Journal of Contemporary Psychotherapy

, Volume 38, Issue 1, pp 45–53 | Cite as

An Integrative Approach to Somatoform Disorders Combining Interpersonal and Cognitive-behavioral Theory and Techniques

  • Scott Stuart
  • Russell NoyesJr.
  • Vladan Starcevic
  • Arthur Barsky
Original Paper


Data regarding the treatment of somatoform disorders suggest that the gains associated with current psychopharmacologic or psychotherapeutic treatments are modest at best. There have been a few moderately effective treatments for selected functional somatic syndromes, but patients who present with multi-system symptoms meeting criteria for the DSM-IV somatoform disorders are notoriously unresponsive to treatment. Experts in the field have advocated several approaches, including interpersonally oriented and cognitive-behavioral therapies, and have emphasized the importance of the provision of reassurance within the doctor-patient relationship. While each individual approach has merit, none is likely to be maximally efficacious as a stand-alone treatment. In this article we describe the theoretical underpinnings and technical aspects of a treatment for somatizing patients that integrates these three elements.


Interpersonal Therapy Somatic 



This work was supported by the following grants: 5K24MH72757-02 (NIMH- Stuart). A. Barsky's work was supported by grant NIMH MH 040487 and NIAMS AR47014


  1. Allen, L. A., Escobar, J. I., Lehrer, P. M., Gara, M. A., & Woolfolk, R. L. (2002). Psychosocial treatments for multiple unexplained physical symptoms: A review of the literature. Psychosomatic Medicine, 64, 939–950.PubMedCrossRefGoogle Scholar
  2. Allen, L. A., Woolfolk, R. L., Escobar J. I, Gara, M. A., & Hamer, R. M. (2006). Cognitive-behavioral therapy for somatization disorder: A randomized controlled trial. Archives of Internal Medicine, 166, 1512–1518.PubMedCrossRefGoogle Scholar
  3. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.Google Scholar
  4. Avia, M. D., Ruiz, A., Olivares, M. E., Crespo, M., Guisado, A. B., & Sanchez, A. (1996). The meaning of psychological symptoms: Effectiveness of a group intervention with hypochondriacal patients. Behavioral Research and Therapy, 34, 23–31.CrossRefGoogle Scholar
  5. Barr, G. (1965). Reassurance. Scottish Medical Journal, 10, 356–360.PubMedGoogle Scholar
  6. Barsky, A. J. (1996). Hypochondriasis: Medical management and psychiatric treatment. Psychosomatics, 37, 48–56.PubMedGoogle Scholar
  7. Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis. JAMA, 291, 1464–1470.PubMedCrossRefGoogle Scholar
  8. Barsky, A. J., & Borus, J. F. (1999). Functional somatic syndromes. Annals of Internal Medicine, 130, 910–921.PubMedGoogle Scholar
  9. Barsky, A. J., Orav, E. J., & Bates, D. W. (2005). Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Archives of General Psychiatry, 62, 903–910.PubMedCrossRefGoogle Scholar
  10. Barsky, A. J., Orav, E. J., & Bates, D. W. (2006). Distinctive patterns of medical care utilization in patients who somatize. Medical Care, 44, 803–811.PubMedCrossRefGoogle Scholar
  11. Barsky, A. J., & Wyshak, G. (1990). Hypochondriasis and somatosensory amplification. British Journal of Psychiatry, 157, 404–409.PubMedCrossRefGoogle Scholar
  12. Bouman, T. K., & Visser, S. (1998). Cognitive and behavioural treatment of hypochondriasis. Psychotherapy and Psychosomatics, 67, 214–221.PubMedCrossRefGoogle Scholar
  13. Ciechanowski, P., Katon, W. J., Russo, J. E., & Dwight-Johnson, M. M. (2002). Association of attachment style to lifetime medically unexplained symptoms in patients with hepatitis C. Psychosomatics, 43, 206–212.PubMedCrossRefGoogle Scholar
  14. Ciechanowski, P., Russo, J. E., Katon, W. J., VonKorff, M., Ludman, E., & Lin, E. (2004). Influence of patient attachment style on self-care and outcomes in diabetes. Psychosomatic Medicine, 66, 720–728.PubMedCrossRefGoogle Scholar
  15. Ciechanowski, P. S., Hirsch, J. B., & Katon, W. J. (2002). Interpersonal predictors of HbA1C in patients with type 1 diabetes. Diabetes Care, 25, 731–736.PubMedCrossRefGoogle Scholar
  16. Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E. (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64, 660–667.PubMedCrossRefGoogle Scholar
  17. Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461–470.PubMedCrossRefGoogle Scholar
  18. Clark, D. M., Salkovskis, P. M., & Hackman, A. (1998). Two psychological treatments for hypochondriasis. British Journal of Psychiatry, 173, 218–225.PubMedGoogle Scholar
  19. Cooper, C. (1996). The art of reassurance. Australian Family Physician, 25, 695–698.PubMedGoogle Scholar
  20. Creed, F., & Barsky, A. (2004). A systematic review of the epidemiology of somatization disorder and hypochondriasis. Journal of Psychosomatic Research, 56, 391–408.PubMedCrossRefGoogle Scholar
  21. Dickinson, W. P., Dickinson, L. M., deGruy, F. V., Main, D. S., Candib, L. M., & Rost, K. A. (2003). Randomized clinical trial of a care recommendation letter intervention for somatization in primary care. Annals of Family Medicine, 1, 228–235.PubMedCrossRefGoogle Scholar
  22. Escobar, J. I., Golding, J. M., & Hough, R. L. (1987). Somatization in the community: Relationship to disability and use of services. American Journal of Public Health, 77, 837–840.PubMedGoogle Scholar
  23. Escobar, J. I, Waitzkin, H., Silver, R. C., Gara, M., & Holman, A. (1998). Abridged somatization: A study in primary care. Psychosomatic Medicine, 60, 466–472.PubMedGoogle Scholar
  24. Escobar, J. I., Swartz, M., Rubio-Stipec, M., & Manu, P. (1991). Medically unexplained symptoms: Distribution, risk factors, and comorbidity. In L. J. Kirmayer & J. M. Robbins (Eds.), Current concepts of somatization: Research and clinical perspectives. Washington: American Psychiatric Press.Google Scholar
  25. Fava G. A., Fabbri S., Sirri L., & Wise, T. N. (2007). Psychological factors affecting medical condition: A new proposal for DSM-V. Psychosomatics, 48, 103–111.PubMedCrossRefGoogle Scholar
  26. Fink P., Rosendal M., & Olesen, F. (2005). Classification of somatization and functional somatic symptoms in primary care. Australian and New Zealand Journal of Psychiatry, 39, 772–781.PubMedCrossRefGoogle Scholar
  27. Frank J. (1971). Therapeutic factors in psychotherapy. American Journal of Psychotherapy, 25, 350–361.PubMedGoogle Scholar
  28. Greeven A., van Balkom A. J., Visser S., Merkelbach J. W., van Rood Y. R., & van Dyck, R. (2007). Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: A randomized, controlled trial. American Journal of Psychiatry, 164, 91–99.PubMedCrossRefGoogle Scholar
  29. Guthrie E., Creed F., Dawson D., & Tomenson B. (1993). A randomized controlled trial of psychotherapy in patients with refractory irritable bowel syndrome. British Journal of Psychiatry, 163, 315–321.PubMedCrossRefGoogle Scholar
  30. Haenen M.-A., de Jong P. J., Schmidt A. J., Stevens S., & Visser, L. (2000). Hypochondriacs’ estimation of negative outcomes: Domain-specific and responsiveness to reassuring and alarming information. Behaviour Research and Therapy, 38, 819–833.PubMedCrossRefGoogle Scholar
  31. Hanback J. W., & Revelle, W. (1978). Arousal and perceptual sensitivity in hypochondriacs. Abnormal Psychology, 87, 523–530.CrossRefGoogle Scholar
  32. Hansell, S., & Mechanic, D. (1986). The socialization of introspection and illness behavior. In S. McHugh & T. M. Vallis (Eds.), Illness behavior (pp. 253–260). New York: Plenum Press.Google Scholar
  33. Hellman, C. J. C., Budd, M., Borysenko, J., McClelland, D. C., & Benson, H. (1990). A study of the effectiveness of two group behavioral medicine interventions for patients with psychosomatic complaints. Behavioral Medicine, 16, 165–173.PubMedCrossRefGoogle Scholar
  34. Hiller, W., & Reif, W. (2005). Why DSM-III was right to introduce the concept of somatoform disorders. Psychosomatics, 46, 105–108.PubMedCrossRefGoogle Scholar
  35. Howard, L. M., & Wessely, S. (1996). Reappraising reassurance: The role of investigations. Journal of Psychosomatic Research, 41, 307–311.PubMedCrossRefGoogle Scholar
  36. Kashner, T. M., Rost, K., Cohen, B., Anderson, M., & Smith, G. R. (1995). Enhancing the health of somatizion disorder patients: Effectiveness of short-term group therapy. Psychosomatics, 36, 462–470.PubMedGoogle Scholar
  37. Kessel, N. (1979). Reassuarance. The Lancet, 1(8126), 1128–1133.Google Scholar
  38. Kroenke, K. (2006). Physical symptom disorder. Journal of Psychosomatic Research, 60, 335–339.PubMedCrossRefGoogle Scholar
  39. Kroenke, K., Spitzer, R. L., deGruy, F. V., Hahn, S. R., Linzer, M., Williams, J. B. W. et al. (1997). Multisomatiform disorder: An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Archives of General Psychiatry, 54, 352–363.PubMedGoogle Scholar
  40. Kroenke, K., & Swindle, R. (2000). Cognitive-behavioral therapy for somatization and symptom syndromes: A critical review of controlled clinical trials. Psychotherapy and Psychosomatics, 69, 205–215.PubMedCrossRefGoogle Scholar
  41. Larsen, R. J. (1992). Neuroticism and selective encoding and recall of symptoms: Evidence from a combined concurrent-retrospective study. Journal of Personal and Social Psychology, 62, 480–488.CrossRefGoogle Scholar
  42. Levine, J. D., Gordon, N. C., Smith, R., & Fields, H. L. (1982). Post-operative pain: Effect of extent of injury and attention. Brain Research, 234, 500–504.PubMedCrossRefGoogle Scholar
  43. Lidbeck, J. (1997). Group therapy for somatization disorders in general practice: Effectiveness of a short cognitive-behavioural treatment model. Acta Psychiatrica Scandinavia, 96, 14–24.CrossRefGoogle Scholar
  44. Linden, W. (2000). Psychological treatments in cardiac rehabilitation: Review of rationales and outcomes. Journal of Psychosomatic Research, 48, 443–454.PubMedCrossRefGoogle Scholar
  45. Looper, K. J., & Kirmayer, L. J. (2002). Behavioral medicine approaches to somatoform disorders. Journal of Consulting and Clinical Psychology, 70, 810–827.PubMedCrossRefGoogle Scholar
  46. MacLeod, A. K., Haynes, C., & Sensky, T. (1998). Attributions about common bodily sensations: Their associations with hypochondriasis and anxiety. Psychological Medicine, 28, 225–228.PubMedCrossRefGoogle Scholar
  47. Mayou, R., Kirmayer, L. J., Simon, G., Kroenke, K., & Sharpe, M. (2005). Somatoform disorders: Time for a new approach in DSM-V. American Journal of Psychiatry, 162, 847–855.PubMedCrossRefGoogle Scholar
  48. Mayou, R. A., Bryant, B. M., Sanders, D., Bass, C., Klimes, I., & Forfar, C. (1997). A controlled trial of cognitive behavioural therapy for non-cardiac chest pain. Psychological Medicine, 27, 1021–1031.PubMedCrossRefGoogle Scholar
  49. McLeod, C. C., Budd, M. A., & McClelland, D. C. (1997). Treatment of somatization in primary care. General Hospital Psychiatry, 19, 251–258.PubMedCrossRefGoogle Scholar
  50. Noyes, R., Holt, C. S., & Kathol, R. G. (1995). Somatization: Diagnosis and management. Archives of Family Medicine, 4, 790–795.PubMedCrossRefGoogle Scholar
  51. Noyes, R., Stuart, S., & Watson, D. (in press). A reconceptualization of the somatization disorders. Psychosomatics.Google Scholar
  52. Ottaviani, R., & Beck, A. T. (1987). Cognitive aspects of panic disorders. Journal of Anxiety Disorders, 1, 15–28.CrossRefGoogle Scholar
  53. Payne, A., & Blanchard, E. B. (1995). A controlled comparison of cognitive therapy and self-help support groups in the treatment of irritable bowel syndrome. Journal of Consulting and Clinical Psychology, 63, 779–786.PubMedCrossRefGoogle Scholar
  54. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer-Verlag.Google Scholar
  55. Pilowsky, I. (1997). Abnormal illness behavior. Chichester, U K: Wiley.Google Scholar
  56. Reif, W., & Sharpe, M. (2004). Somatoform disorders: New approaches to classification, conceptualization, and treatment. Journal of Psychosomatic Research, 56, 387–390.CrossRefGoogle Scholar
  57. Robbins, J. M., & Kirmayer, L. J. (1991). Attributions of common somatic symptoms. Psychological Medicine, 21, 1029–1045.PubMedCrossRefGoogle Scholar
  58. Salkovskis, P. M., & Warwick, H. M. (1985). Cognitive therapy of obsessive-compulsive disorder: Treating treatment failures. Behavioral Psychotherapy, 13, 243–255.Google Scholar
  59. Salovey, P., & Birnbaum, D. I. (1989). Influence of mood on health-relevant cognitions. Journal of Personal and Social Psychology, 57, 539–551.CrossRefGoogle Scholar
  60. Sensky, T., MacLeod, A. K., & Rigby, M. F. (1996). Causal attributions about common somatic sensations among frequent general practice attenders. Psychological Medicine, 26, 641–646.PubMedGoogle Scholar
  61. Smith, G. R., Rost, K., & Kashner, T. M. (1995). A trial of the effect of a standardized psychiatric consultation on health outcomes and costs in somaticizing patients. Archives of General Psychiatry, 52, 238–243.PubMedGoogle Scholar
  62. Smith, R. C., Lein, C., Collins, C., Lyles, J., Given, B., Dwamena, F. C. et al. (2003). Treating patients with medically unexplained symptoms in primary care. Journal of General Internal Medicine, 18, 478–489.PubMedCrossRefGoogle Scholar
  63. Speckens, A. E. M., van Hemert, A. M., Spinhoven, P., Hawton, K. E., Bolk, J. H., & Rooijmans, H. G. M. (1995). Cognitive behavioural therapy for medically unexplained physical symptoms: A randomized controlled trial. British Medical Journal, 311, 1328–1332.PubMedGoogle Scholar
  64. Starcevic, V. (1990). Role of reassurance and psychopathology in hypochondriasis. Psychiatry, 53, 383–395.PubMedGoogle Scholar
  65. Starcevic, V. (1991). Reassurance and treatment of hypochondriasis. General Hospital Psychiatry, 13, 122–127.PubMedCrossRefGoogle Scholar
  66. Starcevic, V. (2006). Somatoform disorders and DSM-V: Conceptual and political issues in the debate. Psychosomatics, 47, 277–281.PubMedCrossRefGoogle Scholar
  67. Starcevic, V., & Piontek, C. M. (1997). Empathic understanding revisited: Conceptualization, controversies and limitations. American Journal of Psychotherapy, 51, 317–328.PubMedGoogle Scholar
  68. Sternbach, R. A. (1978). Psychological dimensions and perceptual analyses, including pathologies of pain. In E. D. Carterett & M. D. Friedman (Eds.), Handbook of perception (pp. 231–261). New York: Academic Press.Google Scholar
  69. Stuart, S., & Noyes, R. (1999). Attachment and interpersonal communication in somatization disorder. Psychosomatics, 40, 34–43.PubMedGoogle Scholar
  70. Stuart, S., & Noyes, R. (2005). Treating hypochondriasis with Interpersonal Psychotherapy. Journal of Contemporary Psychotherapy, 35, 269–283.CrossRefGoogle Scholar
  71. Stuart, S., & Noyes, R. (2006). Interpersonal psychotherapy for somatizing patients. Psychotherapy and Psychosomatics, 75, 209–219.PubMedCrossRefGoogle Scholar
  72. Stuart, S., & Robertson, M. (2003). Interpersonal psychotherapy: A clinician’s guide. London: Edward Arnold Ltd.Google Scholar
  73. Sumathipala, A., Hewege, S., Hanwella, R., & Mann, A. H. (2000). Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: A feasibility study in Sri Lanka. Psychological Medicine, 30, 747–757.PubMedCrossRefGoogle Scholar
  74. Warwick, H. M. C., Clark, D. M., & Cobb, A. M. (1996). A controlled trial of cognitive-behavioural treatment of hypochondriasis. British Journal of Psychiatry, 169, 189–195.PubMedGoogle Scholar
  75. Warwick, H. M. C., & Salkovskis, P. M. (1985). Reassurance. British Medical Journal, 290, 1028.PubMedGoogle Scholar
  76. Wise, T. N., & Birket-Smith, T. N. (2000). The somatoform disorders for DSM-V: The need for changes in process and content. Psychosomatics, 43, 437–440.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Scott Stuart
    • 1
  • Russell NoyesJr.
    • 1
  • Vladan Starcevic
    • 2
  • Arthur Barsky
    • 3
  1. 1.Department of PsychiatryUniversity of IowaIowa CityUSA
  2. 2.Department of Psychological Medicine, Nepean HospitalUniversity of SydneySydney/PenrithAustralia
  3. 3.Brigham and Women’s HospitalHarvard UniversityBostonUSA

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