Somatoform Disorder (SD) is a complex condition characterized by the presence of physical symptoms without any identifiable medical cause. Individuals with SD often experience significant distress and impairment in their daily lives. In this article, we will explore the diagnosis, treatment, and management strategies for SD at different levels of care, from primary to tertiary settings.

In primary care, a detailed physical examination is crucial to rule out any underlying medical conditions. Management focuses on addressing anemia and nutritional deficiencies, while avoiding the irrational use of pain medications. Low doses of antidepressant medications, such as Amitriptyline, may be prescribed to alleviate symptoms. It is important to educate patients about the delayed onset of medication effects and validate their somatic symptoms. Engaging in routine activities, physical exercise, and relaxation techniques like deep breathing can also be beneficial.

Referral to secondary care is recommended in the following situations:

Difficulty in making a diagnosis.

Lack of improvement after four weeks of treatment with first-line medications.

Presence of comorbid medical illness.

High risk of suicide.

Coexistence of comorbid psychiatric illness.

In secondary care, a comprehensive approach is taken to manage SD. A complete history with behavioral observation is conducted, and investigations are performed to rule out any medical illnesses that may explain the symptoms. Second-line medications, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), may be prescribed. Combination therapy with multiple psychotropic medications might be necessary for individuals with a poor response to single medication. Brief counseling, psychoeducation emphasizing the relationship between stress and physical symptoms, and relaxation training are also provided.

Referral to tertiary care is recommended in the following situations:

Lack of improvement with second-line treatment.

High risk of suicide.

Requirement for intense counseling or psychotherapy.

Challenges in managing difficult patients.

At the tertiary care level, more specialized interventions are available for individuals with SD. Inpatient care may be necessary for individuals with severe symptoms. The addition of second and third-line medications, such as duloxetine, mirtazapine, and anticonvulsants, may be considered. Structured Cognitive Behavioral Therapy (CBT), cognitive restructuring, mindfulness, and acceptance-based approaches are used to address the psychological aspects of SD. Alternative medicine approaches like yoga, collaborative approaches involving physicians, neurology teams, and pain clinics, as well as vocational rehabilitation and physical therapies, are also implemented.

Somatoform Disorder presents unique challenges in diagnosis and management. Collaborative efforts between primary, secondary, and tertiary care levels are essential to provide comprehensive care for individuals with SD. By following evidence-based guidelines and utilizing a multidisciplinary approach, healthcare professionals can improve the quality of life for those living with SD.