In terms of past medical illness, you want to also explore what their childhood was like any
illnesses in childhood. Were they sickly, was anyone in their family is sickly? You want to know
about any kind of anxiety disorders or previous depressions. Have they ever been treated before
with psychiatric medications? Take a look at their past medical records and you’re looking for
any patterns of seeing a doctor frequently, any patterns of having work-ups that were actually
reassuring that showed normal results and you want to also be attuned to what kind of advice
the patient has been given before and if they followed up with care. Ask about compliance and
do a systematic evaluation of your patient. Ask about their family history for a few things to
note that you want to ask about, in addition ask about their social history so they could have
stress for any number of these reasons and you really want to explore this in a comfortable, relaxed
way with your patient where they feel non-confronted and as if you’re being non-judgmental.
During the physical exam, you should definitely screen for other medical diseases, take vital
signs, look for a baseline from your patient in terms of how they do when they’re at their best.
Doing a thorough physical exam will reassure your patient that you’re taking them seriously
and it also provides you the opportunity to screen for medical causes of their symptoms and
you should also include in your physical exam a complete neurological examination. Make sure
to get vital signs and go through the entire cranial nerve exam as well as multiple organ systems.
When everything is reassuring and you find no focal neurological or systemic deficits, you
want to be careful about doing ancillary testing especially if your review of medical records
show that this patient already had a thorough work-up with lots of expensive testing that was
all normal and reassuring. So you want to be careful not to redo or overdo things that might
not lead towards any other answers when things have been, again, reassuring up until this point.
So, you want to be a bit careful about your testing. Be attuned to the fact that even normal
lab results may not quite reassure your patient so you want to stay open and ask them what
their concerns are, what their fears are because you really want to help the patient build on
their strengths and reassure them from a point where they’re ready to hear it and also set up
a monitoring program, maybe frequent checks with the primary care doctor because this is
something that will help the patient feel listened to and as if they’re going to have followup and
somebody who’s going to be caring for them and taking their illness seriously. One of the things
a psychiatrist can do when it gets to the point that they are involved is actually named the
illness. Okay, so you don’t want to debate with the patient whether or not they’re having symptoms.
Acknowledge that they have symptoms and really name what’s happening, explain that while
there’s no evidence of a life-threatening illness, they do have described symptoms and that
you are going to be attentive to them. Patients feel better when they can actually put a name
to what they’re experiencing but sometimes a psychiatric diagnosis will serve no purpose and it
will only incite the patient and can be detrimental to their ongoing health. So patients diagnosed
with a psychiatric illness can be informed that their condition is likely treatable and you can
reassure them this way. Tell them that they may be also experiencing something comorbid like
anxiety or depression and that there are in fact ways to approach that and be prepared, though,
as a doctor that your patient might get defensive with you. So that’s a summary of the history
and evolvement of somatization and somatoform disorders. You know a little bit about diagnosis,
you know a little bit about the history and also controversies surrounding the diagnosis and
how to approach the management of your patient while being very attuned to listening to their
physical complaints and ruling out general medical conditions.