Somatic Symptom Disorder

Somatic Symptom Disorder is a mental disorder characterized by multiple, current, somatic symptoms that are distressing or result in significant disruption of daily life. Commonly, only one severe symptom, pain is present. The individual's suffering is authentic, whether or not it is medically explained. The diagnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together.

Epidemiology

The prevalence of somatic symptom disorder is unknown since it is a new diagnosis, but estimated to be between 5-7%. The prevalence is expected to be higher than the old and more restrictive DSM-IV diagnosis of somatization disorder (<1%) but lower than that of undifferentiated somatoform disorder (19%). It affects females more than males.

Prognosis

Individuals with severe somatic symptom disorder have poorer health status scores (more than 2 standard deviations below population norms).

Comorbidity

Comorbid anxiety or depression is common and may exacerbate symptoms and impairment.[1]

Risk Factors

Lower education, low socioeconomic status, and recent stressful life events are risk factors.[2]

Somatic symptom disorder is a new diagnosis in the DSM-5. Individuals previously diagnosed with somatisation disorder, hypochondriasis, pain disorder, and/or undifferentiated somatoform disorder are typically subsumed under this new diagnosis. The lumping of these diagnoses has not been without controversy.[3] About 25% of individuals with the old DSM-IV diagnosis of hypochondriasis are now diagnosed with illness anxiety disorder. This applies when they do not have prominent somatic symptoms. The other 75% of hypochondriasis are subsumed somatic symptom disorder.

Criterion A

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

Criterion B

Excessive thoughts, feelings, or behaviours related to the somatic symptoms or associated health concerns as manifested by at least 1 of the following:

  1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
  2. Persistently high level of anxiety about health or symptoms.
  3. Excessive time and energy devoted to these symptoms or health concerns.
Criterion C

Although any 1 somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

In children, the most common symptoms are recurrent abdominal pain, headache, fatigue, and nausea. A single prominent symptom is more common in children than in adults. While young children may have somatic complaints, they rarely worry about “illness” per se prior to adolescence. The parents' response to the symptom is important, as this may determine the level of associated distress. It is the parent who may determine the interpretation of symptoms and the associated time off school and medical help seeking.

Specifiers

  • With predominant pain (previously known as pain disorder): this specifier is for individuals whose somatic symptoms predominantly involve pain
  • Persistent: a persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months)

Severity Specifier

  • Mild: Only 1 of the symptoms specified in Criterion B is fulfilled.
  • Moderate: 2 or more of the symptoms specified in Criterion B are fulfilled.
  • Severe: 2 or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or 1 very severe somatic symptom).

Associated symptoms may include repeated checking for bodily abnormalities, repeated seeking of medical help and reassurance, and avoidance of physical activity. These symptoms can be the most in severe, persistent somatic symptom disorder. Individuals may be so concerned about somatic symptom(s) that they cannot be redirected to other matters, and it may be very difficult to individuals to be reassured by their physician.

  • Other medical conditions
    • The presence of somatic symptoms of unclear etiology is not in itself sufficient to make the diagnosis of somatic symptom disorder. The symptoms of many individuals with disorders like irritable bowel syndrome or fibromyalgia would not satisfy the criterion necessary to diagnose somatic symptom disorder (Criterion B). Conversely, the presence of somatic symptoms of an established medical disorder (e.g. - diabetes or heart disease) does not exclude the diagnosis of somatic symptom disorder if the criteria are otherwise met.
    • In panic disorder, somatic symptoms and anxiety about health tend to occur in acute episodes, whereas in somatic symptom disorder, anxiety and somatic symptoms are more persistent.
    • Individuals with generalized anxiety disorder worry about multiple events, situations, or activities, only one of which may involve their health. The main focus is not usually somatic symptoms or fear of illness as it is in somatic symptom disorder.
    • Depressive disorders are commonly accompanied by somatic symptoms. However, depressive disorders are differentiated from somatic symptom dis order by the core depressive symptoms of low (dysphoric) mood and anhedonia.
    • If the individual has extensive worries about health but no or minimal somatic symptoms, it may be more appropriate to consider illness anxiety disorder.
  • Conversion disorder (functional neurological symptom disorder)
    • In conversion disorder, the presenting symptom is loss of function (e.g. - of a limb), whereas in somatic symptom disorder, the focus is on the distress that particular symptoms cause. The features listed under Criterion B of somatic symptom disorder may be helpful in differentiating the two disorders.
    • In somatic symptom disorder, the individual's beliefs that somatic symptoms might reflect serious underlying physical illness are not held with delusional intensity. Nonetheless, the individual's beliefs concerning the somatic symptoms can be firmly held. In contrast, in delusional disorder, somatic subtype, the somatic symptom beliefs and behaviour are stronger than those found in somatic symptom disorder.
    • In body dysmorphic disorder, the individual is excessively concerned about, and preoccupied by, a perceived defect in his or her physical features. In contrast, in somatic symptom disorder, the concern about somatic symptoms reflects fear of underlying illness, not of a defect in appearance.
    • In somatic symptom disorder, the recurrent ideas about somatic symptoms or illness are less intrusive, and individuals with this disorder do not exhibit the associated repetitive behaviours aimed at reducing anxiety that occur in obsessive-compulsive disorder.
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1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.