A low-frustration strategy for treating somatization

Mrs. M, age 34, was referred for psychiatric evaluation by her primary care physician. She reluctantly agreed to the referral and tells the psychiatrist she “really should be seeing a cardiologist.” Numerous evaluations for chest pain and palpitations—including seven emergency room visits, ECGs and cardiac catheterization—have revealed no medical pathology.

A divorced mother of two children, she says she feels anxious about her “heart condition.” Her father died of a heart attack at age 51. She experiences chest pains at home and at work, particularly when under stress. Sometimes she feels her heart racing and numbness or tingling in her arms.

Although her primary care physician has seen her frequently during the past 6 months, she says the doctor is not taking her complaints seriously. “These chest pains are real,” she says, “so don’t try to tell me they’re all in my head.”

Psychiatrists may be the last doctors patients such as Mrs. M wish to see but the ones best equipped to relieve their suffering. Our experience in treating somatizing patients and the available evidence suggest that cognitive-behavioral therapy (CBT) combined with psychoeducation, reassurance, and sometimes drug therapy is the most effective approach.

Box

Mrs. M’s persistent chest pain of noncardiac origin is a familiar health anxiety, along with functional GI complaints, headaches, chronic fatigue, and lower back pain. Frustrating to their doctors and frustrated themselves, patients with medically unexplained complaints consume an inordinate amount of physicians’ time.¹

Without a clear definition of somatization (Box)^2-9 or useful clinical guidelines, psychiatrists must rely on the literature for guidance in managing somatization disorders. This article summarizes the evidence and describes how we apply these findings to practice. And when all else fails, we offer last-ditch advice for managing patients who resist your treatment efforts.

IDENTIFYING COMORBIDITIES

Identifying psychiatric comorbidities is the first step in successfully treating patients with somatoform complaints. In an epidemiologic study, 60% of patients with somatoform complaints also had a mood disorder and 48% had an anxiety disorder.¹⁰ In a similar study of patients with hypochondriasis, 88% also had one or more Axis I diagnosis.¹¹

If a patient meets criteria for a comorbid psychiatric disorder and is willing to be treated for it, the somatic complaints may resolve along with the underlying disorder. In fact, the presence of an identifiable Axis I disorder order may predict a more positive prognosis.¹²

Personality disorders. Somatization in patients with a personality disorder poses unique challenges.¹³ Granted, when making a diagnosis it is difficult to tease apart somatization from personality disorders because somatization itself may be considered a chronic, maladaptive coping style. However, symptoms such as deception, impulsivity, mood lability, and self-injurious behavior introduce treatment complications that exceed the scope of this article.

Posttraumatic stress disorder (PTSD)—particularly childhood sexual and physical abuse—also predisposes some patients to somatization disorders.^14,15 Patients with comorbid PTSD and somatization disorder require highly specialized treatment that is beyond the scope of this review.

COGNITIVE-BEHAVIORAL TREATMENT

Cognitive-behavioral therapy (CBT) is the best-studied and most effective treatment for somatoform disorders.¹⁶ CBT for somatization relies on both physiologic and cognitive explanations to account for the patient’s experience, without committing to an “either/or” dichotomy. It offers patients an alternate explanation of what is wrong with them—illness anxiety instead of severe physical illness.

By making patients aware of their automatic thoughts, feelings, behaviors, and underlying beliefs, CBT helps them normalize and cope with their illness anxiety. CBT techniques can be applied in a predetermined course of therapy (such as 12 sessions with a mental health clinician), in a group setting, or piecemeal by any health care provider.

Effective strategies. In a review of 30 controlled trials of CBT for somatoform disorders, Looper¹⁷ showed overall effect ranging from 0.38 to 2.5, where 0.2 was defined as a small effect, 0.5 as medium, and 0.8 as large. Hypochondriasis, somatization disorder, body dysmorphic disorder, chronic pain, chronic fatigue, and noncardiac chest pain were included in this review. The most effective strategies:

• included 6 to 16 treatment sessions
• were symptom-focused as opposed to providing general relaxation training
• included maintenance sessions after the initial series.

Four factors of health anxiety. CBT primarily targets the patient’s false beliefs that he or she is physically ill. These beliefs are based on how the patient misinterprets innocuous physical symptoms and responds to them.¹⁸ The cognitive theory of health anxiety holds that health anxiety severity is affected by four factors:

• perceived likelihood of illness
• perceived burden of illness
• perceived ability to cope with illness
• perception of the extent to which external factors will help.¹⁹

Table 1

Common dysfunctional beliefs of somatizing patients

The first two factors worsen and the latter two mitigate health anxiety. An individual patient’s presenting fears often suggest which factors to address. For example, Mrs. M may describe the burden of illness as the focus of her fears (“If I have a heart attack, who will care for my children?”). This information cues you to shift the focus of therapy to helping her cope with child care needs despite her recurring symptoms.

If she focuses on her likelihood of illness, then uncoupling the symptoms from the diagnosis could be more productive. When she reports palpitations, diaphoresis, and dizziness, have her do breathing exercises that induce those symptoms without producing a heart attack.

Table 2

Journaling homework: 5 questions for patients to answer about one symptom each day

She might describe feeling unable to cope when she feels symptoms or when cardiologists tell her nothing is wrong with her heart. In that case, focus on relaxation techniques, global stress reduction, and reducing cardiac risk factors to bolster her ability to cope with her illness.

Journaling is a critical component of CBT in treating somatization disorders. Regular journaling by the patient can reveal dysfunctional beliefs that may be driving his or her health anxieties, such as those listed in Table 1. We find it useful to assign patients to answer five questions about one symptom experience each day (Table 2). This self-monitoring provides material to work on with the patient during each session.

Cognitive restructuring. During therapy sessions, we ask patients to suggest alternate explanations for the symptoms recorded in their journals. We then ask them to determine which explanations are more feasible.

For example, if Mrs. M develops palpitations during emotionally charged arguments, we would ask her to develop explanations other than, “I was having a heart attack.” Reality testing includes rhetorical questions such as, “Would you be alive today if you were having a heart attack every time you had palpitations?” Automatic thoughts are successively identified and then tested aloud with the patient:

• “Has every unexplained symptom led to the discovery of a serious illness?”
• “Does every instance of hurt equal harm?”

Eventually, patterns of automatic thoughts emerge, and these reveal the underlying dysfunctional beliefs.

Dysfunctional beliefs are maintained when patients selectively attend to and amplify somatic sensations. Behavioral experiments during sessions can demonstrate to the patient in vivo the process by which they misattribute illness to physical symptoms. For example, overbreathing with a patient during a session may elicit light-headedness, paresthesias, or tachycardia, which can then be linked to overbreathing rather than a chronic or catastrophic illness.

Furthermore, patients can be taught to control the experience. Some patients with headaches or GI pain may be made aware of symptoms by simply asking them to focus their attention on the respective organs. Simply explaining the cycle of misattribution, autonomic activation, and further symptom development with an in vivo demonstration can be illuminating.

Response prevention. Another behavioral technique is to cut back in small increments on actions the patient takes in response to physical symptoms and automatic thoughts. For example, a patient could take medicine and seek reassurance less frequently and avoid rubbing the affected area.

PSYCHOEDUCATION

Two psychoeducation programs for somatization behavior have been formally studied.

The Personal Health Improvement Program²⁰—led by trained facilitators—includes classroom videos, cognitive-behavioral exercises, and home study assignments. After completing the 6-week course, 171 patients with somatization disorders reported reduced physical and psychological distress and increased function. They also visited their primary care physicians less often.

Table 3

How to effectively reassure somatizing patients

Coping with Illness Anxiety²¹ relies on mini-lectures, demonstrations, videos, and focused group discussions. After six 2-hour sessions, 33 of 43 study patients (78%) used medical services less often and reported reduced disease conviction, consequences of bodily complaints, health anxiety, and checking and avoidance behaviors. Two psychology graduate students taught the course from a manual, with 6 to 9 patients per group.

Psychoeducation in this context relies on didactic presentations, readings, role playing, and videotaped material. The goal is to teach patients to recognize thoughts, emotions, and behaviors that lead to and result from somatic preoccupation. Patients can improve when they recognize dysfunctional behavioral patterns and learn alternate coping strategies.

Somatizing patients—with their aversion to the stigma of mental illness—may find psychoeducation particularly attractive. They can be treated as students who are being educated, rather than as patients who are being treated. Classrooms in both studies cited above were located in medical outpatient offices, not in mental health facilities.

REASSURANCE

Reassurance is a common therapeutic technique in medicine, although it is poorly understood, poorly taught, and not methodically applied. Reassurance alleviates anxiety, enables patients to endure dysphoria, encourages hope, gives insight, and enhances the doctor-patient relationship.²²

Table 4

How to avoid becoming frustrated with persistent somatization

Whereas CBT seeks to challenge patients’ underlying beliefs and restructure their thought processes,²³ reassurance can help them tolerate their dysfunctional beliefs and dissuade them from believing their health is dangerously impaired. Reassurance offers a substitute explanation of patients’ dysfunction, although this explanation is not as central or detailed as it is in CBT.

How to reassure. Patients may consider reassurance offered prematurely or by a stranger to be patronizing or dismissive. Reassurance is most effective when:

• given by a trusted person who is reliable, consistent, firm, and empathic
• the patient’s condition has been established as unresponsive to conventional diagnostics or biological therapies.

Patients are most receptive to reassurance when they express distress or frustration with their unexplained symptoms. Affirming that their suffering is legitimate opens the door to further treatment.

Reassurance is least effective when a patient is expressing anger or mistrust, although this is when the physician may feel most pressured to reassure. To successfully reassure a patient, the psychiatrist needs to:

• credibly identify with the patient’s distress
• and listen empathically (such as using body language and facial expressions that convey concern and consideration to the patient).²⁴

Starcevic suggests useful techniques for providing reassurance (Table 3).²²

DRUG THERAPIES

Psychotropics are considered a first-line treatment for patients with somatization disorders when:

• the patient spontaneously identifies any discrete, vegetative, or psychological complaints that may respond to drug therapy, such as insomnia, weight loss, sadness, or preoccupation
• the patient meets diagnostic criteria for comorbid anxiety or depressive disorders
• the therapeutic alliance is strong enough to weather the inevitable struggle with side effects and incomplete response to treatment. We do not recommend medication in the first encounter, when it may threaten a nascent alliance.

A common obstacle to prescribing psychotropics to somatizing patients is their sensitivity to suggestions that their complaints are “all in their heads.” To sidestep this resistance, describe the medication as treating the stress caused. by—not causing.—their chronic physical complaints. Proposing antidepressant therapy after—rather than instead of—physical exams and other diagnostics may elicit a more positive response.

Antidepressants. In clinical trials, somatoform complaints show moderate improvement after antidepressant treatment. In a meta-analysis of 6,595 patients with unexplained symptoms treated only with antidepressants, the number needed to treat was 3 to yield a positive response.²⁵ This report of 94 medication trials included patients with headache, fibromyalgia, functional GI syndromes, idiopathic pain, tinnitus, or chronic fatigue.

In other trials:

• Amitriptyline has reduced somatic symptoms in patients labeled as having “masked depression.”²⁶
• Sertraline has reduced disease fear, disease conviction, and bodily preoccupation in patients with hypochondriasis and panic disorder.²⁷

Consider side effects when choosing medication for patients with somatoform disorders. Selective serotonin reuptake inhibitors (SSRIs) in general—and sertraline, citalopram, and escitalopram specifically—have fewer side effects than tricyclics. The adage of “start low, go slow” is appropriate for somatizing patients; we usually start with one-half the dosages recommended for treating depression.

Antipsychotics. In case reports, patients with “atypical psychosis,” “monosymptomatic hypochondriacal psychosis,” or “delusional disorder, somatic type” have responded to antipsychotics. These patients’ somatic beliefs are of delusional intensity, such as the rare fear of being eaten alive by an intestinal parasite (delusional parasitosis). Reported behaviors associated with the delusion include starvation, excessive laxative abuse, ingestion of sharp objects, and self-inflicted stab wounds. Treatments described in the literature include the typical agents pimozide and haloperidol and the atypicals olanzapine and risperidone.

TREATMENT-RESISTANT PATIENTS

Some patients with somatoform disorders will not accept CBT, psychotropics, reassurance, or referrals to group psychoeducation. Despite your best efforts, they may persist in focusing on somatic complaints. If you are willing to maintain a therapeutic relationship with them, be prepared to tolerate several ongoing paradoxes (Table 4).

Behaviorally, you must “listen more and do less.” Emotionally, you must be willing to enter into a long-term relationship with an inherently frustrating patient whose pathologies make you feel therapeutically hopeless and helpless. Understand that their physical symptoms function as a metaphor for psychological distress. You are not required to explore the source, content, or meaning of the metaphor in detail but simply listen to their somatic complaints through that psychological filter.

Related resources

• Starcevic V, Lipsitt D (eds). Hypochondriasis: modern perspectives on an ancient malady. New York: Oxford University Press, 2001.
• Information and support Web site for persons with health anxiety or hypochondria. www.healthanxiety.com
• Anxiety Disorders Association of America. www.adaa.org

Drug brand names

• Amitriptyline • Elavil
• Citalopram • Celexa
• Escitalopram • Lexapro
• Haloperidol • Haldol
• Olanzapine • Zyprexa
• Pimozide • Orap
• Risperidone • Risperdal
• Sertraline • Zoloft

Disclosure

Dr. Isaac reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Wise receives grant support from Eli Lilly & Co. and is a consultant or speaker for Eli Lilly & Co., Pfizer Inc., Bristol-Myers Squibb Co., and GlaxoSmithKline.

Mrs. M, age 34, was referred for psychiatric evaluation by her primary care physician. She reluctantly agreed to the referral and tells the psychiatrist she “really should be seeing a cardiologist.” Numerous evaluations for chest pain and palpitations—including seven emergency room visits, ECGs and cardiac catheterization—have revealed no medical pathology.

A divorced mother of two children, she says she feels anxious about her “heart condition.” Her father died of a heart attack at age 51. She experiences chest pains at home and at work, particularly when under stress. Sometimes she feels her heart racing and numbness or tingling in her arms.

Although her primary care physician has seen her frequently during the past 6 months, she says the doctor is not taking her complaints seriously. “These chest pains are real,” she says, “so don’t try to tell me they’re all in my head.”

Psychiatrists may be the last doctors patients such as Mrs. M wish to see but the ones best equipped to relieve their suffering. Our experience in treating somatizing patients and the available evidence suggest that cognitive-behavioral therapy (CBT) combined with psychoeducation, reassurance, and sometimes drug therapy is the most effective approach.

Box

Mrs. M’s persistent chest pain of noncardiac origin is a familiar health anxiety, along with functional GI complaints, headaches, chronic fatigue, and lower back pain. Frustrating to their doctors and frustrated themselves, patients with medically unexplained complaints consume an inordinate amount of physicians’ time.¹

Without a clear definition of somatization (Box)^2-9 or useful clinical guidelines, psychiatrists must rely on the literature for guidance in managing somatization disorders. This article summarizes the evidence and describes how we apply these findings to practice. And when all else fails, we offer last-ditch advice for managing patients who resist your treatment efforts.

IDENTIFYING COMORBIDITIES

Identifying psychiatric comorbidities is the first step in successfully treating patients with somatoform complaints. In an epidemiologic study, 60% of patients with somatoform complaints also had a mood disorder and 48% had an anxiety disorder.¹⁰ In a similar study of patients with hypochondriasis, 88% also had one or more Axis I diagnosis.¹¹

If a patient meets criteria for a comorbid psychiatric disorder and is willing to be treated for it, the somatic complaints may resolve along with the underlying disorder. In fact, the presence of an identifiable Axis I disorder order may predict a more positive prognosis.¹²

Personality disorders. Somatization in patients with a personality disorder poses unique challenges.¹³ Granted, when making a diagnosis it is difficult to tease apart somatization from personality disorders because somatization itself may be considered a chronic, maladaptive coping style. However, symptoms such as deception, impulsivity, mood lability, and self-injurious behavior introduce treatment complications that exceed the scope of this article.

Posttraumatic stress disorder (PTSD)—particularly childhood sexual and physical abuse—also predisposes some patients to somatization disorders.^14,15 Patients with comorbid PTSD and somatization disorder require highly specialized treatment that is beyond the scope of this review.

COGNITIVE-BEHAVIORAL TREATMENT

Cognitive-behavioral therapy (CBT) is the best-studied and most effective treatment for somatoform disorders.¹⁶ CBT for somatization relies on both physiologic and cognitive explanations to account for the patient’s experience, without committing to an “either/or” dichotomy. It offers patients an alternate explanation of what is wrong with them—illness anxiety instead of severe physical illness.

By making patients aware of their automatic thoughts, feelings, behaviors, and underlying beliefs, CBT helps them normalize and cope with their illness anxiety. CBT techniques can be applied in a predetermined course of therapy (such as 12 sessions with a mental health clinician), in a group setting, or piecemeal by any health care provider.

Effective strategies. In a review of 30 controlled trials of CBT for somatoform disorders, Looper¹⁷ showed overall effect ranging from 0.38 to 2.5, where 0.2 was defined as a small effect, 0.5 as medium, and 0.8 as large. Hypochondriasis, somatization disorder, body dysmorphic disorder, chronic pain, chronic fatigue, and noncardiac chest pain were included in this review. The most effective strategies:

• included 6 to 16 treatment sessions
• were symptom-focused as opposed to providing general relaxation training
• included maintenance sessions after the initial series.

Four factors of health anxiety. CBT primarily targets the patient’s false beliefs that he or she is physically ill. These beliefs are based on how the patient misinterprets innocuous physical symptoms and responds to them.¹⁸ The cognitive theory of health anxiety holds that health anxiety severity is affected by four factors:

• perceived likelihood of illness
• perceived burden of illness
• perceived ability to cope with illness
• perception of the extent to which external factors will help.¹⁹

Table 1

Common dysfunctional beliefs of somatizing patients

The first two factors worsen and the latter two mitigate health anxiety. An individual patient’s presenting fears often suggest which factors to address. For example, Mrs. M may describe the burden of illness as the focus of her fears (“If I have a heart attack, who will care for my children?”). This information cues you to shift the focus of therapy to helping her cope with child care needs despite her recurring symptoms.

If she focuses on her likelihood of illness, then uncoupling the symptoms from the diagnosis could be more productive. When she reports palpitations, diaphoresis, and dizziness, have her do breathing exercises that induce those symptoms without producing a heart attack.

Table 2

Journaling homework: 5 questions for patients to answer about one symptom each day

She might describe feeling unable to cope when she feels symptoms or when cardiologists tell her nothing is wrong with her heart. In that case, focus on relaxation techniques, global stress reduction, and reducing cardiac risk factors to bolster her ability to cope with her illness.

Journaling is a critical component of CBT in treating somatization disorders. Regular journaling by the patient can reveal dysfunctional beliefs that may be driving his or her health anxieties, such as those listed in Table 1. We find it useful to assign patients to answer five questions about one symptom experience each day (Table 2). This self-monitoring provides material to work on with the patient during each session.

Cognitive restructuring. During therapy sessions, we ask patients to suggest alternate explanations for the symptoms recorded in their journals. We then ask them to determine which explanations are more feasible.

For example, if Mrs. M develops palpitations during emotionally charged arguments, we would ask her to develop explanations other than, “I was having a heart attack.” Reality testing includes rhetorical questions such as, “Would you be alive today if you were having a heart attack every time you had palpitations?” Automatic thoughts are successively identified and then tested aloud with the patient:

• “Has every unexplained symptom led to the discovery of a serious illness?”
• “Does every instance of hurt equal harm?”

Eventually, patterns of automatic thoughts emerge, and these reveal the underlying dysfunctional beliefs.

Dysfunctional beliefs are maintained when patients selectively attend to and amplify somatic sensations. Behavioral experiments during sessions can demonstrate to the patient in vivo the process by which they misattribute illness to physical symptoms. For example, overbreathing with a patient during a session may elicit light-headedness, paresthesias, or tachycardia, which can then be linked to overbreathing rather than a chronic or catastrophic illness.

Furthermore, patients can be taught to control the experience. Some patients with headaches or GI pain may be made aware of symptoms by simply asking them to focus their attention on the respective organs. Simply explaining the cycle of misattribution, autonomic activation, and further symptom development with an in vivo demonstration can be illuminating.

Response prevention. Another behavioral technique is to cut back in small increments on actions the patient takes in response to physical symptoms and automatic thoughts. For example, a patient could take medicine and seek reassurance less frequently and avoid rubbing the affected area.

PSYCHOEDUCATION

Two psychoeducation programs for somatization behavior have been formally studied.

The Personal Health Improvement Program²⁰—led by trained facilitators—includes classroom videos, cognitive-behavioral exercises, and home study assignments. After completing the 6-week course, 171 patients with somatization disorders reported reduced physical and psychological distress and increased function. They also visited their primary care physicians less often.

Table 3

How to effectively reassure somatizing patients

Coping with Illness Anxiety²¹ relies on mini-lectures, demonstrations, videos, and focused group discussions. After six 2-hour sessions, 33 of 43 study patients (78%) used medical services less often and reported reduced disease conviction, consequences of bodily complaints, health anxiety, and checking and avoidance behaviors. Two psychology graduate students taught the course from a manual, with 6 to 9 patients per group.

Psychoeducation in this context relies on didactic presentations, readings, role playing, and videotaped material. The goal is to teach patients to recognize thoughts, emotions, and behaviors that lead to and result from somatic preoccupation. Patients can improve when they recognize dysfunctional behavioral patterns and learn alternate coping strategies.

Somatizing patients—with their aversion to the stigma of mental illness—may find psychoeducation particularly attractive. They can be treated as students who are being educated, rather than as patients who are being treated. Classrooms in both studies cited above were located in medical outpatient offices, not in mental health facilities.

REASSURANCE

Reassurance is a common therapeutic technique in medicine, although it is poorly understood, poorly taught, and not methodically applied. Reassurance alleviates anxiety, enables patients to endure dysphoria, encourages hope, gives insight, and enhances the doctor-patient relationship.²²

Table 4

How to avoid becoming frustrated with persistent somatization

Whereas CBT seeks to challenge patients’ underlying beliefs and restructure their thought processes,²³ reassurance can help them tolerate their dysfunctional beliefs and dissuade them from believing their health is dangerously impaired. Reassurance offers a substitute explanation of patients’ dysfunction, although this explanation is not as central or detailed as it is in CBT.

How to reassure. Patients may consider reassurance offered prematurely or by a stranger to be patronizing or dismissive. Reassurance is most effective when:

• given by a trusted person who is reliable, consistent, firm, and empathic
• the patient’s condition has been established as unresponsive to conventional diagnostics or biological therapies.

Patients are most receptive to reassurance when they express distress or frustration with their unexplained symptoms. Affirming that their suffering is legitimate opens the door to further treatment.

Reassurance is least effective when a patient is expressing anger or mistrust, although this is when the physician may feel most pressured to reassure. To successfully reassure a patient, the psychiatrist needs to:

• credibly identify with the patient’s distress
• and listen empathically (such as using body language and facial expressions that convey concern and consideration to the patient).²⁴

Starcevic suggests useful techniques for providing reassurance (Table 3).²²

DRUG THERAPIES

Psychotropics are considered a first-line treatment for patients with somatization disorders when:

• the patient spontaneously identifies any discrete, vegetative, or psychological complaints that may respond to drug therapy, such as insomnia, weight loss, sadness, or preoccupation
• the patient meets diagnostic criteria for comorbid anxiety or depressive disorders
• the therapeutic alliance is strong enough to weather the inevitable struggle with side effects and incomplete response to treatment. We do not recommend medication in the first encounter, when it may threaten a nascent alliance.

A common obstacle to prescribing psychotropics to somatizing patients is their sensitivity to suggestions that their complaints are “all in their heads.” To sidestep this resistance, describe the medication as treating the stress caused. by—not causing.—their chronic physical complaints. Proposing antidepressant therapy after—rather than instead of—physical exams and other diagnostics may elicit a more positive response.

Antidepressants. In clinical trials, somatoform complaints show moderate improvement after antidepressant treatment. In a meta-analysis of 6,595 patients with unexplained symptoms treated only with antidepressants, the number needed to treat was 3 to yield a positive response.²⁵ This report of 94 medication trials included patients with headache, fibromyalgia, functional GI syndromes, idiopathic pain, tinnitus, or chronic fatigue.

In other trials:

• Amitriptyline has reduced somatic symptoms in patients labeled as having “masked depression.”²⁶
• Sertraline has reduced disease fear, disease conviction, and bodily preoccupation in patients with hypochondriasis and panic disorder.²⁷

Consider side effects when choosing medication for patients with somatoform disorders. Selective serotonin reuptake inhibitors (SSRIs) in general—and sertraline, citalopram, and escitalopram specifically—have fewer side effects than tricyclics. The adage of “start low, go slow” is appropriate for somatizing patients; we usually start with one-half the dosages recommended for treating depression.

Antipsychotics. In case reports, patients with “atypical psychosis,” “monosymptomatic hypochondriacal psychosis,” or “delusional disorder, somatic type” have responded to antipsychotics. These patients’ somatic beliefs are of delusional intensity, such as the rare fear of being eaten alive by an intestinal parasite (delusional parasitosis). Reported behaviors associated with the delusion include starvation, excessive laxative abuse, ingestion of sharp objects, and self-inflicted stab wounds. Treatments described in the literature include the typical agents pimozide and haloperidol and the atypicals olanzapine and risperidone.

TREATMENT-RESISTANT PATIENTS

Some patients with somatoform disorders will not accept CBT, psychotropics, reassurance, or referrals to group psychoeducation. Despite your best efforts, they may persist in focusing on somatic complaints. If you are willing to maintain a therapeutic relationship with them, be prepared to tolerate several ongoing paradoxes (Table 4).

Behaviorally, you must “listen more and do less.” Emotionally, you must be willing to enter into a long-term relationship with an inherently frustrating patient whose pathologies make you feel therapeutically hopeless and helpless. Understand that their physical symptoms function as a metaphor for psychological distress. You are not required to explore the source, content, or meaning of the metaphor in detail but simply listen to their somatic complaints through that psychological filter.

Related resources

• Starcevic V, Lipsitt D (eds). Hypochondriasis: modern perspectives on an ancient malady. New York: Oxford University Press, 2001.
• Information and support Web site for persons with health anxiety or hypochondria. www.healthanxiety.com
• Anxiety Disorders Association of America. www.adaa.org

Drug brand names

• Amitriptyline • Elavil
• Citalopram • Celexa
• Escitalopram • Lexapro
• Haloperidol • Haldol
• Olanzapine • Zyprexa
• Pimozide • Orap
• Risperidone • Risperdal
• Sertraline • Zoloft

Disclosure

Dr. Isaac reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Wise receives grant support from Eli Lilly & Co. and is a consultant or speaker for Eli Lilly & Co., Pfizer Inc., Bristol-Myers Squibb Co., and GlaxoSmithKline.

Mrs. M, age 34, was referred for psychiatric evaluation by her primary care physician. She reluctantly agreed to the referral and tells the psychiatrist she “really should be seeing a cardiologist.” Numerous evaluations for chest pain and palpitations—including seven emergency room visits, ECGs and cardiac catheterization—have revealed no medical pathology.

A divorced mother of two children, she says she feels anxious about her “heart condition.” Her father died of a heart attack at age 51. She experiences chest pains at home and at work, particularly when under stress. Sometimes she feels her heart racing and numbness or tingling in her arms.

Although her primary care physician has seen her frequently during the past 6 months, she says the doctor is not taking her complaints seriously. “These chest pains are real,” she says, “so don’t try to tell me they’re all in my head.”

Psychiatrists may be the last doctors patients such as Mrs. M wish to see but the ones best equipped to relieve their suffering. Our experience in treating somatizing patients and the available evidence suggest that cognitive-behavioral therapy (CBT) combined with psychoeducation, reassurance, and sometimes drug therapy is the most effective approach.

Box

Mrs. M’s persistent chest pain of noncardiac origin is a familiar health anxiety, along with functional GI complaints, headaches, chronic fatigue, and lower back pain. Frustrating to their doctors and frustrated themselves, patients with medically unexplained complaints consume an inordinate amount of physicians’ time.¹

Without a clear definition of somatization (Box)^2-9 or useful clinical guidelines, psychiatrists must rely on the literature for guidance in managing somatization disorders. This article summarizes the evidence and describes how we apply these findings to practice. And when all else fails, we offer last-ditch advice for managing patients who resist your treatment efforts.

IDENTIFYING COMORBIDITIES

Identifying psychiatric comorbidities is the first step in successfully treating patients with somatoform complaints. In an epidemiologic study, 60% of patients with somatoform complaints also had a mood disorder and 48% had an anxiety disorder.¹⁰ In a similar study of patients with hypochondriasis, 88% also had one or more Axis I diagnosis.¹¹

If a patient meets criteria for a comorbid psychiatric disorder and is willing to be treated for it, the somatic complaints may resolve along with the underlying disorder. In fact, the presence of an identifiable Axis I disorder order may predict a more positive prognosis.¹²

Personality disorders. Somatization in patients with a personality disorder poses unique challenges.¹³ Granted, when making a diagnosis it is difficult to tease apart somatization from personality disorders because somatization itself may be considered a chronic, maladaptive coping style. However, symptoms such as deception, impulsivity, mood lability, and self-injurious behavior introduce treatment complications that exceed the scope of this article.

Posttraumatic stress disorder (PTSD)—particularly childhood sexual and physical abuse—also predisposes some patients to somatization disorders.^14,15 Patients with comorbid PTSD and somatization disorder require highly specialized treatment that is beyond the scope of this review.

COGNITIVE-BEHAVIORAL TREATMENT

Cognitive-behavioral therapy (CBT) is the best-studied and most effective treatment for somatoform disorders.¹⁶ CBT for somatization relies on both physiologic and cognitive explanations to account for the patient’s experience, without committing to an “either/or” dichotomy. It offers patients an alternate explanation of what is wrong with them—illness anxiety instead of severe physical illness.

By making patients aware of their automatic thoughts, feelings, behaviors, and underlying beliefs, CBT helps them normalize and cope with their illness anxiety. CBT techniques can be applied in a predetermined course of therapy (such as 12 sessions with a mental health clinician), in a group setting, or piecemeal by any health care provider.

Effective strategies. In a review of 30 controlled trials of CBT for somatoform disorders, Looper¹⁷ showed overall effect ranging from 0.38 to 2.5, where 0.2 was defined as a small effect, 0.5 as medium, and 0.8 as large. Hypochondriasis, somatization disorder, body dysmorphic disorder, chronic pain, chronic fatigue, and noncardiac chest pain were included in this review. The most effective strategies:

• included 6 to 16 treatment sessions
• were symptom-focused as opposed to providing general relaxation training
• included maintenance sessions after the initial series.

Four factors of health anxiety. CBT primarily targets the patient’s false beliefs that he or she is physically ill. These beliefs are based on how the patient misinterprets innocuous physical symptoms and responds to them.¹⁸ The cognitive theory of health anxiety holds that health anxiety severity is affected by four factors:

• perceived likelihood of illness
• perceived burden of illness
• perceived ability to cope with illness
• perception of the extent to which external factors will help.¹⁹

Table 1

Common dysfunctional beliefs of somatizing patients

The first two factors worsen and the latter two mitigate health anxiety. An individual patient’s presenting fears often suggest which factors to address. For example, Mrs. M may describe the burden of illness as the focus of her fears (“If I have a heart attack, who will care for my children?”). This information cues you to shift the focus of therapy to helping her cope with child care needs despite her recurring symptoms.

If she focuses on her likelihood of illness, then uncoupling the symptoms from the diagnosis could be more productive. When she reports palpitations, diaphoresis, and dizziness, have her do breathing exercises that induce those symptoms without producing a heart attack.

Table 2

Journaling homework: 5 questions for patients to answer about one symptom each day

She might describe feeling unable to cope when she feels symptoms or when cardiologists tell her nothing is wrong with her heart. In that case, focus on relaxation techniques, global stress reduction, and reducing cardiac risk factors to bolster her ability to cope with her illness.

Journaling is a critical component of CBT in treating somatization disorders. Regular journaling by the patient can reveal dysfunctional beliefs that may be driving his or her health anxieties, such as those listed in Table 1. We find it useful to assign patients to answer five questions about one symptom experience each day (Table 2). This self-monitoring provides material to work on with the patient during each session.

Cognitive restructuring. During therapy sessions, we ask patients to suggest alternate explanations for the symptoms recorded in their journals. We then ask them to determine which explanations are more feasible.

For example, if Mrs. M develops palpitations during emotionally charged arguments, we would ask her to develop explanations other than, “I was having a heart attack.” Reality testing includes rhetorical questions such as, “Would you be alive today if you were having a heart attack every time you had palpitations?” Automatic thoughts are successively identified and then tested aloud with the patient:

• “Has every unexplained symptom led to the discovery of a serious illness?”
• “Does every instance of hurt equal harm?”

Eventually, patterns of automatic thoughts emerge, and these reveal the underlying dysfunctional beliefs.

Dysfunctional beliefs are maintained when patients selectively attend to and amplify somatic sensations. Behavioral experiments during sessions can demonstrate to the patient in vivo the process by which they misattribute illness to physical symptoms. For example, overbreathing with a patient during a session may elicit light-headedness, paresthesias, or tachycardia, which can then be linked to overbreathing rather than a chronic or catastrophic illness.

Furthermore, patients can be taught to control the experience. Some patients with headaches or GI pain may be made aware of symptoms by simply asking them to focus their attention on the respective organs. Simply explaining the cycle of misattribution, autonomic activation, and further symptom development with an in vivo demonstration can be illuminating.

Response prevention. Another behavioral technique is to cut back in small increments on actions the patient takes in response to physical symptoms and automatic thoughts. For example, a patient could take medicine and seek reassurance less frequently and avoid rubbing the affected area.

PSYCHOEDUCATION

Two psychoeducation programs for somatization behavior have been formally studied.

The Personal Health Improvement Program²⁰—led by trained facilitators—includes classroom videos, cognitive-behavioral exercises, and home study assignments. After completing the 6-week course, 171 patients with somatization disorders reported reduced physical and psychological distress and increased function. They also visited their primary care physicians less often.

Table 3

How to effectively reassure somatizing patients

Coping with Illness Anxiety²¹ relies on mini-lectures, demonstrations, videos, and focused group discussions. After six 2-hour sessions, 33 of 43 study patients (78%) used medical services less often and reported reduced disease conviction, consequences of bodily complaints, health anxiety, and checking and avoidance behaviors. Two psychology graduate students taught the course from a manual, with 6 to 9 patients per group.

Psychoeducation in this context relies on didactic presentations, readings, role playing, and videotaped material. The goal is to teach patients to recognize thoughts, emotions, and behaviors that lead to and result from somatic preoccupation. Patients can improve when they recognize dysfunctional behavioral patterns and learn alternate coping strategies.

Somatizing patients—with their aversion to the stigma of mental illness—may find psychoeducation particularly attractive. They can be treated as students who are being educated, rather than as patients who are being treated. Classrooms in both studies cited above were located in medical outpatient offices, not in mental health facilities.

REASSURANCE

Reassurance is a common therapeutic technique in medicine, although it is poorly understood, poorly taught, and not methodically applied. Reassurance alleviates anxiety, enables patients to endure dysphoria, encourages hope, gives insight, and enhances the doctor-patient relationship.²²

Table 4

How to avoid becoming frustrated with persistent somatization

Whereas CBT seeks to challenge patients’ underlying beliefs and restructure their thought processes,²³ reassurance can help them tolerate their dysfunctional beliefs and dissuade them from believing their health is dangerously impaired. Reassurance offers a substitute explanation of patients’ dysfunction, although this explanation is not as central or detailed as it is in CBT.

How to reassure. Patients may consider reassurance offered prematurely or by a stranger to be patronizing or dismissive. Reassurance is most effective when:

• given by a trusted person who is reliable, consistent, firm, and empathic
• the patient’s condition has been established as unresponsive to conventional diagnostics or biological therapies.

Patients are most receptive to reassurance when they express distress or frustration with their unexplained symptoms. Affirming that their suffering is legitimate opens the door to further treatment.

Reassurance is least effective when a patient is expressing anger or mistrust, although this is when the physician may feel most pressured to reassure. To successfully reassure a patient, the psychiatrist needs to:

• credibly identify with the patient’s distress
• and listen empathically (such as using body language and facial expressions that convey concern and consideration to the patient).²⁴

Starcevic suggests useful techniques for providing reassurance (Table 3).²²

DRUG THERAPIES

Psychotropics are considered a first-line treatment for patients with somatization disorders when:

• the patient spontaneously identifies any discrete, vegetative, or psychological complaints that may respond to drug therapy, such as insomnia, weight loss, sadness, or preoccupation
• the patient meets diagnostic criteria for comorbid anxiety or depressive disorders
• the therapeutic alliance is strong enough to weather the inevitable struggle with side effects and incomplete response to treatment. We do not recommend medication in the first encounter, when it may threaten a nascent alliance.

A common obstacle to prescribing psychotropics to somatizing patients is their sensitivity to suggestions that their complaints are “all in their heads.” To sidestep this resistance, describe the medication as treating the stress caused. by—not causing.—their chronic physical complaints. Proposing antidepressant therapy after—rather than instead of—physical exams and other diagnostics may elicit a more positive response.

Antidepressants. In clinical trials, somatoform complaints show moderate improvement after antidepressant treatment. In a meta-analysis of 6,595 patients with unexplained symptoms treated only with antidepressants, the number needed to treat was 3 to yield a positive response.²⁵ This report of 94 medication trials included patients with headache, fibromyalgia, functional GI syndromes, idiopathic pain, tinnitus, or chronic fatigue.

In other trials:

• Amitriptyline has reduced somatic symptoms in patients labeled as having “masked depression.”²⁶
• Sertraline has reduced disease fear, disease conviction, and bodily preoccupation in patients with hypochondriasis and panic disorder.²⁷

Consider side effects when choosing medication for patients with somatoform disorders. Selective serotonin reuptake inhibitors (SSRIs) in general—and sertraline, citalopram, and escitalopram specifically—have fewer side effects than tricyclics. The adage of “start low, go slow” is appropriate for somatizing patients; we usually start with one-half the dosages recommended for treating depression.

Antipsychotics. In case reports, patients with “atypical psychosis,” “monosymptomatic hypochondriacal psychosis,” or “delusional disorder, somatic type” have responded to antipsychotics. These patients’ somatic beliefs are of delusional intensity, such as the rare fear of being eaten alive by an intestinal parasite (delusional parasitosis). Reported behaviors associated with the delusion include starvation, excessive laxative abuse, ingestion of sharp objects, and self-inflicted stab wounds. Treatments described in the literature include the typical agents pimozide and haloperidol and the atypicals olanzapine and risperidone.

TREATMENT-RESISTANT PATIENTS

Some patients with somatoform disorders will not accept CBT, psychotropics, reassurance, or referrals to group psychoeducation. Despite your best efforts, they may persist in focusing on somatic complaints. If you are willing to maintain a therapeutic relationship with them, be prepared to tolerate several ongoing paradoxes (Table 4).

Behaviorally, you must “listen more and do less.” Emotionally, you must be willing to enter into a long-term relationship with an inherently frustrating patient whose pathologies make you feel therapeutically hopeless and helpless. Understand that their physical symptoms function as a metaphor for psychological distress. You are not required to explore the source, content, or meaning of the metaphor in detail but simply listen to their somatic complaints through that psychological filter.

Related resources

• Starcevic V, Lipsitt D (eds). Hypochondriasis: modern perspectives on an ancient malady. New York: Oxford University Press, 2001.
• Information and support Web site for persons with health anxiety or hypochondria. www.healthanxiety.com
• Anxiety Disorders Association of America. www.adaa.org

Drug brand names

• Amitriptyline • Elavil
• Citalopram • Celexa
• Escitalopram • Lexapro
• Haloperidol • Haldol
• Olanzapine • Zyprexa
• Pimozide • Orap
• Risperidone • Risperdal
• Sertraline • Zoloft

Disclosure

Dr. Isaac reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Dr. Wise receives grant support from Eli Lilly & Co. and is a consultant or speaker for Eli Lilly & Co., Pfizer Inc., Bristol-Myers Squibb Co., and GlaxoSmithKline.