Day # 119: Somatic Symptom Disorder

Today we will continue our current theme of psychosomatic disorders as we discuss somatic symptom disorder.

Today's Content Level: Beginner, Intermediate

Introduction 1

• Somatic symptom disorder (SSD) is a psychosomatic condition characterized by at least one (and often multiple) physical symptoms that are distressing to the patient or result in significant disruption of their daily life.

• The key difference between somatic symptom disorder and illness anxiety is that somatic symptom disorder is characterized by perseveration about multiple somatic symptoms whereas illness anxiety is generated by fear of having or developing a serious illness.

• This diagnosis was introduced in the DSM-5 and patients were previously diagnosed with "hypochondriasis".

Diagnostic Criteria 2

• One or more somatic symptoms that are distressing or result in significant disruption of daily life.

• Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns. Examples include persistent and excessive thoughts about the seriousness of symptoms, high level of anxiety about symptoms, excessive time/energy devoted to these symptoms or health concerns.

• Duration of symptoms typically ≥ 6 months.

• Specifiers: with predominant pain (previously pain disorder); persistent (severe symptoms, marked impair­ment, and long duration); severity (mild/moderate/severe)

Epidemiology/Pathogenesis 3, 4

• Prevalence estimated to be about 5-7% in the general adult population.

• Prevalence increases to approximately 17% in the primary care patient population.

• Higher female representation (female-to-male ratio about 10:1).

• Can occur in childhood, adolescence, or adulthood, but symptoms may worsen with age.

• Risk factors include history of childhood sexual abuse, childhood neglect, chaotic lifestyle, fewer years of education, lower socioeconomic status, unemployment, alcohol and substance abuse, personality disorders, and certain populations with functional disorders including irritable bowel syndrome, fibromyalgia, and chronic fatigue syndrome

Clinical Pearls 5, 6

• People with somatic symptom disorder (SSD) often seek initial care from their primary care provider as opposed to a mental health care provider.

• Common somatic symptoms reported by patients with SSD include pain (most common), headaches, weakness, dizziness, fainting, diarrhea, constipation, bowel or bladder incontinence, painful menstrual periods, or pain during sexual activity.

• A diagnosis may first be suggested by a vague and often inconsistent history of present illness, symptoms that are rarely alleviated with medical interventions, patient attribution of normal sensations as medical illness, avoidance of physical activity, high sensitivity to medication adverse effects, and/or medical care from multiple providers for the same complaints.

• Somatic symptoms are typically present consistently for at least 6 months, but the specific physical symptoms may change over that period of time.

• Somatic symptom disorder patients typically express significant concern over their condition and chronically perseverate over it, whereas conversion disorder patients often have an abrupt onset of their neurological symptoms (blindness, etc.) but not infrequently appear unconcerned.

• Keep in mind that symptoms may or may not be associated with another medical condition. The di­agnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together. For example, an individual may become se­riously disabled by symptoms of somatic symptom disorder after an uncomplicated viral infection even if the infection itself did not result in any disability.

• Obtain a thorough history, a full review of systems (not only at the location of the symptom), and a comprehensive physical exam.

• Important elements to consider when gathering the history-> determine patients beliefs about cause of symptoms; associated thoughts, behaviors, emotions, and impact on function; duration of symptoms; mitigating and exacerbating factors; prior pattern of similar presentations; prior and concurrent workups; relationships with previous providers; and insight regarding symptoms and behaviors.

• Limited laboratory testing is recommended as it is common for patients with SSD to have had a thorough prior workup, excessive testing introduces the risk of false-positive results, and may enforce over-utilization of medical resources.

• A full psychiatric evaluation should also be performed given the high frequency of comorbid psychiatric disease. Rule out anxiety, mood, substance use, personality, trauma, and other somatic disorders.

• Optional questionnaires: the Patient Health Questionnaire-15 (PHQ-15); The Somatoform Disorders Symptom Checklist; The Somatic Symptom Scale–8 (SSS-8); Symptom Checklist-90 somatization scale, Whiteley Index, and 29-item Illness Attitude Scale.

• Differential diagnosis: consider illness anxiety disorder, obsessive-compulsive disorder, body dysmorphic disorder, or delusional disorder, somatic type.

• Prognosis: the course tends to be chronic and debilitating. Symptoms may periodically improve and then worsen under stress. Longitudinal studies show considerable chronicity, with up to 90% of cases lasting longer than 5 years.

Treatment 7, 8

• Treatment approach is largely based on studies of patients with hypochondriasis and thus overlaps with treatment of illness anxiety disorder.

• General approach: Team-based approach with primary care and behavioral health. There should be regularly scheduled visits to one primary care physician with a focus on reassurance, acknowledging health fears, education about coping, and limiting unnecessary tests/referrals. Discuss which medical conditions, including ones that are life-threatening, have been ruled out and offer evidence. Educate and empathically acknowledge that real symptoms can be present even in the absence of other disease and clarify that symptoms are real (not faked). It is often best to address psychological issues slowly, and patients may initially resist referral to a mental health professional. The main goal of treatment is to improve patients functional status and coping rather than elimination of symptoms. This is the most fundamental part of the successful management of IAD. It is a delicate balance of validating the patients' concerns regarding their health fears, yet providing reassurance and education about normal bodily functions

• Psychotherapy: Cognitive behavioral therapy (CBT) is first-line treatment and involves cognitive restructuring of dysfunctional beliefs, misattribution of symptoms, and modification of maladaptive behaviors. Other forms of therapy have been studied with some benefit including acceptance and commitment therapy (ACT), mindfulness-based cognitive therapy, relaxation training, problem-solving therapy, and behavioral stress management. Other techniques can reduce somatic symptoms including relaxation training (diaphragmatic breathing, progressive muscle relaxation, meditation) and behavioral activation (increase patients participation in activities despite physical or emotional barriers).

• Pharmacotherapy: Comorbid anxiety and depressive disorders should be treated with selective serotonin reuptake inhibitors (SSRIs) or other appropriate psychotropic medications (see treatment of depression; treatment of anxiety). Some evidence suggests SSRIs may be effective in somatic symptom disorder even in the absence of comorbid psychiatric symptoms. Low-quality evidence suggested combined treatment with SSRIs and antipsychotics may be more effective. Start low and go slow with any medication initiation given their sensitivity/concern about side effects.

Conclusion

• Next lesson we will discuss functional neurologic disorder ("conversion disorder"). If you want more learning resources then check out our recommended resources page.

• Resources for today's post include: Pocket Psychiatry, DSMV-5, and First Aid for the Psychiatry Clerkship.

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