Diagnosing somatisation in adults in the first consultation: moving beyond diagnosis by exclusion

Brett Mann and Hamish Wilson

British Journal of General Practice 2013; 63 (616): 607-608. DOI: https://doi.org/10.3399/bjgp13X674602

https://bjgp.org/content/63/616/607

FOUR SPECIFIC QUESTIONS TO ELICIT SOMATISATION

‘What was going on in your life around the time the symptom started?’

Establish relation to symptoms:  

‘Is your symptom ever related to pressure, responsibility, or relationship challenges?’

Use 'pressure' instead of  ‘stress’

This avoids negative implications such as not coping.

Times when the symptom seems to be better or goes away entirely 

Times when the symptom is more likely or always present.

The concept of ‘triggering’

'Persistent or chronic symptoms have often been caused by a stressful event or series of events and can become extremely sensitive to the minor stresses of day-to-day life, even if the triggering event has resolved. Symptoms can be generated by a mere thought crossing the mind such as contemplating a relatively minor upcoming challenge'

APPROACH TO PATIENTS WITH SOMATISATION

Empathy

Empathise with patients’ concerns and their experiences of illness. 

Expression authentic empathy: this increases trust in the provisional diagnosis.

Normalisation

Patients can be unaware that somatisation is normal. 

Explain how everyone can get physical symptoms with pressure. 'This helps patients understand that the doctor does not think they are ‘strange’ or ‘stupid’ or imagining their symptoms.'

Exculpation

pre-empt the patient’s perceptions of inadequacy or criticism. 

Example: ‘Possible connections between what is going on in your life and your symptoms do not necessarily mean you are not coping’.

This can facilitate the patient’s willingness to consider psychosocial factors.