Management of somatic symptoms disorders General principles Early

Management of somatic symptoms disorders General principles Early identification and avoidance of multiple investigation and physical treatment is paramount. s Enabiling the patient to make the link between their emotional and physical symptoms is the key to success. physician must simultaneously maintains an appropriate level of vigilance for undiagnosed physical illness while avoiding unnecessary tools and therapies. maintaining an ongoing therapeutic alliance.

Adopting ‘caring rather than curing as the goal’ is useful. providing a positive explanation for the symptoms, without dismissing them. Symptoms are to be seen as real and the physician has to appear as one who is keen to explore all possibilities for symptom removal. “I am more sick than my doctors think” Ensuring regular follow-u p (and not ‘symptom-driven’ visits). Treating mood or anxiety disorders.

Minimizing polypharmacy “Writing prescriptions is easy, understanding people hard ”! Providing specific therapy (eg: physiotherapy to reduce musculo-skeletal pain) Emphasizing doctor- patient relationship Recognizing counter-transference Suggestions and reassurance

focuses on dysfunctional neurotransmission and brain circuits which are influenced by external stressors and internal conflicts leading on to symptoms referal to psychiatrist may be prefaced by stating that the cause for the medical symptoms have not been found and that in similar cases , assessement of the role of stress by medical psychiatrist is required Encourge the patients to remain active and limit the effect of target symptoms on the quality of life and daily functioning. antidepressants, antiepileptics, antipsychotics, and natural products, effectiveness of these has limited support.

Somatic symptoms disorder(somatization) • the goal of treatment is to provide care for the patient but not on curing the disease. • The best treatment occurs in the context of a long term relationship with an empathetic primary care provider

allow the patient to maintain the sick role. schedule regular follow-up appointments of a set length. set the agenda of the visit. do no more and no less for the somatic patient than for any other patient. set limits on contacts outside of visit time. introduce psychosocial issues slowly, using stress or mind-body language. minimizing unnecessary investigation and prevent iatrogenic complication.

Illness anxiety disorder Physician should answer questions and reduce patient's fear of specific illness. Regular contact with a caring medical physician should be maintained with palliation, and not cure, as the goal. The workups should be based only on objective findings group psychotherapy may provide social support and reduce anxiety

Conversion disorder • Support, reassurance, and interpretation of the symptoms on psychological bases are helpful • (indirect examination of stressors can lead to relief). • Avoid confrontation , as it result in loss of face. • avoid reinforcement or trivializing the symptoms. • Treatment of any associated psychiatric disorder • Educating the patients family about the disorder and stressing that is not a serious disease

Factitious disorder strategy 1: is therapeutic ‘double-bind' In this approach the patient is presented with two choices: prove that his or her disorder is not factitious by responding to a relatively minor and benign medical intervention, or prove that the disorder is factitious by failing to respond

• a woman was offered the double-bind for a wound that had failed to heal in 4 years despite numerous surgical closures. Following this strategy the plastic surgeon told her that her wound should respond to a skin grafting procedure. If it did not, it would mean that her disorder was factitious in origin. The graft took place, and there was no recurrence of infection at 2 -year follow-up. The strategy was successful in providing patients with a face-saving legitimization of both their illnesses and recoveries.

• Strategy 2: ‘inexact interpretations', • suggesting a relationship between certain events or stressors, for example being abandoned, and emergence of factitious symptoms. It involves presenting a brief formulation of the problem to the patient, stopping short of overtly identifying the factitious origin. • By avoiding confrontation the doctor makes it safe for the patient to relinquish the symptom with a feeling of control.

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