Thoughts on Renmark, Waikerie, and Video Games

Renmark, 2002-3.

A couple days ago, my mother said that she remembers when my father made the decision to move from Renmark to Waikerie, to work for Agri-Tech, and when both myself and my brother were told this we both burst into tears. 

I remember that in Waikerie I began feeling overall disconnected, even though at the Lutheran school I was starting to fit in and make friends, this feeling became more pronounced when I started at the high school.

I don't remember this feeling in Renmark, although I think it possibly existed at some level.

I definitely don't remember feeling consistently anxious or detached. I do remember moments where I felt anxious, confused, detached, etc., however not as a consistent state/mood.

I'm currently not sure how else to describe that period in time. 

Maybe I could make a note on detachment.

I did feel some detachment, more similar to how I felt (or remembered feeling) at Gateway. Floating between individuals, groups, activities, and locations. At times dreaming. I did feel a disconnection with culture and history, and personal experiences. 

I remember times where I'd watch a larger group of more 'popular' kids play together on/near the playground and eventually participating briefly with them in, I think, a game of tag. I think I found the interpersonal dynamics/contentions/issues(?) a bit too much for me (unnecessary? complex?). I did understand, at least in a basic sense, why they occurred and that a part of what was going on was bringing to centre-stage what was happening within the group, working out what was un/acceptable, how to handle it (as an individual, between individuals, and as a group), and how to then maintain those changes or rules.

Regarding the maintenance of social/group rules, I remember thinking something along the lines that 'this is too much effort' and thereafter no longer spending time with them. Curious.

Video games.

While I did not spend much time playing video games, I do remember the fascination I had with them when at someone else's house, likely as they were novel and given a much wider degree of freedom to use them.

Waikerie 2003-5.

When we moved to Waikerie, I had begun to stop caring or getting invested in the external world, becoming more detached. The outside world was just full of unimportant importances; it was all important up until I next moved and then none of it mattered. 

On the other hand, video games were a secure constant. They were fun, interesting, and took me away from all the confusion and instability of life. 

Considering ADHD, video games were probably quite likely going to end up with a big role in my life, although for likely different reasons and in a healthier manner.

The change from the Lutheran school to the high school was another shock for me; another significant change in which I became more detached from the outside world.

In this way, it makes sense that my interest and enjoyment in playing video games increased. The rules were clear and didn't change on me consistently or when I moved to a new place, friendships could be maintained, mistakes had no IRL consequences, and I had a sense of control and an expressive outlet.

Auckland 2024: Drivers, roads, and driving

As a whole, I have been describing drivers as careless or carefree. Road rules are not often followed and drivers seem to drive to their own pace, yet not aggressive and reckless in the same way I see Newcastle drivers.

Drivers rarely follow the speed limit. 

There is a wide range that people drive at.

Drivers are often travelling above the speed limit, often as much as 20km/h above even in 50km zones but especially at 80km and faster zones. It's also fairly common to see drivers travelling 5-10km below the speed limit. 

Interection traffic lights seem to be followed fairly regularly. Other road rules are occasionally followed, as far as I can tell/remember, e.g., road works.

Indicating for lane changes are infrequent, yet still done at a higher frequency than Newcastle.

Some roads and intersections have poor designs, see the Brown Road, Sandspit Road, Hill Street, and Twin Coast Discovery Highway intersection at Warkworth 0910.

Quite a few roads entering highways have a traffic light system that stops traffic entering and is supposed to let one or two cars merge onto the highway at a time. From what I understand, they are supposed to help with busy traffic, however, they cause entering traffic to become severely backlogged and instead get ignored. I don't understand when or why they get turned on, and have seen them turned on with light-moderate traffic and off with moderate-heavy traffic (or off on the weekend).

Untitled: Taboo

I had a conversation in which I was discussing what I understood about the background of the Jewish people and Imperialism from the book 'The Origins of Totalitarianism', and the conversation moved towards how younger generations of the Western world don't quite understand the concept of Colonialism. More so that it doesn't get spoken about, that it's 'taboo'.

They went on to say 'How can you address a problem if you're not allowed to talk about it?' and I thought this to be rather apt as it had made clear an issue I've had in regards to Australian society.

A Quick Update After Deleting An Unfinished Post

    The end of last year I started writing a post, however, twice, I was unhappy with the content and intent of what I'd written. I'd hoped to have returned to finish the post yet found my thoughts changing away from the original expression. I considered publishing it regardless but the thought of stating my dissatisfaction with the subsequent garble of unfinished thoughts irritated me. As such I've removed that draft and am moving on.

    Though I'm now uncertain as to what I would like to write about. A common problem. 
So, I think I'll just write what comes to mind.

    Thinking back over the last couple months, I've been feeling a lot better. I'm not sure of which more concise words to use to describe these feelings. I've definitely been feeling calmer, more confident, happier, and more content. My mind has been a lot less jumbled, with less 'fog', and overall feels cleaner and works better. I still go through ups and downs, generally related to motivation, but they aren't as deep or long lasting - it's easier to manage them as well. 
I haven't felt as strong a need to be constantly playing video games for the sake of playing them which also means I've been doing a larger variety of alternate activities, especially socialising. I haven't been relying on lists to remember what needs to be done or when, and have found it easier, enjoyable even, to go shopping for longer periods of time. 

    Just last week I took the canvas painting to get framed. Only taken just over 5 years to do. 

    There was a period of time where I started settling back into old habits. After I became concerned about this I found what was happening after to be strange. 
Those habits began to shift away into newer habits and attitudes in a way that has required much less effort from me overall. This used to be something that I'd have to put in a lot energy to start changing, and even then maintaining that change was even harder. I do still have some trouble getting to bed earlier and more consistently, so that's something I still need to work on. I plan to speak to my psychiatrist about getting melatonin combined with the dex to help with that. 

 
    I'm back to uni next week, in 3 days, and I'm a bit nervous. A lot of that feeling has to do with not feeling like I've done enough of the aims I'd set out at the start of the uni break. It's likely that those aims involved the completion of those aims, but even then there are a few that I didn't even start on, let alone get halfway through. So, I dunno.

    Well, that's all I feel like writing.

Started/Trialling ADHD medication

Just some quick notes on what's been happening with the meds. Brain is falling apart so hopefully I remember my points tomorrow.

Started 3rd Nov 22. First two to three days were the most intense. New chemical in the system. Unwanted effects were the headache, dry mouth, slight dehydration, going to the toilet more, and disrupted sleep, e.g., waking up multiple times through the night, and/or poor sleep quality.
I also was becoming incredibly tired between 2-4pm, often needing to lie down for a tad then I'd be good till about 8-9pm. I thought this to be a result of the dose timing, and I think that is remains true.
Oddly I've found myself shifting from a 'night owl' to a 'morning lark'. I used to have trouble getting to sleep before 12am and waking up before 8am, but now I find myself waking up around 7am and ready to sleep by 11pm. I've decided to just run with it and shift everything to match it.
I haven't been running out of motivation as quickly. Best analogy I could think of at this time of night. Basically doing things has become so much easier to do. I don't feel like I'm fighting myself every step of the way. Getting out of bed is easy, starting almost any task is so much easier, staying focused, paying attention, remembering,,,, so much easier. Something I struggled with constantly is showering after the gym. I'd get home and just need several hours to recover before being able to get myself to the shower. Now I get back home from the gym and go shower almost immediately. It's a huge relief to just be able to do something like that without having to fight myself every step of the way. After the shower I do something else, like reading, organising my room, planning, ect. Some mornings I've managed to get 2-3 tasks done between showering after the gym and lunch time ... 2-3 different tasks used to be the limit of what I often could do a day. Being able to read through more complex texts without constantly forgetting or being zoning off is no longer a chore. 

One analogy I've been somewhat using is that of driving a car. Driving a car that runs out of fuel quickly, with the handbrake partially on, several music stations playing, several news stations discussing something important, someone in the passenger seat trying to have a deep conversation with you, someone in the back trying to get your attention with a bunch of interrupting methods, no idea what is going on with the third person in the car but they're really upset with you for something, and you need to get to the fuel station, workplace, the museum, and possibly somewhere else but you're not sure where.
When taking the meds, suddenly the music and news stations get quieter or go away, the passengers are quieter, more patient and not trying to talk over each other, or constantly trying to grab your attention, the third person isn't upset with you for something, the handbrake is down, the fuel leakage has slowed down a lot, and you realise that your GPS now shows the route you need to take to drop the third passenger off at the museum, fill up fuel and get to work on time.

20 Days later: The last 20 days taking the meds has been enlightening; definitely provided a contrast to how I've been living/functioning to that of 'normal' people. Most side effects are no longer present. I've still been having some issues with sleep quality, but my overall circadian rhythm remains consistent. I find myself waking up around 7am with a positive mood and although I try to sleep for a bit longer due to the general low quality of sleep, when I do decide to actually 'wake up' and get going then it's a lot easier to do so. It becomes a case of making the decision to get up then enacting it, rather than making the decision and finding myself struggling against myself to do just that. I used to force myself downstairs to make a coffee and breakfast then return to my room to slowly wake up. If I came across anyone during the day then I'd often have short conversations with them before running out of steam. With the meds it's a little different and I have a differing perspective. For a start I don't need to put in extra effort just to pay attention to what's being said and forming thought out sentences, but also I can track what's been said, what my thoughts and feelings are, what thoughts and emotions they have and are expressing, to a degree I can pull up relevant info at will, and not forget about all the things I was going to do just then or for the whole day (something that bothered me; was disruptive.).
    So, getting going in the morning is easier. It's easier to have conversations with people as I can pay attention easier, pay attention to more things, and keep track of plans and actions. Another thing, although I do try practice it as well, is mentally putting aside the things I want to talk about to let the other person speak so that my own thoughts aren't, I guess, 'louder' than the other person.
    In general, being able to plan and enact has been significantly improved. Nor does doing this require a huge effort that sucks up most of my energy for the day. Starting and finishing tasks, even if I don't particularly feel like doing them, has become effortless in most instances. 
    An example would be mornings where I go to the gym: getting ready (mentally and emotionally) is barely an issue, I'm consistently arriving at the time I've set to arrive at instead of being inconsistent, being able to remember what stretches I need or want to do and change them as needed without needing a list or other reminders, remembering subsequent exercises, remembering rep and set counts, remembering conversation topics, are more things that have become substantially easier to do (to the point where I can do them all simultaneously), I'm finding myself a lot more emotionally stable and no longer finding myself getting easily flustered/frustrated over mistakes or having other easy mood swings, and when I get home I'm not so drained in all aspects that I spend a couple hours on the computer or phone before getting myself into the shower and instead I'm able to get home, play with Minnie, talk with housemates, shower, and start cooking lunch before 1130 (not to mention that the gym session ends a little later than with Tys, ~1005, and I'm getting home around 1025). Before 1130 I have the freedom to do something else although often I catch up on the idle mobile game I've running. 
    Something else I've noticed is how consistent my mood and emotions have been, compared to what they used to be. At first I thought that it was the euphoria from the meds that fuelled my good mood, and they probably do to a degree, but I'm finding that even when I feel them wearing off or when I wake up before taking them that I'm still in that consistent good mood. I haven't been as easily swayed by negative emotions or thoughts, things that bother me. I still do get bothered by stuff, however they don't become as extreme or consuming, and it's easier to return myself to that good mood. 
    A couple more observations that I remember. Not feeling as strong a desire to (binge) eat junk or sugary foods, and not feeling like I constantly need to be playing games (more specifically, LoL). Like I still enjoy playing LoL but no longer feel a constant need to be playing it, or to be sitting at the computer getting lost in video's or games.

That's all I can think of currently.

I suspect that I'd benefit from a higher dose but I'm more than happy to sit at this current dose for a while, iron out some kinks, and practice improving executive function skills. Another thing is that the dose is low enough that it reminds me, in a sense, of what it was like before I started taking them, but I feel those memories are starting to become distant.
    I don't wish to become addicted on them. I may have to accepted dependence, I'm dependent on glasses already, but to become addicted is something I'd very much hope to avoid. I feel a part of me would slip into addiction if it got the chance, but in saying that, as long as I don't decide to start taking more for the high then I should be fine. There is the possibility that worrying about it too much will keep it on my mind and increase the likelihood of a spontaneous decision to take an extra one or two.

A Case Regarding An ADHD Diagnosis

 Since writing the title I've been distracted by something shiny out the corner of the title, taken a bite of food, moved my phone from in front of me to the right of me, wanted to put some music on, been bothered by where I've moved my phone, forgotten how I was going to write this all out, and am trying to- wait gotta move the keyboard over slightly, and am trying to remember the- now my back and neck is tight and sore so it needs stretching, and am trying to remember how I was going to organise my thoughts to- fuck, maybe more coffee will help me focus. Uhm, ADHD, potential diagnosis, reasons for and against, trying hard to focus. Fuck. Thankfully sitting here recapping everything I've read has just amounted to me daydreaming or spacing out. This isn't exactly an uncommon part of my day. 

So basically my plan now is just to wing it, stream of consciousness style, write a list of things I wanted to focus on, and type as much out as quickly as possible cause I got other things that need to be done asap; as for why I'm not doing the more important things right now, the things that I need to do now or else I won't get them done .... shhhh, don't think about it, just do.

1) Reasons for and again (though at this point I'm having a hard time arguing against)
    a) Possible examples through my history, vaguely up till the army.
    b) Examples in the army.
    c) Examples outside, during study

2) Cliffnotes on what ADHD is, ect

3) Something something, definitely didn't forget.
    a) Conclusion? 

Lets see:

• Zimbabwe, primary school years 1-3: 
• Daydreaming a lot (like even I'm aware that it's a lot)
• During breaks I'd roam around the school and temporarily hang out with other people before moving on
• Did lots of sports.
• New Zealand: 
• Not sure what to say here
• The Riverland, Renmark & Waikerie: 
• Same here. Felt distanced from others, assumed it was from moving so much.
• Reading a lot of books to pass time.
• In Waikerie it's here I first noticed that once I was doing something it was often difficult for me to stop doing it and do something else, e.g., going from reading to swim training.
• Adelaide:
• Still feeling really distanced (assumption that none of it mattered and there was no point to paying attention to any of it).
• Still reading a lot of books to pass time.
• Staying up late reading, unwilling to stop to go to sleep.
• Start really getting into the internet and gaming, late 2000's
• Feeling distant from almost everything in my life.
• Doing hockey, cricket, swimming, and briefly tennis.
• Introduced to cannabis and alcohol
• Big drinks, big smokes.
• Worked at the video production company, constantly late to work and had no idea what I was supposed to be doing. 
• Playing a lot of video games.
• Staying up late till I couldn't keep my eyes open anymore, normal behaviour.
• Townsville: 
• Still smoking and drinking, feeling disconnected from life.
• Interactions with other people helped me start feeling happier and more connected. 
• No longer Christian, looking for Truth & the meaning of life through other avenues.
• Frequently late to work. I remember never really being sure of what I was supposed to be doing or how to do it, much as if there was just an empty gap between knowing I have to do something and the something itself. 
• Working as a kitchen hand kinda worked for me at the time; I knew the process of wash dishes, take food out, buzz the number, prepare salads, make and bake pizza's, and it all needed to be done immediately. It was a mix between simplicity, minor variations, and urgency that worked for me.
• I remember that when I'd take rubbish out to the skip bins, I'd be captured by everything else, the atmosphere, the lights and reflections, the quiet, to the point where I'd almost forget what I was doing and needed to be doing.
• It's about here where I notice, or am making an attempt to take in all information at once and experience it. If that's an ADHD thing or not, I'm not sure, I assumed it was due to the influence of Taoism and Zen.
• Sleep schedule is non-existent.
• Adelaide:
• Wanting to be a pro-gamer but finding I just can't make things work. I remember not understanding how other people were able to both plan so far into the game, I couldn't see past 15s of gameplay, let alone 5mins.
• University. Being stimulated by all the new information, and trying to work it all out. 
• Struggled to care. Not sure how to explain this further, I do know that I didn't like how uni is kinda pre-job training, though I don't think that's the most accurate reason.
• Finding myself unable to find motivation or enough meaning to do anything, or chase something.
• Contemplating and almost attempted suicide.
• Bluewater, Waikerie & and Asad:
• Not sure what to say here.
• When things are urgent or highly stimulating then brain go brrrr
• The Army:
• There was so much to do and learn immediately that I really enjoyed this. Super stimulating.
• Start noticing a few issues here:
• Really struggling to do drills, or things that require planning-  Especially when I'm being assessed.
• Emotions tended to be more extreme, more prone to fluctuation.
• A lot of difficulty winding down after doing something. 
• Smoking and drinking more heavily to try relax.
• Most of free time spent playing games to try relax.
• Forgetting simple and important things like: patches, hats, thermal sights, ect
• Becoming lost in the moment or the task (or hyperfocusing)
• Inability to let go of negative thoughts and feelings. Ruminating
• Singleton specific?: 
• Loss of urgency
• Loss of goals
• Loss of constant learning
• Frequent punishments
• Next to nothing to do off base
• Living on base
• Having no way to escape from army life
• Arm/shoulder/neck issues
• Studying:
• Similar to the above
• Difficulty maintaining focus during self-regulated learning.
• Difficulty in regulating emotions, or at least being more stable.
• Constantly being distracted by everything else
• Passive procrastination, constantly.
• Alternating between a high urgency, highly stimulated and obsessed state, or an uninterested, unable to focus on or be motivated about state.
• Difficulty in having a regular sleep pattern.
• Planning assignments is a challenge.
• 
  
•  

3) Something something, definitely didn't forget. Against? Conclusion? Questions, Queries, Concerns?

• Perhaps I didn't properly learn executive function while growing up. Parents, teachers, or other carers basically told me where to be and what to do, and my day-to-day was pretty structured.
• Perhaps I just had a very different view on life and living as a result of growing up in Zimbabwe then NZ and around Auz, being a Christian and seeing the world through those lenses, adopting Tao/Buddhist/Zen views, thinking about the world through the use of drugs, seeing the world not from a mainstream perspective, through the different experiences and places I've been, and through the array of differing viewpoints and attitudes I've come across along the way.
• Ruminating on negatives. May posit an argument for what is a negative but in this case it'd be topics that the general social considers negative.
• High cannabis use for several years straight. I don't think this could have had lasting effects as deep as what ADHD/I'm experiencing now.
• Generally accepting or considering that day-to-day tasks are challenging. Surely most people don't struggle with day-to-day stuff in the manner I do? Though it seems that people with ADHD struggle with day-to-day stuff the way that I do.
• Difference with/from ADHD and Big5 personality. I think this is negligible; the personality tests give an indication of where those aspects of your personality sit in relation with the other people being tested. Having ADHD or not would still mean that your personality would be in relation with other people.
• What is ADHD? (apart from having a terrible name). Neurochemical and physiological differences, generally deficits.
• Is there correlation between ADHD and attitudes, belief systems, culture, ect? Not in the way I was originally approaching this. 
• What about the framework and theories humans use to explain/understand the world or how they operate within it? Again, not in the way I was originally approaching this. 
• ADHD and head injuries (e.g., ACP)
• What about testing for neurochemical imbalances? Without actually taking tissue samples, possibly the next best thing would be taking dopamine/noradrenaline reuptake inhibitors (stimulants) and seeing how they influence the distractibility and focus.
• What about the consideration that my current situation is, in a sense, new and different for me. This may be the first time I'm consciously trying to dedicate myself to achieving a long term outcome. Up till ending high school I had little input on my life and what I was doing. Moving to Townsville was me leaving my current situation and trying to make sense of something. Having figured out that I need a goal, or direction, to orientate myself towards I tried to become a professional LoL player and the way that differs from now is that I was still playing competitive sports/games and they basically play themselves - very different to learning how to have relationships with people or helping others overcome their own problems. I went to uni out of curiosity, and with no further plan went fruit picking to get away from things and think for myself. I joined the army, and all its structures, with the desire to enter combat situations. Now I'm trying to structure the rest of my life, both my internal and external life, so that I'll be competent in helping other people make their lives better - is that not different enough that some aspects of the ADHD symptoms don't make sense? (not really). I've been in my current situation for almost 1.5 years and it's pretty stable, the fact that I'm still having difficulties with routine, planning, emotions, distractions, ect, ect, which are the things that people with ADHD have trouble with. I think at this point, considering how stable my situation has been, ADHD seems most likely.

4) The conclusion after a hiatus. Will the questions from 3) ever be answered?

Given my limited knowledge, essentially ADHD is the name given when the brain doesn't have enough of certain chemicals, most notably Dopamine. Other chemical/s include noradrenaline.

It seems that some of the strongest evidence in favor of ADHD is that I've been taking Modafinil, a dopamine reuptake inhibitor, for help me get motivated and stay focused on getting day-to-day tasks and study done.

Another strong indicator for me is alternating between these two generalised states: 1) difficulties focusing on any thing, low motivation to do anything, easily distracted, or 2) obsessed/hyperfocused on one thing, and highly stimulated when it comes to that one thing.

DSM-V: Somatic Symptom Disorder (Most of it anyways)

Somatic Symptom Disorder

Diagnostic Criteria(F45.1)
One or more somatic symptoms that are distressing or result in significant disruption of daily life.
~ Excessive thoughts, feelings, or 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.
~ Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
Specify if:
With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.
Specify if:
Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).
Specify current severity:
Mild: Only one of the symptoms specified in Criterion B is fulfilled.
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

Diagnostic Features

Individuals with somatic symptom disorder typically have multiple, current, somatic symptoms that are distressing or result in significant disruption of daily life (Criterion A), although sometimes only one severe symptom, most commonly pain, is present. Symptoms may be specific (e.g., localized pain) or relatively nonspecific (e.g., fatigue). The symptoms sometimes represent normal bodily sensations or discomfort that does not generally signify serious disease. Somatic symptoms without an evident medical explanation are not sufficient to make this diagnosis. The individual’s suffering is authentic, whether or not it is medically explained.

The symptoms may or may not be associated with another medical condition. The diagnoses of somatic symptom disorder and a concurrent medical illness are not mutually exclusive, and these frequently occur together. For example, an individual may become seriously disabled by symptoms of somatic symptom disorder after an uncomplicated myocardial infarction even if the myocardial infarction itself did not result in any disability. If another medical condition or high risk for developing one is present (e.g., strong family history), the thoughts, feelings, and behaviors associated with this condition are excessive (Criterion B).

Individuals with somatic symptom disorder tend to have very high levels of worry about illness (Criterion B). They appraise their bodily symptoms as unduly threatening, harmful, or troublesome and often think the worst about their health. Even when there is evidence to the contrary, some individuals still fear the medical seriousness of their symptoms. In severe somatic symptom disorder, health concerns may assume a central role in the individual’s life, becoming a feature of his or her identity and dominating interpersonal relationships.

Individuals typically experience distress that is principally focused on somatic symptoms and their significance. When asked directly about their distress, some individuals describe it in relation to other aspects of their lives, while others deny any source of distress other than the somatic symptoms. Health-related quality of life is often impaired, both physically and mentally. The diagnosis can further be specified by stating whether complaints predominantly involve pain and/or if complaints are marked by a persistent course(Katz et al. 2015).

Additionally, severity of somatic symptom disorder can be specified by the number of fulfilled B criteria. Mild forms of somatic symptom disorder (one symptom as specified in Criterion B is fulfilled) are more prevalent(Rief and Martin 2014; Voigt et al. 2012), while moderate (two or more B criteria are present) and severe cases (two or more symptoms as specified in Criterion B are fulfilled in combination with multiple somatic complaints or one very severe somatic symptom) are marked by higher levels of impairment(Claassen-van Dessel et al. 2016; Hüsing et al. 2018; Limburg et al. 2016). In severe somatic symptom disorder, the impairment is marked, and when persistent, the disorder can lead to invalidism.

There is often a high level of medical care utilization, which rarely alleviates the individual’s concerns. Consequently, the individual may seek care from multiple doctors for the same symptoms. These individuals often seem unresponsive to medical interventions, and new interventions may only exacerbate the presenting symptoms. Some individuals with the disorder seem unusually sensitive to medication side effects. Some feel that their medical assessment and treatment have been inadequate.

Associated Features

Cognitive features include attention focused on somatic symptoms, attribution of normal bodily sensations to physical illness (possibly with catastrophic interpretations), worry about illness, a self-concept of bodily weakness, and intolerance of bodily complaints(Voigt et al. 2012; Voigt et al. 2013). Besides health anxiety, emotional features may include negative affectivity, desperation, and demoralization related to somatic symptoms(Rief and Martin 2014). The relevant associated behavioral features may include repeated bodily checking for abnormalities, repeated seeking of medical help and reassurance, and avoidance of physical activity(Voigt et al. 2010). These behavioral features are most pronounced in severe, persistent somatic symptom disorder. These features are usually associated with frequent requests for medical help for different somatic symptoms. This may lead to medical consultations in which individuals are so focused on their concerns about somatic symptom(s) that they cannot be redirected to other matters. Any reassurance by the doctor that the symptoms are not indicative of serious physical illness tends to be short-lived and/or is experienced by the individuals as the doctor not taking their symptoms with due seriousness. As the focus on somatic symptoms is a primary feature of the disorder, individuals with somatic symptom disorder typically present to general medical health services rather than mental health services. The suggestion of referral to a mental health specialist may be met with surprise or even frank refusal by individuals with somatic symptom disorder.

Development and Course

The course of somatic symptom disorder is likely to be chronic and fluctuating and influenced by the number of symptoms, individual’s age, level of impairment, and any comorbidity(Creed and Barsky 2004; olde Hartman et al. 2009; van Geelen et al. 2015). The course is also influenced by personality traits, with less harm avoidance and greater cooperativeness associated with a shorter time to remission(Greeven et al. 2014).

In older individuals, pain localized in several body regions appears to be the most common symptom(Hiller et al. 2006). Somatic symptoms and concurrent medical illnesses are common as multimorbidity increases with age. Prevalence rates of somatic symptom disorder seem to be stable until age 65 years and might decrease thereafter(Hilderink et al. 2013). For making the diagnosis in older individuals, a focus on the requirement for excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns (Criterion B) is crucial. Somatic symptom disorder may be underdiagnosed in older adults either because certain somatic symptoms (e.g., pain, fatigue) are considered part of normal aging or because illness worry is considered “understandable” in older adults who have more general medical illnesses and medications than do younger people.

Risk and Prognostic Factors

Temperamental

The personality trait of negative affectivity (neuroticism) has been identified as an independent correlate/risk factor of a high number of somatic symptoms(Creed et al. 2012). Comorbid anxiety or depression is common and may exacerbate symptoms and impairment(Lee et al. 2015; Limburg et al. 2017).

Environmental

Somatic symptom disorder is more frequent in individuals with few years of education and low socioeconomic status, and in those who have recently experienced stressful or health-related life events(Creed and Barsky 2004; Creed et al. 2012; Deary et al. 2007; Reddy et al. 2019). Early lifetime adversity such as childhood sexual abuse is also likely a risk factor for somatic symptom disorder in adults(Eberhard-Gran et al. 2007; Rief and Martin 2014).

Course modifiers

Persistent somatic symptoms are associated with demographic features (women, older age, fewer years of education, lower socioeconomic status, unemployment), a reported history of sexual abuse or other childhood adversity, concurrent chronic physical illness or mental disorder (depression, anxiety, persistent depressive disorder, panic), social stress, and reinforcing social factors such as illness benefits(Deary et al. 2007). Total somatic symptom severity is probably associated with female gender, anxiety, depression and general medical illness(Tomenson et al. 2013). Cognitive factors that affect clinical course include sensitization to pain, heightened attention to bodily sensations, and attribution of bodily symptoms to a possible medical illness rather than recognizing them as a normal phenomenon or psychological stress(Deary et al. 2007; Rief and Broadbent 2007; Rief et al. 2004).

Culture-Related Diagnostic Issues

High numbers of somatic symptoms are found in population-based and primary care studies around the world, with a similar pattern of the most commonly reported somatic symptoms, impairment, and treatment seeking(Gierk et al. 2014; Lee et al. 2015; Rask et al. 2016). The relationship between number of somatic symptoms and illness worry is similar in different cultural contexts, and marked illness worry is associated with impairment and greater treatment seeking cross-culturally(Lee et al. 2011; Lee et al. 2015). In many cultural contexts, individuals with depression commonly present with somatic symptoms(Bagayogo et al. 2013; Dreher et al. 2017).

Despite these similarities, there are differences in somatic symptoms across cultural contexts and ethnoracial groups(Rohlof et al. 2014). Sociocultural factors, particularly stigma related to mental disorders, may explain differences in somatic symptom reporting across cultural contexts(Bagayogo et al. 2013; Löwe and Gerloff 2018; Wilkins et al. 2018). The description of somatic symptoms varies with linguistic and other local cultural factors.

Association With Suicidal Thoughts or Behavior

Somatic symptom disorder is associated with suicidal thoughts(Wiborg et al. 2013a; Wiborg et al. 2013b) and suicide attempts(Asselmann et al. 2018). It is likely that suicidal thoughts and behaviors are partly explained by the diagnostic overlap and frequent comorbidity of somatic symptom disorder and depressive disorders(Wiborg et al. 2013a). In addition, dysfunctional illness perceptions and the severity of somatic symptoms appear to be independently associated with an increased risk of suicidal ideation(Jeong et al. 2014; Wiborg et al. 2013a; Wiborg et al. 2013b).

Functional Consequences of Somatic Symptom Disorder

The disorder is associated with marked impairment of health status and high psychological distress(Voigt et al. 2012). Many individuals with severe somatic symptom disorder are likely to have impaired health status scores more than 2 standard deviations below population norms(Lee et al. 2015; Tomenson et al. 2013). Health status is particularly impaired in the presence of multiple or severe symptoms(Creed et al. 2013).

Differential Diagnosis

If the somatic symptoms are consistent with another mental disorder (e.g., panic disorder), and the diagnostic criteria for that disorder are fulfilled, then that mental disorder should be considered as an alternative or additional diagnosis. If, as commonly occurs, the criteria for both somatic symptom disorder and another mental disorder diagnosis are fulfilled, then both should be diagnosed, as both may require treatment.

Other medical conditions

The presence of somatic symptoms of unclear etiology is not in itself sufficient to make the diagnosis of somatic symptom disorder. The symptoms of many individuals with disorders like irritable bowel syndrome or fibromyalgia would not satisfy the criterion necessary to diagnose somatic symptom disorder (Criterion B). Conversely, the presence of somatic symptoms of an established medical condition (e.g., diabetes or heart disease) does not exclude the diagnosis of somatic symptom disorder if the criteria are otherwise met. Factors that distinguish individuals with somatic symptom disorder from individuals with general medical conditions alone include the ineffectiveness of analgesics, a history of mental disorders, unclear provocative or palliative factors, persistence without cessation, and stress(Suzuki et al. 2017).

Psychological factors affecting other medical conditions

The diagnosis of somatic symptom disorder requires distressing or impairing somatic symptoms that may or may not be associated with another medical condition but must be accompanied by excessive or disproportionate thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns. In contrast, the diagnosis of psychological factors affecting other medical conditions requires the presence of a medical condition, as well as psychological factors that adversely affect its course or interfere with its treatment.

Panic disorder

In panic disorder, somatic symptoms and anxiety about health tend to occur in acute episodes, whereas in somatic symptom disorder, anxiety and somatic symptoms are more persistent.

Generalized anxiety disorder

Individuals with generalized anxiety disorder worry about multiple events, situations, or activities, only one of which may involve their health. The main focus is not usually somatic symptoms or fear of illness as it is in somatic symptom disorder.

Depressive disorders

Depressive disorders are commonly accompanied by somatic symptoms such as fatigue, headaches, or joint, abdominal, or other pains. However, depressive disorders are differentiated from somatic symptom disorder by the requirement of the presence of depressed mood or, in the case of major depressive disorder, either depressed mood or decreased interest or pleasure in activities. In some cultural contexts, these core symptoms of depression may be initially denied or deemphasized by individuals whose presentations would otherwise meet criteria for a depressive disorder(Lanzara et al. 2019; Ryder and Chentsova-Dutton 2012; Ryder et al. 2008). Such individuals might instead emphasize somatic symptoms that may be idiomatic (e.g., heavy heart) and unfamiliar to clinicians(Ahmad et al. 2018; Bragazzi et al. 2014; Haroz et al. 2017; Seifsafari et al. 2013).

Functional neurological symptom disorder (conversion disorder)

In functional neurological symptom disorder, the presenting symptom is loss of function (e.g., of a limb), whereas in somatic symptom disorder, the focus is on the distress that particular symptoms cause. The features listed under Criterion B of somatic symptom disorder may be helpful in differentiating the two disorders.

Comorbidity

Somatic symptom disorder is associated with high rates of comorbidity with other mental disorders as well as general medical conditions. The most relevant co-occurring mental disorders are anxiety and depressive disorders, each of which occurs in up to 50% of cases of somatic symptom disorders(Bailer et al. 2016; Newby et al. 2017) and significantly contributes to overall functional impairment and poorer quality of life(Liao et al. 2019; Löwe et al. 2008). Other mental disorders that have been found to co-occur with somatic symptom disorder are posttraumatic stress disorder and obsessive-compulsive disorder(Bailer et al. 2016; Liao et al. 2019). Other evidence indicates an association with sexual dysfunction in men(Fanni et al. 2016).

Elevated levels of the psychological features (Criterion B) of somatic symptom disorder have been found in several general medical conditions(Kop et al. 2019). When a concurrent general medical condition is present, the degree of impairment is more marked than would be expected from the physical illness alone. Moreover, somatization in medical illness has been shown to worsen disease and treatment outcomes, adherence, and quality of life and to increase health care utilization(Grassi et al. 2013).