Somatic Symptom Disorders

Updated: Apr 23, 2019
  • Author: William R Yates, MD, MS; Chief Editor: Glen L Xiong, MD  more...
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Overview

Background

The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) [1] category of Somatic Symptom Disorders and Other Related Disorders represents a group of disorders characterized by thoughts, feelings, or behaviors related to somatic symptoms. This category represents psychiatric conditions because the somatic symptoms are excessive for any medical disorder that may be present.

Somatic symptom disorders and other related disorders challenge medical providers. Clinicians need to estimate the relative contribution of psychological factors to somatic symptoms. A somatic symptom disorder may be present when the somatic symptom is a focus of attention, is distressing, or is contributing to impairment.

Anxiety disorders and mood disorders commonly produce physical symptoms. Clinicians need to rule out somatic symptoms due another primary psychiatric condition before considering a somatic symptom disorder diagnosis. Somatic symptoms can dramatically improve with successful treatment of the anxiety or mood disorder.However, it bears mentioning that the presence of general medical conditions with reasonable physical explanation for symptoms does not preclude the possibility of a somatic symptom disorder diagnosis. Rather, a diagnosis of somatic symptom disorder suggests a distortion in the perception or interpretation of somatic symptoms. [1]

The DSM-5 includes 7 specific diagnoses in the Somatic Symptom Disorder and Other Related Disorder category. [1] These diagnoses include (1) somatic symptom disorder, (2) illness anxiety disorder, (3) conversion disorder (functional neurological symptom disorder), (4) psychological factors affecting a medical condition, (5) factitious disorder, (6) other unspecified somatic symptom and related disorders, and (7) unspecified somatic symptom and related disorders. This article focuses on somatic symptom disorder. 

DSM-5 produced significant changes in this category of disorders. This category had previously been named Somatoform Disorders in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). [2] Somatic symptom disorder replaces the DSM-IV-TR diagnosis of somatization disorder. Approximately 75% of cases previousy diagnosed as hypochondriasis (those with predominant focus on physical symptoms) qualify for a diagnosis of somatic symptom disorder. The remaining 25% of patients have predominant anxiety concerns in the absence of somatic symptoms, and are more appropriately diagnosed with illness anxiety disorder. [1] . Pain disorder has been removed and is instead a specifier for somatic symptom disorder (with predominant pain). Psychological factors affecting a medical condition and factitious disorder have been added to the new Somatic Symptom and Related Disorders category. Finally, a residual category of other specific and nonspecific somatic symptom disorder has been created with DSM-5.

Case study

Ms. J is a 37-year-old woman who presents to the emergency department with abdominal pain. She reports that she has suffered from chronic pain since her adolescence. She has a history of multiple abdominal surgeries, the most recent was for pain felt due to adhesions. These operations have failed to reduce her complaints of pain. Her physical examination, vital signs, and laboratory examination, including CBC, urinalysis, and chemistry profile, are within normal limits. She is referred back to her primary care physician.

Ms. J's primary care physician has followed her for many years and has made the diagnosis of somatic symptom disorder. The treatment plan includes regular frequent visits to monitor her chronic pain complaints. Use of medication with addictive potential is restricted. Physical symptoms are monitored with limited use of invasive diagnostic procedures. Outpatient visits focus on identifying sources of stress and encouraging healthy coping mechanisms.

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Pathophysiology

The pathophysiology of somatic symptom disorder is unknown. Primary somatic symptom disorders may be associated with a heightened awareness of normal bodily sensations. This heightened awareness may be paired with a cognitive bias to interpret any physical symptom as indicative of medical illness. Autonomic arousal may be high in some patients with somatization. This autonomic arousal may be associated with physiologic effects of endogenous noradrenergic compounds such as tachycardia or gastric hypermotility. Heightened arousal also may induce muscle tension and pain associated with muscular hyperactivity, as is seen with muscle tension headaches.

There has been evidence in the basic science literature correlating certain genetic markers to the development of somatic symptoms, suggesting a possible genetic component to the development of somatic symptom disorder syndromes. [3]

Brain imaging studies support an association between one or more of the somatic symptom disorders, with reduced volume of the brain amygdala [4] and brain connectivity between the amygdala and brain regions controlling executive and motor function. [5]

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Epidemiology

Frequency

United States

Prevalence rates for the most restrictive previous diagnosis of somatization disorder appear low in community samples (0.1%). Low community prevalence rates for somatic symptom disorder may be due to a reporting bias.

One review estimates that the prevalence of somatic symptom disorder in the general population is approximately 5%–7%. This suggests that these concerns are among the most common patient concerns in the primary care setting. [6]

 An estimated 20%–25% of patients who present with acute somatic symptoms go on to develop a chronic somatic illness. These disorders can begin in childhood, adolescence, or adulthood. [6]

The existing evidence shows that somatoform disorders and medically unexplained symptoms are common in later life. The available data suggest that prevalence rates may decline after the age of 65 years. [7] There is evidence that somatic symptom disorder is highly prevalent in patients suffering from vertigo or dizziness symptoms. [8]

International

A study in Belgium reported that somatization syndrome is the third highest psychiatric disorder, with a prevalence rate of 8.9%. The first and second most common psychiatric disorders were depression and anxiety disorders. [9]

Somatic symptom disorders contribute a significant economic burden to the costs of brain disorders. A European survey estimated the cost of somatic symptom disorders across Europe to be 22 billion Euro/year (approximately $30 billion US dollars per year). This makes the cost of somatic symptom disorders in the range of that for multiple sclerosis, Parkinson disease, or traumatic brain injury. [9]

Mortality/Morbidity

Somatic symptom disorders do not appear to independently increase the risk of death. Some evidence exists that somatization disorder is associated with increased risk for suicide attempts. [10]

Previous research indicates that suicidality is a substantial problem in primary care patients with somatoform disorders, especially when major depression or anxiety realm disorders are comorbid. However, dysfunctional illness perception has been demonstrated to be related to active suicidal ideation independent of other psychiatric comorbidities. [11]

Patients with somatic symptom disorders may be misdiagnosed as having a medical condition and therefore experience iatrogenic complications due to invasive diagnostic procedures or surgical operations.

Sex

Females tend to present with somatic symptom disorder more frequently than males, with an estimated F:M ratio of 10:1. [6] This may be due to a greater willingness to report somatic symptoms in the female population.

Age

Somatic symptom disorders may begin in childhood, adolescence, or early adulthood. New onset of unexplained somatic symptom disorders in older adults should prompt a search for occult medical illness or evidence of major depression associated with somatization. An estimated 20%–25% of patients who present with acute somatic symptoms go on to develop a chronic somatic illness. [6]

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