II. Management: Strategies to avoid

  1. See Somatoform Disorder Management Pitfalls
  2. Do not suggest "it's all in your head"
  3. Do not order endless testing without indications
    1. Avoid unnecessary invasive tests or medications
    2. Avoid over referring to specialists
  4. Do not focus on symptoms (focus on function instead)

III. Management: Protocol

  1. Assign a single designated physician
    1. Establish long-term empathetic relationship
    2. Physician's role is care not cure
    3. Patients role is learing to cope
  2. Schedule frequent visits (e.g. 15 minute visit/month)
    1. Replaces emergency visits and telephone calls
    2. Allows patient attention without a new symptom
    3. Not contingent on new complaints
    4. Not focused on symptoms
    5. See Primary Care Counseling below
  3. Approach
    1. Encourage patient to assume active role in their care
    2. Focus on function
    3. Manage comorbid psychiatric conditions
    4. Provider reassurance that serious conditions have been ruled out
      1. Avoid additional lab testing and subspecialist referral
    5. Spend most of the encounter listening
      1. Acknowledge that what they are feeling is real
      2. Allow the "sick role"
  4. Consider medications
    1. Amitriptyline
    2. Fluoxetine (Prozac)
    3. St. John's Wort
    4. Other agents have not shown benefit

IV. Management: Counseling

  1. Primary care counseling of psychosocial concerns
    1. Use the BATHE Technique
  2. Cognitive Behavioral Therapy
    1. Patient's own strategies have not been working
    2. Gentle challenging of maladaptive behaviors
  3. Mindfulness-based therapy
  4. Group therapy for Somatization
    1. Stress management
    2. Problem solving
    3. Social skills training
    4. Specific interventions
      1. Amplification
      2. Need-to-be sick role

V. Management: Stress reduction

  1. Counseling on improving family relationship
  2. Exercise at least three 20 minute sessions per week
  3. Social gatherings or pleasurable activities with others
  4. Relaxation Technique
    1. Yoga, meditation or Mindfulness
    2. Nature walks

VI. Management: Benign measures

  1. Hot and cold packs
  2. Bandages
  3. Canes
  4. Lotions
  5. Vitamins or Nutritional Supplements
  6. Acupuncture
  7. Chiropractic massage therapy
  8. Biofeedback

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