Key Feature 1: In patients with recurrent physical symptoms, diagnose somatization only after an adequate work-up to rule out any medical or psychiatric condition (ex: depression).
Skill: Clinical Reasoning
Phase: Diagnosis, Hypothesis generation
Key Feature 2: Do not assume that somatization is the cause of new or ongoing symptoms in patients previously diagnosed as somatizers. Periodically reassess the need to extend/repeat the work-up in these patients.
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis
Key Feature 3: Acknowledge the illness experience of patients who somatize, and strive to find common ground with them concerning their diagnosis and management, including investigations. This is usually a long-term project, and should be planned as such.
Skill: Patient Centered
Phase: Treatment, Follow-up
Key Feature 4: In patients who somatize, inquire about the use of and suggest therapies that may provide symptomatic relief, and/or help them cope with their symptoms (ex: with biofeedback, acupuncture, or naturopathy).
Skill: Clinical Reasoning
Phase: Treatment, History
When I was training to be a physiotherapist prior to entering medical school (I was in this for a mere 2 months, just long enough to have some exposure to medicine and light a fire in me to pursue it instead), I remember learning about a patient who was receiving physiotherapy in hospital and who was suspected by the health care team of somatization. The history of the patient's presentation was that she fell onto the floor in the kitchen, and could then no longer move her leg. Medical investigations revealed no structural or nerve damage, but she did have a history of being bullied in school, and this was the week she was about to start school at a new junior high school. I was just doing a day observing in the hospital when I learned about this adolescent's case of possible somatization, but I remember being fascinated.
The DSM 5 diagnostic criteria for Somatic Symptom Disorder are as follows:
Unlike the other DSM 5 diagnostic criteria I've been reviewing lately, surprisingly these diagnostic criteria do not include ruling out a medical condition, substance use, or another psychiatric condition that may better fit the symptomatology. However, depending on the presentation, this may be what makes the most sense. It's important to first work up the patient for their symptoms, just as any other presenting complaint. If there is no objective evidence of disease, then consider the range of psychiatric conditions that may explain or contribute to the patient's symptoms, such as active depression, anxiety, or psychosis.
This adolescent patient had never had a past history of somatization as far as I can remember the case, but it is not uncommon for clinicians to anchor a new presenting complaint as keeping with past history. One of the reasons for this is because common things are common, and new complaints that fit in with a history of a past diagnosis in a patient seem as though they are part of that same sort of disease process. Like the patient who presents with a gout flare with a history of recurrent gout flares, a suspicion of septic arthritis would be lower on the differential diagnosis. But, as we are taught in medical school, the patient absolutely cannot afford to have a missed diagnosis of septic arthritis, and this diagnosis must always be considered in an acute inflamed joint. Here I will draw the parallel with somatic symptoms. Although the complaint could in fact be recurrent somatization in a patient with a history of this diagnosis, the symptoms may also be based on real tissue pathology, and considering and reconsidering this if symptoms are not resolving is important in doing one's due diligence and trying to provide as much beneficence as is reasonable. It is also important that the patient believes you are taking their complaint seriously. And if you think they are somatizing after an appropriate medical work-up, then it is equally important to take their complaint seriously even if it is suspected somatization. Just because there is no objective evidence of pathology, it does not make it any less symptomatic for the patient experiencing the symptoms. I think if one truly believes this, providing appropriate empathic care is much more feasible.
Naturally, patients with unexplained distressing symptoms continue to seek remedies - an adaptive thing to do - and when physicians are unable to cure suffering, these patients often turn to alternative and complementary therapies. Often, these are not harmful, but may provide benefit. If a patient tries something that works, and there is little harm, great! Just because there isn't evidence to support some treatment modalities, as an extension of empathising with somatic unexplained symptoms, I think appreciating that some unexplained treatments provide relief is central to providing patient-centered care. Although clinicians should always be alert for harmful consequences, I think they should also rejoice when alternative therapies provide benefit for symptoms that Western Medicine does not cure. Creating this space of openness at the very least can help patients feel they are safe and free of judgment to share what they are engaging in for treatment, and that way if a treatment appears to be potentially harmful, clinicians can be in the know to counsel accordingly.