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).