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Treatment of Somatoform Disorders in Western Medical Tradition

CHAPTER TWO LITERATURE REVIEW

2.5 Somatoform Disorder

2.5.3 Treatment of Somatoform Disorders in Western Medical Tradition

It would seem like the difficulties healthcare practitioners are facing in their attempts to understand somatoform disorders will keep them away from trying to treat somatoform disorders. On the contrary, efforts have been made to manage and treat these conditions, even though it is difficult to clearly state the causes.

Scholars have embarked on a number of treatment procedures and the levels of success achieved give some hope. All the trials so far are based on the speculation that somatoform disorder can be linked to one of the methods of interpreting it; that is, psychosomatic, biomedical or social problems. No attempt has been

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made to view and treat it from a traditional or cultural perspective, even though culture and belief systems are not excluded from possible causes of somatoform disorders.

Psychotherapy: Even though there have been scepticism about the effectiveness of psychotherapy for somatoform disorder, some controlled studies have been reported which indicated possible restoration of a sense of well-being in somatising patients in comparison with no treatment (Kellner, 1986).

Chappell and Stevenson (1936) reported some level of success in the first known controlled study of psychotherapy with patients having psychosomatic disorder. Draspa (1959) did another control study of Psychotherapy in the treatment of functional somatic symptoms. This result indicated that the control group recovered twice as long as those in the experimental group. The same level of success was observed when Svedlund et. al. (1983) studied patients with irritable bowel syndrome without any demonstrable organic disease. The study showed that in a 16-month follow-up, psychotherapy had help in the recovery process.

Behavioural Therapy: There have been attempts to consider somatoform disorder from the point of view of behavioural conditions and not strictly as a psychological or a medical condition that requires the attention of healthcare givers. Looper and Kirmayer (2002) evaluated the attempts to treat patients with somatoform disorder using a Cognitive Behavioural Therapy (CBT). These attempts show considerable progress in establishing the efficacy of CBT for the treatment of somatoform disorders. These CBT interventions produced moderate to large magnitudes of effect. Given the lack of effective medication for most of these conditions, Looper and Kirmayer (2002) held that CBT should be considered the first line treatment for somatoform disorders.

Rief et. al. (2004) also noted that CBT helps patients suffering from somatoform disorder because of the belief that somatoform disorders are caused by the way people relate to their illness. It is believed that a patient‘s condition makes him/her begin to feel or imagine other symptom that are not diagnosable. It is held that, the way people think about and interpret their illness, creates other somatic symptoms in the healthcare-seeking individual, thereby bringing about disability and coping behavior. This approach is used to interpret common somatic symptoms, such as abdominal pain, back pain, chest pain, or headache which have been classified as key features of somatoform disorders in DSM-IV.

In line with Looper and Kirmayer (2002), Rief et. al. (2004) and Kroenke (2007) considered somatoform disorders to be among the most prevalent disorders that ―allow one strong and several tentative conclusions regarding the efficacy of treatment for somatoform disorders. He noted that CBT is consistently effective (11 of 13 trials) across a spectrum of somatoform disorders... A variety of other treatments have been evaluated for which the results have been either negative or inconclusive‖ (Kroenke, 2007:886).

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Inpatient Treatment: This is a form of treatment programme that ―stresses social reinforcement and avoidance of occupational activities in the development of somatisation and care-eliciting interpersonal behaviours. The programme involves the patient in his or her own care, and includes (a) behavior modification techniques to reduce symptoms; (b) social skills training, and (c) family therapy‖ (Eze, 1993:100). This is closely knit with behavioural therapies.

Pharmacologic Strategies: Pharmacology has not enjoyed total support. Hans-Peter Volz,t et. al. (2000) observed that some attempts at behavioural therapy yielded some positive results in the care and treatment of somatoform disorders. But this success story is not so evident in pharmacological treatment. This does not rule out the fact that there have been some trials of pharmacological treatments.

A trial of Opipramol, a psychopharmacon widely prescribed in Germany, showed the drug‘s effectiveness in anxiety states alongside somatic complaints. Given the success, they tried the efficacy of Opipramol in somatoform disorders, using adequate clinical trial methods. For this trial, researchers adopted a multicentre, randomised, 6-week, placebo-controlled clinical trial in a total of 200 patients suffering from somatoform disorders according to ICD-10.

In the main outcome criterion, the somatic sub-score of the Hamilton Anxiety Scale, and in nearly all other outcome criteria Opipramol (200 mg/day), was statistically more effective than placebo. A similar number of adverse events were noted in both groups. The results of this first-placebo-controlled study in somatoform disorders suggest efficacy of opipramol in this indication but need replication (Hans-Peter Volz et. al. 2000). The conclusions of this trial were not popular because the effect was noticed only in somatic sub-score and there were other adverse effects noticed in patients.

Fallon (2004) noted that there has been a resurgence of hope in the possibility of pharmacologic strategies in helping patients with somatoform disorders. This hope however is not to be overblown as the success rate is just in some aspects of somatoform disorders and there is an increase need for additional research to investigate the efficacy of novel pharmacologic strategies for patients with illness fears and unexplained bodily sensations.

Fallon (2004) observed that:

Pharmacotherapy with serotonin-reuptake inhibitors appears to be

effective for patients with the obsessional cluster of somatoform

disorders… No controlled trials have been conducted on the

pharmacologic management of patients with the somatization cluster of

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somatoform disorders. This represents a major gap in the area of pharmacologic research because subsyndromal somatization syndromes are so common and contribute so much to public health expenditures (p.

455).

To buttress the partial efficacy of pharmacotherapy, Marcq and Claes (2006) reported a case of a female Nigerian refugee who presented a ―combination of paranoia and symptoms of somatoform disorder. Her symptoms were interpreted as a cultural expression of postpartum depression‖ (p. 661). This report indicated that the psychotic symptoms subsided when the patient was admitted to a psychiatric crisis unit and was given antipsychotics, but the paranoia lingered.

Scholars have also tried to investigate efficacy and safety of St. John‘s wort (SJW) LI 1602 in somatoform disorders. The trial done by Muller et. al. (2004) demonstrated the efficacy and safety of 600 mg daily of the SJW extract LI 160 in somatoform disorders, thereby confirming results from a previous study done by Volz, et. al. (2002). Again, the success of this trial was noted in only some symptoms of somatoform disorders.

Other Treatment Consideration: There have been recommendations for different strategies in dealing with somatoform disorders. Lowy (1975, 1977) suggest primary prevention. Rosen, Kleinman and Katon (1982) proposed a bio psychosocial approach whereby attention is given to both the relevant biomedical data and the psychosocial dimension (family, social, cultural and possible stressors in the patient‘s environment). These show the possibility of other forms of treatment for somatoform disorders.