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Somatoform disorders in the elderly

Bart Sheehan
Health Sciences Research
Institute, Medical School
Building, University of
Warwick, Coventry
CV4 7AL, UK
Tel.: +44 247 657 4387;
Fax: +44 247 652 8375;
E-mail: B.Sheehan@
warwick.ac.uk
Somatoform disorders are presentations where physical symptoms worry a patient, there is
no organic pathology to explain them, but reassurance fails. They represent a murky
borderland between medicine and psychiatry and understanding has not been helped by
the plethora of terms used in this area. A typical scenario would be a 68-year-old woman
who was recently widowed complaining to a general practitioner of headache, trouble
sleeping, tiredness and muscle pain. Blood tests are negative but the patient says “there
must be something wrong”. Faced with uncertainty, clinicians may easily fall back on a
fruitless path of investigations and referrals. There is plenty of knowledge regarding
somatoform disorders among younger people (who have fewer physical illnesses), but
much less regarding older people. This article focuses on what is known about these
disorders in older people, a practical way forward and what may develop in the future.

Keywords: cognitive behavior
therapy, hypochondriasis,
medicolegal, older, primary
care, secondary care,
somatoform, uncertainty
The term somatoform disorders is a technical
term describing illnesses in which people with
psychological distress present to clinicians with
physical symptoms that worry them. These
symptoms are generally not accounted for by
organic illness and investigations are likely to be
negative. Many people are reassured regarding
such symptoms or respond to treatment of
underlying psychological problems; when the
presentation and worry persist a somatoform dis-
order may be diagnosed. Such presentations have
been described for centuries; they occupy a
rather ill-lit hinterland between medicine and
psychiatry. Confusion regarding definitions is
common. This is not helped by the plethora of
competing terms used in the area. Somatization,
medically unexplained symptoms, somatoform
disorders, frequent attenders, functional ill-
nesses; all of these terms and more may be used.
Considerable progress in understanding these
presentations has been made in under 65-year-
olds; however, there has been relatively little
focus on somatoform disorders among older
people. In this article I will seek to define these
presentations and review the evidence regarding
their prevalence, cause and treatment among
older people. In addition, I will reflect upon cur-
rent research and service shortcomings and
potential future directions.
No definition can be considered gold standard
in this field. Common to any term used is the
notion of persistent physical symptoms, unac-
counted for by organic pathology, which concern
the patient and lead to repeated presentations
despite reassurance and negative investigations.
Underlying psychological distress is usually
assumed and may sometimes be obvious. Inde-
pendent presentations in which the unexplained
medical symptoms dominate, but another psy-
chiatric disorder such as depressive or anxiety dis-
order is absent, are unusual and such relatively
rare presentations are referred to as somatoform
disorders by the International Classification of
Disease (ICD) and the Diagnostic and Statistical
Manual of Mental Disorders (DSM), the main
classification systems. The best known classic
somatoform disorders are somatization disorder,
in which multiple unexplained symptoms persist
for many years, and hypochondriacal disorder, in
which there is a primary fear of a particular con-
dition, such as AIDS or cancer, despite negative
investigations. Also found are somatoform auto-
nomic dysfunction, in which autonomic arousal
leads to symptoms attributable to particular sys-
tems, for example palpitations or hyperventila-
tion, and somatoform pain disorder, where severe
unexplained pain, typically headache or back-
ache, persists. More common are presentations
where a handful of physical symptoms are
reported by patients with minor psychological ill-
ness; research now tends to include these
‘abridged’ presentations when considering the full
impact of somatoform disorders.
Epidemiology
This article will report on studies in clinical pop-
ulations as these disorders are mainly defined by
contact with clinical services. Repeated studies

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REVIEW – Sheehan
Box 1. An example of
somatization disorder.
A 74-year-old man has attended primary care at
least once a week for 15 years. He is known as a
‘heartsink’ patient and the GPs share his care on
a rota. He has ongoing fluctuating backache,
stiffness, abdominal pain, bloating and
constipation, dry eyes and mouth, shortness of
breath, tiredness and chest-wall pain. He also
smokes and has a diagnosis of diverticular disease
and early arthritis. He is on 13 medications and
has seen 12 hospital specialists.
have demonstrated that somatoform presenta-
tions are extremely common in primary care.
The large-scale WHO study of primary care
showed that restricted definitions of ICD and
DSM somatoform disorders were rare (1 and 3%
respectively) but that an abridged significant
level of somatoform disorder was found in
19.7% of all primary-care attenders [1,2]. Con-
trary to widespread belief, this was found in all
cultures and was equally common in men and
women. These presentations frequently accom-
panied psychiatric disorder, and most psychiatric
cases in primary care were found to present with
physical symptoms, confirming previous find-
ings. There was some evidence that older people
in this all-age sample were more likely to present
in this fashion. Somatoform disorders, full or
abridged, are also common in secondary-care
settings, where they are associated with high
medical utilization, frequent attendance and
high costs [3]. Symptoms of any type may present
in primary or secondary care. Classical ‘hysteri-
cal’ presentations with paralysis or aphasia are
rare but very common are presentations with
unexplained bowel symptoms (irritable bowel
syndrome), unexplained fatigue (chronic fatigue
syndrome if severe and prolonged) or headache.
There has been relatively little research on
somatoform disorders among older people. Stud-
ies have used widely varying definitions of
somatoform presentations, making comparisons
difficult. In UK primary care, 5% of older attend-
ers were found to have a somatoform disorder
(hypochondriacal neurosis) but many more had
individual somatoform symptoms or attributed
neutral symptoms to physical illness [4]. In the
same study, general practitioners rated over a third
of older patients as having mainly or equally a
somatoform explanation of physical symptoms [5].
Somatoform disorder was associated with reduced
quality of life, independent of physical illness and
depression, and frequent attendance [6]. In a large,
1036
Italian primary-care sample of older people, using
PRIMary care Evaluation of Mental Disorders
(PRIME-MD) criteria [7], 8.1% of older attenders
had a primary somatoform disorder. Comparisons
between older and younger primary-care popula-
tions are relatively hard to find; in a further study
in Italian primary-care attenders, 8.4% of those
aged over 60 years and 11.0% of younger people
had medically unexplained symptoms [8]. A US
study also found that general psychological dis-
tress and health worry was similar for older versus
younger primary-care patients [9]. In the commu-
nity, no difference was shown between older and
younger people in rates of somatoform disorders
at high or low severity [10]. In a specialist UK ter-
tiary referral center for somatoform disorders, 5%
of a series of 900 cases seen were aged over
65 years [11]. Most had true somatoform disorders
of long duration, whereas those with depressive
illness had much shorter histories of symptoms.
Causes
Many theories for the etiology of somatoform
disorders have been advanced, ranging from
unconscious transformation of psychological
conflicts into physical symptoms, childhood
experience of serious illness or parental neglect,
rewards bestowed on those with abnormal ‘ill-
ness behavior’, low physiological thresholds for
bodily sensations or inability to reflect on emo-
tional states (alexithymia). Few of these theories
are consistently supported by evidence. Another
theory is that aging itself may predispose to
somatoform disorder, through the intervening
appearance of physical illness, that is, an under-
standable age-related worry about health. In
fact, studies consistently show that older people
worry no more, or indeed less, than younger
people about physical health. This applies to
both primary [9] and secondary care [12].
Traditional explanations of somatoform dis-
orders in older people focus on ‘masked depres-
sion’, in which depressive disorder underlies the
presentation. There is clearly a major overlap
between somatoform disorders and common
psychiatric disorders and this association is also
found among older people in primary [13] and
secondary [11] care. More recent work confirms
the association with depression among older
patients in primary and secondary care [14].
Somatoform disorders have been reported to be
associated with higher rates of physical
illness [15], although the association with depres-
sion is stronger and appears to be independent
of physical illness [13,14].
Aging Health (2006) 2(6)
 Somatoform disorders in the elderly – REVIEW
Box 2. An example of hypochondriacal disorder.
A 68-year-old woman, recently widowed, presents with headache, tiredness,
poor sleep and muscle pain. She feels she has a brain tumor and wants a
brain scan. Blood tests are negative and she rejects any suggestions she may
be depressed.
Treatment
Much of the evidence for a reasonable approach to
management must be taken from studies among
patients aged under 65 years. A systematic review
of studies of psychological treatment for somato-
form disorders identified 31 controlled trials, of
which only one included older patients (and those
a specific group of patients with chronic tinnitus
accepting group cognitive therapy) [16]. Both this
and a subsequent review suggest that the majority
of studies show some benefit for psychological
treatment but modest effect sizes and uncertain
longer-term outcomes [17]. Some of the best-con-
ducted randomized, controlled trials involve
expert cognitive behavior therapy clinicians in
highly specialist settings and may be difficult to
reproduce elsewhere [18]. Noninvolvement of
older people in treatment studies may be more
than just exclusion of older people with higher
prevalence of physical illness; attempts to recruit
older patient into treatment groups have been
reported to fail due to low rates of referral [19]. A
framework has been outlined for a psychothera-
peutic approach to older patients with hypochon-
driasis; the approach remains unproven among
older people [20].
Drug treatment may also have a place in the
management of somatoform disorders. A sys-
tematic review showed significant benefit for
antidepressants in treating somatoform disor-
ders [21]. Few older patients were found in any of
the studies identified. No class of antidepressant
showed clear superiority, although a trend for
smaller effect size for selective serotonin
reuptake inhibitors (SSRIs) was found. This
trend has also been reported in a trial of paroxet-
ine (an SSRI) versus mirtazepine among older
patients with depression; the anxiety/somatiza-
tion factor of the Hamilton Rating Scale for
Depression (Ham-D) improved less in patients
receiving the SSRI [22].
At least one uncontrolled study has followed
the outcome of somatoform disorder among
older patients receiving treatment, reporting that
somatoform attributions of physical symptoms
reduced significantly as depressive and anxiety
symptoms improved among older patients of an
old-age psychiatry service [23].
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Dearth of research
A burgeoning evidence base has allowed
enhanced understanding of the prevalence,
causes and treatment of somatoform disorders
among younger people. Older people have been
almost always excluded from such studies and
primary work among older people has barely
begun to get off the ground. Why this is the case
is worth considering. Older people do of course
have a higher prevalence of physical illness. Diag-
nostic systems for somatoform disorders require
the exclusion of physical illness as part of the
diagnostic process. Thus, older people in whom
there may be significant somatoform elements to
a presentation may fail to reach the criteria for
these diagnoses. In the clinical setting, clinicians
may also prefer, for reasons of lack of training or
medico–legal defensiveness, to attend to physical
rather than psychological aspects of a presenta-
tion. An older patient with multiple vague symp-
toms is likely to have at least one previous
diagnosis or medication that might explain some
of the presentation; this may be an easier avenue
for the doctor than suggesting attention to psy-
chological distress as a way forward. An uneasy
collusion between doctor and patient may thus
be set up, in which real progress is unlikely.
Further suggestions include the lack of valida-
tion of these disorders among older people, the
absence of interest among specialist older peoples’
services (which often specialize in treating
dementia) for treating these complex cases and
the absence of evidence of effective treatments in
older people, which may encourage a ‘what’s the
point?’ attitude [24]. Ultimately, an unhealthy mix
of diagnostic confusion, lack of confidence,
absence of suitable services to refer to and a prob-
ably unwarranted perception that older people
prefer to discuss physical symptoms are probably
to blame.
Conclusion
Any clinician working with older people will be
aware that many present with physical symptoms
in which psychological factors make a significant
contribution. Service and training factors tend to
mean a concentration on the physical at the
expense of the psychological. Recent research
confirms that somatoform disorders are probably
just as common among older people as they are
among their younger counterparts and are asso-
ciated with high attendance and reduced quality
of life. In many cases, an underlying depressive
illness may be the cause and an appropriate tar-
get for intervention. Evidence for management
1037
REVIEW – Sheehan

approaches has to be borrowed from studies
among younger people as interventions have not
been trialed among older people, perhaps for
medico–legal or other reasons.
Future perspective
It is conventional to call for more research and,
in particular, more trials, in any under-
researched area. More research would obviously
help us in understanding somatoform disorders
among older people. Expecting large new trials
of treatment for somatoform disorders among
older people is probably unrealistic; such efforts
may founder for reasons of lack of funding
opportunities, patient and referrer unwillingness
to participate [23] and a systematic tendency to
emphasize physical over psychological factors in
understanding older people’s health. It may be
that current arrangement, in which the legions
of older people who do present in such a manner
to clinicians are effectively handled by current
approaches – we simply do not know. What is
really needed in the short term is research inves-
tigating what happens to common somatoform
disorders in older primary-care patients, where
some combination of attention, examination,
investigation and reassurance is presumably
given at each presentation. Establishing the nat-
uralistic outcome of such cases, and in particular
what seems to predict best outcome, will be
most helpful. For those relatively unusual cases
who cannot be helped by the conventional
approach mentioned, and treatment of underly-
ing psychiatric illness, importing methods used
in younger people, such as cognitive behavior
therapy, should be appropriate. We do not, after
all, need a new trial of antibiotics in older people
to know how to treat pneumonia. Only if cur-
rent arrangements do not work should new trials
be necessary.

Executive summary
Introduction
• Somatoform presentations involve medically unexplained physical presentations. These distress the patient and persist
despite reassurance.
Epidemiology
• These presentations are as common among older people as among younger people.
Causes
• Depressive illness is a frequent underlying cause among older people.
Treatment
• Specific management relies mainly on use of antidepressants and/or cognitive behavior therapy.
Dearth of research
• Research among older people is comparatively rare. Medico–legal defensiveness and a higher prevalence of physical illness may
partly explain this lack of research.
Future perspective
• Future work should establish how effective current management is, rather than simply reproducing trials among older people.

Bibliography 4. Sheehan B, Bass C, Briggs R, Jacoby R: 8. Menchetti M, Cevennia N, De Ronchi D,

Papers of special note have been highlighted as
either of interest (•) or of considerable interest (••)
to readers.
1. Simon SE, Gureje O: Stability of
somatization disorder and somatization
symptoms among primary care patients.
Arch. Gen. Psychiat. 56, 90–95 (1999).
2. Gureje O, Simon GE: The natural history of
somatization in primary care. Psychol. Med.
29, 669–676 (1999).
3. Reid S, Wessely S, Crayford T, Hotopf M:
Frequent attenders with medically
unexplained symptoms: service use and costs
in secondary care. Br. J. Psychiat. 180,
248–253 (2002).
Somatization among older primary care
attenders. Psychol. Med. 33, 867–877 (2003).
5. Sheehan B, Bass C, Briggs R, Jacoby R: Do
General Practitioners believe that their older
patients physical symptoms are somatized?
J. Psychosom. Res. 56, 313–316 (2004).
6. Sheehan B, Lall R, Bass C: Does
somatization influence quality of life among
older primary care patients? Int. J. Geriat.
Psychiat. 20, 967–972 (2005).
7. Balestrieri M, Marcon G, Samani F et al.:
Mental disorders associated with
benzodiazepine use among older primary
care attenders. Soc. Psychiatry Psychiatr.
Epidemiol. 40, 308–315 (2005).
Quartesan R, Berardi D: Depression and
frequent attendance in elderly primary care
patients. Gen. Hosp. Psychiat. 28, 119–124
(2006).
9. Klapow J, Kroenke K, Horton T,
Schhmidt S, Spitzer R, Williams JBW:
Psychological disorders and distress in older
primary care patients: a comparison of older
and younger samples. Psychosom. Med. 64,
635–643 (2002).
10. Pribor EF, Smith DS, Yutzy SH:
Somatization disorder in elderly patients.
Am. J. Geriat. Psychiat. 2, 109–117 (1994).

1038 Aging Health (2006) 2(6)


11. Wilkinson P, Bolton J, Bass C: Older
patients referred to a consultation-liaison
psychiatry clinic. Int. J. Geriat. Psychiat.
16(1), 100–105 (2001).
12. Wijeratne C, Shome S, Hickie I,
Koschera A: An age based comparison of
chronic pain clinic patients. Int. J. Geriat.
Psychiat. 16, 477–483 (2001).
13. Sheehan B, Bass C, Briggs R, Jacoby R:
Somatic symptoms among older depressed
primary care patients. Int. J. Geriat. Psychiat.
18, 547–548 (2003).
• Illustrates which physical symptoms may
be expected among older people
with depression.
14. Drayer RA, Mulsant BH, Lenze EJ et al.:
Somatic symptoms of depression in elderly
patients with medical comorbidities. Int. J.
Geriat. Psychiat. 20, 973–982 (2005).
15. Fuentes K, Cox B: Assessment of anxiety in
older adults: a community-based survey and
comparison with younger adults. Behav. Res.
Ther. (38) 297–309 (2000).
www.futuremedicine.com
Somatoform disorders in the elderly – REVIEW
16. Kroenke K, Swindle R: Cognitive behavioral
therapy for somatization and symptom
syndromes: a critical review of controlled
clinical trials. Psychother. Psychosom. 69,
205–215 (2000).
17. Allen LA, Escobar JI, Lehrer PM, Gara MA,
Woodfolk RL: Psychosocial treatments for
multiple unexplained physical symptoms: a
review of the literature. Psychosom. Med. 64,
939–950 (2002).
18. Warwick HMC, Clark DM, Cobb AM,
Salkovskis PM: A controlled trial of
cognitive–behavioural treatment of
hypochondriasis. Br. J. Psychiat. 169,
189–195 (1996).
19. Sheehan B, Holmes J, Macdonald A,
Walker D: Neglect of somatoform disorders
(letter) Int. J. Geriat. Psychiat. 19, 497
(2004).
20. Monopoli J: Managing hypochondriasis in
elderly clients. J. Contemp. Psychother. 35(3),
285–300 (2005).
21. O’Malley PG, Jackson JL, Santoro J,
Tomkins G, Balden E, Kroenke K:
Antidepressant therapy for unexplained
symptoms and symptom syndromes. J. Fam.
Pract. 48(12), 980–990 (1999).
22. Schatzberg AF, Kremer C, Rodrigues HE
et al.: Double-blind, randomized
comparison of mirtazepine and paroxetine
in elderly depressed patients. Am. J. Geriat.
Psychiat. 10(5), 541–550 (2002).
23. Sheehan B, Philpot M, Banerjee S:
Attributions of physical symptoms in
patients of an old age psychiatry service. Int.
J. Geriat. Psychiat. 17, 61–64 (2002).
24. Wijeratne C, Brodaty H, Hickie I: The
neglect of somatoform disorders by old age
psychiatry: some explanations and
suggestions for future research. Int. J. Geriat.
Psychiat. 18, 812–819 (2003).
• Summarizes reasons why this area is
avoided in research and practice.
1039