Somatoform Disorders

Chapter 4.11 from the Management of Mental Disorders, published by World Health
Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United
Kingdom.

See also www.thiswayup.org.au

Somatoform disorders are multiple somatic complaints in which physical symptoms cause
significant and often long-term distress and often have no medical explanation. Somatization
is a process in which mental or emotional problems result in physical symptoms. For
example, many people experience occasional headaches, abdominal distress, chest pains,
tiredness, fatigue, dizziness, back pain, and other aches and pains as a result of emotional
stress. Somatoform disorders can be diagnosed if somatization leads to multiple somatic
complaints in which physical symptoms cause significant and often long-term distress.
Although many of these physical symptoms have no medical explanation, individuals with
somatoform disorders are usually convinced that their symptoms have a physical cause.
Persistent complaints of fatigue and exhaustion after minor physical effort are
classified as Neurasthenia. This condition is best resolved by establishing a strict sixteen
hours out of bed and eight hours in bed regime coupled with a thorough review of activities
to be carried out and goals to be attained when awake. If unexplained somatic complaints
are numerous, severe, and long-standing, the individual may qualify for a diagnosis of
Somatization Disorder, which is a rare type of somatoform disorder characterized by many
physical complaints from different parts of the body, in which the individual experiences
multiple, recurrent, and frequently changing physical symptoms for several years.
Management of these individuals is more difficult than dealing with specific isolated somatic
symptoms and warrant referral to specialist services. Hypochondriacal disorder is another
type of somatoform disorder and is characterized by the individual’s preoccupation with the
belief that he or she has a serious illness. For example, an individual may believe that a
minor headache is caused by a brain tumor or that a mild rash is the start of skin cancer. This
preoccupation occurs without adequate organic pathology to account for the degree of
concern and persists in spite of medical reassurance. The course of hypochondriacal disorder
is thought to be chronic and fluctuating and has been shown to affect about 3% of patients
in primary care settings. The preoccupation with illness may cause distress, anxiety, and
reassurance-seeking behavior, yet some individuals will otherwise function normally. Some
individuals may dominate or manipulate family and social networks as a result of their
symptoms.

Differential Diagnosis
In unexplained somatic complaints or in somatisation disorder, the focus is on the presence
of the symptoms, whereas in hypochondriacal disorder, the focus is on the presence of an
underlying disorder and its future consequences. Individuals with hypochondriacal disorder
may accept that their symptoms are minor (unlike in somatisation disorder) but believe or
fear that they are caused by some serious disease.
Individuals who have a depressive disorder are often very aware of everyday physical
aches and pains or may become morbidly preoccupied with the belief that they have a
serious illness. Depression may be secondary to a primary somatoform disorder, and
establishing which problem started first is important. In addition, in schizophrenia,
delusional disorder, or depression, individuals may have strange somatic beliefs, such as the
belief that an organ or a part of the body is decaying. However, the beliefs associated with
somatoform disorders are not as fixed as disorders that are accompanied by somatic
delusions. Furthermore, individuals with long-standing hypochondriacal concerns may have
been labeled as personality disordered since they often become dissatisfied or even hostile
when faced with the perceived failure of health professionals to deal with their problems.
While anxiety about health can occur transiently in any individual, somatisation and
hypochondriacal concerns may feature in a number of anxiety disorders. One of the domains
of worry in generalized anxiety disorder (GAD) may be concern about physical illness in
either oneself or one’s family. However, in GAD, the illness anxiety is just one of many
concerns rather than being the sole cause of distress. During panic attacks, avoidance and
preoccupation with thoughts of physical or mental disease are prominent (i.e., fear of dying,
going mad, or losing control). However, individuals with panic disorder tend to misinterpret
their acute anxiety responses (which then tend to escalate as anxiety increases), while in
somatoform disorders, the symptoms that are misinterpreted are more likely to be those not
related to anxiety (e.g., lumps and blemishes). The panic misinterpretations also tend to be
acute, occurring while the individual experiences anxiety symptoms (e.g., heart attack),
while hypochondriacal fears (i.e., cancer) and unexplained somatic complaints tend to be
longer term. Many people with hypochondriasis experience intrusive thoughts followed by
compulsive checking, which is similar to symptoms of obsessive-compulsive disorder.
However, while people with hypochondriasis are afraid of having an illness, people with OCD
may fear that they or their family will develop a serious illness such as AIDS or cancer.

Management of Somatoform Disorders

The management of somatisation and hypochondriacal disorders have much in common,

although the clinician needs to adapt the management plan below depending on the
specific symptom profile. The main principle of management for individuals with
somatisation and hypochondriacal disorders is to help them cope with their physical
symptoms. This principle is equally applicable to individuals who have more isolated somatic
complaints. The goal of management is not the acute relief of symptoms but rather
assistance with rehabilitation in the face of chronic disability. Treatment would ideally
include the following components:

1. Ongoing Assessment
 Medical assessment: Typically, individuals with these complaints will have previously
undergone a routine medical examination with their general medical practitioner so as to
rule out underlying physical disease. Following a complete medical assessment, the
clinician can discuss the symptoms with the individual, and the main points of education
in this context would include:
• An explanation of the results of the medical tests or physical examinations.
• An emphasis on the finding that there are no life-threatening symptoms present or
underlying illnesses.
• If appropriate, the provision of a physiological explanation for the symptoms,
particularly for individuals with somatisation disorder (e.g., “Muscle tension can
often cause pain—think of how your arms have felt after carrying heavy shopping
bags for a long period of time”). Relaxation methods may help relieve symptoms
related to tension
• The general practitioner should limit further medical investigations and access to
prescription drugs, provide time-limited, regularly-scheduled appointments, and deal
sensibly with all new signs and symptoms that are presented.

Psychological assessment: The clinician should also establish whether the individual has
co-occurring mental disorders and determine which problem is primary or secondary.
Anxiety or depressive disorders are common in this population, and the underlying or
accompanying disorders will require treatment.

2. Establish a Strong Therapeutic Relationship

This step is important as many individuals will be reluctant to view their problems as being
caused by anything other than a medical condition and will therefore be resistant to
engaging in treatment or to discussing any other possibilities related to the cause of
symptoms. Since individuals will be unlikely to link their experience of illness to
psychological factors, the communication of a psychiatric diagnosis is not helpful. In
addition, since the individual will be unlikely to present for specialist mental health
treatment, the general practitioner is central to the management of these disorders.
Presenting the treatment approach as one in which various hypotheses about the origins of
the symptoms can be tested may be useful, and such an approach will be more readily
accepted if a trusting therapeutic relationship has been established.
Acknowledging that the individual’s experience of the physical symptoms is real and
that the symptoms are not lies, inventions, or figments of the individual’s imagination, as
well as acknowledging the distress caused by the individual’s concerns, will also help
establish rapport and engage the individual in treatment. The clinician may also want to
discuss the individual’s previous experience of how medical professionals have responded to
the symptoms, which will enable the individual to “feel heard.”

3. Cognitive Behavioral Therapy

CBT is the best-established treatment for somatoform disorders and targets the thoughts,
feelings, and behaviors that perpetuate the disorder. For example, thinking of one’s physical
aliment as catastrophic may lead to a decrease in activities for fear that participating in
activities will make the symptoms worse. A decrease in activities may then lead to more
time thinking about one’s ailments and consequently result in greater stress. Furthermore,
increased stress and anxiety may actually worsen the physical symptoms and disability.
• Cognitive interventions: Therapy targets the individual’s negative thoughts and
overemphasized fears related to his or her physical ailments. For individuals with
hypochondriasis in particular, the clinician should present alternative rational
explanations and explain why the individual’s ideas may be mistaken. For example,
consider the case in which an individual presented to his clinician with the belief that
a lump on his forehead was proof that he had a brain tumor. Every time he looked in
the mirror he thought the lump was growing bigger. Three previous CAT scans had
not provided reassurance. However, when presented with the testable alternative
hypothesis that the lump was not growing, he conceded that if the lump really was
growing, it would have been the size of a golf ball by now. He agreed that it was
possible that the lump had always been there and that it was therefore less likely to
be a brain tumor, and his anxiety was considerably lessened.
• Behavioral interventions: The goal is to help individuals reintroduce activities and
develop other interests despite continued physical symptoms. Use graded exposure
concepts and activity planning to encourage activities and structured problem solving
to facilitate planning. Behavioral interventions focused on modifying inappropriate
reassurance seeking or checking behavior and avoidance is particularly important,
and the clinician should review the figure below with the individual.

For inappropriate reassurance-seeking or checking behavior:

 Point out the role of this behavior in perpetuating somatic concerns (see diagram).
Checking and reassurance seeking, while decreasing anxiety in the short-term,
focuses the individual’s attention on the symptoms. This heightened awareness often
results in greater anxiety and overinterpretation of symptoms. Furthermore, constant
checking and prodding can actually cause tenderness and other injury.
 Once you have provided appropriate information, advise the individual to stop
checking or seeking reassurance so that he or she may break the cycle. Explain that
this will lead to a temporary increase in anxiety but that this will in time decrease.
 Come to an agreement with the individual that he or she will seek no further tests or
medical opinions. This agreement may require the involvement and agreement of
 any partner or spouse. Treatment, like that for OCD, involves exposure to the cues for
hypochondriasis and prevention or inhibition of the reassurance-seeking responses.

For avoidance:
 Individuals can overcome avoidance using the principles of graded exposure. For
example, individuals who gradually begin a program of exercise can test whether
physical exertion leads to a worsening of their symptoms (and in doing so will
probably learn that they feel better with exercise).

4. Increasing Emotional Awareness and Identifying Perpetuating Factors

For individuals with somatisation disorder, this step is particularly important in facilitating an
understanding of the link between emotions and physical symptoms.

• Individuals with somatisation disorder often have difficulty identifying and expressing
their own emotions, and they may need skills such as mindfulness and emotion
regulation as central components of treatment.
• The clinician should also encourage individuals to systematically identify and list all
the principal factors that perpetuate the symptoms. Factors may include low mood,
stress, poor sleep, misinterpretation of bodily sensations, and unhelpful coping
behaviour (e.g., lying in bed all day). The clinician should encourage discussion of
emotional stressors that were present when symptoms arose or that seem to
exacerbate symptoms. Keeping a diary of symptoms and events on a daily basis may
help clarify these connections.

5. Further Management
For individuals with somatisation disorder, the clinician should avoid referrals to medical
specialists unless new symptoms or signs arise, as somatic concerns are best managed by
regular planned contact with general medical practitioners. When hypochondriacal concerns
are severe and are a major feature of an individual’s difficulties, expert consultation may be
required to develop and enhance the treatment strategies outlined above. Consultation with
clinicians who have expertise in cognitive behavioral strategies may be useful.
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