Table 1

 The 10-step symptomatic approach to managing common psychiatric disorders19

1. Acknowledge distress: Acknowledging distress suggests that patients’ symptoms have been carefully considered, and also reflects an empathetic attitude and contributes to establishing an effective rapport and the formation of a therapeutic alliance, which are essential in facilitating improvement
2. Elicit patient’s perspective on symptoms: Providing appropriate reassurance is an important part of the medical consultation. It is most effective if based on the patient’s actual concerns. Eliciting such explanations will also allow for focused examination, investigations and specific reassurance
3. Focused history, physical examination and laboratory investigations: This will go a long way in reassuring the patient that medical causes have not been overlooked
4. Reassure patients about symptoms: Reassurance is crucial in allaying the patient’s concern and changing their help-seeking behaviour. Explanations that completely deny all disease often makes patients wonder if the doctor disbelieves their symptoms. Explanations that provide tangible mechanisms grounded in patients’ concerns, often linking physical and psychological factors, are necessary as they have a greater chance of acceptance by patients and better psychosocial outcome20
5. Providing alternative explanation for symptoms: A common expectation among patients is a better understanding of their symptoms. Worrying about their health is bound to recur if the symptoms persist, especially if the patients lack a satisfactory explanation that allows them to interpret their symptoms as benign. Consequently, it becomes necessary to manage the patient’s beliefs, misconceptions and concerns about health. Altered bodily function (eg, irritable bowel syndrome) as an explanation is helpful for many patients. Alternative explanations for symptoms (ie, the individual’s tendency to interpret innocuous bodily sensations as bodily dysfunctions or symptoms related to stress) are also useful. Simple explanations of possible links between anxiety and stress causing physical symptoms or how depression lowers the pain threshold are constructive. Patients often present their need for explanation by explicit questions, statements of concern about symptoms, suggestions that disease might be absent or tentative references to serious disease. Doctors should take the opportunities to work with patients in developing explanations that offer hope, and indicate ways forward or out of their current predicaments21
6. Prescribe drugs: Patients may expect drugs to be prescribed. Antidepressant drugs are useful and can be prescribed if depression, anxiety, panic, phobia or obsessive–compulsive symptoms are present, or when the pain is incapacitating (eg, headache, irritable bowel syndrome, atypical chest pain). Serotonin selective reuptake inhibitors are generally preferred as they have fewer side effects. However, tricyclic or newer sedative antidepressants are favoured in patients with insomnia. Nevertheless, the placebo response has been documented in trials for major depression. Patients who wish to avoid psychotropic drugs and those without such symptoms can be given vitamins, and the placebo response often helps them cope with their circumstances and reduces symptoms and distress22
7. Suggest general stress-reduction strategies: Recommending regular physical exercise, involvement in religious activities, hobbies, leisure, yoga or meditation to improve coping are useful. Incorporating such activities into the patient’s daily routine is cardinal for success
8. Explore possible stress and specific measures to reduce tension: Patients with specific problems will need help with problem solving. Often, life situations may be difficult to resolve and may require acceptance and change in coping strategies. Asking patients to look for specific solutions to their difficulties and giving them time to examine the issues is obligatory. Problem solving and simple cognitive behavioural techniques can be included in follow-up sessions
9. Discussing patient’s choices, alternatives and responsibility: Some patients expect cures from doctors, whereas many have limited expectations and mainly expect emotional support and explanation.23 The provision of emotional support and explanation are necessary, but there is also a need to discuss the patient’s choices, alternatives and responsibility
10. Give a specific appointment for review: Agree on a treatment plan. Regular progress review is necessary for most patients with scheduled, brief appointments. Restoration of function and psychological support are the treatment goal rather than complete symptom elimination. Referral to specialists should be avoided as these patients are best managed in primary care settings. Psychiatric evaluation and specialist counselling may be necessary for persistent and incapacitating mental disorders, suicidal ideation, interpersonal difficulties, sexual dysfunction and substance dependence