Furthermore, patients can be taught to control the experience. Some patients with headaches or GI pain may be made aware of symptoms by simply asking them to focus their attention on the respective organs. Simply explaining the cycle of misattribution, autonomic activation, and further symptom development with an in vivo demonstration can be illuminating.
Response prevention. Another behavioral technique is to cut back in small increments on actions the patient takes in response to physical symptoms and automatic thoughts. For example, a patient could take medicine and seek reassurance less frequently and avoid rubbing the affected area.
PSYCHOEDUCATION
Two psychoeducation programs for somatization behavior have been formally studied.
The Personal Health Improvement Program20—led by trained facilitators—includes classroom videos, cognitive-behavioral exercises, and home study assignments. After completing the 6-week course, 171 patients with somatization disorders reported reduced physical and psychological distress and increased function. They also visited their primary care physicians less often.
Table 3
How to effectively reassure somatizing patients
| Action | Benefit |
|---|---|
| Review records in front of patients | Demonstrates that you take complaints and histories seriously |
| Acknowledge the severity of patients’ distress | Validates subjective suffering |
| Schedule follow-up visits at regular intervals | Provides access to you and continuity of care; reduces extra phone calls and emergency visits |
| Use clear and simple language | Improves communication |
| Explain that they do not have life-threatening structural disease | Opens door to cognitive restructuring |
| Assign jobs, such as journaling 15 min/day and rounding up medical records | Builds therapeutic alliance, fosters patient responsibility, and restores patients’ sense of control |
| Identify and support the patient’s strengths | Builds self-esteem |
| Use specialty referrals sparingly | Reduces risk of further medical testing and patient anxiety while awaiting results |
Coping with Illness Anxiety21 relies on mini-lectures, demonstrations, videos, and focused group discussions. After six 2-hour sessions, 33 of 43 study patients (78%) used medical services less often and reported reduced disease conviction, consequences of bodily complaints, health anxiety, and checking and avoidance behaviors. Two psychology graduate students taught the course from a manual, with 6 to 9 patients per group.
Psychoeducation in this context relies on didactic presentations, readings, role playing, and videotaped material. The goal is to teach patients to recognize thoughts, emotions, and behaviors that lead to and result from somatic preoccupation. Patients can improve when they recognize dysfunctional behavioral patterns and learn alternate coping strategies.
Somatizing patients—with their aversion to the stigma of mental illness—may find psychoeducation particularly attractive. They can be treated as students who are being educated, rather than as patients who are being treated. Classrooms in both studies cited above were located in medical outpatient offices, not in mental health facilities.
REASSURANCE
Reassurance is a common therapeutic technique in medicine, although it is poorly understood, poorly taught, and not methodically applied. Reassurance alleviates anxiety, enables patients to endure dysphoria, encourages hope, gives insight, and enhances the doctor-patient relationship.22
Table 4
How to avoid becoming frustrated with persistent somatization
| Situation | Response |
|---|---|
| Despite patients’ urgency | Watch and wait, knowing that psychological distress has been chronic |
| Despite patients’ belief that a single pill or procedure will ‘cure’ them | Persist in ‘rehabilitative’ approach |
| Despite patients’ provocations to force you to take a dichotomous approach | Persist in using both physical and psychological explanations |
| Despite your knowledge that patients are actively maintaining their illness beliefs | Try to be patient as they attribute their misfortune to ‘fate,’ ‘bad luck,’ or ‘misfortune’ |
| Despite the fact that you have agreed to treat the patient | Realize that his or her family or culture may reinforce the ‘sick role’ as the only acceptable form of distress |
| Despite patients’ desire to discuss symptoms | Reorient them to sustaining daily function (such as parenting while tolerating fatigue) |
Whereas CBT seeks to challenge patients’ underlying beliefs and restructure their thought processes,23 reassurance can help them tolerate their dysfunctional beliefs and dissuade them from believing their health is dangerously impaired. Reassurance offers a substitute explanation of patients’ dysfunction, although this explanation is not as central or detailed as it is in CBT.
How to reassure. Patients may consider reassurance offered prematurely or by a stranger to be patronizing or dismissive. Reassurance is most effective when:
- given by a trusted person who is reliable, consistent, firm, and empathic
- the patient’s condition has been established as unresponsive to conventional diagnostics or biological therapies.
Patients are most receptive to reassurance when they express distress or frustration with their unexplained symptoms. Affirming that their suffering is legitimate opens the door to further treatment.
Reassurance is least effective when a patient is expressing anger or mistrust, although this is when the physician may feel most pressured to reassure. To successfully reassure a patient, the psychiatrist needs to:
- credibly identify with the patient’s distress
- and listen empathically (such as using body language and facial expressions that convey concern and consideration to the patient).24