Somatic Symptom Disorder and Psychosomatic Illness

New DSM-5 classification sheds light on a misunderstood condition

In This Article

"Psychosomatic" is a term that is not only overused in modern culture but one that is largely misunderstood. The term is popularly used to describe a mental disorder, such as depression or anxiety, that manifests with seemingly unrelated physical symptoms. For a condition to be considered psychosomatic, there must be no other medical explanation for the symptoms.

Today, the term somatic symptom disorder (SSD) is used in place of "psychosomatic" to describe a form of mental illness that causes one or more bodily symptoms, including pain, which cannot be traced to a general medical condition, other mental illnesses, or substance abuse. 

For your condition to be diagnosed as SSD, it must meet the criteria established in the Diagnostic and Statistical Manual of Mental Disorders, Issue 5 (DSM-5) issued by the American Psychiatric Association.

Current Criteria

SSD is characterized by somatic (physical) symptoms that are either very distressing or cause a significant disruption in your ability to function normally. There must also be excessive and disproportionate thoughts, feelings, and behaviors related to the symptoms or your health. To be diagnosed with SSD, you must have persistent symptoms lasting for at least six months.

With the issue of the DSM-5 in 2013, many of the diagnostic classifications used in previous editions have been removed, including somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder. Many of the people previously diagnosed with these conditions meet the current criteria for SSD.

Unlike the classifications used in the previous DSM-4, people with SSD are not required to have symptoms from four specific symptom groups (pain, gastrointestinal, sexual, and pseudo-neurological) in order to be diagnosed. Neither does a doctor need to waste time deciding if the symptoms are intentionally feigned or produced.

Today, SSD symptoms simply need to be significantly distressing or disruptive and be accompanied by excessive thoughts, feelings, or behaviors.

Differentiating Characteristics

Another key change to the DSM-5 criteria is that physical symptoms do not need to be medically unexplained in order for SSD to be diagnosed. In the past, this was a requirement. The current rationale asserts that doctors cannot reasonably diagnose a mental disorder simply because a medical cause cannot be found.

Clinicians today better understand that 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 such example is chronic fatigue syndrome, which in the past was considered by many to be psychosomatic, especially in women. Today, the American Psychiatric Association recognizes that the lack of a medical cause does not mean that an illness is "all in one's head."

There are a number of characteristics that differentiate SSD from idiopathic illnesses:

  • 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.

By contrast, idiopathic illnesses are ones in which the physical symptoms are generally consistent among those affected. With that said, 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 are 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.

Disorders Related to SSD

There are a number of conditions in psychiatry that are related to SSD. These were not melded into the new DSM-5 classification but are either facets of the previous classification, comorbid (co-existing) mental conditions, or disorders with similar features. These 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

As unnerving as a diagnosis of SSD may seem, there are people who consider it a blessing in disguise. As a diagnosis of exclusion, it rules out a potentially serious somatic illness as well as unnecessary and potentially harmful medical treatments. Moreover, 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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Article Sources

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