Appropriate treatment of somatization disorder can begin once the correct disorder has been diagnosed. However, because the etiology of this disorder is not known and no curative or ameliorative therapies have been found, a discussion of treatment necessarily focuses on management of symptoms. Although there have been few formal treatment or management studies, a broad consensus concerning appropriate management strategies exists among experienced clinicians.

Kashner et al. (1992), Rost et al. (1994), and G. R. Smith et al. (1986a) investigated cost-effective approaches to treating patients with somatization disorder in primary care settings. These researchers found that certain management strategies resulted in improvement or maintenance of a constant health status among patients with somatization disorder, decreased use of health care services, and increased patients’ satisfaction with their care: 1) making the primary care physician the patient’s primary and, if possible, only physician; 2) scheduling regular outpatient visits every 4-6 weeks; 3) making these frequent visits brief enough to fit into a busy primary care practice; and 4) conducting a partial physical examination of the organ system that is the object of the patient’s complaints during each visit.

Primary care physicians also should consider that symptoms can communicate emotional needs as well as physical disease. If they look for signs of disease rather than focus on symptoms, they can often avoid unnecessary diagnostic tests, laboratory evaluations, and diagnostic or operative procedures. Another goal of primary care management, not tested in these studies, should be to prepare some patients for referral to the mental health sector for care.

Primary Care Physician as Patient’s Only Physician
A primary element in effectively managing the patient with somatization disorder is establishing a relationship based on trust between the patient and one physician. Somatization disorder patients are constantly changing doctors, which is countertherapeutic. In my experience, the lack of a coordinated management approach frustrates both the patient and the physician, leading to a poor prognosis for the patient.

Regular Outpatient Visits
It is important to establish a schedule of regular visits with patients who have somatization disorder, particularly during the first year of seeing the patient or immediately after an acute episode. Physicians often create management problems by telling these patients that they can find nothing wrong and by suggesting that they should return if the need arises. Consequently, the patient must develop a new symptom to see the physician again. Seeing the physician is of primary importance to these patients, and physicians will create fewer problems for themselves by scheduling routine visits. By capitalizing on a patient’s desire to see a doctor, primary care physicians can actually facilitate that patient’s management.

Although the optimal amount of time between visits is not known, Kashner et al. (1992), Rost et al. (1994), and G. R. Smith et al. (1986a) all recommended an interval of 4-6 weeks, which seems clinically appropriate. Stable patients can anticipate their next visit and often save any new complaints for their next regularly scheduled appointment. However, this interval is too long during the initiation of a new doctor-patient relationship, during a relapse, or during a time of psychosocial distress. A shorter interval between visits needs to be scheduled to preclude extra visits to the office or emergency room. During such unscheduled visits, the patient presents with new symptoms that require additional diagnostic time and effort. A 1- to 2-week interval between scheduled visits may be necessary for patients to feel that they can stop initiating visits. When the patient stops initiating visits, the time between scheduled visits should not be changed for weeks or even months, and only then gradually increased. However, during the first year of management, unless the patient suggests it, the interval between scheduled visits should not exceed 6 weeks.

Physical Examination and Diagnostic Tests
For the patient who presents with a new symptom, it is important for the physician to conduct a physical examination of at least the organ system that is the object of the patient’s complaint. The examination serves two purposes: 1) it reassures the physician that no signs of organic disease are present, and 2) it is a symbolic gesture that comforts the patient. After taking a brief history of the symptom and physically examining the appropriate part of the body, the physician should reassure the patient that although nothing seriously wrong was found, the physician is nevertheless interested in both the patient and the symptom and wants to follow up the patient closely to make sure that the symptom resolves. Such reassurance teaches the patient that the relationship with the physician is ongoing and that the physician will provide care for both the patient and the symptom. The physician must communicate concern for both the patient and the symptom without suggesting that the symptom does not exist or is not substantial. Because the patient actually hurts and experiences the symptom, suggestions to the contrary not only challenge the stability of the relationship but also complicate the management of the patient.

The patient who presents with a new symptom is communicating an emotional need, saying “I hurt” or “I am in distress.” Rarely do new symptoms reported by patients with somatization disorder represent the onset of disease. When, in fact, a new symptom does represent disease, the patient’s manner tends to be qualitatively different, prompting a different approach by the physician. The physician’s vigilance in looking for signs of disease during the patient’s frequent visits usually precludes missing the true onset of new disease.

Successful management of somatization disorder also includes performing only those diagnostic procedures, laboratory tests, and surgical procedures that are clearly indicated. The physician who deliberately refrains from performing unnecessary procedures 1) contains the extraordinary health care use of these patients, 2) decreases these patients’ inordinate exposure to iatrogenic complications, and 3) reduces false-positive laboratory test findings in patients who have no real indication for the test. True-positive and true-negative responses to laboratory and diagnostic tests are based on sensitivities and specificities set by groups of patients with appropriate indications for these tests. The criteria for a positive result established for patients with appropriate indications do not apply to those without appropriate indications. Management of somatization disorder may be complicated by a positive laboratory test result that appears to relate to the symptom but is actually a false-positive result. Such a finding usually compels further unnecessary diagnostic interventions.

An important management goal is the referral of patients with somatization disorder to the mental health sector. However, the patient’s willingness to be referred usually only grows out of a long-term doctor-patient relationship. With such a relationship in place, primary care physicians may gently, yet empathetically, tell their patients that they understand the distress that the disorder must be causing and suggest that this distress might be reduced by their seeing someone who could spend more time with them. Clinical experience suggests that such an approach works with a substantial number of patients with somatization disorder, but only after the doctor-patient relationship is well established and ongoing. Patients must not conclude that the primary care physician is abandoning them; rather, the physician must be perceived as still wanting to follow up the patient and as continuing to be available.