II. Management: Strategies to avoid
- See Somatoform Disorder Management Pitfalls
- Do not suggest "it's all in your head"
- Do not order endless testing without indications
- Avoid unnecessary invasive tests or medications
- Avoid over referring to specialists
- Do not focus on symptoms (focus on function instead)
III. Management: Protocol
- Assign a single designated physician
- Establish long-term empathetic relationship
- Physician's role is care not cure
- Patients role is learing to cope
- Schedule frequent visits (e.g. 15 minute visit/month)
- Replaces emergency visits and telephone calls
- Allows patient attention without a new symptom
- Not contingent on new complaints
- Not focused on symptoms
- See Primary Care Counseling below
- Approach
- Encourage patient to assume active role in their care
- Focus on function
- Manage comorbid psychiatric conditions
- Provider reassurance that serious conditions have been ruled out
- Avoid additional lab testing and subspecialist referral
- Spend most of the encounter listening
- Acknowledge that what they are feeling is real
- Allow the "sick role"
- Consider medications
- Amitriptyline
- Fluoxetine (Prozac)
- St. John's Wort
- Other agents have not shown benefit
IV. Management: Counseling
- Primary care counseling of psychosocial concerns
- Use the BATHE Technique
-
Cognitive Behavioral Therapy
- Patient's own strategies have not been working
- Gentle challenging of maladaptive behaviors
- Mindfulness-based therapy
- Group therapy for Somatization
- Stress management
- Problem solving
- Social skills training
- Specific interventions
- Amplification
- Need-to-be sick role
V. Management: Stress reduction
- Counseling on improving family relationship
- Exercise at least three 20 minute sessions per week
- Social gatherings or pleasurable activities with others
-
Relaxation Technique
- Yoga, meditation or Mindfulness
- Nature walks
VI. Management: Benign measures
- Hot and cold packs
- Bandages
- Canes
- Lotions
- Vitamins or Nutritional Supplements
- Acupuncture
- Chiropractic massage therapy
- Biofeedback