Somatic Symptom Disorder

The typical presentation of somatic symptom disorder is recurring physical complaints, which usually begin before age 30, and sometimes during childhood. Most patients have multiple somatic symptoms, but some have only 1 severe symptom, typically pain. Any body part may be affected, and specific symptoms and their frequency vary across cultures. 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.

The central feature of somatic symptom disorder is the patient's excessive or maladaptive thoughts, feelings, or behaviors in response to the symptoms. When somatic symptom disorder accompanies a general medical condition, patients may have an exaggerated response to the implications of the medical disorder; for example, patients who have completely physically recovered 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 condition, patients worry excessively about the symptoms and their possible catastrophic consequences and are very difficult to reassure. Attempts at reassurance may often be 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 the adverse effects of medications.

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 be a coping mechanism for patients to avoid responsibilities, but such symptoms may concomitantly prevent pleasure and act as punishment, suggesting underlying feelings of unworthiness and guilt.

• Psychiatric assessment

• General medical evaluation

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 should include 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 condition is the cause of the symptoms. Once a general medical condition 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 clinician is uncertain the diagnosis is benign. However, because patients with somatic symptom disorder, like all individuals, may subsequently develop general medical conditions, appropriate examinations and tests should be done when symptoms change significantly and new symptoms or objective signs develop.

Somatic symptom disorder may be difficult to diagnose in older patients because certain symptoms, such as fatigue or pain, may normally be present as a patient ages.

Several other disorders may mimic the presentation of somatic symptom disorder. 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 their accompanying excessive thoughts, feelings, and behaviors.

• Cognitive-behavioral therapy

• Antidepressants

The first-line treatment for somatic symptom disorder is psychotherapy, particularly cognitive-behavioral therapy. Patients, even those who have a satisfactory relationship with a primary care clinician, should be referred to a psychiatrist. Such therapy has demonstrated effectiveness in durably reducing somatic symptoms, psychological distress, and improving physical functioning (1, 2). 

Pharmacologic treatment, particularly with newer-generation antidepressants (eg, SSRI, SNRI) are considered second-line and may benefit those with concurrent psychiatric disorders (eg, depression) (3).

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.