What is the recommended treatment approach for psychosomatic disorders?

Treatment of Psychosomatic Disorders

Psychological treatment based on cognitive-behavioral therapy (CBT) principles should be the first-line treatment for patients with medically unexplained somatic complaints who are in substantial distress and do not meet criteria for depressive disorder. 1

Initial Assessment and Treatment Selection

The treatment approach must prioritize identifying whether a formal psychiatric disorder underlies the somatic complaints, as this fundamentally changes management:

• Screen for depressive episode/disorder first - if moderate to severe depression is present, tricyclic antidepressants or fluoxetine should be initiated rather than treating the somatic complaints in isolation 1
• Evaluate for anxiety disorders - these are highly prevalent (2.5-55%) in patients with somatic diseases and require specific treatment 2
• Rule out panic disorder - if panic attacks are present, psychological treatment based on CBT principles is indicated 1

Primary Treatment Algorithm

For Patients WITHOUT Formal Psychiatric Diagnosis

CBT-based psychological treatment is the definitive first-line intervention for patients with medically unexplained somatic complaints who have distress or functional impairment but do not meet criteria for a psychiatric disorder 1. This approach has demonstrated effectiveness specifically for this population 2.

For Patients WITH Depressive Symptoms (No Formal Episode)

• Problem-solving treatment should be offered to patients with depressive symptoms in the absence of a formal depressive episode who are in distress or have impaired functioning 1
• Antidepressants and benzodiazepines should NOT be used for initial treatment of complaints of depressive symptoms without current or prior depressive episode/disorder 1

For Patients WITH Formal Depressive Episode/Disorder

The treatment hierarchy depends on severity:

• Mild depression: Antidepressants should NOT be considered for initial treatment 1
• Moderate to severe depression: Tricyclic antidepressants or fluoxetine should be initiated 1
• Treatment duration: Continue antidepressant treatment for 9-12 months after recovery before considering discontinuation 1

Psychotherapeutic Interventions

Multiple evidence-based psychological treatments are available:

• Interpersonal therapy and CBT (including behavioral activation) should be considered for depressive episodes in non-specialized settings if sufficient human resources exist 1
• Problem-solving treatment can be used as adjunct treatment in moderate and severe depression 1
• Relaxation training and physical activity advice may be considered as adjunct treatments in moderate and severe depression 1

Critical Pitfalls to Avoid

What NOT to Do

• Never use psychological debriefing for recent traumatic events to reduce risk of post-traumatic stress, anxiety, or depressive symptoms - this intervention is contraindicated 1
• Avoid benzodiazepines for chronic anxiety in this population due to potential behavioral side effects including disinhibition 1
• Do not prescribe antidepressants for mild depression or subthreshold symptoms without formal diagnosis 1

Common Diagnostic Errors

The most critical error is treating somatic symptoms without recognizing underlying psychiatric disorders that require specific treatment 2, 3. Approximately 15-30% of patients in primary care and internal medicine settings have primarily psychosomatic disturbances requiring a comprehensive biopsychosocial approach 4.

Multidisciplinary Considerations

For complex cases with comorbid somatic diseases:

• Inpatient psychosomatic treatment may be indicated for anxiety disorders comorbid with somatic diseases when outpatient interventions are insufficient 2
• Comprehensive assessment should include psychosocial factors affecting vulnerability, life events, chronic stress, illness behavior, and quality of life 3
• Integrated care combining psychological therapies with medical management improves outcomes for prevention, treatment, and rehabilitation 5, 3

Treatment Monitoring

• Assess treatment response by evaluating both symptom reduction and functional improvement, not just symptom complaints 3
• Monitor for psychiatric comorbidity including depression, anxiety, and substance misuse throughout treatment 1
• Evaluate quality of life as a key outcome measure beyond symptom resolution 3