Somatization: Treatment and prognosis
- Donna B Greenberg, MD
Donna B Greenberg, MD
- Associate Professor of Psychiatry
- Harvard Medical School
Somatization is a syndrome of nonspecific physical symptoms that are distressing and may not be fully explained by a known medical condition after appropriate investigation. This syndrome has also been called "medically unexplained symptoms," "medically unexplained physical symptoms," "functional somatic symptoms," and "somatic symptom disorders." The symptoms are associated with distress and may be caused or exacerbated by anxiety, depression, and interpersonal conflicts [1-4]. Somatization can be conscious or unconscious and may be influenced by a desire for the sick role or for personal gain .
Somatization often occurs in primary care patients . It increases use of medical services independent of any accompanying psychiatric or nonpsychiatric disorder, and leads to frustration in both the patient and the clinician [4,6-9].
This topic reviews the treatment and prognosis of somatization. The epidemiology, pathogenesis, clinical features, and medical evaluation of somatization; diagnosis of specific disorders; and the treatment and prognosis of hypochondriasis and conversion disorder are discussed separately. (See "Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis" and "Illness anxiety disorder: Treatment and prognosis" and "Conversion disorder in adults: Treatment".)
TERMINOLOGY AND DSM-5
The term "somatization" as used in this topic refers to a syndrome consisting of physical symptoms that cause substantial distress and psychosocial impairment, and in some instances, are not explained by a known general medical disease. The syndrome has also been referred to as medically unexplained symptoms and functional somatic symptoms. Somatization can be viewed as a dimensional syndrome with a spectrum of expression ranging from the exaggeration of common symptoms to unrelenting disabling symptoms . The same principles of management apply to patients across the spectrum.
Somatization is an overarching term that encompasses many different illnesses and terms including “somatoform disorders,” which is a group of disorders that are recognized in the World Health Organization's International Classification of Diseases-10th Revision (ICD-10) , and were previously described in the American Psychiatric Association's Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) (table 1) . (See "Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis", section on 'Somatoform disorders'.)
- Yutzy SH, Parish BS. Somatoform disorders. In: The American Psychiatric Publishing Textbook of Substance Abuse Treatment, 4th ed, Galanter M, Kleber HD (Eds), American Psychiatric Publishing, Washington, DC 2008. p.609.
- Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130:910.
- Bornschein S, Förstl H, Zilker T. Idiopathic environmental intolerances (formerly multiple chemical sensitivity) psychiatric perspectives. J Intern Med 2001; 250:309.
- Epstein RM, Quill TE, McWhinney IR. Somatization reconsidered: incorporating the patient's experience of illness. Arch Intern Med 1999; 159:215.
- Löwe B, Spitzer RL, Williams JB, et al. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment. Gen Hosp Psychiatry 2008; 30:191.
- Barsky AJ. Clinical practice. The patient with hypochondriasis. N Engl J Med 2001; 345:1395.
- Ring A, Dowrick CF, Humphris GM, et al. The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Soc Sci Med 2005; 61:1505.
- Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med 2007; 69:881.
- Sumathipala A. What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosom Med 2007; 69:889.
- Katon W, Lin E, Von Korff M, et al. Somatization: a spectrum of severity. Am J Psychiatry 1991; 148:34.
- The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed on June 08, 2012).
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC 2000.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Creed F, Barsky A. A systematic review of the epidemiology of somatisation disorder and hypochondriasis. J Psychosom Res 2004; 56:391.
- Löwe B, Mundt C, Herzog W, et al. Validity of current somatoform disorder diagnoses: perspectives for classification in DSM-V and ICD-11. Psychopathology 2008; 41:4.
- Keeley R, Smith M, Miller J. Somatoform symptoms and treatment nonadherence in depressed family medicine outpatients. Arch Fam Med 2000; 9:46.
- Abbey SE, Wulsin L, Levenson JL. Somatization and somatoform disorders. In: The American Psychiatric Publishing Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, American Psychiatric Publishing, Inc., Washington, DC 2011. p.261.
- McDermott BE, Leamon MH, Feldman MD, Scott CL. Factitious disorder and malingering. In: The American Psychiatric Publishing Textbook of Psychiatry, 5th ed, Hales RE, Yudofsky SC, Gabbard GO (Eds), American Psychiatric Publishing, Washington, DC 2008. p.643.
- O'Malley PG, Jackson JL, Santoro J, et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999; 48:980.
- Fallon BA. Pharmacotherapy of somatoform disorders. J Psychosom Res 2004; 56:455.
- Huang M, Luo B, Hu J, et al. Combination of citalopram plus paliperidone is better than citalopram alone in the treatment of somatoform disorder: results of a 6-week randomized study. Int Clin Psychopharmacol 2012; 27:151.
- Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Psychosom Med 1998; 60:503.
- Onghena P, Van Houdenhove B. Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Pain 1992; 49:205.
- Quilici S, Chancellor J, Löthgren M, et al. Meta-analysis of duloxetine vs. pregabalin and gabapentin in the treatment of diabetic peripheral neuropathic pain. BMC Neurol 2009; 9:6.
- Briley M, Moret C. Treatment of comorbid pain with serotonin norepinephrine reuptake inhibitors. CNS Spectr 2008; 13:22.
- Kadiroglu AK, Sit D, Kayabasi H, et al. The effect of venlafaxine HCl on painful peripheral diabetic neuropathy in patients with type 2 diabetes mellitus. J Diabetes Complications 2008; 22:241.
- Pae CU, Park MH, Marks DM, et al. Desvenlafaxine, a serotonin-norepinephrine uptake inhibitor for major depressive disorder, neuropathic pain and the vasomotor symptoms associated with menopause. Curr Opin Investig Drugs 2009; 10:75.
- Teh CF, Zaslavsky AM, Reynolds CF 3rd, Cleary PD. Effect of depression treatment on chronic pain outcomes. Psychosom Med 2010; 72:61.
- Folks DB, Feldman MD, Ford CV. omatoform disorders, factitious disorders, and malingering. In: Psychiatric Care of the Medical Patient, 2nd ed, Stoudemire, A, Fogel, B, Greenberg, DB (Eds), Oxford, New York 2000. p.459.
- Smith GR. Somatization in the Medical Setting, American Psychiatric Press Inc., Washington, DC 1991.
- Barsky AJ, Ettner SL, Horsky J, Bates DW. Resource utilization of patients with hypochondriacal health anxiety and somatization. Med Care 2001; 39:705.
- Barsky AJ, Geringer E, Wool CA. A cognitive-educational treatment for hypochondriasis. Gen Hosp Psychiatry 1988; 10:322.
- Hellman CJ, Budd M, Borysenko J, et al. A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behav Med 1990; 16:165.
- Henningsen P, Zipfel S, Herzog W. Management of functional somatic syndromes. Lancet 2007; 369:946.
- Greeven A, van Balkom AJ, Visser S, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: a randomized controlled trial. Am J Psychiatry 2007; 164:91.
- Staudenmayer H. Psychological treatment of psychogenic idiopathic environmental intolerance. Occup Med 2000; 15:627.
- Thomson AB, Page LA. Psychotherapies for hypochondriasis. Cochrane Database Syst Rev 2007; :CD006520.
- Staudenmayer H. Clinical consequences of the EI/MCS "diagnosis": two paths. Regul Toxicol Pharmacol 1996; 24:S96.
- Koelen JA, Houtveen JH, Abbass A, et al. Effectiveness of psychotherapy for severe somatoform disorder: meta-analysis. Br J Psychiatry 2014; 204:12.
- Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom 2000; 69:205.
- Moreno S, Gili M, Magallón R, et al. Effectiveness of group versus individual cognitive-behavioral therapy in patients with abridged somatization disorder: a randomized controlled trial. Psychosom Med 2013; 75:600.
- Sharpe M, Peveler R, Mayou R. The psychological treatment of patients with functional somatic symptoms: a practical guide. J Psychosom Res 1992; 36:515.
- Lidbeck J. Group therapy for somatization disorders in general practice: effectiveness of a short cognitive-behavioural treatment model. Acta Psychiatr Scand 1997; 96:14.
- Hedman E, Axelsson E, Andersson E, et al. Exposure-based cognitive-behavioural therapy via the internet and as bibliotherapy for somatic symptom disorder and illness anxiety disorder: randomised controlled trial. Br J Psychiatry 2016; 209:407.
- Barsky AJ, Ahern DK, Bauer MR, et al. A randomized trial of treatments for high-utilizing somatizing patients. J Gen Intern Med 2013; 28:1396.
- Kashner TM, Rost K, Cohen B, et al. Enhancing the health of somatization disorder patients. Effectiveness of short-term group therapy. Psychosomatics 1995; 36:462.
- Hoedeman R, Blankenstein AH, van der Feltz-Cornelis CM, et al. Consultation letters for medically unexplained physical symptoms in primary care. Cochrane Database Syst Rev 2010; :CD006524.
- Peters S, Stanley I, Rose M, et al. A randomized controlled trial of group aerobic exercise in primary care patients with persistent, unexplained physical symptoms. Fam Pract 2002; 19:665.
- World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Version for 2007. www.who.int/classifications/apps/icd/icd10online/ (Accessed on December 22, 2009).
- Rosendal M, Blankenstein AH, Morriss R, et al. Enhanced care by generalists for functional somatic symptoms and disorders in primary care. Cochrane Database Syst Rev 2013; :CD008142.
- olde Hartman TC, Borghuis MS, Lucassen PL, et al. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. A systematic review. J Psychosom Res 2009; 66:363.
- Jackson JL, Kroenke K. Prevalence, impact, and prognosis of multisomatoform disorder in primary care: a 5-year follow-up study. Psychosom Med 2008; 70:430.