The term “somatoform disorders” refers to several distinct disorders, each characterized by strict diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. These conditions include somatization disorder, conversion disorder, pain disorder with psychological factors, hypochondriasis, body dysmorphic disorder, somatoform disorder not otherwise specified, and undifferentiated somatoform disorder. Two other conditions, factitious disorders and malingering, differ from the somatoform disorders in that the patient consciously produces the symptoms of the disorder.
A logical, stepwise, conservative, and evidence-based approach to diagnosis is recommended in the evaluation of patients with suspected somatization symptoms. Because of the lack of evidence supporting medications to treat somatoform disorder, nondrug therapies are the primary treatments. Psychotherapeutic treatment options include relational therapy, cognitive-behavioral therapy, and psychodynamic psychotherapy. This article contains a discussion of etiology, diagnosis, and treatment approaches, and of the rationale for treating patients with somatoform disorders in the primary care setting.
(Adv Stud Med. 2003;3(8):438-447)
Patients visit physicians seeking treatment for symptoms of disease (physical or emotional complaints); physicians examine their patients for signs of disease. Physicians are trained to use the information from the history and examination to make a diagnosis that guides treatment. Satisfaction for the physician arises from the ability to perform these tasks proficiently and to see the patient benefit. Difficulties may arise when the physician is unable to identify the cause of the patient’s symptoms.
Somatization may be defined as the experience and reporting of physical symptoms that cause distress but lack corresponding tissue damage and cannot be entirely explained by the findings on physical examination, laboratory tests, or radiologic studies. The symptoms suggest an underlying medical or neurological condition, but no such etiology is discovered. Moreover, the symptoms of somatization are linked to psychosocial stress in the patient’s life. They may be transient and present only during a period of significant stress. In these cases, the presentation may consist of an exaggeration of common physical symptoms, such as headache or muscle tension. In other cases, the symptoms are more persistent and may even have been present since childhood.1
If told that no medical cause for their symptoms has been found, affected individuals may be reassured and relieved; or they may become upset and accuse the clinician of incompetence, or of not believing them. They may demand continued diagnostic testing or referrals to specialists. Or they may be resistant to referrals to mental health professionals and refuse to view their condition as anything other than a physical problem. However, somatization symptoms do not respond to the medical treatments that are prescribed for the disease suggested by the symptoms. The combination of this apparent therapeutic failure and increasing demands made by patients can be frustrating for the primary care physician.2
Somatization is ubiquitous in primary care settings. In one study, no medical cause was found for more than 80% of primary care visits scheduled for evaluation of common symptoms, such as fatigue, chest pain, or dizziness.3
In contrast to the more generalized term “somatization,” “somatoform disorders” are a more limited range of distinct disorders with specific diagnostic criteria defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. When compared with the phenomenon of somatization, somatoform disorders are relatively rare in the primary care outpatient setting. Only 0.13% of individuals in the general population meet the criteria for somatoform disorder, as do 5% of patients in family practice clinics.4 Because physician training emphasizes identification and treatment of diseases with a discernable cause, many physicians are not immediately able to recognize somatoform disorders. In a recent study, 17.6% of inpatients on an internal medicine service were found to have undiagnosed somatoform disorders.5
Prior to the Renaissance, anatomic knowledge was limited, and diseases were often believed to result from gross disturbances in the behavior of bodily organs. For example, hysteria in women was attributed by the ancient Greeks to a “wandering uterus.”6
Following the Renaissance, disturbances of the nervous system were implicated in unexplained medical symptoms. Treatments utilized by clinicians of the time did not advance; some neurologists in the latter half of the 17th century advocated hitting patients who exhibited hysteria symptoms with a stick to get the nervous system to work properly.7
By the end of the 17th century, however, clinicians increasingly recognized the role of psychological factors in the origin and maintenance of somatization symptoms. They no longer focused exclusively on somatic therapies, demonstrating an interest in the mental state and welfare of their patients. They were aware of the need to instill in patients a sense of optimism about recovery.
In the 19th century, clinicians recognized that patients suffering from somatization symptoms lacked observable anatomic abnormalities. Somatization was regarded as the consequence of a functional abnormality in the nervous system. Some practitioners maintained that psychological treatments were important. They recognized that therapy must be consistent with the patient’s belief that his or her illness had a physical etiology or the intervention would be rejected.
The rise of psychoanalysis under Freud and his followers at the turn of the 20th century resulted in a significant change in the understanding and treatment of somatization. An exclusively psychological model was proposed. The idea of a functional disturbance of the nervous system was replaced by the concept of psychogenesis, which held that unconscious or repressed mental conflicts had become manifest as physical symptoms. Supporters of the psychogenesis theory believed treatment should focus on uncovering the unconscious conflict so the physical symptoms would become unnecessary.
The concept of psychogenesis represented a major change in the understanding of somatization and has both advantages and disadvantages. An advantage was the attention given to developing effective psychological treatments. Eventually, psychiatrists and psychologists would understand the benefit of utilizing newer approaches, such as cognitive-behavioral therapies and psychotropic medications. A disadvantage was the limited integration of these treatments into general medical practice, not to mention the lack of acceptance by patients who were told, “It’s all in your head.”
Today a paradigm shift is under way: unexplained somatic symptoms are again being considered a functional disturbance of the nervous system and treatments are being integrated into the realm of primary care. Not only is this approach often more acceptable to the patient; it is frequently more cost efficient and effective.8
Today, symptoms of somatization are explained using neurobiological, psychodynamic, cognitive-behavioral, sociocultural, and biopsychosocial theories. Although none of these theories has been proven correct, each provides a framework for understanding the symptoms and suggests methods for treating patients.
The neurobiological theory maintains that symptoms result from dysfunction in the neuroendocrine systems responsible for processing peripheral sensory and central emotional information.9 According to this theory, affected individuals describe more minor autonomic sensations and interpret them in a catastrophizing manner.10 They also misperceive normal bodily sensations or emotional signals as evidence of a dangerous somatic process.10 They report higher levels of tension in novel situations and are less likely to habituate to the situation over time.11 Affected individuals also have altered physiological responses. Compared to unaffected individuals, their heart rates show a slower return to baseline upon leaving stressful situations.11 Researchers have suggested that hypocortisolism plays a role in posttraumatic stress disorder, fibromyalgia, chronic fatigue syndrome, and some chronic pain disorders.12 Although hypocortisolism has been found in groups of individuals with the above diagnoses, the relationship between a cortisol deficiency and the symptoms of these disorders is not understood.
As discussed by Freud and his followers, the psychodynamic theory holds that somatization symptoms arise solely from the mind. They represent the outward expression of internal psychological conflicts that the individual finds too unacceptable to reveal consciously. Affected individuals show an increased incidence of prior emotional and physical abuse, depression, and anxiety. It is hypothesized that abuse places one at risk.13,14 For example, a woman who was sexually abused as a child may be unable to discuss her feelings of shame and anger. Over time, she may develop chronic pelvic pain that prevents her from engaging in sexual intercourse.
Cognitive-behavioral theorists believe that the way individuals interpret experience determines how they feel and behave. In somatization, symptoms arise from incorrect beliefs about bodily sensations and functions. The affected individual incorrectly attributes a benign physical sensation (eg, shortness of breath and muscle tension after a hard day’s work) to a dangerous pathologic process (eg, a heart attack). The misperception results in maladaptive behaviors, such as refusal to work or exercise for fear of exacerbating the physical symptom, or repeatedly seeking emergency medical attention. The symptoms may be reinforced by factors in the individual’s environment, such as public education about the symptoms of a heart attack. The affected individual interprets minor sensations as evidence of the presence of the disease, while evidence contradicting this belief is ignored. Further, the patient may unconsciously receive benefits from these symptoms, such as a means to cope with anxiety, depression, and interpersonal conflict, resulting in increased attention and support from others. When the somatization symptoms are rewarded in these ways, the affected individual may have difficulty relinquishing these symptoms.
The sociocultural theory of somatization holds that the patient’s culture affects the manner in which somatic representations of emotional distress are expressed. If the clinician and the patient are from different cultures, they may have different ideas about what constitutes appropriate behavior. These cultural interactions play an important role in shaping the relationship between the clinician and the patient. If the cultural idioms of distress are not recognized, the patient may be misdiagnosed and effective treatment delayed. For example, Korean patients may describe having “hwa-byung” or “fire illness.” This term refers to symptoms of epigastric burning (and other forms of somatic distress) as well as to anger due to interpersonal conflict. If the clinician is able to recognize the symptoms as a means of communicating emotional distress, costly diagnostic workups may be avoided and efforts may be directed toward addressing the patient’s social and psychological needs.15,16
The seemingly all-inclusive biopsychosocial theory of somatization holds that every disease has a biological aspect, a psychological aspect, and a social aspect. Illness occurs along a spectrum, with disorders characterized by predominantly somatic problems (such as diabetes) at one end, and disorders with predominantly psychological manifestations (such as depression) at the other end. Because patients with somatization symptoms tend to neglect the psychosocial aspects and focus on biological symptoms, evaluation should routinely include inquiries into both the physical and the psychosocial dimensions of their illness.17
The expression “somatoform disorders” refers to several conditions characterized by strict diagnostic criteria: somatization disorder, conversion disorder, pain disorder with psychological factors, hypochondriasis, body dysmorphic disorder, somatoform disorder not otherwise specified, and undifferentiated somatoform disorder. Two other conditions, factitious disorder and malingering, differ from somatoform disorders because the patient consciously produces the symptoms (Table 1).
Somatization disorder. This disorder typically begins before age 30 years and endures for many years. It involves a combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms. The defining feature is the persistence of multiple-system symptoms without structural abnormalities, lab abnormalities, or physical findings characteristic of the medical condition suggested by the symptoms. The patient unconsciously produces symptoms and actually perceives them as real.
Conversion disorder. In conversion disorder, voluntary motor or sensory function deficits suggest a neurological or other general medical condition. No underlying condition can be identified to explain the symptoms. Since many medical etiologies for apparent conversion syndromes can take years to become evident, the diagnosis should be made conservatively and be viewed as provisional.
Pain disorder with psychological factors. This disorder is characterized by unexplained pain in 1 or more anatomic sites. Psychological factors are judged to have an important role in the onset, severity, exacerbation, and maintenance of the pain.
Hypochondriasis. Hypochondriasis is a preoccupation with the fear of contracting, or the idea that one already has, a serious disease based on the individual’s misinterpretation of bodily symptoms. The fear persists despite a lack of evidence supporting the “diagnosis” on examination and does not respond to reassurance.18
Body dysmorphic disorder. This disorder involves a preoccupation with an imagined or exaggerated defect in the patient’s physical appearance. Patients can become obsessed to the point of being almost delusional.19
Somatoform disorder not otherwise specified. This disorder is general somatization. It refers to any somatoform disorder that does not meet the criteria for any of the other more specific disorders. One example is pseudocyesis — the false belief that one is pregnant — which is often accompanied by signs of pregnancy, such as missed menstrual periods and abdominal distention.
Undifferentiated somatoform disorder. This disorder entails the presence of 1 or more physical complaints that persist for 6 months or longer. The symptoms cannot be explained by any general medical condition, or they are grossly out of proportion to what would be expected by history, physical examination, or laboratory evaluation.
Factitious disorder. Factitious disorder is characterized by the intentional, conscious production of symptoms. The symptoms are fabricated or exaggerated, but there is no discernible external incentive (eg, financial compensation) to produce the symptoms. The patient may not even know why he or she is doing this. The individual’s only apparent goal is to assume or continue to assume the role of sick patient. Factitious disorder and somatization can often be approached and treated similarly, as both are based on the unconscious motivation to embrace the role of sick patient.
Malingering. In malingering, the individual also consciously produces symptoms, but the motivation involves an apparent external gain. These gains may include obtaining a monetary award in a lawsuit, acquiring drugs from a physician, or avoiding an undesirable situation, such as military duty or incarceration. It is important to note that malingering is not considered a mental disorder.16,20
A logical, stepwise, conservative, and evidence-based approach is recommended in the evaluation of patients with suspected somatization symptoms (Table 2). This approach can help prevent unnecessary and costly diagnostic procedures or referrals to specialists. It can also spare the patient potential iatrogenic complications from any of the evaluation procedures.21
The stepwise nature of the evaluation presented below is designed primarily for conceptual clarity. Clinically, it is more useful to recognize the interplay between the physical and psychosocial realms and consider multiple etiologies simultaneously. This approach saves the clinician time, circumvents the appearance of dismissing the patient’s concerns, and avoids relegating psychosocial issues to a secondary position. It also encourages patients to appreciate the interplay of physical and psychosocial issues.
The first step is a careful, detailed, and thorough history of the presenting problem, including a review of the patient’s pertinent medical records. This may include consulting with the patient’s prior physicians, as well as with the spouse and other family members. The physician should then perform appropriate physical and neurological examinations and consider which tests are indicated to confirm or rule out a biomedical disease. The tests should be minimally invasive and able to provide the highest yield of useful information. The urge to order a wide variety of tests (“the shotgun approach”) should be resisted. This is true even though patients often encourage such an approach and may readily submit to unpleasant procedures. Obtaining an informal and objective consultation from a colleague can be useful in determining the appropriate approach to evaluation.
Once it has been determined that the patient’s physical symptoms are not explained by underlying pathologic abnormalities, the focus can turn to psychological disorders. Assessment can be accomplished through a careful clinical interview, a semistructured interview tool, and/or referral to a mental health specialist. The clinical interview can help establish the presence of psychiatric illness and offers the added benefit of communicating the physician’s interest in the individual. Standardized instruments, such as the PRIME-MD Patient Health Questionnaire,22 the Beck Depression Inventory,23,24 or the Carroll Depression Scales,25,26 can be rapidly administered in the waiting room, are easily scored, have established validity, and, depending on the instrument selected, can help screen for a variety of psychiatric conditions. Mental health referrals are not likely to be accepted by many patients, at least initially, because of the implication that their complaints are being dismissed.22,25-28
Although the use of psychotropic medications is promising, they have been studied only in a small number of patients with somatoform disorders. Therefore, evidence is limited regarding the effectiveness of drugs in treating these patients. In an open-label study, gabapentin 1200 to 1600 mg per day was effective in treating somatization disorder when pain was the main symptom. The patients showed improvement in the following areas: self-assessed and physician-assessed global level of functioning, and physician-assessed symptomatic improvement. The study did not, how-ever, find a significant improvement in the subjects’ anxiety and depression.26
Medications that increase the level of serotonin in the central nervous system have also been found to be effective in some somatoform disorders. Fluvoxamine and clomipramine have been studied in patients with body dysmorphic disorder. Treated patients improved significantly, even if they seemed to have delusional beliefs about their bodies. This indicates that even patients with body dysmorphic disorder, who may have a psychotic level of disturbance about their bodies, can improve without antipsychotic medication.28,29
Others have examined the nociceptive properties of antidepressant medications. Fishbain reviewed published studies of the pain-relieving effects of antidepressant medications and found that medications with combined serotonin-norepinephrine action have more consistent analgesic properties than those with only serotonin action.30 In addition, a meta-analysis of existing randomized, placebo-controlled trials of the analgesic effect of antidepressants in patients with psychogenic and somatoform pain disorders revealed that patients treated with antidepressant medication had a significant decrease in pain intensity.31
A key component in the pharmacologic management of somatization is providing the affected individuals with symptomatic relief. However, this can be a complex process. For example, many patients will present with pain, insomnia, or muscle tension. It is often tempting to utilize opiate or sedative medications (eg, benzodiazepines or barbiturates) in these situations. However, these medications carry a significant risk of abuse, especially when considering the chronic nature of these symptoms in many individuals. As a result, it is prudent to avoid these medications in this setting.
Due to the lack of evidence supporting the use of medications to treat somatoform disorders, nondrug therapies are the primary treatments at the present time. Treatment strategies for individuals with somatoform disorders are not diagnosis specific. As a result, it is less important to make a specific psychiatric diagnosis than it is to recognize that the patient’s symptoms represent somatization. The exception to this approach occurs when a psychiatric disorder — such as anxiety, depression, or psychosis — is identified as driving the somatic symptoms. In these cases the treatment should focus on treating the underlying disorder.32
Psychotherapeutic treatment options include relational therapy, cognitive-behavioral therapy, and psychodynamic psychotherapy (Table 3).
Relational therapy. Relational therapy is based on the idea that illnesses such as somatization develop within the context of the family. Therefore, to be effective, the treatment must take place within this environment. The patients being treated and their family members must learn to integrate the biological and psychosocial aspects of their illness. The physician takes a collaborative stance with the patient and the patient’s family toward treating the illness and demonstrates true interest in and curiosity about the patient’s symptoms, family, relationships, and life (the bio- psychosocial theory). The therapy encourages patients and their families to move from “either-or” thinking (eg, it is either a physical problem or a mental problem), to “both-and” thinking (eg, the problem has both physical and mental facets), and to accept that there is both a biological and an emotional basis for their disease. Relational therapy has been used in adults as well as in children and adolescents. Although this therapy has not been studied in randomized trials, it has been found useful in a number of settings. It also has the advantages of promoting an integrated view of illness and of involving the patient, his or her family, and the physician in a collaborative effort to cope with the illness.33,34
Cognitive-behavioral therapy. Cognitive-behavioral therapy (CBT) is based on the theory that individuals with somatization misinterpret bodily sensations. These interpretations lead to the incorrect beliefs about bodily functioning and related dysfunctional behaviors that underlie the symptoms of somatoform disorders. The therapist seeks to identify these beliefs and behaviors as well as to provide the patient with more accurate information about bodily functioning. The therapist then helps the patient examine the false beliefs and test whether they are based in reality. Through this process the patient is assisted in correcting his or her misinterpretations of bodily sensations and the accompanying beliefs about bodily function. At the same time, the affected individual is encouraged to modify his or her dysfunctional behaviors. This brief therapy, which typically takes 1 hour per week and lasts about 16 weeks, has been found to be effective. A recent study reviewed data from 31 controlled trials to evaluate the efficacy of CBT in the treatment of patients with symptoms of somatization. In 25 of the studies, the treatment targeted a specific syndrome (eg, pain or chronic fatigue) and in 6, the treatment focused on more general symptoms of somatization. The control and treatment groups were compared using the outcomes measures of physical symptom severity, psychological distress, and functional status. The CBT-treated patients experienced a statistically significant improvement in physical symptom severity vs the control group in 71% of the studies and, although not statistically significant, an improvement in physical symptom severity vs the control group in an additional 11% of the studies. In contrast, the CBT-treated subjects had an improvement in their levels of psychological distress in only 38% of the studies and in their functional status in only 47% of the studies.35
Psychodynamic psychotherapy. Psychodynamic psychotherapy takes longer to put into practice, and although it is believed to be of some benefit, there are no published studies of the efficacy of this treatment. The therapy is based on the assumption, articulated by Freud, that somatic symptoms are the manifestation of internal emotional conflicts. Psychodynamic psychotherapy attempts to uncover these conflicts so the patient can express them openly in therapy sessions. The somatic symptoms then become “unnecessary” as the underlying issues are resolved. Unfortunately, this process can last for months, if not years, and most affected patients are not enthusiastic about exploring their unconscious conflicts.36
Because of the dearth of studies proving the efficacy of psychotropic medications for somatoform disorders, and because psychotherapy techniques require specialized training, are time consuming, and are based on little empiric evidence, there is a need for more emphasis on treatments for somatoform disorders that are appropriate to and effective in the primary care setting.
Why treat these disorders in the primary care setting? First, patients with somatization symptoms most often present to the primary care physician. Second, patients tend to be resistant to psychiatric referrals for the specialized therapies mentioned above. They can become trapped in a “no-man’s-land” where there is no somatic condition to treat, yet they resist therapy from mental health practitioners. Treatment by primary care clinicians offers a chance to integrate disparate views of the pathology (neurobiological, sociocultural, and biopsychosocial). Moreover, primary care treatment is more likely to be accepted by patients because it is congruent with their beliefs about the nature of illness: namely, that it is a physical disorder with physical symptoms that requires treatment by a medical doctor.
However, the treatment of these individuals can be very frustrating for the primary care physician. The patients make frequent demands on the physician’s time and energy, and their symptoms seem resistant to treatment. In addition, the patients are often dissatisfied with the care they receive. Yet, these individuals are responsive to treatment. In one study of patients with unexplained medical symptoms in primary care settings, 86% of these individuals suffered from depression, anxiety, or both.37 In another study, researchers found that when patients were treated with antidepressant medication, education, and behavior modification, they experienced a decrease in somatic symptoms and an improvement in self-rated perceptions of overall health.38 Additionally, it has been shown that treatment of somatization by primary care physicians is cost effective.39 These findings indicate that improving the skills of recognizing and treating these disorders in the primary care setting can result in decreased symptoms and disability for the patient and improved satisfaction and decreased frustration for physicians.
The development of an empathic, trusting relationship is critical to both diagnosis and treatment. However, patients with somatization can be challenging to work with, and developing such a relationship can be difficult. It can be helpful to remember that these patients are reacting in the best way available to them, and, without treatment, in the only way available to them. With these factors in mind, it is useful to discuss methods that primary care physicians can use when interacting with patients with somatization.
The physician should never challenge the reality of the patient’s physical symptoms. Somatization is an unconscious process; therefore, the somatic complaints are very real to the individual. Since most of the symptoms are subjective in nature, there is no way to verify or dispute them. Explicitly acknowledging the patient’s suffering can be useful in bolstering the therapeutic relationship. Physicians should avoid the use of psychological labels, such as “depression” or “anxiety.” Instead, easily understandable and mutually acceptable language should be used to discuss symptoms. Such discussions help patients gain feelings of satisfaction and empowerment. These explanations provide a link between physical and emotional symptoms and suggest a means for the patient to manage the symptoms. (Unfortunately, in one study, these explanations were the rarest type of interaction.40)
Each appointment should begin with a discussion of the somatic complaint. The doctor may then use descriptive physiological explanations for the patient’s symptoms (eg, “Abnormally tense muscles in your neck go into painful spasm.”). While such descriptors imply a physiological component to the symptoms, they do not give an etiology. The practitioner should also ask about other aspects of the patient’s life (eg, work, home life, recreational interests, etc). Over time, the patient may become more open to exploring possible explanations that integrate somatic and psychosocial aspects.
As the physician continues with this approach in successive office visits patients begin to recognize the integration of the physical and emotional aspects of the complaint. Another management approach in the primary care setting involves continuing to schedule the patient for office visits at brief, regularly spaced intervals once the somatization is identified. For example, the physician may have the patient return every week for a 15-minute visit. These visits are time contingent, not symptom contingent; the patient need not have new symptoms to be able to meet regularly with the medical provider. During these meetings, the physician can discuss the patient’s emotional well-being, relationships, and events in the patient’s life. Regular visits reinforce the patient’s feeling that the doctor cares, tend to have a calming effect on the patient, and remove the patient’s unconscious motivation to have new symptoms. The clinician may also ask the patient’s preference regarding scheduling the next visit—providing the patient with a sense of control. Over time many patients suggest lengthening the interval between appointments.41 An alternative is to regularly call the patient on the telephone, or have the office staff call, and ask how the patient is doing.
The practitioner is advised to adopt a conservative approach toward new treatments or diagnostic workups when the patient presents with new or worsening symptoms. The goal is to focus the patient’s attention on behaviors that promote well-being, and to discuss the psychosocial aspects of his or her life and illness. The patient should be discouraged from pursuing new therapies for or new evaluations of the symptoms, from investigating “pop” or folk cures, and from joining illness support groups. At the same time, the individual sees that the p
1.Campo JV, Di Lorenzo C, Chiappetta L, et al. Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it? Pediatrics. 2001;108:E1.
2.Hahn SR. Physical symptoms and physician-experienced difficulty in the physician-patient relationship. Ann Intern Med. 2001;134:897-904.
3.Servan-Schreiber D, Kolb NR, Tabas G. Somatizing patients: Part I. Practical diagnosis. Am Fam Physician. 2000;61;1073-1078.
4.Guggenheim FG. Somatoform disorders. In: Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Comprehen-sive Textbook of Psychiatry. 7th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.
5.Hansen MS, Fink P, Frydenberg M, Oxhoj ML, Sondergaard L, Munk-Jorgensen P. Mental disorders among internal medical inpatients: prevalence, detection, and treatment status. J Psychosom Res. 2001;50:199-204.
6.Veith I. Hysteria: The History of the Disease. Chicago, Ill: University of Chicago Press; 1965.
7.Willis T. An Essay of the Pathology of the Brain and Nervous Stock: In Which Convulsive Diseases Are Treated of. Pordage S, trans. London, England: Dring, Leigh and Harper; 1684.
8.Sharpe M, Carson A. “Unexplained” somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med. 2001;134:926-930.
9.Hakal M, Karlsson H, Routsalainen U, et al. Severe somatization in women is associated with altered cerebral glucose metabolism. Psychol Med. 2002;32:1379-1385.
10.Rief W, Hiller W, Margraf J. Cognitive aspects in hypochondriasis and the somatization syndrome. J Abnorm Psychol. 1998;107:587-595.
11.Rief W, Auer C. Is somatization a habituation disorder? Physiological reactivity in somatization syndrome. Psychiatry Res. 2001;101:63-74.
12.Heim C, Ehlert U, Hellhammer DH. The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendo-crinology. 2000;25:1-35.
13.Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001;134:917-925.
14.Colegrave S, Holcombe C, Salmon P. Psychological characteristics of women presenting with breast pain. J Psychosom Res. 2001;50:303-307.
15.Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62(suppl 13):22-28, 29-30.
16.Guo Y, Kuroki T, Koizumi S. Abnormal illness behavior of patients with functional somatic symptoms: relation to psychiatric disorders. Gen Hosp Psychiatry. 2001;23:223-229.
17.Main CJ, Richards HL, Fortune DG. Why put new wine in old bottles: the need for a biopsychosocial approach to the assessment, treatment, and understanding of unexplained and explained symptoms in medicine. J Psychosom Res. 2000; 48:511-514.
18.Tyrer P, Seivewright N, Seivewright H. Long-term outcome of hypochondriacal personality disorder. J Psychosom Res. 1999;46:177-185.
19.Allen A, Hollander E. Body dysmorphic disorder. Psychiatr Clin North Am. 2000;23:617-628.
20.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 2000.
21.Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med. 1999;130:910-921.
22.Spitzer RL, Williams JB, Kroenke K, Hornyak R, McMurray J. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. Am J Obstet Gynecol. 2000;183:759-769.
23.Senra C. Evaluation and monitoring of symptom severity and change in depressed outpatients. J Clin Psychol. 1996;52:317-324.
24.Avasarala JR, Cross AH, Trinkaus K. Comparative assessment of Yale Single Question and Beck Depression Inventory Scale in screening for depression in multiple sclerosis. Mult Scler. 2003;9:307-310.
25.Cassidy EM, Tomkins E, Hardiman O, O’Keane V. Factors associated with burden of primary headache in a specialty clinic. Headache. 2003;43:638-644.
26.Koenig HG, Meador KG, Cohen HJ, Blazer DG. Self-rated depression scales and screening for major depression the older hospitalized patient with medical illness. J Am Geriatr Soc. 1988;36:699-706.
27.Garcia-Campayo J, Sanz-Carrillo C. Gabapentin for the treatment of patients with somatization disorder. J Clin Psychiatry. 2001;62:474.
28.Phillips KA, McElroy SL, Dwight MM, Eisen JL, Rasmussen SA. Delusionality and response to open-label fluvoxamine in body dysmorphic disorder. J Clin Psychiatry. 2001;62:87-91.
29.Hollander E, Allen A, Kwon J, et al. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry. 1999;56:1033-1039. 30.Fishbain D. Evidence-based data on pain relief with antidepressants. Ann Med. 2000;32:305-316.
31.Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis. Psychosom Med. 1998;60:503-509.
32.Smith GC, Clarke DM, Handrinos D, Dunsis A, McKenzie DP. Consultation-liaison psychiatrists’ management of somatoform disorders. Psychosomatics. 2000;41:481-489.
33.Watson WH, McDaniel SH. Relational therapy in medical settings: working with somatizing patients and their families. J Clin Psychol. 2000;56:1065-1082.
34.Wood BL. Physically manifested illness in children and adolescents. A biobehavioral family approach. Child Adolesc Psychiatr Clin N Am. 2001;10:543-562, viii.
35.Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000;69:205-215.
36.Kassel P, Franko DL. Body image disturbance and psychodynamic psychotherapy with gay men. Harvard Rev Psychiatry. 2000;8:307-317.
37.Stanley IM, Peters S, Salmon P. A primary care perspective on prevailing assumptions about persistent medically unexplained physical symptoms. Int J Psychiatry Med. 2002;32:125-140.
38.Simon GE, Katon W, Rutter C, et al. Impact of improved depression treatment in primary care on daily functioning and disability. Psychol Med. 1998;28:693-701.
39.Morriss R, Gask L, Ronalds C, et al. Cost-effectiveness of a new treatment for somatized mental disorder taught to GPs. Fam Pract. 1998;15:119-125.
40.Salmon P, Peters S, Stanley I. Patients’ perceptions of medical explanations for somatisation disorders: qualitative analysis. BMJ. 1999;318:372-376.
41.Smith RC. A clinical approach to the somatizing patient. J Fam Pract. 1985;21:294-301.
42.Noyes R Jr, Holt CS, Kathol RG. Somatization. Diagnosis and management. Arch Fam Med. 1995;4:790-795.
43.Holloway KL, Zerbe KJ. Simplified approach to somatization disorder. When less may prove to be more. Postgrad Med. 2000;108:89-92, 95.
44.Morriss RK, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Goldberg D. Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general-practitioners. Br J Gen Pract. 1999;49:263-267.
45.Klapow JC, Schmidt SM, Taylor LA, et. al. Symptom management in older primary care patients: feasibility of an experimental, written self-disclosure protocol. Ann Intern Med. 2001;134:905-911.
46.Schilte AF, Portegijs PJ, Blankenstein AH, et al. Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care. BMJ. 2001;323:86.