Despite a high prevalence of somatic symptoms without demonstrable organic cause in nearly every branch of medicine, understanding, classification and treatment of these disorders have posed a considerable challenge.
As the DSM-V is in development, the proposed changes in comparison to the DSM-IV can be seen to reşect the current understanding of non-organic physical symptoms. It is likely that somatization disorder, hypochondriasis, undifferentiated somatoform disorder and pain disorder will be combined into a new category entitled "Complex Somatic Symptom Disorder" (CSSD) which emphasizes the symptoms plus the patients' abnormal cognitive processes. The term "complex" is intended to indicate that the symptoms must be persistent and must include both somatic symptoms (criterion A) as well as dysfunctional cognitive processes (criterion B) for the diagnosis to be made.
Cognitive processes such as dysfunctional attention focusing, symptom catastrophizing, and symptom expectation that may be included in criterion B also show the inşuence cognitive models have exercised in the understanding of these disorders.
These cognitive processes have to be evaluated against the background of possible psychiatric comorbidities, current life stressors, possible past traumatic events and learning experiences that shaped emotion regulation in an unhelpful way. Contributing to the maintenance of symptoms and resulting from dysfunctional cognitions are behaviours such as imbalanced level of activity, avoidance and safety-seeking and reassurance-seeking behaviors.
In cognitive behavioural therapy (CBT) of these disorders all the factors maintaining and contributing to the disorder are possible targets for treatment. The first and possibly most important step is to develop, in cooperation with the patient, an alternative explanation of the patient's symptoms other than the presence of an organic cause. During the course of treatment the patient can then collect evidence that supports the alternative explanation of symptoms.
The techniques that can be employed within the framework of the cognitive-behavioral approach are aimed at addressing the underlying dysfunctional cognitive processes and behaviors. They may comprise cognitive restructuring, attention-training, behavioral experiments, exposure, activity planning, and emotional-regulation techniques.
Conventionally, treatment can be conducted in individual and group sessions and usually comprises about 15 one-hour sessions. There is evidence showing that CBT is effective in decreasing symptom severity and overall distress. However, there are limited number of studies comparing different treatment modalities such as CBT and pharmacological interventions. Also it is not clear if combining CBT and pharmacological treatment increases effectiveness. In addition different forms of therapy such as computer-based treatment have been developed.
The cognitive behavioral model has been inşuencing the current understanding of somatization and CBT has shown effectiveness in its treatment although further studies are welcomed. Even if a full course of CBT cannot be offered, e.g. in an outpatient setting, and pharmacological treatment is chosen, it appears promising to integrate at least certain parts of cognitive-behavioral treatment such as developing an alternative explanation for the patient's symptoms and exploring the role of processes such as attention, avoidance, unbalanced activity levels and safety-seeking and reassurance-seeking behaviors.