Somatoform Disorder – Treatment of Somatoform Disorders and Physical Symptoms of the Condition

Somatoform disorders include, among others,

• somatoform pain disorder,
• somatization disorder, and
• hypochondriacal disorder.

In these conditions, those affected suffer from persistent, frequently changing physical symptoms for which no physical cause can be found despite the most thorough examinations. This means that, medically speaking, the body is healthy. Nevertheless, those affected are not imagining their symptoms: rather, the symptoms are psychologically caused.

However, those affected are usually convinced that they are suffering from a physical illness. Classifying their symptoms as “psychologically caused” often offends them deeply. They tend to avoid many activities and focus intensely on their symptoms. As a result, the symptoms frequently lead to psychological and social limitations.

Somatoform disorders are classified in the ICD-10 according to the frequency, type, and organ involvement of the physical symptoms:

• Somatization disorder (F 45.0): Rare, extreme forms with multiple symptoms and a course lasting for years.
• Undifferentiated somatoform disorders (F 45.1): A much more common, milder form. A single symptom lasting more than six months is sufficient.
• Hypochondriacal disorders (F 45.2): Patients suffer primarily from anxiety-laden beliefs about the cause of their symptoms (cancer, AIDS), not from the symptoms themselves.
• Somatoform autonomic dysfunction (F 45.3): Subdivided according to autonomic nervous system-innervated organs, e.g., cardiovascular, gastrointestinal, respiratory, and genital systems.
• Persistent somatoform pain disorders (F 45.4): Psychogenic pain symptoms predominate.

About 13 percent of all people are affected by a somatoform disorder at some point in their lives, with women affected twice as often as men. The most common is the somatoform pain disorder, primarily involving back and headaches. About two-thirds of those affected also have another mental disorder, very often depression.

Somatoform disorders can occur at any age. This sets them apart from many other mental disorders, which typically begin in young adulthood.

25 percent of all patients in primary care have somatoform disorders, 5 percent in dermatology, 30 percent in neurology, and 50 percent in gastroenterology. These disorders often develop in conjunction with stressful events or life phases. To outsiders, a clear connection is evident, but for those affected, it often is not.

The disorder is perpetuated by

• an extreme focus on physical symptoms,
• adopting a “resting posture” without sufficient physical activity, and
• the abandonment of many social activities.

A complex process—involving many factors—plays a role in the development of somatoform disorders. These factors include

• psychological and family dynamics,
• learning and systems theory-based,
• socio-,
• physiological and neurological, as well as
• genetic

aspects that influence one another. The following aspects are significant in somatoform disorders:

• Disturbance in the perception of affect, i.e., physical or mental tension or arousal is no longer perceived adequately,
• increased physiological reactivity and somatosensory amplification (heightened experience of pain),
• biographical vulnerability (psychological “sensitivity” due to negative life experiences, such as a history of abuse or violence),
• cognitive misattribution (catastrophizing) and conflict-coping strategies, attribution of somatic symptoms (physical symptoms are always attributed to specific causes),
• priming due to prior physical injuries,
• comorbidity (co-occurring conditions) with affective disorders,
• social and societal aspects of symptom onset and maintenance,
• iatrogenic chronicity (a chronic disorder caused by inappropriate medical interventions).

Patients with somatoform disorders have physical symptoms for which there is no physical cause © buritora | AdobeStock

The primary form of treatment is psychotherapy.

Patients are often referred by other doctors for psychiatric or psychotherapeutic treatment without seeing the point of it. Consequently, they are skeptical about being labeled as “crazy” or “malingering” and often feel deeply offended.

Therefore, establishing a positive and respectful therapeutic relationship is particularly important.

Furthermore, therapy should focus on

• generally understanding the connections between the mind and the body,
• better managing one’s own symptoms, as well as
• social withdrawal, “self-protective behavior,”
• excessive use of medication, and
• the use of medical facilities.

In addition, patients should seek ways to make their lives more satisfying and enjoyable.

Outpatient or inpatient specialized psychotherapy may be considered if:

• there has been no improvement in symptoms over a period of 3 months,
• the sick leave began more than four weeks ago,
• there are mental health comorbidities, particularly depression, anxiety disorders, or personality disorders,
• there are indications of severe biographical stressors (e.g., trauma),
• the patient expresses a desire for psychotherapeutic treatment.

The following section describes the most important somatoform disorder presentations and forms of somatoform disorders.

Somatization Disorder

In somatization disorder, physical symptoms occur over a prolonged period for which no organic cause can be found. The symptoms frequently vary in nature, and different organ systems are often affected. For example, the patient may suffer successively over several months from

• severe bronchitis,
• fatigue and exhaustion,
• pain when urinating,
• nausea, and
• abdominal bloating.

Patients tend to dwell on their symptoms and the underlying illnesses. They frequently visit doctors and often withdraw from social situations.

Somatization disorders are classified in the ICD-10 under

• F 45.0 (Somatization Disorder) and
• F 45.1 (Undifferentiated somatization disorder)

.

Hypochondriacal Disorders

In hypochondriacal disorder (“hypochondria”), the affected person fears that they are suffering from a serious physical illness, such as cancer. They can specify the suspected illness in detail and describe corresponding symptoms. They closely monitor symptoms and discomforts of all kinds and interpret them as confirmation of the assumed illness.

Consequently, they demand numerous medical examinations, but the normal results do not reassure them in the long term. The affected individual continues to monitor their supposed signs of illness and does not trust the doctors.

The patient suffers greatly from the symptoms or the associated thoughts and anxiety.

Cognitive-behavioral psychotherapy or an interpersonal form of psychotherapy, such as psychodynamic therapy, is effective.

Hypochondriacal disorders are classified under F 45.2 in the ICD-10. They may be associated with obsessive-compulsive disorder or specific phobias (health anxiety).

Somatoform Pain Disorder

Somatoform pain disorders are pain conditions that persist for an extended period and cannot be explained, or cannot be sufficiently explained, by a physiological process or a physical illness.

According to this definition, pain syndromes caused by muscle tension are not classified as somatoform disorders. In practice, however, purely centralized pain syndromes are rather rare. Much more common are mixed presentations in which peripheral processes (e.g., muscular tension) and pain centralization occur in tandem.

In somatoform pain disorder, persistent pain is the primary symptom. The pain frequently varies in location and intensity.

According to ICD-10, somatoform pain disorder is classified under diagnostic code F 45.4. It must be distinguished from somatization disorders (F 45.0 and F 45.1), in which pain may also occur.

The lifetime prevalence of somatoform pain disorders in Germany is approximately 12.3 percent. Among patients seeking care at medical facilities, the proportion is correspondingly higher, ranging from 20 to 40 percent in general practices and hospital specialty departments.

The diagnosis of a somatoform pain disorder first requires

• a thorough organic and biographical evaluation,
• a social history, and
• a medication history.

Stressors experienced during childhood appear to lead to increased vulnerability.

Comorbidities (concurrent conditions) include

• depression,
• anxiety,
• personality disorders, and
• conduct disorders.

Specialized psychotherapy is necessary if

• the symptoms have persisted for a long time,
• there is mental health comorbidity, and
• there are pronounced psychosocial conflicts.

Furthermore,

• indications of personality development disorders and early childhood trauma, as well as
• significant psychosocial risks of chronicity

are indications for outpatient or inpatient psychotherapy.

Case Study: Somatoform Pain Disorder

Mr. F., a 54-year-old technical employee, is referred by his primary care physician to a psychotherapist due to his chronic pain. He reports that he has been experiencing increasing pain in his joints and back for approximately 15 years. The pain has been repeatedly evaluated, primarily from an orthopedic perspective, without any findings.

Initially, treatments such as fango and massages had helped, but for about 10 years now, these have no longer provided any relief. Since then, he has been reliant on pain medication, initially mainly acetaminophen and aspirin. About two years ago, the pain became so severe that he switched to morphine-based medications prescribed by his family doctor. He now regularly takes three times the recommended maximum daily dose.

After further investigation, it turns out that the pain is significantly less when the patient engages in his beloved hobby of gardening.

Regarding his social situation, he reports that he had been married for a long time. His wife moved out two and a half years ago; they had grown apart. Since then, he has been in a casual relationship with an acquaintance. The family doctor reports that his wife’s decision to leave came as a great surprise to the patient. It hit him hard.

Professionally, he works in the technical department of a medium-sized publishing house. There has been increasing pressure there in recent years since the company was sold. Many long-time colleagues were laid off afterward. So far, the patient has been able to avoid termination thanks to his status as a severely disabled person, which he acquired due to his pain. He hopes to qualify for disability benefits due to his pain before the termination notice finally reaches him.

Functional Disorder of the Digestive Tract

Functional disorders of the digestive tract are defined as persistent digestive disturbances and pain in the stomach and intestines for which, despite appropriate examination, no sufficient organic explanation—such as inflammation—can be found.

They can be distinguished based on whether they affect the upper or lower gastrointestinal tract. These include:

• psychogenic aerophagia (air swallowing),
• psychogenic singultus (hiccups),
• dyspepsia (irritable stomach),
• pyloric spasm (spasm at the outlet of the stomach),
• gastric neurosis,
• psychogenic flatulence,
• psychogenic irritable bowel syndrome,
• psychogenic diarrhea.

In addition, autonomic symptoms are present, such as

• palpitations,
• sweating, and
• hot flashes.

In addition to somatoform physical symptoms, anxiety or depressive disorders may also occur.

Two somatoform disorders of the digestive tract are particularly significant:

• non-ulcer dyspepsia and
• irritable bowel syndrome (IBS).

Psychosomatic treatment is indicated when symptom-oriented treatment fails to produce improvement. In addition, there must be clear psychosocial stressors, either present or past. Psychoeducational treatment is a sensible first step. Its goal is to promote the patient’s capacity for self-help and thus enable them to actively participate in their own recovery.

Psychoeducation centers on joint discussions and the exchange of experiences between

• patients,
• family members among themselves, and
• the therapist.

The participants’ existing experiential knowledge is consistently drawn upon.

Building on this, the therapist conveys the most important scientific findings. This enables patients and family members to gain a clear understanding of

• the disease,
• the necessary treatment measures, and
• the self-help options

. This treatment may be followed by short-term psychotherapy or behavioral therapy. Body-oriented psychotherapies and relaxation techniques are also effective.

Functional Disorders of the Cardiovascular System

Functional disorders of the cardiovascular system are defined as persistent pain and other symptoms that the affected person experiences as signs of heart disease, even though an appropriate medical examination fails to confirm a corresponding disease of the heart or other thoracic organs (e.g., the esophagus). In the ICD-10, these are classified under “somatoform autonomic dysfunction of the cardiovascular system” (F 45.3). This category includes conditions such as cardiac neurosis and neurocirculatory asthenia (DaCosta syndrome).

Pain and other symptoms affecting the heart are closely linked to anxiety in two ways: The experience of anxiety itself includes an element of chest tightness and discomfort that is perceived as a sign of heart disease. This is accompanied by fears of a heart attack and a general fear of death, which further exacerbate the experienced symptoms.

Functional disorders of the cardiovascular system are treated in the same way as general somatoform disorders. Behavioral therapies and psychodynamic psychotherapies have been shown to be effective. Furthermore, patients respond well to relaxation techniques as well as body awareness exercises. Medication with beta-blockers can alleviate the symptoms.

Functional Disorders of the Urogenital Tract

Functional disorders of the urogenital tract are characterized by three symptom complexes that partially overlap:

• Urination disorders,
• pain syndromes,
• functional sexual disorders.

Disorders of micturition present with the following manifestations:

• Psychogenic urinary retention,
• Increased urinary frequency (psychogenic overactive bladder),
• psychogenic urinary incontinence.

According to ICD-10, they are classified under F 45.3 and F 45.4.

Psychogenic bladder emptying disorders are generally rooted in neurotic conflicts. Fear and shame are central to these disorders. Furthermore, from a psychodynamic perspective, the integration of aggressive impulses has not been successful. Secondarily, avoidance behavior and social reinforcement conditions can also lead to a fixation of the symptoms.

Treatment is usually provided on an outpatient basis, either

• at a urology practice through basic psychosomatic care, or
• in the case of an underlying deeper neurotic disorder or personality disorder, through specialized psychotherapy.

Pain syndromes in the urogenital region constitute a distinct group:

• pelvic floor myalgia,
• pelvipathy (abdominal pain in women without organic causes), and
• urethral syndrome (irritable bladder).

The most common causes are

• traumatic sexual experiences,
• disorders of sexual development,
• relationship conflicts, and
• disorders of personality development.

Treatment is primarily conservative and symptomatic. In some cases, it is necessary to address the underlying psychological conflicts or structural disorders.

What is a somatoform disorder?
A somatoform disorder is a psychosomatic disorder in which physical symptoms occur without any identifiable organic cause. The symptoms are real and distressing, even though no clear physical cause can be identified. Somatoform disorders are mental health conditions with a wide range of manifestations.

What symptoms occur in somatoform disorders?
Typical symptoms of a somatoform disorder include chronic pain, neurological symptoms, gastrointestinal complaints, or persistent physical complaints. The physical symptoms often change over the course of a somatoform disorder. Psychological symptoms and emotional distress may also occur.

How is the diagnosis made?
A diagnosis of a somatoform disorder is made following a thorough evaluation and the exclusion of any physical illness. According to the ICD-10, symptoms must often have persisted for at least six months. Doctors assess whether an organic cause can be identified or whether the symptoms are functionally based.

What treatment helps with a somatoform disorder?
Treatment for somatoform disorders usually includes psychotherapy, psychotherapeutic interventions, and supportive measures for stress management. The goal of therapy for somatoform disorders is to alleviate symptoms and improve coping with symptoms that are perceived as distressing. In some cases, medication or psychosomatically oriented approaches are also used.

What types of somatoform disorders are there?
Types of somatoform disorders include somatization disorder, hypochondriacal disorder, somatoform pain disorder, and undifferentiated somatoform disorder. In addition, there are other somatoform disorders as well as somatoform autonomic dysfunction. Patients with somatoform disorders often exhibit various physical symptoms without any apparent organic cause.