Somatic Symptom Disorder

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Original Editors - Lauren Rouse & Laura Stigler from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Lauren Rouse, Laura Stigler, Elaine Lonnemann, Admin, Wendy Walker, WikiSysop, Kim Jackson and Vidya Acharya  

Definition/Description

Somatic symptom disorder (SSD), as defined by the DSM-V code, occurs in individuals experiencing exaggerated and disrupted physical symptoms in multiple areas of the body, accompanied by exaggerated thoughts impairing activities of daily living. Diagnosis of SSD requires that the individual has experienced these symptoms for at least six months. This disorder has recently been updated from DSM-IV code of "somatization disorder" to the DSM-V code of "SSD". The prior diagnosis required patient complaints from four different symptom groups; however, this is no longer required with the DSM-V code¹. In addition, patients experiencing these symptoms associated with other comorbidities such as heart disease, osteoarthritis, or cancer were previously excluded from the DSM-IV diagnostic code. The DSM-V definition now includes these patients under the diagnostic code of SSD, even if the psychological symptoms were secondary to the primary diagnosis. These patients are considered appropriate for psychological treatment; however, a full psychological evaluation is needed to rule out other possible disorders².

Prevalence

Information about the prevalence of SSD is lacking due to the recent changes in the DSM-V code in 2013. The prevalence of the DSM-IV code of somatization disorder is more widely known and the following data has been obtained: 

• For restrictive diagnoses, rates are low in community samples (0.1%) but this may be due to reporting bias³
• The disorder may be as high as 2% in community dwelling women, whereas some cases are reported to be as high as 11.6% of the population³
  
• The female-to-male ratio is 10:1 and may begin in childhood, adolescence, or early adulthood³.
• Older adults diagnosed with somatization disorder is a rare finding. Older patients should be referred to a medical specialist for an underlying medical illness or consider depression as the primary cause of the individual’s perception of pain³.
  
• 25% in neurology outpatient medical settings (P Fink, M)
  
• 27% in primary care (P Fink, L)
  

3. Van noorden MS, Giltay EJ, Van der wee NJ, Zitman FG. [The Leiden Routine Outcome Monitoring Study: mood, anxiety and somatoform disorders in patients attending a day clinic]. Tijdschr Psychiatr. 2014;56(1):22-31.

P Fink, M Steen Hansen, L SondergaardSomatoform disorders among first-time referrals to a neurology service

P Fink, L Sørensen, M Engberg, M Holm, P Munk-Jørgensen. Somatization in primary care. Prevalence, health care utilization, and general practitioner recognition. Psychosomatics, 4 (Jul–Aug 1999), pp. 330–338

Statistical prevalence on the prior DSM IV code is inaccurate do to the confusing description of the disoder; therefore, non-psychiatric physicians have rarely diagnosed somatoform disorders. In addition, psychiatric physicians used ambiguous terminology in diagnosis of patients with this disorder. Lack of consensus among the medical community has lead to inaccurate prevalence statistics. Despite the frequency encountered in clinics and studies in medical studies, prevalence among Anthem Blue Cross insured individuals was 0.00002 out of 28 million subscribers and appeared rarely in the medical databases of Medicare, Medicaid and Veteran's Administration. Creation of the new DSM V code is attempting to provide a straightforward and simplified definition of the disorder so that medical professionals are able to effectively communicate the medical diagnosis of SSD.

Dimsdale J, Creed F, Levenson J, et al. Somatic Symptom Disorder: An important change in DSM. Journal Of Psychosomatic Research [serial online]. September 2013;75(3):223-228. Available from: PsycINFO, Ipswich, MA. Accessed March 7, 2014.

Characteristics/Clinical Presentation

Criteria for SSD as defined by the American Psychiatric Assocation (APA):

Table 1.

Criteria for Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.

B. Excessive thoughts, feelings, behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

Disproportionate and persistent thoughts about the seriousness of one's symptoms. Persistently high level of anxiety about health or symptoms. Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously persent, the state of being symptomatic (typically more than 6 months)

 Somatic Symptom Disorder: An important change in DSM

Dimsdale JE, Creed F, Escobar J, et al. Somatic symptom disorder: an important change in DSM. J Psychosom Res. 2013;75(3):223-8.

Associated Co-morbidities

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Medications

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Diagnostic Tests/Lab Tests/Lab Values

Table 1.

Criteria for Somatic Symptom Disorder

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.

B. Excessive thoughts, feelings, behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

Disproportionate and persistent thoughts about the seriousness of one's symptoms. Persistently high level of anxiety about health or symptoms. Excessive time and energy devoted to these symptoms or health concerns.

C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 9c) 2013). American Psychiatric Association. All rights reserved.

The diagnostic criteria for SSD focuses not only on somatic symptoms but also on psychological responses, including the patient's emotions, thinking and behavior of their symptoms. The severity of SSD can also be diagnosed as mild, moderate or severe. Diagnosis may or may not include another diagnosed medical conditions. Medically unexplained symptoms are no longer included in the diagnostic criteria and are discouraged. Describing the patients symptoms as medically unexplained is inaccurate because oftentimes symptoms are unexamined. In addition, patients suffering from somatic complaints may feel that medical professionals view their symptoms as inauthentic.

Dimsdale JE, Creed F, Escobar J, et al. Somatic symptom disorder: an important change in DSM. J Psychosom Res. 2013;75(3):223-8.

The interrater reliability of diagnoses for SSD was listed as 0.61 in adult diagnoses. B-type criteria also has good test-retest reliability among physicians with an ICC of 0.680. Global rating of the severity of a patient's symptoms was found to have acceptable reliability with an ICC of 0.483.

HC Kraemer, DJ Kupfer, DE Clarke, WE Narrow, DA Regier. DSM5: how reliable is reliable enough? Am J Psychiatry, 169 (2012), pp. 13–15

Etiology/Causes

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Systemic Involvement

Patients diagnosed with the DSM-V disoder may present with the following systemic symptoms:

Cardiac

• Shortness of breath
• Palpitations
• Chest pain
  

Gastrointestinal

• Vomiting
• Abdominal pain
• Difficulty swallowing
• Nausea
• Bloating
• Diarrhea
  
  

Musculoskeletal

• Pain in the legs or arms
• Back and joint pain
  

Neurological

• Headaches
• Dizziness
• Amnesia
• Vision changes
• Paralysis or muscle weakness

Urogenital

• Pain during urination
• Low libido
• Dyspareunia
• Impotence
• Dysmenorrhea
  

Available at: http://www.patient.co.uk/doctor/somatic-symptom-disorder. Accessed February 27, 2014.

Medical Management (current best evidence)

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Physical Therapy Management (current best evidence)

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Alternative/Holistic Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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