Somatic Symptom Disorder

Somatic symptom and related disordersOpens in new window are defined by excessive concerns about physical symptoms or health.

Somatic symptom disorder is a mental health condition in which a person feels significantly distressed about physical symptoms and has abnormal thoughts, feelings and behaviors in response to them. The disorder disrupts their daily functioning and quality of life (Cleveland Clinic).

The key feature of somatic symptom disorder (SSD) is excessive anxiety, energy, or behavior focused on somatic symptoms that persists for at least 6 months. The person with this disorder is typically quite worried about his or her health and tends to view small physical concerns as a sign of looming disease.

Tormented by a broad range of somatic symptoms that were not solved by visiting 20 different doctors (Campbell & Matthews, 2005), Charles DarwinOpens in new window completed a log for 6 years of his bodily complaints, which was dominated by ratings of his flatulence and other gastrointestinal complaints.

Although his symptoms were likely genuine, his extensive notes signal that he was spending too much energy monitoring his health (Dillon, 2010). As illustrated by the Clinical Case of Maria, some might experience a multitude of symptoms from many different body systems. Others experience pain as the major concern.

Maria’s Clinical Case of SDD
Maria was 32 when her physician referred her to a psychologist after seeing her 23 times in 6 months for a range of complaints—general aches and pains, bouts of nausea, fatigue, irregular menstruation, and dizziness. Various tests, including complete blood workups, X-rays, and spinal taps, had not revealed any pathology. On meeting her therapist, Maria let him know that she was a reluctant client: “I’m here only because I trust my doctor, and she urged me to come. I’m physically sick and don’t see how a psychologist is going to help.” But when the therapist asked Maria to describe the history of her physical problems, she quickly warmed to the task. According to Maria, she had always been sick. As a child, she had had episodes of high fever, frequent respiratory infections, convulsions, and her first two operations—an appendectomyOpens in new window and a tonsillectomyOpens in new window. During her 20s, Maria had gone from one physician to another. She had suffered with unbearable periods of vomiting. She had seen several gynecologists for her menstrual irregularity and for pain during intercourse, and she had undergone dilation and curettage (scraping the lining of the uterus). She had been referred to neurologists for her headaches, dizziness, and fainting spells, and they had performed EEGs, spinal taps, and a CT scan. Other physicians had ordered EKGs for her chest pains. Maria seemed genuinely distressed by her health problems, and doctors responding to her desperate pleas for a cure had performed rectal and gall-bladder surgery. When the interview shifted away from Maria’s medical history, it became clear that she was anxious in many situations, particularly those in which she feared others might evaluate her. Indeed, some of her physical symptoms were typical of those experienced by people diagnosed with anxiety disorders.

Maria’s Clinical Case of SDD

Maria was 32 when her physician referred her to a psychologist after seeing her 23 times in 6 months for a range of complaints—general aches and pains, bouts of nausea, fatigue, irregular menstruation, and dizziness. Various tests, including complete blood workups, X-rays, and spinal taps, had not revealed any pathology.

On meeting her therapist, Maria let him know that she was a reluctant client: “I’m here only because I trust my doctor, and she urged me to come. I’m physically sick and don’t see how a psychologist is going to help.” But when the therapist asked Maria to describe the history of her physical problems, she quickly warmed to the task.

According to Maria, she had always been sick. As a child, she had had episodes of high fever, frequent respiratory infections, convulsions, and her first two operations—an appendectomy and a tonsillectomy. During her 20s, Maria had gone from one physician to another. She had suffered with unbearable periods of vomiting. She had seen several gynecologists for her menstrual irregularity and for pain during intercourse, and she had undergone dilation and curettage (scraping the lining of the uterus). She had been referred to neurologists for her headaches, dizziness, and fainting spells, and they had performed EEGs, spinal taps, and a CT scan. Other physicians had ordered EKGs for her chest pains. Maria seemed genuinely distressed by her health problems, and doctors responding to her desperate pleas for a cure had performed rectal and gall-bladder surgery.

When the interview shifted away from Maria’s medical history, it became clear that she was anxious in many situations, particularly those in which she feared others might evaluate her. Indeed, some of her physical symptoms were typical of those experienced by people diagnosed with anxiety disorders.

Somatic symptom disorder can be diagnosed regardless of whether symptoms can be explained medically. It is nearly impossible to determine some symptoms are biologically caused. Doctors often disagree on whether a symptom has a medical cause (RIef & Broadbent, 2007).

Indeed, when asked about their physical symptoms, people receiving primary care report that two-thirds of their symptoms have not received a medical explanation (Steinbrecher et al., 2011). Some people might have a condition that defies diagnosis because of limits in medical knowledge and technology.

As technology has improved, the medical profession now understands some conditions that were historically difficult to explain. As one example, complex regional pain syndromeOpens in new window was previously believed to be caused by psychological factors, but animal and human research now indicate that these symptoms result from inflammation secondary to autoimmune disorder (Cooper & Clark, 2013).

Many common syndromes remain a focus for research because their etiology is not well understood, including irritiable bowel syndromeOpens in new window, fibromyalgiaOpens in new window, chronic fatigueOpens in new window, nonulcer dyspepsiaOpens in new window, and some forms of chronic pain (Cooper & Clark, 2013). The presence of these syndromes is not a reason to diagnose somatic symptom disorders. When psychological factors exert a negative effect on medical symptoms, an alternative DSM diagnosis, labeled Psychological Factors Affecting Other Medical ConditionsOpens in new window, may be appropriately considered.

Treatment of Somatic Symptom Disorder

Therapists use many different cognitive strategies to treat somatic symptom disorder. Some involve training people to pay less attention to their body. Alternatively, cognitive strategies might help people identify and challenge negative thoughts about their health (Warwick & Salkovskis, 2001).

The person who struggles with thoughts such as “I cannot cope with this pain” might be taught to make more positive self-statements, such as “I’ve been able to manage bouts of pain on other days, and I’ll get through this one as well” (Christensen, Frostholm, et al., 2015).

MindfulnessOpens in new window can also help client disengage from a focus on their symptoms; clients who were taught to engage in daily mindfulness practice reported less health anxiety than participants who received standard medical care (McManus, Suraway, et al., 2012).

Behavioral techniques might help people reduce safety behaviors, resume healthy activities, and rebuild a lifestyle damaged by too focus on illness-related concerns (Warwick & Salkovskis, 2001). Maria, the woman whose Clinical Case was described earlier, revealed that she was extremely anxious about her shaky marriage and about situations in which other people might judge her.

Couple therapyOpens in new window, assertiveness training, and social skills training—for example, coaching Maria in effective ways to approach and talk to people—could help her improve her social interactions.

In general, behavioral and couples work can encourage patients to re-engage in satisfying activities and improve relationships. Behavioral and family approaches could also help change Maria’s reliance on playing the role of a sick person (Warwick & Salkovskis, 2001).

If Maria’s family members have adjusted to her illness by reinforcing her avoidance of responsibilities, family therapyOpens in new window might involve teaching family members about operant conditioningOpens in new window so that they reduce the amount of attention (reinforcement) they give to her somatic symptoms.

When the focus of somatic symptom disorder is on pain, several techniques can be helpful. Low-dose antidepressants, CBT, hypnosis, and a variant of CBT called acceptance and commitment therapy (ACT) have all been found to be helpful in randomized controlled trials. In ACT, the therapist encourages the client to adopt a more accepting attitude toward pain, suffering, and moments of depression and anxiety (Rief & Martin, 2014), these treatments are preferred over opioid medications, which are highly addictive (Streltzer & Johansen, 2006).

Specialties

Somatic Symptom Disorder

Treatment of Somatic Symptom Disorder

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