Multiple medication use in somatic symptom disorders: From augmentation to diminution strategies

Abstract

The diagnostic category of somatoform disorders (F45.X in the ICD-10) includes somatization disorder, undifferentiated somatoform disorder, somatoform autonomous disorder, somatoform pain disorder, hypochondriac disorder, and other somatoform disorders. The DSM-IV includes a similar category. The categories will undergo significant changes in the forthcoming editions of both classifications (ICD-11 and DSM-V). Diagnosis and treatment of the disorders require interdisciplinary approaches of somatic, psychosomatic, psychotherapeutic and psychiatric departments. Extensive exclusion of somatic illness is needed to establish the diagnoses. Non-response to somatic medication can be one factor supporting the diagnoses. The disorders result in high utilization of the health care system and in high costs. Psychotherapy is the first line treatment but unacceptable to many of the patients. Medication is a second line treatment option, more acceptable to many of the patients. There are two distinct pharmacological strategies to influence the symptoms. One is the use of somatic medication targeting symptoms in the periphery. Second is the use of psychotropic drugs with central nervous action. The chapter will outline the evidence base for psychotropic, in particular antidepressant, antiepileptic and antipsychotic medications for the treatment of somatic symptom disorders. Challenges arising with the use of psychotropic medication in somatic symptom disorders will be discussed: It is mostly initiated after non-response to somatic medication. It is frequently started in addition to somatic medications resulting in multiple medication use across medical specialties. It may require an increase of dosage and augmentation upon non-response similarly to other disease entities outlined in the more general chapters of this book. Hypochondriac ideation may cause sensitivity to adverse drug reactions and frequent changes of treatment strategies. Adverse drug reactions are hard to distinguish from the symptoms of the disorders. The evidence for efficacy of psychotropic medication is scarce in somatic symptom disorders. Pharmacological combination treatment is frequently initiated and rarely useful. After multiple frustrating diagnostic and/or therapeutic contacts with medical services, the patients often encounter doubts on the side of their therapists about the genuineness of their complaints. Holding on to multiple medications may alleviate this doubt. Strategies for systematic reduction of medication without disrespect to the feeling of genuineness of complaints seem a necessary yet difficult to achieve goal.