The initial assessment must be more than a fact-finding exercise, therefore it is important for the engagement of the patient that the necessary time is available. Because patients with somatization disorder may be inconsistent historians, it is vitally important to review the medical case notes before the interview and to gather information from other outside sources (e.g. the primary care physician and the family or close friends). The attitudes and behaviour of the family may be a crucial factor in understanding the presentation and in planning the intervention.

The purposes of the initial psychiatric contact are as follows:

1. establish the diagnosis;

2. examine whether psychiatric intervention is possible, and if so which specific management or treatment strategy is possible and the best for the patient;

3. engage the patient in therapy. (16>

A scheme for the initial assessment is given in Table,.,.

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Table 2 The initial assessment interview

The patients' possible resistance to the psychiatric contact should be addressed directly by asking patients what they have been told by the referring doctor, their reasons for coming to see the psychiatrist, and their feelings about it.

Patients often have an unrealistic expectation of what medicine can do, and they must be helped to face the limits of medicine and to acknowledge that continued medical consultations will be fruitless. The reality of the patient's illness can be acknowledged by making the distinction between 'disease' (organ pathology) and 'illness' (symptoms and handicap), and by discussing how these can occur independently of each other.(1. 38) Furthermore, it is necessary to discuss the idea that all illnesses have an emotional component and that a psychological treatment focusing on the emotional component is often helpful in reducing their suffering. In acknowledging the patient's fears of being stigmatized, it may be helpful to discuss negative public attitudes to psychiatry.

The patient's physical complaints should be reviewed in detail to make the patient feel listened to and understood.

Psychological interventions are usually impossible if the patient has recently received one of the 'unfound' symptom-focused diagnostic labels often given to these patients (e.g. fibromyalgia). However, from time to time those 'diagnoses' are usually reconsidered and the patient may then be more open to a psychological approach.(38)

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