Characteristics of 200 patients with somatoform pain disorder

doi:10.21203/rs.3.rs-3408623/v1

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Research Article

Characteristics of 200 patients with somatoform pain disorder

https://doi.org/10.21203/rs.3.rs-3408623/v1

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Background

Patients with somatoform pain experience physical pain, that cannot be attributed to any underlying medical or physiological cause, and it is often thought to be related to psychological factors. Health professionals encounter difficulties identifying this specific type of chronic pain, leading to suboptimal treatment strategies. Therefore, we aimed to describe the characteristics of patients with somatoform pain, to support the identification of affected patients.

Methods

We collected and analyzed data of a multicentre cross-sectional study from 200 patients with somatoform pain admitted to psychosomatic centers in Germany between July 2013 and Juli 2014. The survey contains ten different categories, all of them referring to pain related topics. Here, we present the following five: Personal data, Body: Pain perception, Cognition: Pain processing, Pain behavior, and Physical complaints.

Results

Our results highlight that most of these patients experience persisting pain in several body parts, which lasts > 12 hours/day (50%), and is constantly changing (71%). Furthermore, patients indicate feelings of helplessness by agreeing to expressions like "the pain is controlling me" (70%). Finally, we found that pain is recognized less in a symbolic way, but predominantly seen as suffering by the patients, despite cognitively acknowledging the dependency of emotional and physical pain.

Conclusion

The study identified specific and distinctive characteristics in the emotional and behavioral responses of patients with somatoform pain, potentially distinguishing them from other patients with chronic pain and helping clinicians to identify these patients.

Chronic pain

somatoform pain

functional somatic symptoms

quality of life

psychotherapy.

Chronic pain, characterized by its persistent duration exceeding three to six months, arises from a diverse range of medical conditions, injuries, or diseases, and significantly impacts an individual's overall well-being [7]. Somatoform pain, a specific type of chronic pain, denotes pain experiences without evident physiological explanations, often originating from psychological distress. This highlights the intricate interplay between emotional states and physical sensations [2]. According to Roenneberg et al. [16], approximately 10% of the general population and around one-third of adult patients in clinical populations exhibit functional somatic symptoms. These symptoms (including chronic pain) are diverse, frequently manifest chronically, and adversely affect both quality of life and functional capacity. Life expectancy appears unaffected, aside from an elevated suicide risk [3] as 13–18% have already attempted suicide at some point in their lives [8]. The patients with somatoform pain are more often affected by mental illnesses (especially anxiety, depression), affecting about 50% of them [11;13]. Despite the prevalence of somatoform pain, its precise aetiology often remains unclear [12]. Consequently, conventional medical assessments yield inconclusive results. Consequently, somatoform pain presents a significant public health challenge, necessitating effective treatments [12].

The clinical guideline "Management of Patients with Non-Specific, Functional, and Somatoform Bodily Complaints'' addresses different levels of severity of persistent non-specific symptoms prompting medical visits but lacking clear diagnoses. It suggests three distinct phases of treatment: (1) during initial interactions, the primary focus is on fundamental diagnostics coupled with guidance and reassurance. (2) In instances of persistent and distressing symptoms, it is advised to conduct a broader, simultaneous, and balanced assessment of both physical and psychosocial factors, while placing psychotherapeutic emphasis and strategies for self-help. (3) In instances of more severe cases, a comprehensive treatment approach includes supplementary elements such as (body-focused) psychotherapeutic and social medicine. Thus, psychotherapy is recommended for the second and third phase, as it helps to alleviate pain and improve quality of life of patients with somatoform pain [20; 1].

According to Ringel et al. [14] handling patients with somatoform disorders requires a balanced approach. Positive actions include actively validating patients through thorough questioning and ensuring comprehension, offering reassurance, conducting brief physical examinations focusing on discomfort areas, and delicately introducing psychosocial aspects in everyday language. Regular, time-based medical appointments should be established. Negative interventions involve unnecessary diagnostic procedures or invasive treatments, using language that downplays the situation, suggesting unverified causal hypotheses, or even stigmatizing patients. It is essential not to solely attribute symptoms to psychosocial factors, avoiding the "psychological" label. A holistic, empathetic, and patient-centered approach is crucial for effectively managing somatoform patients.

To date, health care professionals, besides psychotherapists, struggle to identify somatoform pain patients and differentiate them from other chronic pain patients. Consequently, they often provided inadequate treatments [17], which lead to a vicious circle of misunderstanding and frustration on the patient as well as the health professional's side.

To support the identification of patients with somatoform pain, which enabels an efficient doctor-patient interaction, we aim to describe the characteristics of this specific patient group.

Study design

This survey study is based on a multicentre cross-sectional investigation aiming at descriping patients with a somatoform pain disorder. In reporting the results, we followed the Cross Guidelines according to Sharma et al. [18].

Setting and Data Source

Our study was conducted at three psychosomatic centers in northern Germany. Data was collected consecutively of 200 patients admitted to one of the centers between July 2013 and July 2014. The response rate was 100%. Most participants spontaneously completed the survey, however if not, they were asked to supplement questionnaires the following days. This led to a complete dataset with no missing values. All experiments were performed in accordance with relevant guidelines and regulations. All participants were informed about the study and asked if they would like to participate. If they agreed and signed a related consent form, they were included in the study.

Participants

Patients included in this study needed to have a diagnosis of somatoform pain disorder (ICD-10: F45.40), be at least 18 years old and have good German language skills. The ICD-10 diagnosis was made by an experienced clinician, based on the admission interview, using the ICD-10 criteria: predominant complaint is a persistent, severe, and distressing pain that cannot be adequately explained by a physiological process or physical disorder. It occurs in association with emotional conflicts or psychosocial stressors, which play a central role in the onset, severity, exacerbation, or maintenance of the pain. Patients were excluded if they had a physical brain condition, or a diagnosis of a psychotic or eating disorder. This clinical diagnosis was verified with the Structured Clinical Interview for DSM-IV [6]. Although the diagnosis of somatoform pain disorder has been abandoned in DSM-5 and replaced by the broader concept of somatic symptom disorder, we still used somatoform pain disorder for the purpose of this study, because the use of somatic symptom disorder for patients with chronic pain is not recommended [9]. Consequently, all included patients fulfill the ICD-10 criteria for the diagnosis of somatoform pain which require the presence of persistent, severe pain that is excessively preoccupying and distressing, with psychological factors playing a significant role, and with no alternative physiological or psychiatric explanation for the pain.

Survey

The survey was organized into ten main categories: Personal data, Body: Pain perception, Cognition: pain processing, Emotions: satisfaction, mood, stress, Pain behavior, Contacts: doctors appointments, communication, support, Worries and apprehension, Physical complaints, Mood during the last week, and State of health and quality of life. The last four categories contain each a validated questionnaire while the former categories include information, typically obtained during psychotherapeutic treatments. In this article we focus and present the main categories Personal data, Body: Pain perception, Cognition: pain processing, Pain behavior, and Physical complaints. Detailed information on the involved questions is provided below. Further, a summary of the remaining categories is presented.

Personal data contains information of eleven items: age (in years), gender (female, male), height (cm), profession (free text), current activity (free text), labor status (full time, part time, unemployed), Labour capacity (capable of work, incapable), intake of current medication (free text) and pain duration (in years). In this paper we dichotomized the variable current pain medication into yes, no. The other two variables with a free text answer option are not presented in this paper.

Body: Pain perception covers the information of seven main questions with one to six subheadings. For the first main question “Where do you have pain?” participants could indicate the presence or absence of pain individually for the subheading head, stomach, back, and extremities. Secondly, information on the quality of pain was obtained. Participants indicated the presence or absence of the following pain qualities: dull/pressing, sharp/stabbing, pounding/throbbing, dragging/ripping, burning. Afterwards they were asked if the pain was radiating (yes/no). The fourth question was on the maximal pain level during the last four weeks on a scale from 0 - no pain to 10- worst pain. Participants could choose between 0–1, 2–3, 4–5, 6–7, 8–9 and 10. Furthermore, the participants indicated if the pain was worst: during the morning (yes, no), noon (yes, no), evening (yes, no), night (yes, no), constantly changing (yes, no), always the same (yes, no). In the sixth question participants indicate the normal duration of their daily pain as less than two hours (yes, no), between 2 and 4 hours (yes, no), between 4 and 8 hours (yes, no), between 8 and 12 hour (yes, no), more than 12 hours (yes, no). Finally, the participants were asked if the pain was worse at rest (yes, no), during loading (yes, no), changing – once at rest than during loading (yes, no), always the same - at rest and at loading (yes, no).

Cognition: pain processing involves four main items with three to 13 subheadings. The participant could indicate totally agree, agree, disagree, or completely disagree to each item and subheading. In this article, we dichotomized the responses into strongly agree and agree vs disagree and completely disagree. In the first item, participants were asked about the origin of their pain. They rated the three subheadings the pain is 1) constitutional, 2) psychological and 3) constitutional as well as psychological. In the second item participants indicated if their pain meant: suffering, punishment, injustice, warning, relief, chance, fate, and pleasure. In the third item, participants were asked regarding their attitude towards their body. They evaluated the subheadings: In general, I like my body, I accept my body, I trust my body, I am disappointed by my body, sometimes I would like to have a different body, sometimes I hate my body. Finally, participants were asked to rate the following general statements about pain: Pain subserve self-discovery, pain dependence on the culture, pain depends on faith, pain is superfluous, pain needs to combated, pain is vital, pain can facilitate a conscious life, pain is an independent disease, psychological pain is worse than constitutional, constitutional pain is worse than psychological, there is no difference between constitutional and psychological pain, constitutional and psychological pain interact with each other, in the population there are prejudices towards psychological diseases.

Pain behavior contains six questions with five to twelve subheadings. First participants were asked if there are situations in which the intensity of the pain is changing for each subheading they could indicate total agreement, agreement, disagreement, or complete disagreement. The following five subheadings were rated: When I am relaxed, the pain is less intense, when I am distracted the pain is less intense, my pain increases when I am upset, my pain increases when I get angry, my pain increases when I am frustrated. The next item is on the ability to reduce pain by movements, relaxing, distraction, pleasure, medication, and conversations. The ability to reduce pain of each of these six subheadings was rated by participants as very strong, strong, weak, not at all. Next participants evaluated areas in which they feel very restricted, restricted, less restricted or not restricted by the pain. The areas of subheading were: self-supply (e.g. groceries), relationships (family, partner, friends), profession/labor, independence, decisions, physical activity, eating/drinking, sleep, and sexuality. As part of the fourth item, participants were asked to imagine they would have no pain from tomorrow on, then they should indicate how they expect to react. They rated the following six subheadings as strongly agree, agree, disagree completely disagree: I would be relieved and satisfied, I would exuberantly celebrate, I would disbelief and be skeptical, I would solve other problems, I would not change anything, I cannot imagine this situation (of freedom of pain). In the following Item participants were asked how they can influence their pain. They rated the following ten statements again on a four-point-scale from strongly agree to completely disagree: I can influence the pain via my body, I can influence my pain through my behavior, I cannot control my pain, the pain controls me, I can influence the pain, the pain is influencing me, I could not accept if the pain would last forever. For the yet five mentioned pain behavior items, we again dichotomized the response options by merging the upper two and lower two response options. In the final sixth item of this category the participants were asked what they expected from a therapy and what their goals would be. They evaluated the following twelve subheadings as being a goal (yes, no): freedom of pain, reduction of pain, learning a better way to handle the pain, understanding the cause of the pain, reducing the need of pain medication, obtain knowledge on pain-keeping and increasing factors, learn to arrange with the pain, increase the self-confidence, increase the professional workability for the job, increasing the body's flexibility, regain zest for life/vital energy, nothing.

Physical complaints were measured with the Screening for Somatoform Disorders (SOMS2) questionnaire [5]. SOMS-2 is a widely used screening tool for somatoform disorders. Thus, respondents were asked to indicate whether they suffered from 47 different somatic symptoms (e.g. headache, back pain, nausea), for which no organic cause has been identified by a physician, during the past two years. The number of endorsed symptoms is condensed into the somatising complaint index which is used to indicate severity of somatic symptoms in this study. A cut-off of ≥ 17 has been suggested to indicate somatoform problems [14]. The internal consistency of the 47 symptom items in the present sample was ⍺ = .92.

Of the remaining categories: Affects: your satisfaction, mood, stress, Contacts: doctors appointments, communication, support, Worries and apprehension, Mood during the last week, and State of health and quality of life, the later three base on validated questionnaire, the STAI [19], the BDI [10], and the SF-12 [21] respectively. The category on affects involved eight questions with four to 31 subheadings and the category on contacts involved three questions with 12 to 15 subheadings.

Statistical methods

We analyzed the data utilizing SPSS and provided descriptive statistics as mean and standard deviations (SD) or frequencies with proportions (n (%)), respectively.

All characteristics of the patients are presented in Table 1. Their mean age was 49 years and 80% were female. Sixty-three percent of the sample indicated to be unable to work.

The pain was experienced as persistent > 12h/day by 50% and with high intensities (> 7) by 58% of the patients. Patients reported the intensity to be constantly changing throughout the day (71%) and mostly as pulling (72%) and dull (63%). Most patients reported pain in the back (89%) and in extremities (86%), with 59% of all patients reporting more than two different pain locations.

Patients saw the reason for the pain as being constitutional (73%), psychological (69%) and both (87%). They also agreed to physical and emotional pain to be depending on each other (92%). For most patients the pain meant suffering (85%) and warning (75.5%). Finally, they indicated that the population has prejudiced against patients with psychological diseases (97%).

The pain significantly disrupted the patients’ daily lives as indicated by more than 50% agreeing to each suggested area to be limited by the pain, involving work (90.5%), physical activities (83%), and sleep (78.5%). Patients indicated that they feel helpless by agreeing to the statements: “I cannot control the pain” (66%), “The pain controls me” (70%), and “The pain influences me” (87%). To reduce the pain, mostly medication was mentioned by the patients (57%), followed by relaxation (47%) and distraction (37%). Only 18% consider conversations to allow a pain reduction. The patient's strong desire to confront and manage their pain was evident by agreeing to several of the suggested therapy goals. However, 55% could not imagine being pain free.

Table 1

Characteristics of the included participants
A. Personal data
Age, mean (SD)	49.1 (9.9)
Pain duration, mean (SD)	12.5 ( 11.8)
Sex, n (%) - Female - Male	160 (80) 40 (20)
Labour situation, n (%) - Full time employment - Part time employment - Without work	74 (37) 46 (23) 58 (29)
Work ability, n (%) - Able to work - Unable to work	51 (25.5) 126 (63)
Intake of pain medication, n (%) - Yes - No	154 (77) 43 (21.4)
B. Body: Pain perception
Pain in the following body parts, n (%). - Head - Stomach - Back - Extremities	128 (64) 68 (34) 178 (89) 171 (85,5)
Pain quality, n (%) - Dull - Sharp/stabbing	127 (63.5) 115 (57.5)

- Throbbing

- Pulling

- Burning

81 (40.5)

144 (72)

96 (48)

Radiation of pain, n (%)

175 (87.5)

Pain intensity on a scale from 0 no to 10 high pain, n (%)

- 0–1

- 2–3

- 4–5

- 6–7

- 8–9

- 10

0 (0)

4 (2)

17 (8.5)

63 (31.5)

93 (46.5)

23 (11.5)

When is the pain the worst, n(%)

Ín the…

- Morning

- Noon

- Evenings

- Nights

- Constantly changing

- Always the same

82 (41)

38 (19)

78 (39)

50 (25)

142 (71)

34 (17)

Normal duration of pain in hours, n (%)

- < 2h

- 2-4h

- 4-8h

- 8-12h

- > 12h

17 (8.5)

37 (18.5)

50 (25)

42 (21)

100 (50)

When is the pain the worst?, n (%)

- At rest

- Under stress

- Changing

- Independent of resting and loading

43 (21.5)

92 (46)

99 (49.5)

57 (28.5)

C. Cognition: pain processing

What is the reason for the pain, n (%)

The pain is…. (agree)

- Constitutional

- Psychological

- Both constitutional and psychological

145 (72.5)

137 (68.5)

174 (87)

Personal reason of pain, n (%)

The pain means to me… (agree)

- Suffering

- Punishment

- Injustice

- Warning

- Relief

- Chance

- Fate

- Desire/Pleasure

170 (85)

42 (21)

50 (25)

151 (75.7)

13 (6.5)

24 (12)

71 (35.5)

19 (9.5)

Attitude towards the body, n (%)

Agreement on

- In general I like my body

- I accept my body

- I trust my body

- I am disappointed from my body

- Sometimes I would like to have a different body

- Sometimes I hate my body

- Pain serves self-discovery

- Pain is dependent on culture

- Pain is dependent on believing

- Pain is superfluous

- Pain needs to be fighted

- Pain is vital

- Pain can support conscious life

- Pain is an independent disease

- Emotional pain is worse than physical pain

- Physical pain is worse than emotional pain

- There is no difference between emotional and physical pain

- Physical and emotional pain depend each other

- The population has prejudiced against patients with psychological diseases

118 (59)

139 (69.5)

110 (55)

73 (36.5)

112 (56)

69 (34.5)

49 (24.5)

25 (12.5)

13 (6.5)

60 (30)

161 (80.5)

118 (59)

143 (71.5)

93 (46.5)

90 (45)

64 (32)

86 (43)

184 (92)

194 (97)

E. Pain behaviour

Situations in which the strength or intensity of your pain changes (agree)

- When I relax, my pain becomes less intense

- When I distract myself, my pain becomes less intense

- My pain increases when I get upset

- My pain increases when I get angry

- My pain increases when I am frustrated

125 (62.5)

118 (59)

138 (69)

133 (66.5)

124 (62)

Pain can be reduced by… (agree)

- Movement

- Relaxation

- Distraction

47 (23.5)

94 (47)

74 (37)

- Enjoyment

- Medications

- Conversations

23 (11.5)

114 (57)

37 (18.5)

In which areas do you feel limited by the pain? (agree)

- Self-care (e.g., going shopping)

- Relationships (family, partnership, friends)

- Occupation / Work

- Independence

- Decision-making

- Physical movement

- Eating / Drinking

- Sleep

- Sexuality

110 (55)

141 (70.5)

181 (90.5)

126 (63)

105 (52.5)

166 (83)

43 (21.5)

157 (78.5)

129 (64.5)

Imagine that starting tomorrow, you would have no pain at all. How do you think you would react (agree)?

- I would be relieved and satisfied

- I would celebrate exuberantly

- I would be incredulous and skeptical

- I could then solve other problems

- Nothing would change

- I cannot imagine such a situation (pain-free)

196 (98)

78 (39)

122 (61)

137 (68.5)

19 (9.5)

109 (54.5)

In what ways can your pain be influenced (agree)? - I can influence the pain through my body

- I can influence the pain through my thoughts

- I can influence the pain through my emotions

- I can influence the pain through my behavior

- I cannot control my pain

- I can control my pain

- The pain controls me

- I can influence the pain

- The pain influences me

- I could never accept if my pain were to last forever

52 (26)

47 (23.5)

60 (30)

103 (51.5)

132 (66)

25 (12.5)

140 (70)

59 (29.5)

173 (86.5)

123 (61.5)

What would you expect from therapy, i.e. what goals would you set for yourself in therapy (agree)?

- Freedom from pain

- Relief from pain

- Learn to manage pain better

- Better understand the causes of pain

- Reduce the need for pain medication

- Gain knowledge about pain-aggravating/maintaining factors

- Learn to cope with the pain

- Strengthen self-confidence

119 (59.5)

187 (93.5)

185 (92.5)

191 (95.5)

171 (85.5)

168 (84)

144 (72)

166 (83)

Improve performance at work

Enhance physical mobility

Regain enthusiasm for life

Nothing

174 (87)

185 (92.5)

1 (0.5)

We provide an overview of the characteristics of 200 patients with somatoform pain to allow their identification and an adequate treatment. Our results highlight somatoform pain persistent (> 12 hours/day) and constantly changing nature, which is accompanied by feelings of helplessness among patients. A passive assistance-seeking tendency and reliance on medical interventions might be prominent and combined with neglecting a potential psychological cause of pain. Although somatoform pain patients desire relief and satisfaction through reduced pain, envisioning such relief remains challenging.

Notably, we found that pain lacks symbolic significance and is predominantly seen as suffering, failing to convey emotional pain, despite cognitively acknowledging the dependency of emotional and physical pain. The disconnect between pain and emotions persists, as patients do not recognize that conversations allow the investigation of relationships between the two. Recommended psychotherapy focuses on communication to uncover the interpersonal significance of symptoms and access the patient's inner world, enabling emotional expression and differentiation between physical symptoms and emotions. Additionally, it addresses early relationship experiences to replace insecure attachment patterns with secure ones. Therefore, it is vital to consider childhood attachment issues.

Ringel [15], addresses challenges in medical as well as therapeutic interventions with somatoform patients. He identified an implicit dialogue between doctors and their patients causing a tremendous amount of distress in both parties. Our data provide similar findings: patients exhibit a high level of expectation towards the healthcare system and seek support due to potential pragmatic, organic causes, as they perceive fewer opportunities to act themselves highlighted by their agreement to the statements “I cannot control the pain” and “Pain can be reduced by medication”. This vicious circle might repeat adverse childhood experiences, associated with detrimental effects on both somatic and mental health aspects.

Individuals who were maltreated in childhood have a higher risk for morbidity and mortality related to chronic diseases as well as neurobiological, endocrine and immunological changes [4]. In this context, the hypothesis can be formulated that the experienced helplessness (“I cannot control my pain”) and associated passivity (“The pain influences me”) reflect an early learned helplessness and thus are being re-enacted. This leaves patients more susceptible to heightened physical and emotional reactions, coupled with reduced self-regulation. Hence, patients with somatoform pain still experience emotional distress during physical interactions with others. Further, it might be hypothesized that a patient's approach to relationships combines a desire for them (“the pain limits my relationships”) with a fear of rejection (“The population has prejudiced against patients with psychological diseases”), often hindering their engagement in interactions. Psychotherapists have more time with the patient and education on emotional management strategies, nonetheless, however knowledge about these specific circles of interaction is vital for other health professionals as well.

In summary, our data might assist identifying somatoform pain patients with the following aspects: In cases of somatoform pain disorder, the pain manifests as a persistent, diffuse sensation that proves challenging to discern or attribute to a specific source. Patients acknowledge the dependency of emotional and psychological pain but do not translate this to themself and seem not to consider any emotional factors underlying their discomfort. Furthermore, there tends to be discrepancies among patients regarding the causes, potential remedies, and necessary behaviors in relation to their experience of pain (e.g. desire to confront and manage pain, yet the feeling of limitation in controlling its intensity, identifying a strong dependency solely on medication for relief), which further complicats the understanding and treatment of this condition.

Consequently, in case, health professionals identify a potential patient with somatoform pain the following suggestions, in line with Sauer & Eich [17], might be followed: validate patients, offer reassurance, conduct short physical examinations, slowly introducing psychosocial aspects as well as regular appointments. This might be more effective than keeping the focus on finding a physiological cause of the pain as well as focusing on psychological reasons, before patients are ready. Finally, in line with the S3 guidelines psychotherapeutic care should be initiated. Similar findings as well as the efficacy of a psychotherapeutic intervention (both psychodynamic psychotherapy and behavioral therapy) was additionally analyzed through a systematic review by Sauer & Eich [17].

Strength and Limitations

In this paper, we offer a comprehensive description of our patient cohort, utilizing tools that, while partially validated, are the only viable options available. Notably, our patient sample primarily comprises hospitalized individuals, potentially introducing bias compared to the population with somatoform pain visiting general practitioners. While we assume that this our and the latter population has some similarity in patient characteristics, this needs empirical validation. Our study's strengths lie in its detailed patient description.

The study examines 200 patients with somatoform pain and identifies key characteristics, including the persistent and constantly changing nature of the pain, patients' feelings of helplessness, and a tendency to rely on medical interventions while neglecting potential psychological causes. It also highlights the disconnect between pain and emotions in these patients, which can emphasize the importance of addressing childhood attachment issues and improving communication in therapy. In line with clinical guidelines, we suggest that health professionals should focus on validation, reassurance, and psychosocial aspects in treatment rather than solely searching for a physiological cause of the pain. Further research needs to carefully address this specific finding and compare it to populations with other chronic pain disorders as well as a healthy population in order to verify our results as discriminative.

Ethical Approval and Consent to participate

The study was approved by the responsible ethics committees at the University of Lübeck on 13.08.2013, ID: 13-08. All participants provided written informed consent.

Availability of supporting data

The data is available for sharing upon reasonable request.

Competing interests

The authors declare any conflicts of interest.

Funding

Not applicable.

Ethics approval Consent to Participate

All experiments were performed in accordance with relevant guidelines and regulations.

Consent for Publication

Not Applicable.

Acknowledgements

Not applicable.

Authors´contributions

Lena Barth: Conceptualization of the manuscript, Methodology of the manuscript, Formal Analysis, Writing- Original Draft, Writing – Review & Editing.

Linda Baumbach: Conceptualization of the manuscript, Methodology of the manuscript, Formal Analysis, Writing- Original Draft, Writing – Review & Editing.

André Hajek: Conceptualization of the manuscript, Methodology of the manuscript, Formal Analysis, Writing – Review & Editing.

Lutz Goetzmann: Conceptualization of the study, Methodology of the study, Data collection, Writing – Review & Editing.

Katrin Feiks: Conceptualization of the study, Data Collection, Review & Editing.

Michael Rufer: Conceptualization of the study, Data Collection, Review & Editing.

Kyrill Schwegler: Conceptualization of the study, Data Collection, Review & Editing.

Bianca Schwennen: Conceptualization of the study, Data Collection, Review & Editing.

Kirstin Bernhardt: Conceptualization of the study, Data Collection, Review & Editing.

Uwe Wutzler: Conceptualization of the study, Data Collection, Review & Editing.

Paul Kaiser: Methodology of the study, Writing – Review & Editing

Barbara Ruettner: Methodology of the study, Writing – Review & Editing

Adrian M. Siegel: Conceptualization of the study, Methodology of the study, Data collection, Writing – Review & Editing.

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Characteristics of 200 patients with somatoform pain disorder

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