How to Manage Somatic Symptom Disorder in Medical Settings

Somatic Symptom Disorder (previously known, roughly, as somatization disorder) is a maladaptive and counterproductive focus on physical symptoms or sensations, real or imagined. Patients with somatization disorders are really (and sometimes really, really!) suffering, it’s just that they have non-physical states and comorbidities that are making their symptoms worse. These include psychological determinants (e.g., anxiety, depression), social determinants (e.g., social isolation), behavioral determinants (e.g., sedentary lifestyle), various cognitive factors (e.g., pessimism, tendency toward catastrophizing, etc.).

Various biological factors (e.g., polypharmacy) also seem to play a role.

Try something along these lines:

I am really sorry that you are experiencing these distressing symptoms. The fact that all the tests we’ve done so far have turned up negative is somewhat reassuring because it suggests that there is nothing physically and immediately dangerous going on. While I don’t think we are going to make all of your symptoms go away during this visit, I would like to suggest to you that it is often the case that many patients who have medically unexplained physical symptoms also have  a lot of underlying anxiety, either from the symptoms themselves or from some other cause. This anxiety often makes the physical symptoms a bit harder to cope with. What do you think?

Why this approach is effective:

Bad answer: Nothing or, It’s all in your head.

Better answer: I think you have distressing physical symptoms (… or sensations?). I also think that some of the thoughts and feelings that you have about these symptoms, might be making your symptoms harder to cope with. As far as your workup is concerned, it is very reassuring that there is nothing imminently dangerous or life threatening going on.

Horrible answer: Yes.

Better answer: No (or, at least, Not necessarily). I am suggesting, however, that there may be cognitive and emotional factors here which, if addressed, might make your physical symptoms a lot easier to deal with.

Wrong answer: I don’t know or It’s hard to say. (These answers tend to unnecessarily reinforce the patient’s anxieties and pessimistic tendencies.)

Better answer: Many patients do get better. (+/- Whether or not patients get better often depends upon a number of factors, including duration of symptoms, psychological comorbidities, motivation, support systems, etc.).

What not to say

• Don’t try to “talk them out of it” or, worse, try to convince them that they are crazy with phrases like, I think it’s all in your head or even, I don’t think there is anything wrong with you. That won’t work for patients with somatization disorders and may only make them even more miserable and symptomatic.
• Do not reinforce their pessimistic outlook with comments like, I don’t know if you are ever going to get better, or, It’s hard to say whether you will ever get better, or even, You’re just gonna hafta learn how to live with it. (See below for suggested alternatives).
• Do not abandon your patient! Avoid saying things like, Unfortunately, I have nothing else to offer you. You have plenty to offer in the form of support, reassurance and referral to psychological professional, when appropriate.

What not to do

• Avoid over-testing and over-consulting. Tests beget more–and increasingly invasive–tests and interventions. The same is true for consults.