Psychology Somatoform Disorders
Karl Julian Looper, Laurence J. Kirmayer
  • LAST REVIEWED: 18 October 2017
  • LAST MODIFIED: 22 April 2013
  • DOI: 10.1093/obo/9780199828340-0106


Around the world, physical symptoms are the most common manifestation of psychological distress. This seeming contradiction presents a diagnostic challenge for health care professionals who are consulted to provide treatment and illness management. In many situations, it is difficult to clearly identify the psychological cause of physical symptoms, and, at times, it is equally difficult to exclude the possibility of an underlying biomedical process. This clinical challenge has led to the construction of the diagnostic category of somatoform disorders, a group of psychiatric disorders characterized by the presence of physical symptoms causing significant distress or functional impairment that cannot be fully explained by a general medical condition, substance use, or any other mental disorder. This category of disorders was established based on clinical utility and the need to exclude medical causes in health care settings rather than on a theoretical model of psychopathology or shared etiology. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, American Psychiatric Association 2000, cited under Classification), the somatoform disorders include somatization disorder, hypochondriasis, body dysmorphic disorder, conversion disorder, pain disorder, undifferentiated somatoform disorder, and somatoform disorder not otherwise specified. Some authors prefer other terminology, including use of the terms medically unexplained symptoms, emphasizing the uncertainty about diagnosis, or functional somatic syndromes, suggesting that symptoms are due to disturbances in the function of psychophysiological systems rather than structural or anatomical pathology.

Reference Books

Most general textbooks on psychiatry and psychopathology have chapters on somatoform disorders. In recent years, several texts devoted to somatoform disorders have been published. Overviews of research and conceptual issues are provided in Maj, et al. 2005 and Dimsdale 2009. Creed, et al. 2011 and Johnson 2008 present reviews oriented to primary care and psychology, respectively. More specialized reviews approach the topic from the perspectives of neuropsychology (Lamberty 2008) and forensic psychiatry (Trimble 2010). Popular accounts of interest to professionals as well as clients address specific disorders such as Phillips 2009 on body dysmorphic disorder.

  • Creed, Francis, Peter Henningsen, and Per Fink. 2011. Medically unexplained symptoms, somatisation, and bodily distress: Developing better clinical services. Cambridge, UK: Cambridge Univ. Press.

    DOI: 10.1017/CBO9780511977862Save Citation »Export Citation »E-mail Citation »

    A critical overview of current thinking on somatoform disorders by leading researchers.

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    • Dimsdale, Joel E. 2009. Somatic presentations of mental disorders: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Association.

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      Based on a workshop held in 2006, an international roster of contributors discuss research and conceptual issues needed to rethink the somatoform disorders for DSM-5.

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      • Johnson, Susan K. 2008. Medically unexplained illness: Gender and biopsychosocial implications. Washington, DC: American Psychological Association.

        DOI: 10.1037/11623-000Save Citation »Export Citation »E-mail Citation »

        An integrative biopsychosocial approach to somatoform disorders with an emphasis on gender issues.

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        • Lamberty, Gregory J. 2008. Understanding somatization in the practice of clinical neuropsychology. New York: Oxford Univ. Press.

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          Directed to neuropsychologists, this book focuses on assessment and management of somatoform disorders.

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          • Maj, Mario, Hagop P. Akiskal, Juan Mezzich, and Ahmed Okasha, eds. 2005. Somatoform disorders. Chichester, UK: Wiley.

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            A review of major categories of somatoform disorders organized in five sections (somatization and conversion disorders, pain disorder, hypochondriasis, body dysmorphic disorder, chronic fatigue and neurasthenia, and factitious physical disorders) with multiple commentaries by scholars from around the globe with interesting critical reflections and perspectives.

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            • Phillips, Katharine A. 2009. Understanding body dysmorphic disorder: An essential guide. Oxford: Oxford Univ. Press.

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              Oriented toward body dysmorphic disorder (BDD) sufferers, families, and lay individuals, this volume presents up-to-date research as well as outlining effective approaches to treatment.

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              • Trimble, Michael R. 2010. Somatoform disorders: A medicolegal guide. Cambridge, UK: Cambridge Univ. Press.

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                Addresses topics ranging from malingering to injury and disability relevant to legal and forensic settings.

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                Associations and Organizations

                A variety of professional associations in psychosomatic medicine and behavioral medicine address issues related to somatoform disorders. These groups, including the American Psychosomatic Society, Academy of Psychosomatic Medicine, International College of Psychosomatic Medicine, European Association for Psychosomatic Medicine, Society of Behavioral Medicine, and International Society of Behavioral Medicine, organize meetings, publish journals, and maintain websites that have useful resources regarding current issues and concerns.


                Research and clinical reviews on somatoform disorders are presented in journals devoted to abnormal psychology, behavioral medicine and health psychology, psychosomatic medicine (Journal of Psychosomatic Research,Psychosomatics, Psychosomatic Medicine, Psychotherapy and Psychosomatics), and especially to consultation-liaison psychiatry (General Hospital Psychiatry). Because somatoform disorders are common in primary care and general medicine, journals in these areas include practical clinical reviews and some research (Psychological Medicine). Each medical specialty has its own common medically unexplained symptoms and syndromes and these topics appears in general medical journals as well as the corresponding specialty journals.


                An historical perspective is helpful in understanding this complex category of psychiatric disorders, which has its roots in older notions of hysteria (Scull 2011, Shorter 1992). Ancient Egyptian and Greek medical writing identified a pattern of illness in women attributed to the effects of the uterus pressing on other bodily organs (Merskey 1983). This gave rise to the term hysteria, from the Greek hystera, referring to the uterus. The term hypochondriasis originally referred to the anatomical region of the abdomen (below the rib cage) where the visceral organs are located, which were believed to be involved in the production of somatic symptoms (Noyes 2011). In Europe during the Middle Ages, dramatic bodily symptoms such as seizures were sometimes viewed as a sign of possession by the devil. A more modern conceptualization of somatoform disorders dates to the 19th century when Thomas Sydenham described hysteria as a psychological disturbance that may occur in men as well as women (Micale 1995). Conversion symptoms were a central concern of early neurology, as represented in the work of Jean-Martin Charcot and others. Freud developed the psychoanalytic theory of hysteria (Breuer and Freud 1957, cited under Psychoanalytic and Psychodynamic Theories) in which the distress of an internal psychological conflict was converted into somatic symptoms, hence the term conversion that is used in current psychiatric nosology. The phenomenological approach of the DSM can be traced back to Paul Briquet, a 19th-century neurologist known for the first detailed symptomatic description of hysteria, which became known as Briquet’s syndrome. This eponym was supplanted by new diagnostic labels described in the DSM-III, which distinguished the syndrome of somatization disorder from conversion disorder and histrionic personality disorder. While hysteria has been historically associated with women (Showalter 1997), similar forms of illness are common in men (Micale 2008).

                • Hyler, Steven E., and Robert L. Spitzer. 1978. Hysteria split asunder. American Journal of Psychiatry 135.12: 1500–1504.

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                  Explains the innovations in the diagnostic classification of hysteria introduced with DSM-III.

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                  • Merskey, Harold. 1983. Hysteria: The history of an idea. Canadian Journal of Psychiatry 28.6: 428–433.

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                    Succinctly describes the contributions of Charcot and Freud to the modern concept of hysteria.

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                    • Micale, Mark. 1995. Approaching hysteria: Disease and its interpretations. Princeton, NJ: Princeton Univ. Press.

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                      Comprehensive work on the ways that hysteria has been approached in the literature of the history of medicine.

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                      • Micale, Mark S. 2008. Hysterical men: The hidden history of male nervous illness. Cambridge, MA: Harvard Univ. Press.

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                        Although hysteria has been viewed as strongly associated with the female gender, this book traces the parallel history of conversion symptoms, war neurosis, neurasthenia, and other conditions that are linked to men.

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                        • Noyes, R., Jr. 2011. The transformation of hypochondriasis in British medicine. 1680–1830. Social History of Medicine 24.2: 281–298.

                          DOI: 10.1093/shm/hkq052Save Citation »Export Citation »E-mail Citation »

                          An interesting account of the shifting meanings of the diagnosis of hypochondriasis.

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                          • Scull, Andrew T. 2011. Hysteria: The disturbing history. Oxford: Oxford Univ. Press.

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                            A popular account that traces the transformations of hysteria from the 1600s to contemporary trauma-related disorders.

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                            • Shorter, Edward. 1992. From paralysis to fatigue: A history of psychosomatic illness in the modern era. New York: Free Press.

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                              An account of the evolution of somatization emphasizing the way popular concepts, attitudes, help-seeking, and medical approaches from the 18th century until recent times have shaped modes of expressing distress.

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                              • Showalter, Elaine. 1997. Hystories: Hysterical epidemics and modern media. New York: Columbia Univ. Press.

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                                An account of epidemics of conversion disorder and other medically unexplained symptoms with an emphasis on the role of gender stereotypes in illness behavior and diagnosis.

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                                The somatoform disorders are defined and described in two major international classification systems, which are detailed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) by the American Psychiatric Association and the Classification of Mental and Behavioural Disorders by the World Health Organization. The current versions of these documents are the DSM-IV-TR (American Psychiatric Association 2000) and the ICD-10 (see World Health Organization 1992 and World Health Organization 1993 ICD-10 for Mental and Behavioural Disorders Diagnostic Criteria for Research). The somatoform disorders include: somatization disorder, which is characterized by the presence of multiple physical complaints with onset prior to age thirty spanning several years in duration; conversion disorder, which consists of the presence of one or more symptom or deficits in voluntary motor or sensory functions that may appear to be neurological in origin but cannot be explained by a neurological or other medical condition; pain disorder, which is characterized by pain that cannot be fully explained by an injury or a general medical condition; hypochondriasis, which consists of a preoccupation or fear of having a serious disease based on the misinterpretation of bodily symptoms that persist for a minimum of six months and do not respond to medical reassurance; and body dysmorphic disorder, which is characterized by a preoccupation with a perceived defect in appearance that may be imaginary or markedly excessive with respect to an existing physical anomaly. Two diagnoses exist as residual categories for somatoform disorders that do not meet the criteria of any of the specific disorders. Undifferentiated somatoform disorder is characterized by one or more physical complaints that last for at least six months. Somatoform disorder not otherwise specified is used for conditions for which there is a clinically relevant somatoform symptom that does not meet the diagnostic criteria of other somatoform disorders. The ICD and DSM classification systems are generally consistent with one another, with some exceptions such as conversion disorder, which is classified under dissociative disorders in the ICD and somatoform disorders in the DSM. The ICD system also includes a category of autonomic somatoform dysfunction, including conditions of the disruption of particular body systems. Criticism of existing nosologies has been extensive. Criticisms are summarized in Mayou, et al. 2005, which also provides suggestions for reclassification. Other proposals for revamping nosology are presented in Brown, et al. 2007 and in Porcelli and Sonino 2007. Both the ICD and the DSM are developing new editions. Extensive changes have been proposed for the somatoform disorder category for the fifth edition of the DSM (see DSM-V Development). This includes new diagnostic syndromes, labels, and criteria as well as reassigning some diagnoses to new categories.

                                Specific Syndromes

                                A large number of specific functional somatic syndromes have their own terminology within medical specialties but they may fall under the general rubric of somatoform disorders. For example, irritable bowel syndrome (Henningsen and Herzog 2008), fibromyalgia syndrome (Yunus 2008), and chronic fatigue syndrome (Hickie, et al. 2009) have all been viewed as somatoform disorders. In part, this depends on current diagnostic fashion and the state of medical knowledge of underlying mechanisms. Evidence exists for overlap among these conditions as well as their independent occurrence, raising questions about the role of a common underlying somatoform disorder that might be expressed in diverse ways (Kato, et al. 2010; Wessely, et al. 1999; Witthöft, et al. 2012). More clear-cut examples of specific somatoform disorders involve conversion symptoms, including psychogenic movement disorders (Hallett, et al. 2011) and pseudoseizures (psychogenic nonepileptic seizures; see Brown, et al. 2011). Somatoform disorders may also occur in post-traumatic situations, where they present diagnostic challenges.

                                • Brown, Richard J., Tanvir U. Syed, Benbadis, Selim, W. Curt LaFrance Jr., and Markus Reuber. 2011. Psychogenic nonepileptic seizures. Epilepsy & Behavior 22.1: 2, 85–93.

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                                  This review describes recent progress in developing testable models of the psychopathology of pseudoseizures.

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                                  • Hallett, Mark, A. E. Lang, J. Jankovic, et al., eds. 2011. Psychogenic movement disorders and other conversion disorders. Cambridge, UK: Cambridge Univ. Press.

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                                    With contributions from the fields of neurology, psychiatry, psychology, neuroimaging, neurophysiology, and genetics, this book covers the range of clinical issues related to psychogenic movement disorders and other conversion disorders from all of the most relevant clinical angles. An accompanying CD provides more than one hundred video clips with examples of movement disorders.

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                                    • Henningsen, Peter, and Wolfgang Herzog. 2008. Irritable bowel syndrome and somatoform disorders. Journal of Psychosomatic Research 64:625–629.

                                      DOI: 10.1016/j.jpsychores.2008.02.015Save Citation »Export Citation »E-mail Citation »

                                      A literature review that examines the relationship between irritable bowel syndrome and somatoform disorders and suggests the need for a category of medical interface disorders.

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                                      • Hickie, Ian, Tracey Davenport, Suzanne D. Vernon, et al. 2009. Are chronic fatigue and chronic fatigue syndrome valid clinical entities across countries and health-care settings?. Australian and New Zealand Journal of Psychiatry 43:25–35.

                                        DOI: 10.1080/00048670802534432Save Citation »Export Citation »E-mail Citation »

                                        A factor analytic study based on aggregating data from studies in many countries shows five dimensions with some variation in the syndrome of chronic fatigue across sites.

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                                        • Kato, Kenji, Patrick F. Sullivan, and Nany L. Pedersen. 2010. Latent class analysis of functional somatic symptoms in a population-based sample of twins. Journal of Psychosomatic Research 68.5: 447–453.

                                          DOI: 10.1016/j.jpsychores.2010.01.010Save Citation »Export Citation »E-mail Citation »

                                          A twin study showing both a general dimension of somatic distress and specific dimensions that may be associated with functional syndromes.

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                                          • Wessely, Simon, C. Nimnuan, and Michael Sharpe. 1999. Functional somatic syndromes: One or many? Lancet 354:936–939.

                                            DOI: 10.1016/S0140-6736(98)08320-2Save Citation »Export Citation »E-mail Citation »

                                            A literature review arguing for a single underlying syndrome of somatic distress in diverse functional syndromes.

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                                            • Witthöft, Michael, Wolfgang Hiller, Noelle Loch, and Fabien Jasper. 2012. The latent structure of medically unexplained symptoms and its relation to functional somatic syndromes. International Journal of Behavioral Medicine 5:1–12.

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                                              Evidence for multiple dimensions underlying the patterns of medically unexplained syndromes on a brief symptom questionnaire.

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                                              • Yunus, Muhammad B. 2008. Central sensitivity syndromes: A new paradigm and group nosology for fibromyalgia and overlapping conditions, and the related issue of disease versus illness. Seminars in Arthritis and Rheumatism 37.6: 339–352.

                                                DOI: 10.1016/j.semarthrit.2007.09.003Save Citation »Export Citation »E-mail Citation »

                                                Argues for viewing fibromyalgia and other chronic pain syndromes as central sensitization syndromes.

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                                                The reported prevalence of somatoform disorders varies widely depending on the measures used and the context of the survey. Higher rates are seen in clinical populations than in the community setting, and higher percentages of people surveyed will report a clinically relevant syndrome of medically unexplained symptoms than will meet the more restrictive criteria of specific somatoform disorders. The National Institutes of Mental Health Epidemiological Study was the first large-scale survey of mental disorders. Using these data, Regier, et al. 1988 reports the prevalence of somatization disorder (DSM-III criteria) as 0.1 percent. Based on the World Health Organization International Survey of Mental Disorders in Primary Care, Gureje and colleagues (Gureje, et al. 1997a; Gureje, et al. 1997b) report a prevalence of 2.8 percent for somatization disorder and 0.8 percent for hypochondriasis, using ICD-10 criteria. Fully 19.7 percent of the sample had a multisymptom disorder based on a threshold of four somatic symptoms for men and six for women. Both forms of somatization were more common in the South American centers, which may reflect cultural variation or differences in clinical populations due to help-seeking pathways. Recent population-based studies in Germany (Rief, et al. 2006) and in the United States (Koran, et al. 2008) have estimated the prevalence of body dysmorphic disorder as 1.7 and 2.4 percent, respectively. The low base rate, brief duration, and heterogeneity of conversion disorder have limited epidemiological studies of this disorder, while conceptual issues of attributing pain symptoms to psychological factors pose challenges for studies of pain disorder. By far the most prevalent of somatoform disorders are the undifferentiated and not otherwise specified categories; however, these are typically not included in epidemiological surveys due to the nonspecific nature of these constructs. Gender differences are observed for some somatoform disorders with respect to prevalence. Somatization disorder and, by extension, undifferentiated somatoform disorder are more common in women than men while equal rates across genders are seen for hypochondriasis and body dysmorphic disorder.

                                                • Gureje, Oye, Gregory E. Simon, Tevfik B. Ustun, and David P. Goldberg. 1997a. Somatization in cross-cultural perspective: A World Health Organization study in primary care. American Journal of Psychiatry 154:989–995.

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                                                  Reports the prevalence of somatization disorder in the primary care setting in fourteen countries based on nearly twenty-six thousand participants.

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                                                  • Gureje, Oye, Tevfik B. Ustün, and Gregory E. Simon. 1997b. The syndrome of hypochondriasis: A cross-national study in primary care. Psychological Medicine 27.5: 1001–1010.

                                                    DOI: 10.1017/S0033291797005345Save Citation »Export Citation »E-mail Citation »

                                                    Reports the prevalence of hypochondriasis in the primary care setting in fourteen countries based on nearly twenty-six thousand participants.

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                                                    • Koran, Lorrin M., Elias Abujaoude, Michael D. Large, and Richard T. Serpe. 2008. The prevalence of body dysmorphic disorder in the United States adult population. CNS Spectrum 13.4 (April): 316–322.

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                                                      Telephone survey of body dysmorphic disorder in a US community population of approximately two thousand participants.

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                                                      • Regier, Darrel A., Jeffrey H. Boyd, Jack D. Burke Jr., et al. 1988. One-month prevalence of mental disorders in the United States: Based on five Epidemiologic Catchment Area sites. Archives of General Psychiatry 45.11: 977–986.

                                                        DOI: 10.1001/archpsyc.1988.01800350011002Save Citation »Export Citation »E-mail Citation »

                                                        Reports the prevalence of the major psychiatric disorders, including somatization disorder, based on the National Institutes of Mental Health community survey of more than 18,500 participants.

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                                                        • Rief, Winifried, U. Buhlmann, S. Wilhelm, A. Borkenhagen, and E. Brähler. 2006. The prevalence of body dysmorphic disorder: A population-based survey. Psychological Medicine 36.6: 877–885.

                                                          DOI: 10.1017/S0033291706007264Save Citation »Export Citation »E-mail Citation »

                                                          In-person survey of body dysmorphic disorder in a representative community sample of approximately twenty-five hundred participants in Germany.

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                                                          There is a degree of diagnostic overlap among the somatoform disorders and comorbidity of somatoform disorders with depression and anxiety. For example, the authors of de Waal, et al. 2004, a study in a primary care population, observe a comorbidity of 4.2 percent between somatoform disorders and anxiety and depressive disorders that was 3.3 times more than expected only by chance. Other studies, such as Kirmayer and Robbins 1991, have identified distinct characteristics of somatization, hypochondriasis, and mood and anxiety disorders validating these constructs as separate entities. Personality disorders have also been found to coexist with somatoform disorders, particularly somatization disorder (Bass and Murphy 1995). The relationship between body dysmorphic disorder and obsessive compulsive disorder has suggested that they be viewed as part of a continuum of illness (Phillips and Kaye 2007).

                                                          Economic Implications

                                                          Somatoform disorders are associated with elevated levels of health care utilization and impairment in functioning. Because patients with somatoform disorders tend to attribute their health problems to medical rather than psychological causes, they tend to pursue medical and surgical treatments, which are of limited benefit to their condition and that may put them at risk for complications and iatrogenic illness. Choric somatoform disorders may be associated with significant disability. This combination of factors increases the economic costs of somatoform disorders. Barsky, et al. 2005, a study in the United States, demonstrates that patients with somatization had more visits to primary care physicians, specialists, and emergency departments. They also had more frequent admissions, higher inpatient costs, and higher outpatient costs compared with nonsomatizing patients. Controlling for comorbid psychiatric and medical conditions had little effect on these results, and the estimated annual medical care cost of somatization was US $256 billion. More recent studies in the United Kingdom—Bermingham, et al. 2010—and in Europe—Gustavsson, et al. 2011—have confirmed the high cost of somatoform disorders in terms of health care utilization and loss of productivity.

                                                          Course of Illness

                                                          Medically unexplained somatic symptoms are very common in primary care settings. Most cases resolve spontaneously or respond to medical reassurance and follow-up. These situations are not considered psychiatric conditions or somatoform disorders. The diagnostic criteria for somatoform disorders define clinical syndromes in terms of the number, type, and duration of symptoms as well as the consequent distress and impairment of functioning. The presence of multiple somatic symptoms is a risk factor for chronicity in primary care patients (Jackson and Kroenke 2008). Olde Hartman, et al. 2009 reviews thirteen prospective cohort studies to verify the longitudinal course of the somatoform disorders. The study found that 50 to 70 percent of patients with medically unexplained symptoms improved during the follow-up while 10–30 percent deteriorated. Patients with hypochondriasis showed an improvement of 30–50 percent. Body dysmorphic disorder tends to be unremitting, with only sixteen of 161 patients completely recovering in a one-year follow-up period (Phillips, et al. 2006). Although little reliable longitudinal outcome data are available for conversion disorder, older studies, notably that of Slater 1965, have raised the concern that there may be a high rate of misdiagnosis of conversion disorder in conditions later identified as medical illnesses. This has not been confirmed by more recent reviews, such as Stone, et al. 2005, that indicate a misdiagnosis rate of approximately 4 percent. When misdiagnosis does occur it can have devastating effects, as illustrated in the powerful account in Atkins and Hodges 2010.

                                                          Mechanisms of Somatoform Disorder

                                                          The common characteristic of somatoform disorders are bodily symptoms or concerns about having a medical illness when no evidence of physical disease is found thorough medical assessment. The dilemma of a category defined by what it is not (i.e., diagnosis by exclusion) creates an inherent challenge for patients who wish to understand and resolve their illness experience and for clinicians who must develop an effective treatment plan. Although somatoform disorders are generally assumed to be psychological in origin, many plausible mechanisms exist at the level of physiology, illness cognition, and social interaction that may contribute to symptom production, intensification, and subsequent distress and disability.

                                                          Biological Factors

                                                          The traditional medical model is based on the identification of an underlying biological pathology or structural abnormality. Where none is found, the term functional is often applied to denote a presumed disruption of the functioning of a physiological system even though the actual cause may not be possible to demonstrate. Several physiological systems appear to be involved in the production of unexplained somatic symptoms, including the Autonomic Nervous System, Immune System, Endocrine System, Pain System, and Sensorimotor System, and they include both the central and the peripheral nervous system. The interconnections between these systems make it likely that multiple systems are involved and can help to explain the frequent coexistence of different types of symptoms.

                                                          Autonomic Nervous System

                                                          The autonomic nervous system regulates basic bodily functions, including the activity of the heart, digestive tract, and other visceral organs. Dysregulation of these functions could give rise to bodily symptoms without structural damage. As Rief and Barsky 2005 suggests, this may account for a wide range of bodily symptoms. This breaks down the distinction between somatoform disorders and functional disorders in other areas of medicine, e.g., irritable bowel syndrome and functional dyspepsia as seen in gastroenterology (Mayer and Tillisch 2011).

                                                          Endocrine System

                                                          The hypothalamic-pituitary-adrenal (HPA) axis has been implicated in depression, pain, and functional somatic syndromes. The most convincing evidence comes from the observed mood abnormalities seen in patients with altered cortisol related to medical illnesses such as Cushing’s disease or Addison’s disease, or who are administered exogenous steroids for the treatment of rheumatological or other medical problems. Different patterns of HPA abnormalities have been associated with depression and somatic symptoms. While elevated cortisol is typically associated with a depressive syndrome, a suppression of cortisol has been linked to chronic fatigue and pain (Rief, et al. 2010). Activation of the HPA axis, which occurs following stress, leads to a suppression of proinflammatory cytokines of the immune system by cortisol.

                                                          • Rief, Winifried, Anike Hennings, Sabine Riemer, and Frank Euteneuer. 2010. Psychobiological differences between depression and somatization. Journal of Psychosomatic Research 68.5: 495–502.

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                                                            Differentiates somatization from depression based on physiological mechanisms; describes endocrine changes in the context of interacting systems that may explain the development of somatization.

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                                                            Immune System

                                                            The role of the immune system in behavioral responses to illness has become more evident in recent decades. This follows from the observation that use of interferon alpha and interleukin in the treatment of cancer and hepatic disease led to behavioral changes resembling depression. Current theory posits that immune cells release proinflammatory cytokines in response to pathogen-associated molecular patterns and to endogenous danger signals. Cytokines act on the brain to produce the central component of the acute phase reaction or malaise, which includes “sickness behavior” such as loss of appetite, fatigue, social withdrawal, fever, and myalgia (Dantzer 2005). Prolonged activation and repeated exposure to environmental stimuli during early stages of development may sensitize the brain cytokine system to the extent that it is triggered by nonimmune stimuli, which allows for the possibility that stress may trigger this reaction in the absence of an infection.

                                                            Pain System

                                                            Ronald Melzack and Patrick Wall revolutionized our understanding of pain pathways. They proposed the gate control theory, which suggests that when a potentially painful stimulus is conveyed from the periphery to the central nervous system, it passes through a sequence of neuronal gates at which the transmission of the signal can be modulated or blocked by local and top-down influences from the brain. Psychological processes thus can modulate pain signals. This line of research evolved into the neuromatrix theory of pain in which a widely distributed neural network involving somatosensory, limbic, and thalamocortical circuits integrate the sensory-discriminative, affective-motivational, and evaluative-cognitive dimensions of pain experience (Melzack 1999). This theory can account for the activation and modulation of pain by psychological factors and social/environmental conditions in the context of somatoform disorders and functional somatic syndromes. This approach is central to current integrative models of pain experience, as reviewed in Gatchel, et al. 2007. Woolf 2011 shows how central nervous system mechanisms of sensitization in response to experimental pain may lead to chronic pain conditions. The key issue for somatoform disorders is that all pain is mediated by central mechanisms and “medically unexplained” chronic pain may reflect physiological mechanisms as well as psychosocial contingencies.

                                                            • Gatchel, Robert J., Yuan B. Peng, Madelon L. Peters, Perry N. Fuchs, and Dennis C. Turk. 2007. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin 133.4: 581–624.

                                                              DOI: 10.1037/0033-2909.133.4.581Save Citation »Export Citation »E-mail Citation »

                                                              A discussion of current theory and practice related to all forms of chronic pain with applications to somatoform pain disorder.

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                                                              • Melzack, Ronald. 1999. From the gate to the neuromatrix. Pain 6: S121–S126.

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                                                                Explains the psychological influence on pain perception based on the accumulated research of the neurology of pain and an integrative theoretical model of the experience of pain.

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                                                                • Woolf, Clifford J. 2011. Central sensitization: Implications for the diagnosis and treatment of pain. Pain 152.3: S2–S15.

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                                                                  The experience of pain can result in increased sensitivity in central neural pain pathways, setting up a vicious circle that leads to chronic pain in a wide range of conditions that include fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders, and postsurgical pain.

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                                                                  Sensorimotor System

                                                                  In the past decade, neuroimaging techniques have been used to study somatoform disorders. One paradigm compares the functional neuroimaging of patients with conversion paralysis compared to controls with simulated weakness (Stone, et al. 2007). Other research has identified a range of structural and functional abnormalities of patients with somatoform disorders, although the reliability of these results has not been demonstrated. Two suggestive findings are an increased activity of limbic structures, including the insula and anterior cingulated cortex, in response to aversive stimuli in pain patients as well as a decrease in grey matter in pain and fatigue patients (Browning, et al. 2011). In general, functional brain imaging must be combined with good neuropsychological theories of normal function and psychopathology to yield meaningful models (Baslet 2011).

                                                                  Psychological Factors

                                                                  Psychological processes that have been implicated in the development of somatoform disorders include developmental processes that shape the way individuals experience and respond to bodily distress as well as attentional, cognitive, and behavioral processes. The following sections consider Psychoanalytic and Psychodynamic Theories; Developmental and Personality Factors, including personality traits as well as childhood trauma exposure and illness experience; Cognitive-Behavioral Factors, including attention, symptom attribution, and illness interpretation. Sociocultural Factors are also considered.

                                                                  Psychoanalytic and Psychodynamic Theories

                                                                  Sigmund Freud proposed the psychodynamic concepts of dissociation, repression, and psychological defenses to explain hysterical or unexplained somatic symptoms (Nemiah 2000). He postulated that hysterical or somatoform symptoms might arise through the repression of traumatic events or psychological conflicts, which are converted from conscious awareness to somatic symptoms that symbolically represent the trauma or conflict (Breuer and Freud 1957). More recent work has emphasized the notion of disorders of affect regulation (Waller, E. and C. E. Scheidt. 2006. “Somatoform disorders as disorders of affect regulation: a development perspective.” International Review of Psychiatry 18.1: 13–24). This has been operationalized in terms of the construct of alexithymia, an inability to experience and communicate on an emotional level, which may lead to the expression of distress in a somatic form. Although alexithymia has been associated with somatization in some studies (Mattila, et al. 2008), the association is inconsistent (de Gucht and Heiser 2003; Kooiman, et al. 2004) and likely involves interactions with other factors (Bailey and Henry 2007).

                                                                  Developmental and Personality Factors

                                                                  Health behavior modeled in the family environment may affect later symptom experience. Craig, et al. 2002 finds that children of somatizing mothers were more likely to seek medical attention than control groups. The increased rate of childhood traumatic experiences among patients with somatoform disorders has led to the notion that trauma is a risk factor for somatoform disorders (Roelofs and Spinhoven 2007). Brown, et al. 2005 shows that patients with somatization disorders were more likely to experience physical and emotional abuse and a negative family environment compared to medical patients; however, sexual abuse was not more common in the somatization group. Traumatic experiences may contribute to dissociation and result in conversion symptoms alone or as part of somatization disorder or a personality disorder (Sar, et al. 2004). A range of personality traits has been associated with somatoform disorders. The personality trait of neuroticism or negative affectivity is a pervasive tendency to experience negative mood states. These personality traits alone or interacting with other cognitive and perceptual factors may contribute to a tendency to report bodily symptoms, as seen for example in Kolk, et al. 2003. This general propensity to report high levels of common somatic symptoms may contribute, in turn, to somatoform disorders.

                                                                  Cognitive-Behavioral Factors

                                                                  A variety of cognitive behavioral models of somatoform disorders have been developed, which are reviewed in Rief and Broadbent 2007 and Witthöft and Hiller 2010. The somatic symptoms and preoccupations of patients with somatoform disorders may develop from increased sensitivity to bodily experiences of discomfort or from misperception or misinterpretation of distress. Arthur Barsky coined the term somatosensory amplification to refer to the tendency to experience somatic sensations as intense, noxious, and disturbing (Nakao and Barsky 2007). Robbins and Kirmayer 1991 emphasizes the role of attentional, attributional, and social-interactional processes in somatization. Patients with somatoform disorders may have heightened attention to bodily sensations and may tend to misattribute sensations to pathological rather than normalizing causes. However, as shown in Schaefer, et al. 2012, patients with somatoform disorders may also be less accurate in their bodily perceptions and, hence, more liable to cognitive biases and misinterpretations based on negative expectations. Catastrophizing has been observed to contribute to intensifying pain experience as well as health anxiety and help-seeking (Sullivan, et al. 2001). Research has tried to identify the specific cognitive steps involved in these processes. Brown 2004 and Deary, et al. 2007 have developed cognitive behavioral models of symptom development and illness behavior in somatoform disorders that can be applied to assessment and treatment.

                                                                  Sociocultural Factors

                                                                  All symptom experience is shaped by cultural models, social norms, and contingencies that influence illness behavior (Mechanic 1972). Building on this work, Pilowsky 1990 introduces the term abnormal illness behavior to refer to excessive or inadequate response to symptoms. Problematic health behaviors are frequently seen in somatoform disorders, particularly excessive help-seeking, and avoidant behaviors leading to disability. This can account for the wide variation in symptom experience and expression across cultures (Kirmayer and Sartorius 2007). Due in part to the highly stigmatized nature of mental illness, the tendency in many clinical contexts may be to present distress in somatic rather than psychological terms. Consistent with this, Raguram, et al. 1996 demonstrates a negative relationship between reported stigma and prominence of somatoform symptoms among patients attending hospital clinics in India. The ways in which people formulate and communicate their problems and distress draws from available cultural models or prototypes (Kirmayer, et al. 2004) and depends on social context or setting (Risør 2009). Physicians’ responses may contribute to exacerbating symptoms and poor clinical outcomes among patients with medically unexplained symptoms (Epstein, et al. 2006). In many cases, bodily symptoms may function as part of cultural idioms of distress, providing a common, nonstigmatizing language to communicate concerns. Historical changes in diagnostic models and symptom preferences provide further evidence of the ways in which social and cultural factors shape illness expression and behavior (see Shorter 1992 cited under History). For example, the spread of diagnoses such as neurasthenia from the United States to East Asia provides an example of the social construction of diagnoses with corresponding changes in the illness behavior of patients (Lee and Kleinman 2007). Across cultures, sociosomatic theories that link social circumstances with bodily illness may be more common than psychosomatic models that emphasize individual mental processes.


                                                                  The treatment of somatoform disorders is particularly challenging. This stems from their heterogeneity, and the impact of persistent diagnostic uncertainty as well as from the incongruence between the clinician’s psychological understanding of somatoform disorders in contrast to the patient’s body-centered illness experience and somatic symptom attributions and explanatory models.

                                                                  General Management

                                                                  Evidence-based treatment interventions for somatoform disorders include general management strategies, namely psychotherapeutic and pharmacological treatments. Several characteristics of somatoform disorders such as the multiplicity of symptoms, the lack of response to medical reassurance, and the tendency to seek multiple assessments lead to fragmented and disorganized care and a risk for iatrogenic illness. Providing a psychiatric consultation to primary care providers that recommends a structure such as regular prescheduled visits and an approach to the assessment and treatment of new symptoms has been shown to be effective for the management of somatization disorders and medically unexplained symptoms (Hoedeman, et al. 2010).

                                                                  • Hoedeman, Rob, Annette H. Blankenstein, Christina M. van der Feltz-Cornelis, Boudien Krol, Roy Stewart, and Johan W. Groothoff. 2010. Consultation letters for medically unexplained physical symptoms in primary care. Cochrane Database of Systematic Reviews 8.12 (December): CD006524.

                                                                    DOI: 10.1002/14651858.CD006524.pub2Save Citation »Export Citation »E-mail Citation »

                                                                    Meta-analysis of RCTs on the use of a consultation recommended structured care and limiting the use of unnecessary medical investigations indicates a modest benefit of consultation letters.

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                                                                    Specific psychotherapeutic approaches have been developed based on the conceptual models used to understand somatoform disorders. Short-term dynamic therapy has been studied for somatic symptoms (Abbass, et al. 2009). However, the most widely applied psychotherapy for somatoform disorders has been cognitive-behavioral therapy (CBT), emphasizing symptom management, reattribution, and coping skills (Looper and Kirmayer 2002). Woolfolk and Allen 2007 presents a general approach to CBT for somatoform disorders while Furer, et al. 2007 addresses the treatment of hypochondriasis and health anxiety more broadly. Randomized controlled trials have demonstrated the effectiveness of CBT for somatization disorder and similar conditions of medically unexplained syndromes meeting less stringent diagnostic thresholds, namely hypochondriasis and body dysmorphic disorder, as seen in Kroenke 2007. Therapeutic approaches, including hypnosis and paradoxical interventions for conversion disorder, have been studied using randomized controlled designs but, as yet, limited support exists for their efficacy. Several studies, such as Gask, et al. 2011, have trained primary care physicians to apply cognitive behavioral techniques in the management of medically unexplained symptoms with equivocal results. Recently, mindfulness-based stress reduction has been applied in a wide range of chronic medical conditions with promising results (Bohlmeijer, et al. 2010).

                                                                    Pharmacological Treatments

                                                                    There are no medications with an official indication for use in somatoform disorders or specific efficacy. However, the use of medications for symptomatic treatment of patients with somatoform disorders is widespread and supported by a small number of randomized controlled studies. Antidepressant medications, including serotonin specific reuptake inhibitors (SSRIs), have been reported to be effective in the treatment of hypochondriasis (Fallon, et al. 2008; Greeven, et al. 2007) and body dysmorphic disorder (Ipser, et al. 2009). This is consistent with the evidence that antidepressants can be helpful in the treatment of anxiety disorders and obsessive-compulsive disorder, which may be related to these somatoform disorders. Clinical trials also support the use of antidepressants in a range of functional somatic syndromes (Henningsen, et al. 2007), and a large number of studies have established the benefit of tricyclic antidepressants in chronic pain (Kroenke, et al. 2009). One study has investigated the use of an antidepressant in somatoform pain disorder (Luo, et al. 2009).

                                                                    Nonpsychiatric Treatments

                                                                    Accessibility and acceptability are both barriers to receiving appropriate treatment for patients with somatoform disorders. Due to the stigma of psychiatric labeling, patients may avoid or reject psychiatric or psychological treatment. The use of complementary and alternative therapies is widespread among patients with somatoform disorders, possibly reflecting the modest benefits of standard medical treatments and a greater compatibility of the explanatory models with patients’ own illness perceptions (García-Campayo and Sanz-Carrillo 2000). Although antidepressants and cognitive behavioral therapy may be of benefit for body dysmorphic disorder, the strong conviction of having a physical abnormality drives patients to pursue dermatological and surgical procedures with little long-term benefit (Crerand, et al. 2005).

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