Chapter 2

Somatoform disorders in general practice:

prevalence, functional impairment and
comorbidity with anxiety and depressive
disorders.
Margot W.M. de Waal, Ingrid A. Arnold, Just A.H. Eekhof, Albert M. van Hemert.

This is an author-produced electronic version of an article accepted for publication in the British Journal of
Psychiatry. The definitive publisher-authenticated version is available online at http://bjp.rcpsych.org.

Published in Br J Psychiatry 2004;184:470-6.

Als dubbelpublicatie verschenen in Ned Tijdsch Geneeskd 2006;150:671-6.

Chapter 2

Abstract
Background General practitioners play a pivotal part in the recognition and treatment
of psychiatric disorders. Identifying somatoform disorders is important for the choice
of treatment.
Aims To quantify the prevalence of, and functional impairment associated with,
somatoform disorders, and their comorbidity with anxiety/depressive disorders.
Method Two-stage prevalence study: a set of questionnaires was completed by 1046
consecutive patients of general practitioners (aged 25-80 years), followed by a
standardised diagnostic interview (SCAN 2.1).
Results The prevalence of somatoform disorders was 16.1% (95% CI 12.8-19.4).
When disorders with only mild impairment were included, the prevalence increased to
21.9%. Comorbidity of somatoform disorders and anxiety/depressive disorders was 3.3
times more likely than expected by chance. In patients with comorbid disorders,
physical symptoms, depressive symptoms and functional limitations were additive.
Conclusions Our findings underline the importance of a comprehensive diagnostic
approach to psychiatric disorders in general practice.

18

Epidemiology

Introduction
Psychiatric disorders are common in general practice and the general practitioner has a
pivotal role in the recognition and subsequent treatment of psychiatric disorders.
Although psychiatric attention tends to focus on anxiety and depressive disorders,
these disorders are not the most prevalent in general practice. Fink et al reported a
prevalence of somatoform disorders as high as 30.3%.1 The comorbidity of
somatoform disorders with anxiety and depressive disorders is high and the burden of
illness may be substantial.2 3 A critical review demonstrated that cognitive-behavioural
therapy can be effective in treating patients with somatoform disorders.4 Few
comprehensive studies have focused on an accurate quantification of clinically
relevant disorders. The aim of the present study was to quantify the prevalence of
somatoform disorders and comorbidity with anxiety and depressive disorders in
primary care using DSM-IV criteria5, with a particular emphasis on functional
impairment.

Method
Study design
The somatisation study of the University of Leiden (SOUL study) was designed as a
two-stage prevalence study. In the initial stage, screening questionnaires were used to
identify high-risk patients. In the second stage, all high-risk patients and a sample of
15% of the low-risk patients were invited for a psychiatric diagnostic interview. After
a follow-up of 6 months, participants with a somatoform disorder will be included in a
subsequent controlled treatment study of cognitive-behavioural therapy given by their
own general practitioner (not reported here).
Setting
The study took place in eight university affiliated general practices in The
Netherlands. The age and gender distributions are comparable to those of the Dutch
population. The electronic medical records of all patients were available through the
central database (Registratie Netwerk Universitaire Huisartspraktijken Leiden En
Omstreken (RNUH-LEO)) of the family practice registration network of Leiden (13
practices). The database contains diagnostic codings according to the International
Classification of Primary Care for each consultation.6

19

Chapter 2

Patients
Between April 2000 and December 2001 a sample of 1778 attendees, aged 25-80
years, was sent the screening questionnaires by mail. After 2 weeks those who had not
responded were sent a reminder, including the questionnaires. For each general
practice the sample consisted of all consecutive patients on 13-30 arbitrary days within
a 3-month period. To avoid problems with language, the study was limited to Dutch
natives. Patients were not included if they were unable to participate in an interview
because of difficulties such as deafness, aphasia or cognitive impairment. A total of
1046 patients (59%) returned the questionnaire and indicated that they were willing to
participate. Data from the RNUH-LEO database allowed fairly detailed analyses of
non-response characteristics. Non-response analyses showed that male patients of 2544 years of age in particular were less willing to participate (response of 46%). When
comparing reasons for consultation in the 3 months prior to selection, non-responders
did not have more psychological problems (ICPC classification chapter P: 14%) than
responders but they did have slightly more social problems (ICPC classification
chapter Z: 7% v. 4%). Approximately 50% of both non-responders and responders
consulted a general practitioner five or more times in the year prior to selection.
Logistic regression modelling showed that after correction for age and gender (which
both still have a significant effect) the only other variable with a significant effect was
a social reason for encounter (odds ratio=0.6). Social problems are mainly problems in
the relationship with a partner or other, mourning and problems related to the work
situation.
Questionnaires
Participants completed the SF-36 functional limitation questionnaire7 as a measure of
functional impairment, the Hospital Anxiety and Depression Scale8 (HADS) as a
measure of anxiety and depression and the Physical Symptom Checklist (PSC;
available from the authors on request) to quantify the number of reported physical
symptoms. The first two questionnaires have been validated extensively and described
sufficiently elsewhere. In general medical outpatients the total HADS scale has been
validated for detecting psychiatric disorders: a cut-off point of 15 gave a sensitivity of
74% and a specificity of 84%.9 The PSC is a checklist of 55 physical symptoms that
were mentioned in the DSM-III classification10 and includes a broad array of
symptoms covering most organ systems. The presence of symptoms is rated on a
severity scale of 0-3 for the preceding week. A symptom is rated as present for scores
2 and 3. The total score represents the sum of the number of symptoms that are
endorsed. In previous studies physical symptoms were a useful severity indicator of
somatoform disorders and a fair predictor of medical utilisation.11 12 13

20

Epidemiology

High-risk sample
A total score of 15 or more on the HADS or a score of 5 or more on the PSC defined
the high-risk sample, which is 48% of the total sample. Of the 506 high-risk patients,
190 patients screened positive on both the HADS and the PSC, 265 patients screened
positive only on the PSC and 51 patients screened positive only on the HADS. The
choice of instruments and cut-off values for the high-risk sample are somewhat
arbitrary because a sample of low-risk patients was interviewed as well. The procedure
merely aimed at increasing the number of interview positives for a subsequent
treatment study without affecting the prevalence estimate.
Diagnostic interview
Of all the high-risk patients, 80% (404/ 506) participated in the diagnostic interview.
Of the 540 low-risk patients, 15% were invited for diagnostic interview and 84%
(69/82) participated. We tried several times to contact non-responders by mail or by
telephone. Non-responders to the diagnostic interview were somewhat younger and
scored 1.5 points higher on the HADS anxiety sub-scale (possible range 0-21): no
differences were found in the number of physical symptoms or functional impairment
(SF-36 sub-scales).
The Schedules for Clinical Assessment in Neuropsychiatry (WHO-SCAN 2.1)
were used by World Health Organization-certified psychologists for the psychiatric
diagnostic interviews.14 Throughout the study we held regular sessions with the
interviewers to maintain diagnostic standards. During the interview patients were
asked about concurrent physical illnesses, and the interviewers made the clinical
decision on whether symptoms were unexplained or not. The researcher (IAA)
supervised all interviews for medical diagnostic data. Whenever necessary, medical
diagnostic data concerning symptoms were obtained from the individual general
practitioners. When doubt remained, the symptom was regarded as explained. The
scoring algorithm needed to be modified slightly to allow separate and accurate
diagnoses of hypochondriasis and somatisation disorder according to the criteria of
DSM-IV. The modifications were reported to the World Health Organization task
force that is developing the SCAN. Because the overlap between somatoform
disorders and anxiety and depressive disorders is the object of this study, hierarchical
rules between these disorders were not applied. Within the DSM-IV chapters the
hierarchical rules were preserved. All chronic somatoform disorders were diagnosed
(duration of at least 6 months): both acute pain disorder and somatoform disorder not
otherwise specified were excluded. An important modification of DSM-IV (compared
with its predecessors) is that a severity criterion of significant clinical distress or
functional impairment has been included in most Axis I disorders. The distinction
between Axis I and Axis V has become blurred. From a clinical point of view this
21

Chapter 2

modification is well justified, but from an epidemiological point of view the

modification introduces an element of subjectivity in the diagnostic process and
comparisons with previous studies may have become hampered. We took meticulous
care to rate this item separately for each diagnosis throughout all interviews. To
analyse the influence of this criterion, the prevalence rates were re-analysed using all
criteria of symptoms and duration, with the exception of the severity criterion.
Analyses
Of the 404 high-risk patients interviewed, 116 had a DSM-IV somatoform disorder, 40
had an anxiety disorder and 34 had a depressive disorder. Of the 69 low-risk patients,
3 had a somatoform disorder and 1 had an anxiety disorder. All prevalence estimates
and confidence limits were weighted for the sampling procedure.15 To quantify the
overlap of somatoform disorders and anxiety and/ or depressive disorders, the
weighted prevalence and confidence limits for the combinations are given. In addition,
we calculated the ratio that represents the factor by which comorbidity exceeds chance
expectations: by taking the observed prevalence and dividing it by the prevalence
expected by chance. Analyses were conducted using SPSS for Windows 11.0 and
MsExcell 97 software.

Results
Prevalence estimates
An estimated prevalence of DSM-IV somatoform disorders of 16.1% was found in a
Dutch general practice consulting population (Table 1). The most common
somatoform disorder was the undifferentiated somatoform disorder, with a prevalence
of 13.1%. These patients suffer from one or more unexplained physical symptoms (e.g.
fatigue, headache or gastrointestinal symptoms) that cause clinically significant
distress or impairment for at least 6 months. The prevalence of current anxiety
disorders was 5.5% and of current depressive disorders was 4.1%. When the new
DSM-IV criterion of moderate to severe clinical impairment was ignored (for all
diagnoses), the prevalence of somatoform disorders increased from 16.1% to 21.9%,
the prevalence of anxiety disorders increased from 5.5% to 7.0% and the prevalence of
depressive disorders increased from 4.0% to 6.8%. It must be noted that patients who
had no symptoms because of effective medical treatment were not diagnosed. This was
a substantial group of patients: use of antidepressants without current significant
symptoms was present in 7.4% (95% CI 4.8-9.9) of patients and use of anxiolytics
without current significant symptoms was present in 4.5% (95% CI 2.5-6.4) of

22

Epidemiology

Table 1. Estimated prevalence (weighted percentages) of DSM-IV somatoform disorders, anxiety - and
depressive disorders (with current symptoms) in a consulting population of general practices.
Estimated prevalence:
DSM-IV
criteria
%

2
3

95% CI

95% CI

Somatoform disorders1
Somatization disorder (300.81)
Undifferentiated somatoform disorder (300.81)
Pain disorder, chronic (307.xx)
Hypochondriasis (300.7)
Bodydysmorphic disorder (300.7)
Conversion disorder (300.11)

0.5
13.0
1.6
1.1
0.2

0.0 0.9
9.8 16.2
0.7 2.4
0.4 1.8
0 0.6

0.5
17.7
2.3
1.4
0.2

0.0 0.9
13.9 21.6
1.3 3.3
0.6 2.2
0 0.6

Total

16.1

12.8 19.4

21.9

18.0 25.8

2.7
0.5
1.8
0.8
0.5
0.2
0.8

0.9 4.4
0.0 0.9
0.9 2.7
0.2 1.5
0.0 0.9
0.0 0.6
0.2 1.5

2.7
0.5
3.0
1.4
0.8
0.2
0.8

0.9 4.4
0.0 0.9
1.9 4.1
0.6 2.2
0.2 1.5
0.0 0.6
0.2 1.5

Total

5.5

3.5 7.6

7.0

4.6 8.8

Depressive disorders
Major depressive disorders, single or recurrent
Bipolar disorder
Dysthymia

2.9
0.4
0.8

1.7 4.0
0.0 0.8
0.2 1.4

3.9
0.4
2.5

2.7 5.2
0.0 0.8
0.8 4.3

Total

4.1

2.7 5.3

6.8

4.7 8.9

Anxiety disorders
Panic disorder with or without agoraphobia
Agoraphobia without history of panic disorder
Specific phobia
Social phobia
Obsessive-compulsive disorder
Posttraumatic stress disorder
Generalized anxiety disorder

Estimated prevalence:
DSM-IV, including
disorders with no or mild
impairment

2
2

Excluding acute pain disorder and somatoform disorders Not Otherwise Specified.
DSM-IV criteria do not include overall judgement of impairment; the two prevalence estimates are identical.
There is no posttraumatic stress disorder with no or mild impairment, prevalence estimate for DSM-IV
criteria is used.

patients. The age and gender distributions of the prevalence figures are summarised in
Table 2. The estimated prevalence of somatoform disorders was much lower in
patients aged 65 years and over. The same was found for anxiety disorders and
depressive disorders. Women tended to have more somatoform disorders (no
significant difference). We found no gender differences for anxiety disorders.
Depressive disorders were slightly but not significantly more prevalent in females.
23

Table 2. Patient characteristics and prevalence of somatoform disorders, anxiety disorders and depressive disorders in consulting population of general practices:
disorders to DSM-IV (i.e. moderate to severe clinical impairment) and DSM-IV disorders with no or mild impairment.

No of pats
interviewed
(n=473)

Somatoform disorders
Weighted prevalence (s.e.)

Anxiety disorders
Weighted prevalence (s.e.)
DSM-IV

DSM-IV
Incl. no/ mild

Depressive disorders
Weighted prevalence (s.e.)

DSM-IV

DSM-IV
Incl. no/ mild

DSM-IV

DSM-IV
Incl. no/ mild

169
234
70

21.8 (15.3-28.3)
15.3 (10.4-20.2)
5.4 ( 1.3- 9.5)

27.8 (20.3-35.2)
22.4 (16.2-28.7)
7.2 ( 2.5-11.8)

8.7 ( 4.0-13.4)
4.2 ( 2.3- 6.1)
1.8 ( 0.0- 4.2)

10.4 ( 5.5-15.2)
5.8 ( 3.7- 8.0)
1.8 ( 0.0- 4.2)

4.1 ( 1.9- 6.3)

4.9 ( 2.9- 6.9)
0.9 ( 0.0- 2.6)

5.7 ( 3.2- 8.3)

9.7 ( 5.1-14.3)
0.9 ( 0.0- 2.6)

127
346

11.1 ( 4.6-17.5)
18.6 (14.7-22.5)

14.0 ( 7.4-20.6)
25.5 (20.7-30.3)

5.9 ( 0.0-11.9)
5.7 ( 3.8- 7.5)

7.0 ( 0.9-13.1)
7.2 ( 5.2- 9.3)

3.7 ( 1.5- 5.9)

4.2 ( 2.6- 5.9)

4.5 ( 2.1- 6.9)

7.9 ( 5.1-10.7)

473

16.1 (12.8-19.4)

21.9 (18.0-25.8)

5.5 ( 3.5- 7.6)

7.0 ( 4.8- 9.1)

4.1 ( 2.8- 5.4)

6.8 ( 4.7- 9.0)

Patient
characteristics
Age groups
- 25-44 years
- 45-64 years
- 65-79 years
Gender
- male
- female
Total

Epidemiology

Figure 1. Overlap between somatoform disorders (S.) and anxiety or depressive disorders (A.D.): weighted
prevalence (s.e.). Observed co-morbidity 4.20%, expected co-morbidity 1.26%: ratio=3.3. Within somatoform
disorders: 26% anxiety and/or depressive disorders; within anxiety and/ or depressive disorders: 54%
somatoform disorders.

11.9 (1.6)
S.

4.2 (0.7)

3.6 (0.9)
A.D.

80.3 (1.9) no disorder

S. = somatoform disorders
A.D. = anxiety/ depressive disorders

Comorbidity and functional impairment

The comorbidity of DSM-IV somatoform disorders and anxiety or depressive
disorders is considerable (Fig. 1). The observed comorbidity of somatoform disorders
and anxiety/depressive disorders was 4.2% (95% CI 2.9-5.5). The expected percentage
of comorbidity occurring only by chance was 1.3% (95% CI 1.9-7.2). The observed/
expected ratio was 3.3 (95% CI 1.8-6.1). Of all patients with a somatoform disorder,
26% (95% CI 23-28) also had an anxiety and/or depressive disorder: 17% (95% CI 1223) had an anxiety disorder and 17% (95% CI 12-23) had a depressive disorder. Of all
patients with an anxiety and/or depressive disorder, 54% (95% CI 48-60) also had a
somatoform disorder. The symptoms and functional limitations of patients with a
somatoform disorder together with an anxiety or depressive disorder are more severe:
they add up when comorbidity is present (Table 3). In comparison with patients
without disorders, the rating on the PSC was 5.1 (95% CI 2-8) points higher for
patients who only had an anxiety or depressive disorder and 5.4 (95% CI 4-7) points
higher for patients who only had a somatoform disorder. For the patients with
comorbid somatoform and anxiety or depressive disorders the rating was 10.2 points
higher (95% CI 7-13), which approximately equals the sum of the increase due to the
separate categories. The same applied to the HADS depression scale, whose rating

25

Chapter 2

Table 3. Symptoms and functional limitations in patients with or without somatoform disorder (S) and with or
without anxiety/ depressive disorder (AD): weighted means with 95% confidence intervals.

Somatoform disorder (S)

Anxiety/depressive disorder (AD)

Symptoms
- No of physical symptoms1
- HADS depression score2
- HADS anxiety score2
Functional limitations3
- Physical functioning
- Social functioning
- Role funct: physical problems
- Role funct: emotional problems
- Pain
- Subjective health

S
AD
(n=329)

4.4 (4-5)
3.3 (3-4)
4.8 (4-5)

80
80
66
84
71
66

(78-83)
(77-82)
(61-70)
(79-86)
(68-73)
(64-68)

S
AD +
(n=25)

S+
AD
(n=84)

9.4 (7-12)
8.0 (6-10)
10.7 (9-13)

9.8 (8-11)
5.4 (5- 6)
7.4 (7- 8)

76
53
53
33
66
56

73
60
34
51
55
54

(66-87)
(44-62)
(35-71)
(17-49)
(57-76)
(48-65)

(69-78)
(55-65)
(25-42)
(41-60)
(50-60)
(50-58)

S+
AD +
(n=35)

14.7 (12-18)
10.2 ( 9-11)
11.3 (10-13)

66
45
29
22
58
44

(57-75)
(36-53)
(16-41)
(11-33)
(50-66)
(38-49)

**
**
**

**
**
**
**

Symptoms on Physical Symptom Checklist bothersome often or most of the time during last week
(total number of symptoms for men n=52, for women n=54).
2
Scales of the Hospital Anxiety and Depression Scale: depression (range 0-21) and anxiety (range 0-21).
3
Scales of SF-36: standardised to range 0-100.
** Significant difference (Kruskal-Wallis: P<0.01).

increased by 4.8, 2.2 and 6.9 points, respectively. For the HADS anxiety scale the
increase in rating in the subgroup with comorbid disorders (6.5) was less than the sum
of the increase in the separate subgroups (5.9 and 2.7, respectively). Functional
impairment according to the SF-36 showed a different pattern for somatoform
compared with anxiety or depressive disorders. In comparison with patients without
psychiatric diagnoses, patients with only anxiety or depressive disorders were most
severely limited in their social functioning and in their role functioning because of
emotional problems. Patients who only had somatoform disorders were limited in all
areas covered by the SF-36. Patients with comorbid disorders were more limited in all
areas, and when compared with patients with only somatoform disorders their scores
were significantly worse for social functioning, role functioning because of emotional
problems and subjective health.

26

Epidemiology

Discussion
Main findings
Our study demonstrates that somatoform disorders are among the most prevalent
psychiatric disorders in general practice. A somatoform disorder was diagnosed in
16.1% of consecutive consulting patients. The prevalence of anxiety or depressive
disorders was 4.0% and 5.5%, respectively. Comorbidity of somatoform disorders and
anxiety or depressive disorders was 3.3 times more likely than could have been
expected by chance. More than half the patients with an anxiety or a depressive
disorder fulfilled the criteria of a comorbid somatoform disorder. All patients were, by
definition, at least moderately impaired owing to their symptoms. Somatoform
disorders as well as anxiety or depressive disorders were associated with substantial
functional impairment. In patients with comorbid disorders the symptoms and
functional limitations increased proportionally, which resulted in a substantially higher
burden of illness for patients with comorbid disorders.
Strengths and weaknesses of the study
This is a comprehensive study of the prevalence of strictly defined DSM-IV
somatoform disorders, anxiety disorders and depressive disorders in a consulting
general practice population, with special emphasis on functional impairment.
The 59% response rate, although not uncommon in primary care, was fairly low
for a prevalence study. Selectivity of the responding sample could, in theory,
invalidate our prevalence estimates. We addressed this issue with a detailed nonresponse analysis using registered data from the RNUH-LEO database. The response
selection was independent of frequency of consultation and of psychological problems,
as seen by the general practitioner. Response was comparatively low in the younger
males (46%). If they were the healthier subjects, this may have resulted in some
overestimation of disorders. On the other hand, social problems were slightly
underrepresented in the responding sample, which could have affected the rates
towards some underestimation.
The exclusion of somatic disorders as a potential explanation of symptoms is
one of the unsolved problems in studies of somatoform disorders. Some form of
clinical judgement will have to be involved. In the present study we adopted a cautious
approach. The interviewers and the supervising general practitioner made an initial
judgement of information provided by the patients. If there was any doubt about the
possibility of a somatic disorder as an explanation of the presenting symptoms,
additional information was sought from the general practitioner treating the patient.
When doubt remained over whether a diagnosis of somatoform disorders was justified,

27

Chapter 2

the symptom was regarded as explained. This may have resulted in an

underestimation of the prevalence of somatoform disorders.
Prevalence estimates
When comparing our study with previous prevalence studies, our estimates are
relatively low. For DSM-IV somatoform disorders a prevalence estimate of 30% has
been found.1 For current depressive disorders previous prevalence estimates were 8%
16
(DSM-IV), 11.1-26% 17 18 19 (DSM-III-R) and 11.7% 20(ICD-10). Prevalence
estimates for current anxiety disorders were 11.6% 16 (DSM-IV), 14.4-18% 17 18 19
(DSM-III- R) and 10.2% 20 (ICD-10). Prevalences rather resembled the rates found in
community surveys, for example in Italy and The Netherlands.21 22
Our lower estimates are most likely due to our strict definition of the disorders.
The SCAN interview is known as a highthreshold diagnostic interview with a
comparatively strong emphasis on clinically relevant symptoms.23 24 In addition, we
took meticulous care to rate the criterion of functional impairment that was introduced
in most Axis I disorders in the update from DSM-III-R to DSM-IV. It has been
demonstrated recently that adherence to clinical significance criteria may reduce the
prevalence estimates of anxiety and depressive disorders by approximately one-third.25
Another explanation for our low estimates could be found in the use of psychotropic
medication, which may vary between populations. It is theoretically possible that the
prevalence rates could be reduced by 50% or more in a population with optimal
treatment. So far, other studies have not reported any figures concerning psychotropic
treatment.
Surprisingly, no differences were found by gender for prevalence rates of
anxiety disorders, and gender differences for depressive disorders were minimal. This
could be due to limited statistical power, because confidence limits, especially in men,
were rather large. Another possibility is that our emphasis on impairment contributed
to this finding. For depressive disorders (but not for anxiety disorders) the gender
differences increased when the DSM-IV criterion of moderate to severe clinical
impairment was ignored.
Comorbidity
A high comorbidity of somatoform disorders and anxiety or depressive disorders has
been a common finding in previous studies.26 27 28 2 Functional somatic syndromes are
also related to (but not fully dependent on) anxiety and depression.29
Kroenke et al showed that anxiety disorders, depressive disorders,
multisomatoform disorder and somatoform disorder not otherwise specified have
independent effects on functional limitations.3 This study confirms that the symptoms
and functional limitations of the disorders can be summated, with the most prevalent
28

Epidemiology

somatoform disorders in the present study being undifferentiated somatoform disorder.

Patients who have anxiety or depressive disorders are particularly limited in social
functioning, role functioning because of emotional problems and subjective health.
Patients with somatoform disorders are limited in all areas that are measured by the
SF-36. In patients with comorbidity the impairments are summated.
Implications of the study
The findings on comorbidity have implications for the focus of treatment. To engage
patients in treatment it is of primary importance to distinguish clearly whether the
patient initially presents with psychological or physical symptoms. Patients with a
somatoform presentation tend to attribute their symptoms primarily to a physical
disorder. The initial motivation for treatment of psychological symptoms will be
limited. To engage subjects in a psychologically oriented treatment the somatoform
presentation of symptoms should be recognised and dealt with.30 4 Patients might
accept that psychological distress is a consequence of persistent somatic symptoms, or
that the relationship is circular (symptoms lead to distress, which, in turn, exacerbates
the symptoms).
With DSM-V on the horizon, discussion again has started about the
classification of somatoform disorders.31 It has been argued that somatoform disorders
are not psychiatric disorders in a strict sense. Indeed, it is not very clear that
unexplained physical symptoms are caused by psychological factors. It is clear,
however, that there is a strong relationship with anxiety and depression, given that half
of the patients in general practice with anxiety or depression suffer from a somatoform
disorder as well. The relationship could be due to anxiety and depression causing
(awareness of) physical symptoms, or physical symptoms causing anxiety and
depression, or there may be a more complex relationship such as a circular causality.
Furthermore, a third factor, such as consulting behaviour, could be related to both. In
addition to patients with comorbid disorders, many more patients suffer from a
somatoform disorder without anxiety or depression. From our study it is evident that
both somatoform disorders and anxiety and depression come with substantial
functional impairment and that the combination is even worse. A somatoform
presentation seems to result from a complex interplay of perception and attribution of
symptoms, resulting in unproductive illness behaviour. It has been demonstrated
repeatedly that a cognitive-behavioural approach can be effective in alleviating this
burden.4 The inclusion of a well-defined category of somatoform disorders in DSM-V
is needed to facilitate further research on the effective treatment of such patients.

29

Chapter 2

Burden of illness and primary care

Somatoform disorders have a major impact on the burden of psychiatric illness. At
least one out of six patients seen by a general practitioner has a somatoform disorder.
Furthermore, our findings demonstrate that when somatoform disorders occur in
combination with anxiety or depressive disorders, symptoms and impairments can be
summated. To engage patients in an effective psychological treatment it is important to
recognise the somatoform presentation of symptoms. General practitioners should
have a strong working knowledge of the principles of diagnosis and treatment of
somatoform disorders, as well as of anxiety and depressive disorders.

Acknowledgements
The Netherlands Organization for Health Research and Development (ZON-MW)
funded the study. The interviewers were J.E. Piederiet and B.M. Brouwer, with data
assistance from L. Hoogenboom and G. Driebergen. We thank J. Ormel for his
comments on an earlier version of this manuscript.

Clinical implications
-

Somatoform disorders are among the most prevalent psychiatric disorders in

general practice.
- More than half of the patients with an anxiety or depressive disorder fulfilled the
criteria for a comorbid somatoform disorder, which should have implications for
the engagement of patients in treatment.
- In patients with comorbid disorders the physical symptoms, depressive symptoms
and functional limitations can be summated.

Limitations
-

Given a response rate of 59%, selective non-response may have affected our
prevalence estimates.
- In a primary care setting the presence of somatic disorders cannot be ruled out
entirely.
- Comparisons are based on dichotomous groups, with DSM-IV disorders present or
absent. Analyses using a dimensional approach might give more insight into the
relationship between depression/anxiety and somatoform disorders.

30

Epidemiology

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