Treatment Options

Evidence is rapidly growing for the usefulness of modified cognitive-behavioral therapies for somatoform syndromes.30,31 A comprehensive model successfully applied in several studies included relaxation training, behavioral management, cognitive restructuring, emotion identification, emotion regulation, and interpersonal skills training.32 Other types of psychotherapy have not been tested in well-controlled studies. However, it is our impression that intensive or exploratory therapies that focus on internal conflict and mental change may be counterproductive.

As mentioned, mental disorders such as significant depression and anxiety are common in those with SD and should be specifically addressed. However, there is no clear evidence from randomized clinical trials demonstrating the efficacy of psychotropic drugs for the treatment of unexplained physical symptoms. The benefit observed in some studies has been attributed to the effect of medications on anxiety or depressive symptoms and not to a direct effect on somatic symptoms.

On the basis of our clinical experience, patients with SD accompanied by significant depression and anxiety symptoms can be initially treated with an SSRI or a serotonin norepinephrine reuptake inhibitor. Mirtazapine seems to be a reasonable first option for patients with unexplained symptoms who have significant insomnia or anorexia because of the drug’s positive effects on sleep and appetite. In patients with significant fatigue/sleepiness or poor concentration, or those in whom the avoidance of sexual adverse effects is paramount, bupropion may be a good first-line agent.

Because patients with SD may be at a heightened risk for addiction or dependence, caution must be exercised when prescribing medications with addictive potential, such as opiate analgesics and tranquilizers such as benzodiazepines. In patients with SD, pain complaints are very common and include headaches, and joint, abdominal, and pelvic pain. NSAIDs should be used whenever possible for pain relief.

FDA-Approved Medications

The anticonvulsant pregabalin and the antidepressant duloxetine have been recently approved for the treatment of fibromyalgia. Pregabalin has analgesic properties, especially for neuropathic pain, and has also shown some antianxiety effects in randomized clinical trials. Duloxetine, a dual action antidepressant, also seems to exert some analgesic properties similar to those reported for other dual action drugs as well as tricyclic antidepressants.

Lufriprostone has been approved for clinical use in irritable bowel symptoms alternating with chronic idiopathic constipation syndromes. This drug appears to exert a laxative action by increasing the secretion of chloride and fluid in the intestinal epithelium.

Fluoxetine, paroxetine, and sertraline have been approved for the treatment of premenstrual dysphoric disorder/premenstrual syndrome, which have a number of somatic manifestations and also include anxiety and depression symptoms. A recent meta-analysis found that all SSRIs seem to be about equally helpful for premenstrual symptoms, their continuous use is better than intermittent use, and their clinical effect on symptoms seems to be relatively small.33

The Future Definition of SD

As we prepare for the new edition of DSM-V, we suggest the following:

 

• Consider a dimensional approach for unexplained physical symptoms with differences in severity.
• Avoid further expansion of somatoform categories and the mechanistic count of symptoms and systems. There is a need for evidence-based,inclusive, and simpler definitions.
• Do not devalue the psychological, cultural, and social aspects in patients with somatoform disorders; instead, emphasize their character as complex expressions of distress and sickness.
• Do not subordinate somatic presentations to other mental disorders or to purely mental mechanisms. Acknowledge the unique and independent nature of somatoform disorders.

 

Drugs Mentioned in This Article
Bupropion (Wellbutrin, Zyban)
Duloxetine (Cymbalta)
Fluoxetine (Prozac, Sarafem)
Gabapentin (Neurontin)
Lubriprostone (Amitiza)
Mirtazapine (Remeron)
Paroxetine (Paxil)
Pregabalin (Lyrica)
Sertraline (Zoloft)

 
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