7 responses to “Managing the complicated somatoform disorder patient”

  1. Wow! Thank you so much for this article. I find your approach to this problem to be a significant advance on what I’ve been taught before about managing these difficult conditions. I also appreciate that it is patient centered, addressing their most significant concerns while not diminishing them. I would really love to see more from you along the same lines. As I get more experienced in the practice of medicine, it’s the conditions that medicine traditionally does not treat well that have become the most challenging. There are so many patients suffering from these conditions who are not served well by our traditional views of illness and patterns of practice.

  2. Both conditions are so common in our practice. I was happy reading a topic difficult to approach. Thank you I liked the you addressed, not to blame the patient, acknowledge his complaint even refer the. Psychiatric management
    Good topic

  3. It is important to examine the patient.

  4. I appreciate the author’s thorough, well-contemplated, comprehensive approach to primary care patients with unexplained medical symptoms and traits of somatoform disorder.

    Ideas I may incorporate into my own practice:
    – Screening for family history of similar functional or like disorders
    – Avoiding the use of the generic term “stress” as a label for unexplained cause of symptoms, instead using a more applicable term such as “emotional distress” when communicating diagnosis and possibility of somatoform disorders to patients.
    – I like the structured approach to specialist psychiatry referral, which I believe I underuse for such patients in my own practice
    – Giving the patient literature regarding the disorder to confirm its authenticity and not downplay its significance as a medical/psychological entity

    Ideas that I disagree with:
    – While appropriate limited specialist consultation(s) to initially rule out organic causes or potential missed diagnoses of potential life-threatening diseases is certainly warranted, I particularly disagree with the author’s request for annual specialist follow-up for patient reassurance for unusual symptoms or missed diagnoses. There is great risk of iatrogenic harm with multiple consults and ongoing follow-up without adequate clinical suspicion of a particular medical diagnosis, particularly the more consultants that are involved in the patient’s care and for the greater length of follow-up time. These ongoing reassessments without specific indication are also costly and may lead to further inappropriate testing given the atypical and evolving nature of somatoform symptoms and natural fear of MDs of misdiagnosis or litigation.

    This approach may also allow the primary care physician to “collude” with the patient’s disorder, continuing the low-yield pursuit of a secondary cause for symptoms, giving further credence to the “medical” nature of the symptoms. Medical evidence suggests that negative diagnostic testing and reassurance from consultants has poor efficacy in reassuring such patients, addressing their fears or relieving their symptoms. I suspect that these reassessments by specialist colleagues do more to allay fears in the primary care physician rather than the treated patient.

    This recommendation seems to go against current evidence and recommendations for somatoform conditions emphasizing that care should be provided by a designated physician on a scheduled, structured basis, limiting the number of frivolous testing and associated physicians providing ancillary care.

  5. I like how secondary gain is explained to patient as unintended consequence of handling their disability at the same time acknowledging their difficultied. This approach increases the chance of long term follow up.

  6. This is quite educative

  7. When we don’t have the proper diagnostics, patients get thrown into a somatization diagnosis which can destroy their lives. If psychiatrists see them as “easy to treat” when, in fact, they have a serious illness that needs an alternate approach, the patient will worsen and be blamed for it. Psychiatry is not a hard science. Doctors should admit that they don’t know, or that they cannot help a patient instead of erroneously pigeon-holing them with an inappropriate diagnosis. We have a lot to learn about the body and many diseases. Just a few decades ago, MS was blamed on “demons”; just a decade ago, I watched a PPMS Pt get ridiculed for being a drug-seeking psychosomatic whiner by hospital staff simply because the first MRI was negative. The second wasn’t. And, this is only regarding a Pt case where diagnostics are mostly reliable. What about lupus, ME, and the myriad other conditions that don’t have hard bio-markers or adequate diagnostics yet? It doesn’t mean they don’t exist. It means no epoch is finally privileged; we are all tomorrow’s food (thanks, Ken Wilber).

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