Assessment and treatment

The majority of those presenting with unexplained symptoms in primary care require no more than medically appropriate assessment and reassurance ( Tabled). The latter should convey to the patient that the symptoms are accepted as real and provide an explanation for their origin as well as answering the patient's worries. It is also necessary to discuss the results of any negative investigations fully.

Consider psyc hcto^itil fcttori from it* cuUH

Uie jppropri.iit phpS'ii! ¡riMMtij3rjc.il exclude physical came Clarify psychological j id physical ccn- plamtí Clarify previous perianal^ and coflcwni atom physical IUjwk Uidt'¿Qri pi-.ere'; beliefs and expectations Identify depress on or other psychiatric diiOnder Identify plyihosOOai pnO&lemi

Table 4 General principles of assessment

Symptoms that are persistent or recurrent despite reassurance are generally regarded as difficult to treat. Continuing symptoms without any specific medical explanation are likely to confirm and maintain worries about serious illness, which may be further exacerbated by secondary anxiety and behavioural consequences. Therefore effective treatment depends upon sympathetic treatment that meets the needs of both the patient and the family. A multicausal view of aetiology leads to conclusions about treatment and avoids psychiatric diagnoses that may be unacceptable to the patient. Much can be done by general practitioners or non-specialists.

The general principles of treatment (Table.5) are similar for all forms of unexplained symptoms, single or multiple, but individual treatment plans must take account of psychiatric diagnoses of anxiety or depression and the particular type of physical symptoms. The specific treatments for particular forms of somatoform disorder are discussed in later chapters. The chapter on chronic fatigue is an example of a particular clinical syndrome. The treatment of irritable bowel syndrome, chronic fatigue, and atypical facial pain all depend on the therapist being familiar with these syndromes and being able to provide an appropriate combination of treatment methods. For example, the management of physical deconditioning is central to the treatment of chronic fatigue, whereas antidepressant medication has a major role in the treatment of atypical facial pain.

Émpíiajire vi a r lyrnptomj are real and fiiiniliir jud that radical tve \i appropriate Minimise arid tarird physical care Offer an explznatioti nd discuss Alkm patitnu a id frnili« :o a sit questions D¡KUB (l»e fgli cí p^holcgitaL NctflJS in all med kill Hart Treat arty primary pijchiatrk disorder Agree a ™tment jjbn

Table 5 General principles of treatment

Much can be achieved by good non-specialist care, such as the following:

• discussion and explanation of the aetiology

• treatment of any minor underlying physical problem

• anxiety management (including tapes and handouts)

• advice on diary monitoring and graded return to full activities

• specific self-help programmes (e.g. chronic fatigue, irritable bowel syndrome)

• involvement of relatives and explanation of the treatment.

However, chronic and recurrent problems may need specialist treatment:

• psychotropic medication (antidepressants, anxiolytics)

• cognitive-behavioural therapy

• interpretative psychotherapy (individual and group)

• specific psychiatric treatment for associated psychiatric and social problems

• a programme to co-ordinate and control all medical care.

There is good evidence for the effectiveness of a range of treatments in specialist care, but there is much less evidence about simple routine measures. The outlook for simpler syndromes of relatively recent onset is good, but the prognosis for very prolonged chronic, multiple, or recurrent syndromes (e.g. somatization disorder) is much less good. In these circumstances the control of medical care and the prevention of further iatrogenic disability may be more realistic than cure.

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