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somatization disorder treatment guidelines

Prognosis and Treatment of Somatization Disorder

Somatization disorder is a condition with a poor prognosis. The disorder runs a fluctuating course with periodic exacerbations during stressful episodes, but as noted earlier, somatization disorder is not associated with a higher mortality rate than that of the general population. Briquet stated that hysteria was one of the most difficult illnesses to cure. He reported that one-quarter of hysterics never recover. More dramatically, young girls with hysteria before the age of 12 or 13 were condemned to a lifetime of suffering; if the onset of hysteria occurred after 25 years of age, then the prognosis was more favorable. In another study, only 31% of patients with somatization disorder fully recovered in 15-year follow-up assessments. Guze and his colleagues noted that 80 to 90% of their cases retained the diagnosis of hysteria 6 to 8 years later. Unlike other psychiatric conditions, there is no definitive therapy for all somatizers.

From a medical viewpoint, in many respects, the best treatment is no treatment at all. Medical management focuses on early diagnosis and conservative treatment to reduce iatrogenic effects from invasive diagnostics and surgical interventions. A study by Smith, Monson, and Ray  demonstrated the cost-effectiveness of noninvasive, supportive long-term care of somatization disorder patients by focusing largely on containing their health care utilization. Thirty-eight patients with somatization disorder were randomly assigned either to a treatment group (i.e., instructing primary care physicians to see patients in a supportive manner, perform brief physical examinations, and avoid unnecessary hospitalizations) or to a no-treatment control group, and the two groups crossed over 8 months later. The investigators found a 40 to 53% decrease in health care charges for the treatment condition. Much of the general discussion around treating somatization disorder is geared toward physicians in primary care, because they are most likely to see psychiatric disorders, somatizing or not.

Unfortunately, general practitioners are not equipped to handle this type of patient on their own, and somatizers often refuse psychiatric referral. Reducing the physical distance between the physician’s office and the mental health professional by relocating the mental health professional in the physician’s office or right next door does much to increase the follow-through on psychological evaluation and possible treatment. The aim of treatment for somatizers is to help them cope with their symptoms, not to cure them. Given the chronic nature of somatization disorder, a rehabilitative approach that consists of comprehensive medical, psychiatric, and psychosocial evaluation and treatment with adequate follow-up to prevent relapses is well suited to somatization disorder.

Psychiatric and psychological management typically has consisted of ego-supportive techniques and has been beneficial in treating somatizers. Several studies described the utility of inpatient and outpatient group therapy with somatization disorder. Group treatment has consisted of different combinations of therapeutic approaches with varying emphasis on support therapy, problem-solving skills, improving interpersonal relationships, occupational and vocational rehabilitation, physiotherapy, and cognitivebehavioral techniques.

However, these studies are generally descriptive instead of evaluative, they are usually uncontrolled studies with poor methodology and small sample sizes, and they tend to lack objective outcome measures. More recently, Kasher, Rost, Cohen, Anderson, and Smith  conducted a randomized controlled clinical trial of group therapy for seventy somatization disorder patients. The patients as signed to the treatment condition were required to attend eight group meetings lasting 2 hours each; these group meetings were held every 2 weeks. Groups of four to six patients were involved in a number of exercises designed to increase peer support, increase communications about coping with physical problems, develop strategies to express emotions more openly, and increase personal risk-taking. The experimental group experienced better physical and mental health in the year following group treatment. The experimental condition also resulted in a 52% net saving in health charges. Employing Kellner’s definition for somatization disorder rather than the stricter DSM-IV definition, Lidbeck assigned fifty somatization disordered subjects either to a treatment condition or to a waiting-list control condition. Using a cognitive-behavioral treatment approach (e.g., stress management, relaxation training, and cognitive restructuring), subjects met for eight, 3-hour meetings. At 6 months follow-up, the treatment group evidenced modest improvement with respect to physical illness, somatic preoccupation, hypochondriasis, and medication usage. Although these two studies of group treatment for somatization disorder  suffer from a number of threats to internal validity (e.g., small samples sizes, less restrictive definition of somatization disorder, and patients only from primary care facilities), the utility of group treatment for somatization disorder is still worth pursuing. Pharmacotherapy should be avoided whenever possible with somatizers, but judicious use of antidepressants and anxiolytics is helpful.

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