• It is common for comorbidity of mental health problems to exist in veterans presenting with somatic complaints.
• The boundary between physical and mental health can be difficult to determine.
• CBT programs, including group-based programs, may result in reduction of somatic symptoms. 

Key characteristics

General practitioners commonly encounter individuals who display excessive concern with a health complaint or physical symptoms that have no readily evident organic cause. These presentations can lead to a diagnosis of a somatic symptom disorder (previously known as somatoform disorders).

The category of somatic symptom disorder includes a range of clinical presentations such as:

• health anxiety (previously hypochondriasis)
• medically unexplained symptoms
• persistent pain

Common to all these conditions is the central place of somatic symptoms in the presenting problem. Along with cognitive distortions and/or excessive thoughts, feelings and behaviours related to these physical complaints.

For example, a veteran may present with multiple physical symptoms that medical investigations fail to explain. He or she may report disproportionate concerns about the seriousness of those symptoms, along with a tendency to devote excessive time and energy to behaviours associated with them. It is important to note that:

• these symptoms are not intentional or fabricated
• they cause significant distress and impairment for the veteran

The boundary between physical and mental health can be difficult to determine. As a general rule, a veteran’s physical complaints should be considered as part of a mental health diagnosis when all the following are present:

• cognitive
• emotional and
• behavioural problems

Screening and assessment

There are no well-established and widely accepted measures to screen for somatic symptoms and related disorders. However, the following questions adapted from the Mini International Neuropsychiatric Interview (MINI) may help identify veterans with a problem in this area:

• Have you had many physical complaints not clearly related to a specific disease?
• In the past six months, have you worried a lot about having a serious physical illness?
• Currently, is pain your main problem?

Assess further if the client: 

1. responds ‘yes’ to one or more questions, and 
2. there is no adequate physical explanation, and/or
3. there is significant distress in relation to the symptoms

The Patient Health Questionnaire-15 (PHQ-15) is a tool for assessing the presence and severity of somatic symptoms.

Important assessment considerations

In all assessments, practitioners need to be alert to the common comorbidity of mental health problems in veterans presenting with somatic complaints.

1. Ensure that any medical issue related to the complaint is attended to (e.g. ensuring that organic causes are investigated and pain is adequately medicated).
2. Avoid referral for ongoing specialist investigations unless there is clear evidence of a physical problem.
3. Consider transcultural variations in presentation. In some cultures, physical symptoms are an accepted way of expressing emotional distress and may not be problematic. The veteran may still need treatment for other psychological issues such as anxiety or depression. For example, it is not unusual for Indigenous Australian clients to present with somatic symptoms as part of their depression (Dudgeon et al., 2000).

Treatment

There has been little advance in the understanding of somatic symptom disorders or their treatment over the past 20 years. To date, there is insufficient evidence from the research literature to make firm recommendations for the treatment of somatic symptom disorders. Many veterans with somatic symptom disorders will be primarily treated by their general practitioners. Recommended management principles are listed below:

• Acknowledge the reality of the problem. In this way, the veteran will feel ‘heard’ and it will be acknowledged that his/her symptoms are not ‘put on’ or imagined.
• Schedule regular review appointments rather than make appointments in response to the individual’s psychosomatic crises.
• Conduct a routine medical assessment that includes a thorough physical examination. Avoid diagnostic testing, prescription of new medication or referral to a medical specialist for each new symptom unless clearly indicated. Of course, results should be discussed with the veteran.
• When somatic symptoms have become entrenched, shift treatment emphasis from symptom eradication to maintenance care and rehabilitation.
• The veteran should be strongly encouraged and supported in maintaining or resuming normal routines and activities.

Psychological interventions

There is no current consensus on the best psychological treatments for somatic symptom disorders as there have been insufficient studies to warrant a meta-analysis. However, a review of the published studies has found that cognitive behavioural therapy (CBT) appears to be the most promising psychological approach for managing health anxiety, somatic symptoms, and pain (Jing et al., 2019). Although several variations of CBT have been employed, two elements are common to all:

• cognitive therapy – this allows for the identification and modification of unhelpful beliefs about symptoms and disease
• behavioural techniques – these are helpful to alter illness and sick role behaviours, resume engagement in normal activities and promote more effective coping

Treatment setting and duration

In research studies, CBT treatment for somatic symptom disorders varies between 6 and 16 sessions. However, reviews have suggested that CBT is most effective with 10 or more sessions (Jing et al., 2019). Treatments may occur on an individual or group basis. There is evidence that group-based CBT programs may result in greater reductions in somatic symptoms compared to individual treatment (Jing et al., 2019). Hospitalisation should be avoided.

Psychoeducation and self-management strategies

While undergoing more targeted psychological intervention it is also important to encourage the veteran to do the following:

• monitor symptoms to help identify psychosocial factors (e.g. times, situations and emotional states) which exacerbate their symptoms, emphasising the links between psychological factors and the experience of somatic symptoms. Then assist the veteran to manage these perpetuating factors through strategies that may include anxiety management, problem solving, facilitating engagement with social support etc
• maintain (or re-establish) their daily routine and current roles (e.g. work, family). This is particularly important for veterans who have a lot of unstructured time
• reduce substance use - it is common for veterans to self-medicate with alcohol and other drugs when struggling with pain and other somatic symptoms. While alcohol and drugs may alleviate distress and somatic symptoms in the short term, they inhibit recovery. If analgesic medication is used, it should be taken on a regular schedule as far as possible, rather than on an ‘as needed’ or ‘prn’ basis

Pain management programs

Pain management programs (PMPs) are the treatment of choice for veterans suffering from chronic pain syndromes, including somatoform pain disorders. Effective PMPs adopt an explicit biopsychosocial model embedded within a cognitive behavioural paradigm, and include the following elements:

• multidisciplinary teams
• a holistic view of the veteran
• education on pain coping strategies
• promotion of self-efficacy beliefs and self-management
• support for improved function and lifestyle
• targeting of related depression and anxiety
• encouragement for improved general physical health and fitness

PMPs typically occur in a group setting and vary from two to six weeks duration.

Pharmacological interventions

Given the lack of firm evidence for the efficacy of pharmacological interventions, CBT should be considered the first-line treatment for somatic symptom disorders. However, medication may be beneficial for veterans who:

• are unwilling or unable to engage in CBT, or
• when appropriate psychological treatment is unavailable

In cases where medication is considered necessary, antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are the preferred first-line treatment (Kleinstäuber et al., 2014). Veterans with predominant pain symptoms may also respond to anticonvulsants, such as gabapentin (e.g. Neurontin) or pregablin (e.g. Lyrica).

See also