Biological Psychiatry - Vol. 2

By Hugo D'Haenen; J.A. Den Boer et al. | Go to book overview

Psychobiology of Somatoform Disorders

Winfried Rief and Cornelia Exner


Unexplained physical symptoms are one of the major problems of the health care system. Depending on the medical setting under investigation, between 15% and 80% of doctor visits are due to persons with physical symptoms which cannot be accounted for by a clear organic cause. Most common symptoms are pains and aches, gastrointestinal complaints, and cardiovascular symptoms. Kroenke and Mangelsdorff (1989) demonstrated that only about 16% of the most common physical symptoms can be explained by a clear organic pathology. In their longitudinal study, patients with multiple unexplained physical symptoms and with an illness duration of more than four months had the worst prognosis. As will be shown below, unfortunately this is the most frequent combination of features in patients with somatoform disorders. Accordingly, this group of patients is one of the most expensive subgroups in the health care system. Fink (1992) analysed a subgroup of high utilizers of the health care system who had had at least ten inpatient treatments during the last eight years. He found that about 20% of these frequent hospitalizations were due to unexplained physical symptoms.

Some experts believe that illness behaviour is the most typical feature of somatization. Typical features of illness behaviour are frequent doctor visits, wandering around from doctor to doctor and from treatment unit to treatment unit, taking unnecessary medication, urging doctors to do unnecessary investigations which may lead to complications, avoidance behaviour and reduction of social activities, a high number of sick-leaves, and reduced social functioning. Health anxiety is a frequent, but not a necessary condition for the development and maintenance of unexplained physical symptoms. It is unclear whether these features are consequences of the disorder or else maintaining factors, or even the cause of additional physical problems.

Patients with somatoform disorders are also characterized by a specific cognitive-perceptual style. Barsky et al. (1993) emphasized that patients with hypochondriasis and somatoform symptoms have an over-exclusive concept of being healthy. They conceive health as a state of perfect physical well-being without any physical discomfort. However, physical discomfort is a common sensation even to healthy persons. Therefore persons with somatoform disorders are concerned about normal bodily perceptions; they focus their attention on bodily processes, which leads to an amplified perception of physical changes. This can encourage the interpretation of physical discomfort as illness symptoms.

While Barsky's concept of somatosensory amplification (Barsky and Wyshak, 1990) related primarily to patients with hypochondriasis, our own group demonstrated that patients with somatization syndromes without hypochondriasis also tend to catastrophize their perception of physical processes (Rief et al., 1998). Patients with somatization syndromes have a bias to interpret minor physical

Figure XX.1 Somatization from a cognitive–psychobiological perspec-
tive (Rief and Nanke, 1999)

changes (e.g., heart beat acceleration while taking a hot bath) as a possible sign of a severe illness (e.g., cardiomyopathy). This cognitive–perceptual style leads to the behavioural consequences described above. Moreover, the cognitive and behavioural features of somatization interact with biological properties of the disorder and maintain a vicious circle (see Figure XX. 1). Affective consequences such as demoralization, negative affectivity, or depression might present a negative feedback loop that helps to maintain the problem.


The common feature of the somatoform disorders is the presence of physical symptoms which are not fully explained by a general medical condition, by the direct effect of a substance, or by another mental disorder. The symptoms must cause clinically significant distress or impairment in social functioning. Seeking medical help or para-medical consultation is very frequent. Historically, these syndromes have been labelled 'hysteria', a term which is presendy less used because of stigmatizing effects.

Despite the fact mat single physical complaints are very common, persons with multiple physical complaints represent the most serious subgroup for the health care system. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (APA, 1994) suggests the diagnosis of somatization disorder for polysymptomatic pictures of somatization. The disorder starts typically before age 30 years, extends over a period of years and is characterized by a


Notes for this page

Add a new note
If you are trying to select text to create highlights or citations, remember that you must now click or tap on the first word, and then click or tap on the last word.
One moment ...
Default project is now your active project.
Project items

Items saved from this book

This book has been saved
Highlights (0)
Some of your highlights are legacy items.

Highlights saved before July 30, 2012 will not be displayed on their respective source pages.

You can easily re-create the highlights by opening the book page or article, selecting the text, and clicking “Highlight.”

Citations (0)
Some of your citations are legacy items.

Any citation created before July 30, 2012 will labeled as a “Cited page.” New citations will be saved as cited passages, pages or articles.

We also added the ability to view new citations from your projects or the book or article where you created them.

Notes (0)
Bookmarks (0)

You have no saved items from this book

Project items include:
  • Saved book/article
  • Highlights
  • Quotes/citations
  • Notes
  • Bookmarks
Cite this page

Cited page

Citations are available only to our active members.
Buy instant access to cite pages or passages in MLA, APA and Chicago citation styles.

(Einhorn, 1992, p. 25)

(Einhorn 25)

1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25,

Cited page

Bookmark this page
Biological Psychiatry - Vol. 2
Table of contents

Table of contents



Text size Smaller Larger Reset View mode
Search within

Search within this book

Look up

Look up a word

  • Dictionary
  • Thesaurus
Please submit a word or phrase above.
Print this page

Print this page

Why can't I print more than one page at a time?

Full screen
/ 730

matching results for page

    Questia reader help

    How to highlight and cite specific passages

    1. Click or tap the first word you want to select.
    2. Click or tap the last word you want to select, and you’ll see everything in between get selected.
    3. You’ll then get a menu of options like creating a highlight or a citation from that passage of text.

    OK, got it!

    Cited passage

    Citations are available only to our active members.
    Buy instant access to cite pages or passages in MLA, APA and Chicago citation styles.

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn, 1992, p. 25).

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences." (Einhorn 25)

    "Portraying himself as an honest, ordinary person helped Lincoln identify with his audiences."1

    1. Lois J. Einhorn, Abraham Lincoln, the Orator: Penetrating the Lincoln Legend (Westport, CT: Greenwood Press, 1992), 25,

    Cited passage

    Thanks for trying Questia!

    Please continue trying out our research tools, but please note, full functionality is available only to our active members.

    Your work will be lost once you leave this Web page.

    Buy instant access to save your work.

    Already a member? Log in now.

    Author Advanced search


    An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.