511675

2013

APY22110.1177/1039856213511675Australasian PsychiatryMohan et al.

AP

Somatoform disorders

Somatoform disorders in patients

with chronic pain

Australasian Psychiatry
2014, Vol 22(1) 6670
The Royal Australian and
New Zealand College of Psychiatrists 2013
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1039856213511675
apy.sagepub.com

Indra Mohan Consultant Psychiatrist, The Northern Hospital Psychiatry, Epping, VIC, Australia
Christine Lawson-Smith Consultation-Liaison Psychiatrist, Royal Perth Hospital, Perth, WA, Australia
David A Coall Senior Lecturer, School of Medical Sciences, Edith Cowan University, Joondalup, WA; Adjunct Research Fellow,
School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, WA, Australia
Gillian Van der Watt Senior Research officer, School of Psychiatry and Clinical Neurosciences, University of Western
Australia, Perth, WA, Australia

Aleksandar Janca Winthrop Professor and Head of School, School of Psychiatry and Clinical Neurosciences, University of
Western Australia, Perth, WA, Australia

Abstract
Objective: To assess the frequency and characteristics of somatoform disorders in patients with chronic pain.
Method: The study took place in the psychiatric outpatient clinic of a rehabilitation hospital. Participants were
interviewed using the World Health Organization Somatoform Disorders Schedule (WHO-SDS) version 2.0. Thirty
new and 30 current attendees to the clinic were interviewed following referral by pain medicine specialists.
Results: Somatoform disorders were commonly co-morbid with chronic pain in the study population. Persistent
somatoform pain disorder (PSPD) was the commonest somatoform disorder. There was a significant difference
between women and men suffering from somatic autonomic dysfunction (SAD).
Conclusions: The findings of this study confirm that somatoform disorders are common co-morbid diagnoses in
patients with chronic pain. Combining psychological treatments with medication, appropriate physical treatments
and attending to social issues, may indeed improve the well-being of such patients.
Keywords: somatoform disorders, chronic pain, persistent somatoform pain disorder, somatisation, somatoform
autonomic dysfunction

ain is ubiquitous in medical practice, causing significant distress and disability.1,2 The co-morbidity
of chronic pain and psychiatric disorders (in particular depression and anxiety) has long been known.37
Somatisation, known to occur in patients with chronic
pain, is also a common, costly problem encountered in
health care, involving not only ever-increasing treatment expenses, but also significant costs to families and
the community through unemployment and sick days
off work.8,9 There has been a major, philosophical shift
in the concept of somatisation, a term regarded by
many, along with medically unexplained symptoms,
as rather pejorative.1012 Nevertheless, patients who have
clusters of functional symptoms in addition to their
chronic pain, are difficult to treat. Considerable research
world-wide has been undertaken to understand better
the complexities of these patients; this includes sophisticated imaging techniques that not only demonstrate
the cerebral changes that occur in chronic pain, but also
the effects of certain treatments.5,13
The aim of this study was to establish the frequency and
characteristics of somatoform disorders in patients with

chronic pain attending an outpatient psychiatric clinic

in a rehabilitation hospital in Western Australia. To our
knowledge, there is no published outpatient study that
has explored somatoform disorders in patients with
chronic pain in Australia.

Methods

Design and participants

The study was not funded and participants were interviewed using the World Health Organization Somatoform
Disorders Schedule (WHO-SDS) version 2.0.14,15 The
sample consisted of 60 patients referred to the psychiatric outpatients clinic by pain medicine specialists; 30
were new attendees and 30 were current attendees. All
patients suffered from chronic pain. Approval for the
study was obtained from the Royal Perth Hospital Ethics
Correspondence:
Indra Mohan, Consultant Psychiatrist, The Northern
Hospital Psychiatry, 185 Cooper Street, Epping, VIC 3076,
Australia.
Email: Indra.mohan@mh.org.au

66
Downloaded from apy.sagepub.com by guest on May 20, 2015

Mohan et al.

Committee. An information sheet about the study was

provided for participants and their informed consent
was gained prior to inclusion in the study. Patients could
withdraw from the study at any time. Confidentiality of
the information obtained was assured.
Participants had to be aged between 18 and 60 years to
be included in the study. In addition, they had to be
referred by pain medicine specialists who suspected psychological symptoms were present and that their
patients would benefit from a psychiatric assessment.
Participants also had to have suffered from chronic pain
for a period of at least 6 months and informed consent
had to be obtained.
Patients with a moderate to severe intellectual disability,
a significant physical disability, dementia, significant
speech or hearing difficulties were excluded from the
study. Patients using illicit drugs or were alcohol dependent were excluded, as were people with a psychotic illness and those with suicidal ideation.
Data collection
The sample was assessed using the WHO-SDS (version
2.0), which is a reliable and valid instrument for the
detection and assessment of somatic symptoms.1416
Training in the use of the instrument was provided. The
data collectors were a consultation-liaison psychiatrist
and a psychiatric registrar. On average, an hour was
spent gathering the data from each patient.
Statistical analyses
The sample size calculations were performed using the
STASTICA data analysis software system, taking into
account that the expected frequency of somatoform disorders within pain clinic settings is at least 20%, with

and accuracy of +/1%. A total of 50 patients would be

required for 95% power, assuming a type 1 error rate of
alpha=0.05. Therefore, a sample size of 60 would ensure
sufficient power.
Pearsons zero-order correlations and t-tests were used to
examine the bivariate relationships between continuous
and categorical variables. Chi-squared tests explored differences in proportions between categorical variables.
The independent influences of gender and age on the
duration of persistent somatoform pain disorder (PSPD)
and the duration of somatoform autonomic dysfunction
(SAD) were examined using the linear regression procedure in IBM SPSS Statistics 19. In all cases, the unstandardised regression coefficient (B) is reported, which
shows the change in the dependent variable that results
from a one unit change in the explanatory variable.

Results
The number of participants in the study was 60. The
majority were female (58%) and the mean age was 45.6
(+/ 9.34) years. Forty-three percent of participants were
married and 33% were separated or divorced. Only
23.3% of participants were employed at the time of the
study, while the majority (71.1%) had been unemployed
for at least 12 months prior to the study. Two participants were studying at secondary educational colleges.
The majority of participants (75%) had completed 10
years or more of schooling. There were no significant
differences between male and female participants on
socio-demographic variables.
PSPD was seen in 83% of patients, satisfying both the
Diagnostic and Statistical Manual 4th edition (DSM-1V)17
and the International Classification of Diseases 10th edition (ICD-10)18 diagnostic classification schedules. PSPD
was of lengthy duration i.e.: 17.3 (+/-14.7) years. Very

Table 1. Study population characteristicsa (n=60)

Variables
Persistent Somatoform Pain Disorder (F45.4)
Present
Absent
Assessment impossible
Number of factors
Duration (years)
Treatments (four or more different treatments)
Number of professionals in last 12 months
General health (most of life)
Excellent
Good
Fair
Poor
aVariability

Mean (%)

50
1
9
50
50
10

83%
2%
15%
2.4
17.3
16.9%
27.8

4
18
12
24

7%
30%
20%
40%

SD

1.6
14.7

Range

06
058

5130

in sample size due to missing values.

67
Downloaded from apy.sagepub.com by guest on May 20, 2015

Australasian Psychiatry 22(1)

Table 2. Participants who received specific treatments

Treatment

Total

Medicine
Psychotherapy or counseling
Surgery
Acupuncture
Other treatment
Other alternative treatment

59a
34
19
13
16
6

100
58
32
22
27
10

34a
21
10
8
7
6

100
62
29
24
21
18

25
13
9
5
9
0

100
52
36
20
36
0

aVariability

Female

Male

in sample size due to missing values.

Table 3. Impact of symptoms on participants

Symptom

Total
(n = 60)

Persistent somatoform
pain disorder (F45.4)
Present (n = 50) Absent (n = 10)

Somatoform disorders
Bothered a great deal for 6 months or more by pains
Pains kept you from working/seeing friends
Pains last experienced less than 2 weeks ago
Digestive system problems interfered with normal activities
Digestive system problems last experienced less than 2 weeks ago
Bodily problems (B25B46) interfered with normal activities
Bodily problems (B25B46) last experienced less than 2 weeks ago
Bodily problems (B50B61) interfered with normal activities
Bodily problems (B50B61) last experienced less than 2 weeks ago
Hypochondriasis
Worry about condition interfere with life
Worry about condition last experienced less than 2 weeks ago
Neurasthenia
Feeling tired interfered with normal activities
Feeling tired last experienced less than 2 weeks ago

49
46
50
16
28
18
25
18
17

82
77
83
27
47
43b
86b
43b
59b

49
46
49
12
23
14
20
15
13

100b
100b
98
24
46
40b
83b
42b
52b

0
0
1
4
5
4
5
3
4

0
0
10
40
50
57b
50
50b
100b

15
15

98b
83b

12
12

85b
86b

3
3

100b
75b

45
43

96b
92b

43
42

98b
98b

1
1

25b
10

aVariability

in sample size due to missing values.

out of those individuals reporting symptom due to missing cases.
The selection criteria for symptoms to be included in this list were those symptom that were experienced by 25% or more
(n = 15) of the total sample (nw = 60).
bPercentage

few (7%) rated their health as excellent and 40% rated

their health as being poor (Table 1). All participants
received medications irrespective of gender. Fewer male
than female participants had received psychotherapy or
counselling (male 52% compared to female 62%). Other
treatments, such as surgery or acupuncture, were less
commonly undertaken (Table 2). All participants who

had PSPD complained of disturbing pains which interfered with their quality of life, including their ability to
work and socialise (Table 3). Chest pains (48%), pounding of the heart (56%) and headaches (48%) were
amongst the commonest complaints. Sleep difficulties
(84%), impatience, irritability associated with fatigue
(86%) and an inability to relax (85%) were commonly

68
Downloaded from apy.sagepub.com by guest on May 20, 2015

Mohan et al.

Table 4. Symptoms experienced by participants

Symptom

Total
(n = 60)

Persistent somatoform pain

disorder (F45.4)
Present (n = 50) Absent (n = 10)

Somatoform disorders
Chest pains
Headaches
Stomach churning
Lump in throat
Periods of weakness
Trouble keeping balance
Body shook a lot
Shortness of breath
Heavy and fast breathing
Heart pounding
Heaviness or lightness
Skin blotchiness
Sex was not pleasurable
Hypochondriasis
Worry about serious physical illness/deformity
Neurasthenia
Tired all the time
Get easily tired
Weakness/exhaustion from little effort
Difficult to recover from fatigue
Dizziness during fatigue
Sleep difficulties during fatigue
Impatient/irritable during fatigue
Unable to relax during fatigue

26
25
21
16
22
17
18
25
23
31
15
17
15

43
40
35
27
37
28
30
42
38
52
25
28
25

24
24
19
15
21
15
16
21
22
28
14
14
12

48
48
38
30
42
30
32
42
44
56
28
28
24

2
0
2
1
1
2
2
4
1
3
1
3
3

20
0
20
10
10
20
20
40
10
30
10
30
30

16

27

12

24

40

36
35
24
22
19
39
40
46

60
58
40
37
32
65
67
77

33
33
23
22
17
36
37
36

66
66
46
50b
39b
84b
86b
85b

3
2
1
0
2
3
3
3

30
20
10
0
50b
75b
75b
75b

aVariability

in sample size due to missing values.

out of those individuals reporting symptom due to missing cases.
The selection criteria for symptoms to be included in this list were those symptom that were experienced by 25% or more
(n = 15) of the total sample (n = 60).
bPercentage

reported amongst those who were diagnosed as having

co-morbid neurasthenia and PSPD (Table 4).
The analysis used the DSM-IV diagnosis of PSPD, which
was also consistent with ICD-10 criteria.17,18 Spearmans
rho was used to assess associations between continuous
variables with PSPD. A diagnosis of PSPD was associated
with more of these patients with this disorder consulting
more health professionals in the last year (r=.257,
p<=0.051) and having undergone more treatments for
their health problems (r=.302, p<=0.022), than did those
who did not suffer from this disorder. Correspondingly,
the number of treatments that an individual received

was strongly associated with the number of professional

health carers they had consulted in the last year
(r=.582, p<0.0005). There was a significantly longer
mean duration of PSPD in women (21.1 years), compared to men (10.1 years). The number of factors present
in reaching the diagnosis, however, was not significantly
different (females = 2.7, males = 2.1, equal variances
assumed, t=1.27, df=45, p<=0.212). Chi-squared tests
showed there were no differences in the proportion of
males and females diagnosed with any of the somatoform disorders. There was a significant difference for
SAD, with females having a mean duration of 30 years,
which was nearly double the mean for males (17 years;
69

Downloaded from apy.sagepub.com by guest on May 20, 2015

Australasian Psychiatry 22(1)

equal variances assumed, t=1.82, df=18, p<=0.086). A

multivariate model was used, with age and gender being
entered. Both gender (B=8.913, t=3.765. p<=0.024) and
age (B=1.564, t=6.875, p<0.0005) remained independent
predictors of the duration of SAD. The duration of PSPD
was not seen to be associated with any other factors.

References
1. Sharp J and Keefe B. Psychiatry in chronic pain: a review and update. Focus 2006; 4:
573580.
2. De Waal MWM, Arnold IA, Eekhof JAH, etal. Somatoform disorders in general practice:
prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry 2004; 184: 470476.
3. Pilowsky I. Abnormal illness behaviour. Br J Med Psychol 1969; 42: 347351.
4. Gureje O. Psychiatric aspects of pain. Curr Opin Psychiatry 2007; 20: 4246.

Discussion
This study revealed a high incidence of somatoform
symptoms and disorders in participants. By far the most
prevalent diagnosis was PSPD, with 83% of participants
being diagnosed with this disorder, following ICD 10 and
DSM IV criteria. In patients with chronic pain, co-morbid
PSPD is an expected finding, highlighting a key issue in
further management of these patients whose quality of
life had been seriously impaired by this disorder. Of interest is the significantly longer mean duration of PSPD in
women (21.1 years) when compared to men (10.1 years).
It is difficult to account for this marked difference, but it
has been long noted that woman suffer more from
depressive symptoms than men, with gender, as an independent predictor being acknowledged in the extensive
literature regarding gender differences in psychiatric
research.1921 Being older was associated with a longer
duration of PSPD and also SAD. Thus increasing age has
a more negative impact on prognosis and recovery.
Our study supports the association between chronic
pain conditions and somatoform disorders. The biopsychosocial model, of which Engel was an early proponent,22,23 is becoming frequently used as an appropriate
model for managing these challenging patients and better comprehending their symptomatology which, at this
stage, appears to have intertwining genetic, physiological and neurochemical causative factors.5,10
Somatoform disorders are complex, often co-morbid;
this study shows the severe impact of pain and somatoform symptoms on people. These disorders require further unravelling to improve our knowledge and so
provide more effective treatment for our patients to
reduce the social and financial burden on families and
the health system.

5. Gatchel RJ, Peng YB, Peters ML, etal. The biopsychosocial approach to chronic pain:
scientific advances and future directions. Psychol Bull 2007; 133: 581624.
6. Beesdo K, Jacobi F, Hoyer J, etal. Pain associated with specific anxiety and depressive
disorders in a nationally representative population sample. Soc Psychiatry Psychiatr Epidemiol 2010; 45: 89104.
7. Ho PT, Li CF, Ng YK, etal. Prevalence of and factors associated with psychiatric morbidity
in chronic pain patients. J Psychosom Res 2011; 70: 541547.
8. Hiller W, Fichter MM and Rief W. A controlled treatment study of somatoform disorders
including analysis of healthcare utilization and cost-effectiveness. J Psychosom Res
2003; 54: 369380.
9. Hoedeman R, Blankenstein A, Krol B, etal. The contribution of high levels of somatic
symptom severity to sickness absence duration, disability and discharge. J Occup Rehabil 2010; 20: 264273.
10. Henningsen P and Creed F. The genetic, physiological and psychological mechanisms
underlying disabling medically unexplained symptoms and somatisation. J Psychosom
Res 2010; 68: 395397.
11. Creed F, Guthrie E, Fink P, etal. Is there a better term than medically unexplained symptoms? J Psychosom Res 2010; 68: 58.
12. Crombez G, Beirens K, Van Damme S, etal. The unbearable lightness of somatisation: a
systematic review of the concept of somatisation in empirical studies of pain. Pain 2009;
145: 3135.
13. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med 2007; 69: 881888.
14. World Health Organization. WHO international study of somatoform disorders: study
protocol and instruments. Geneva: World Health Organization, 1994a
15. World Health Organization. Somatoform Disorders Schedule (SDS). Geneva: World
Health Organization, 1994b.
16. Janca A, Burke J Jr, Isaac M, etal. The World Health Organization somatoform disorders schedule. A preliminary report on design and reliability. Eur Psychiatry 1995; 10:
373378.
17. American Psychiatric Association. Diagnostic and statistical manual of mental disorders
DSM IV. 4th ed. Washington, DC: APA, 1994.
18. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: WHO, 1992.
19. Munce SEP and Stewart DE. Gender differences in depression and chronic pain conditions in a national epidemiologic survey. Psychosomatics 2007; 48: 394399.

Acknowledgements
The authors would like to acknowledge Denis Brown for his time and expertise in managing
the software for data collection and analysis. The authors would also like to acknowledge
Prof.Schug and other pain medicine specialists in RPH for referring patients to this study.

20. Kessler RC. Epidemiology of women and depression. J Affect Disord 2003; 74: 513.
21. Barsky AJ, Peekna HM and Borus JF. Somatic symptom reporting in women and men.
J Gen Intern Med 2001; 16: 266275.
22. Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980;
137: 535544.

Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.

23. Engel GL. The biopsychosocial model and the education of health professionals. Ann N
Y Acad Sci 1978; 310: 169181.

70
Downloaded from apy.sagepub.com by guest on May 20, 2015