Rethinking somatoform disorders.

Current Opinion in Psychiatry. 18(1):65-71, January 2005.

Janca, Aleksandar

School of Psychiatry and Clinical Neurosciences, University of
Western Australia, Perth, Australia

Correspondence to Aleksandar Janca, School of Psychiatry and Clinical
Neurosciences, University of Western Australia, Medical Research
Foundation Building, 50 Murray Street, Perth, WA 6000, Australia,
Tel.: +61 8 9224 0293; fax: +61 8 9224 0285. e-mail:
ajanca@cyllene.uwa.edu.au

Abstract:
Purpose of review: From the very moment of their inclusion in contemporary 
classification systems in psychiatry, the concept of somatization and 
diagnostic categories of somatoform disorders became a matter of 
controversy that created an ongoing debate about their validity, 
reliability and applicability in clinical and research settings. 
The aim of this review is to provide an insight into the current 
theoretical, research and clinical dilemmas in the area of somatoform 
disorders and to illustrate them with brief summaries of scientific 
papers recently published in this field.

Recent findings: In the period covered by this review, the most 
valuable scientific contributions to the current state of knowledge 
on somatoform disorders were (surprisingly numerous) review papers 
produced by the leading experts in this field. These comprehensive 
and critical metaanalyses covered historical, conceptual, 
epidemiological and cross-cultural aspects of somatoform disorders.

Another and a relatively smaller group of recently published papers 
reported on some novel treatment strategies for patients with specific 
somatoform disorders, their service utilization and health care-related costs.

Summary: If one were to find a common denominator of the papers 
covered by this review, it is a general agreement amongst their 
authors that the current concepts of somatization and somatoform 
disorders have serious theoretical and practical limitations in 
both research and clinical settings. They suggest that the time 
has come to seriously rethink these concepts so as to find better 
nosological solutions for the forthcoming revisions of classification 
systems in psychiatry and medicine.

Keywords: functional; psychosomatic; somatization; somatoform


Introduction
The main focus of this review is somatoform disorders - a somewhat
dubious and quite controversial diagnostic category introduced into
the psychiatric classification systems some 25 years ago. Ever since,
there has been a debate about the validity of this diagnostic
concept, which has a psychodynamic basis and is related to another
ambiguous concept of 'somatization'.

In addition to the assumption of psychogenesis, the 'operational'
definitions of somatoform disorders are based on terminology that is
often found to be confusing and misleading (e.g. 'medically
unexplained' symptoms, 'functional' somatic symptoms, 'subjective
health complaints', etc.) Indeed, even the name of this group of
disorders (containing the suffix 'form') is misleading, as such a
term is often used in psychiatric nosology to describe a condition
which is similar to or mimics another syndrome or disorder.

Over the years, many experts have expressed their reservations about
the concepts of somatization and somatoform disorders and raised many
questions about their validity and applicability in research and
clinical settings. The purpose of this paper is to provide an
overview of the recently published literature on this topic and give
the reader an insight into the current state of knowledge in this
field. A particular emphasis is placed on papers which elaborate on
theoretical and practical limitations of the concept of somatoform
disorders and offer some constructive proposals for the ways forward.

Reviewing history
In order to identify longitudinal patterns of somatization, Jones and
Wessely [1•] carried out an interesting retrospective study of
retired UK army personnel who had participated in various wars over
the past century. Somatic symptoms of randomly selected retired
servicemen diagnosed with postcombat syndromes were related to the
contemporary somatic symptom and syndrome accounts.

The results of this comparative analysis showed that somatic symptoms
continued to be common during and after World War II, suggesting that
their decline was not as substantial as previously believed. Although
psychological presentations of personal distress increased over time,
they did not replace conversion symptoms.

The authors concluded that the occurrence of somatoform disorders did
not disappear from military personnel in a smooth progression;
rather, they changed their form and focus (going 'from the heart to
the gut'), primarily in response to the powerful socio-cultural
changes and new medical trends.

In another interesting and comprehensive literature review with a
focus on chronic fatigue syndrome (CFS) and its predecessor
neurasthenia, Luthra and Wessely [2•] looked into the fact that both
of these conditions had been linked to technological advances
in 'developed' countries.

The authors thought that this led to a form of 'race thinking' which
helps us to better understand the historic, conceptual and
epidemiological aspects of these two syndromes. The authors reviewed
an impressive amount of medical and lay literature on neurasthenia
and CFS and discussed it in the context of social Darwinism and other
contemporary evolutionary theories.

They pointed out that the nineteenth century belief that non-whites
were protected from neurasthenia is clearly seen to re-emerge in the
current literature on CFS. However, a relatively low percentage of
non-white patients seen in tertiary referral clinics for CFS is more
likely to be the result of perceptions of CFS by doctors and
patients, rather than any specific aspect of the illness.

More recent research results suggest that the relationship between
ethnicity and CFS is far more complex and the authors concluded that
a further examination of the intersection of race and class is
essential if we are to fully understand the biases inherent in the
diagnoses of neurasthenia and CFS.

Interesting retrospective literature searches were also done by
Sumathipala et al. [3] who explored the dhat (or semen-loss anxiety)
syndrome and ascertained the presence of similar symptoms and
syndromes in different cultures and settings. Although historically
perceived as a 'neurosis of the Orient', dhat syndrome and related
concepts have been found and described in other cultures including
the USA, the UK and Australia. Consequently, the authors stated that
dhat is not a culture-bound syndrome and proposed modification of the
current diagnostic and classification systems in psychiatry so as to
correct this long-held misconception.

Revisiting concepts
Over the past 2 years, there have been a number of papers focusing on
the concepts of somatization and somatoform disorders and commenting
upon their theoretical and practical limitations. Following a meeting
of an international group of experts working in this area, Rief and
Sharpe [4••] published an extensive summary of the conceptual issues
raised by the meeting participants, including terminology,
conceptualization, classification and treatment of somatoform
disorders.

The group reached a consensus on the limitations of terms currently
used in this field such as 'medically unexplained
symptoms', 'functional somatic symptoms' and 'subjective health
complaints', which were found to be inadequate and often misleading.

A similar conclusion was drawn in relation to the complexity of
the 'operational' definitions and classification of somatoform
disorders, which require consideration of multiple and often
incongruent aspects of the underlying somatization process, including
patients' interpretation of somatic symptoms, selective focusing of
attention onto bodily sensations, sensitization (inability to
tolerate somatic symptoms) and patient illness behaviour.

The expert group agreed that a broader conceptualization of the
concept of somatization is needed, which would place more emphasis on
the biological and pathophysiological aspects of somatoform disorders.

In a more recent editorial, Sharpe and Mayou [5••] further elaborated
on problems with the classification of somatoform disorders. They
pointed out that, although the currently used system is supposed to
be aetiologically neutral, its main theoretical limitation is the
assumption of psychogenesis of this group of disorders.

The authors stated that the diagnostic category of somatoform
disorders has also been unhelpful by perpetuating the body-mind
dualism.

They concluded that the abolition of this diagnostic concept and
classification category disorders would have a positive impact on
both medicine and psychiatry. This insightful review finishes with
the following question:

"Does diagnosing these somatic symptoms as somatoform disorders help
or hinder us, not only in our efforts to understand and treat this
neglected group of patients, but also in our overall approach to
human illness?"

Such a question resonates with conclusions of some other reviewed
papers, which point out that somatoform disorders have been a
neglected problem in both adult and old age psychiatry. In view of
the fact that they are common, disabling and costly medical
conditions, it is recommended that they should be given more priority
in teaching, training and research in psychiatry [6,7].

In an interesting debate on the pros and cons for replacing the
current classification of medically unexplained syndromes with the
concept of 'a general functional somatic syndrome', Wessely [8•]
argued that the rationale for such a decision could be based on the
following facts:

(1) every specialty in medicine has its own 'unexplained' syndrome;

(2) there is a big overlap between two or more of the medically
unexplained syndromes currently in use;

(3) the outcomes of these conditions are often very similar; and (4)
almost all of them have links or are comorbid with depression and
anxiety.

Representing the opposite view in this stimulating debate, White
stated that the concept of 'a general functional somatic syndrome'
supports the mind-body dualism and psychogenesis of the condition,
which is unhelpful in understanding its aetiology and does not lead
to better treatment, prognosis and outcome of the disorder.

According to White, illnesses characterized by unexplained physical
symptoms are best considered in an integrated way, that is when
paying equal attention to body, mind and social context.

The lay meaning of the term 'psychosomatic' and its social
connotations have been examined by Stone et al. [9•], who
systematically reviewed a large number of articles published in US
and UK newspapers between 1996 and 2002.

They found that in about one-third of the reviewed articles, the
term 'psychosomatic' had a pejorative meaning, such as 'imaginary'
or 'made up'. In more than 50% of cases, the term 'psychosomatic' was
used to describe a process that was essentially seen as psychological
(i.e. in which mind affects the body) rather than as a reciprocal and
primarily somatic interaction (5%).

The authors concluded that much more needs to be done to educate the
media about the actual meaning of the term so as to make it less
stigmatizing and more acceptable to patients, families and the
general public.

Exploring evidence
In a systematic review of the articles published in English since
1966, Creed and Barsky [10••] examined the prevalence,
characteristics and associated features of somatization disorder and
hypochondriasis in population-based and primary care samples.

They found that the prevalence rates of somatization disorder and
hypochondriasis were too low to examine associated features in a
reliable way. In studies using less stringent criteria for these two
disorders, there was a consistent relationship with low education but
no expected female predominance was found in either disorder.

A comparative analysis of several longitudinal studies showed that
there was a close relationship between somatoform, anxiety and
depressive disorders, with a linear relationship between numbers of
somatic and other symptoms of personal distress.

However, none of the reviewed studies showed that these symptom
clusters fulfill the required onset, duration and outcome criteria
necessary for the status of discrete mental disorders.

Consequently, the authors concluded that somatization disorder and
hypochondriasis cannot be regarded as definite nosological categories
in spite of the fact that the presence of illness worry or multiple
somatic symptoms may be associated with impairment in social
functioning and high health care utilization.

Such a bold conclusion is based not only on the considerable
evidence that these disorders are closely linked to anxiety and
depressive disorders, but also on very few research findings which
support their distinction from one another.

A number of other recently published papers reported high prevalence,
significant functional impairment and substantial comorbidity between
somatoform and other mental disorders in the general population as
well as in primary care, general medical and internal medicine
settings.

In a two-stage prevalence study of somatoform, anxiety and
depressive disorders, de Waal and colleagues [11] used a semi-
structured and clinician-administered interview schedule on a sample
of more than 1000 patients in general practice and found that the
prevalence rate of somatoform disorders was above 16%. When
somatoform disorders resulting only in mild impairment were included
in the analysis, their prevalence rate increased to 21%. Comorbidity
between somatoform and anxiety/depressive disorders was found to be
3.3 times more likely than expected by chance. In patients with such
comorbid disorders, physical symptoms, depressive symptoms and
functional impairments were found to be additive.

The prevalence of somatoform disorders and their comorbidity with
other ICD-10 (10th revision of the International Classification of
Diseases) and DSM-IV (Diagnostic and Statistical Manual of Mental
Disorders, fourth edition) mental disorders was explored in a sample
of about 300 internal medicine inpatients in Denmark. Fink et al.
[12] found marked differences between their rates across the two
diagnostic systems (i.e. a total of 18.1% of the patients fulfilled
diagnostic criteria for an ICD-10 disorder and 20.2% for a DSM-IV
disorder).

The prevalence of specific somatoform disorders was also markedly
different across the two diagnostic systems, for example,
somatization disorder was more prevalent in the ICD-10 (5%) than in
the DSM-IV (1.5%) equivalent. Interestingly, quite the contrary was
found in the undifferentiated somatoform disorder category (0.7% in
ICD-10 and 10% in DSM-IV). The study also found that somatoform
disorders were more prevalent in younger women and that 36% of the
patients with somatoform disorders had another comorbid psychiatric
condition (11% depression, 25% an anxiety disorder).

Another epidemiological study was recently carried out in the context
of the German National Health Interview and Examination survey, which
used the Munich version of the Composite International Diagnostic
Interview [13].

A multi-stratified random sample of about 4000 representatives of
the German general population were assessed by the instrument which
generated computerized DSM-IV diagnoses. According to the results of
this study, the overall prevalence of mental disorders was 31%, with
anxiety, mood and somatoform disorders being the most frequent DSM-IV
diagnoses. Comorbidity rates among these disorders ranged from 44 to
94%, which also had an impact on the health service utilization (30%
in 'pure', 76% in highly comorbid cases). Socio-demographic
correlates of increased rates and comorbidity between somatoform and
other mental disorders were female gender, not being married, low
social class and poor physical health.

Comparing cultures
In order to examine differences and similarities in rates and other
characteristics of somatoform disorders across cultures and settings,
several investigators revisited the data collected in the Study of
Psychological Problems in General Health Care, which was carried out
by the World Health Organization (WHO) in 14 countries using a
primary care modification of the Composite International Diagnostic
Interview.

Gureje [14•] examined the extent of cross-cultural variations and
correlates of somatic distress (related to diagnoses of somatization,
hypochondriasis and persistent pain disorder) to determine if it
could be ascribed to cultural differences. He found that somatic
distress varied in its occurrence across cultures but, with the
exception of Latin America, the pattern of these differences did not
follow clear cultural lines.

In a secondary analysis of the same WHO data set, Skapinakis and
colleagues [15] explored cross-cultural variation in prevalence rates
of unexplained fatigue as a presenting complaint in primary care. The
prevalence rate of unexplained fatigue differed across participating
centers with a range between 2.2 and 15%.

Participants from more developed countries were more likely to
report unexplained fatigue but were less likely to present with it to
primary care physicians (compared with those from less developed
countries). The authors postulated that in less-developed countries,
unexplained fatigue may be an indicator of unmet psychiatric need,
while in more-developed countries it probably represents a symbol of
psychosocial distress.

A number of recently published studies found no significant cross-
cultural differences in rates and socio-demographic correlates of
somatoform and other mental disorders. For example, a large mental
health survey was carried out in Iran involving 35 000 individuals
screened by the General Health Questionnaire.

According to the results of the subsequent clinical interviews by
local general practitioners, about 21% of interviewed household
members had experienced depressive or anxiety symptoms and 18% had
medically unexplained somatic symptoms. The symptom rates increased
with age and were higher in women, married, widowed, divorced,
unemployed and retired people.

In spite of the wide regional difference in the country, the authors
concluded that the prevalence rates and socio-demographic correlates
of somatoform and other mental disorders in Iran were comparable with
international studies [16].

No difference with the international research results was found in a
household survey of mental disorders among elderly people in the
United Arab Emirates. About 600 participants were assessed using the
Geriatric Mental State Interview administered by trained, Arab-
speaking interviewers. The mean age of the interviewees was 68 years
and the most commonly diagnosed mental disorders were depression
(20.2%), anxiety (5.6%) and hypochondriasis (4.4%). The prevalence
rates of these disorders showed significant correlation with female
gender, insufficient income, being separated, divorced or widowed
[17].

Notwithstanding the cross-cultural similarities in the frequency of
somatoform disorders, during the period of this review there have
been a number of studies highlighting the importance of culture-
specific somatic manifestations, including a study of jiko-shu-kyofu
(an olfactory reference syndrome that represents a subtype of taijin-
kyofu) in Japan [18], a study of psychosomatic symptoms and syndromes
in India [19], a study of somatic symptoms of depression in Nigeria
[20] and a study of illness beliefs of depressed Chinese-American
patients in a primary care setting in the USA [21].

Examining specific syndromes
In a state-of-the-art literature review, Afari and Buchwald [22••]
reviewed 230 scientific papers and discussed the case definition,
prevalence, clinical presentation, assessment, prognosis,
pathophysiology and treatment of CFS.

This impressive piece of metaanalytic work summarized the current
state of knowledge on CSF - a still controversial diagnostic entity
characterized by disabling fatigue of at least 6 months' duration and
accompanied by a mixture of psychological and somatic symptoms such
as impaired memory or concentration, sore throat, aching or stiff
muscles, unrefreshing sleep, etc.

The results of this comprehensive review show that the
pathophysiological abnormalities exist across many CFS domains,
suggesting that it is heterogeneous condition of multifactorial
etiology.

Although CSF significantly overlaps with a number of mental
disorders, several lines of research suggest that it may be a
distinct and not exclusively a mental health condition.

The most recent research findings on CSF suggest that physiological
and psychological factors work together to predispose, precipitate
and perpetuate this illness. Consequently, its assessment, treatment
and management should be multidimensional and tailored to individual
patients.

In a similarly comprehensive review of the current state of knowledge
on psychological aspects of persistent pain, Keefe and colleagues
[23••] examined factors associated with increased/decreased pain as
well as factors associated with poorer/improved adjustment to pain.

They also explored an impressive amount of literature on various
behavioural and psychosocial aspects of persistent pain and drew the
following conclusions: (1) further research is required to develop
more comprehensive and integrative conceptual models of persistent
pain; (2) social context of pain requires increased attention; (3)
links between psychological factors and pain-related brain activation
mechanisms have to be further explored; and (4) investigations of
mechanisms underlying the efficacy of psychological treatment for
pain should be continued.

Persistent pain as a syndrome was also examined in a number of recent
research studies focusing on the validity of diagnosis of somatoform
pain disorder [24], the role of psychogenic and somatic factors in
the etiology of chronic pain disorder [25] and the relationship
between the experience of pain and somatization [26].

A common denominator and a general conclusion of these studies
appears to be the paucity of differences and significant overlap
between the pain and other somatoform syndromes which, according to
Binzer and colleagues [25], 'pose one more piece of evidence for the
futility of the dichotomous organic vs. psychogenic distinction of
chronic pain disorders' (p. 61).

Evaluating treatments
Using Medline as a data source, Fallon [27•] identified all
scientific papers published between 1970 and 2003 on pharmacotherapy
of somatoform disorders, selecting the best-designed studies for
inclusion in his review.

The review revealed that patients with the obsessional cluster of
somatoform disorders (i.e. hypochondriasis and body dysmorphic
disorder) tend to respond well to serotonin reuptake inhibitors.
However, no controlled trials have been conducted on the
pharmacological treatment of patients with a primarily somatic
cluster of somatoform disorders (i.e. somatization and pain
disorder), which are particularly common across health care settings
and substantially contribute to public health expenditures.

Another literature review including a qualitative comparison of
information on understanding and treatment of medically unexplained
somatic symptoms was carried out by Burton [28]. He found that
cognitive behaviour therapy (CBT) and antidepressant drugs are both
effective treatments, but their effects may be greatest when patients
feel empowered by their doctors to tackle their problems.

A couple of interesting placebo-controlled trials have recently been
published reporting on the efficacy of St John's wort in the
treatment of somatization disorder, undifferentiated somatoform
disorder and somatoform autonomic dysfunction [29,30]. A set of
standardized assessment instruments and outcome measures was used in
both studies and the data showed excellent efficacy, tolerability and
safety of St John's wort, independent of any existing depressive
symptomatology.

The effectiveness of CBT in the treatment of patients with somatoform
disorders and hypochondriasis has been explored in a number of
European and American studies. For example, Bleichhardt and
colleagues [31•] compared two types of 'standard' CBT treatments to
evaluate the differential efficacy of the 'soma' group management
training. The 'soma' management program was added to the 'standard'
CBT treatment of one of the two patient groups, each presenting with
eight or more somatoform symptoms. After a 12-month follow up, all
outcome measurement criteria were significantly reduced and the
differential effect of the additional 'soma' treatment was
particularly significant in the reduction of presenting somatoform
symptoms and doctor visits.

In a randomized control trial, Barsky and Ahern [32•] assessed the
efficacy of an individual CBT developed specifically to alter
hypochondriacal thinking and restructure hypochondriacal beliefs. A
total of 102 individuals were assigned to this type of CBT and
another 85 were assigned to medical care as usual. At 12-month follow-
up, CBT patients had significantly lower levels of hypochondriacal
symptoms, beliefs, attitudes and health-related anxiety. They also
had significantly less impaired social role functioning, including
activities of daily living. The authors concluded that this brief,
individual CBT intervention appears to have significantly beneficial
long-term effects on the symptoms of hypochondriasis.

Estimating costs
It has been well documented that patients with somatoform disorders
are frequent users of various types of health services and this
persistent help-seeking behaviour pattern is tremendously expensive
and creates a burden on health services all over the world. Reid and
colleagues [33] compared health care use and costs of patients
presenting with medically unexplained somatic symptoms and other
frequent attenders in secondary care.

Of the frequent attenders, 17% had two or more medically unexplained
consultation episodes. These patients also had a greater number of
referrals to secondary care and were more likely to undergo
particular medical investigations. The authors concluded that
frequent attenders with medically unexplained symptoms account for
levels of service use and expenditure that are comparable with other
frequent attenders, but the use and cost of medical investigations in
this group are significantly higher (74.5 and 85.9% of total
outpatient care costs for somatizing and nonsomatizing frequent
attenders, respectively).

Hiller and Fichter [34•] recently completed a study of somatizing
patients with the aim of finding out if the high medical costs can be
predicted from patient characteristics, psychopathology and CBT
treatment response. High utilizers had higher levels of self and
observer-rated illness behaviour, self-perceived bodily weakness, and
psychosocial disabilities. Although they did not report more
somatoform symptoms, their subjective symptom distress was higher.

There were no differences between high and average utilizers
concerning general psychopathology, comorbidity and personality
profiles. Although there was a similarity in the treatment outcomes,
the authors concluded that high and average-utilizing somatizers
represented distinguishable patient subgroups. The results of this
study emphasize the importance of some underlying mechanisms
specifically related to somatoform distress, which may facilitate
early detection of patients who are likely to develop an inclination
for the costly overutilization of health services.

Conclusion
This paper represents a review of the recently published scientific
literature in the area of somatoform disorders. It covers the field
from a number of different perspectives including historic reviews;
conceptual, terminological and nosological debates; analyses of
epidemiological evidence; cross-cultural comparisons; development and
evaluation of novel treatment and management strategies; service use
and related health care costs. It may be of interest to note that in
the period covered by this overall review, there have been several
other review papers focusing on specific aspects and particular
categories of somatoform disorders. Such a coincidence made the task
of this reviewer somewhat easier and a bit more challenging (how to
review a review?).

The general conclusion of many papers included in this review is that
the current concept of somatization and diagnostic criteria for
somatoform disorders have serious theoretical and practical
limitations in both research and clinical settings. There is an
almost unanimous agreement amongst the authors that the time has come
to seriously rethink the concept of somatization and
its 'operationalization' and translation into diagnostic categories.

The discussions about the next revision of the international
classificatory systems in psychiatry and medicine are already under
way and it is hoped that this review will make a contribution to this
complicated and laborious process.

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Res 2004; 56:455-460. The author provides a very comprehensive
overview of the pharmacological treatment of somatoform disorders
covering more than 30 years of research in this complex and
controversial area.

28 Burton C. Beyond somatisation: a review of the understanding and
treatment of medically unexplained physical symptoms (MUPS). Br J Gen
Pract 2003; 53:231-239.

29 Volz HP, Murck H, Kasper S, Moller HJ. St John's wort extract (LI
160) in somatoform disorders: results of a placebo-controlled trial
Psychopharmacology 2002; 164:294-300.

30 Muller T, Mannel M, Murck H, Rahlfs VW. Treatment of somatoform
disorders with St. John's wort: a randomised, double-blind and
placebo-controlled trial. Psychosom Med 2004; 66:538-547.

31 Bleichhardt G, Timmer B, Rief W. Cognitive-behavioural therapy
for patients with multiple somatoform symptoms: a randomised
controlled trial in tertiary care. J Psychosom Res 2004; 56:449-454.
A methodologically sound project which evaluated the benefits of a
novel method of CBT specifically designed for patients with multiple
and medically unexplained somatic symptoms.

32 Barsky AJ, Ahern DK. Cognitive behaviour therapy for
hypochondriasis: a randomised controlled trial. JAMA 2004; 291:1464-
1470. An individual CBT intervention method was evaluated in an
interesting follow-up study of patients with hypochondriacal
symptoms.

33 Reid S, Wessely S, Crayford T, Hotopf M. Frequent attenders with
medically unexplained symptoms: service use and costs in secondary
care. Br J Psychiatry 2002; 180:248-253.

34 Hiller W, Fichter MM. High utilisers of medical care: a critical
subgroup among somatising patients. J Psychosom Res 2004; 56:437-443.
The authors describe a methodologically sound project and quite
interesting results, which could be used in the development of some
strategies for early detection of somatizing patients who might
become frequent and costly users of health care services.


© 2005 Lippincott Williams & Wilkins, Inc.