off alarms" for you. You will be able to say "no red flags or alarms" whenever you deny future pleas for more tests.
• Encourage forward movement. Emphasize that now that the investigations have demonstrated no sinister pathology, it is time to focus on managing symptoms and building a satisfactory quality of life despite the symptoms.

Establish regular follow-up appointments

It is easier to work with patients who are somatizing when you do it on a schedule that works for both of you.

Schedule follow-ups at the minimum interval between patients' current visits using standing appointments. If patients are arriving at your office once a week, make a weekly appointment at a time of day that works for you.

Regular follow-up removes from patients the sense that they need to present with a physical complaint. When you remove this need and offer regular follow-up because "they have a lot of symptoms and are dealing with a lot" and you "want to help them," patients will gradually begin to focus less on their physical symptoms when they are with you.

At the follow-ups, allot at most a couple of minutes for an update on physical symptoms and focus the conversation on activities the patient has been doing. These sessions will come to feel like social chats, but they are powerful reinforcers of the patient's increased functioning and a much more pleasant way for both of you to spend the time together.

Primary care providers new to this strategy often say, "But aren't I wasting the health care system's money by talking about ____________ (e.g., cooking, children, sports)?" In fact, this strategy saves the health care system significant amounts of money because it reduces visits to emergency rooms and specialists, as well as investigations and drug costs.

Slowly increase the time between appointments as the patient "settles down." Take advantage of natural breaks, such as conference leaves, to increase the time between appointments. Be sure the patient has settled down before beginning to increase intervals or the situation will decompensate. For the most challenging patients, move very slowly. It may take a year or two before you can begin to space out appointments.

Treat what can be treated

Treat major psychiatric disorders if they are present.

Patients with long-standing symptoms, low functioning and significant deconditioning will benefit from a slow and graded physical reactivation. Get patients to keep a chart and record what they do each day. Walking is the best activity for most patients, as it is easy, free and doesn't require equipment.

Establish a starting target for physical activity. There are two approaches to setting targets for physical activity:

• You can start with what your patient can do on the worst days and then have them do that every day.
• You can find out what your patients can comfortably do on an average day and then cut the time in half and have them begin by doing that every day.

For the most deconditioned patients, aim lower. For example, if a patient can walk only to the bathroom on the worst days, a reconditioning exercise can involve walking that distance every day for a week and then slowly increasing the distance.

Increase patients' activity level in small increments. For example, increase their activity each week by one or two minutes. Patients who are in fairly good physical condition can progress faster. The ultimate goal for patients with no medical contraindications is to get into the cardiovascular training range where they will benefit from enhanced endorphin release and the positive benefits on mood (i.e., 30 minutes, five days a week). This may take six months or more.

Symptomatic treatments such as massage may be helpful, but think carefully before you suggest them. Consider whether the treatment will be a bridge to increased function or if it may be construed as evidence of fragility. If patients are passive recipients of treatment, could this undermine your attempts to have them assume more control over their lives?

Evaluate and tailor pharmacotherapy

Patients who are somatizing often have long lists of medications. Often it is because they have seen many practitioners, each adding medications targeting various symptoms. Many patients with somatization disorder are on extensive "cocktails" of multiple opioids and benzodiazepines.

Make a list of the patient's current medications. Evaluate where there is overlap and assess the value of each medication, determining whether it is benign or whether it is associated with negative effects or side-effects. If possible, have patients bring in all of their medications and go through each one with them to figure out how often they use it and under what conditions.

Make a list of all prn (as needed) medications. Determine how often patients use them during the average bad and not as bad day. Check this against the rate at which they fill their prescription or ask them to monitor their use for a couple of weeks. Do their current prn medications make sense? Could their needs be better met with a standing medication?

Opioids and benzodiazepines need to be carefully evaluated. The crucial test is whether their use is associated with improved functioning and an acceptable side-effect profile.

Opioids are particularly problematic because, in addition to having side-effects such as constipation and sedation, they may also be associated with hyperalgesia, rebound headaches and pain, and decreased testosterone. While a trial of opioids may be appropriate in the context of chronic non-malignant pain, ongoing use requires evidence of increased functioning.

Many patients require very slow, gradual tapers of opioids and benzodiazepines in order to function optimally.

Develop an optimal pharmacotherapy plan and then work over time to gradually get the patient there. It may take a year or more to rationalize the pharmacotherapy of many of these patients.

Manage your reaction to the patient

Most health care professionals find patients who are somatizing very challenging to work with. They have various reasons for this feeling:

• minimal gratification as symptoms are not rapidly treated
• irritation with patients' degree of disability compared to patients with major medical illnesses who are coping in the face of considerable pain and morbidity
• difficult personality disorders that are over-represented in this patient group

Recognize that these patients can evoke negative feelings. The problem is not the negative feelings that we can handle professionally but rather denying the negative feelings and then acting out on the patient.

The following strategies can help clinicians to manage their reactions to challenging patients:

• Find something you can like about the patient or something intriguing about them.
• Take pleasure in small gains. Working with these patients is a slow process. We need to recognize when they have done something positive (e.g., a patient with somatization disorder who goes to a walk-in clinic in response to a new symptom rather than going to the emergency room).
• Remember that you should never be working harder at getting your patient better than the patient is working.
• Do something nice for yourself when you have had a particularly challenging encounter.
• Be realistic. Some patients are somatically preoccupied because it is the only alternative available for them in the context of their very challenging life circumstances. It may be impossible for them to shift their behaviour because it serves important functions in their lives.