• Psychosomatic symptoms are symptoms occurring when there is a functional somatic disorder that has a psychological aetiology (such as stress) and can manifest in many different forms. Psychosomatic symptoms are often associated with somatic symptom (somatoform) disorder but they may also occur in almost any psychiatric disorder.
• The doctor should not question the existence of the patient’s symptoms, their subjective severity or the degree of consequent functional impairment, even if there is a discrepancy between the symptoms and findings. The symptoms are real for the patient, and they indicate a need for help.
• The doctor should inform the patient about the possible role of psychological factors in the symptom picture, reassure the patient regarding somatic illnesses, correct wrong perceptions about illnesses and, working together with the patient, the doctor should aim to establish an explanatory model for the symptoms.
• Patients with somatoform disorders use more health care services than average. A long relationship with the same doctor is often necessary before the patient is ready to start gradually broaching the psychosocial problems behind the symptoms and to process their association with the somatic symptom picture.
• A consultation with a psychiatrist may be needed for the assessment, differential diagnosis and treatment of psychiatric disorders and, in particular, to assess whether the patient is in need of psychotherapy.

• Somatisation denotes a tendency to experience, conceptualise and communicate psychological conflicts as somatic symptoms or changes. The term somatisation may also be used in a wider sense to describe all the functional symptoms that practically everyone experiences at least sometimes and that cannot be explained by somatic pathology, or to describe fear of an illness.
• Somatised symptoms may cause suffering and affect the person’s functional capacity, but somatisation is not a diagnosis included in disease classifications.
  • Common somatic symptoms which cannot be explained by a medical condition, even after comprehensive investigations, include abdominal complaints, backache, headache and fatigue.
• Prevalence
  • In the general population, up to 60–80% have at least one somatic symptom that causes them some discomfort.
  • Among primary care patients, 20–35% have one or more unexplained somatic symptom; about 70% of these patients are women.
  • Among patients within specialized care and among frequent users of health services, the prevalence of somatised symptoms is higher; 25–45% have one or more inexplicable somatic symptom.

• Somatoform disorders are characterized by chronic physical symptoms not explained by any physical disease. Even if there is a physical disease, it does not explain the type or number of symptoms or the person's anxiety and concentration on their symptoms (ICD-10).
• Somatoform disorders are often severe and chronic, they are associated with seeking to be investigated and treated and with inappropriate illness behaviour, and the disorder causes disruption of social, occupational or other areas of functioning.
  • Symptoms may occur in any organ system, and patients seek medical help within primary health care or different somatic specialties related to the symptoms.
• The annual prevalence of somatoform disorders in the general population is 6%, which is of the same order as the prevalence of depression. In primary health care patients, the prevalence is 17%, and in patients with functional syndromes (such as fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome) 25–60%.

Subgroups in ICD-10

• Somatisation disorder (F45.0)
  • At least 6 different somatic symptoms in two or more different organ systems of at least two years’ duration
  • The most severe form of somatoform disorder
  • Prevalence 0.2–2%, almost exclusively in women
• Undifferentiated somatoform disorder (F45.1)
  • Not all the criteria for somatisation disorder are met.
  • Prevalence 8%
• Hypochondriacal disorder and body dysmorphic disorder (F45.2)
  • Persistent fear of becoming ill, a belief of having a serious disease or a defect in one’s physical features, or excessive preoccupation with a perceived abnormal physical appearance
  • Excessive concern about one's own health; the individual is usually alarmed about his/her state of health.
  • There are usually no somatic symptoms, or they are only mild.
  • The individual constantly monitors his/her body for the signs of a possible disease.
  • Prevalence: hypochondria 2–7%, body dysmorphic disorder 1–2%, among patients undergoing plastic surgery 6–15%
• Somatoform autonomic dysfunction (F45.3)
  • Arousal of at least one organ system which is under autonomic control and at least two autonomic symptoms (e.g. palpitations, sweating, dry mouth or nonspecific epigastric discomfort) and, in addition, at least one other symptom that is more nonspecific, e.g. irritable bowel (in 10% of patients) or hyperventilation
• Persistent somatoform pain disorder (F45.4)
  • Pain that requires clinical attention in one or more anatomic locations
  • The criteria of somatoform disorder are met in 5–10% of pain patients within medical care.
  • Prevalence: chronic pain is present in 10% of the population
• Other and unspecified somatoform disorders (F45.8, F45.9)
  • For example, psychogenic dysmenorrhoea, psychogenic headache
  • Prevalence: chronic headache in 5% of the population; the life time prevalence may be as high as 80%.

Other diagnostic codes

• In DSM-5, the US system of diagnosis of mental and behavioural disturbances, somatic symptom disorder also includes
  • functional neurological symptom disorder or “conversion disorder” (300.11), a name used for various clinical pictures (such as muscle weakness, ictal symptoms, changed sensory function) which in ICD-10 are classified as dissociative disorders (F44.4–F44.7)
  • psychological factors adversely affecting other medical conditions 316 (F54), and
  • factitious disorder 300.19 (F68.10).
• Dissociative disorders (conversion disorders; F44.4–F44.7), functional neurological symptom disorder
  • One or more dissociative symptoms affecting motor or sensory function
    • F44.4 weakness or paralysis
    • F44.4 abnormal movement, such as tremor, dystonia, myoclonus, gait disorder
    • F44.4 swallowing symptoms
    • F44.4 speech symptoms (dysphonia, tachyphemia)
    • F44.5 seizures or convulsions
    • F44.6 anaesthesia or sensory loss
    • F44.6 special sensory symptom (visual, hearing, olfactory)
    • F44.7 mixed symptoms
  • Dissociative disorders are often associated with traumatic events.
  • Clinical examination reveals discrepancies between the patient's symptoms and the assumed neurological or other somatic disease.
  • The diagnosis should be based on the clinical picture as a whole and not merely on a single finding.
  • Non-epileptic seizures are most common in patients at the age of 20–30 years and motor symptoms at the age of 30–40.
  • The prevalence of the disorder is 1–3% among primary care patients, and 5% within outpatient neurology clinics. The disorder is 2–10 times more common in women than in men.
• Worsening of physical symptoms due to psychological factors (F54)
  • Physical symptoms consistent with a diagnosed physical disorder, disease or injury, and originally caused by such a disorder, disease or injury, are prolonged or become excessively severe due to the person's mental state; for example, asthma F54 and J45.
• Intentional production or feigning of either somatic or mental symptoms/signs (factitious disorder; F68.1)
  • The person repeatedly feigns symptoms even though no physical or mental disorder, disease or fault has been diagnosed and assuming the sick role would not appear to clearly benefit the person.
  • A malingerer (Z76.5) aims consciously to gain concrete benefit from pretending to be sick.

Special features of DSM-5

• In the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, 2013), developed by the American Psychiatric Association, the earlier diagnostic group “somatoform disorders” is replaced by the heading ”somatic symptom disorder and related disorders”, and the diagnostic criteria have been simplified. Additionally, there are fewer individual diagnoses and additional features, such as persistence and whether pain is the predominant symptom, are used to separate the different types of disease.
• This group of disorders contains the diagnoses somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors adversely affecting other medical conditions, and factitious disorder. Dissociation symptoms are classified in their own dissociative disorders group.
• The essential criterion of somatic symptom disorder (DSM-5) is the existence of one or more somatic symptoms that are distressing or result in significant disruption of daily life.
• The diagnostic criteria no longer include the exclusion of somatic illnesses, but it is essential that the patient’s somatic symptoms or health worries involve at least one of the following:
  • disproportionate and persistent thoughts about the seriousness of one’s symptoms
  • persistently high level of anxiety about health or symptoms
  • excessive time and energy devoted to these symptoms or health concerns.
• This change emphasizes that the mere exclusion of somatic illnesses is not a justification for making the diagnosis of a mental disorder. Furthermore, the change is expected to reduce the earlier overlap in diagnoses, to increase the feasibility of the diagnosis especially within somatic specialties, to reduce the stigma caused by the diagnosis and to more generally emphasize the importance of recognizing and treating mental problems in somatically ill patients.

• Diagnoses of somatic symptom disorder and of simultaneous somatic disease are not mutually exclusive but often coexistent (DSM-5).
• Somatic disorders (not earlier recognized)
  • In 2–10% of patients a somatic disorder that explains the physical symptoms is found within a few years following the diagnosis of somatic symptom disorder.
  • Many somatic disorders (e.g. epilepsy, MS) predispose to somatisation.
    • Adequate somatic investigations are essential.
    • Iatrogenic harm should be avoided.
• Depressive disorders
  • Major depression may manifest itself as, for example, pain syndrome or somatic fatigue state (”masked depression”), but the core symptoms of depression (depressed mood and inability to enjoy things) are usually present.
  • About one quarter of those with chronic pain syndrome meet the diagnostic criteria for major depressive disorder.
  • As many as 50% of patients with major depressive disorder who seek help in primary care complain principally of somatic symptoms.
  • As many as two out of three patients with depression have disturbing pain.
• Anxiety disorders
  • Particularly in panic disorder and generalised anxiety disorder, the patient may exhibit symptoms which are related to hyperactivity of the autonomic nervous system (hyperventilation, palpitations, chest pain, dyspnoea, dizziness, weakness, sweating).
  • In generalized anxiety disorder, the patient's worrying usually has several targets, and the concern about health is only one of them.
  • In post-traumatic stress disorder (Antisocial personality disorder) events may intrude into the patient's consciousness and he/she may re-experience them; symptoms may also include avoidance behaviour, hyperalertness, memory problems, somatic manifestations of anxiety and different kinds of dissociative symptoms.
• Other mental illnesses and malingering
  • Psychotic disorders
    • A psychotic disorder may be associated with somatic delusions, e.g. a conviction about a bad smell or worms that live under the skin.
  • Factitious disorders (F68.1)
    • Characterized by intentional production of either physical or mental symptoms/signs. The person’s central aim (mainly unconscious) is adoption of the sick role.
  • Malingering (Z76.5)
    • Not classified as a psychiatric disorder
    • A malingerer aims consciously to gain external benefit from his/her symptoms.

• Somatic illnesses are common associated disorders. The decline in functional capacity associated with somatic illnesses is worsened by comorbidity.
• Mood and anxiety disorders
  • Depressive or anxiety disorders are encountered in association with somatic symptom disorder in up to 50% of patients, which is more than the average number of cases seen in chronic somatic conditions.
  • Depression and anxiety prolong and further increase the patient’s tendency towards somatisation.
• Other subtypes of somatic symptom disorder
  • A patient with one subtype of somatic symptom disorder often also meets the diagnostic criteria for another subtype.

• Female sex
• Low level of education or low socioeconomic status
• Events in childhood
  • Chronic diseases
  • Adverse experiences and trauma (such as maltreatment, sexual abuse)
• Trauma in adulthood
• Physical and psychiatric diseases
• Tendency to worry about falling ill
• Chronic diseases in the family

• The mechanism behind somatic symptom disorder is increased awareness of various bodily sensations, combined with a tendency to interpret such sensations as suggesting a somatic disease.
• Personal factors
  • Physiological mechanisms
    • Hyperactivation of the autonomic nervous system or the hypothalamic-pituitary-adrenal axis, muscle tension, hyperventilation, sedentary lifestyle, past or present somatic illnesses.
  • Genetic and epigenetic factors
    • According to a study, the relative share of genetic factors (heredity) was 7–21% .
    • Simultaneous anxiety and depression may involve a genetic component.
  • Factors associated with development and learning
    • Weak emotional awareness and increased negative emotions
    • Neglect, sexual and physical violence, parents’ illnesses and illness behaviour
    • Insecure attachment style and care-seeking behaviour
  • Cognitive style, the way the person processes information
    • Observation of physical sensations and their catastrophic interpretation
  • Psychodynamic factors
    • Difficulties in self-expression
      • Somatic symptoms may reflect emotional distress or mental conflict which the person cannot describe verbally (alexithymia), or the somatic symptoms are a manifestation of an attempt to reconstruct a fragmented self-image (self psychology).
  • Personality traits and characteristics
    • Low self-esteem, pessimism
    • Being prone to self-monitoring
    • Being demanding, suspicious, and attention-seeking
• Psychosocial and sociocultural factors
  • Family conflicts
  • Symptoms and resorting to the sick role may offer the patient some advantages, such as social support, release from obligations, unemployment benefits or a way of dealing with internal conflicts. This may maintain the disorder.
  • There are cultural differences in the prevalence of somatisation disorders.
  • Somatic symptom disorder is more common in societies where psychiatric disorders are seen as ”stigmatising”.
• Iatrogenic factors
  • Excessive investigations without appropriate treatment may increase the occurrence of somatisation.
  • Reimbursement entitlements for somatic conditions may reinforce and prolong somatisation.

• Transient symptoms similar to somatisation may occur in almost anyone in stress situations and during a life crisis.
• Somatic symptom disorders usually starts during adolescence or early adulthood. The severity of the disorder may fluctuate with time.
• Patients with somatoform symptoms characteristically seek medical investigations but rarely ask for psychiatric treatment and may even resist such a referral.
• A study showed that the most severely somatising patients (14% in a questionnaire assessing somatisation) had higher medical care utilisation rates than all the rest of the patients in the study.
• Many patients with somatic symptom disorder (30%) perceive their quality of life as being poor, and the functional capacity of some (10%) may be worse than that of patients with chronic physical conditions.
• The disorder may be complicated by unnecessary surgical interventions or substance use disorders, for example.
• The disorder may lead to reduced social participation, giving up hobbies, divorce, etc.
• The course of the disease is often chronic and fluctuating. Eventual recovery or remission may still be expected in 50–70% of patients but relapses are also possible.
• Factors suggesting a poorer prognosis are a large number of somatic symptoms, advanced age, significantly impaired functional capacity, concomitant anxiety and depression or a personality disorder.
• When assessing the patient's ability to work and the feasibility of rehabilitation, instead of concentrating on the scarcity of somatic findings, attention should be focused on the possibility of comorbid depression and its treatment and rehabilitation attempts, as well as on possible exhaustion, the patient's overall health, personality and life situation.
• It is a good idea to obtain a comprehensive psychological or psychiatric statement at the early stages of the work ability assessment already.

• An appointment should be long enough to allow the patient to talk about his/her physical symptoms and to feel that they have been listened to and taken seriously. This will also make it easier to talk about their current life situation. What are the patient’s main symptoms or the main worry? What factors have influenced symptom onset, prolongation or aggravation? What factors have alleviated symptoms?
  • Somatisation tendency may be investigated by reviewing the patient’s history of symptoms regarding all organ systems and starting from childhood. Find out how the symptoms have affected functional capacity and how they have been treated.
• Current and past psychosocial stress factors which either preceded the symptoms or predisposed (see aetiology) the patient to symptom emergence
  • The doctor could suggest examples of common situations where stress produces physical symptoms (e.g. tension headache, hyperventilation).
• Significant human relationships (from childhood to the present) should be discussed together with any associated worries or problems and, on the other hand, any support gained from these relationships.
• What effect have the symptoms had on the quality of life and functional capacity (study, work, social relationships)?
• Features suggesting somatic symptom disorder found in primary health care or in somatic specialties
  • History of current disease vague or inconsistent
  • Health worries rarely alleviated despite heavy use of somatic health services
  • Symptoms not alleviated by repeated ordinary treatment and explanations and reassurance by doctors
  • Normal physical sensations interpreted as being associated with physical diseases
  • Recurring checking of the body to detect anything abnormal
  • Avoiding physical activity
  • Unusual sensitivity to side-effects of drugs
  • Seeking treatment by several doctors for the same somatic symptoms
  • Refusal to allow discussion with other doctors
  • Doctors feeling frustrated
• The PHQ-15 (see e.g. https://www.phqscreeners.com/) is the most commonly used tool for assessing the quantity of somatic symptoms provoking anxiety. PHQ-15 score and severity of somatic symptoms:
  • 0–4 – minimal
  • 5–9 – mild
  • 10–14 – moderate
  • 15–30 – severe
• All previous clinical and laboratory examinations must be carefully scrutinised before any possible new investigations. The doctor should always also personally carry out a somatic examination. Laboratory investigations are indicated only as dictated by objective findings.
• Are there signs of psychiatric comorbidity (depressive (Recognition and diagnostics of depression) (Depression in the elderly) (Depression in adolescents) and anxiety (Anxiety disorder) disorders)? Screening tools can be used.
• What is the patient’s own impression of the causes and significance of the symptoms? Does that differ from the doctor’s view?
• It is advisable that the doctor does not put forward his/her own interpretation of the aetiology during the examination.

• A good relationship forms an integral part of treatment (psychoeducation and supportive psychotherapy). Given that the patient perceives their symptoms to have a physical basis, a general practitioner or another doctor with expertise in somatic illnesses is often most suited to take overall responsibility for the care. A psychiatrist may act as a consultant.
  • When the patient is ready for psychiatric therapy, the psychiatric unit should be ready to take over the primary responsibility for the therapy. Units of general psychiatry within hospitals are suitable for this purpose.
• Medical expertise is required so that the patient can be reassured, wrong perceptions of illnesses corrected and appropriate information provided.
• Listening with interest and showing understanding create an atmosphere of trust. This will also facilitate the gradual introduction of other subjects into the conversation, in addition to the symptoms. The patient’s symptoms must be accepted to be ”real”. If the patient is only told that there is nothing wrong, they will leave disappointed and seek help elsewhere.
• The patient should undergo one comprehensive and thorough examination. Further, unnecessary somatic examinations should be avoided.
• Reassurance: discuss the patient’s fears (e.g. fear of cancer). Encourage the patient to express their thoughts and feelings about the current and past symptoms. In an acute phase, the patient may be reassured that no serious cause has been found for the symptoms and they will improve with time.
• Explanation: the psychological and biological sides should both be considered together. Unsubstantiated diagnoses may only serve to prolong the symptoms. It is better to admit a certain degree of uncertainty. However, the aim is to find an explanatory model for the symptoms that is acceptable to the patient; physical factors and factors relating to the current life situation should be combined.
  • Explain that the body can produce symptoms in the absence of physical illness and that psychological and social problems (such as stress or conflicts) may affect the body. Focussing on a certain part of the body will make the person more aware of any sensations in that part.
• A plan should be made together with the patient. The goal may consist of coping mechanisms rather than a total cure.
• Regular follow-up visits not depending on active symptoms should be agreed at first, initially more frequently. During a follow-up visit, the symptoms should be discussed briefly. The focus of conversation should be on how the patient has coped with the symptoms. Is there something that has worsened or improved the situation? The aim is to support and highlight the patient’s personal strengths and skills.
• Unnecessary medication should be avoided. All medication that may lead to dependence should be gradually tapered off or even totally withdrawn.
• Somatising patients often pose a challenge; many are demanding and exhibit attention seeking behaviour. It may be beneficial to initially yield partially to the patient’s wishes whilst setting limits to the number of phone calls allowed and the duration of visits, for example.
• The patient may be dissatisfied and disappointed. Talking about disagreements in an understanding manner may prevent the situation from worsening.
• To avoid becoming exhausted the doctor may team up with a nurse or public health nurse.
• With time, consultation with a psychiatrist may become possible. It should particularly be considered in cases where the diagnosis remains uncertain, the treatment yields no help or the patient has significant psychiatric comorbidity.
• The treatment relationship with the general practitioner should continue even after the patient has been referred to a psychiatrist.
• Short periods of sick leave given at the appropriate junctures, particularly during demanding life situations, may sometimes be indicated.

• Drug therapy for a somatising patient should mainly be considered for the management of any psychiatric comorbidity (e.g. anxiety, depression).
• In some studies, antidepressants (SSRIs, SNRIs, and low-dose tricyclic antidepressants) have been noted to have positive effect in the treatment of somatic symptom disorder. SNRI drugs are best suited for the treatment of chronic pain.
  • Antidepressants should be started at a low dose and increased gradually as tolerated to reach the therapeutic level, as the patients’ somatic sensitivity and fear of disease create a low threshold for observing side-effects. In patients unwilling to try antidepressants due to their general sensitivity to side-effects, medication should be started at the lowest possible dose.
• Pharmacotherapy should be combined with a mental state evaluation.
• Appointments for the follow-up of medication should be organized in such a way that not only the medication is discussed, but that there is time to process psychosocial matters, too.

• Cognitive behavioural therapy
  • Cognitive behavioural therapy, delivered either as individual or group therapy may be beneficial [Evidence Level: C].
  • Explore with the patient the factors which maintain his/her fixation with health problems, avoidance behaviour, belief in the existence of diseases and misinterpretation of symptoms. An approach of this kind aims to change the person's illness behaviour. In many cases, the patient is more willing to accept a referral for cognitive behavioural therapy than drug therapy.
• Trauma therapy, if severe traumatization of the patient is established
• Suggestion therapy and dynamic individual or group therapy.
  • Hypnosis has been used in the diagnosis and treatment of conversion disorder.
  • Intensive psychodynamic therapy may sometimes be considered in the treatment of conversion disorder.
  • Couple therapy and family therapy may be beneficial (if the symptom clearly appears to be a part of family-centred problems).
• Other non-pharmacological treatment
  • A gradual and supervised increase in physical exercise may be beneficial. The baseline should be set at the level of the patient’s worst days.
  • Physiotherapy may be necessary in conversion disorder if the patient has remained immobile for a long time, and sometimes it may suffice as the only treatment modality in acute cases. Psychophysical physiotherapy works well as a link between the psychological and somatic treatment.
  • Mindfulness exercises, different kinds of relaxation methods and biofeedback training (when individually considered) are suitable forms of therapy complementing other treatments.