- reduce physiologic arousal though relaxation techniques
- enhance activity regulation through increasing exercise and meaningful pleasurable activities and pacing activities
- increase awareness of emotions
- modify dysfunctional beliefs
- enhance communication of thoughts and emotions
- reduce spousal reinforcement of illness behavior.
Psychotherapy’s success in these and other studies supports the idea that somatoform spectrum disorders resemble other conditions—such as mood and anxiety disorders—that respond to psychological treatment.
Antidepressant therapy
Controlled trials also have shown that some antidepressants are more effective than placebo in improving somatoform symptoms.
St. John’s wort. In a randomized, placebo-controlled, double-blind trial, 184 patients with somatoform disorders but not major depression received St. John’s wort extract, 300 mg bid, or placebo. After 6 weeks, 45% of patients responded to St. John’s wort, compared with 21% for placebo (P=0.0006). Six measures determined response; St. John’s wort and placebo were equally well tolerated.16
Consultation letter for somatization: Discourage saying ‘it’s in your head’
Extended-release venlafaxine. A pilot study enrolled 112 adult primary care patients with multisomatoform disorder (≥3 medically unexplained, bothersome physical symptoms plus ≥2-year history of somatization) and comorbid major depressive disorder, generalized anxiety disorder, or social anxiety disorder. Patients were randomly assigned to double-blind treatment with venlafaxine ER, ≤225 mg/d (n=55), or placebo (n=57).Describe somatoform disorder, its relapsing course, and low morbidity and mortality rates
Encourage the primary care physician to:
- serve as the patient’s primary doctor and avoid fragmented care from numerous sources
- schedule regular appointments with the patient
- perform physical exams at each visit
- eliminate unnecessary tests or hospitalizations
- avoid statements such as “it’s all in your head” when medical tests are negative
Primary outcome was change in the 15-item Patient Health Questionnaire (PHQ-15) somatic symptom severity score. After 12 weeks, PHQ-15 scores declined significantly (P P=0.097). Among secondary measures, venlafaxine ER was more effective than placebo in improving bodily pain (P=0.03), physical symptoms (P=0.02), and anxiety (P=0.02).17
Citalopram. In an 8-week trial, investigators compared the efficacy of a selective serotonin reuptake inhibitor (SSRI) and a selective noradrenaline reuptake inhibitor (SNRI) on pain symptoms in 35 patients with somatoform pain disorder. Patients were randomly assigned to double-blind treatment with the SSRI citalopram, 40 mg/d (n=17), or the SNRI reboxetine, 8 mg/d (n=18).
In patients receiving citalopram, scores decreased significantly from baseline on the Present Pain Intensity scale (3.5 vs 2.8, P=0.045) and Total Pain Rating Index of the McGill Pain Questionnaire (41.9 vs 30, P=0.004), but these scores did not change significantly in patients receiving reboxetine. Depression symptoms, as measured by the Zung Self-Rating Depression Scale, did not change significantly in either group.
The authors concluded that citalopram was moderately effective for somatoform pain disorder in this small trial. Although antidepressants’ efficacy for somatoform symptoms may be mediated through changes in comorbid mood and anxiety disorders, these authors observed that citalopram’s analgesic effect appeared to be independent of how patients rated their depressive symptoms.18
Treatment recommendations
Based on the evidence and our experience, we recommend offering CBT to patients with recent symptom onset and insight into their comorbid mood and anxiety disorders. If the patient does not improve after 8 to 12 sessions, consider adding an antidepressant such as:
- citalopram, 20 to 60 mg/d
- venlafaxine XR, 150 to 375 mg/d.
Side effects are a frequent concern in this patient population, so titrate dosages slowly. Aim for the target antidepressant dosages used to treat major depression, and avoid declaring a treatment failure without first completing adequate trials. Once the patient is stable on medication, continue for a least 1 somatization-free year.
Allow patients to discuss their physical concerns, and attempt to support them in their suffering. At the same time, help them focus on attaining realistic goals for occupational and social functioning.
Work closely with the primary care provider in treatment planning to avoid sending the patient mixed messages. Communicating in the spirit of respect and collaboration with primary care colleagues can help prevent “splitting,” in which the patient may come to idealize one practitioner and devalue the other.
Remember that patients with somatization can become medically ill. Remind their primary care providers to perform expected evaluations as dictated by objective findings.
Related resources
- VHA/DoD clinical practice guideline for the management of medically unexplained symptoms: chronic pain and fatigue (brief summary). www.guideline.gov/summary/summary.aspx?doc_id=3415.
- Abbey SE. Somatization and somatoform disorders. In: Levenson JL, ed. The American Psychiatric Publishing textbook of psychosomatic medicine. Washington, DC: American Psychiatric Publishing; 2005:271-96.