Somatic symptom disorder is characterized by disproportionate and excessive thoughts, feelings, and concerns about physical symptoms. The symptoms are not intentionally produced or feigned and may or may or may not accompany a general medical illness. Diagnosis is based on history from the patient and occasionally from family members. Treatment includes cognitive-behavioral therapy. Patients benefit from establishing a consistent, supportive physician-patient relationship that avoids exposing the patient to unnecessary diagnostic testing and therapies.
(See also Overview of Somatization.)
Several previously distinct somatization disorders—somatization disorder, undifferentiated somatoform disorder, and somatoform pain disorder—that were included in previous editions of the Diagnostic and Statistical Manual of Mental Disorders are now categorized into 1 diagnosis, called somatic symptom disorder. The diagnosis is characterized by the patient having disproportionately excessive thoughts, feelings, and concerns about physical symptoms. Another change from the previous diagnostic criteria is that somatic symptom disorder is not excluded by the presence of a general medical condition associated with the symptoms; some patients have concurrent physical and psychiatric disorders.
Patients are commonly unaware of their underlying psychiatric issue and believe that they have physical ailments, so they typically continue to pressure clinicians for additional or repeated tests and treatments even after results of a thorough evaluation have been negative.
Symptoms and Signs of Somatic Symptom Disorder
Recurring physical complaints usually begin before age 30, sometimes during childhood. Most patients have multiple somatic symptoms, but some have only one severe symptom, typically pain. Severity may fluctuate, but symptoms persist and rarely remit for any extended period. The symptoms themselves or excessive worry about them is distressing or disrupts daily life. Some patients become overtly depressed.
When somatic symptom disorder accompanies a general medical disorder, patients typically overrespond to the implications of the medical disorder; for example, patients who have had complete physical recovery from an uncomplicated myocardial infarction (MI) may continue to behave as invalids or constantly worry about having another MI.
Whether or not symptoms are related to a general medical disorder, patients worry excessively about the symptoms and their possible catastrophic consequences and are very difficult to reassure. Attempts at reassurance are often interpreted as the clinician not taking their symptoms seriously.
Health concerns often assume a central and sometimes all-consuming role in a patient's life. Patients are very anxious about their health and frequently seem unusually sensitive to adverse effects of medications.
Any body part may be affected, and specific symptoms and their frequency vary across cultures.
Whatever the manifestations, the essence of somatic symptom disorder is the patient's excessive or maladaptive thoughts, feelings, or behaviors in response to the symptoms.
Patients may become dependent on others, demanding help and emotional support and becoming angry when they feel their needs are not met. They may also threaten or attempt suicide. Often dissatisfied with their medical care, they typically go from one physician to another or seek treatment from several physicians concurrently.
The intensity and persistence of symptoms may reflect a strong desire to be cared for. Symptoms may help patients avoid responsibilities but may also prevent pleasure and act as punishment, suggesting underlying feelings of unworthiness and guilt.
Diagnosis of Somatic Symptom Disorder
Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria
General medical evaluation to exclude other etiologies
Symptoms must be distressing or disruptive of daily life for > 6 months and be associated with at least one of the following (1):
Disproportionate and persistent thoughts about the seriousness of the symptoms
Persistently high anxiety about health or the symptoms
Excessive time and energy spent on the symptoms or health concerns
Evaluation at first presentation includes an extensive history (sometimes conferring with family members), a thorough physical examination, and often further evaluation with laboratory testing or imaging to determine whether a general medical disorder is the cause of the symptoms. Once a medical disorder associated with existing symptoms has clearly been excluded or a disorder has been identified and treated, tests to evaluate those symptoms should not be repeated. Patients are rarely reassured by negative test results and may interpret continued testing as confirmation that the physician is uncertain the diagnosis is benign. However, because patients with somatic symptom disorder, like all individuals, may subsequently develop general medical disorders, appropriate examinations and tests should be done when symptoms change significantly, new symptoms develop, or objective signs develop.
Pearls & Pitfalls
|
Somatic symptom disorder may not be diagnosed in older patients because certain symptoms, such as fatigue or pain, are considered part of aging. Their preoccupation with these symptoms of aging is understandable, particularly when several comorbidities and polypharmacy are present.
Illness anxiety disorder has similar manifestations except that physical symptoms are absent or minimal. Somatic symptom disorder is distinguished from generalized anxiety disorder, functional neurological symptom disorder, and major depression by the predominance, multiplicity, and persistence of physical symptoms and the accompanying excessive thoughts, feelings, and behaviors.
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, 2022, pp 351-356.
Treatment of Somatic Symptom Disorder
Cognitive-behavioral therapy
Patients, even those who have a satisfactory relationship with a primary care clinician, are commonly referred to a psychiatrist. Pharmacologic treatment of concurrent psychiatric disorders (eg, depression) may help; however, the primary intervention is psychotherapy, particularly cognitive-behavioral therapy.
Patients also benefit from having a supportive relationship with a primary care clinician, who coordinates all of their health care, offers symptomatic relief, sees them regularly, and protects them from unnecessary tests and procedures.
Depression, if present, is treated.
