Somatic symptom disorder

Background

• Somatic symptoms associated with distress and impairment that cannot be medically explained
  • Most common symptom is pain — 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

1. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
2. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one 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.
3. Although any one somatic symptom may not be continuously present, the state of be­ing symptomatic is persistent (typically more than 6 months).

Differential Diagnosis

• Medical conditions
  • Irritable bowel syndrome
  • Fibromyalgia
  • Endocrine disorders
    • Hyperparathyroidism
    • Thyroid disorders
    • Addison's disease
    • Insulinoma
    • Panhypopituitarism
  • Poisonings
    • Botulism
    • carbon monoxide
    • Heavy metals
  • Porphyria
  • Multiple sclerosis
  • Systemic lupus erythematosus
  • Wilson's disease
  • Myasthenia gravis
  • Guillain-Barré syndrome
  • Uremia

• Psychiatric conditions
  • Panic disorder
  • Generalized anxiety disorder
  • 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 → 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 → safeguards sick role → 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 — 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 — threatens sick role
• Patients fear abandonment → 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 — threatens sick role
  • Patient may escalate illness behaviors — 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 — 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 — 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