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Somatic Symptom Disorder

Somatic symptom disorder (SSD; formerly known as "somatization disorder" or "somatoform disorder") is a condition characterized by the presence of 1 or more physical symptoms associated with excessive thoughts and feelings about symptom severity. Symptoms are usually not dangerous, but the patient devotes excessive time and energy to figuring out their underlying cause and how to treat them. Management relies on a strong therapeutic alliance between patient and provider.

Last updated: Nov 10, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Epidemiology and Etiology

Epidemiology

  • Estimated prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in the general population: 0.1%
  • More commonly affects women 
  • Risk factors:
    • Low socioeconomic status 
    • Low educational level 
    • Minority population

Etiology

  • Unknown
  • Often associated with physical and sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse in childhood
  • Poor awareness of emotions and emotional development during childhood due to parental neglect Neglect Child Abuse or lack of emotional closeness
  • Excessive anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder and attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment to bodily processes or illnesses
  • Comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus
    • Mood disorders
    • Substance use disorder
    • PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD)

Clinical Presentation

Age of onset

  • Manifests in adolescence and early adulthood 
  • Older adults presenting for the first time with somatic symptoms Somatic symptoms Major Depressive Disorder are much more likely to have an occult organic condition than somatic symptom disorder.

Physical complaints

  • Presents with multiple somatic complaints, often across various organ systems
  • Symptoms may include (but are not limited to) nonspecific pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, GI distress, palpitations Palpitations Ebstein’s Anomaly, weakness, and numbness.
  • Note: Descriptions of somatic symptoms Somatic symptoms Major Depressive Disorder may vary depending on cultural factors.

Emotional complaints

  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are significantly distressed about their symptoms and have a high level of worry about their health.
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship‘ concerns are time consuming and limit Limit A value (e.g., pressure or time) that should not be exceeded and which is specified by the operator to protect the lung Invasive Mechanical Ventilation activities of daily living.

Diagnosis

A diagnosis of somatic symptom disorder (SSD) may not be made until the symptoms have no other clinical explanation.

Diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests

The following diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests may be used to explain or rule out physical causes of the symptoms. 

  • CBC
  • Basic metabolic panel Basic Metabolic Panel Primary vs Secondary Headaches
  • Thyroid Thyroid The thyroid gland is one of the largest endocrine glands in the human body. The thyroid gland is a highly vascular, brownish-red gland located in the visceral compartment of the anterior region of the neck. Thyroid Gland: Anatomy panel
  • Liver function tests Liver function tests Liver function tests, also known as hepatic function panels, are one of the most commonly performed screening blood tests. Such tests are also used to detect, evaluate, and monitor acute and chronic liver diseases. Liver Function Tests
  • Urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children
  • Toxicology screen
  • Imaging

Diagnostic criteria

  • Emotional distress or functional impairment related to ≥ 1 somatic symptom
  • Significant emotional or behavioral impairment related to somatic symptoms Somatic symptoms Major Depressive Disorder, as evidenced by  ≥ 1 of the following manifestations:
    • Preoccupation Preoccupation Body Dysmorphic Disorder with symptom severity
    • Persistent and severe anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder related to the somatic symptom(s) and overall health status
    • Excessive commitment of time and resources to exploring and/or attempting to resolve the symptom(s)
  • Duration of above manifestations > 6 months
Table: Features of somatic symptom disorder compared with similar conditions
Symptoms Excessive worry Exam findings
Somatic symptom disorder + +
Illness anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder +
Conversion disorder Conversion disorder Conversion disorder (CD), also called functional neurological symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Conversion Disorder + Atypical

Management

Practice principles

Individuals with SSD often feel misunderstood. Therefore, the primary goal of treatment is to form a therapeutic alliance with the patient. 

  • Regularly schedule visits with the same physician to establish a relationship and address patient concerns. 
  • Encourage functional behavior, such as relaxation techniques and moderate exercise.
  • Avoid repetitive, risky, or costly diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests that serve to calm the patient.
  • Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship should be discouraged from seeking multiple specialist opinions and ED consultations unless severe symptoms arise.

Treatment focus

Whether to put the focus of treatment on the physical or psychiatric symptoms is often difficult to determine. 

Differential Diagnosis

  • Illness anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder: a condition characterized by prolonged and exaggerated concern about one’s health and possible illness. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of serious medical conditions. Somatic symptoms Somatic symptoms Major Depressive Disorder are only mild or nonexistent. 
  • Conversion disorder Conversion disorder Conversion disorder (CD), also called functional neurological symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Conversion Disorder: the presence of symptoms or deficits that affect voluntary motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function in a way that suggests a neurological condition but is not explained by medical findings. Diagnosis is clinical, and management includes psychological and physical therapy Physical Therapy Becker Muscular Dystrophy. Unlike SSD, the motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology or sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology symptoms of conversion disorder Conversion disorder Conversion disorder (CD), also called functional neurological symptom disorder, is a psychiatric disorder with prominent motor or sensory impairment which is not compatible with any known neurologic medical condition. The deficits are not consciously produced. Conversion Disorder are specific and more well defined. 
  • Delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder: a psychiatric condition in which patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship cannot tell the difference between reality and imagination. These delusions have a fixed quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement. Compared with delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder, individuals with SSD are able to accept the possibility that they may not have a certain disease.

References

  1. American Psychiatric Association. (2013). Somatic symptom and related disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
  2. D’Souza RS, Hooten WM. Somatic Syndrome Disorders. [Updated 2021 Mar 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK532253/
  3. Sadock, BJ, Sadock, VA, & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 13, Psychosomatic medicine, pages 465-503. Philadelphia, PA: Lippincott Williams and Wilkins.
  4. Henningsen P. (2018). Management of somatic symptom disorder. Dialogues in clinical neuroscience, 20(1), 23–31. https://doi.org/10.31887/DCNS.2018.20.1/phenningsen

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