General approach

Somatizing patients need tactful handling. Some are reluctant to consider a psychological aspect of their condition, are on bad terms with their doctors (the term 'heartsink patient' has been applied to chronic somatizers in general practice), and become angry if psychiatric referral is broached. Others welcome an opportunity to discuss the psychosocial background to their symptoms. If several health-care professionals are involved, it is important for them to cooperate with each other, to ensure a consistent policy.

A key point is that most of these disorders are to be coped with over long periods, rather than cured. The vast majority will be cared for by the primary health-care team. A GP who has known a patient for many years will often be able to identify lifelong hypochondriacal tendencies, and so contain an increase in symptoms and consultations at times of stress without needless interventions.

Case example

A 27-year-old woman had been looked after by one GP throughout her life. Her parents had separated, her father being an alcoholic, and there was some suggestion that she had been sexually abused by her stepfather. She herself tended to form abusive relationships with a succession of violent males, her main outlet being frequent consultations with her doctor with bitter complaints of symptoms in a variety of body systems. Although the GP viewed her as one of her 'heartsink' patients, and never felt that she was achieving much progress, she managed to contain her with only infrequent symptomatic treatments and simple investigations.

While her usual GP was on holiday she consulted a locum, complaining of pelvic pain and in great distress. She was referred to the local gynaecologist. At the hospital, where she saw a succession of junior doctors, various medications were tried to no effect, and eventually a hysterectomy was performed. The patient then complained that her pain had actually got worse. A psychiatric referral followed, and a diagnosis of somatization disorder was made, but the patient refused to engage in any form of psychological treatment and spoke of suing the gynaecologist.

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