Psychotherapy

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Various psychotherapies have been traditionally used to treat somatization disorder. Early clinical experience suggested that somatizing patients do not respond well to conventional insight-oriented psychotherapies (Ford 1983). Contemporary psycho-therapies, such as time-limited cognitive behavioral therapy, appear more effective than open-ended psychoanalytically oriented strategies (Kellner 1986).

Cognitive-behavioral strategies are directed toward the cognitive, affective, and behavioral components of patients' symptoms. Clinicians should discuss with patients their tendency to employ catastrophic and negative thinking when they experience physiologic reactions and should illustrate the cognitions and behaviors that occur when patients experience unpleasant sensations. To help patients understand their affective responses to such sensations, the clinician can ask them to keep a behavioral log documenting their discomfort, the activities during which they experience discomfort, their emotional reactions, and the way they cope with the sensations. Essentially, patients and clinicians should pinpoint visceral sensations, the thoughts that were elicited by the discomfort, and the context in which the discomfort occurred. This allows a transition from a disease-focused worry to a broader understanding of the psychosocial context in which the discomfort occurred and facilitates identification of thoughts that automatically arose and the cognitive distortions that occurred. This cognitive approach may be done individually or in a group setting.

Primary care clinics at the Harvard Health Plan have established brief group therapy programs specifically for somatizing patients. Some of these programs have been remarkably effective in improving function and reducing distress. The sessions (8 to 16) combine general advice on topics such as stress management, problem solving, and social skills training, with specific interventions targeted at the mechanism of amplification and the need to be sick that underlies somatization. In a study of a 6-week group cognitive-behavioral intervention (n = 171), McLeod and Budd (1997) determined that patients experienced a decrease in emotional and physical distress, an increase in functional status, and a decrease in medical services utilization up to 12 months later. An inclusion criterion was unexplained somatic complaints, although not necessarily somatization disorder per se.

Reassurance is one of the most important modalities clinicians can use. Kathol (1997) suggests six steps that are needed to effectively reassure patients with benign disease or symptoms not explained by disease: 1) question and examine the patient, 2) assure the patient that serious illness is not present, 3) suggest that the symptom will resolve, 4) tell the patient to return to normal activity, 5) consider nonspecific treatment, and 6) follow the patient.

This approach acknowledges patients' suffering and their experiences of disability. Recognizing the somatic experience allows the clinician to take a more empathetic stance. In addition, the clinician's awareness of the behavioral reinforcers he or she controls may be helpful in changing unproductive patterns of interaction. Appropriate limits must be set, but the clinician must also make it clear that he or she is accessible to the patient, for it is this accessibility, rather than technical medical intervention, that is the mainstay of the treatment.

One way to help patients with an inability to deal with or communicate emotions (alexithymia) is to use nonverbal techniques, with the goal of helping the patient recognize the relationship between life situations and bodily reactions. Nonverbal therapies such as diet, meditation, physiotherapy, relaxation techniques, biofeedback, massage, and exercise are generally accepted by patients, as long as patients do not interpret their use as meaning that the physician is rejecting or discounting their somatic experience. Empirical evidence on the efficacy of these approaches is needed.

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