In all areas of healthcare, practitioners must contend with a broad range of emotional reactions to illness displayed by patients, as well as feelings within themselves. This dynamic of the doctor–patient relationship is critical in understanding patients with medically unexplained physical symptoms (MUPS).
MUPS are defined as complaints of physical symptoms or signs for which there is no adequate objective pathophysiologic evidence to explain the distress.1 The diversity of conditions that fall under this classification remains a source of controversy and paradox. Known throughout history, these disorders continue to frustrate patients and clinicians alike.
Although frequently understandable in psychological terms, MUPS are encountered principally in medical settings, where patients and clinicians often are unfamiliar with psychological explanations. Lacking commensurate evidence of physical disease in the traditional sense, patients with MUPS nevertheless often are severely disabled and contribute significantly to the costs of healthcare and lost productivity.
This article provides a brief overview of principles, problems, and progress in the study of MUPS. These will be illustrated in relation to specific disorders in the other articles in this issue.
Phenomenology and Nosology
For centuries, clinicians have attempted to reconcile the discrepancies they observed between the subjective experience of feeling ill and the presence of disease.2 Historically, the Greeks championed the understanding of disease as the product of mind-body unity and natural processes.2 During the Middle Ages, theories of disease reverted to religious doctrines until challenged by science during the Renaissance. However, study of psychopathology lagged behind, which perpetuated the Cartesian legacy of dichotomous thinking in human biology.
This dichotomy was re-examined by Freud and his contemporaries, whose work sparked debate that dominated thinking on MUPS throughout the past century.3 Drawing from clinical observations, Freud distinguished “psychoneuroses” (hysteria), which were psychological in origin, from the “actual neuroses” (hypochondriasis), which were viewed as somatic in origin and not subject to interpretation.3 Correctly perceiving the complexities of the mind-body continuum, Freud warned against attempting to analyze patients with a somatic basis for their symptoms.3 Traditional psychoanalytic theory and recent psychodynamic and neurocognitive research often are neglected or misunderstood in current discussions, thereby reinforcing dichotomous thinking that either “re-medicalizes” symptoms as being devoid of emotional meaning or attributes all MUPS to unconscious conflicts.4
Definitions and phenomenology of MUPS remain confusing and arbitrary but have attracted increasing scrutiny recently. MUPS implies the presence of symptoms that do not conform to known disease processes. Kirmayer et al.5 said MUPS defines a predicament rather than a disorder, “a way of drawing attention to a societal situation in which the meaning of distress is contested.” It is critical to accept that “unexplained” does not necessarily imply purely psychological origins, as the history of psychiatry is replete with examples of disorders once considered “functional,” that were subsequently proven to result from “organic” processes (eg, drug-induced neuroleptic malignant syndrome mistaken for idiopathic catatonia, or general paresis due to neurosyphilis).
In addition, some patients may have vague symptoms initially that appear to be “unexplained,” only to manifest clearer evidence of underlying disease later in the course of illness (eg, multiple sclerosis or myasthenia gravis). Conversely, premature medicalization of MUPS may inhibit recognition of treatable psychiatric disorders (eg, depression).
Fink et al.6 cogently outlined shortcomings and differences in definitions of MUPS. For example, differences in the use of the terms MUPS (a general description of symptoms), somatoform disorders (referring to patients with MUPS not due to other psychiatric disorders), and functional somatic syndromes (a subtype of somatoform disorders) often are confusing. How many symptoms are required to diagnose a somatoform disorder? Is it normal for patients to occasionally seek reassurance for transient physical symptoms? What is the threshold for distinguishing MUPS from “worried-wellness,” and should it depend on symptoms, severity, chronicity, or functional impairment? Is the degree of conscious awareness versus volitional control a reliable factor in distinguishing MUPS disorders?7,8 Is primary versus secondary gain a meaningful and reliable distinction?7,8
The limitations of standardized criteria for certain somatoform disorders with MUPS have been highlighted by several authors.9–13 Wessely et al.9,10 found substantial overlap among functional somatic syndromes. They suggested current diagnoses reflected medical specialization and fragmentation and proposed instead the concept of one generalized syndrome. Similarly, Barsky and Borus11 noted that functional somatic syndromes have a high degree of clinical overlap and co-occurrence and considered them to be variants of a common biopsychosocial process. Sharpe and Mayou12 questioned the validity of MUPS as a defining feature of somatoform disorders and challenged the assumption of psychogenesis in many of these disorders. Ballas and Staab13 also questioned contemporary criteria and suggested classifying MUPS based on organ systems.
Apart from cognitive mental processes, there is a perceptual component to MUPS as well. While some patients seem to have a sixth or visceral sense, patients vary in their ability to perceive and report usually undetected internal autonomic processes. Because of early experiences, anxiety, or intercurrent medical illness, patients may become attuned to and fixated on vegetative functions.11 In parallel with other sensory modalities, visceral sensations appear in some patients to rise to a psychotic level (parasitosis) or to assume the form of illusions based on apparent misinterpretation of visceral stimuli (hypochondriasis).
MUPS frequently are observed in association with other psychiatric disorders, especially depression and anxiety. Are these secondary physical symptoms similar to primary MUPS? Are comorbid depression and anxiety the cause or the result of MUPS?11 Can chronic activation resulting from psychological anxiety and stress affect physiological systems and produce secondary physical symptoms?3
Finally, there is the common clinical situation in which a patient's subjective distress is disproportionate to what the clinician expects based on the degree of real and existing organic pathology.1 This discrepancy between subjective experience and the presence of verified, underlying disease sometimes is referred to as the “functional delta.”1 This is an important qualifier that serves as a bridge between MUPS on the one hand and the universe of psychological reactions to medical illness experienced by all patients on the other.
The prevalence of MUPS is difficult to determine precisely. Estimates depend on the clinical setting, the sample population, sensitivity and specificity of criteria, and the reliability of screening methods. Nevertheless, recent efforts have provided reasonable estimates that confirm the widespread occurrence of MUPS.
In community-based surveys, Kirmayer et al.5 found approximately 10% of respondents reported at least one MUPS in the preceding year. Citing earlier figures of 4% to 5%, Grabe et al.14 found that 20% of a community sample could be diagnosed with undifferentiated somatoform disorder, which included only 1% with a more specific MUPS disorder.
Among general practice patients, Fink et al. found that over 60% presented with at least one MUPS,6 25% met ICD-10 criteria for a somatoform disorder,15 and 58% met criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSMIV).16 Using DSM-IV criteria, de Waal et al.17 recently reported a prevalence of 16% of somatoform disorders among general practice patients, which increased to 22% when mild symptoms were included. These figures approximate previous numbers indicating that 15% to 30% of patients present with MUPS in general medical settings.5,6,17 In most of these studies, however, the most common diagnoses were the non-specific designations of undifferentiated somatoform disorder or somatoform disorder, not otherwise specified, thus highlighting the nosologic uncertainties and ambiguities of this entire category.
General practitioners showed only modest success in correctly identifying these patients. Fink et al.6 reported that physicians detected between 36% and 71% of somatoform disorders in their patients, depending on the criteria used. Kroenke and Mangelsdorff18 showed physicians could not establish a medical or psychological basis for common acute symptoms in 74% of cases.
Some studies have suggested age and sex differences in association with specific MUPS disorders. (For example, hypochondriasis and pain are more common in men while somatization disorders are more common in women.) However, results have been inconsistent, with no significant differences noted in some studies.6,16
The direct and indirect economic costs attributable to MUPS are staggering. Patients with MUPS have increased healthcare utilization rates, including frequent visits, demands for tests, unnecessary surgery, numerous consultations, and hospitalizations.19 Building on an earlier conservative assumption by Ford that MUPS account for 10% of medical expenditures, the current financial cost of MUPS in the United States exceeds $100 billion annually.20 This does not include substantial indirect costs of lost workplace productivity and disability payments. Another burden and hidden cost to society stems from prescription and over-the-counter drug sales targeting common minor ailments and fueled by direct-to-consumer advertising.
Specific Somatoform Disorders
Secondary MUPS Syndromes
Secondary MUPS syndromes encompass patients with primary psychiatric disorders. A variety of nonspecific physical complaints often are associated with major depression. Up to 76% of patients hospitalized for depression report multiple pain symptoms.21 Vegetative symptoms form an integral part of diagnostic criteria for depression, may dominate the clinical picture, often signify a more severe depression, and may predict response to biological treatments.1,16 Patients may even deny affective and cognitive aspects of depression and instead ruminate about fatigue, weight loss, or pain. Labeled as “depressive equivalents,” “somatic depression,” or “masked depression,” these physical ailments occur frequently in depression, especially among the elderly.1,16 Effective treatment with antidepressants or electroconvulsive therapy alleviates somatic, affective, and cognitive symptoms of depression simultaneously.
Similarly, MUPS are common among patients with anxiety disorders and comprise a significant component of diagnostic criteria.1,16 Anxiety often is experienced through activation of the autonomic nervous system and comes to clinical attention because of palpitations, chest pain, dizziness, abdominal discomfort, and other symptoms. Development of these MUPS may cause or worsen anxiety, or it may protect against generalized anxiety by binding and localizing concerns on physical symptoms.
The close association between MUPS, depression, and anxiety has been confirmed in numerous studies.6,17,22 Fink et al.6 reported psychiatric comorbidity ranging from 35% to 50% among patients with somatoform disorders. Using DSM-IV criteria, de Waal et al.17 found 26% of patients with somatoform disorders also had depression, anxiety disorders, or both, while 54% of patients with depression or anxiety disorders could be diagnosed as having a somatoform disorder. Having a somatoform disorder conferred a threefold increased risk of depression or anxiety. In addition, patients with comorbidity had increased risk of more severe functional disability.17,23
Patients with psychotic disorders — schizophrenia, mood disorders, substance-induced psychosis, delusional disorder, delirium, or dementia — also may present with MUPS.1 Psychotic examples of MUPS often are bizarre and may consist of disturbance of thought (somatic delusions) or perception (formication associated with cocaine addiction).
Delusional Disorder – Somatic Type
Delusional disorder – somatic type, or monosymptomatic hypochondriacal psychosis, is a unique psychotic disorder.1 Such patients represent the extreme end of the spectrum of MUPS. Traditionally, encapsulated somatic delusions that are characteristic of delusional disorder include olfactory reference syndrome, dysmorphophobia, and parasitosis, although similar delusional thought content can be observed in any psychotic disorder.
Often appearing otherwise normal without psychological dysfunction, these patients usually present to medical specialists and are difficult to treat. Pimozide often has been advocated as a specific treatment, although controlled comparisons with other psychotropic agents have been limited.24
There are several primary somatoform disorders with MUPS. Somatization disorder, or Briquet's syndrome, consists of multiple symptoms in different organ systems beginning before age 30, a chronic course, and significant distress and impairment.1,16,25 Patients are dramatic and seek frequent clinical contacts, medications, tests, and procedures. Disability is striking.
An emerging controversy is how these criteria relate to patients with less pervasive or enduring MUPS who are classified as having somatoform disorder either undifferentiated or not otherwise specified. Are these all manifestations of the same functional somatic syndrome proposed by Wessely et al., differing only in the choice of organ system or medical specialty?9,10
In recent decades, a proliferation of disorders have been included among the so-called functional somatic syndromes (eg, multiple chemical dependency, chronic candidiasis, chronic Lyme disease, chronic fatigue syndrome, irritable bowel syndrome). These diagnoses are highly controversial and transcend traditional biomedical and scientific approaches, with major repercussions in legal, political, and social domains.9–12,25
Patients with conversion disorder experience an alteration of function of a component of the nervous system that cannot be explained solely on the basis of known neurological processes.1,3,16,25 They may present with positive symptoms (increased activity, eg, pseudo-seizures) or negative symptoms (loss of activity, eg, blindness). Because conversion disorders derive from psychological factors and patients' beliefs about bodily function, they usually violate rules of anatomy. For example, sensory deficits may cross the midline.
Although unconsciously produced, conversion symptoms frequently are influenced by emotional or social stressors whose effects take place outside the patient's conscious awareness. Conversion disorder usually is monosymptomatic, acute, and time limited. Between 90% and 100% of patients experience symptom resolution within 1 month, although 25% may have a recurrence.25 It may be useful to consider conversion disorder a state phenomenon and somatization disorder a trait phenomenon.1
Hypochondriasis is defined by ruminations and fears of having serious disease despite medical evaluation and reassurance during the course of at least 6 months.1,16,25 However, duration of symptoms and lack of response to reassurance have been criticized as too restrictive as criteria in DSM-IV.16,26 The disorder may occur in up to 5% to 10% of primary care patients.25
One way to conceptualize hypochondriasis is to think of it as stemming from inappropriate processing of somatic information. This may arise from a combination of hypervigilance with attention to benign bodily sensations, faulty somatic perceptions, misattribution to pathological processes, and unrealistic appraisals of threats to health, which results in a vicious cycle of amplification of symptoms and anxiety that is resistant to attempts at reassurance.1,11,26,27
The course of hypochondriasis is usually chronic but varies in severity. Problems of definition stem from overlapping boundaries with the “worried-well,” anxiety disorders, and other somatoform disorders.
Body Dysmorphic Disorder
Body dysmorphic disorder, or dysmorphopobia, is described as a preoccupation with an imagined or exaggerated physical defect leading to significant psychological and social disability.1,16,25 These symptoms prompt patients to seek remedial intervention to correct perceived defects.25
It is interesting to speculate on whether this disorder could become an emerging social problem in terms of healthcare expenditures and iatrogenic complications, because of a contemporary culture that celebrates and sells superficial, physical self-improvement (eg, “extreme makeovers,” cosmetic surgery, steroid abuse). Symptoms of this type can reach psychotic intensity in delusional disorder and anorexia nervosa.1,16,25
Pain disorder is one of the most common presenting complaints, yet evaluation of pain is enormously complex, the means for objective measurement of pain is lacking, and the pathophysiology of pain is incompletely understood.28 Practitioners are admonished to consider pain as a vital sign and treat it aggressively; however, at the same time, pain is highly subjective and influenced by emotional factors. Pain treatment is a multibillion-dollar market for the pharmaceutical industry and is associated with abuse of prescription and illicit drugs in a small minority of patients.
Psychogenic pain is assumed when pain causes significant distress and impairment and is judged by the practitioner to be inadequately accounted for by pathophysiological findings.16 Psychogenic pain is often chronic and incapacitating, and can be difficult to distinguish from other somatoform and factitious disorders, or malingering.
Factitious disorders are diagnosed in patients who feign or produce physical or psychological symptoms to assume the sick role.1,16,25,29 These disorders are complex and difficult to study because patients are intent on deceiving, leave treatment once confronted, and resist psychiatric referral. Some evidence suggests they are more common in women and tend to occur in patients with a background in or knowledge of healthcare professions.1,25
Munchausen syndrome is a widely publicized variant of factitious disorder, characterized by dramatic presentations, traveling to obtain medical contacts, and patholological lying.1,25 Factitious disorders can also occur “by proxy” when signs of illness are induced in others (eg, children, elderly) who are under the care of a person who seeks to assume the sick role vicariously.
Factitious disorders may be difficult to distinguish from or may co-exist with actual medical or psychiatric disorders, as well as conversion disorder or other somatoform disorders. The latter two disorders are assumed to result from unconscious mechanisms, whereas factitious disorders result from intentional dissimulation.7,8 However, judgment of intentionality is arbitrary in some cases, and patients with factitious disorders also have unconscious motivating factors, have often suffered abuse in childhood, and may be re-enacting conflicts over dependency and control by seeking attention and care through the sick role.1,25
The overdetermined and compulsive quality of patients with this disorder has been described, with the observation that these patients appear to be in a dissociated state when inducing their symptoms.1 At the other extreme, factitious disorders can be difficult to distinguish from malingering (see below). Both conditions are confounded by direct and indirect benefits in avoiding responsibilities, denying unacceptable behavior, and obtaining financial gains.8
Treatment of factitious disorders is difficult but can be directed at underlying mood, anxiety, and personality disorders. Supportive psychotherapy can be offered, but direct confrontation is usually necessary especially when the patient or proxy is at risk for complications or death.8
Although traditionally included in reviews of MUPS, malingering is not a mental disorder but more of an allegation of conscious deceit for external gain rather than a diagnosis.1,16,25,30 More commonly encountered in criminal, civil, and compensation-related litigation, malingering can be observed in medical and psychiatric settings. It can be difficult to distinguish from factitious or somatoform disorders because of the ambiguities of assessing conscious motivation and external gain, as well as the presence of significant character pathology in many such patients.
Some investigators have advocated “re-medicalizing” the field of MUPS, based on studies of pathways subserving visceral and pain sensation in the nervous system.4,11,12,30–32 Rief et al.34,35 noted decreased serotonergic function in patients with MUPS even in the absence of depression and also found altered immune function in some patients with somatoform disorders.
Psychological explanatory models of MUPS have been studied extensively.1–3,11 Early psychodynamic hypotheses were based on studies of hysteria. Central to this line of reasoning is the notion of conversion as reflecting defense mechanisms that symbolically transform unconscious emotional trauma and conflict into physical symptoms. The key aspect of this process is the symbolic condensation or mental representation of feelings in a somatic symptom. Symptoms are viewed as reflecting multiple determinants that serve to defend against as well as express an unconscious wish along with associated feelings (eg, anger, shame, guilt).1,3
However, more recent work in experimental cognitive neuropsychology extends and clarifies psychodynamic mechanisms underlying MUPS.3,36 New ideas concern the development of emotional processing from nonverbal, subsymbolic expression in childhood to more mature, adaptive and verbal abilities that allow for translation of emotional states into identifiable feelings on an abstract, logical and reality-based level.3,36 By this model, MUPS are the result of activation of or regression to subsymbolic somatic symptoms dissociated from verbal, symbolic representations of feelings and objects. Patients therefore experience somatic signs only, detached from psychological meaning — or in other words, they exhibit alexithymia.3
CBT has been studied extensively and is appealing as an explanatory model for MUPS.11,27,37 Characterized by faulty cognitive processing (eg, amplification, misinterpretation, misattribution), confusing symptom beliefs (eg, disease conviction, catastrophizing), and dysfunctional behaviors (eg, doctor shopping, obsessive body attention, checking or avoidant behavior), somatoform disorders lend themselves to CBT interventions.11,27,37
Sociological and cultural theories also have been proposed based on ideas advanced by Parsons, who wrote about societal conventions regarding the sick role.5,38 The definition of sickness, the role in society of individuals who are sick, and the tolerance of emotional expression vary by history and culture and may significantly influence the manifestations and management of MUPS.
No single treatment is effective for all patients with MUPS.1,25 Most patients are seen and expect care in medical settings. Thus, the role of the psychiatrist or psychologist usually is to provide information and diagnostic clarification about these disorders to medical colleagues, and to offer specific suggestions for management. Patients with MUPS are a common source of countertransference reactions that lead to premature diagnostic closure and rejection of the patient, or to excessive diagnostic rigor.
Helpful management goals and steps that could be recommended to medical providers were summarized elsewhere.25 Goals entail diminishing distress, increasing functional ability, decreasing symptoms and reducing inappropriate use of medical services. Specific steps are listed in the Sidebar (see page 303).
Management Steps for Treatment of MUPS25
- Maintain a therapeutic alliance with regular appointments independent of symptom exacerbations.
- Emphasize care, not cure.
- Carefully consider new or changed symptoms to exclude medical or psychiatric disorders.
- Keep visits brief and structured.
- Be conservative with pharmacotherapy and avoid addicting drugs.
- Reinforce improvements in daily functioning.
- Discuss the effect of psychosocial stress on physical symptoms.
- Discuss psychiatric consultation.
- Collaborate with medical colleagues.
Management Steps for Treatment of MUPS
Pharmacologically, it is important to identify and treat underlying psychiatric disorders. Reduction of depression and anxiety may significantly reduce somatic preoccupations. Furthermore, an emerging literature suggests potential benefits of pharmacotherapy for specific MUPS syndromes. A recent meta-analysis of treatment of fibromyalgia demonstrated a fourfold increase in improvement with antidepressants.39 Another review found antidepressants were three times more likely than placebo to produce symptomatic improvement in patients with MUPS.40 However, this study acknowledged it was unclear from the data whether benefits accrued from treatment of underlying subclinical depression and anxiety, from nonspecific effects on pain thresholds, or from direct effects on neurotransmitter systems involved in somatoform disorders.
Psychotherapies have been studied extensively for patients with MUPS and remain the mainstay of treatment. Psychodynamic techniques vary depending on the diagnosis.1,3 Psychoanalysis may be required in some patients with conversion disorders to resolve unconscious conflicts, whereas in most somatoform disorders, supportive psychotherapy directed at strengthening connections between subsymbolic and symbolic elements may be more effective in transforming the meaning behind symptoms.
CBT has proven to be beneficial in controlled trials.11,27,37 CBT entails reexamination of health beliefs, exploring effects of stress and the sick role, finding alternative explanations for benign bodily symptoms and restructuring faulty disease beliefs and expectations.11
Kroenke and Swindle37 conducted a meta-analysis that showed advantages for CBT over controls in 71% of trials. MUPS appeared to be most responsive, with improvement occurring whether or not comorbid psychological symptoms were ameliorated. Barsky and Ahern27 recently reported sustained benefits in hypochondriasis using brief CBT targeting symptom amplification and misattribution, bodily hypervigilance, and beliefs about etiology, illness, and sick role behaviors.
MUPS and associated somatoform disorders remain an enormous problem in terms of prevalence, personal suffering and disability, and costs to society. Challenging problems in nosology, etiological understanding, and treatment effectiveness are ideally suited for integrative psychiatric and psychological investigation.
Fortunately, advances in diagnosis and management have attracted significant attention and are being actively pursued. In the culture of the modern era, characterized by increasing social, political, and economic pressures to label syndromes with or without scientific support, to promote quick and profitable remedies, and to control costs all at the same time, the need for better understanding of MUPS has never been more compelling.
- Stinnett JL. The functional somatic symptom. Psychiatr Clin North Am. 1987;10(1):19–33. doi:10.1016/S0193-953X(18)30574-4 [CrossRef]3575159
- Kaplan HI. Current psychodynamic concepts in psychosomatic medicine. In: Pasnau RO, ed. Consultation-Liaison Psychiatry. New York, NY: Grune & Stratton; 1975:33–46.
- Taylor GJ. Somatization and conversion: distinct or overlapping constructs?J Am Acad Psychoanal Dyn Psychiatry. 2003;31(3):487–508. doi:10.1521/jaap.31.3.487.22136 [CrossRef]14535614
- Komaroff AL. Symptoms: in the head or the brain?Ann Intern Med. 2001;134(9 Pt 1): 783–785. doi:10.7326/0003-4819-134-9_Part_1-200105010-00016 [CrossRef]11329237
- Kirmayer LJ, Groleau D, Looper KJ, Dao MD. Explaining medically unexplained symptoms. Can J Psychiatry. 2004;49(10): 663–672. doi:10.1177/070674370404901003 [CrossRef]15560312
- Fink P, Sorensen L, Engberg M, Holm M, Munk-Jorgensen P. Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition. Psychosomatics. 1999;40(4):330–338. doi:10.1016/S0033-3182(99)71228-4 [CrossRef]10402880
- Cohen LM, Chang K. Comorbid factitious and conversion disorders. Psychosomatics. 2004;45(3):243–246. doi:10.1176/appi.psy.45.3.243 [CrossRef]15123851
- Eisendrath SJ, McNiel DE. Factitious physical disorders, litigation, and mortality. Psychosomatics. 2004;45(4):350–353. doi:10.1176/appi.psy.45.4.350 [CrossRef]15232050
- Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many?Lancet. 1999;354(9182):936–939. doi:10.1016/S0140-6736(98)08320-2 [CrossRef]10489969
- Wessely S, White PD. There is only one functional somatic syndrome. Br J Psychiatry. 2004Aug;185:95–96. doi:10.1192/bjp.185.2.95 [CrossRef]15286058
- Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med. 1999;130(11): 910–921. doi:10.7326/0003-4819-130-11-199906010-00016 [CrossRef]10375340
- Sharpe M., Mayou R. Somatoform disorders: a help or hindrance to good patient care?Br J Psychiatry. 2004Jun;184:465–467. doi:10.1192/bjp.184.6.465 [CrossRef]15172937
- Ballas CA, Staab JP. Medically unexplained physical symptoms: toward an alternative paradigm for diagnosis and treatment. CNS Spectr. 2003;8(12 Suppl 3):20–26. doi:10.1017/S1092852900008245 [CrossRef]
- Grabe HJ, Meyer C, Hapke U, et al. Specific somatoform disorders in the general population. Psychosomatics. 2003;44(4):304–311. doi:10.1176/appi.psy.44.4.304 [CrossRef]12832596
- The ICD-10 Classification of Mental and Behavioral Disorders. Diagnostic Criteria for Research. Geneva, Switzerland: World Health Organization; 1993.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 1994.
- de Waal MW, Arnold IA, Eekhof JA, van Hemert AM. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry. 2004Jun;184: 470–476. doi:10.1192/bjp.184.6.470 [CrossRef]15172939
- Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med. 1989;86(3):262–266. doi:10.1016/0002-9343(89)90293-3 [CrossRef]2919607
- Smith GR Jr, Monson RA, Ray DC. Patients with multiple unexplained symptoms. Their characteristics, functional health and health care utilization. Arch Intern Med. 1986; 146(1):69–72. doi:10.1001/archinte.1986.00360130079012 [CrossRef]3942467
- Ford CV. The Somatizing Disorders: Illness as a Way of Life. New York, NY: Elsevier; 1983.
- Corruble E, Guelfi JD. Pain complaints in depressed inpatients. Psychopathology. 2000; 33(6):307–309. doi:10.1159/000029163 [CrossRef]11060514
- Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosomatic Med. 2003;65(4): 528–533. doi:10.1097/01.PSY.0000075977.90337.E7 [CrossRef]
- Kroenke K, Spitzer RL, deGruy FV 3rd, et al. Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry. 1997;54(4):352–388. doi:10.1001/archpsyc.1997.01830160080011 [CrossRef]9107152
- Lorenzo CR, Koo J. Pimozide in dermatologic practice: a comprehensive review. Am J Clin Dermatol. 2004;5(5):339–349. doi:10.2165/00128071-200405050-00007 [CrossRef]15554735
- DeMichele SG, Stinnett JL. Somatoform and related disorders. In: Gliatto MF, Caroff SN, Kaiser R, eds. Psychiatry for Primary Care Practitioners. Washington, DC: American Psychiatric Publishing; 1999.
- Fink P, Ornbol E, Toft T, et al. A new, empirically established hypochondriasis diagnosis. Am J Psychiatry. 2004;161(9):1680–1691. doi:10.1176/appi.ajp.161.9.1680 [CrossRef]15337660
- Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA. 2004;291(12):1464–1470. doi:10.1001/jama.291.12.1464 [CrossRef]15039413
- Covington EC. Psychogenic pain – what it means, why it does not exist, and how to diagnose it. Pain Med. 2000;1(4):287–294. doi:10.1046/j.1526-4637.2000.00049.x [CrossRef]
- Krahn LE, Li H, O'Connor MK. Patients who strive to be ill: factitious disorder with physical symptoms. Am J Psychiatry. 2003;160(6): 1163–1168. doi:10.1176/appi.ajp.160.6.1163 [CrossRef]12777276
- Slick DJ, Tan JE, Strauss EH, Hultsch DF. Detecting malingering: a survey of experts' practices. Arch Clin Neuropsychol. 2004; 19(4):465–473. doi:10.1016/j.acn.2003.04.001 [CrossRef]15163448
- Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001;134(9 Pt 2):917–925. doi:10.7326/0003-4819-134-9_Part_2-200105011-00017 [CrossRef]11346329
- Barsky AJ. Palpitations, arrhythmias, and awareness of cardiac activity. Ann Intern Med. 2001;134(9 Pt 2):832–837. doi:10.7326/0003-4819-134-9_Part_2-200105011-00006 [CrossRef]11346318
- Sharpe M, Carson A. “Unexplained” somatic symptoms, functional syndromes and somatization: do we need a paradigm shift?Ann Intern Med. 2001;134(9 Pt 2):926–930. doi:10.7326/0003-4819-134-9_Part_2-200105011-00018 [CrossRef]11346330
- Rief W, Pilger F, Ihle D, et al. Psychobiological aspects of somatoform disorders: contribution of monoaminergic transmitter systems. Neuropsychobiology. 2004;49(1):24–29. doi:10.1159/000075335 [CrossRef]14730197
- Rief W, Pilger F, Ihle D, et al. Immunological differences between patients with major depression and somatization syndrome. Psychiatry Res. 2001;105(3):165–174. doi:10.1016/S0165-1781(01)00338-9 [CrossRef]
- Bucci W. Symptoms and symbols: a multiple code theory of somatization. Psychoanalytic Inquiry. 1997;17(2):151–172. doi:10.1080/07351699709534117 [CrossRef]
- Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000;69(4): 205–215. doi:10.1159/000012395 [CrossRef]10867588
- Parsons T. The Social System. Glencoe, IL: Free Press; 1951.
- O'Malley PG, Balden E, Tomkins G, et al. Treatment of fibromyalgia with antidepressants: a meta-analysis. J Gen Intern Med. 2000;15(9):659–666. doi:10.1046/j.1525-1497.2000.06279.x [CrossRef]11029681
- O'Malley PG, Jackson JL, Santro J, et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999;48(12):980–990.