What are the recommended management strategies for patients with somatisation disorder in primary care?

For patients presenting with somatisation disorder in primary care, management strategies focus on comprehensive assessment, effective communication, and a stepped-care approach to interventions.

Recognition and Assessment

Healthcare professionals should be alert to possible anxiety disorders in individuals presenting with somatic symptoms or those frequently attending primary care seeking reassurance about such symptoms NICE CG113. It is important to consider if some symptoms may be due to Generalized Anxiety Disorder (GAD) when a person seeks reassurance about chronic physical health problems or somatic symptoms NICE CG113. A comprehensive assessment should not solely rely on symptom number, severity, and duration, but also consider the degree of distress and functional impairment NICE CG113. Clinicians are expected to have a high standard of consultation skills to take a structured approach to diagnosis and management NICE CG113. The diagnostic process should gather relevant information including personal history, self-medication, and cultural or individual characteristics NICE CG113. Identifying and communicating the diagnosis of GAD early can help patients understand the disorder and initiate effective treatment promptly NICE CG113. Experts emphasize that a good doctor-patient relationship and strong communication skills are crucial for managing medically unexplained symptoms (MUS) in primary care (Heijmans et al. 2011).

Communication Strategies

A key strategy for managing somatic preoccupation involves acknowledging the patient's symptoms and suffering, thereby validating their experience (Righter & Sansone 1999). It is generally advisable to avoid directly confronting the patient about the psychological origin of their symptoms, as this approach can be counterproductive (Righter & Sansone 1999). Instead, the focus should be on functional improvement and developing coping strategies, rather than solely on symptom eradication (Righter & Sansone 1999). Consultation letters for MUS in primary care should include a clear diagnosis, a management plan, and incorporate the patient's perspective (Hoedeman et al. 2010).

Primary Care Interventions (Stepped Care Approach)

Following a stepped-care model, initial interventions in primary care for conditions like panic disorder (which can present with somatic symptoms) include offering or referring for low-intensity interventions such as individual non-facilitated or facilitated self-help NICE CG113. Information about support groups should also be offered where available NICE CG113. The benefits of exercise as part of general health should be discussed NICE CG113. Where available, consideration should be given to providing psychotherapies in the person's own language if this is not English NICE CG113.

Psychological Interventions

For patients with conditions like Irritable Bowel Syndrome (IBS) who do not respond to pharmacological treatments after 12 months and have a continuing symptom profile, referral for psychological interventions such as Cognitive Behavioural Therapy (CBT), hypnotherapy, and/or psychological therapy should be considered NICE CG61. CBT is also a high-intensity psychological intervention option for GAD when low-intensity interventions are insufficient NICE CG113. Experts also highlight the importance of psychological interventions, including CBT, for medically unexplained symptoms (Heijmans et al. 2011).

Pharmacological Considerations

For conditions like IBS, Tricyclic Antidepressants (TCAs) may be considered, starting at a low dose (e.g., 5mg to 10mg equivalent of amitriptyline) once at night, with regular review and dose increases if needed, typically not exceeding 30mg NICE CG61. Selective Serotonin Reuptake Inhibitors (SSRIs) may be considered if TCAs are ineffective NICE CG61. It is important to note that at the time of publication (February 2015), TCAs and SSRIs did not have a UK marketing authorisation for IBS, requiring prescribers to follow professional guidance, obtain informed consent, and take full responsibility for the decision NICE CG61. When prescribing SSRIs, clinicians should be aware of potential drug-drug interactions, such as with cocaine use, and avoid concurrent use of multiple serotonergic drugs NICE CG113.

Follow-up and Relapse Prevention

Follow-up should be agreed upon between the healthcare professional and the patient, based on the response of symptoms to interventions, and should form part of the annual patient review NICE CG61. The emergence of any 'red flag' symptoms during management and follow-up should prompt further investigation or referral to secondary care NICE CG61. For individuals at significant risk of relapse or with a history of recurrent problems, discussions should include treatments to reduce recurrence risk, considering previous treatment response, residual symptoms, discontinuation symptoms, and the person's preference NICE CG113. The choice of treatment or referral should be informed by these factors and the person's preference NICE CG113.