Somatic Symptom Disorder
Somatic symptom disorder is characterized by multiple persistent physical complaints that are associated with excessive and maladaptive thoughts, feelings, and behaviors related to those symptoms. The symptoms are not intentionally produced or feigned and may or may not accompany known medical illness. Diagnosis is based on history from the patient and occasionally from family members. Treatment focuses on establishing a consistent, supportive physician-patient relationship that avoids exposing the patient to unnecessary diagnostic testing and therapies.
Some previously distinct somatic disorders—somatization disorder, undifferentiated somatoform disorder, hypochondriasis, and somatoform pain disorder—are now considered somatic symptom disorders. All have common features, including somatization—the expression of mental phenomena as physical (somatic) symptoms.
The symptoms may or may not be associated with another medical problem; symptoms no longer have to be medically unexplained but are characterized by the patient having disproportionately excessive thoughts, feelings and concerns about them. Sometimes the symptoms are normal body sensations or discomfort that do not signify a serious disorder.
Patients are commonly unaware of their underlying mental problem and believe that they have physical ailments, so they typically continue to pressure physicians for additional or repeated tests and treatments even after results of a thorough evaluation have been negative.
Recurring physical complaints usually begin before age 30; 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 another medical disorder, patients overrespond to the implications of the medical disorder; for example, patients who have had complete physical recovery from an uncomplicated MI may continue to behave as invalids or constantly worry about having another MI.
Whether or not symptoms are related to another 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 physician 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 drug effects.
Any body part may be affected, and specific symptoms and their frequency vary among 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.
Symptoms must be distressing or disruptive of daily life for > 6 mo and be associated with at least one of the following:
At first presentation, physicians take an extensive history (sometimes conferring with family members) and do a thorough examination and often testing to determine whether a medical disorder is the cause. Because patients with somatic symptom disorder may develop concurrent physical disorders, appropriate examinations and tests should also be done when symptoms change significantly or when objective signs develop. However, once a medical disorder has clearly been excluded or a mild disorder has been identified and treated, physicians should avoid repeating tests; patients are rarely reassured by negative test results and may interpret continued testing as confirmation that the physician is uncertain the diagnosis is benign.
Illness anxiety disorder has similar manifestations except that physical symptoms are absent or minimal. Somatic symptom disorder is distinguished from generalized anxiety disorder, conversion disorder, and major depression by the predominance, multiplicity, and persistence of physical symptoms and the accompanying excessive thoughts, feelings, and behaviors.
Patients, even those who have a satisfactory relationship with a primary physician, are commonly referred to a psychiatrist. Pharmacologic treatment of concurrent mental 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 physician, who coordinates all of their health care, offers symptomatic relief, sees them regularly, and protects them from unnecessary tests and procedures.