Somatoform Disorders

WHAT ARE SOMATOFORM DISORDERS?

Somatoform disorders are a group of problems characterized by physical problems, such as pain, immobility, and discomfort. (The root “soma” refers to the physical body.) Typically, this group of disorders includes somatization disorder, conversion disorder, pain disorder, and hypochondriasis.¹ (Officially, body dysmorphic disorder is also a somatoform disorder, but it’s described separately on this website.)

In all of these illnesses, the problems are serious enough to interfere with the person’s daily life, work, and relationships. The problems are also usually bad enough to cause the person to seek medical treatment. However, for many of these problems there are no medical explanations or successful medical treatments. As a result, many people with somatoform disorders are referred to mental health care professionals for additional assessment, explanations, and treatments.

However, just because a person is referred to a nonmedical professional doesn’t mean that the person’s pain isn’t real. People with somatoform disorders aren’t pretending to be sick; their pain is very real despite the fact that there is no known cause. People with somatoform disorders are often referred to mental health care professionals for treatment instead of (or in addition to) medical professionals for a number of reasons: these problems are often made worse by psychological stress; they can be made worse by a person’s behaviors; they often lead to emotional issues such as depression; and in some cases, the cause of the problem is psychologically related.

WHO IS AFFECTED BY SOMATOFORM DISORDERS?

The prevalence of somatoform disorders appears to be high. As a group, somatoform disorders have been called the most common psychiatric problems seen by general practice medical professionals.² In a study of over one thousand patients examined by their general practitioners, 16 percent met the criteria for severe somatoform disorders, and when mild impairment was included, the rate jumped to 22 percent.² Many of these people also suffered with depression and anxiety. In a study of hospital patients,³ approximately 36 percent of the people who met the criteria for any somatoform disorder also had other mental health problems, such as depression and anxiety.

WHAT CAUSES SOMATOFORM DISORDERS?

The cause of a pain disorder is usually a clearly identifiable event, such as an accident or the onset of a disease. However, the causes of somatization disorder, conversion disorder, and hypochondriasis are still largely unknown. Some evidence suggests that relatives of people with these problems are sometimes at a greater risk for developing them,¹ but it’s not clear if this is due to inheritable factors or to the fact that these people often live in the same environment.

Clearly, there are also other causes involved. For example, in some cultures it’s more acceptable or more common to express psychological pain, such as sadness or suffering, as either physical pain or unexplained fatigue.⁴

WHAT TREATMENTS ARE EFFECTIVE FOR SOMATOFORM DISORDERS?

Cognitive behavioral therapy has been shown to be an effective treatment for somatoform disorders.⁵ This type of treatment might be used by itself to relieve some of the physical pain and discomfort, or it might be used in conjunction with conventional medical treatments, such as medication. Cognitive behavioral therapy examines how people’s thoughts and behaviors can be modified to relieve pain, such as by increasing a person’s activities and social connections.⁵

Not only is this form of therapy effective for treating the pain associated with somatoform disorders, it’s also been shown to be cost-effective when compared with the long-term costs when constant medical care is required for these illnesses.⁶ In a two-year study, some patients saved 64 percent on their medical expenses as compared to the group who didn’t receive cognitive behavioral therapy.

Following below is more specific information on each of the somatoform disorders.

SOMATIZATION DISORDER

What Is Somatization Disorder?

A somatization disorder is characterized by chronic pain that is widespread throughout a person’s body.¹ Over the course of several years, the pain typically affect multiple parts of the body, including the joints, head, back, stomach, and feet. A person’s sexual functioning is also affected, particularly the person’s sexual activity, performance, comfort, and enjoyment. Unusual menstruation or erectile problems are also common. People with somatization disorder also have some kind of problem with their digestive system, such as abdominal pain, digestion problems, diarrhea, nausea, vomiting, or bloating.¹ Plus, many people with this problem experience at least one other inexplicable health problem, such as difficulty swallowing, seeing, hearing, feeling, walking, or thinking.

Typically, a somatization disorder lasts for many years.¹ However, if the problem isn’t as severe or pervasive as described above but lasts for at least six months, a diagnosis of undifferentiated somatoform disorder might be made.¹

Who Is Affected by Somatization Disorder?

Some evidence suggests that a person’s chances of developing somatization disorder are increased if a family member also has this problem.¹ The disorder typically begins before the age of thirty.¹ Rates of somatization disorder range from almost 1 to 2 percent for women and are lower for men.1, 3 Estimated rates for undifferentiated somatoform disorder, however, are much higher, ranging from approximately 10 percent (in a study of hospital patients³) to almost 20 percent (in a study of the general population of Germany⁷).

What Treatments Are Effective for Somatization Disorder?

Group cognitive behavioral therapy, including problem solving, assertiveness training, relaxation training, and emotional expression, has been shown to be an effective treatment for somatization disorder.^{8, 9}(Click here for information about problem-solving skills, assertiveness training, relaxation training, and emotional expression.)

Similarly, successful results have been found using individual cognitive behavioral therapy for the treatment of undifferentiated somatoform disorder. In a study of seventy-nine patients who received six to sixteen sessions of therapy, 73 percent of the patients were rated as recovered or improved after treatment.¹⁰(Click here for more information about cognitive behavioral therapy.)

In addition, Saint-John’s-wort, an herbal remedy, has been shown to relieve symptoms of anxiety, depression, and overall discomfort related to somatoform disorders, including somatization disorder.¹¹

CONVERSION DISORDER

What Is Conversion Disorder?

A conversion disorder is characterized by problems moving a part of the body or using one of the senses.¹ For example, people with conversion disorder might have problems keeping their balance when walking or be unable to move one arm because it’s paralyzed. Or they might have difficulties speaking, swallowing, or using one of their senses, like hearing. It’s also possible that people with conversion disorder have a loss of feeling in part of their body, as well as muscle weakness. Some people with this disorder experience hallucinations, dizziness, confusion, and seizures.

As with all somatoform disorders, there’s no known medical cause for these very serious problems. However, the symptoms do appear to increase in frequency or severity because of factors such as stress, so they’re thought to have psychological influences and possibly psychological origins.

Who Is Affected by Conversion Disorder?

The prevalence of conversion disorder appears to be rare in the general population, less than 1 percent.¹ However, it’s been reported in larger percentages of specific populations, such as mental health clinic patients and surgical patients.¹ Conversion disorders typically develop between the ages of ten and thirty-five, but later development is not uncommon.¹

What Treatments Are Effective for Conversion Disorder?

In one study of conversion disorder, patients with trouble walking experienced small improvements in their range of motion as a result of cognitive behavioral and stress-management therapies.¹² Improvements were seen in as few as twelve days and were still maintained two years later. (Click here for information about cognitive behavioral therapy and stress-management techniques.)

Hypnotherapy¹³ has also proved effective for the treatment of conversion disorder.(Click here for information about hypnotherapy.)

Successes have also been achieved using family therapy¹⁴ and biofeedback,¹⁵ a form of treatment that helps people monitor and alter their muscle tension, heartbeat, blood pressure, and body temperature.

PAIN DISORDER

What Is Pain Disorder?

A pain disorder is characterized by severe pain in any part of the body that causes great disturbances in the person’s life.¹ There are two kinds of pain disorders: those that begin without any known cause and those that follow a trauma, such as a car accident. Unlike pain that eventually stops within weeks or months after a bad accident, the physical discomfort associated with pain disorder continues for a longer period of time and is sometimes greater than what would be expected. Often, pain that lasts longer than six months is referred to as chronic pain.

Many people who seek treatment for pain disorder are suffering from very real, very severe illnesses and problems, such as cancer, arthritis, back pain, headaches, complex regional pain syndrome (reflex sympathetic dystrophy syndrome), carpal tunnel syndrome, fibromyalgia, nerve damage, shingles, sports injuries, chronic myofascial pain, repetitive motion injuries, and osteoporosis. Because they often are unable to find a satisfactory medical treatment for their pain, people suffering with these conditions frequently seek help from a mental health care professional, or a mental health care professional might be added to the person’s treatment team as part of a multidisciplinary approach to treating the pain. This approach often includes the services of a medical professional, physical therapist, acupuncturist, massage therapist, and others. When someone with this condition is treated by a mental health care professional, the diagnosis of a pain disorder will be given, since this is the focus of the treatment.

Who Is Affected by Pain Disorder?

The prevalence of pain disorder in the general population is unknown.¹ However, millions of people struggle with short-term and long-term pain issues on a daily basis. Based on one survey of 3,600 adults, almost half of the general population struggles with chronic pain.^{16, 17} In another study, involving over five thousand patients, 40 percent visited their primary care physicians for pain-related issues—mostly back and head pain.¹⁸ In fact, it’s estimated that 59 percent of adults experience back pain during their lives,¹⁹ and as many as ten million adults suffer with migraine headaches in the United States alone.²⁰ Many people with pain issues also frequently suffer with depression and anxiety,^{21, 22} which is another reason why they’re often referred to mental health care professionals for treatment.

What Treatments Are Effective for Pain Disorder?

Cognitive behavioral therapy has proven to be an effective treatment for relieving the physical discomfort associated with pain disorder,^23-26 as has acceptance and commitment therapy.^{27, 28} In a study using a version of acceptance and commitment therapy, the participants increased their daily functioning levels and experienced reductions in both pain and related symptoms of depression.²⁹(Click here for information about cognitive behavioral therapy and acceptance and commitment therapy.)

Hypnotherapy^30-32 is also an effective treatment for pain. It can teach people how to use creative visualization to control pain.(Click here for information about hypnotherapy.)

Additional treatments for pain relief include biofeedback,^33-35 acupuncture,^36-38 exercise,³⁹ mindfulness-based stress reduction therapy,^{40, 41} tai chi, guided breathing exercises, guided imagery, and yoga.⁴²(Click here for information about stress reduction skills and breathing exercises.)

A variety of pain-relief medications are often used in conjunction with many of the above treatments. These medications may include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Naprosyn); acetaminophen (Tylenol); anticonvulsants such as gabapentin (Neurontin); opioid analgesics such as morphine, oxycodone (OxyContin), fentanyl (Sublimaze), and acetaminophen plus hydrocodone (Vicodin); tricyclic antidepressants such as nortriptyline (Pamelor); and newer antidepressant medications such as duloxetine (Cymbalta) and venlafaxine (Effexor).^{43, 44}(Click here for information about the use of medications.)

HYPOCHONDRIASIS

What Is Hypochondriasis?

Hypochondriasis is perhaps the most widely known of the somatoform disorders, and probably the most misunderstood. A person with hypochondriasis, known as a hypochondriac, is not faking an illness. Those who pretend to be in pain in order to avoid something, such as jury duty or military service, are referred to as malingerers. Those who pretend to be sick or who make themselves sick for no apparent reason are said to suffer from a factitious disorder.

In comparison, a person with hypochondriasis is genuinely concerned that he or she has an illness or disease, despite repeated medical examinations that can find no cause for alarm. Chances are that the person has seen many medical professionals looking for the “right” one, who will find and treat the person’s problems. As a result, people with hypochondriasis are often diagnosed with many different ailments or are told that there’s nothing wrong with them, despite how bad they feel.

In some cases, there’s a genuine medical problem that’s being overlooked. In other cases, there might be factors that cause the person to perceive their problems as worse than they really are. For this reason, people with hypochondriasis are often referred to mental health care professionals for additional treatment.

Who Is Affected by Hypochondriasis?

The rates of hypochondriasis range from approximately 1 to 5 percent in the general population to almost 7 percent in certain medical facilities.^{1, 3} Although hypochondriasis can begin at any age, it’s typically thought to begin in a person’s twenties or thirties.¹

What Treatments Are Effective for Hypochondriasis?

In one study of hypochondriasis, cognitive behavioral therapy was administered over the course of four months.⁴⁵ At the end of treatment, 76 percent of the people reported improvements in the severity of their symptoms. (Click here for information about cognitive behavioral therapy.)

Relief for hypochondriasis has also been obtained by using stress-management therapies, which incorporate relaxation training and problem-solving skills.⁴⁶(Click here for information about stress reduction techniques and problem-solving skills.)

In addition, the use of certain kinds of antidepressants, such as fluvoxamine (Luvox), fluoxetine (Prozac), nefazodone (Serzone), and citalopram (Celexa), has been shown to be effective.⁴⁷ (Click here for information about the use of medications.)

COGNITIVE BEHAVIORAL THERAPY FOR SOMATOFORM DISORDERS IN GENERAL

There is no single cognitive behavioral treatment for all somatoform disorders. Each treatment will be specifically tailored to the demands of the person’s problem. However, there are many similar elements among the various treatments.

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives and lessen their pain.

The CBT treatment for many somatoform disorders often includes the following seven steps:

Conduct an assessment and provide education
Develop stress reduction and mindfulness skills
Apply specific coping skills
Get reactivated in life
Challenge and correct self-defeating thoughts
Develop problem-solving skills
Prevent relapse

1. Conduct an Assessment and Provide Education

The first step of the CBT treatment for somatoform disorders is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with a somatoform disorder and not some other similar problem. Once people have been diagnosed with a somatoform disorder, such as chronic pain, it’s important that they understand the basic nature and causes of the disorder (as highlighted above). It’s also important that they understand CBT is an active form of treatment that requires them to do work outside of the therapy session.(Click here for information on assessment and education for somatoform disorders.)

2. Develop Stress Reduction and Mindfulness Skills

Often, the next step of the CBT treatment for somatoform disorders is to develop stress reduction and mindfulness skills. These skills have proven to be very effective for reducing stress, as well as for reducing the experience of pain and muscle tension. There are a variety of skills that a person can learn. Included here are five of the most important.

The first relaxation skill that’s usually taught is mindful breathing. This technique focuses a person’s attention on slow, rhythmic abdominal breathing, which often produces a feeling of calmness. In addition, there are many other mindfulness skills that people can learn, such as mindful-body scans and radical acceptance. The goals of these mindfulness exercises are to help people focus on what’s happening in the moment, to create a feeling of calm, and to help people stop making critical judgments, both of themselves and of their experiences. (Click here for a full description of mindfulness techniques.)

The next relaxation skill is progressive muscle relaxation. It involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling.

The next step is learning how to release muscle tension without first tensing the muscles. This is done by focusing attention on the muscles and visualizing the tension being released.

The next relaxation skill is cue-controlled relaxation, in which a person is taught to relax his or her body by saying a relaxing word, such as “peace” or “relax,” with each slow exhalation.

And, finally, the last relaxation skill is special-place visualization. This skill teaches the person to envision a place of safety and comfort in his or her imagination. The person can go to this “mental safe place” during the treatment of somatoform disorders if he or she is overwhelmed by distressing feelings.(Click here for a full description of relaxation techniques.)

3. Apply Specific Coping Skills

For some somatoform disorders, especially pain disorders, there are specific coping strategies that can be utilized.

The treatment of carpal tunnel syndrome and other repetitive motion injuries includes specific stretches and exercises that are often helpful, such as the Rossiter System.(Click here for information about the treatment of carpal tunnel syndrome and repetitive motion injuries.)

The treatment of fibromyalgia, chronic fatigue syndrome, and chronic musculoskeletal pain problems includes self-help techniques such as trigger point therapy and the Matrix Repatterning program.(Click here for information about the treatment of fibromyalgia, chronic fatigue syndrome, and chronic musculoskeletal pain.)

The treatment of chronic back pain includes helpful stretches and exercises like the Multifidus Back Pain Solution.(Click here for information about the treatment of chronic back pain.)

Similar techniques and skills also exist for the treatment of other chronic pain issues, such as chronic headaches, temporomandibular joint (TMJ) pain, and complex regional pain syndrome (formerly known as reflex sympathetic dystrophy syndrome).(Click here for information about the treatment of chronic headaches, TMJ pain, and complex regional pain syndrome.)

4. Get Reactivated in Life

The next step of the CBT treatment for somatoform disorders is to help people begin scheduling pleasurable activities back into their lives. Very often, people with somatoform disorders avoid pleasurable activities, isolate themselves from the rest of the world, and stop doing their usual routine. However, this only increases their frustration, pain, and depression. One of the most important steps of treatment, therefore, is to get people reactivated in life and help them reengage in activities. This can be done in many ways, but using a schedule to plan and record activities is often helpful and motivating.(Click here for instructions on how to plan an activity schedule.)

5. Challenge and Correct Self-Defeating Thoughts

The next step of the CBT treatment for somatoform disorders might be to challenge and correct self-defeating thoughts. These thoughts are often the cause of sad and hopeless feelings. At the most observable level are automatic thoughts. These are critical thoughts that people think and say to themselves that sabotage success and happiness. Two examples of automatic thoughts might be “I don’t deserve anything good happening to me” and “Why bother trying? I’m just going to fail.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels sad or hopeless.(Click here for information on identifying automatic thoughts.)

The CBT treatment for somatoform disorders will help the person identify and reevaluate these errors in thinking. This can be done with the use of a thought record. The thought record helps the person with the problem look for evidence that supports and contradicts these thoughts. Then, most importantly, it helps the person create a more balanced thought. For example, if a person struggling with chronic pain had the thought “Why bother trying? I’m just going to fail,” the thought record would offer evidence of this thought being true and examples of it not being true in the person’s life.

The thought record also helps the person identify different types of cognitive distortions, unhelpful thinking styles that perpetuate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life.(Click here for information on identifying cognitive distortions.)

By evaluating the evidence and cognitive distortions, the goal of the thought record is to help the person find a new, more balanced thought and ease feelings of pain, sadness, and hopelessness. In this example, perhaps a more balanced thought would be “Even though I don’t do everything perfectly, I’m still capable of doing most things pretty well.” And instead of feeling excessively sad, such as 8 on a scale of 1 to 10, perhaps this newer thought will help the person feel less sad, say only a 5 out of 10.(Click here for instructions on using a thought record.)

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to anxiety and depression. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m worthless,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques.(Click here for instructions on challenging core beliefs.)

6. Develop Problem-Solving Skills

The next step of the CBT treatment for somatoform disorders might be to learn problem-solving skills. People with a somatoform disorders often feel like they don’t know what to do in many situations. Problem-solving skills can help them identify and select healthy solutions to difficult, anxiety-provoking situations. The steps to problem solving include defining the problem, outlining the desired goals, brainstorming possible solutions, evaluating the possible consequences, putting the chosen plan into action, and evaluating the results.(Click here for instructions on problem solving.)

7. Prevent Relapse

Finally, the last step of the CBT treatment for somatoform disorders is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of returning problems in order to take steps to prevent relapse.(Click here for instructions on preventing relapse of somatoform disorders.)

ACCEPTANCE AND COMMITMENT THERAPY FOR PAIN DISORDER

Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.

ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of undesirable feelings, emotions, and thoughts. Often, people try to get rid of feelings, emotions, and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings, emotions, and thoughts can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her feelings, emotions, and thoughts, the more powerful they often become and the longer they stick around.

The ACT treatment for pain disorder generally includes eight steps:⁴⁸

Educate about chronic pain and ACT
Develop creative hopelessness
Clarify values
Utilize cognitive defusion
Focus on contact with the present moment
Develop acceptance
Commit to taking action
Stay committed to values and actions

1. Educate About Chronic Pain and ACT

The initial step of the ACT treatment for any pain disorder is to educate the person about the nature of chronic pain. It’s especially important for the person to understand the nature of pain from an ACT point of view. According to this treatment, emotions such as anxiety and fear tend to make the sensations of pain worse. Plus, many sensations of pain can’t be controlled or eliminated, so to some degree, they must be accepted. This doesn’t mean that they must be appreciated or enjoyed, but to some extent, life can’t move forward until the person accepts that the pain is real and might not go away. Starting with the early stages of treatment, it’s also important for people to understand that ACT is an active, participatory treatment designed to help them live a more fulfilling life, not necessarily a “happier” one. (Click here for more information about acceptance and commitment therapy.)

2. Develop Creative Hopelessness

In order to develop what ACT calls “creative hopelessness,” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with pain and upsetting emotions. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of pain, which are never very successful. For example, a man who attempts to control his pain by drinking alcohol actually develops a worse problem, as does a woman who tries to avoid her pain by choosing not to talk to her loved ones about it. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with pain.(Click here for instructions on how to develop creative hopelessness.)

3. Clarify Values

ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. People with chronic pain problems often avoid many of the important relationships and activities in their lives. Either they’re afraid that their pain will prevent them from enjoying these aspects of life, or they’re afraid that they’ll ruin the experience for others. Whatever the reason, this avoidance of pleasurable activities and relationships often turns pain into long-term suffering. The solution, according to ACT, is for the person to clarify and establish what he or she values in order to live a more fulfilling life, despite having pain or feelings of anxiety or fear.

Values are the elements of life that give it meaning and importance, like “maintaining a loving relationship with my spouse or partner” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a loving relationship and still have a loving relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values.(Click here for instructions on how to clarify and establish values.)

4. Utilize Cognitive Defusion

Cognitive defusion is a mindfulness technique that helps people observe their painful and anxious thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with chronic pain to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that chronic pain could worsen over time if a person were to follow or believe every thought and emotion that arose.

Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings.(Click here for instructions on how to develop cognitive defusion skills.)

5. Focus on Contact with the Present Moment

Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling pain and anxiety. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body.(Click here for instructions on how to develop present-focused mindfulness skills.)

6. Develop Acceptance

In ACT, learning to accept pain and anxious emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.

In order to cultivate acceptance, people are encouraged to experience the distressing emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded.(Click here for instructions on how to develop acceptance skills.)

7. Commit to Taking Action

After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a person’s value is to be an active member of her community, she might list a number of different goals to fulfill that value, such as “attend community meetings twice a month.” This is something that can be completed and thereby create a sense of valued living. The ACT treatment for chronic pain includes development of skills and goals that lead to taking committed action.(Click here for instructions on how to commit to taking action.)

8. Stay Committed to Values and Actions

In order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past.(Click here for instructions on how to stay committed to values and actions.)

HYPNOSIS FOR THE TREATMENT OF CHRONIC PAIN

Hypnosis has been used to treat mental health problems for over two hundred years. Its utilization began in late eighteenth-century France, where patients were “mesmerized” by Franz Anton Mesmer, who relieved them of their symptoms using magnets and the power of suggestion. Later, in the 1840s, James Braid, a Scottish physician, used the technique as an anesthesia for his patients, but he realized that the magnets were unnecessary for the method to work. He then renamed the treatment hypnosis, from the Greek word hypnos, meaning “sleep.”(Click here for more information about hypnosis.)

Unfortunately, hypnosis has suffered a great deal at the hands of the popular media. Today, it’s largely thought of for its entertainment value. However, hypnotherapy—the psychotherapeutic form of hypnosis—is officially recognized by both the American Psychological Association and the American Medical Association as an effective treatment for certain conditions, including chronic pain.^49-51 Research has even shown that hypnosis has a direct, observable effect on the brain.^{52, 53}

Many people expect to be put into a sleeplike trance when they undergo hypnotherapy. However, this is another misconception. Hypnosis is a state of deep relaxation and focus in which a person becomes more receptive to suggestions made by a hypnotherapist or by the person himself or herself. In fact, self-hypnosis is often very successful if practiced regularly. In one form of self-hypnosis, called autogenics, a person induces muscle relaxation and a feeling of calm by focusing on certain areas of his or her body and sending commands to those areas to relax. With practice, this technique often helps relieve pain.(Click here for instructions on using autogenics.)

Other options for self-hypnosis begin with listening to soothing recordings made for this purpose or practicing some form of relaxation, such as progressive muscle relaxation or safe-place visualization.(Click here for self-hypnosis recordings and for instructions on stress reduction and relaxation techniques.) Then, once the person is relaxed and focused, he or she can use verbal suggestions to relieve stress, lessen pain, and gain confidence. These suggestions can be in the form of a professional hypnosis recording, or the person can make his or her own hypnosis recording.(Click here for self-hypnosis recordings and for instructions on how to make a hypnosis recording.) For example, a woman with migraine headaches might give herself the suggestion that the muscles in her neck and forehead are releasing as she imagines a cool breeze blowing across her forehead, or a man with pain in his lower back might imagine those muscles elongating and releasing the nerves that are being constricted.(Click here for examples of self-hypnotic scripts to follow.)

REFERENCES FOR SOMATOFORM DISORDERS

1. American Psychiatric Association. 2000. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association.

2. De Waal, M. W. M., I. A. Arnold, J. A. H. Eekhof, and A. M. van Hemert. 2004. Somatoform disorders in general practice: Prevalence, functional impairment and comorbidity with anxiety and depressive disorders. British Journal of Psychiatry 184: 470-476.

3. Fink, P., M. S. Hansen, and M.-L. Oxhoj. 2004. The prevalence of somatoform disorders among internal medical inpatients. Journal of Psychosomatic Research 56: 413-418.

4. Skapinakis, P., G. Lewis, and V. Mavreas. 2003. Cross-cultural differences in the epidemiology of unexplained fatigue syndromes in primary care. British Journal of Psychiatry 184: 205-209.

5. Looper, K. J., and L. J. Kirmayer. 2002. Behavioral medicine approaches to somatoform disorders. Journal of Consulting and Clinical Psychology 70: 810-827.

6. Hiller, W., M. M. Fichter, and W. Rief. 2003. A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost-effectiveness. Journal of Psychosomatic Research 54: 369-380.

7. Grabe, H. J., C. Meyer, U. Hapke, H.-J. Rumpf, H. J. Freyberger, H. Dilling, et al. 2003. Specific somatoform disorder in the general population. Psychosomatics: Journal of Consultation Liaison Psychiatry 44: 304-311.

8. Kashner, T. M., K. Rost, B. Cohen, M. Anderson, and G. R. Smith. 1995. Enhancing the health of somatization disorder patients: Effectiveness of short-term group therapy. Psychosomatics 36: 462-470.

9. Lidbeck, J. 1997. Group therapy for somatization disorders in general practice: Effectiveness of a short cognitive-behavioral treatment model. Acta Psychiatrica Scandinavica 96: 14-24.

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