Somatization: Psychosocial treatment and pharmacotherapy
Psychopharmacological treatment can have several goals:
- treat a specific psychiatric disorder (e.g., depression or anxiety) that is either the primary cause of the somatic symptoms or occurs secondary to a soamtic symptom or related disorder or functional somatic syndrome
- ameliorate specific target symptoms (e.g., sleep, fatigue)
- treat a somatic symptom disorder.
Psychotherapeutic approaches include various psychotherapeutic models and techniques. Unfortunately, it is difficult to find therapists skilled or interested in using these therapies with patients who have somatic symptom and related disorders.
The evidence base for psychotherapeutic treatment remains limited. In deciding about therapy, it is helpful to consider the following points:
- Cognitive-behavioural therapy (CBT): The best-studied psychotherapy for these patients. Unfortunately, finding appropriate practitioners is often a struggle. If the patient is receiving disability benefits, an advocacy letter to the disability insurer may result in funding for CBT with an appropriately trained psychologist.
- General supportive therapy: Particularly useful when patients are experiencing high levels of stress and have poor social supports. If you are willing and able to make time to see them, you can provide the support. The key is to make follow-up consistent and predictable. Alternatively, you may serve these patients best by monitoring them medically and referring them to a GP psychotherapist, the local mental health clinic or a family service association for support.
- Insight-oriented psychotherapies: Helpful for patients who show an ability to form a therapeutic relationship and display a degree of psychological mindedness.
- Family or marital therapy: May be appropriate when family and relationship issues form a prominent part of the patient's presentation.
- Relaxation therapies: May help to decrease the physiological consequences of stress (e.g., muscle tension) and may thus decrease symptom burden.
- Mindfulness-based stress reduction: May assist patients in managing stress better and leading their lives despite their symptoms.
- Support groups: Groups, especially those without professional facilitation, cannot be wholly recommended because some are very helpful while others are not. Support groups that focus on how sick and dysfunctional everyone is are particularly unhelpful because they emphasize passivity and undermine your goal of increasing the patient's functional status. Ask patients about the perspective of the support groups they attend to get an idea about which groupsunity are likely to be helpful.
Helping the patient's family
The families of people who somatize often struggle, given the significant degree to which symptoms dominate the lives of patients and render them dysfunctional. You can support families in various ways:
- Encourage family members to get support for themselves if they need it.
- Assess whether marital or family therapy is needed.
- Explain that how we respond to behaviour can make that behaviour either more or less likely in the future. We can inadvertently reinforce dysfunction and passivity when we provide attention or support for behaviours of inactivity and disability. Similarly, we can reinforce positive behaviours by providing attention and praising those behaviours.
Psychiatry in primary care toolkit
The Psychiatry in Primary Care App has been decommissioned.
The revised print version of Psychiatry in Primary Care is avaible through the CAMH store.