Somatic Symptom Disorder

Background

• Somatic symptom disorder (SSD) is characterized by somatic symptoms that are distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors regarding those symptoms.
• Risk factors for SSD include chronic childhood illnesses, childhood adversities, comorbid medical illness or psychiatric diagnosis, and poor coping abilities.
• Comorbid psychiatric and psychosocial disorders such as anxiety, depression, personality disorders, and substance use disorders are strongly associated with somatic symptom disorder.
• Functional somatic syndromes include irritable bowel syndrome, functional dyspepsia, and fibromyalgia, although not all patients with a functional somatic syndrome meet diagnostic criteria for SSD.

Evaluation

• Patients with SSD usually present with persistent and excessive symptoms that appear to involve many organ systems but lack diagnostic support for a specific physical illness.
• Suspect somatization if there are inconsistencies in patient history and/or physical exam.
• Diagnose somatic symptom disorder using Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5):
  • ≥ 1 somatic symptom that is distressing or results in a significant disruption of daily life
  • excessive thoughts, feelings, and behaviors related to somatic symptoms or associated health concerns as manifested by ≥ 1 of:
    • disproportionate and persistent thoughts about the seriousness of symptoms
    • persistently high level of anxiety about health or symptoms
    • excessive time and energy devoted to these symptoms or health concerns
  • somatic symptom does not have to always be present but must be persistent (≥ 6 months)
• Early interdisciplinary consultations, particularly in inpatient setting, can help avoid disjointed evaluation and miscommunication about the diagnosis.

Management

• Offer an individualized, multifaceted approach to address any psychological, social, and/or cultural factors contributing to somatic symptoms.
• Build a sound therapeutic alliance with the patient by collaborating in setting treatment goals and educating the patient on psychosocial stressors and coping strategies.
• Consider psychological therapy, particularly cognitive behavioral therapy, to reduce somatization in patients with SSD.
• Consider antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).
• Consider other strategies for patient management such as:
  • scheduling time-limited regular appointments (such as every 4-6 weeks) rather than erratic appointments to address complaints
  • performing brief physical examinations at each visit to address new symptoms or health concerns
  • avoiding unnecessary diagnostic tests unless objective evidence of a disease is present
  • treating comorbid psychiatric disorders
  • minimizing polypharmacy and taper and discontinuing medications with a high potential for abuse (including narcotic agents, sedatives)
  • prescribing regular dosing of pain medications and avoiding as needed analgesics (especially opiates)
  • encouraging mobility to prevent physical deconditioning (such as physical therapy, regular exercise)