Pain disorder could be removed from DSM because of persistent concerns about the validity of this diagnostic category. Tyrer8 reviewed his clinical experience and reported shifting from a view that people with excessive pain had a psychiatric disorder to the view that living with chronic pain produces a profile similar to that of a person with a psychiatric disorder.
Problems with DSM categorization of somatoform disorders
Physiologic component. Others recommend caution before radically altering DSM’s categorizations. Rather than shift symptoms to Axis III—as Kroenke suggests—Starcevic9 would use unexplained physical symptoms as an organizing principle and group disorders with common features, such as somatization disorder, conversion disorder, pain disorder, and undifferentiated somatoform disorder. Body dysmorphic disorder and hypochondriasis—focusing on dysfunctional appraisal of physical symptoms—would likely move elsewhere.- Somatoform disorders lack clearly defined thresholds that establish a difference between normal and pathologic behaviors
- Somatoform disorders do not form a coherent category, and exclusion criteria are ambiguous
- By existing, the category suggests that some disorders are physical and others are mental, leaving little room for intermediate or mixed conditions
- Patients reject the term “somatoform” because it conveys doubt about the reality of their conditions
- Somatoform disorders are incompatible with some cultures’ views of mental illness (for example, the DSM translation used in China does not include the somatoform category)
- Nonspecific somatoform illness subcategories cannot achieve established reliability standards in studies examining diagnoses
- Medical-legal cases and insurance entitlements are complicated by unclear descriptions of somatoform disorders
Treatment approach to patients with somatoform disorders
Hiller and Rief10—who advocate strongly for keeping somatoform disorders in DSM—suggest 4 categories: monosymptomatic, polysymptomatic, hypochondriasis, and body dysmorphic disorder. They believe grouping diagnoses in this way would improve and refine existing nosology.- Carefully evaluate for mood, anxiety, and substance use disorders
- Assess over-the-counter, prescription, and illicit drugs the patient may be using to control pain and other physical symptoms
- Review medical and psychiatric records, laboratory and radiographic findings
- Discuss the patient’s case with his or her primary care physician, and provide formal feedback or a consultation letter
- Treat comorbid psychiatric disorders with medications such as selective serotonin reuptake inhibitors or venlafaxine, which have improved somatoform symptoms in randomized, controlled trials
- Offer the patient cognitive-behavioral therapy (10 to 20 sessions) that focuses on reducing somatoform symptoms, and advise the primary care provider to schedule monthly follow-up intervals
New treatment approaches
As the categorization debate continues, a treatment approach is developing that includes cognitive-behavioral therapy (CBT) and antidepressants to address the psychological and physiologic effects of resistant somatoform disorders (Box 3).
Consultation letters. Sending a consultation letter to the patient’s primary care physician is considered the standard of care (Box 4).11 In the study that introduced the consultation letter,12 patients with somatization disorder were randomly assigned to treatment (a consultation letter) or control (treatment as usual). Health care utilization costs declined approximately 50%—largely because of decreased hospitalization—when patients’ physicians received consultation letters, compared with no change for usual treatment.
Consultation letters may reduce health care spending but are less effective in improving symptoms. Evidence is changing treatment as psychotherapies have been found to help patients with somatoform disorders.
Group psychotherapy. In a controlled trial, primary care patients with somatization disorder received short-term group CBT or treatment as usual, with follow-up 6 months later. Those in the CBT group—who had received patient education and relaxation training—showed moderate but significant improvement in physical illness and somatic preoccupation, hypochondriasis, and medication use. Usual-care patients did not improve.13
CBT vs relaxation. A group of 191 inpatients described as “highly impaired” by somatization syndrome—≥8 DSM-IV somatoform symptoms—was evaluated for psychopathology, subjective health status, and life satisfaction. They then were randomly assigned to somatization-focused CBT (“soma”) or relaxation training and compared with 34 control patients. At 1-year follow-up, doctor visits had declined significantly in patients who received CBT (“soma”), and their somatoform symptoms were reduced compared with controls’.11
Psychotherapy vs listening. In a randomized, controlled trial, 102 patients with chronic refractory irritable bowel syndrome were assigned to receive exploratory psychotherapy or supportive listening. After 12 weeks, psychotherapy was more effective in improving physical and psychological symptoms, although the difference was statistically significant only in women. After 1 year, patients who received psychotherapy remained well and control patients who declined psychotherapy had relapsed.14
CBT vs usual treatment. In a randomized controlled trial, 84 patients with somatization disorder received 10 CBT sessions or treatment as usual. CBT’s goals were to: