View source for Somatic symptom disorder

==Background==
*Somatic symptoms associated with distress and impairment that cannot be medically explained
**Most common symptom is pain &mdash; may be specific, generalized, or nonspecific (eg, [[fatigue]])
**May represent normal bodily sensations (eg, [[borborygmus]])
**May occur concurrently or secondarily to a medical condition
*Typically encountered in primary care and other medical settings
**Less commonly encountered in psychiatric and other mental health settings

==Clinical Features==
DSM-5 Diagnostic Criteria for Somatic Symptom Disorder<ref>American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.</ref>

<ol style="list-style-type: upper-alpha;">
<li>One or more somatic symptoms that are distressing or result in significant disruption of daily life.</li>
<li>Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:</li>

<ol style="list-style-type: numeral;">
<li>Disproportionate and persistent thoughts about the seriousness of one’s symptoms.</li>
<li>Persistently high level of anxiety about health or symptoms.</li>
<li>Excessive time and energy devoted to these symptoms or health concerns.</li>
</ol>

<li>Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).</li>
</ol>

==Differential Diagnosis==
*Medical conditions
**[[Irritable bowel syndrome]]
**[[Fibromyalgia]]
**Endocrine disorders
***[[Hyperparathyroidism]]
***[[Thyroid]] disorders
***[[Addison's disease]]
***[[Insulinoma]]
***[[Panhypopituitarism]]
**Poisonings
***[[Botulism]]
***[[Carbon_monoxide_toxicity|carbon monoxide]]
***[[Heavy metals]]
**[[Porphyria]]
**[[Multiple sclerosis]]
**[[Systemic lupus erythematosus]]
**[[Eponyms_(T-Z)#Wilson.27s_disease|Wilson's disease]]
**[[Myasthenia gravis]]
**[[Eponyms_(F-L)#Guillain-Barr.C3.A9_syndrome|Guillain-Barré syndrome]]
**[[Uremia]]

*Psychiatric conditions
**[[Panic_attack|Panic disorder]]
**[[Generalized anxiety disorder]]
**[[Depression|Depressive disorders]]
**[[Illness anxiety disorder]]
**[[Conversion disorder]]
**[[Delusional disorder]]
**[[Body dysmorphic disorder]]
**[[Obsessive-compulsive disorder]]
**[[Factitious disorder]]
**[[Malingering]]

==Evaluation==
*Screen for organic causes of symptoms
*Psychiatric consultation

==Management==

===Reassurance===
*May be successful in young patients with no underlying medical or psychiatric illnesses with clear psycho-social stress
*Unlikely to be successful in patients with chronic somatization
**Perceived as denial of sick role
**Desire for acknowledgment and recognition &rarr; disappointment when no pathology discovered
**Resistance to recovery because "specter of cure" threatens sick role
***Development of new side effects, allergic reactions, and symptoms

===Legitimization of Symptoms===
*Listen and attempt to understand patient's experience
*Explain that patient's illness causes many symptoms but does not lead to medical deterioration
*Offer only guarded projections about patient's condition &rarr; safeguards sick role &rarr; may limit illness behavior

===Diagnosis===
*Clarify precise meaning of terms to avoid misinterpretation
*Somatic responses and descriptions may be better accepted than purely psychiatric diagnoses
**Hyperventilation, tension headache, muscle tension, muscle strain, muscle spasm, and stress
*Communicating diagnostic uncertainty may be helpful
**"atypical pain", "multiple complaints following injury"

===Medications===
*Patient with somatic symptom disorder have a high affinity for medications and are reluctant to discontinue drugs, regardless of benefit
**Prioritize lifestyle modification
**Benign remedies may be helpful &mdash; lotions, supplements, elastic bandages, and heating pads
*Avoid drugs that cannot be safely continued indefinitely
*Avoid drugs that produce abstinence syndromes or dependence
*Avoid pain medications; if necessary, prescribe to be take on schedule, not "as needed"
*Antidepressants may be beneficial, including tricyclics

===Mental Health Consultation===
*Patients resist psychiatric evaluation &mdash; threatens sick role
*Patients fear abandonment &rarr; reassure primary physician will continue caring for them
*Patients may accept treatment as "stress management" or "education" that targets physical symptoms and somatic distress.

===Physician Attitudes===
*Focus on understanding patient's subjective experience
**Avoid telling patient nothing is wrong or symptoms require no treatment
*Avoid counter-transference when no physiologic explanation can be found
**Attempt to retain compassion
**Don't label as "difficult patient"

===Treatment Goals===
*Patients lack insight.  Do not attempt insight-oriented psychotherapy.
*Do not promise or attempt cure &mdash; threatens sick role
**Patient may escalate illness behaviors &mdash; new side effects, allergic reactions, and symptoms
**Reassure that patient will "probably always be ill" and should "learn to live with some pain"
*Avoid unnecessary tests and procedures &mdash; may encourage somatization
*Focus on modification of illness behavior and improved functional status
**Decreased frequency and urgency of medical use
**Avoidance of expensive and hazardous procedures
**Improved work or school performance
**More social activities
**Better personal relationships

==Disposition==
*Provide appropriate psychiatric referrals.
*Discharge with education and instructions.
**There are no alarming findings
**No further testing or medications are indicated
**Ongoing care and reassessment will be arranged
*Follow up with primary-care physician &mdash; becomes gatekeeper for all medical consultation and care.
**Avoid outpatient tests or hospitalization unless indicated by clear objective signs
**Scheduled follow-up on time-contingent basis (every 2-4 weeks)
***Reduce association between medical contact and necessity for escalation of illness behaviors
***Reduce fear of abandonment

==See Also==
*[[Factitious disorder]]
*[[Illness anxiety disorder]]
*[[Conversion disorder]]

==External Links==

==References==
<references/>

[[Category:Psychiatry]]