SOMATISCHE
SYMPTOOM
STOORNISSEN
SUMMARY
Master Mental Health
2024/2025
Maastricht University
Emma Leibbrand
, 1
TABLE OF CONTENTS
Task 1: Bodily Complaints Without a Clear Cause .............. 1
Task 2: What’s Wrong with My Back? .......................... 24
Task 3: Suffering on the Third Wave ......................... 55
Task 4: Chronic Fatigue Syndrome ............................ 85
Task 5: Similar, Yet Different ............................ 110
Task 6: The Case of Tanja D. .............................. 138
, 2
[ Task 1 – Bodily Complaints Without a Clear
Cause]
(1) HENNINGSEN: MANAGEMENT OF SOMATIC SYMPTOM DISORDER
ABSTRACT
This paper gives an overview of the management of somatic symptom disorder.
INTRODUCTION
Many patients at all levels of health care suffer from bodily complaints (e.g. pain in different locations of the
body, fatigue, disturbances in cardiovascular functions).
Suffering does not only entail bodily complains, it also entails psychological complaints (e.g. health
anxiety). In most patients, bodily symptoms are central to suffering, but in some, anxiety is central.
BUT Bodily complaints are often assumed to have organic causes, even when it is not found.
o Different medical specialties handle these complaints differently in diagnosis + treatment.
o These approaches are often inconsistent with each other.
o Patients often get frustrated Doctors often experiences them as difficult to treat.
There is no well-defined structural organic pathology to be found that correlates to the symptoms.
o Hence, the symptoms are said to be functional.
o BUT Sometimes, an organic pathology is present, but it doesn’t explain the severity of the
person’s symptoms or their level of suffering.
There is uncertainty among doctors Many feel unsure about how much an underlying physical problem
(if any) contributes to a patient’s symptoms.
o This uncertainty makes diagnosing functional symptoms challenging.
The total number of bodily symptoms a patient experiences is a key predictor of their condition’s severity. It
is more relevant than the intensity of any single symptom or whether the symptoms are labelled as medically
unexplained. Higher number of symptoms is associated with greater disability.
Impact of functional symptoms is high reduced QoL + difficulties with work.
Long-term outcomes for patients with functional symptoms are often poor.
Functional somatic symptoms and bodily distress in general are associated with higher rates of depression and
anxiety than diseases with comparable symptoms but well-defined organic pathology.
BUT Not all patients with somatic symptoms experience depression/anxiety In other words, while
there is a link between somatic symptoms and mental health, the relationship is complex and not solely
psychological. Some patients experience functional symptoms without any sign. mental health issues.
CLASSIFICATION IN DSM-5
DSM-5 New classification: Somatic Symptom Disorder (SSD). 2 major changes compared with DSM-4:
The requirement that the somatic symptoms be organically unexplained has been dropped.
Certain psycho-behavioural features now have to be present in order to justify the diagnosis.
To fulfil the diagnostic criteria, the following must be present:
DSM-5 DIAGNOSTIC CRITERIA SSD
One or more somatic symptoms that are distressing and/or result in significant disruption of daily life.
One or more excessive thoughts, feeling and/or behaviours related to the following somatic symptoms:
o Dispropriate and persistent thoughts about the seriousness of one’s symptoms.
o Persistently high level of anxiety about health or symptoms.
o Excessive time and energy devoted to these symptoms or health concern.
Although any one symptom may not be continuously present, the state of being symptomatic is
persistent and lasts more than 6 months.
, 3
The condition is considered to be…
… mild when only one of the psycho behavioural symptoms is fulfilled.
… moderate when two or more of these symptoms are fulfilled.
… severe when two or more of these symptoms are fulfilled + multiple somatic complaints.
The differences between the DSM-4 and DSM-5 are discussed later in this task (they are put in a table).
ETIOLOGY
Early psychodynamic models of bodily distress suggested a top-down process, where psychological factors
influenced the body and caused persistent symptoms. More recent models focus on a bottom-up process,
where pain signals and other bodily sensations are overly amplified by the brain or social factors.
BUT Evidence is mixed, as people have a decreased ability to accurately perceive own body signals.
A model which states that bodily distress is a disorder of perception has gained ground In this model,
expectations and predictions play a major role = the brain ‘constructs’ its reality, including bodily sensations.
When the brain makes overly rigid or incorrect predictions, this can lead to persistent symptoms. This has
important implications for treatment and prevention, as adjusting expectations and attention could help
reduce bodily distress.
Bodily distress, or somatisation, is influenced by several psychological, social, and systemic factors.
Attachment patterns If mother is not sensitive to child needs at 18 months, the child is more likely to
develop somatisation by age of 5. In adulthood, insecure attachment styles are linked to health anxiety.
Difficulty in recognising and regulation emotions E.g. people with alexithymia (=struggle to identify +
express emotions) are more prone to bodily distress.
Cultural influences Some cultures have higher tendency to express psychological distress through
physical symptoms, regardless of individual personality traits, healthcare systems or environments.
Life events Can trigger bodily distress (e.g. organic illness, stressful work). These stressors + certain
individual personality traits (e.g. emotional sensitivity, anxiety) = symptoms may become chronic.
Systematic healthcare issues Misdiagnosis, delayed treatment, ineffective interventions contribute to
the maintenance of bodily distress.
o Major barrier to proper care is the belief (by doctors + patients) that the symptoms have purely
physical causes, preventing the consideration of psychological treatments.
DIAGNOSIS
Diagnosing SSD is relatively straightforward, because:
Patients are usually referred with a suspected diagnosis of SSD, so clinicians already expect it.
Diagnostic process is now simpler compared to older criteria, which required proving that symptoms
were not caused by a physical condition Now, symptoms don’t need to be medically unexplained.
o What matters is how the patients thinks, feels and behaves in response to them.
Essentially, SSD is easier to diagnose in these settings than older somatoform disorders, partly because
doctors no longer have to prove the symptoms have no organic cause.
Self-report questionnaires that exist for screening and aid in diagnosis are:
1. Patient Health Questionnaire (PHQ-15) for somatic symptom burden.
2. Whiteley Index for health anxiety.
Difference in diagnostic process between mental health settings and primary/specialist care Diagnosing SSD
in primary and specialist somatic care is more difficult, because doctors and patients assume there must be an
underlying physical cause and spend a lot of time looking for it Prolonged medical investigations and delay.
SSD is often overlooked or diagnosed late.
, 4
How to improve recognition and management of SSD?
SDD should be considered early, without assuming malingering.
Repetitive or unnecessary medical tests should be avoided, especially if they serve only to reassure.
Look beyond the primary symptom and assess broader indicators of distress, such as emotional
symptoms, substance use, and suicidal thoughts.
It is important to evaluate the patient’s illness-related thoughts and behaviours, including
catastrophising, body checking, avoidance, and excessive healthcare use.
Once SSD is diagnosed, its severity should be determined (mild, moderate, severe) for appropriate
treatment.
TREATMENT
Evidence based treatment Practice principles
Psychotherapy: Various forms of short-term Doctor-patient communication: Take symptoms
psychotherapy, including CBT, hypnotherapy, seriously, avoid dualistic thinking (physical vs.
mindfulness-based therapy, and multidisciplinary mental), and provide reassurance with clear,
therapy, show low-to-moderate efficacy, with functional explanations.
hypnotherapy and multidisciplinary therapy
showing the strongest effects. Encouraging active coping: Support lifestyle changes
like sleep hygiene, exercise, and hobbies. Set realistic
Antidepressants: Low evidence for efficacy in IBS,
goals for symptom management.
with tricyclic antidepressants showing moderate
effects in Fibromyalgia Syndrome (FMS).
Structured follow-up: Schedule regular appointments
Pregabalin and gabapentin have limited support.
instead of waiting for patients to initiate contact.
Self-help & activating therapies: Includes
relaxation techniques, graded exercise, and self- Contextualizing symptoms: Frame psychosocial and
help guides, all showing at least low to moderate biological factors as amplifiers, not direct causes.
efficacy. Help build a blame-free, meaningful symptom
Consultation letters & psychiatric consults: In narrative.
primary care, these interventions show low-to-
moderate efficacy in improving patient outcomes. Symptomatic support: Allow temporary
complementary medicine if desired, and use pain
Multidisciplinary treatment: Integrates relief or digestives as needed, explaining their
psychotherapy, physiotherapy, occupational limitations.
therapy, and symptomatic medical treatment,
with strong evidence for efficacy. Careful referral to psychotherapy: Acknowledge
Treatment of severe cases: When outpatient care patient scepticism about psychological treatment and
is insufficient, integrated care with structured help them see its potential benefit.
multidisciplinary programs is recommended.
Addressing comorbidities: Trauma, medication Psychotherapy engagement: Help patients create a
misuse, factitious symptoms, or legal stressors structured illness narrative, focus on emotional
should be assessed as maintaining factors. reactions, and avoid premature psychosocial
attributions.
No strong evidence for physician training:
Enhanced care training for primary care physicians Collaboration with other professionals: Ensure
has shown no significant impact. coordinated care among medical and mental health
providers to prevent excessive diagnostics and
unnecessary treatments.
, 5
(2) MURRAY: THE CHALLENGE OF DIAGNOSING NON-SPECIFIC, FUNCTIONAL,
AND SOMATOFORM DISORDERS
ABSTRACT
Aim To identify and aggregate potential barriers to the diagnosis in primary care settings.
INTRODUCTION
Primary care practitioners (PCPs) are at the forefront of receiving patients who present with medically
unexplained symptoms (MUS), as well as functional or somatoform disorders.
Despite prevalence, SSD often remains unrecognised + underdiagnosed.
PCPs have to be prepared to diagnose + manage these patients.
Diagnosis = challenging + requires skills and knowledge.
Etiopathogenetic models suggest that psychosocial, biological, iatrogenic and sociocultural aspects
influence the predisposition towards, as well as the triggering and maintenance of symptoms.
Given their often on-going relationship with patients and their role as being the ‘first contact’, PCPs are in
the perfect position to monitor patients’ health behaviour over time and be aware of all potential
contributing factors.
Patients are often referred from primary care onto other specialists in a vicious cycle which can be difficult to
break This can preclude appropriate care and further exacerbate patient’s complaints.
It is important to identify patients early. Diagnosis must be facilitated.
The diagnosis and management of somatoform disorders are inconsistent, complicating research and
communication. DSM-IV and ICD-10 required symptoms to be "medically unexplained," reinforcing mind-body
dualism, while PCPs preferred functional labels. Many rely on their own assessment methods, making
comparison difficult.
DSM-5 removes some barriers but doesn’t solve all issues. Clearer diagnostic strategies and better
communication in primary care are needed.
METHOD
Systematic review They looked for barriers in diagnosis (=factor that creates problems in diagnosis).
RESULTS
To make things easier to understand, they organised all barriers into 16 thematic categories, which they further
grouped into 5 broad themes:
Patient- Communication and consultation behaviour Patients’ narratives can be chaotic,
related complex, and inconsistent = makes it hard for PCPs to organise the info + figure out what
barriers is going on.
Predominance of biomedical disease model Many patients view their symptoms via a
biomedical lens and expect physical exams + medical treatments. They worry that
mentioning psychological factors distracts doctors from taking physical symptoms
seriously. Many resist psychological explanations due to stigma.
Belief that primary care is an inappropriate setting Patients may believe that primary
care is an inappropriate setting to discuss psychosocial issues. This includes a strong belief
en self-management of symptoms or an assumption that treatment options are poor.
There is a lack of faith in PCPs’ ability to manage such complaints.
PCP related Communication and consultation behaviour
barriers o PCPs do not always fully explore MUS patients’ concerns.
o They do not provide evidence based responses and may use vague or ineffective
explanations for patients’ complaints.
o PCPs may exhibit a lack of empathy (some report psychological disengagement
from their patients).
Predominance of the biomedical disease model An emphasis on the biological side
may negatively affect diagnostic processes. A lot of time is spend on medical
SYMPTOOM
STOORNISSEN
SUMMARY
Master Mental Health
2024/2025
Maastricht University
Emma Leibbrand
, 1
TABLE OF CONTENTS
Task 1: Bodily Complaints Without a Clear Cause .............. 1
Task 2: What’s Wrong with My Back? .......................... 24
Task 3: Suffering on the Third Wave ......................... 55
Task 4: Chronic Fatigue Syndrome ............................ 85
Task 5: Similar, Yet Different ............................ 110
Task 6: The Case of Tanja D. .............................. 138
, 2
[ Task 1 – Bodily Complaints Without a Clear
Cause]
(1) HENNINGSEN: MANAGEMENT OF SOMATIC SYMPTOM DISORDER
ABSTRACT
This paper gives an overview of the management of somatic symptom disorder.
INTRODUCTION
Many patients at all levels of health care suffer from bodily complaints (e.g. pain in different locations of the
body, fatigue, disturbances in cardiovascular functions).
Suffering does not only entail bodily complains, it also entails psychological complaints (e.g. health
anxiety). In most patients, bodily symptoms are central to suffering, but in some, anxiety is central.
BUT Bodily complaints are often assumed to have organic causes, even when it is not found.
o Different medical specialties handle these complaints differently in diagnosis + treatment.
o These approaches are often inconsistent with each other.
o Patients often get frustrated Doctors often experiences them as difficult to treat.
There is no well-defined structural organic pathology to be found that correlates to the symptoms.
o Hence, the symptoms are said to be functional.
o BUT Sometimes, an organic pathology is present, but it doesn’t explain the severity of the
person’s symptoms or their level of suffering.
There is uncertainty among doctors Many feel unsure about how much an underlying physical problem
(if any) contributes to a patient’s symptoms.
o This uncertainty makes diagnosing functional symptoms challenging.
The total number of bodily symptoms a patient experiences is a key predictor of their condition’s severity. It
is more relevant than the intensity of any single symptom or whether the symptoms are labelled as medically
unexplained. Higher number of symptoms is associated with greater disability.
Impact of functional symptoms is high reduced QoL + difficulties with work.
Long-term outcomes for patients with functional symptoms are often poor.
Functional somatic symptoms and bodily distress in general are associated with higher rates of depression and
anxiety than diseases with comparable symptoms but well-defined organic pathology.
BUT Not all patients with somatic symptoms experience depression/anxiety In other words, while
there is a link between somatic symptoms and mental health, the relationship is complex and not solely
psychological. Some patients experience functional symptoms without any sign. mental health issues.
CLASSIFICATION IN DSM-5
DSM-5 New classification: Somatic Symptom Disorder (SSD). 2 major changes compared with DSM-4:
The requirement that the somatic symptoms be organically unexplained has been dropped.
Certain psycho-behavioural features now have to be present in order to justify the diagnosis.
To fulfil the diagnostic criteria, the following must be present:
DSM-5 DIAGNOSTIC CRITERIA SSD
One or more somatic symptoms that are distressing and/or result in significant disruption of daily life.
One or more excessive thoughts, feeling and/or behaviours related to the following somatic symptoms:
o Dispropriate and persistent thoughts about the seriousness of one’s symptoms.
o Persistently high level of anxiety about health or symptoms.
o Excessive time and energy devoted to these symptoms or health concern.
Although any one symptom may not be continuously present, the state of being symptomatic is
persistent and lasts more than 6 months.
, 3
The condition is considered to be…
… mild when only one of the psycho behavioural symptoms is fulfilled.
… moderate when two or more of these symptoms are fulfilled.
… severe when two or more of these symptoms are fulfilled + multiple somatic complaints.
The differences between the DSM-4 and DSM-5 are discussed later in this task (they are put in a table).
ETIOLOGY
Early psychodynamic models of bodily distress suggested a top-down process, where psychological factors
influenced the body and caused persistent symptoms. More recent models focus on a bottom-up process,
where pain signals and other bodily sensations are overly amplified by the brain or social factors.
BUT Evidence is mixed, as people have a decreased ability to accurately perceive own body signals.
A model which states that bodily distress is a disorder of perception has gained ground In this model,
expectations and predictions play a major role = the brain ‘constructs’ its reality, including bodily sensations.
When the brain makes overly rigid or incorrect predictions, this can lead to persistent symptoms. This has
important implications for treatment and prevention, as adjusting expectations and attention could help
reduce bodily distress.
Bodily distress, or somatisation, is influenced by several psychological, social, and systemic factors.
Attachment patterns If mother is not sensitive to child needs at 18 months, the child is more likely to
develop somatisation by age of 5. In adulthood, insecure attachment styles are linked to health anxiety.
Difficulty in recognising and regulation emotions E.g. people with alexithymia (=struggle to identify +
express emotions) are more prone to bodily distress.
Cultural influences Some cultures have higher tendency to express psychological distress through
physical symptoms, regardless of individual personality traits, healthcare systems or environments.
Life events Can trigger bodily distress (e.g. organic illness, stressful work). These stressors + certain
individual personality traits (e.g. emotional sensitivity, anxiety) = symptoms may become chronic.
Systematic healthcare issues Misdiagnosis, delayed treatment, ineffective interventions contribute to
the maintenance of bodily distress.
o Major barrier to proper care is the belief (by doctors + patients) that the symptoms have purely
physical causes, preventing the consideration of psychological treatments.
DIAGNOSIS
Diagnosing SSD is relatively straightforward, because:
Patients are usually referred with a suspected diagnosis of SSD, so clinicians already expect it.
Diagnostic process is now simpler compared to older criteria, which required proving that symptoms
were not caused by a physical condition Now, symptoms don’t need to be medically unexplained.
o What matters is how the patients thinks, feels and behaves in response to them.
Essentially, SSD is easier to diagnose in these settings than older somatoform disorders, partly because
doctors no longer have to prove the symptoms have no organic cause.
Self-report questionnaires that exist for screening and aid in diagnosis are:
1. Patient Health Questionnaire (PHQ-15) for somatic symptom burden.
2. Whiteley Index for health anxiety.
Difference in diagnostic process between mental health settings and primary/specialist care Diagnosing SSD
in primary and specialist somatic care is more difficult, because doctors and patients assume there must be an
underlying physical cause and spend a lot of time looking for it Prolonged medical investigations and delay.
SSD is often overlooked or diagnosed late.
, 4
How to improve recognition and management of SSD?
SDD should be considered early, without assuming malingering.
Repetitive or unnecessary medical tests should be avoided, especially if they serve only to reassure.
Look beyond the primary symptom and assess broader indicators of distress, such as emotional
symptoms, substance use, and suicidal thoughts.
It is important to evaluate the patient’s illness-related thoughts and behaviours, including
catastrophising, body checking, avoidance, and excessive healthcare use.
Once SSD is diagnosed, its severity should be determined (mild, moderate, severe) for appropriate
treatment.
TREATMENT
Evidence based treatment Practice principles
Psychotherapy: Various forms of short-term Doctor-patient communication: Take symptoms
psychotherapy, including CBT, hypnotherapy, seriously, avoid dualistic thinking (physical vs.
mindfulness-based therapy, and multidisciplinary mental), and provide reassurance with clear,
therapy, show low-to-moderate efficacy, with functional explanations.
hypnotherapy and multidisciplinary therapy
showing the strongest effects. Encouraging active coping: Support lifestyle changes
like sleep hygiene, exercise, and hobbies. Set realistic
Antidepressants: Low evidence for efficacy in IBS,
goals for symptom management.
with tricyclic antidepressants showing moderate
effects in Fibromyalgia Syndrome (FMS).
Structured follow-up: Schedule regular appointments
Pregabalin and gabapentin have limited support.
instead of waiting for patients to initiate contact.
Self-help & activating therapies: Includes
relaxation techniques, graded exercise, and self- Contextualizing symptoms: Frame psychosocial and
help guides, all showing at least low to moderate biological factors as amplifiers, not direct causes.
efficacy. Help build a blame-free, meaningful symptom
Consultation letters & psychiatric consults: In narrative.
primary care, these interventions show low-to-
moderate efficacy in improving patient outcomes. Symptomatic support: Allow temporary
complementary medicine if desired, and use pain
Multidisciplinary treatment: Integrates relief or digestives as needed, explaining their
psychotherapy, physiotherapy, occupational limitations.
therapy, and symptomatic medical treatment,
with strong evidence for efficacy. Careful referral to psychotherapy: Acknowledge
Treatment of severe cases: When outpatient care patient scepticism about psychological treatment and
is insufficient, integrated care with structured help them see its potential benefit.
multidisciplinary programs is recommended.
Addressing comorbidities: Trauma, medication Psychotherapy engagement: Help patients create a
misuse, factitious symptoms, or legal stressors structured illness narrative, focus on emotional
should be assessed as maintaining factors. reactions, and avoid premature psychosocial
attributions.
No strong evidence for physician training:
Enhanced care training for primary care physicians Collaboration with other professionals: Ensure
has shown no significant impact. coordinated care among medical and mental health
providers to prevent excessive diagnostics and
unnecessary treatments.
, 5
(2) MURRAY: THE CHALLENGE OF DIAGNOSING NON-SPECIFIC, FUNCTIONAL,
AND SOMATOFORM DISORDERS
ABSTRACT
Aim To identify and aggregate potential barriers to the diagnosis in primary care settings.
INTRODUCTION
Primary care practitioners (PCPs) are at the forefront of receiving patients who present with medically
unexplained symptoms (MUS), as well as functional or somatoform disorders.
Despite prevalence, SSD often remains unrecognised + underdiagnosed.
PCPs have to be prepared to diagnose + manage these patients.
Diagnosis = challenging + requires skills and knowledge.
Etiopathogenetic models suggest that psychosocial, biological, iatrogenic and sociocultural aspects
influence the predisposition towards, as well as the triggering and maintenance of symptoms.
Given their often on-going relationship with patients and their role as being the ‘first contact’, PCPs are in
the perfect position to monitor patients’ health behaviour over time and be aware of all potential
contributing factors.
Patients are often referred from primary care onto other specialists in a vicious cycle which can be difficult to
break This can preclude appropriate care and further exacerbate patient’s complaints.
It is important to identify patients early. Diagnosis must be facilitated.
The diagnosis and management of somatoform disorders are inconsistent, complicating research and
communication. DSM-IV and ICD-10 required symptoms to be "medically unexplained," reinforcing mind-body
dualism, while PCPs preferred functional labels. Many rely on their own assessment methods, making
comparison difficult.
DSM-5 removes some barriers but doesn’t solve all issues. Clearer diagnostic strategies and better
communication in primary care are needed.
METHOD
Systematic review They looked for barriers in diagnosis (=factor that creates problems in diagnosis).
RESULTS
To make things easier to understand, they organised all barriers into 16 thematic categories, which they further
grouped into 5 broad themes:
Patient- Communication and consultation behaviour Patients’ narratives can be chaotic,
related complex, and inconsistent = makes it hard for PCPs to organise the info + figure out what
barriers is going on.
Predominance of biomedical disease model Many patients view their symptoms via a
biomedical lens and expect physical exams + medical treatments. They worry that
mentioning psychological factors distracts doctors from taking physical symptoms
seriously. Many resist psychological explanations due to stigma.
Belief that primary care is an inappropriate setting Patients may believe that primary
care is an inappropriate setting to discuss psychosocial issues. This includes a strong belief
en self-management of symptoms or an assumption that treatment options are poor.
There is a lack of faith in PCPs’ ability to manage such complaints.
PCP related Communication and consultation behaviour
barriers o PCPs do not always fully explore MUS patients’ concerns.
o They do not provide evidence based responses and may use vague or ineffective
explanations for patients’ complaints.
o PCPs may exhibit a lack of empathy (some report psychological disengagement
from their patients).
Predominance of the biomedical disease model An emphasis on the biological side
may negatively affect diagnostic processes. A lot of time is spend on medical
