Management Algorithm for Somatization

Kroenke's algorithm can lead to a medical explanation, an antidepressant-responsive condition, or presumptive evidence of chronic somatization. Primary care clinicians can use the following guidelines when dealing with patients who present with symptoms (Kroenke, 2002):

• In the patient with chronic somatization, the physician should follow the guidelines offered in Smith's consultation letter (see next section).

• Many somatic patients have sustained serious abuse. The physician should inquire about abuse, and in most cases offer a referral to a skilled mental health professional.

• Antidepressants may be effective against some forms of somatization. Further study is needed.

• Cognitive-behavioral therapy, group psychotherapy, and short-term dynamic psychotherapy are effective for somatic patients. If available, such therapy should be offered.

• St. John's wort has been shown to be effective against somatoform disorders.

• Massage therapy may be effective for somatic pain syndromes.

When dealing with potential somatization, the clinician can never become complacent and assume without further inquiry that any given symptom is somatoform. If the symptom is not medically explained, a focused history and physical examination are warranted, and if there are physical abnormalities, additional laboratory work may be indicated. Some symptoms suggest conditions that require immediate attention, such as dyspnea, crushing chest pain, syncope, severe abdominal pain, and sudden severe headache. Because many symptoms resolve spontaneously, however, the physician is often justified in deferring an extensive workup until nonthreaten-ing symptoms have time to resolve. Follow-up is preferable to workup; if symptoms persist at follow-up, the physician is justified in beginning a focused diagnostic workup.

What are the patient's specific concerns or expectations? For the one third of patients whose symptoms are neither acutely serious nor readily explainable, two patient questions are in order:

1. "Is there anything else you are worried about?" This question elicits unexpressed concerns. Patients can be concerned that their symptoms might mean something serious, or they can be concerned about a particular disease such as cancer. They might be concerned about the prognosis of the symptom, wondering whether it is advisable to take a planned vacation, or whether they are likely to miss work. They might be concerned about whether further testing is ahead.

2. "Is there anything else you have thought might be helpful?" This question is designed to elicit additional expectations. Some patients present for symptom relief, others for an explanation. Some patients want further diagnostic tests, and others expect a referral to a specialist or a mental health professional. This question helps the clinician address expectations that might not have been voiced during the discussion of specific symptoms.

The physician should ask himself or herself three additional questions:

1. Does the patient have a depressive or anxiety disorder? Most patients with somatic symptoms meet criteria for a mental diagnosis. If such a diagnosis is present, prescribing an antidepressant or other treatment known to be effective is appropriate. In addition to the benefit to the patient's overall health, it can specifically improve the symptom severity.

2. Does the patient have a syndrome known to respond to antidepressants? There is some evidence that syndromes such as fibromyalgia, irritable bowel syndrome, premenstrual syndrome, chronic pain disorders, and chronic headaches, or even recurrent migraine headaches respond to antidepressants (O'Malley et al., 1999). Thus, a trial of antidepressants is warranted in these patients.

3. Does the patient have a history of chronic somatization? The physician can answer this question affirmatively only after working through the previous questions and determining that the patient has had a number of unexplained complaints over time, or at least had a single unexplained symptom that has persisted for a long time. At this point, a number of management recommendations apply.

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