What is the management approach for psychosomatic disorders?

Management of Psychosomatic Disorders

Core Definition and Recognition

Psychosomatic disorders are conditions where psychological stresses adversely affect physiological functioning to the point of distress, requiring a biopsychosocial treatment approach that addresses both the physical symptoms and underlying psychological factors. 1

• These disorders involve dysfunction or structural damage in physical organs through inappropriate activation of the involuntary nervous system and biochemical stress responses 1
• The psychosomatic symptom develops as a physiological manifestation of an emotional state—when chronic anxiety persists unexpressed, the associated physiological symptoms (elevated blood pressure, increased pulse, respiratory changes) continue even after the initial stressor 1
• In pediatric populations, 81% of children presenting with medically unexplained chest pain meet diagnostic criteria for anxiety disorders, with 28% having full panic disorder 2

Initial Assessment: What to Look For

Conduct a comprehensive evaluation focusing on three specific domains: psychosocial stressors (life events, chronic stress, allostatic load), psychiatric comorbidities (depression, anxiety, substance misuse), and illness behavior patterns (healthcare utilization, functional impairment). 3

• Assess individual vulnerability factors including recent life events, chronic stress exposure, well-being status, and health attitudes 3
• Evaluate psychosocial correlates: psychiatric disturbances, psychological symptoms, illness behavior patterns, and quality of life 3
• In children, obtain detailed history about school performance, family stresses, and multiple somatic complaints (headaches, abdominal pain, back pain) which commonly cluster together 2
• Screen maternal mental health—mothers with high somatic symptom scores have 1.8 times higher odds of bringing their child to the ED (95% CI 0.99-3.38) 2

Diagnostic Terminology: Critical Updates

Use the term "somatic cough disorder" instead of "psychogenic cough" and "tic cough" instead of "habit cough" to align with DSM-5 classification. 2

• The DSM-5 no longer recognizes "habit" or "psychogenic" terminology 2
• Somatic cough disorder can only be diagnosed after extensive evaluation ruling out tic disorders and uncommon causes, and the patient must meet DSM-5 criteria for somatic symptom disorder 2
• Tic cough diagnosis requires core clinical features: suppressibility, distractibility, suggestibility, variability, and presence of premonitory sensation 2
• Night-time cough or barking/honking character should NOT be used to diagnose or exclude these conditions 2

Treatment Algorithm

Step 1: Provide Reassurance and Establish Therapeutic Alliance

Take time to obtain detailed history and comprehensive physical examination to convey that symptoms are heard and taken seriously. 2

• Elicit and directly address the child's and family's specific anxieties and fears about the symptoms 2
• Reaffirm that providers are working collaboratively to continue evaluation and treatment 2
• Emphasize that symptoms are real and not being dismissed, while introducing the concept of working on improving functioning alongside symptom resolution 2
• Educate about the mind-body connection: explain how persistent emotional states (chronic anxiety, unexpressed fear) maintain physiological symptoms even when the initial stressor has passed 1

Step 2: Implement Psychological Interventions (First-Line)

Cognitive behavioral therapy (CBT) is the primary treatment for adults with medically unexplained somatic complaints who are in substantial distress and do not meet criteria for depressive disorder. 2

• CBT-based psychological treatment should be offered to repeat adult help-seekers with medically unexplained somatic complaints 2
• For children with somatic cough disorder, use non-pharmacological trials of hypnosis or suggestion therapy, or combinations of reassurance and counseling 2
• Refer to psychologist and/or psychiatrist when symptoms persist despite initial interventions 2
• Short-term psychodynamic psychotherapy (STPP) shows 91.3% effectiveness for physical symptoms, 91.6% for psychological symptoms, and 76.2% for social-occupational function across 23 studies 4
• STPP demonstrates 54% greater treatment retention compared to controls 4

Step 3: Address Comorbid Psychiatric Conditions

Screen for and actively treat depression, anxiety disorders, and substance misuse, as these commonly perpetuate psychosomatic symptoms. 2, 3

• For adults with moderate to severe depressive episodes, consider tricyclic antidepressants or fluoxetine 2
• Do NOT use antidepressants for initial treatment of mild depressive episodes 2
• Do NOT use antidepressants or benzodiazepines for depressive symptoms in absence of current/prior depressive episode 2
• Problem-solving treatment should be considered for people with depressive symptoms who are in distress or have impaired functioning 2
• Continue antidepressant treatment for 9-12 months after recovery 2

Step 4: Adjunctive Interventions

Incorporate relaxation training, physical activity advice, and family interventions as adjunct treatments. 2

• Relaxation training and advice on physical activity may be considered for adults with depressive symptoms; in moderate-severe cases, use as adjunct to primary treatment 2
• Clinical hypnosis and meditative states can be important for symptom management of neuro-psychobiological stress responses 1
• Include families in assessment and treatment planning, providing psychoeducation about the condition 2

Step 5: Lifestyle Modification and Long-Term Management

Apply specific interventions targeting lifestyle modification, treatment of psychiatric comorbidity, and abnormal illness behavior. 3

• Address health attitudes and behaviors that perpetuate symptoms 3
• Provide ongoing assessment of psychosocial factors affecting vulnerability 3
• Monitor quality of life and functional status as treatment outcomes 3

Common Pitfalls to Avoid

Do NOT use psychological debriefing for recent traumatic events—it does not reduce risk of post-traumatic stress, anxiety, or depressive symptoms. 2

• Avoid dismissing symptoms as "all in your head"—this destroys therapeutic alliance and is clinically inaccurate 2
• Do not pursue endless medical testing once comprehensive evaluation is complete—this reinforces illness behavior 2
• Recognize that patients and families often fear being labeled "psychosomatic" due to stigma—address this explicitly 2
• Do not discharge patients once acute symptoms improve—maintain continuity of care 2

Special Populations

Pediatric Considerations

• Common precipitating factors in children include school phobia, fear of rejection, and need for attention 2
• Associated psychopathology is rarely diagnosed despite high symptom burden 2
• Somatic cough syndrome is more common in adolescents; tic cough occurs in younger children and more commonly in boys (mean age 4-18 years, 58% male) 2

High-Risk Scenarios Requiring Different Approach

• If psychotic symptoms are present with somatic complaints, follow psychosis management guidelines with immediate psychiatric evaluation 2
• If delirium is suspected, management focuses on treating underlying medical cause, controlling symptoms with non-pharmacological approaches, and medication when appropriate 2

Treatment Efficacy Evidence

• Meta-analysis of 14 studies shows STPP produces significant effects on physical symptoms, psychiatric symptoms, and social adjustment maintained at long-term follow-up 4
• Effects remain significant even with random-effect modeling, though somewhat attenuated 4
• Healthcare utilization decreases in 77.8% of cases with appropriate psychosomatic treatment 4