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Somatic Symptom (Somatization) Disorder

BASICS

  • Description:
  • Somatic symptom disorder (SSD) involves ≥1 somatic symptoms persisting >6 months, causing distress or significant disruption of daily life.
  • Symptoms appear physical but are medically unexplained.
  • Diagnosis (DSM-5) focuses on patient presentation and perception, not symptom counts or absence of medical explanation.
  • SSD encompasses most cases formerly called somatization disorder and now includes presentations previously diagnosed as hypochondriasis.
  • Illness anxiety disorder (replaces hypochondriasis) applies when preoccupation with illness exists without somatic symptoms.
  • Suffering is authentic; symptoms are not intentionally produced or feigned.
  • Sometimes referred to as "functional disorders."

EPIDEMIOLOGY

  • Onset: Usually adolescence
  • Sex: Female > Male (10:1)
  • Prevalence:
  • 2% among women, <0.2% among men
  • Up to 29% in primary care settings
  • Age: Prevalence decreases after age 65
  • Culture: More frequent in non-Western settings; symptom profiles vary

ETIOLOGY & PATHOPHYSIOLOGY

  • Biological:
  • Distinct patterns in heart rate variability and brain functional connectivity; possible attention deficits affecting body perception.
  • Decreased density in brain regions for somatic sensation/emotion.
  • Genetics:
  • Genetic and environmental factors both contribute (supported by consanguinity and SNP studies).
  • Triggers:
  • Childhood abuse (esp. sexual abuse)
  • Worsens after loss (job, close relative)
  • Intensified by stress

COMMONLY ASSOCIATED CONDITIONS

  • Comorbid psychiatric conditions likely: 20–50% (anxiety, depression, personality disorders)

DIAGNOSIS

  • Diagnosis is based on symptom pattern rather than exclusion of medical causes.
  • Up to 10% of those diagnosed with SSD may be false positives.
  • History:
  • ≥1 somatic complaints (may be vague, multiple, or non-specific)
  • Unrealistic thoughts/feelings/behaviors re: symptoms, such as:
    • Disproportionate/persistent thoughts about seriousness
    • Persistent health/symptom anxiety
    • Excessive time/energy devoted to symptoms/health concerns
  • Symptoms may include:
    • Pain (head, abdomen, back, joints, chest, extremities, rectum, menstruation, sex, urination)
    • GI symptoms (nausea, vomiting, diarrhea, bloating, food intolerance)
    • Sexual symptoms (indifference, sexual dysfunction, menstrual irregularities)
    • Pseudoneurologic symptoms (balance, weakness, swallowing, voice, sensation, blindness, seizures, amnesia, dissociation)
  • Explore alternative treatments the patient may be using.
  • Physical Exam:
  • Largely normal; absence of objective findings
  • Screening tools:
  • Patient Health Questionnaire (PHQ-15)
  • Minnesota Multiphasic Personality Inventory (MMPI)

DIFFERENTIAL DIAGNOSIS

  • Psychiatric:
  • Depression, anxiety, schizophrenia, illness anxiety disorder, conversion disorder, factitious disorder, body dysmorphic disorder, malingering
  • Medical:
  • Lupus, hyper/hypothyroidism, hyperparathyroidism, Lyme, porphyria
  • Clues: Accumulation of multiple diagnoses (>13 letters; e.g., fibromyalgia syndrome, chronic fatigue syndrome, etc.). Failure of more than three physicians to make a meaningful diagnosis suggests somatization.

DIAGNOSTIC TESTS

  • Labs and imaging: Typically do not support complaints
  • No specific abnormal test findings
  • Diagnosis is clinical

TREATMENT

  • General:
  • Focus on controlling symptoms, not eliminating them.
  • Do not tell patients symptoms are “all in their head.”
  • Supportive, regular relationship with a single primary care provider is key.
  • Regularly scheduled visits (at least 15 min/month) to review symptoms and coping
  • Reassure, explain tests/results, acknowledge suffering
  • Avoid excessive referrals/investigations
  • Medications:
  • Antidepressants (SSRIs) for comorbid depression/anxiety; fluoxetine may help illness anxiety, though many may not respond
  • Therapy:
  • Cognitive-behavioral therapy (CBT) is most effective; addresses health anxiety, beliefs, catastrophizing, health behaviors
  • Group or individual therapy
  • For children: Focus on reducing school absence, address school anxiety/malingering
  • Multidisciplinary care (dietitians, hypnotherapists, psychiatry, physiotherapy) for functional GI and other syndromes

ONGOING CARE

  • Follow-up:
  • Regular visits with primary care, psychiatry, and/or therapist
  • Patient Education:
  • Psychoeducation, stress reduction, exercise, time for pleasurable activities

PROGNOSIS

  • Chronic, fluctuating course; full remission is rare
  • No increased mortality/major illness risk, but greater disability and role impairment

COMPLICATIONS

  • Risk from unnecessary invasive tests/treatments
  • Potential dependency on pain relievers/sedatives

ICD-10

  • F45.9: Somatoform disorder, unspecified
  • F45.20: Hypochondriacal disorder, unspecified
  • F45.22: Body dysmorphic disorder

CLINICAL PEARLS

  • Diagnosis is by pattern, not exclusion.
  • Inability of >3 physicians to make a diagnosis points to somatization.
  • Always acknowledge and validate the patient's experience and suffering.
  • Avoid suggesting that symptoms are “all in their head.”
  • Discuss treatment limitations, but provide reassurance and options to reduce suffering.