Bernard Biermann, MD, PhD

FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Somatic symptom and related disorders (SSRDs) are a set of psychiatric conditions characterized by physical symptoms that are inconsistent with physical disease and influenced by psychological factors. They are common in pediatric medicine, with prevalence rates ranging from 13% to 50% depending on the setting. Across all ages, SSRDs account for nearly 20% of health care spending annually.

 Additionally, a small subset of patients have multiple somatic complaints and tend to access crisis and emergency services and hospital services at higher rates. They also have high recidivism rates.

Despite the recognition of the impact of SSRDs on pediatric health care, clinicians and patients/families continue to be frustrated with the evaluation and management of these conditions.

 Without early incorporation of a broader biopsychosocial conceptualization, there can be an undue focus on disability, impairment, and somatic complaints. This leads to low-yield diagnostic testing and increased polypharmacy interventions that do not address the rehabilitative needs of the patient and family.

 In the absence of an explanatory model for symptoms, patients and families may feel they are being dismissed, creating a dynamic of mistrust between patients/families and the medical system. Ultimately, without a clear road map for evaluation and management, care can be inconsistent and misuse of health care resources may occur, which, in turn, can lead to poor outcomes.

As SSRDs most often present in nonpsychiatric settings, a patient’s first contact with a mental health care provider may be through psychiatric consultation in the emergency department or in a hospital setting. Therefore, psychiatric consultation should be considered as early as possible to foster the perception that consultation-liaison (CL) psychiatrists are an integral part of the multispecialty team.

“Julie,” a previously physically healthy 12-year-old female, presented with 6 months of abdominal pain, weight loss, and emesis that began shortly after her parents divorced. As a result, she missed several weeks of schooling.

Work-up included a complete blood count, comprehensive metabolic profile, thyroid studies, C-reactive protein test, erythrocyte sedimentation rate, abdominal x-ray, abdominal ultrasound, upper and lower endoscopy, and stool culture, all of which were unremarkable. Eliminating gluten from her diet was not helpful. The patient had no previous physical health concerns, including no previous gastrointestinal pathology. There was no history of substance use, sexual activity, psychological trauma, or abuse.

Julie was admitted for her fourth medical admission within 4 months. Child and adolescent psychiatry was consulted for evaluation of anxiety. Julie and her parents were skeptical about any psychological factors influencing her presentation and were hesitant to agree to psychiatric consultation. The parents were advocating for the use of opioids for her pain and an expanded work-up.

The patient received concurrent evaluation by the pediatric hospitalist service, gastroenterology, psychology, and psychiatry. No further diagnostic testing was pursued. The team found Julie had comorbid learning difficulties, nonspecific anxiety, maladaptive coping, and increased familial expressed emotion contributing to her presentation in the context of the recent divorce. A multidisciplinary meeting was held with Julie and her parents to discuss the diagnosis of somatic symptom disorder (DSM-5 300.82). The family was presented with a conceptual framework for symptom development by the multidisciplinary care team, in addition to biopsychosocial contributors to her presentation and a future management plan.

Julie was referred for outpatient cognitive behavioral therapy and prescribed mirtazapine 7.5 mg at bedtime for anxiety and sleep difficulties. Her symptoms improved by discharge, and she was minimally symptomatic upon follow-up with her primary care provider

SSRDs account for approximately 15% to 20% of psychiatric consults in the pediatric hospital setting and have been reported as the second most common reason for consultation after suicide assessments.

 As such, there is a growing effort to standardize the evaluation and management of pediatric SSRDs. Most recently, the 

American Academy of Child and Adolescent Psychiatry 

(AACAP) published a Clinical Consensus Pathway for SSRD Evaluation and Management.

Most SSRDs are seen in nonpsychiatric settings, with approximately 6% of hospitalized children relaying symptoms consistent with an SSRD.

 The most common complaints include neurologic symptoms, pain, gastrointestinal distress, and fatigue.

 SSRDs can present at any age, but they are more common and less problematic in prepubertal youth, with increasing impairment and pathology in adolescents.

 Prevalence rates are equal across sexes prior to puberty; after puberty, higher prevalence is seen in female sex.

 Although psychological trauma, particularly sexual trauma, is a well-associated risk factor for SSRDs in adults, it is not necessarily associated with SSRDs in youth.

 However, if present, trauma in youth with SSRDs often results in a more complicated treatment course, more severe symptoms, and increased risk for need of higher levels of psychiatric care.

Table 1. Risk Factors for the Development and Perpetuation of SSRDs in Youth

Table 2. Expectation Setting and Goals of Care

The evaluation and management of youth experiencing an SSRD are predicated on early recognition of risk factors (

). The foundation of an SSRD evaluation is built on concurrent mental health and physical health evaluation, unified evidence-based language that is consistent across disciplines, and direct communication with the family regarding the multifactorial nature of SSRD presentation. Care of youth with SSRDs requires close interprofessional team support. This includes collaboration among the primary care physician (PCP), emergency physician, hospitalist physician, nursing, social work, child life, rehabilitative staff, subspecialty pediatricians, and CL psychiatrist/psychologist. Roles should be delineated early in the management course.

CL psychology/psychiatry should be consulted at the earliest suspicion of an SSRD to normalize psychiatric involvement in comprehensive care. Beyond assessment, CL psychology/psychiatry can aid with framing conversations with the patient and family, providing evidence-based interventions, and addressing psychiatric comorbidities. Although SSRDs do not necessarily accompany other discrete psychiatric conditions, anxiety disorders and mood disorders may be present in up to 50% of youth with SSRDs. These comorbidities should be incorporated in the case formulation for proper management of these conditions.

 Ultimately, this process is dynamic and highly interactive and should adapt to the needs of the patient and family.

Discussion of symptom development and diagnostic conceptualization should be paired with management strategies, highlighting the multifactorial contributors to symptom development. Pairing the multiple biopsychosocial factors allows for a coherent, systematic approach to rehabilitative care, psychotherapeutic management, and judicious use of targeted psychopharmacology. Joint communication by all involved physicians and other clinicians using consistent DSM-5 language and clear discussions of a conceptual framework for symptom development, highlighting mind-body interactions, are crucial.

Once the evaluation is complete and the diagnosis of SSRD is confirmed, it is helpful to have an interprofessional care meeting with the patient family to share the diagnosis. Explaining a conceptualization of how symptoms formed, progressed, and continue to present—along with the related biopsychosocial factors influencing presentation—is the most critical part of this conversation. This is accomplished via joint physical health and mental health providers using consistent DSM language with the relationship of physical, environmental, psychological, social, and cognitive factors to symptom development. For the patient and family to invest in the diagnoses and partner in the ongoing management of SSRD, they must understand this conceptualization.

Importantly, clinicians should gauge the patient’s and family’s readiness to accept the information. As such, communication must be geared to the individual’s understanding, values, and readiness. It is often valuable to pair discussions with the use of motivational interviewing to enhance engagement and understand the patient’s or family member’s experience. Discussions may start with a more biological conceptualization, emphasizing concepts such as somatosensory amplification and visceral hypersensitivity; analogies may be used to highlight mind-body interactions. Some families may be able to appreciate and incorporate psychological constructs earlier in the discussion of this conceptual framework. It is important to validate emotions while shifting discussions to functionality. Patients may want to focus on their impairment; it is, therefore, important to pivot conversation to highlight strengths, abilities, and incremental improvements.

Management of an SSRD in youth is an iterative process that begins with setting clear goals and expectations. Misalignment of expectations is often a point of conflict. Patients and families may expect complete resolution of symptoms following initial encounters. Here, psychoeducation is key to the initial framing of the concept of somatization, discussing mind-body interactions, and describing joint medical and psychiatric management. Cognitive behavioral therapy (CBT) has a strong evidence base in addressing psychological factors underpinning pediatric SSRD.

 CBT aids in greater awareness of how cognition, emotions, and other psychological processes impact physical sensations, and it empowers the patient with strategies to dampen somatic complaints. It focuses on improving functioning in small, achievable steps while shifting the focus away from impairment.

CBT psychotherapy can occur in tandem with delivery of rehabilitative services. As many as 50% of youth with an SSRD will have a comorbid depressive or anxiety disorder, making treatment of psychiatric comorbidities an important component of SSRD management.

 Close involvement with the PCP is necessary, including proactive, regularly scheduled brief visits. These visits should be used to coordinate services, address questions, monitor progress, provide reassurance, and promote functioning. PCPs should conduct judicious evaluations of new concerns, collaborating with psychiatry, psychology, and subspecialty pediatrics as needed. In this way, the propensity to seek care in crisis and pursue care in a disjointed fashion can be extinguished over time.

Care should be provided in the setting that best matches the patient’s needs and severity of illness. For youth with severe worsening of function without a clear diagnostic understanding, medical admission may be warranted for further evaluation and management. Youth with significant psychiatric comorbidity may benefit from inpatient or partial psychiatric hospitalization. Those patients with significant rehabilitative needs will benefit from intensive outpatient or inpatient rehabilitation. Most youth, however, can be successfully managed in the outpatient setting with regular PCP evaluations, ongoing psychotherapy, and psychiatric care, as well as additional rehabilitative and pediatric subspecialty follow-up.1 This approach, which aligns with national consensus, provides the best framework for youth to regain functioning, improve symptomatically, and succeed in the care of SSRD.

Care of youth with SSRDs highlights the important liaison role of CL psychiatry. CL psychiatrists aid in the dissemination of information and develop a shared understanding with the patient and family; they also support appropriate language use and incorporate psychological, social, psychiatric, familial, and cognitive factors in the overall assessment with the larger care team. This should include clearly defining care team roles, as well as setting expectations with patients and their families (

The CL psychiatrist should describe mind-body interactions using analogies that simplify understanding for the patient and family. For example, a computer analogy helps explain SSRDs, in which physical disease is more akin to a hardware problem and psychosocial and environmental factors are more akin to a software issue. Similarly, it can be helpful to describe SSRDs as the body’s alarm system being overactive or hypersensitive to somatosensory interactions, which can lead to identification of factors that can heighten or dampen normative reactions to bodily sensations. The goal is to aid patients and families in understanding the interplay of physiologic, psychological, social, and emotional factors that influence somatic symptoms.

Given the diverse and wide-ranging issues and the number of team members involved in effective SSRD care, the CL psychiatrist should also be at the forefront in aiding standardization of multidisciplinary, evidence-based interventions. This should be informed by existing consensus guidelines, such as those published by the AACAP in 2020, and local resources, systems of care, and practice experiences.

CL psychiatrists may be asked about the use of psychopharmacology in managing SSRDs. There is no evidence to demonstrate that psychopharmacology can directly ameliorate the symptoms of SSRDs, and this should be expressed clearly to patients and families as well as to the larger care team.14 At times, youth and families may become frustrated that psychopharmacology has not resulted in resolution of symptoms. Therefore, it is important to reiterate, early on, that management of SSRDs is predicated on a multidisciplinary approach that targets the factors fostering symptom-development and persistence. Here the focus is shifted to improvement in functioning and incremental rehabilitation of cognitive, emotional, and physical health factors.

Psychopharmacology can be helpful in addressing psychiatric comorbidities and may provide more immediate relief for other psychiatric factors resulting in acute distress. When provided, psychopharmacological options should have clear targets for management with clear expectations within the greater context of treatment. It is important to explore familial expectations and continue to set realistic expectations, emphasizing the importance of ongoing engagement with other care teams, including psychology and rehabilitative services.

CL psychiatry can also have an important role in informing longitudinal management of SSRDs, which may be accomplished through collaborative clinical models. Such models often have psychiatry and psychology providing integrated care in a primary care or subspecialty pediatric practice. Inpatient psychiatric care may be needed for young patients with severe psychiatric comorbidities, safety concerns related to suicidal ideation or behavior, or severe psychological trauma. Ultimately, disposition planning must account for the level of training, experience, resources, and standardization of practice that exists within different settings in a given health system.

 is a child and adolescent psychiatry fellow at the University of Michigan. Dr Biermann is clinical assistant professor in the Department of Psychiatry at the University of Michigan.

is a clinical instructor and associate medical director of the Nyman Family Unit in the Department of Psychiatry at the University of Michigan. 

is associate professor in the Departments of Psychiatry and Pediatrics at the University of Michigan.

1. Malas N, Donohue L, Cook RJ, et al. Pediatric somatic symptom and related disorders: primary care provider perspectives. 

2. Kullgren KA, Shefler A, Malas N, et al. Taking the pain out of somatization: development and implementation of a hospital-based clinical practice guideline to address pediatric somatic symptom and related disorders. 

3. Ibeziako P, Brahmbhatt K, Chapman A, et al S. Developing a clinical pathway for somatic symptom and related disorders in pediatric hospital settings. 

4. Shaw RJ, Pao M, Holland JE, DeMaso DR. Practice patterns revisited in pediatric psychosomatic medicine. 

5. Bujoreanu S, White MT, Gerber B, Ibeziako P. Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges. 

6. Ibeziako P, Bujoreanu S. Approach to psychosomatic illness in adolescents. 

7. Rask CU. Functional somatic symptoms in 5-7 year old children: assessment, prevalence and co-occurrence. 

8. Jones GT, Silman AJ, Power C, Macfarlane GJ. Are common symptoms in childhood associated with chronic widespread body pain in adulthood? results from the 1958 British Birth Cohort Study. 

9. Malas N, Ortiz-Aguayo R, Giles L, Ibeziako P. Pediatric somatic symptom disorders. 

10. Plioplys S, Doss J, Siddarth P, et al. Risk factors for comorbid psychopathology in youth with psychogenic nonepileptic seizures. 

11. Thomson K, Randall E, Ibeziako P, Bujoreanu IS. Somatoform disorders and trauma in medically-admitted children, adolescents, and young adults: prevalence rates and psychosocial characteristics. 

12. Liu J, Gill NS, Teodorczuk A, et al. The efficacy of cognitive behavioral therapy in somatoform disorders and medically unexplained physical symptoms: a meta-analysis of randomized controlled trials. 

13. Ibeziako P, Randall E, Vassilopoulos A, et al. Prevalence, patterns, and correlates of pain in medically hospitalized pediatric patients with somatic symptom and related disorders. 

14. Kleinstäuber M, Witthöft M, Steffanowski A, et al. Pharmacological interventions for somatoform disorders in adults. 

Articles

There is a growing effort to standardize the evaluation and management of pediatric SSRDs, which have been reported as the second most common reason for consultation after suicide assessments.

Care of Youth Hospitalized With Somatic Symptom and Related Disorders

Somatic symptom and related disorders (SSRDs) are a set of psychiatric conditions characterized by physical symptoms that are inconsistent with physical disease and influenced by psychological factors. They are common in pediatric medicine, with prevalence rates ranging from 13% to 50% depending on the setting. Across all ages, SSRDs account for nearly 

 There is also a small subset of patients who have multiple somatic complaints and tend to access crisis and emergency services, hospital services at higher rates. They also have high 

Despite the impact of SSRDs on pediatric health care, there is a high level of clinician and patient/familial frustration associated with the evaluation and management of these conditions.

 Without early incorporation of a broader biopsychosocial conceptualization, there can be an undue focus on disability, impairment, and somatic complaints. This leads to low-yield diagnostic testing and increased polypharmacy interventions that do not address the rehabilitative needs of the 

 In the absence of an explanatory model for symptoms, patients and families may feel they are being dismissed, creating a dynamic of mistrust between patients/families and the medical system. Ultimately, without a clear roadmap for evaluation and management, care can be inconsistent and there may be misuse of health care resources, ultimately leading to poor outcomes.

As SSRDs most often present in non-psychiatric settings, a patient’s first contact with a mental health care provider may be through psychiatric consultation in the emergency department or a hospital setting. Therefore, psychiatric consultation should be considered as early as possible in order to foster the perception that consultation-liaison psychiatrists are an integral part of the multispecialty team.

SSRDs account for approximately 15% to 20% of psychiatric consults in the pediatric hospital setting and have been reported as the second most common reason for consultation after 

 As such, there is growing effort to standardize the evaluation and management of pediatric SSRDs. Most recently, the American Academy of Child and Adolescent Psychiatry (AACAP) published a Clinical Consensus Pathway for SSRD Evaluation and Management.

Workup included a complete blood count, comprehensive metabolic profile, thyroid studies, C-reactive protein, erythrocyte sedimentation rate, abdominal X-ray, abdominal ultrasound, upper and lower endoscopy, and stool culture, all of which were unremarkable. Elimination of gluten from her diet was not helpful. The patient had no previous physical health concerns, including no previous gastrointestinal pathology. There was no history of substance use, sexual activity, psychological trauma, or abuse.

Julie was admitted for her fourth medical admission within 4 months. Child and adolescent psychiatry was consulted for evaluation of anxiety. Julie and her parents were skeptical about any psychological factors influencing her presentation and were hesitant to agree to psychiatric consultation. The parents were advocating for the use of opioids for her pain and an expanded workup.

Julie was referred for outpatient cognitive behavioral therapy and mirtazapine 7.5 mg at bedtime as initiated for anxiety and sleep difficulties. Her symptoms improved by discharge, and she was minimally symptomatic upon follow up with her primary care provider.

Most SSRDs are seen in non-psychiatric settings, with roughly 6% of hospitalized children relaying symptoms consistent with an SSRD.

 SSRDs can present at any age, but are more common and less problematic in pre-pubertal youth with increasing impairment and pathology in adolescents.

 Prevalence rates are equal across genders prior to puberty; after puberty, higher prevalence is seen in females.

The evaluation and management of youth experiencing an SSRD is predicated on early recognition of risk factors (

). The foundation of an SSRD evaluation is built on concurrent mental health and physical health evaluation, unified evidence-based language that is consistent across disciplines, and direct communication with the family regarding the multifactorial nature of SSRD presentation. Care of youth with SSRDs requires close interprofessional team support. This includes collaboration among the primary care physician (PCP), emergency physician, hospitalist physician, nursing, social work, child life, rehabilitative staff, subspecialty pediatricians, and consultation-liaison (CL) psychiatrist/psychologist. Roles should be delineated early in the management course.

CL psychology and psychiatry should be consulted at the earliest suspicion of an SSRD to normalize psychiatric involvement in comprehensive care. Beyond assessment, CL psychology and psychiatry can aid with framing conversations with the patient and family, provision of evidence-based interventions, as well as addressing psychiatric comorbidities. Although SSRDs do not necessarily present with other discrete psychiatric conditions, anxiety disorders and mood disorders may be present in up to 50% of youth presenting with SSRDs. These comorbidities should be incorporated in the case formulation for proper management of these conditions.

 Ultimately, this process is dynamic, highly interactive, and should adapt to the needs of the patient and family.

Discussion of symptom development and diagnostic conceptualization should be paired with management strategies, highlighting the multifactorial contributors to symptom development. Pairing the multiple biopsychosocial factors allows for a coherent, systematic approach to rehabilitative care, psychotherapeutic management, and judicious use of targeted psychopharmacology. Joint communication by all involved physicians and other clinicians using consistent DSM-5 language and clear discussions of a conceptual framework for symptom development, highlighting mind-body interactions, is crucial.

Once the evaluation is complete and the diagnosis of SSRD is confirmed, it is helpful to have an interprofessional care meeting with the patient family to share the diagnosis. Explaining a conceptualization of how symptoms formed, progressed, and continue to present along with the related biopsychosocial factors influencing presentation is the most critical part of this conversation. This is accomplished via joint physical health and mental health providers using consistent DSM language with the relationship of physical, environmental, psychological, social, and cognitive factors to symptom development. For the patient and family to invest in the diagnoses and partner in the ongoing management of SSRD, it is crucial they understand this conceptualization.

Importantly, clinicians should gauge the patient’s and family’s readiness to accept the information. As such, communication must be geared to each individual’s understanding, values, and readiness. It is often valuable to pair discussions with the use of motivational interviewing to enhance engagement and understand the patient’s or family member’s experience. Discussions may start with a more biological conceptualization, emphasizing concepts such as somatosensory amplification and visceral hypersensitivity; analogies may be used to highlight mind-body interactions. Some families may be able to appreciate and incorporate psychological constructs earlier in the discussion of this conceptual framework. It is important to validate emotions while shifting discussions to functionality. Patients may want to focus on their impairment; it is, therefore, important to pivot conversation to highlight strengths, abilities, and incremental improvements.

Management an SSRD in youth is an iterative process that begins with setting clear goals and expectations. Misalignment of expectations is often a point of conflict. Patients and families may expect complete resolution of symptoms following initial encounters. Here, psychoeducation is key to the initial framing of the concept of somatization, discussing mind-body interactions, and describing joint medical and psychiatric management. Cognitive behavioral therapy (CBT) has a strong evidence base in addressing psychological factors underpinning pediatric SSRD.

 CBT aids in greater awareness of how cognition, emotions, and other psychological processes impact physical sensations, and it empowers the patient with strategies to dampen somatic complaints. It focuses on improving functioning in small, achievable steps, while shifting the focus away from impairment.

 Close involvement with the PCP is necessary, including proactive, regularly scheduled brief visits. These visits should be used to coordinate services, address questions, monitor progress, provide reassurance, and promote functioning. PCPS should conduct judicious evaluations of new concerns, collaborating with psychiatry, psychology, and subspecialty pediatrics as needed. In this way, the propensity to seek care in crisis and pursue care in a disjointed fashion can be extinguished over time.

Care should be provided in the setting that best matches the patient’s needs and severity of illness. For youth with severe worsening of function without a clear diagnostic understanding, medical admission may be warranted for further evaluation and management. Youth with significant psychiatric comorbidity may benefit from inpatient or partial psychiatric hospitalization. Those patients with significant rehabilitative needs will benefit from intensive outpatient or inpatient rehabilitation. Most youth, however, can be successfully managed in the outpatient setting with regular PCP evaluations, ongoing psychotherapy, and psychiatric care, as well as additional rehabilitative and pediatric subspecialty follow-up.

 This approach, which aligns with national consensus, provides the best framework for youth to regain functioning, improve symptomatically, and succeed in the care of SSRD.

Role of the Consultation-Liaison Psychiatrist

The CL psychiatrist should describe mind-body interactions using analogies that simplify understanding for the patient and family. For example, a computer analogy helps explain SSRDs, in which physical disease is more akin to a hardware problem and a psychosocial and environmental factors are more akin to software issue. Similarly, it can be helpful to describe SSRDs as the body’s alarm system being overactive or hypersensitive to somatosensory interactions, which can lead to identification of factors that can heighten or dampen normative reactions to bodily sensations. The goal is to aid patients and families in understanding the interplay of physiologic, psychological, social, and emotional factors that influence somatic symptoms.

Given the diverse and wide-ranging issues and team members involved in effective SSRD care, the CL psychiatrist should also be at the forefront in aiding standardization of multidisciplinary, evidence-based interventions. This should be informed by existing consensus guidelines, such as those published by the American Academy of Child and Adolescent Psychiatry in 2020, and local resources, systems of care, and practice experiences.

CL psychiatrists may be asked about the use of psychopharmacology in managing SSRDs. There is no evidence to demonstrate that psychopharmacology can directly ameliorate the symptoms of SSRDs, and this should be expressed clearly to patients and families as well as the larger care team.

 At times, youth and families may become frustrated that psychopharmacology has not resulted in resolution of symptoms. Therefore, it is important to reiterate, early on, that management of SSRDs is predicated on a multidisciplinary approach that targets the factors fostering symptom-development and persistence. Here the focus is shifted to improvement in functioning and incremental rehabilitation of cognitive, emotional, and physical health factors.

Psychopharmacology can be helpful in addressing psychiatric comorbidities, and they may provide more immediate relief for other psychiatric factors that are resulting in acute distress. When provided, psychopharmacology should have clear targets for management with clear expectations within the greater context of treatment. It is important to explore familial expectations and continue to set realistic expectations, emphasizing the importance of ongoing engagement with other teams including psychology and rehabilitative services.

CL psychiatry can also have an important role in informing longitudinal management of SSRDs, which may be accomplished through collaborative clinical models. Such models often have psychiatry and psychology providing integrated care in a primary care or subspecialty pediatric practice. Inpatient psychiatric care may be needed for youth with severe psychiatric comorbidities, safety concerns related to suicidal ideation or behavior, or severe psychological trauma. Ultimately, disposition planning must account for the level of training, experience, resources, and standardization of practice that exists within different settings in a given health system.

is a child and adolescent psychiatry fellow at the University of Michigan

is clinical assistant professor in the Department of Psychiatry at the University of Michigan

is a clinical instructor and associate medical director, Nyman Family Unit, Department of Psychiatry, University of Michigan

7. Ibeziako P, Bujoreanu S. Approach to psychosomatic illness in adolescents. 

8. Jones GT, Silman AJ, Power C, Macfarlane GJ. Are common symptoms in childhood associated with chronic widespread body pain in adulthood? Results from the 1958 British Birth Cohort Study. 

12. Liu J, Gill NS, Teodorczuk A, et al. The efficacy of cognitive behavioral therapy in somatoform disorders and medically unexplained physical symptoms: A meta-analysis of randomized controlled trials. 

Clinicians, families, and patients all report frustration with SSRD treatment in hospitals. It’s time to improve it. 

New Best Practices for Treating Youth With Somatic Symptom and Related Disorders 

Theory has long been the well-combed tail wagging the psychotherapy dog. This article presents a model that turns theory-based psychotherapy on its head.

During this first century of Western psychotherapy, arguments among and between the schools of psychotherapy have dominated discourse. The psychotherapy of the next century is likely to place theory and associated techniques in their appropriate, practical places in the psychotherapy outcome puzzle.

Behavior therapy, cognitive therapy and interpersonal therapy, for example, appear to be equally effective in the aggregate for the treatment of depression (Frank and colleagues).

The predominant influence of personality-based theorizing is multidetermined. Sigmund Freud can, of course, be blamed. Hoping to stay on the faculty of the University of Vienna, Freud worked in neuropathological research. Finding himself dismissed and married with a family, he had to find work. Viennese internist Josef Breuer, Freud's mentor, suggested hypnotism for patients with neurological disorders having no apparent neurophysiological basis. The ideas of his mentor proved viable. Freud's practice developed reasonably well, but he was more interested in developing a theory of mind than a model of therapy (Gay). His creative energies brought the world a compelling, complex and evolving system that captured the imagination of many. He became disenchanted with the therapy he had introduced (Freud), as did others who brought empathy (Rogers 1942 and 1951), interpersonal relationships (Sullivan), cognitions (Ellis, Beck), emotion (Perls), behavioral exposure (Wolpe) and systems thinking (e.g., Minuchin) to psychotherapeutic conceptualizing. They and their successors felt compelled, sometimes by textbook editors (e.g., Corsini and Wedding) to imitate Freud's system by describing their school's theory of personality, theory of psychopathology and theory of therapy. None had theories of psychopathology and personality as elaborate as Freud's, yet they struggled to match his complexity. 

Of course, school-bound concepts have many benefits. They provide a rallying ground for believers who can form and maintain ideological organizations. Knowledge of personality and psychopathology theory allows therapists to conceive of themselves as experts and feel confident in what they do. But the reality of clinical practice requires different concepts generally unacknowledged by the general body of psychotherapeutic thinking-patient readiness to change, nature of the social network, symptom type and severity, and strength of the working alliance. 

The pragmatic emphasis of managed care is loosening therapists' attachment to schools of therapy and forcing conceptual refinement of practice. Only theories and techniques that correlate with cost-effectiveness and quality are likely to survive in the managed-care environment (Cummings and Sayama). Other developments are also forcing the de-emphasis of schools of therapy. The movement to integrate the psychotherapies has been gathering momentum and support (Norcross and Goldfried). Compelling findings of reductions in caudate and prefrontal hypermetabolic activity associated with cognitive-behavioral treatment of obsessive-compulsive disorder direct therapists to consider how psychotherapy alters brain function (Schwartz and colleagues).

Psychotherapy can be defined by its goals, its process (stages), its tools and the principles for using those tools.

Future-oriented psychotherapy's intent is to help patients do something positive for themselves after they leave the office. The goals of most psychotherapy relationships fall into six categories:

. A person is distraught because his wife has suddenly left him for another man, for example.

. A person has been depressed for several months, which is interfering with his work and social functioning.

. A woman repeatedly develops intimate relationships with abusive men.

Maintenance of change, stabilization, prevention of relapse

. A woman with chronic medical disease, a disabled husband and recurrent depressive episodes requires continuing support to help maintain current functioning.

. A person with reasonably good social and work functioning wants to understand himself more fully.

Development of coping strategies to handle future problems

. A person learns to handle emotions that increase the likelihood of wanting to drink alcohol excessively but wants to generalize this coping strategy to other situations.

Psychotherapy does not usually cure people of problems. Patients may return for a different set of problems or recurrence of the same ones. In this way therapists may act like primary care physicians.

The practice of psychotherapy takes place in the real world, in the lives of patients functioning in their social networks. Several "functional inputs" play greater roles in influencing outcomes than do theory and technique:

 Client readiness to change (Prochaska and DiClemente) and nature of social network (Marziali, Moos, Bankoff and Howard).

 Strength of the working alliance (Horvath and Greenberg).

Number of sessions (Howard and colleagues, Mental health, Lambert 1996). 

A critical next phase in psychotherapy research should relate these functional inputs with outcome findings to determine the degree of influence of each of these factors.

Patient strengths and limitations strongly influence outcome. Therapists do not "do it to them," but instead help patients find the means to change themselves. A study by Jones, Cumming and Horowitz supported the conventional wisdom that higher levels of client pretherapy adjustment correlated with successful outcome. In addition, perseverance, depth of affective experiencing, a specific problem versus a pervasive problem and acute difficulties versus chronic problems are well-established correlates of improvement (Robertson).

Courage (willingness to take risks, to face fears) may also be a crucial but difficult measure variable since change often requires trying the unknown or attempting new action without the certainty of the desired outcome.

Psychotherapists generally help patients solve problems. The dysfunctional pattern(s) need to be defined in a way that suggests solution. Then the patient has a set of guidelines for how to proceed. As the problem or problems are being defined, therapist and patient must be engaged in a working relationship that fosters collaboration. The therapist is responsible for managing their time together efficiently.

All relationships move through the same general stages. Stages guide interventions by providing subgoals for the process of change. These subgoals include engagement, pattern search, change and termination (Beitman 1987). Some patients may change by simply becoming involved in an empathic, understanding relationship (e.g., Rogers). Some may change when, together with their therapists, they clearly define a pattern or set of patterns to change. They may not need the therapist's change-inducing skills.

Change can be divided into three substages: relinquishing an old pattern, initiating a new pattern and maintaining the new pattern. Guided by the subgoals of the psychotherapy process and the substages of change, therapists confront choice points. At each of these choice points (silence, intense affect, report of homework, couple disagreement), therapists access an array of alternative intentions and response modes appropriate to the goals of each stage.

Psychotherapy takes place within patients' psychosocial context. In once-weekly therapy, there are 167 hours outside of the therapists' office. Family members, supportive friends, problem-specific books, cocounseling (Jackins), self-help groups, as well as homework, can all assist.

Patients change during psychotherapy for a number of reasons, some of which have little to do with therapeutic technique. A multitude of studies both pharmacological and psychotherapeutic demonstrate a "time effect," namely, that patients improve simply by the passage of time and being part of a study. Factors contributing to the time effect fall under the broadly defined categories of spontaneous remission and placebo response. The first refers to factors outside of the therapeutic relationship and the second to expectancy factors within the relationship.

In other words, patients sometimes improve because of events in their environments and sometimes because they believe the treatment program will be effective (Lambert and Bergin).

Outlined below are the primary tools of psychotherapists:

. These include the constructive use of empathic understanding; careful management of the therapeutic contract; demonstration of expertise, warmth and nonjudgmental acceptance. A strong working alliance is closely correlated with outcome (Horvath and Greenberg).

Activation of the patient's observing self

. Most psychotherapists activate their patients' capacity to self-observe (Deikman). Disciplined self-observation fosters the opportunity for insight. Using empathic reflections, cognitive homework, affective exercises, behavioral instructions, interpretations and other methods, therapists encourage patients to look within themselves in order to find the data to delineate dysfunctional patterns.

Knowledge of basic patterns of psychological difficulties

. Experienced therapists possess a broad array of generic patterns that characterize the common problems confronting their patients. The themes of these patterns contain cognitive components and generally concern interpersonal relationships. Patients struggle with lack of awareness or excessive anxiety about their own emotions, particularly anger; have poorly constructed and misconstrued interpersonal schemas; and struggle with unresolved tragic, disheartening and/or frightening memories including unresolved grief and traumatic events. Many have used maladaptive, repetitive responses to distressing events, retreating into substance abuse, depression, anxiety and eating disorders. Many patients reflect problems inherent in the thematic crosscurrents of the culture.

The schools of psychotherapy have elaborated on these themes in remarkable and stultifying detail. Commonly used change strategies extracted from the schools are contained in the 

The 21st century is likely to witness the realization of Freud's vision when he attempted the "Project for a Scientific Psychology." We will better understand the mind by better understanding the brain. We will continue to witness changes in the brain associated with changes in mind as suggested by research in obsessive-compulsive disorder (Schwartz and colleagues). Theorizing will increasingly be tethered to the organs of the brain (Beitman 1994).

. Such reasoning requires therapists to generalize from bits of information presented by the patient to explicit patterns of dysfunction.

Information can be gathered in a number of ways including: questions, confrontations, clarifications, homework assignments, reports from significant others, observation of the patient in the office and therapist reactions to the patient.

. Therapists encourage patients to increase emotional awareness, modify cognitions and/or regulate behavior (Frank 1961; Karasu) and/or to refine their self-definitions in relationship to others. The strategies which guide these efforts include encouraging patients to face their fears, helping them to alter the way in which they anticipate the future and offering ways to redesign their role-relationship schemata and scripts.

Effective therapists seem to possess both a solid grounding in the basics of psychotherapy and disciplined flexibility. Disciplined flexibility requires structured ways to adjust psychotherapeutic ideas to the therapist's personality as well as to the individualized needs of patients and to move easily, but prudently, among various strategies for change.

Theory and technique are molded to the individual personality of each therapist

. No matter how leaders of schools might attempt to create therapists who strongly resemble each other, most practitioners seem to adjust their selections of school-bound ideas to their own interpersonal styles and world views.

Theory and technique are shaped by the cultural context in which it is being practiced

. Psychotherapy is strongly influenced by its sociopolitical context and may sometimes influence the culture in which it grows.

Therapists adjust to influences patients bring to the psychotherapy relationship

. Generally, therapists strive to match client characteristics and problems with the most potentially effective interventions rather than attempting to force patients into therapist-imposed restrictive formats.

Effective therapists learn to move easily among the commonly accepted change strategies

. Three meta-strategies guide the application of change strategies:

Key-change strategy: Sometimes the available evidence suggests that one strategy offers the quickest, most efficient avenue to change.

Shifting-change strategy: Therapy begins with the most easily used change strategy. If not effective, switch to another strategy.

Maximum-impact strategy: With some complex cases, therapists must work simultaneously on several patterns. Instead of hoping for a sequential effect, therapists may need to work for a synergistic effect as multiple changes mass together to bring about a desired state. The use of these strategies relies on the principle of using the least amount of energy to produce the greatest output (Prochaska and Prochaska).

Effective therapists reflect on and analyze their own thinking

: Effective therapists seem to reflect upon their own responses to patients to differentiate their own neurotic responses from patient-induced ones. They attempt to utilize this understanding to help patients and also to help themselves grow as individuals and as therapists.

Overall, the guiding strategy of psychotherapists is an ethical one: everything therapists do is intended to help their patients.

The pressure of cost containment is painfully squeezing out the inefficiencies in the helping professions. One such inefficiency is how new knowledge enters the mainstream of clinical practice. Because psychotherapy is not a profession, little formal obligation exists for continuing education in psychotherapy. Because busy clinicians are often caught up in economic and personal concerns, their expansion of psychotherapy knowledge is likely to be haphazard and idiosyncratically built upon their own clinical biases. The primary sources of new knowledge for psychotherapists are theory, clinical experience of both their own and of other clinicians and research. Therapists may also acquire new ideas from the media and from their own personal experiences. For the practice of psychotherapy to become coherent, a new organization for the screening of new ideas may be required. There are numerous psychotherapy journals and newsletters. None seems dedicated to defining only that which therapists need to know in order to improve practice. A publication disseminated through the Internet as a public service to psychotherapists could be created to fill the continuing education need for this constantly evolving process. The organization behind this publication would need to filter information from the four primary sources: theory, clinical practice, controlled research and naturalistic outcome research.

Particularly useful will be feedback from well-constructed data sets based upon outcome and process data from actual clinical practices. Such data bases are currently being formed by managed behavioral health organizations. Simple but profound questions looking, for example, at the relationship between working alliance, stages of change and clinical outcomes could inform clinical practice.

Psychotherapy is not a profession. It is an activity of many different professions. It has no organization to set and uphold professional standards and ethics. In 1996, the American Psychiatric Association established the Commission on Psychotherapy to address the erosion of psychotherapeutic practice. For the long-standing survival and flourishing of psychotherapy, psychotherapists may need to create a multidisciplinary group dedicated to the growth and survival of psychotherapy.

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Bernard Biermann, MD, PhD

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