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CLINICAL PRACTICE GUIDELINES
|Year : 2020
: 62 | Issue : 8 | Page
|Clinical Practice Guideline: Psychotherapies for Somatoform Disorders
Vivek Agarwal1, Anil Nischal1, Samir Kumar Praharaj2, Vikas Menon3, Sujita Kumar Kar1
1 Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh, India
2 Department of Psychiatry, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Psychiatry, JIPMER, Puducherry, India
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|Date of Submission||12-Dec-2019|
|Date of Acceptance||16-Dec-2019|
|Date of Web Publication||17-Jan-2020|
|How to cite this article:|
Agarwal V, Nischal A, Praharaj SK, Menon V, Kar SK. Clinical Practice Guideline: Psychotherapies for Somatoform Disorders. Indian J Psychiatry 2020;62, Suppl S2:263-71
| Introduction|| |
Somatoform disorders are characterized by the chronic presence of physical symptoms, which are not explained by any physical disease. All somatoform disorder subtypes share one common feature; predominance and persistence of unexplained somatic symptoms associated with significant distress and impairment. The International Classification of Diseases, 10th Revision (ICD-10) describes medically unexplained symptoms, with significant psychological distress as “somatoform disorders” [Table 1]. Patients with somatoform disorders often consult multiple physicians/specialists. Limited understanding of the somatoform disorder and its management among general physicians often results in repeated unnecessary investigations and polypharmacy.
This guideline focuses on the evidence-based psychotherapeutic interventions used for the management of somatoform disorders. It will help clinicians and mental health professionals understand the relevance of psychotherapy in the management of somatoform disorders in adults and in adopting various psychotherapeutic modalities in their clinical practice. The guideline for the management of somatoform disorders in children and adolescents has been published separately.
| Assessment|| |
A thorough pretherapy assessment is the cornerstone of any psychotherapy for the somatoform disorder. This includes a detailed description of symptoms, patterns and severity, distress associated, and the effect on functioning [Table 2].
| Assessment of Biopsychosocial Factors|| |
Multiple factors play a role in the development and persistence of symptoms of the somatoform disorder [Table 3]. Identifying and addressing them during the therapy is important. Certain personality characteristics of an individual increase his/her vulnerability for the somatoform disorder. The presence of stress often acts as a predisposing, precipitating as well as perpetuating factor in the development and maintenance of somatoform disorder. Medical and psychiatric comorbidities may lead to the persistence of features of somatoform disorder. The assessment should also focus on identifying the strengths of the individual (the presence of psychosocial support, having a job, and nonsubstance user) and strengthening them further during the therapy process.
| Structured Assessments for Somatoform Disorder|| |
In addition to clinical assessment, subjective and objective rating tools may be used to assess the severity of somatoform disorder at baseline and to monitor the improvement in symptoms with therapy. The commonly used instruments are summarized in [Table 4].
| Formulating a Management Plan for Psychotherapy in Somatoform Disorders|| |
Over the last decade or so, the evidence base for psychotherapies in somatoform disorders has grown significantly. This has contributed greatly to our understanding of what works and what does not in this group of patients. A Cochrane review showed only modest benefits for nonpharmacological interventions, including cognitive-behavior therapy in somatoform disorders. Analyzing these findings, Schroder and colleagues conclude that illness severity, quality and quantity of psychological treatment are important moderators of treatment efficacy. With this in mind, clinicians should note the following general and specific considerations in formulating a treatment plan.
The medications being given for physical as well as psychiatric problems should be continued in liaison with respective physicians. For any new symptoms, the opinion of specialists should be sought.
| Basic Strategies|| |
The basic principles in the management of somatoform disorders can be divided into physician-centered and patient-centered strategies, regardless of their specific diagnosis [Table 5].
| Specific Treatments|| |
Most of the patients benefit from the general measures that have been outlined above. In addition, simple techniques as listed [Table 6] can be used in settings where limited time is available for consultation. If these techniques are not effective, patients may be considered for more specific and intensive psychotherapy.
Various forms of psychotherapy have been recommended for somatoform disorder. Evidence supports the role of cognitive behavior therapy (CBT), mindfulness-based interventions, acceptance and commitment therapy, and relaxation therapy in the management of individual subtypes of somatoform disorders [Table 7]. There are specific forms of psychotherapy described for specific somatoform autonomic dysfunction, for example, gut-directed psychotherapy for patients with irritable bowel syndrome. Patients, who are considered for psychotherapy, need to be assessed for suitability for psychotherapy. The level of evidence for various psychotherapeutic interventions for somatoform disorder has been mentioned in [Table 8].
|Table 7: Evidence-based psychotherapies in individual somatoform disorders|
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The assessment of suitability for specific psychotherapy
Suitability assessment aims at evaluating the factors that decide whether a patient with somatoform disorder is suitable for psychotherapy. Suitability determines the outcome of therapy. The factors can be divided into patient-, illness- and therapist-related factors [Figure 1].
CBT is one of the most evidence-based therapies for patients with somatoform disorder. Patients who are planned for CBT need to be assessed for the cognitive errors (distortions), severity, and nature of distress the individual is experiencing, the maladaptive behavioral patterns (avoidance behavior) along with the sociooccupational and interpersonal impairments. The assessment of several other psychological factors that might be useful from the psychotherapy point of view are – attribution style, coping skills, and perceived stress.
The assessment for psychotherapy in somatoform disorders is not limited to pretherapy assessment. The clinician/therapist needs to evaluate the progress of therapy by serially assessing the improvement during the course of therapy. The therapist needs to assess the client's adherence to therapy, factors that hinder the adherence to tasks assigned during the therapy sessions, any ongoing stressor as well as client's attitude toward therapy. The success of psychotherapy depends a lot on individual responsibility; hence, during therapy, it needs to be assessed and reinforced regularly. The competence of the therapist and compliance of the client determine the outcome of the therapy.
| Choice of Treatment Setting|| |
By and large, most patients with somatoform disorders are treated in the outpatient setting using strategies outlined in the previous section. However, there may be exceptional situations in which one may consider inpatient care for different subtypes of somatoform disorder [Box 1].
Admission is usually time-limited, and once the necessary evaluation or symptom removal is done, it is advisable to discharge the patient and continue further treatment on outpatient basis as prolonged admission may foster the sick role and contribute to chronicity of symptoms.,
| Avoiding Dependence|| |
During psychotherapy, the therapist needs to evaluate the client for evidence of the development of dependence on therapist. Transference may be a reason for the development of dependence. [Box 2] provides an indicative list of situations where dependence on therapist may be suspected.
Early identification of dependence on therapist and timely intervention is essential to achieve the desired outcome of therapy. Carefully setting the agenda, adhering to the agenda, preparing the client to deal with psychological conflicts, spacing the sessions as the therapy progresses, and periodically evaluating for therapeutic dependence will help prevent it. Identifying the development of dependence, discussing the dependency issues with the client during the therapy sessions, working on the self-esteem of the client as well as the psychodynamics of dependence is an integral part of the therapy process.
| Terminating Treatment|| |
Evidence supports that nearly one-fourth of the patients undergoing psychotherapy report improvement after single session, and nearly half of the patients report improvement by the end of eight sessions.
There is no general consensus on “when to stop psychotherapy in somatoform disorder?” Conventionally, patients require 10–20 sessions of therapy. However, some patients may need more sessions. The therapy can be stopped, when:
- There is a substantial improvement of the symptoms
- There is serious transference or counter-transference (may be shifted to another therapist)
- There is no improvement or little improvement despite therapy (with adequate adherence to therapy, and even after evaluating and addressing factors that might contribute to nonresponse)
- The patient is not willing to continue therapy further (as it is a collaborative process).
| Maintenance and Follow-Up in Somatoform Disorders|| |
Follow-up visits should follow a predetermined schedule and should not be symptom contingent. There is no ideal frequency of follow-up that suits or fits all patients. The visit interval differs for individual patients. The goal is to find the right frequency that avoids the need for emergency visits or out of turn physical or telephonic appointments. Crisis calls must be handled supportively, yet firmly. As far as a possible therapist should try to adhere to the follow-up schedule already agreed on. In most cases, a reasonable schedule for stable patients would be one visit every 1 or 2 months. This schedule can be further tapered for those with good recovery.
The focus during follow-up visits is always to encourage functioning and coping. Early detection and treatment may limit functional impairment and improve prognosis in somatoform disorders.
| Additional Considerations During Follow-Up|| |
- Ongoing patient and family education about symptoms and their changing nature may be necessary to allay concerns and facilitate return to normal routines and functioning
- The family members must be educated to spend time with and pay attention to the patient even on symptom-free days so that the secondary gain from the symptoms is reduced
- The patient should be educated that minor variations in symptoms are common and need not be attributed to any “new pathology” in the body. If any stressor is anticipated following return to home or work, plans to address them should be chalked out in advance
- Any fresh symptom in follow-up must be discussed with the primary care provider. The temptation to discuss with family and assign “seriousness” labels must be strictly avoided
- Family members can make use of distraction techniques (such as taking the patient out for a walk or a movie) to reduce the focus on bodily symptoms
- The therapist must be particularly vigilant against the possibility of a continued sick role or adoption of a “dependent” lifestyle on the part of the patient. Periodic assessment for psychiatric comorbidities such as depression, anxiety, and suicidal ideation should be carried out.
| Stepped Care Model|| |
A hierarchical symptom intensity-based approach has been described for the management of somatoform disorders. Essentially, a stepped care model, it advises initial basic care along with watchful waiting and follow-up for mild symptoms while simultaneously recognizing that more intensive, specialist driven psychotherapeutic approaches may be required in addition to basic care for more severe presentations. The distinction between mild, moderate, and severe symptom intensity is essentially based on clinician judgment which takes into account somatic and psychological extent of symptoms, loss of sociooccupational functioning, dysfunctional expectations, and abnormal illness behavior. The salient features of this stepped care model are shown in [Figure 2].
|Figure 2: Hierarchical stepped care model for the management of functional somatic syndromes|
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| Conclusions|| |
The somatoform disorder includes a range of conditions, spanning from single unexplained symptom to polysymptomatic form, involving one organ system to multiple systems, and of varying severity levels. Approach to somatoform disorder includes a thorough assessment and use of simple psychotherapeutic techniques in most cases. A close liaison with other professionals is important to maintain the continuity of treatment. Few patients will require specific psychotherapy techniques and follow-up for a longer term to achieve adequate control of symptoms.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Vivek Agarwal
Department of Psychiatry, King George Medical College, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]