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Somatic Symptom Disorder

by Joel E. Dimsdale, MD

Somatic symptom disorder is characterized by one or more chronic physical symptoms accompanied by significant levels of distress, worries, and difficulty in daily functioning.

  • People with somatic symptom disorder are preoccupied with their symptoms and spend excessive amounts of time and energy on these symptoms and health concerns.

  • Doctors diagnose the disorder when people continue to be preoccupied and concerned with their symptoms after physical disorders have been ruled out or when their response to their physical disorder is unusually intense.

  • Psychotherapy, particularly cognitive behavioral therapy, can help, as can having a supportive, trustful relationship with a doctor.

This disorder replaces several previously used diagnoses, such as somatization disorder, hypochondriasis, pain disorder, undifferentiated somatoform disorder, and some other related disorders, all of which involve physical (somatic) symptoms.

Doctors used to diagnose this type of mental health disorder (sometimes called psychosomatic or somatoform disorders—see Overview of Somatic Symptom and Related Disorders) when people reported physical symptoms that were not explained by a physical disorder. However, it is sometimes difficult for doctors to determine that a person has no physical disorder. Also, it is not usually appropriate to diagnose a person with a mental disorder simply because doctors cannot find a physical cause for the symptoms. Test results could have been wrong, or the wrong tests could have been used. Furthermore, many people may have a physical disorder that contributes to their symptoms, but they react so excessively or inappropriately to it that they are considered to have a mental health disorder. Also, making such a distinction between physical and mental symptoms sometimes makes people think that doctors do not believe their symptoms are real.

Because of these problems, doctors now base the diagnosis of somatic symptom disorder on how people respond to their symptoms or health concerns. The main criterion is that people's preoccupation with their physical symptoms is so strong that it causes significant distress and interferes with daily functioning.

People with somatic symptom disorder do not intentionally produce or pretend to have the symptoms, and the symptoms may or may not be associated with another medical problem. People who have somatic symptom disorder and another medical problem may overreact to the medical problem. For example, after a heart attack, they may completely recover physically, but they may continue to behave as invalids or constantly worry about having another heart attack.

Many people with the disorder do not realize that they have a mental health disorder, and they are convinced that they have physical symptoms requiring medical attention. Consequently, they typically continue to pressure doctors for additional or repeated tests and treatments even after a thorough evaluation has detected nothing or nothing seriously wrong.

Did You Know...

  • People with somatic symptoms disorder may wander from one doctor or hospital to another, searching for what they think is adequate care.

Symptoms

People with somatic symptom disorder are preoccupied with their physical symptoms, particularly how serious they may be. For these people, health concerns are often the main and sometimes all-consuming focus in life.

The physical symptoms usually begin before age 30, sometimes during childhood. Most people have many symptoms, but some have only one severe symptom, typically pain. Symptoms may be specific (such as pain in the abdomen) or vague (such as fatigue). Any part of the body may be the focus of concern.

People worry excessively about the symptoms and their possible catastrophic consequences. Their worry is out of proportion to the symptoms. People may interpret normal sensations or discomfort, such as a grumbling stomach, to a physical disorder. They tend to think the worst about any symptoms they experience. The symptoms themselves or excessive worry about them is distressing or disrupts all aspects of daily life. Some people become depressed.

People may become dependent on others, demanding help and emotional support and becoming angry when they feel their needs are not being met. They may also threaten or attempt suicide. When their doctor tries to reassure them, they often think that the doctor is not taking their symptoms seriously. Often dissatisfied with their medical care, they typically go from one doctor to another or seek treatment from several doctors at the same time. Many do not respond to medical treatment, which may even cause the symptoms to worsen. Some seem unusually sensitive to the side effects of drugs.

The intensity and persistence of symptoms may reflect a strong desire to be cared for. Symptoms may help people avoid responsibilities but may also prevent them from enjoying activities and act as punishment, suggesting that they may have underlying feelings of unworthiness and guilt.

Symptoms may lessen or worsen, but symptoms persist and are rarely completely relieved for any length of time.

Diagnosis

Doctors diagnose the disorder when people do the following:

  • Have symptoms that worry them excessively and/or disrupt their daily life

  • Think about how serious their symptoms are constantly

  • Are extremely anxious about their health or the symptoms

  • Spend an excessive amount of time and energy on the symptoms or health concerns

To determine whether symptoms are due to a physical disorder, doctors do a thorough examination and often do tests.

Somatic symptom disorder can be distinguished from similar mental health disorders by its many persistent symptoms and the accompanying excessive thoughts and worries about the symptoms.

This disorder may be missed in older people because certain symptoms, such as fatigue or pain, are considered part of aging or because worry about symptoms is considered understandable in older people, who usually have several medical problems and take many drugs.

Treatment

Even when people have a good relationship with their primary care doctor, they are often referred to a psychiatrist. Psychotherapy, particularly cognitive behavioral therapy, is the most effective treatment. Depression, if present, is treated.

People with this disorder benefit from having a supportive, trustful relationship with a doctor. The doctor can coordinate their health care, offer treatments to relieve symptoms, see them regularly, and protect them from unnecessary tests and treatments. However, the doctor must remain alert to the possibility that these people may develop a physical disorder that requires evaluation and treatment.

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