What is the treatment approach for somatization disorder?

Treatment of Somatization Disorder

Psychological treatment based on cognitive-behavioral therapy (CBT) principles is the primary evidence-based treatment for somatization disorder, producing clinically meaningful improvements in symptom severity, functioning, and healthcare utilization. 1, 2, 3

Initial Management Approach

The foundation of treatment begins with establishing a therapeutic alliance through specific validation strategies:

• Validate symptoms as real and serious through detailed history-taking and comprehensive physical examination to build rapport 2
• Reassure patients that symptoms are not life-threatening while explicitly acknowledging their distress and functional impact 2
• Avoid dismissive language or suggesting symptoms are "all in their head," as this damages the therapeutic relationship and paradoxically increases healthcare-seeking behavior 2
• Elicit and directly address specific fears about symptoms from both patient and family, which provides clinical insight and reduces anxiety 2
• Schedule regular, time-contingent appointments (not symptom-contingent) to provide ongoing support and prevent emergency department visits 2

Screening for Psychiatric Comorbidities

Psychiatric comorbidities are present in the majority of somatizing patients and require specific treatment:

• Screen all patients for anxiety disorders and depression, which are present in most somatizing patients 2
• In pediatric patients with medically unexplained symptoms, 81% meet criteria for anxiety disorders, with 28% having panic disorder 2
• Assess for psychosocial stressors including domestic violence and, in children, abuse or neglect 2
• Treat identified depression and anxiety when present, as these significantly impact somatization 1, 4

Primary Treatment: Cognitive-Behavioral Therapy

CBT is the only intervention with proven efficacy for somatization disorder:

• CBT produces significant reductions in symptom severity (0.84 points on the CGI-SD 7-point scale at 15 months, P<.001) 3
• 40% of CBT-treated patients achieve "very much improved" or "much improved" status compared to only 5% with standard care alone 3
• Administer 4-12 sessions of individual or group CBT with a mental health clinician, or via self-help/internet-based formats 1
• CBT targets psychological stress, negative emotions, maladaptive cognitive processes, avoidance behaviors, and somatization patterns 1
• CBT decreases healthcare costs in addition to improving symptoms and functioning 3

Alternative Psychological Interventions

When CBT is unavailable or as adjunctive treatment:

• Problem-solving therapy should be considered for repeat adult help-seekers with medically unexplained somatic complaints who are in substantial distress 1
• Suggestion therapy, hypnosis, or combinations of reassurance and counseling are recommended in children when CBT is unavailable 2
• Gut-directed hypnotherapy (7-12 sessions) targets psychological stress, maladaptive cognitive processes, and somatization 1
• Mindfulness-based stress reduction (8-12 sessions) addresses psychological stress and negative emotion 1

Pharmacological Considerations

Antidepressants and benzodiazepines should NOT be used for initial treatment of individuals with somatic complaints in the absence of current or prior depressive episode/disorder 1

However, when comorbid depression or anxiety is identified:

• Treat comorbid depression conservatively with antidepressants when diagnostic criteria are met 1, 5
• Analgesics should be used rationally, favoring non-pharmacological pain management measures 6
• Gradually decrease drugs with praise for reduction as part of behavior modification 5

Framing Mental Health Referral

The approach to psychiatric referral is critical to acceptance:

• Frame referral as helping with coping and functioning rather than implying symptoms are not real 2
• Explain that psychological treatment addresses the brain-body connection and improves quality of life, not that symptoms are imaginary 2
• In pediatric patients with psychogenic non-epileptic seizures, 72% resolve after psychiatric treatment, highlighting the importance of accurate diagnosis and referral 2

Treatment Goals and Expectations

Setting appropriate expectations is essential for treatment success:

• Emphasize improving daily functioning over complete symptom resolution as the primary treatment goal 2
• Quality of life measures and functional assessments should guide treatment success rather than symptom elimination alone 2
• Clarify treatment goals early and address behaviors that threaten the physician-patient relationship 4
• Educate families about limitations of emergency department settings for chronic symptom evaluation 2

Long-Term Management Structure

• Regular scheduled visits prevent symptom-driven healthcare utilization 2, 4
• Restrain from performing excessive workups and assigning multiple diagnoses to somatizing patients 4
• Involve parents in treatment planning while screening for parental somatization patterns 2
• At follow-up, patients continue to have some somatic symptoms, but many improve with appropriate therapy 5

Common Pitfalls to Avoid

• Do not dismiss symptoms or suggest they are "not real" - this increases healthcare-seeking and damages rapport 2
• Avoid symptom-contingent appointments - schedule regular time-based visits instead 2
• Do not use opiates or conventional analgesia as primary pain management strategies 1
• Do not initiate antidepressants without documented depressive episode 1
• Be aware that nearly two-thirds of patients with somatization disorder attempt suicide, requiring ongoing risk assessment 5