somatic sx disorder

Antidepressants — For patients with treatment-resistant somatic symptom disorder, plus prominent symptoms of anxiety disorders, depressive disorders, or OCD (eg, charting bowel movements), we suggest add-on treatment with antidepressants, based upon randomized trials in patients with somatoform disorders and medically unexplained symptoms [30,31]. However, adding a medication may exacerbate somatic symptom disorder by causing adverse effects (ie, other somatic symptoms) that become another source of complaint and concern.

 

Reasonable antidepressant options for somatic symptom disorder include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors, and low-dose tricyclics (table 5). Antidepressants should be initiated at low doses and increased slowly as tolerated to achieve a therapeutic dose, because the somatic sensitivity and health anxiety in patients create a low threshold for perceiving side effects. In patients who are reluctant to try an antidepressant because of a general sensitivity to side effects, clinicians should start with the lowest possible dose. As an example, clinicians can prescribe citalopram or nortriptyline 10 mg/day, or duloxetine 20 mg/day, for the first week and then titrate the dose every four weeks as needed and tolerated.

 

Indirect evidence supporting the use of antidepressants for somatic symptom disorder includes systematic reviews of randomized trials in which antidepressant medication was prescribed for somatoform disorders and medically unexplained symptoms [30-32]. Examples include the following:

 

●A 1999 meta-analysis of 94 randomized trials (n >6500 patients) compared antidepressants (primarily tricyclics) with placebo and found a large benefit for treating unexplained symptoms and unexplained symptom syndromes [33]:

 

•Improvement occurred more than three times as often with antidepressants than placebo (odds ratio 3.4, 95% CI 2.6-4.5).

 

•The number needed to treat was three (ie, treatment of approximately three patients with antidepressants yielded a beneficial response in one additional patient that would not have occurred with placebo).

 

●In a 2014 systematic review that included several meta-analyses of randomized trials, the primary findings included the following [14,34]:

 

•A meta-analysis of three trials (n = 243 patients), lasting 8 or 12 weeks, compared second-generation antidepressants (escitalopram, fluoxetine, or venlafaxine) with placebo and found that improvement of somatoform disorders was greater with antidepressants, and the clinical effect was large. In addition, improvement of depressive symptoms and functioning was greater with antidepressants, and discontinuation of treatment due to adverse effects was comparable for antidepressants and placebo.

 

•A meta-analysis of three trials (n = 177) found that improvement of somatoform disorders was comparable for second-generation antidepressants and tricyclics.

 

•A meta-analysis of two trials (n = 107) compared SSRIs alone (citalopram or paroxetine) with SSRIs plus antipsychotics (paliperidone or quetiapine), and found that improvement of somatoform disorders was greater with combination treatment, and the clinical benefit was large. In addition, discontinuation of treatment due to adverse effects was comparable for the two groups.

 

●A subsequent 10-week randomized trial compared imipramine with placebo in 120 patients with somatic symptoms that involved multiple organ systems, caused distress or substantial disability, and lasted at least two years [35]. Patients with comorbid anxiety disorders or depressive disorders were excluded. Imipramine was started at 10 mg/day for one week and then titrated to 25 to 75 mg/day. Improvement occurred in more patients who received imipramine than placebo (53 versus 25 percent). Although moderate or severe adverse events occurred more often with imipramine than placebo (55 versus 20 percent of patients), discontinuation of treatment due to adverse events was comparable for the two groups (6 and 5 percent). The most common side effects of any intensity with imipramine were dry mouth, dizziness, nausea, diaphoresis, sleep disturbances, and constipation.

 

One of the most common physical symptoms in somatic symptom disorder is pain, and antidepressants are an established treatment for chronic non-cancer pain.

 

Treatment-refractory patients — For treatment-refractory patients with somatic symptom disorder who do not respond satisfactorily to initial treatment, as well as next step interventions for treatment-resistant patients, we suggest that primary care clinicians continue initial treatment and in addition, refer the patient to a psychiatrist or other mental health clinician experienced in diagnosing and treating somatic symptom disorder. Ideally, the consultant is the same psychiatrist with whom the primary care clinician discussed the case. (See 'Treatment-resistant patients' above.)

 

Many patients balk at seeing a psychiatrist, and because of the referral, may feel that the primary care clinician does not understand them [11]. The clinician should offer the referral in such a way that the patient does not feel stigmatized or dismissed (see 'Approach to the patient' above). The willingness of patients to accept a psychiatric referral will likely depend in part upon their conviction that the primary care clinician will not abandon them. It can be helpful to tell patients, “I will continue to be your doctor, but I can do a better job with input from a colleague.” In addition, patients may be more inclined to accept referrals if they are told that the psychiatrist has experience in treating somatic symptom disorder and that the referral does not mean that the patient is “crazy.”

 

Although many patients with somatic symptom disorder are reluctant to accept a psychiatric referral, even a single (first) visit with the consultant may be acceptable and prove useful [11]. In addition, if patients find the one-time consult helpful, they may consent to additional, ongoing treatment with the psychiatrist, including pharmacotherapy and/or psychotherapy.

 

Single consultation — The psychiatrist should attempt to accomplish several tasks during the first visit, and perhaps only interview with the patient. Some of these tasks overlap with what occurred when the case was previously discussed with the primary care clinician, but meeting directly with the patient improves the ability of the psychiatrist to complete the tasks, which include the following:

 

●Verify the diagnosis of somatic symptom disorder

 

●Review the use and outcome of initial treatment with regularly scheduled visits, as well as next step treatments (see 'Initial treatment' above and 'Treatment-resistant patients' above)

 

●Assess the patient for comorbid psychopathology (eg, anxiety disorders and depressive disorders) and for psychosocial problems

 

●Discuss the nature of the relationship between the patient and primary care clinician and explore problems that the patient may hesitate to divulge directly to the primary care clinician

 

Following the visit, the consultation note (letter) to the primary care clinician includes the primary diagnosis, any secondary diagnoses, and treatment recommendations as warranted. As an example, the recommendations may include changes in how the primary care clinician is conducting the regularly scheduled visits or administering antidepressants.

 

Indirect evidence suggests that even a one-time consultation can improve outcomes. A systematic review of six randomized trials (total n = 449 patients with somatization) compared usual care with a one-time consult, and found that the consult reduced the severity of somatic symptoms, improved physical and social functioning, and decreased medical costs [36].

 

 

 

COMORBID PSYCHOPATHOLOGYMajor depression or panic disorder are commonly comorbid in patients with somatic symptom disorder and should be treated as they would when occurring separately. Somatic symptoms and related abnormal thoughts, feelings, and behaviors are likely improve when the comorbid disorder is treated with appropriate pharmacotherapy [56]. (See "Management of panic disorder with or without agoraphobia in adults" and "Unipolar major depression in adults: Choosing initial treatment".)