The Waco Guide

Inadequate
response
Inadequate
response
Somatic Symptom Disorder (SSD)
Medical and Psychiatric
Evaluation
Explain Somatic
Symptom Disorder (SSD)
Diagnosis
- Acknowledge patient's suffering
- Emphasize that somatic symptoms are valid
- SSD is common, with scientific support,
yet etiology is unclear
- Avoid debate over cause of symptoms
Initial Treatment
Combination therapy
- Relaxation training
- Mindfulness based therapy or
CBT if available
SSRI or TCA at low doses
(if not already prescribed for other indication)
Nortriptyline
Desipramine (activating)
Other TCAs may be
reasonable alternatives
Sertraline
Citalopram
Other SSRIs may be
reasonable alternatives
- Titrate medication towards max
effective and tolerable dose
- Consider second trial of SSRI or TCA if
first trial unresponsive at max effective
and tolerable dose for 6-8 weeks
Consider
Psychiatry referral
Pharmacologic
Interventions
Consider deprescribing unnecessary
or ineffective medications
Non-pharmacologic
Interventions
Perform history and physical
with family corroboration and
prior records if available
Evaluate for comorbid psychiatric
disorder and treat appropriately (eg.
MDD, GAD, Panic, OCD)
See corresponding
decision support
Goal: Maximize occupational and social functioning
- Regularly scheduled office visits (every 4-8 weeks)
regardless of patient symptoms
- Manage physical symptoms conservatively
- Reassure the patient will receive appropriate evaluation

Is a comorbid disorder present?