History

History and symptoms vary depending on the specific somatic symptom disorder diagnosis.

The manner in which patients respond to a standardized review of systems differs in those with medically unexplained symptoms and in those with psychiatric disease. The review of systems offers information beyond the actual systems review, and may be useful in the identification of somatization.^[12]

Somatic Symptom Disorder

Somatic symptom disorder replaces somatization disorder with the following criteria:

At least one somatic symptom that results in significant disruption in everyday life
Significant actions, thoughts, or feelings about the symptoms
Somatic symptom actions, thoughts, or feelings are excessively time consuming, out of proportion to the degree of seriousness, or accompanied by a high level of anxiety

Physical

Perform a comprehensive physical examination to rule out physical causes for the patient's somatic complaints. A detailed focus on specific systems (eg, neurological) may be necessary based on the specific complaint.

Include a full mental status examination. A patient with somatic symptom disorder typically displays the following on an examination.

Appearance - Normal
Attitude and behavior - Attitude is appropriate and behavior demonstrates a preoccupation with physical symptoms and complaints
Mood - Mildly anxious and depressed
Affect - Full range and appropriate
Thought disorder - None, although thoughts are limited to issues around physical symptoms
Hallucinations - None
Delusions - None
Obsessions - None
Compulsions - None
Attention - Within normal range
Memory - Within normal range
Concentration - Within normal range
Orientation - Oriented to time, place, and person
Insight and judgment - Insight appears limited in that nonmedical causes of symptoms are not considered; judgment appears unimpaired
Suicidal and homicidal ideation - No evidence of such

Causes

No definitive causes for most of the somatic symptom disorders have been established.

Genetic and environmental influences appear to contribute to somatization. Somatic symptom disorders have been linked to internalizing genetic risk factors and share genetic overlap with other mental disorders, including eating disorders.^[13] Research suggests a possible genetic component to the development of somatic symptom disorder syndromes.^[3]

Somatization may involve abnormalities in tryptophan catabolism, resulting in lower serum tryptophan levels than controls. This finding is limited to the research domain at present and is not a diagnostic test.^[14]

Children raised in homes with a high degree of parental somatization may model somatization. Sexual abuse may be associated with an increased risk of somatization later in life. Poor ability to express emotions (alexithymia) may result in somatization. Somatic symptom disorder may be related to a reduced threshold for tactile and pain perception.^[15]

Psychodynamic causes for unexplained physical symptoms date back to Freud, who coined the term "conversion disorder". Freud viewed some unexplained neurologic symptoms as a result of conversion of intrapsychic distress into physical symptoms.

Attitudes of caregivers may have a profound affect upon the course of somatic symptom disorder in children. One study demonstrated that adolescent children of parents who accepted the validity of a somatic symptom disorder diagnosis were nearly 20 times more likely to recover compared to those of parents who rejected or only partially accepted a somatic symptom Disorder diagnosis.^[16]

Psychiatric comorbidity

Alcohol and drug abuse are common in patients with somatic symptom disorders. Patients may attempt to treat their somatic pain with alcohol or other drugs.

Additionally, alcohol or drug intoxication or withdrawal may induce somatic symptoms of unclear etiology, unless the physician considers the potential role of substances.

Anxiety disorders and mood disorders commonly include physical symptoms as part of the presentation. Ruling out a primary anxiety disorder or mood disorder is key before reviewing the role of somatic symptom disorders.

Differential Diagnoses

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. Fourth Edition. Washington, DC: American Psychiatric Association; 2000. Text Revision.
Holliday KL, Macfarlane GJ, Nicholl BI, Creed F, Thomson W, McBeth J. Genetic variation in neuroendocrine genes associates with somatic symptoms in the general population: results from the EPIFUND study. J Psychosom Res. 2010 May. 68 (5):469-74. [QxMD MEDLINE Link].
Atmaca M, Sirlier B, Yildirim H, Kayali A. Hippocampus and amygdalar volumes in patients with somatization disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Aug 15. 35(7):1699-703. [QxMD MEDLINE Link].
van der Kruijs SJ, Bodde NM, Vaessen MJ, Lazeron RH, Vonck K, Boon P, et al. Functional connectivity of dissociation in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry. 2012 Mar. 83(3):239-47. [QxMD MEDLINE Link].
Kurlansik SL, Maffei MS. Somatic Symptom Disorder. Am Fam Physician. 2016 Jan 1. 93 (1):49-54. [QxMD MEDLINE Link].
Hilderink PH, Collard R, Rosmalen JG, Oude Voshaar RC. Prevalence of somatoform disorders and medically unexplained symptoms in old age populations in comparison with younger age groups: a systematic review. Ageing Res Rev. 2013 Jan. 12 (1):151-6. [QxMD MEDLINE Link].
Limburg K, Sattel H, Radziej K, Lahmann C. DSM-5 somatic symptom disorder in patients with vertigo and dizziness symptoms. J Psychosom Res. 2016 Dec. 91:26-32. [QxMD MEDLINE Link].
Baruffol E, Thilmany MC. Anxiety, depression, somatization and alcohol abuse. Prevalence rates in a general Belgian community sample. Acta Psychiatr Belg. 1993 May-Jun. 93(3):136-53. [QxMD MEDLINE Link].
Chioqueta AP, Stiles TC. Suicide risk in patients with somatization disorder. Crisis. 2004. 25(1):3-7. [QxMD MEDLINE Link].
Wiborg JF, Gieseler D, Fabisch AB, Voigt K, Lautenbach A, Löwe B. Suicidality in primary care patients with somatoform disorders. Psychosom Med. 2013 Nov-Dec. 75 (9):800-6. [QxMD MEDLINE Link].
Okland TS, Gonzalez JR, Ferber AT, Mann SE. Association Between Patient Review of Systems Score and Somatization. JAMA Otolaryngol Head Neck Surg. 2017 Sep 1. 143 (9):870-875. [QxMD MEDLINE Link].
Kendler KS, Aggen SH, Knudsen GP, Røysamb E, Neale MC, Reichborn-Kjennerud T. The structure of genetic and environmental risk factors for syndromal and subsyndromal common DSM-IV axis I and all axis II disorders. Am J Psychiatry. 2011 Jan. 168(1):29-39. [QxMD MEDLINE Link]. [Full Text].
Maes M, Galecki P, Verkerk R, Rief W. Somatization, but not depression, is characterized by disorders in the tryptophan catabolite (TRYCAT) pathway, indicating increased indoleamine 2,3-dioxygenase and lowered kynurenine aminotransferase activity. Neuro Endocrinol Lett. 2011. 32(3):264-73. [QxMD MEDLINE Link].
Katzer A, Oberfeld D, Hiller W, Gerlach AL, Witthöft M. Tactile perceptual processes and their relationship to somatoform disorders. J Abnorm Psychol. 2012 May. 121(2):530-43. [QxMD MEDLINE Link].
Gao X, McSwiney P, Court A, Wiggins A, Sawyer SM. Somatic Symptom Disorders in Adolescent Inpatients. J Adolesc Health. 2018 Dec. 63 (6):779-784. [QxMD MEDLINE Link].
Laferton JAC, Stenzel NM, Rief W, Klaus K, Brähler E, Mewes R. Screening for DSM-5 Somatic Symptom Disorder: Diagnostic Accuracy of Self-Report Measures Within a Population Sample. Psychosom Med. 2017 Nov/Dec. 79 (9):974-981. [QxMD MEDLINE Link].
Gierk B, Kohlmann S, Kroenke K, Spangenberg L, Zenger M, Brähler E, et al. The somatic symptom scale-8 (SSS-8): a brief measure of somatic symptom burden. JAMA Intern Med. 2014 Mar. 174 (3):399-407. [QxMD MEDLINE Link].
Werring DJ, Weston L, Bullmore ET. Functional magnetic resonance imaging of the cerebral response to visual stimulation in medically unexplained visual loss. Psychol Med. 2004 May. 34(4):583-9. [QxMD MEDLINE Link].
Martin A, Rauh E, Fichter M, Rief W. A one-session treatment for patients suffering from medically unexplained symptoms in primary care: a randomized clinical trial. Psychosomatics. 2007 Jul-Aug. 48(4):294-303. [QxMD MEDLINE Link].
Smith GR Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med. 1986 May 29. 314(22):1407-13. [QxMD MEDLINE Link].
Hennings A, Schwarz MJ, Riemer S, Stapf TM, Selberdinger VB, Rief W. Exercise affects symptom severity but not biological measures in depression and somatization - results on IL-6, neopterin, tryptophan, kynurenine and 5-HIAA. Psychiatry Res. 2013 Dec 30. 210 (3):925-33. [QxMD MEDLINE Link].
Erkic M, Bailer J, Fenske SC, Schmidt SNL, Trojan J, Schröder A, et al. Impaired emotion processing and a reduction in trust in patients with somatic symptom disorder. Clin Psychol Psychother. 2018 Jan. 25 (1):163-172. [QxMD MEDLINE Link].
Bleichhardt G, Timmer B, Rief W. Cognitive-behavioural therapy for patients with multiple somatoform symptoms--a randomised controlled trial in tertiary care. J Psychosom Res. 2004 Apr. 56(4):449-54. [QxMD MEDLINE Link].
Beltman MW, Voshaar RC, Speckens AE. Cognitive-behavioural therapy for depression in people with a somatic disease: meta-analysis of randomised controlled trials. Br J Psychiatry. 2010 Jul. 197(1):11-9. [QxMD MEDLINE Link].
Huang M, Luo B, Hu J, Wei N, Chen L, Wang S, et al. Combination of citalopram plus paliperidone is better than citalopram alone in the treatment of somatoform disorder: results of a 6-week randomized study. Int Clin Psychopharmacol. 2012 May. 27(3):151-8. [QxMD MEDLINE Link].
Barsky AJ, Ahern DK. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA. 2004 Mar 24. 291(12):1464-70. [QxMD MEDLINE Link].
Egloff N, Cámara RJ, von Känel R, Klingler N, Marti E, Ferrari ML. Hypersensitivity and hyperalgesia in somatoform pain disorders. Gen Hosp Psychiatry. 2014 May-Jun. 36(3):284-90. [QxMD MEDLINE Link].
Harris AM, Orav EJ, Bates DW, Barsky AJ. Somatization increases disability independent of comorbidity. J Gen Intern Med. 2009 Feb. 24(2):155-61. [QxMD MEDLINE Link]. [Full Text].
Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med. 2007 Dec. 69(9):881-8. [QxMD MEDLINE Link].
Olesen J, Gustavsson A, Svensson M, Wittchen HU, Jönsson B. The economic cost of brain disorders in Europe. Eur J Neurol. 2012 Jan. 19(1):155-62. [QxMD MEDLINE Link].
Roca M, Gili M, Garcia-Garcia M, Salva J, Vives M, Garcia Campayo J, et al. Prevalence and comorbidity of common mental disorders in primary care. J Affect Disord. 2009 Apr 9. [QxMD MEDLINE Link].
Sumathipala A, Siribaddana S, Abeysingha MR, De Silva P, Dewey M, Prince M, et al. Cognitive-behavioural therapy v. structured care for medically unexplained symptoms: randomised controlled trial. Br J Psychiatry. 2008 Jul. 193(1):51-9. [QxMD MEDLINE Link].
van Ravesteijn H, Wittkampf K, Lucassen P, van de Lisdonk E, van den Hoogen H, van Weert H, et al. Detecting somatoform disorders in primary care with the PHQ-15. Ann Fam Med. 2009 May-Jun. 7(3):232-8. [QxMD MEDLINE Link].
Kleinstäuber M, Witthöft M, Steffanowski A, van Marwijk H, Hiller W, Lambert MJ. Pharmacological interventions for somatoform disorders in adults. Cochrane Database Syst Rev. 2014 Nov 7. CD010628. [QxMD MEDLINE Link].