Medical Care

Emergency department care: Somatoform disorders may present to the emergency room for assessment and treatment during periods of acute increase in symptom severity. Electroconvulsive therapy is not effective for somatoform disorders, but it may successfully treat depression occurring in the context of a somatoform disorder. Obtain necessary studies to rule out physical causes such as myocardial infarction or appendicitis. Intravenous or oral acute sedation with benzodiazepines may be used. Avoid long-term benzodiazepines for somatoform disorders. Avoid acute or long-term narcotic analgesics for somatoform disorders. Treatment of conversion disorder in the emergency department: Conversion disorder may be interpreted by the patient and family as a sign of an acute and potentially catastrophic medical condition. ED personnel should quickly rule out potential life-threatening, disabling, or treatable causes for the symptoms. Emotional support should be provided to patient's family members. Early consultation with a psychiatrist may limit unnecessary medical or surgical interventions. Referral to psychiatrist may be prefaced by stating that the cause for the medical symptoms have not been found and that in similar cases, assessment of the role of stress by a medical psychiatrist may be helpful in reducing the discomfort experienced by the patient. Psychosocial interventions (primary care management) Randomized trials have demonstrated the value of physician education in the management of the patient with somatization.[8, 9] Cognitive-behavioral psychotherapy strategies may be specifically helpful in reducing distress and high medical use. Psychosocial interventions directed by physicians form the basis for successful treatment. A strong relationship between the patient and the primary care physician can assist in long-term management. Psychoeducation can be helpful by letting the patient know that physical symptoms may be exacerbated by anxiety or other emotional problems. However, be careful because patients are likely to resist suggestions that their condition is due to emotional rather than physical problems. The primary care physician should inform the patient that the symptoms do not appear to be due to a life-threatening, disabling, medical condition and should schedule regular visits for reassessment and reinforcement of the lacking severity of ongoing symptoms. Psychosocial interventions for specific somatoform disorders Somatization disorder: Patients may resist suggestions for individual or group psychotherapy because they view their illness as a medical problem. Patients who accept psychotherapy may be able to reduce health care utilization. Psychosocial interventions that focus on maintaining social and occupational function despite chronic medical symptoms may be helpful. Conversion disorder: Limited studies about specific psychotherapy exist for conversion disorder. Behavior therapy or hypnosis may be effective. Symptoms often resolve spontaneously. Hypochondriasis: Physicians should attempt to answer questions and reduce the patient's fear of a specific illness. Group psychotherapy may provide social support and reduce anxiety. Cognitive therapy strategies may help by focussing on distorted disease-related cognitions. Individual insight-oriented psychotherapy has not been proven effective. Pain disorder: Behavior therapy, including biofeedback, can be helpful. Hypnosis also may be considered for chronic pain syndromes. Some outcome data supports the effectiveness of individual psychotherapy. Exploration of interpersonal effects of chronic pain may reduce social complications of pain. Cognitive-behavioral therapy: Recent studies have shown that cognitive-behavioral therapy reduces depressive symptoms in people with somatic diseases. In particular, this type of therapy is especially effective for patients who fit the criteria for a depressive disorder. Cognitive-behavioral therapy was superior to control conditions, with even greater effects to groups restricted to participants with depressive disorder.[10]

Medication Summary
Somatization disorder: For people with somatization disorder, medication approaches rarely are successful. Physicians should search for evidence of psychiatric comorbidity, such as depression or

an anxiety disorder. If present, medication interventions specific to the diagnosis can be attempted. Successful treatment of a major depression or an anxiety disorder, such as panic disorder, also may produce significant reduction in somatization disorder. A recent clinical trial in China found a combination of the serotonin reuptake inhibitors (SSRI) citalopram with the atypical antidepressant paliperidone to be more effective than citalopram alone for the treatment of a group of mixed group of somatoform disorder subjects.[11] Nonmedication strategies are the most successful. See psychosocial treatment in Medical Care for more details. Hypochondriasis: Hypochondriasis may be a feature of a mood or anxiety disorder. Pharmacologic treatment of the mood or anxiety disorder may reduce hypochondriacal symptoms. If a mood or anxiety disorder is present, see Medical Care. Group psychotherapy is very effective in a medical setting. Conversion disorder: No specific pharmacological interventions have been shown to be effective for conversion disorder. Pain disorder: Analgesic therapy often is ineffective for somatoform disorders characterized a pain disorder. Tricyclic antidepressants and SSRIs may be helpful. Body dysmorphic disorder: Randomized controlled trials demonstrate that selective serotonin reuptake inhibitors reduce symptoms in as many as one half of individuals with body dysmorphic disorders. Case reports have suggested improvement with other agents, including monoamine oxidase inhibitors, tricyclic antidepressants, and the pimozide (an antipsychotic).

Antidepressants
Class Summary Imipramine is a tricyclic antidepressant that has demonstrated clear superiority over the placebo in double-blind trials for treating specific symptoms of bulimia nervosa. However, SSRIs (eg, fluoxetine) probably should be first-line agents. SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder. Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population. In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive riskbenefit ratio in the treatment of depressive illness in patients younger than 18 years. In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment. Imipramine (Tofranil) Inhibits reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT), at presynaptic neuron. One of the oldest agents available for the treatment of depression and has established efficacy in the treatment of panic disorder. Geriatric and adolescent patients may need lower dosing or slower titration. Fluoxetine (Prozac) Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.