Diagnostic criteria for somatization disorder:

1. Criterion A - Patients show multiple psychosomatic symptoms without organic cause for at least two years, which cannot be explained even when illness is present and impair social life. Occasional vegetative symptoms are not predominant or distressing.
2. Criterion B - Patients repeatedly seek medical help or local healers.
3. Criterion C - Patients reject medical diagnoses without physical cause and accept them only temporarily, often only for a short time after an examination.

• Criterion D - Six or more symptoms from at least two different groups:
  • Gastrointestinal symptoms: Abdominal pain, nausea, feeling of bloating, bad taste in mouth, vomiting, diarrhea.
  • Cardiovascular symptoms: Shortness of breath, chest pain.
  • Urogenital symptoms: Problems urinating, unpleasant sensations in genital area, vaginal discharge.
  • Skin and pain symptoms: Skin discoloration, pain in limbs or joints, numbness or tingling.

F45.0 Somatization disorder and F45.1 undifferentiated somatization disorder (numerous persistent physical complaints without meeting the full criteria of a somatization disorder) belong to the group of somatoform disorders (ICD-10: diagnosis F45).

CBT = Cognitive Behavioral Therapy in the treatment of somatoform disorders, including somatization disorder, is classified as follows in the official guideline: S3 guideline Functional Somatic Symptoms German Association for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN):

1. "CBT for somatoform disorders has the following goals:
   1. Identification and modification of cognitive and behavioral patterns that maintain the symptoms: CBT helps patients recognize negative thoughts and attitudes about their complaints and replace them with more realistic and helpful thoughts.
   2. Improvement of perception and management of body signals: CBT can help patients better understand their body signals and respond to them in a healthy way.
   3. Reduction of avoidance behavior: CBT can help patients reduce avoidance behavior that maintains symptoms and limits quality of life.
   4. Learning coping strategies: CBT can help patients develop coping strategies to deal with stress, anxiety, and difficult emotions.
   5. Improvement of social interaction: CBT can help patients improve their communication and social relationships.
2. CBT for somatoform disorders consists of various techniques, including:
   1. Exposure: In exposure, patients are exposed to their anxiety- and avoidance-triggering stimuli in a graded manner. This can help reduce anxiety and overcome avoidance.
   2. Cognitive restructuring: Cognitive restructuring helps patients recognize negative thought patterns and replace them with more realistic and helpful thoughts.
   3. Relaxation techniques: Relaxation techniques such as progressive muscle relaxation or autogenic training can help reduce stress and tension.
   4. Biofeedback: Biofeedback can help patients better control their bodily functions and reduce their symptoms. CBT is an effective treatment for somatoform disorders. Studies have shown that CBT can significantly alleviate symptoms of somatoform disorders, improve quality of life, and increase functional capacity in daily life".

• Somatoform disorders primarily show physical symptoms, while psychological complaints may only be perceived as a consequence of physical suffering.
• Somatization disorder is a complex mental disorder in which physical complaints occur for which no sufficient medical explanation can be found. This disorder can be promoted by various factors and mechanisms (from a learning theory and psychodynamic perspective):

1. Affect equivalents and conversion/hysteria: Affect equivalents refer to symptoms that indicate psychological pain, while conversion or hysteria condenses conflicts into bodily symptoms to avoid emotions. Here, the body becomes a stage for unresolved conflicts, with psychic energy being redirected into somatic reactions to protect them from consciousness. Hysteria as an expressive illness manifests in compromised enactments, where the body serves as a medium for unconscious conflicts that are expressed in symbols and symptoms.
2. Preparation diseases and chronic sympathetic overstimulation: Preparation diseases show a persistent readiness for action, accompanied by chronic sympathetic overstimulation and a sustained physical preparation response that manifests in physical symptoms. This overstimulation leads to long-term suppressed emotional tensions that can manifest in physical symptoms and can even paradoxically trigger illnesses. At the same time, chronic parasympathetic inhibition can occur, which restricts the ability for solution-oriented action.
3. Increased attention focus on the body or physical symptomatology: An increased attention focus on the body has a function in mental life, for example, by serving self-esteem regulation, self-feeling regulation, maintenance of self-coherence and ego boundaries, defense of self-survival, and support of experiencing self-boundaries. This increased focus can lead to normal physical sensations being overinterpreted and result in persistent rumination about physical symptoms, which can amplify the symptoms.
4. The threat to self-coherence: The separation or absence of feelings interrupts self-coherence, which is evident in how the body is used to stabilize oneself. The physical boundaries are occupied and manipulated to maintain and build oneself up.
5. Defense mechanisms: Problems in life and defense mechanisms of the unconscious can lead to somatic complaints without those affected being aware of it. Defense mechanisms are strategies of the unconscious to deal with stress and conflicts by keeping away or reducing unpleasant thoughts, feelings, or memories. These mechanisms can manifest on a physical level and lead to somatic complaints without us being aware of them.
6. Nature of experienced object relations and difficulties with one's own self: The quality of relationships can affect physical well-being, as difficult or stressful relationships can lead to physical discomfort. Difficulties with one's own self, such as the inability to understand one's own feelings, can lead to physical complaints because emotions cannot be processed appropriately.
7. Interoceptive ability and somatosensory amplification: People with increased interoceptive ability perceive physical sensations more intensely and may interpret them as an indication of illness. Somatosensory amplification leads to normal physical sensations being excessively interpreted as signs of illness, which leads to persistent rumination about physical symptoms and can amplify the symptoms.
8. Reinforcement through attention and reactions of others: Sometimes we also receive attention or are rewarded when we are physically ill. This can lead to us feeling sick more often than we actually are. When other people notice or respond to our physical complaints, we may show physical symptoms more often, even if they are not serious.

Behavioral Therapy Interventions:

Cognitive Interventions:

1. Positive goal conceptions: Use of fantasy and imagination exercises to promote positive future images.
2. Behavioral experiments: Practical tests for identifying and adjusting negative thought patterns.
3. Realistic concept of health: Experiments to change attitudes toward health and illness.
4. Hypochondriacal beliefs: Identification and restructuring of erroneous illness assumptions.
5. Search for alternative explanations: Support in searching for different interpretations of symptoms.

Behavior-focused Interventions:

1. Symptom diaries: Documentation of complaints and influencing factors for analysis.
2. Coping strategies: Teaching practical techniques for symptom control.
3. Relaxation techniques: Application of PMR for stress reduction.
4. Increase resilience: Gradual increase in physical activity.
5. Protective and avoidance behavior: Gradual exposure and reduction of avoidance behavior.

Interpersonal Interventions (group therapy extremely important here):

1. Social skills: Training to improve interpersonal abilities.
2. Closeness-distance regulation: Development of healthy boundaries in relationships.
3. Dyadic relationships: Processing conflicts and promoting understanding in interpersonal relationships.
4. Corrective experiences: Facilitating positive interpersonal interactions to change dysfunctional patterns.
5. Aggression avoidance: Conscious examination of aggression-avoiding behaviors.

Emotion Regulation and Body-oriented Interventions (group therapy extremely important here):

1. Desomatization: Separation of physical and psychological sensations.
2. Symptom relinquishment: Acceptance and processing of psychological suffering.
3. Affect regulation: Improvement of the ability to control and express emotions.
4. Integration of negative affects: Inclusion and processing of negative emotions.
5. Improve body experience: Work on perception and integration of physical sensations.

Therapeutic Relationship and Framework Conditions:

1. Use of one's own perceptions: Use of the therapist's empathy to support therapy. Perception in group therapy work.
2. Education about triggers: Identification and processing of situations that destabilize self-image.
3. Building trust: Development of a safe framework for experiencing and processing emotions.
4. Transformative visions: Promotion of a positive future vision and development of new perspectives.
5. Integration of new insights: Incorporation of new findings and experiences into the self-concept.