Recommended Treatments for Somatic Symptom Disorder
Cognitive behavioral therapy (CBT) based on CBT principles should be the first-line treatment for somatic symptom disorder, as it produces clinically meaningful improvements in symptom severity, physical functioning, and reduces healthcare utilization. 1
First-Line Treatment: Cognitive Behavioral Therapy
CBT is the primary evidence-based treatment for somatic symptom disorder and should be initiated before considering pharmacological interventions. 1 The WHO guidelines specifically recommend psychological treatment based on CBT principles for patients with medically unexplained somatic complaints who are in substantial distress and do not meet criteria for depressive episode/disorder 1.
CBT Treatment Structure and Efficacy
- CBT produces large effect sizes, reducing somatic symptom severity by 1.31 points and demonstrating sustained benefits at follow-up 2
- A manualized, 10-session individual CBT regimen produces clinically meaningful improvement, with 40% of patients rated as "very much improved" or "much improved" compared to only 5% with standard care alone 3
- Sessions should be longer than 50 minutes to maximize reduction in somatic symptom severity 2
- Group-based CBT is particularly beneficial when it incorporates affective components and develops good interpersonal strategies during treatment 2
Optimal Treatment Parameters
- For reducing somatic symptoms: deliver sessions longer than 50 minutes in either individual or group format 2
- For addressing comorbid depression and anxiety: provide more than 10 sessions over at least 12 weeks 2
- CBT should incorporate cognitive restructuring, behavioral activation, and problem-solving techniques tailored to the patient's somatic focus 4, 5
Important caveat: Longer duration and higher frequency treatments (>10 sessions, >12 weeks) are more effective for comorbid symptoms but may result in lower treatment compliance 2. Balance treatment intensity with patient engagement capacity.
Secondary Treatment Considerations
When CBT Alone Is Insufficient
If CBT produces inadequate response or the patient has significant comorbid depression, consider adding an SSRI as augmentation rather than monotherapy. 1 The WHO guidelines specify that antidepressants should NOT be used for initial treatment of individuals with somatic complaints in the absence of current or prior depressive episode/disorder 1.
Pharmacotherapy Role
- Antidepressants (SSRIs) should only be considered when there is comorbid moderate-to-severe depression requiring medication 1
- Pharmacotherapy effectiveness is limited for somatic symptom disorder itself and should not replace CBT as the primary intervention 4
- Anxiolytics and tranquilizers may be considered as adjuncts in combination with reassurance, counseling, and psychological referral, but not as standalone treatments 1
Treatment Algorithm for Clinical Practice
Step 1: Initial Assessment and Diagnosis
- Confirm diagnosis meets DSM-5 criteria for somatic symptom disorder after ruling out medical causes 1
- Assess for comorbid depression, anxiety, or adjustment disorders that may modify treatment approach 6
Step 2: Initiate CBT
- Begin with 10-20 sessions of individual or group CBT incorporating cognitive restructuring and behavioral strategies 2, 3
- Ensure sessions are at least 50 minutes in duration 2
- Include psychoeducation about the mind-body connection and the role of psychological factors in symptom maintenance 5
Step 3: Assess Response at 3 Months
- Good response (symptom reduction ≥30%): Continue CBT with maintenance sessions 3
- Partial response: Extend CBT to >10 sessions and consider adding problem-solving therapy 1, 2
- Poor response with comorbid depression: Add SSRI while continuing CBT 1
Step 4: Long-term Management
- CBT benefits are sustained at follow-up for somatic symptoms, anxiety, and depression 2
- Provide supportive attitude and continuous treatment even without psychiatric consultation 4
- Monitor for relapse and offer booster sessions as needed 3
Common Pitfalls to Avoid
Do not initiate antidepressants as first-line monotherapy for somatic symptom disorder without comorbid depression 1. This is a critical error as pharmacotherapy alone has limited effectiveness for the core somatic symptoms 4.
Do not dismiss the patient's physical symptoms or suggest they are "all in their head" 5. Patients with somatic symptom disorder initially visit physicians because their symptoms are genuinely distressing and they fear physical disease 4. A supportive, validating approach is essential for engagement.
Do not provide brief CBT (<10 sessions) when comorbid anxiety or depression is present 2. While shorter treatments may address somatic symptoms, comorbid psychological distress requires more intensive intervention.
Do not expect immediate reduction in healthcare utilization 2. CBT does not significantly reduce doctor visits in the short term, though it improves physical functioning and reduces healthcare costs over time 3.
Special Populations and Adaptations
For patients who cannot access traditional CBT, consider internet-delivered or remote CBT protocols, which have demonstrated effectiveness 2. Group CBT is more economical than individual therapy with comparable treatment effects and should be utilized when available 6.
For patients with strong somatic focus who resist psychological explanations, Morita therapy may be particularly effective and can be performed in nonpsychiatric clinical settings using comparatively short interviews 4.