Somatic symptom disorder
- Somatic symptoms associated with distress and impairment that cannot be medically explained
- Typically encountered in primary care and other medical settings
- Less commonly encountered in psychiatric and other mental health settings
DSM-5 Diagnostic Criteria for Somatic Symptom Disorder
- One or more somatic symptoms that are distressing or result in significant disruption of daily life.
- Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- Persistently high level of anxiety about health or symptoms.
- Excessive time and energy devoted to these symptoms or health concerns.
- Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
- Medical conditions
- Irritable bowel syndrome
- Endocrine disorders
- Multiple sclerosis
- Systemic lupus erythematosus
- Wilson's disease
- Myasthenia gravis
- Guillain-Barré syndrome
- Psychiatric conditions
- Screen for organic causes of symptoms
- Psychiatric consultation
- 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
- 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"
- 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.
- 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"
- 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
- 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
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.