Specific treatment approaches have not been well studied in somatization disorder or undifferentiated somatoform disorder. However, several studies have provided preliminary evidence that cognitive-behavioral therapy may be effective in patients with medically unexplained symptoms and that group treatment using similar approaches may be effective. In addition, substantial literature recommends specific treatment for these disorders.

Cognitive-Behavioral Therapy
Cognitive-behavioral therapy has been advocated for patients with multiple unexplained somatic symptoms. Speckens et al. reported the results of a randomized controlled trial that found that primary care patients with medically unexplained symptoms had a decrease in the intensity and number of symptoms, an improvement in functioning, and a decrease in illness behavior after cognitive-behavioral therapy. The cognitive-behavioral intervention was delivered in the primary care setting with the encouragement of the primary care physician. The mean number of sessions was 12 delivered over 8 weeks. Although these patients did not specifically have somatization disorder or undifferentiated somatoform disorder, the group certainly contained several patients with these disorders.

Group Treatment
Several authors, giving relatively uniform recommendations, have indicated that group treatment may be beneficial for patients with somatization disorder. Most of these authors recommend directed, time-limited group therapy with an emphasis on ways to improve patients’ socialization and coping skills. Such therapy groups usually are conducted by nonphysician mental health professionals.

The results of Kashner et al.‘s randomized controlled study indicated that short-term, time-limited, cognitive-behavioral group therapy is cost-effective for patients with somatization disorder and improves their health status. Patients who received this type of group treatment reported significantly better physical and mental health than did patients who did not receive the group therapy. Also, a 52% net savings in health care charges was associated with the group treatment. Both the process and the content of the group intervention were tailored to address the overall goals of patients’ developing a source of peer support, sharing methods of coping with physical problems, and increasing their ability to perceive and express emotion; in addition, the group provided an enjoyable experience for the participants. To simulate a classroom atmosphere, each meeting began with a didactic presentation of the selected topic (see description of topics below), followed by a small group discussion to facilitate peer communication. Group members next participated in an exercise to increase group cohesiveness, to develop personal feelings of competence, and to reinforce their ability to take risks. This therapeutic exercise was then discussed by the group, with an emphasis on feelings during the activity, humor, and self-expression. The sessions closed with a presentation of the next meeting’s subject, the appointment of two group members to facilitate during the next session, and a “brag” session for group members to make and receive positive statements about themselves. The focus of each session was as follows:

• Session 1: Set goals and procedural rules for the group.
• Session 2: Address techniques that patients use for coping with their physical problems.
• Session 3: Discuss how to be assertive with physicians.
• Session 4: Discuss how patients can take more control and increase the positive aspects of their own lives.
• Session 5: Address structured problem solving.
• Sessions 6 and 7: Focus on personal risk taking.
• Session 8: Help patients identify any positive changes they have made while part of the group and encourage them to continue making positive changes after the group’s end.

Treatment of Comorbid Conditions
The patient with somatization disorder may experience some symptoms, such as comorbid psychiatric and medical conditions, that require specific interventions. Management of this disorder requires a unified approach, and properly managing these symptoms will affect patients’ overall outcome. Among those conditions requiring specific interventions are depression, anxiety, and comorbid medical conditions.

Depression
Depression is the most common comorbid condition in patients with somatization disorder. Although depressed mood has long been recognized as an associated feature of the disorder, this symptom alone does not call for a pharmacological intervention because depressed mood in and of itself is not responsive to psychotropic drug treatment. However, when major depression co-occurs with somatization disorder, it should be the focus of aggressive pharmacological treatment, psychotherapeutic treatment, or both. As efficacious treatments become more widely available, dysthymia is another condition that should be actively treated.

Anxiety
Anxiety is another common comorbid disorder of somatization disorder. Many patients with somatization disorder report chronic anxiety, much of which may be attributed to their poor interpersonal skills. Therapeutic approaches differ with the specific anxiety disorder experienced by the patient. Aggressive pharmacological and behavioral regimens combine to produce excellent results for patients with panic disorder or agoraphobia, a condition that may result from panic disorder. Chronic persistent anxiety that is severe enough to meet diagnostic criteria for generalized anxiety disorder, however, is the most difficult type of anxiety for both physician and patient to confront. Treatment of generalized anxiety disorder is discussed here.

Comorbid Medical Conditions
The management and treatment of comorbid medical conditions must follow the most conservative methods possible. No invasive diagnostic or therapeutic procedures should be attempted, except as a last resort, because patients with somatization disorder typically overreact to almost any symptom with amplified somatic styles. The physician’s conservative management of comorbid conditions should rely on frequent contact with the patient and the physician’s providing reassurance. For example, the primary care physician should describe the course of the condition in a straightforward, reassuring manner and see the patient for regularly scheduled follow-up visits.

Long-standing clinical wisdom indicates that patients with somatization disorder may overuse prescribed medication. This may be especially so for medications such as benzodiazepines, which are very effective in reducing the anxiety that is often comorbid with somatization disorder. Similarly, other medications may be used for suicidal gestures; therefore, medications with high lethality should be prescribed with caution.