Somatic Symptom Disorder

Somatic symptom disorder (SSD) 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.

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Epidemiology and Etiology

Epidemiology

  • Estimated prevalence 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 or lack of emotional closeness
  • Excessive anxiety and attention to bodily processes or illnesses
  • Comorbidities: 
    • 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 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 Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, fatigue, GI distress, palpitations, weakness, and numbness.
  • Note: Descriptions of somatic symptoms may vary depending on cultural factors.

Emotional complaints

  • Patients are significantly distressed about their symptoms and have a high level of worry about their health.
  • Patients’ concerns are time consuming and limit 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 may be used to explain or rule out physical causes of the symptoms. 

  • CBC
  • Basic metabolic panel
  • Thyroid 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
  • Toxicology screen
  • Imaging

DSM-V diagnostic criteria

  • At least 1 somatic symptom that causes distress or functional impairment
  • Overwhelming thoughts, emotions, or actions associated with somatic symptoms, as demonstrated by 1 or more of the following:
    • Persistent thoughts about the seriousness of the symptoms
    • Severe and constant anxiety about the symptoms or one’s health
    • Devoting exorbitant time and energy to the symptoms
  • The overall disorder is present > 6 months (specific symptoms may change).
Table: Features of somatic symptom disorder compared with similar conditions
Symptoms Excessive worry Exam findings
Somatic symptom disorder + +
Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one's health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety 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 that serve to calm the patient.
  • Patients 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. 

  • CBT is the 1st-line treatment for most patients. 
  • Treatment of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain should be accomplished with nonopioid analgesics.
  • Antidepressants such as selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have shown modest efficacy compared with placebo.

Differential Diagnosis

  • Illness anxiety disorder Illness Anxiety Disorder Illness anxiety disorder, formerly known as hypochondriasis, is a chronic condition characterized by a prolonged and exaggerated concern about one's health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of a serious medical condition. Illness Anxiety Disorder: a condition characterized by prolonged and exaggerated concern about one’s health and possible illness. Patients fear or are convinced that they have a disease and interpret minor or normal bodily symptoms as signs of serious medical conditions. Somatic symptoms 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 or sensory 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. Unlike SSD, the motor or sensory symptoms of 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 cannot tell the difference between reality and imagination. These delusions have a fixed quality. Compared with 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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