What Is Somatic Symptom Disorder?

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Somatic symptom disorder (SSD) is a mental health condition in which a person feels extreme anxiety over physical symptoms that are either real or imagined. 

Previously known as somatization disorder or psychosomatic illnesses, SSD is characterized by extreme, exaggerated anxiety about physical symptoms to the point that it interferes with daily living. 

People with SSD may perceive routine medical procedures or conditions as life-threatening. The feelings and behaviors associated with the concern over illness are not relieved by receiving normal test results. 

Somatic Symptom Disorder Symptoms

Somatic symptom disorder is a psychiatric diagnosis characterized by somatic (physical) symptoms that are either very distressing or cause a significant disruption in the ability to function normally.

Symptoms commonly include pain, fatigue, weakness, or shortness of breath. The degree of symptoms is not relevant to the diagnosis. In some SSD patients, symptoms can be traced to another medical condition, though often no physical cause is found. 

The key feature of SSD is excessive and disproportionate thoughts, feelings, and behaviors related to the symptoms or overall health. To be diagnosed with SSD, you must have persistent symptoms lasting for at least six months.

Causes

Like most psychiatric conditions, the exact cause of somatic symptom disorder is unclear. Factors that may predispose a person to develop SSD include:

  • Age: SSD typically manifests before age 30.
  • Gender: It is more common in women than in men. 
  • Genetics: A family history of SSD or anxiety disorders.
  • Personality: People who are more sensitive to physical or emotional pain and those with a negative outlook.
  • Social history: People who have experienced physical or sexual abuse may be more likely to have SSD, but people who have not experienced abuse or trauma can develop it as well. 

Diagnosis

A diagnosis of somatic symptom disorder typically comes after a long road of unexplained physical symptoms, medical tests, and ineffective treatments. However, physical symptoms do not need to be medically unexplained in order for SSD to be diagnosed.

Your primary care physician may refer to you a psychiatrist who will ask questions and perform additional testing to determine if you meet the criteria established in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Issue 5 (DSM-5).

Many somatic illnesses are idiopathic (meaning of unknown origin). Although the symptoms are very real and occur in common patterns in specific groups, the actual mechanisms for these diseases have yet to be established. One example is chronic fatigue syndrome, which in the past was considered by many to be psychosomatic, especially in women.

Characteristics that differentiate SSD from idiopathic illnesses include:

  • Symptoms of SSD most commonly involve pain in different parts of the body (including the back, joint, head, or chest), disturbances in the organ functions (gastrointestinal, respiratory, etc.), fatigue, and exhaustion.
  • People with SSD usually suffer from multiple physical symptoms as well as co-existing mental and psychosocial issues that perpetuate or precipitate symptoms. (For example, work-related stress may lead to the onset of respiratory symptoms with no organic or chemical cause for the attack.)
  • People with SSD tend to have problems with emotion regulation (the ability to respond to a situation in a manner that is socially acceptable and proportionate). It is not uncommon for people with SSD to be "overreactive" or unable to disengage from an emotional upset.
  • People with SSD often "doctor hop," visiting one practitioner after the next to seek diagnosis or treatment without letting them know that they have undergone the same testing or treatment with another practitioner.

Many of the emotional features of SSD—a preoccupation with symptoms or a worsening of symptoms with emotional triggers—can occur in anyone who has a persistent or chronic illness.

The difference with SSD is that the excessive thoughts, feelings, or behaviors will manifest in at least one of three characteristic ways:

  • The thoughts are persistent and disproportionate to the seriousness of one’s symptoms.
  • There is a persistently high level of anxiety about one's health or symptoms.
  • Excessive time and energy are devoted to these symptoms or health concerns.

If one or all of these emotional features disrupt your ability to function normally, you may want to explore SSD as a possible cause.

Changes to Diagnostic Criteria in the DSM-5

Somatic symptom disorder was introduced in the DSM-5 in 2013 and the following diagnoses from the DSM-IV were removed:

People previously diagnosed with these conditions most likely meet the current criteria for SSD.

Other changes to the DSM-5 include:

  • The requirement that symptoms from four specific symptom groups—pain, gastrointestinal, sexual, and pseudo-neurological—must be present was eliminated.
  • Doctors no longer need to waste time deciding if the symptoms are intentionally feigned or produced.

Differential Diagnoses

Psychiatric conditions related to somatic symptom disorder include:

  • Illness anxiety disorder (IAS), formerly known as hypochondriasis, is the preoccupation with having or developing a serious illness. People with IAS may or may not have diagnosed medical conditions, but no serious disease will be present in most cases. A person with IAS may believe, for instance, that a cough is a sign of lung cancer or that a bruise is a sign of AIDS.
  • Conversion disorder (CD), also known as functional neurological symptom disorder, is characterized by the appearance of neurologic symptoms (like paralysis, seizure, blindness, or deafness) with no organic or biochemical causes. In past eras, such events were often referred to as "hysterical blindness" or "hysterical paralysis."
  • Psychological factors affecting other medical conditions (PFAOMC) is a classification in the DSM-5 in which a general medical condition is adversely affected by a psychological or behavioral problem. This may include the inability to adhere to treatment or engaging in behaviors that prolong illness, exacerbate symptoms, or knowingly place one's health at risk.
  • Factitious disorder (FD) is diagnosed when a person acts if they have an illness by feigning, exaggerating, or producing symptoms, often for the purpose of inciting someone to their care. People with FD often have an eagerness for medical testing, describe complicated but convincing medical conditions, and have frequent hospitalizations.
  • Other specific somatic symptom and related disorder (OSSSRD) is a category in which the symptoms fail to meet the diagnostic criteria of SDD but are still causing significant distress. With OSSSRD, symptoms occur for a period of fewer than six months. An example is pseudocyesis in which a woman falsely believes that she is pregnant due to perceived changes in breast size or the movement of a "fetus" in her abdomen.

Treatment

The treatment of SDD varies from one person to the next. If a person recognizes that the preoccupation with symptoms is interfering with their quality of life, cognitive-behavioral therapy (CBT) may help identify and correct distorted thoughts, unfounded beliefs, and behaviors that trigger health anxiety.

CBT is often used in tandem with mindfulness-based therapy, including meditation, with the aim of disengaging from self-criticism, rumination, and negative moods or thoughts.

A greater challenge occurs when a person with SSD clings to the belief that their symptoms have an underlying physical cause despite a lack of evidence or extensive medical testing. Oftentimes, individuals like these are brought in by a spouse or family member who has also been adversely affected by their loved one's abnormal thoughts and behaviors.

When needed, selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants may be prescribed, both of which have proven effective in alleviating SSD symptoms.

Other antidepressants, such as monoamine oxidase inhibitors (MAOIs) and Wellbutrin (bupropion) are ineffective for the treatment of SSD and should be avoided. The same applies to anticonvulsants and antipsychotics commonly used in the treatment of mood and anxiety disorders.

A Word From Verywell

A diagnosis of SSD may seem unnerving, but with proper therapy and counseling, you can begin the process of restoring your quality of life and the ability to function normally without the specter of fear hanging over you. Don't expect things to change overnight; persistence is key. If you remain uncertain about the diagnosis, don't be afraid to seek a second opinion from a certified psychiatric professional.

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