Somatic Symptom Disorder

Somatic symptom disorder
Other names: Somatoform disorder
Video explanation
Specialty	Psychiatry
Symptoms	Excessive concern or anxiety regarding physical symptoms[1]
Duration	Long-term[2]
Causes	Unclear[3]
Risk factors	Family history, substance misuse, unemployment, history of child abuse[2][3]
Differential diagnosis	Other medical conditions, malingering, generalized anxiety disorder, substance use disorder, chronic fatigue syndrome[1][4]
Treatment	Counselling, medications[4]
Medication	SSRIs[3]
Frequency	~6%[3]

Somatic symptom disorder, formerly known as a somatoform disorder, is characterized by excessive concern or anxiety regarding physical symptoms.^[1] This occurs to a degree that normal functioning is disrupted.^[1] The symptoms may or may not occur as a result of an underlying medical problem.^[3] It may be associated with avoidant personality disorder or obsessive-compulsive disorder.^[3]

The cause is unclear.^[3] Risk factors include family history, substance misuse, unemployment, and history of child abuse.^[2][3] Diagnosis requires the problem to be present for at least six months.^[1] Related disorder include conversion disorder, factitious disorder, and illness anxiety disorder.^[4] It differs from malingering, in which symptoms are produced for secondary gain.^[4]

Treatment may include counselling, such as cognitive behavior therapy, and medications, such as SSRIs.^[4] Frequent efforts to reinforce that symptoms do not represents a life threating condition may help.^[3] It is recommended that excessive testing be avoided due to concerns of false positives and the fact that negative results do not provide meaningful reassurance.^[3] Up to 90% of cases last more than 5 years.^[3]

Somatic symptom disorder is estimated to affect 6% of the population.^[3] Females are affected about 10 times more often than males.^[3] Onset is often during the later part of childhood, though diagnosis may not occur until later.^[2] The condition was described by the Ancient Egyptians and later occurred in the 1900s as hysteria.^[5] Its current name was introduced in 2013 in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V).^[3]

Definition[edit | edit source]

Somatic symptom disorders are a group of disorders, all of which fit the definition of physical symptoms similar to those observed in physical disease or injury for which there is no identifiable physical cause. As such, they are a diagnosis of exclusion. Somatic symptoms may be generalized in four major medical categories: neurological, cardiac, pain, and gastrointestinal somatic symptoms.^[6]

DSM[edit | edit source]

Somatic symptom disorders used to be recognized as Somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. The following^[7] were conditions under the term Somatoform Disorders:

• Conversion disorder: A somatic symptom disorder involving the actual loss of bodily function such as blindness, paralysis, and numbness due to excessive anxiety
• Somatization disorder
• Hypochondriasis
• Body dysmorphic disorder: wherein the afflicted individual is concerned with body image, and is manifested as excessive concern about and preoccupation with a perceived defect of their physical appearance.
• Pain disorder
• Undifferentiated somatic symptom disorder – only one unexplained symptom is required for at least six months.

In the newest version of DSM-5 (2013) somatic symptom disorders are recognized under the term Somatic Symptom and Related Disorders:

• Somatic symptom disorder: Will take over many of what was formerly known as somatization disorders and hypochondriasis(hyperchondiac)
• Factitious disorder: Can be either imposed on oneself, or to someone else (formally known as factitious disorder by proxy).
• Illness anxiety disorder: A somatic symptom disorder involving persistent and excessive worry about developing a serious illness. This disorder has recently gone under review and has been altered into three different classifications.^{[citation needed]}
• Somatoform disorder not otherwise specified (NOS)^[8]

Included among these disorders are false pregnancy, psychogenic urinary retention, and mass psychogenic illness (so-called mass hysteria).

Somatization disorder as a mental disorder was recognized in the DSM-IV-TR classification system, but in the latest version DSM-5, it was combined with undifferentiated somatoform disorder to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.^[9]

ICD[edit | edit source]

The ICD-10, the latest version of the International Statistical Classification of Diseases and Related Health Problems, classifies conversion disorder as a dissociative disorder. ICD-10 still includes somatization syndrome.^[10]

Proposed disorders[edit | edit source]

Additional proposed somatic symptom disorders are:

• Abridged somatization disorder^[11] – at least four unexplained somatic complaints in men and six in women
• Multisomatoform disorder^[12] – at least three unexplained somatic complaints from the PRIME-MD scale for at least two years of active symptoms

These disorders have been proposed because the recognized somatic symptom disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:^[13]

• Somatization disorder – 1%
• Abridged somatization disorder – 6%
• Multisomatoform disorder – 24%
• Undifferentiated somatoform disorder – 69%

Diagnosis[edit | edit source]

Each of the specific somatic symptom disorders has its own diagnostic criteria.

Controversy[edit | edit source]

Somatic symptom disorder has been a controversial diagnosis, since it was historically based primarily on negative criteria – that is, the absence of a medical explanation for the presenting physical complaints. Consequently, any person suffering from a poorly understood illness can potentially fulfill the criteria for this psychiatric diagnosis, even if they exhibit no psychiatric symptoms in the conventional sense.^[14][15] In 2013–14, there were several widely publicized cases of individuals being involuntarily admitted to psychiatric wards on the basis of this diagnosis alone.^[16][17] This has raised concerns about the consequences of potential misuse of this diagnostic category.

Misdiagnosis[edit | edit source]

In the opinion of Allen Frances, chair of the DSM-IV task force, the DSM-5's somatic symptom disorder brings with it a risk of mislabeling a sizable proportion of the population as mentally ill. “Millions of people could be mislabeled, with the burden falling disproportionately on women, because they are more likely to be casually dismissed as ‘catastrophizers’ when presenting with physical symptoms.”^[15]

Treatment[edit | edit source]

Psychotherapy, more specifically, cognitive behavioral therapy (CBT), is the most widely used form of treatment for Somatic symptom disorder. In 2016, a randomized 12-week study suggested steady and significant improvement in health anxiety measures with cognitive behavioral therapy compared to the control group.^[18][19]

CBT can help in some of the following ways:^[20]

• Learn to reduce stress
• Learn to cope with physical symptoms
• Learn to deal with depression and other psychological issues
• Improve quality of life
• Reduce preoccupation with symptom

Moreover, brief psychodynamic interpersonal psychotherapy (PIT) for patients with multisomatoform disorder has shown its long-term efficacy for improving the physical quality of life in patients with multiple, difficult-to-treat, medically unexplained symptoms.^[21]

Antidepressant medication has also been used to treat some of the symptoms of depression and anxiety that are common among people who have somatic symptom disorder.^[20] Medications will not cure somatic symptom disorder, but can help the treatment process when combined with CBT.

History[edit | edit source]

Somitisation disorder was first described by Paul Briquet in 1859 and was subsequently known as Briquet's syndrome. He described patients who had been sickly most of their lives and complained of multiple symptoms from different organ systems. Symptoms persist despite multiple consultations, hospitalisations and investigations. ^[22]

See also[edit | edit source]

• Hypochondriasis
• Hysteria
• Medically unexplained physical symptoms
• Munchausen syndrome
• Nocebo
• Psychosomatic medicine

References[edit | edit source]

External links[edit | edit source]

Classification	ICD-10: F45 ICD-9-CM: 300.8 MeSH: D013001 DiseasesDB: 1645
External resources	eMedicine: med/3527