Patient Care Neurology & Psychiatry - November 2007 - (Page 9)

The15-MinuteVisit What you need to keep in mind during patient encounters Somatization disorder I Problem The patient is a 26-year-old woman who presents with back pain for the last 2 months. Three months ago, she presented with bloating; 6 months ago, with irregular menses. The chart review reveals, over a 2-year period, a history of multiple complaints for which no medical cause could be ascertained despite extensive laboratory and radiologic examinations. What would you do if . . . 1. The patient presented with recurrent constipation for which previous evaluations have been done and were unremarkable? 2. The same patient presented 6 months later with constipation, lethargy, and new-onset bradycardia? Answers 1. Do a focused history and physical exam, and have the patient return for close follow-up. Recommend exercise, stress management, and an appropriate bowel regimen. 2. Check the thyroid-stimulating hormone blood level. (Even patients with somatization disorder can develop hypothyroidism.) I Approach Somatization disorder is one of the somatoform disorders, along with hypochondriasis, conversion disorder, pain disorder, and body dysmorphic disorder, as categorized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The diagnostic criteria for somatization disorder are complex and will not be listed here. However, they include a history of physical complaints related to multiple organ systems, over a several-year period, for which no medical explanation can be found after appropriate investigation. Onset of symptoms occurs before age 30. Note that patients seen in primary care offices often present below the threshold criteria for diagnosis. Somatization disorder causes significant occupational and social impairment. These patients may have coexisting anxiety and depressive disorders—in addition to drug and alcohol use—that complicate the diagnosis. The disorder may be difficult to distinguish from functional disorders such as fibromyalgia, chronic fatigue syndrome, and irritable bowel syndrome. Patients with somatization disorder consume significant medical resources and make demands on the physician’s time. They often are resistant to the suggestion that there may be a psychological or social basis for their symptoms. tom management and treatment of coexisting depression or anxiety. The keys to management include • A committed, empathetic physician • Frequent, brief, regularly scheduled visits (q24wk, depending on the patient) • Focused physical exams and diagnostic evaluations • Avoidance of repetitive diagnostic workups. Physicians should avoid suggesting that there is nothing wrong with the patient or that “it’s all in the patient’s head.” The goal should be to help these patients cope with their symptoms, rather than cure them. If patients are open to psychotherapeutic interventions (most are not), consider stress management programs or cognitive behavioral therapies. DEAN G. GIANAKOS, MD Contributing Editor Associate Professor of Clinical Family Medicine, University of Virginia; Associate Director, Lynchburg Family Medicine Residency, Lynchburg, Va; and a member of the Patient Care Board of Editors. I Management Somatization disorder is a difficult one to treat. Medications are rarely successful except for symp- NOVEMBER 2007 PATIENT CARE NEUROLOGY & PSYCHIATRY 9

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Patient Care Neurology & Psychiatry - November 2007 Contents Research Digest Medicine in the News The 15-Minute Visit Dementia workup and treatment: Do the drugs really work? Help for Your Patients Who Suffer from Specific Phobias Clinical Clips Case & Comment The Science of Healing Classified Advertising

Patient Care Neurology & Psychiatry - November 2007

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