creation date: 2026-03-05 16:45
tags: Pathologies
Somatic Symptom Disorder
Background
Definitions
Somatic symptom disorder is a disorder characterized by one or more somatic symptoms accompanied by excessive thoughts, feelings, and/or behaviours relating to the symptoms.
Previous diagnoses that are no longer formally recognized that have since been consolidated into somatic symptom disorder are:
- Somatization disorder
- Undifferentiated somatoform disorder
- Hypochondriasis
- Pain disorder
Pathogenesis
The pathogenesis is mostly unknown due to the relatively recent introduction. Multiple psychosocial factors are hypothesized to be involved in the pathogenesis:
- Developmental factors - poor care/negative emotions lead to care-seeking behaviours
- Physical and sexual abuse - associated in epidemiological studies
- Cognitive and perceptual distortions - overinclusive/unrealistic concept of good health and dysfunctional assumptions about the prevalence/communicability of severe illnesses resulting in catastrophic interpretations of sensations
- Difficulties with self-expression - physical symptoms may become a mean to express distress
- Family conflict
- Chronic stressors and maladaptive coping skills - “sick role” may allow for social support, escape from obligations, disability payments, etc.
- Iatrogenic effects - amplified or maintained by physicians due to unnecessary diagnostic testing instead of pursuing psychosocial clues
Clinical Presentation
Signs & Symptoms
Core features include:
- One or more current somatic symptoms that are long-standing (≥6 months) that cause distress or functional impairment
- Somatic symptoms or health concerns are associated with excessive thoughts, worrying, or behaviours consuming substantial time and energy
Types of somatic symptoms include:
- Pain (joint, leg/arm, back, headache, chest, abdominal, dysuria, diffuse)
- Fatigue, syncope, dizziness
- Other specific organ system symptoms (eg. bloating, gas, muscle weakness)
Other findings include:
- Excessive checking behaviours (eg. blood pressure measurements)
- Varying levels of insight (some may recognize their excessive focus while others maintain their conviction that they are direly ill)
- Functional impairment
History & Physical Exam
Several questionnaires are available to document the extent of somatic symptoms. Options include:
- PHQ-15 - somatic symptoms
- Somatic Symptom Scale-8
History should comprise of a general history as well as a complete review of system. Additional history from family and other sources may be necessary for children and adolescents.
Risk Factors
Likely risk factors include:
- Female sex
- Fewer years of education
- Lower socioeconomic status
- History of childhood chronic illness
- History of sexual abuse or other trauma
- Concurrent general medical disorders
- Health anxiety
- Concurrent psychiatric disorder
- Family history of chronic illness
- Functional disorders
Diagnosis
Criteria
Diagnosis is made using the DSM-5-TR criteria:
One or more somatic symptoms that cause distress or psychosocial impairment.
- Excessive thoughts, feelings, or behaviors associated with the somatic symptoms, as demonstrated by one or more of the following:
- Persistent thoughts about the seriousness of the symptoms
- Persistent, severe anxiety about the symptoms or one’s general health
- The time and energy devoted to the symptoms or health concerns is excessive
- Although the specific somatic symptom(s) may change, the disorder is persistent (usually more than six months)
A number of specifiers are included which capture pain predominance, severity, and persistence.
Work-up
Excessive testing should be avoided as it may iatrogenically worsen the disorder. Testing may be done if there is reasonable suspicion a medical diagnosis may be a possible explanation.
Differential
Naturally, the primary differential diagnoses is the presence of an underlying medical disorder. It should be noted, however, that the diagnosis of a medical disorder does not exclude the diagnosis of somatic symptom disorder.
Other psychiatric disorders with overlap include:
- Adjustment disorder
- Body dysmorphic disorder
- Functional neurological symptom disorder
- Delusional disorder (somatic subtype)
- Depressive disorders
- Generalized anxiety disorder
- Illness anxiety disorder
- OCD
- Panic disorder
Red Flags / Complications
Management
General Treatment
It should be noted that debating with the patient whether the condition is psychiatric or nonpsychiatric is unproductive and may undermine therapeutic relationship.
Patients can be scheduled for regular visits (q4-8 weeks) to the office not contingent on active symptoms. Goals of this are:
- Establish terapeutic alliance
- Acknowledge and legitimize the somatic symptoms
- Explain symptoms may arise without disease presence
- Set goal of treatment as functional improvement through exercise and activation
- Evaluate for general medical diseases without excessive testing and specialist referral
- Reassurance that grave diseases are ruled out while acknowledging uncertainty
- Taper and discontinue unnecessary medications as required
Treatment-Resistant Patients
Patients who do not respond to initial treatment may require:
- Consultation with psychiatrist (not necessarily referral as patient may feel dismissed)
- Family meeting
- Relaxation training
- Psychoeducation
- Antidepressants (SSRI, SNRI, low-dose tricyclics)