Treatment for Somatic Symptom and Related Disorders
The common characteristic displayed by clients with somatic symptom and related disorders is persistent complaints about somatic symptoms (usually physical symptoms, such as back pain) for which there is no physical explanation. In other words, medical doctors are unable to link the symptoms to a physical/organic cause or abnormality. Somatic symptoms are often positive symptoms (such as an exhibited symptom–for example–pain, rather than negative symptoms, such as flat affect and avolition) (Maxem & Ward, 1995).
For example, a client with somatic symptom disorder may present with persistent inexplicable back pain. Despite having all assessments (such as MRI’s, X-rays, etc.), doctors may be unable to find a physical cause for the client’s pain. In such cases as this, psychological factors could be the source of the client’s physical pain. If psychological factors are identified as the source, then a diagnosis of somatic symptom disorder must be considered. Although doctors may tell patients with somatic symptoms that “it’s all in your head,” this does little to satisfy their complaints and may cause them to feel as if they are not being taken seriously (Maxem & Ward, 1995).
Indeed, clients with somatic symptoms disorders present significant challenges to mental health professionals. Clients with somatic symptom disorders usually seek out medical doctors for help. Many vehemently deny any possibility that psychological factors may be at play. They might even find the suggestion insulting, as if to suggest that they are mentally ill. As such, psychologists/counselors rarely find themselves sitting across from clients who have sought psychotherapy specifically for somatic symptoms. If a psychologist does find himself sitting across from a person with somatic symptoms disorder, it is usually because the client has sought counseling for other concerns, such as depression, anxiety, or addiction.
It is well know that somatic symptoms disorders are often co-morbid and may occur in conjunction with other mental disorders, such as depression, anxiety disorders, addiction, and personality disorders. Depression and anxiety disorders appear to be the most common co-occurring disorders, at a rate of 86% and 43%, respectively (Fekuda, 2014). Furthermore, to complicate things, depression and anxiety disorders often have similar symptoms to somatic disorders. This can make it difficult to distinguish such disorders from one another. The clinician must decide if the somatic symptoms are symptoms of another disorder or are the somatic symptoms the disorder in itself (Maxem & Ward, 1995).
Indeed, many clients with somatic symptoms have poor insight into the cause of their symptoms. For example, in some settings or cultures, experiencing a mental disorder may be socially taboo. In such settings, clients may express their depression or anxiety through somatic complaints. These clients would be unaware that they are doing this; that is, the physical symptoms are experienced as real and not faked by the clients (unless, of course, it is malingering) (Fekuda, 2014). It may be helpful for clinicians to view somatic complaints simply as an expression of suffering (Maxem & Ward, 1995).
As stated above, there are many disorders that may result in somatic complaints. However, recent research has found that certain types of personality/temperament traits positively correlate with somatic complaints. For example, those who are stressed easily are more likely to experience somatic symptoms (Fekuda, 2014). Due to these complexities, mental health professionals must carefully consider many factors before initiating treatment of somatic symptom disorders (Maxem & Ward, 1995).
As mentioned above, clients with somatic symptoms are far more likely to visit their general medical doctor than a psychologist or counselor. However, there are some instances in which a psychologist may find herself sitting across from an individual with somatic symptom disorder. For example, an astute doctor may make a referral, a family member may recognize the problem, or the client may seek counseling for an entirely different reason.
Unquestionably, treating somatic symptoms disorders can be tricky. The first step is to determine if the client is presenting with somatic symptom disorder. If it appears that the client is experiencing a different disorder, such as depression, of which the somatic complaints are simply a symptom, the clinician should proceed with treating that disorder (Maxem & Ward, 1995).
Interestingly, somatic symptoms disorders often respond to the same treatments designed for depression and anxiety disorders. In fact, some research conceptualizes somatic symptom disorders as a sub-type of depression (though this is not how it is conceptualized in the DSM-5) (Goldberg, 2014). Effective treatments include psychotropic medications, such as SSRI’s, SSNRI’s, and tricyclics. SSNRI’s appear especially effective for those experiencing aches and pains. Psycho-stimulants, such as Ritalin or Provigil, may be considered if the somatic complaints involve excessive fatigue. In addition, anti-anxiety medications, such as benzodiazepines, may be considered if the somatic complaints involve excessive worry. Both psycho-stimulants and anti-anxiety medications should be considered with extra caution due to their addictive nature (Goldberg, 2014).
Clients with somatic symptom disorders may be inclined to try to find a cure in the form of a pill, rather than any kind of therapy. Unfortunately, those with pain are inclined to take painkillers. Opiate painkillers should be discouraged, since they are highly addictive. If clients insist on taking some form of painkiller, they should be encouraged to take an over-the-counter medication, such as Tylenol, ibuprofen or aspirin. Other less addictive pain medications that can be obtained through prescription and are preferable to opiates include muscle relaxers and NSAID’s (such as Diclofenac). Essentially, one goal when working with clients with somatic symptom disorders is to assist them with not developing a drug addiction (Maxem & Ward, 1995).
Furthermore, clients with somatic symptoms disorder should be discouraged from “doctor shopping.” In other words, discouraged from going to multiple doctors when they are unsatisfied that their somatic complaints have not been alleviated. The concern is that clients who doctor shop may end up with multiple prescriptions to various types of medications. Needless to say, combining multiple drugs from doctors who are not consulting with one another could be hazardous to the client’s health (Maxem & Ward, 1995).
In contrast, clients should be encouraged to see one doctor for regular checkups (such as one every month or two). Ideally, the doctor should be understanding of the psychological aspects of the disorder, while at the same acknowledging that the symptoms are real to the client. Belittling statements, such as “it’s all in your head” should be avoided by the doctor. Rather than prescribing loads of medications or unnecessary tests, doctors should reassure clients that they are not suffering from a disease or a life-threatening condition. Furthermore, it is helpful for doctors to explain that some somatic symptoms are a normal part of life and that most people experience one to two “weird” body sensations per week (Maxem & Ward, 1995).
In fact, counselors and psychologists in conjunction with medical doctors should strive to normalize their clients’ somatic symptoms and assist them with reinterpreting their symptoms. Most people with somatic symptoms tend to catastrophize their symptoms and imagine the worst. Indeed, those with somatic symptom disorders are overly preoccupied with bodily sensations. Encouraging them to accept that some somatic symptoms—aches and pains, strange bodily sensations—are normal should be a key part of the treatment process (Maxem & Ward, 1995). In fact, one study indicated that nearly 75% of people experience inexplicable somatic symptoms at some point in their lives (Goldberg, 2014).
An important part of treating somatic symptom disorders is to attempt to increase clients’ openness to the possibility that psychological factors may contribute to real physical symptoms. Most people acknowledge that stress can lead to headaches and stomach ulcers. Pointing out such common examples may help clients to realize that there is clear a mind body connection. If a client becomes open to this possibility, psychologists will obviously be more successful in treatment.
Treatment for somatic symptoms disorders may include a range of therapies, including medications, psychotherapy, and psycho-education, and physiotherapy. Psychotherapy, such as CBT and MCBT, appear to be helpful in explaining the mind-body connection. In one study, 73% of clients showed improvement after CBT (McGowan, 2005). Physiotherapy may be appropriate for people with conversion disorder who have lost the use of limbs for extended periods of time, as it can ensure that muscles do not begin to atrophy (McGowan, 2005).
CBT and MCBT may be used as a way to teach clients to ignore or not overly focus on their physical symptoms. In addition, it can be used as a way of teaching them not to attach negative emotions to their symptoms, but rather accept the symptoms for what they are (just physical symptoms). Furthermore, clients should come to realize how their constant complaining or discussion of their symptoms with others may cause them to become alienated from others (since others may find their complaining annoying). If they become too socially isolated, this could lead to additional problems (such as depression). Families can assist by also ignoring the client’s symptoms and not enabling the client by encouraging the client to seek out more and more unnecessary medical treatments (Goldberg, 2014).
Alternative Treatments and Conclusion
In the case that clients are not open to mental health treatment for their somatic complaints, other alternative treatments should be considered. These treatments may include chiropractic care, acupuncture, or massage therapy. Some clients may insist on a physical cure for a disorder that they view as having a physical origin. Depending on one’s culture, other types of treatment may be considered. For example, in Japan there is an herbal medication called Kampo that is used to treat somatic complaints, usually when the main symptom is gastrointestinal complaints (Oka, 2014).
In closing, however, it is important to keep in mind that just because there is no evidence of a physical disorder, does not mean that a physical disorder does not exist. Counselors/psychologists must remain open to the possibility that perhaps science has not identified the physical source yet. In other words, just as we encourage clients to be open to the possibility that physical symptoms may be caused by psychological factors, counselors/psychologists should remain open minded to all possibilities, as well (Zoler, 2013).
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