Unmasking patently psychologically based symptoms by tricking the patient (shouting “Fire!” in the vicinity of a “paralyzed” patient), or documenting the patient’s behavior when she does not realize she is being observed, is momentarily gratifying for medical staff but humiliating for the patient. It may force her to relinquish a symptom, at least temporarily, but she will seek care elsewhere, exacerbating her dysfunction, distrust, and demands on the health care system (173).
Patients with conversion, somatization, and hypochondriacal disorders often benefit from prescriptive behavioral regimens aimed at saving face and improving function (174). It was once believed that a patient relieved of one symptom would soon substitute another, but this assumption is not confirmed by empirical evidence. The behavioral regimen should consist of health-promoting activities relevant to the target symptoms, planned in a stepwise progression, and recommended with reasonable medical conviction and authority. For example, the patient with psychogenic difficulty swallowing could be advised to drink only clear liquids, at specified intervals, for a specified number of days, and then go on similarly to full liquids, purees, soft foods, and finally a regular diet. The patient with difficulties in the extremities can undertake an exercise regimen. The patient’s preoccupation with her symptoms can be channeled into documentation of her progress in a log that she brings to her medical appointments. The physician is not bound to peruse the entire document at each visit. If it is too long, the patient can be asked to prepare a summary. This process may enlighten both her and the physician to the relationships between her symptoms and her diet, relationships, or activities. She should be advised not to dwell on her symptoms apart from this important notation (174).
It is critical to remember that patients whose somatic symptoms result from depression, posttraumatic stress disorder and other anxiety disorders, and domestic violence frequently seek care from gynecologists. In the case of domestic violence, the gynecologist is often the only human contact the abuser allows the patient outside the domestic situation (175– 177). These possibilities must be ruled out before care is directed to symptom management.
Several medical associations have drawn attention to the need to screen women for domestic violence and the infrequency with which this is actually done. It appears that screening alone does not significantly change outcomes. Acknowledging domestic violence and finding and accessing resources are part of an often prolonged and incremental process—of which screening can be an important first step (178).
There is considerable cross-cultural variation in the extent to which feelings and psychological conﬂicts are somatized. In many Asian cultures, for example, presenting problems with feelings, behaviors, and interpersonal relationships are almost unheard of; these problems are expressed, diagnosed, and treated somatically. Conversely, some very sophisticated and psychologically informed patients in Western society may dismiss serious somatic signs and symptoms as indications of psychological conﬂict (177).
Referral Patients with somatizing disorders may resist mental health referral more adamantly than any other single class of patients (167). Focused as they are on physical symptoms, these patients can regard referral as a message that their symptoms are not being taken seriously and as a sign of contempt and rejection by the gynecologist. It is particularly useful with these patients to emphasize that distinctions between mind and body are artificial. The brain is part of the body. Our language expresses this synthesis; anxiety causes “butterﬂies in the stomach,” aggravation “gives us a headache,” and unwelcome news “gives us a heart attack.”