A low-frustration strategy for treating somatization
Psychotherapy that is educational, supportive, and reassuring can change patients’ persistent beliefs that they are physically ill.
Starcevic suggests useful techniques for providing reassurance (Table 3).22
DRUG THERAPIES
Psychotropics are considered a first-line treatment for patients with somatization disorders when:
- the patient spontaneously identifies any discrete, vegetative, or psychological complaints that may respond to drug therapy, such as insomnia, weight loss, sadness, or preoccupation
- the patient meets diagnostic criteria for comorbid anxiety or depressive disorders
- the therapeutic alliance is strong enough to weather the inevitable struggle with side effects and incomplete response to treatment. We do not recommend medication in the first encounter, when it may threaten a nascent alliance.
A common obstacle to prescribing psychotropics to somatizing patients is their sensitivity to suggestions that their complaints are “all in their heads.” To sidestep this resistance, describe the medication as treating the stress caused. by—not causing.—their chronic physical complaints. Proposing antidepressant therapy after—rather than instead of—physical exams and other diagnostics may elicit a more positive response.
Antidepressants. In clinical trials, somatoform complaints show moderate improvement after antidepressant treatment. In a meta-analysis of 6,595 patients with unexplained symptoms treated only with antidepressants, the number needed to treat was 3 to yield a positive response.25 This report of 94 medication trials included patients with headache, fibromyalgia, functional GI syndromes, idiopathic pain, tinnitus, or chronic fatigue.
In other trials:
- Amitriptyline has reduced somatic symptoms in patients labeled as having “masked depression.”26
- Sertraline has reduced disease fear, disease conviction, and bodily preoccupation in patients with hypochondriasis and panic disorder.27
Consider side effects when choosing medication for patients with somatoform disorders. Selective serotonin reuptake inhibitors (SSRIs) in general—and sertraline, citalopram, and escitalopram specifically—have fewer side effects than tricyclics. The adage of “start low, go slow” is appropriate for somatizing patients; we usually start with one-half the dosages recommended for treating depression.
Antipsychotics. In case reports, patients with “atypical psychosis,” “monosymptomatic hypochondriacal psychosis,” or “delusional disorder, somatic type” have responded to antipsychotics. These patients’ somatic beliefs are of delusional intensity, such as the rare fear of being eaten alive by an intestinal parasite (delusional parasitosis). Reported behaviors associated with the delusion include starvation, excessive laxative abuse, ingestion of sharp objects, and self-inflicted stab wounds. Treatments described in the literature include the typical agents pimozide and haloperidol and the atypicals olanzapine and risperidone.
TREATMENT-RESISTANT PATIENTS
Some patients with somatoform disorders will not accept CBT, psychotropics, reassurance, or referrals to group psychoeducation. Despite your best efforts, they may persist in focusing on somatic complaints. If you are willing to maintain a therapeutic relationship with them, be prepared to tolerate several ongoing paradoxes (Table 4).
Behaviorally, you must “listen more and do less.” Emotionally, you must be willing to enter into a long-term relationship with an inherently frustrating patient whose pathologies make you feel therapeutically hopeless and helpless. Understand that their physical symptoms function as a metaphor for psychological distress. You are not required to explore the source, content, or meaning of the metaphor in detail but simply listen to their somatic complaints through that psychological filter.
Related resources
- Starcevic V, Lipsitt D (eds). Hypochondriasis: modern perspectives on an ancient malady. New York: Oxford University Press, 2001.
- Information and support Web site for persons with health anxiety or hypochondria. www.healthanxiety.com
- Anxiety Disorders Association of America. www.adaa.org
Drug brand names
- Amitriptyline • Elavil
- Citalopram • Celexa
- Escitalopram • Lexapro
- Haloperidol • Haldol
- Olanzapine • Zyprexa
- Pimozide • Orap
- Risperidone • Risperdal
- Sertraline • Zoloft
Disclosure
Dr. Isaac reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Wise receives grant support from Eli Lilly & Co. and is a consultant or speaker for Eli Lilly & Co., Pfizer Inc., Bristol-Myers Squibb Co., and GlaxoSmithKline.
