• no longer needs to be medically unexplainable
• suffices if it's disproportionate
• pain disorder has been removed
• hypochondriasis has been removed as its pejorative

• increased sensitivity to pain
• proprioceptive acuity
• abnormality of autonomic and proprioceptive responses
• pituitary-hypothalamic axis
• e.g. imaging has shown hypoperfusion of the non-dominant hemisphere in functional GI syndromes
• TRAIL study: association of cortisol responses and clusters of functional somatic symptoms
• no clear genetics

• hx of violence, abuse, deprivations
• traits: suggestability, dramatic demeanor, flair, flamboyance
• alexithymia - associated with tendency to somatize
• learned behaviour for gain

• attention obtained from having an illness
• lack of reinforcement of nonsomatic expressions of distress
• generally higher in lower socioeconomic strata, developing countries
• in US, certain ethnic groups
• cultural factors

• The symptoms coexist with major psychiatric disorders such as

depression or panic.

• The symptoms closely follow traumatic events.
• The symptoms lead to psychological “gratification” or “secondary gain.”
• The symptoms represent predictable personality traits (coping mechanisms).
• The symptoms become persistent, join a conglomerate of other symptoms, and convey such attitudes as overuse of medical services and dissatisfaction with medical care.

• depression: pain
• anxiety: cardioresp and GI symptoms
• psychosis: somatic delusions

• Pts approach medical encounters with a mixture of magical, unrealistic expectations, pessimism, and distrust of the profession
• respect for the patient’s symptoms and an acknowledgement of their validity.
• Active, receptive listening, tolerance for repetition, and a “neutral” approach (avoiding being dismissive, confrontational, or overly reassuring)

• often "thick charts"
• keep an open mind, despite forewarnings in the medical records, and perform an independent assessment of the patient
• emphasis on psychological questioning and interpretations should be avoided at this stage
• Premature reassurance, although seemingly appropriate from the physician’s perspective, may be perceived by the patient as disinterest or dismissiveness.

• traditional practice of medicine gave high importance to bedside manner and interpersonal issues
• “to comfort,” meaning “to give strength and hope; to ease the grief or trouble; to cheer,”
• new meaning: “to reassure,” simply meaning “to assure anew; or restore to confidence.”
  • doesn't work

• many patients do not readily acknowledge or recognize “emotional” issues
• As the history taking moves along, attitudes, beliefs, and attributions should become clearer and patterns of interaction and illness behavior discernible

• "caring" than "curing"
• restraint in the use of medication
• infrequent but regular appointments (x1/mo) is preferable than random ones based on fluctuations
• clearly spelled out treatment plan
• true insight may never develop, some awareness of psychosocial stressors helps
• should continue to see primary care physician even if seeing a psychiatrist
• Therapeutic goals should be modest at first and be limited to small, attainable gains such as a decrease in medical visits, a commitment to a single primary care physician, and the avoidance of unnecessary tests and procedures.