Somatic Symptom and Related Disorders

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In people who have a somatic symptom and related disorders, medical test results are either normal or don’t explain the person’s symptoms.

As shown in Table X-1, the DSM-5 includes three major somatic symptom-related disorders: somatic symptom disorder, illness anxiety disorder, and conversion disorder. Many of us use the term hypochondriasis to describe chronic worries about developing a serious medical illness.

Although hypochondriasisOpens in new window is not a DSM-5 diagnosis, both somatic symptom disorderOpens in new window and illness anxiety disorderOpens in new window overlap to some degree with hypochondriasis in that they involve high levels of distress and energy expenditure about a health concern.

In somatic symptom disorderOpens in new window, the distress revolves around a somatic symptom that exists, whereas in illness anxiety disorderOpens in new window, the distress is about the potential for a medical illness in the absence of significant somatic symptoms. Conversion disorderOpens in new window involves neurological symptoms that are medically unexplained (labeled as functional neurological disorder in medical literature). Table X-1 also lists malingeringOpens in new window and factitious disorderOpens in new window.

Somatic symptom disorders lead to medical expenditures estimated at $256 billion per year in the United States (Barsky, Orav, & Bates, 2005). In the UK, the average cost of medical care for patients with high levels of health anxiety was £2,796 (roughly $4,622) for a 6-month period in 2009 – 2010 (Barrett, Tyrer, et al., 2012).

Although people with these disorders seek medical care quite frequently, they are often dissatisfied when doctors cannot provide a medical care quite frequently, they are often dissatisfied when doctors cannot provide a medical explanation or cure. They often view their physicians as incompetent and uncaring (Persing, Stuart, et al., 2000).

Despite their negative assessment of the medical profession, they will often continue extensive treatment-seeking, visiting new doctors and demanding new tests. Many patients become unable to work because of the severity of their concerns (van der Leeuw, Gerrits, et al., 2015). For patients for whom pain is a concern, dependency on painkillers is a risk.

The DSM-5 diagnoses of somatic symptoms and related disorders can be reliably diagnosed, particularly if a semistructrued clinical interview is conducted (Axelsson, Andersson, et al., 2016).

Nonetheless, there are a couple important criticisms of the diagnostic criteria for somatic symptom and related disorders:

• These conditions are remarkably varied. For example, some people develop somatic symptoms in the context of anxiety and depressive disorders, whereas others do not (Lieb, Meinlschmidt, & Araya, 2007).
• Patients often find the diagnosis of somatic symptom and related disorders stigmatizing. This may interfere with applying diagnoses of somatic symptom disorders in clinical practice.

Because these disorders are defined differently than they were in DSM-IV-TR (where they were labeled as somatoform disorders), we don’t have data on the epidemiology or course of the somatic symptom-related disorders.

When the fears about a serious disease are accompanied by somatic symptoms, the appropriate DSM-5 diagnosis is somatic symptom disorder. Because so few people with intense fears about their health are free of somatic symptoms, somatic symptom disorderOpens in new window is estimated to be three times as common as illness anxiety disorderOpens in new window (Bailer, Kerstner, et al., 2016).

Somatic symptom disorder and illness anxiety disorder both involve health anxiety. Anxieties about health tend to develop early in adulthood (Cloninger, Martin, et al., 1985). Many experience these concerns throughout their lifetime.

In longitudinal studies, less than half of those with somatic symptom-related disorders achieve remission within a 5-year period (Olde Hartman, Borghuis, et al., 2009), although the severity of symptoms may wax and wane. Somatic symptom-related disorders tend to co-occur with anxiety disordersOpens in new window, mood disordersOpens in new window, and personality disordersOpens in new window (APA, 2013).

Symptoms of these disorders may begin or intensify after some conflict or stress. To an outside observer, it may seem that the person is using the health concern to avoid some unpleasant activity or to get attention and sympathyOpens in new window. People with somatic symptom and related disorders have no sense of this, however; they experience their symptoms as completely medical. Their distress over their symptoms is authentic.

Treatment of Somatic Symptom and Related Disorders

Because most people with somatic symptom and related disorders seek treatment from general practitioners, one approach has been to teach primary care teams how to tailor care for people with these disorders.

In one study, researchers randomly assigned patients with distressing and medically unexplained gastrointestinal symptoms to receive standard care or high levels of warmth, attention, and reassurance from doctors.

Those who received high levels of support showed more improvement in symptoms and quality of life over the next 6 weeks than those who received standard care (Kaptchuk, Kelley, et al., 2008).

Another health care system intervention involves alerting physicians when a patient is an intensive user of health care services so as to minimize the use of diagnostic tests and medications. This type of intervention with physicians can reduce the unnecessary provision of costly health care services (Konnopka, Schaefert, et al., 2012).

Cognitive behavior therapy (CBT)Opens in new window makes use of many different techniques to help people with somatic symptom and related disorders. These techniques include helping people:

1. identity and change the emotions that trigger somatic concerns
2. change cognitions regarding their somatic symptoms, and
3. change behaviors so as to improve social interactions (Looper & Kirmayer, 2002).

Family interventions are also often provided. It should be noted that the negative emotionOpens in new windows that accompany anxiety and depressive disorders often trigger physiological symptoms and intensifty the distress about those somatic symptoms. It should be no surprise that treating anxiety and depression often reduces somatic symptoms.

CBT is more efficacious in reducing health concerns, depression, and anxiety than is standard medical care or psychodynamic treatment of somatic symptom and related disoreders (Olatunji, Kauffman, et al., 2014). In one study, CBT was as effective as antidepressant treatment in reducing illness anxiety symptoms (Greeven, van Balkom, et al., 2007).

In addition to reducing distress and anxiety, CBT produces reductions in the actual somatic symptoms compared to control treatment, the effects are small (van Dessel, den Boeft, et al., 2014). That is, these interventions may do more to reduce the distress about somatic symptoms than they do to reduce the actual somatic symptoms.