Somatic Symptom Disorder

Author(s): Jason Hunt, MD, Ankit Patel, MD

Originally published:09/21/2016

Last updated:09/21/2016

1. DISEASE/DISORDER

Definition

Somatic Symptom Disorder (SSD) is a new diagnosis listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) released in 2013. SSD loosely replaces several old diagnoses, namely Somatization Disorder, Undifferentiated Somatoform Disorder, Pain Disorder, and also includes a portion of the old diagnosis Hypochondriasis.

The diagnostic criteria changed in such a way as to simplify and re-conceptualize the criteria to be easier for non-psychiatrists to diagnose.1 The focus has shifted towards positive diagnostic signs and symptoms, rather than on the absence of a medical explanation for the signs and symptoms. The new positive diagnostic criteria is that the symptoms significantly impact the individual for an extended time period.

Somatic Symptom Disorder Diagnostic Criteria per DSM V1

  1. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
  2. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
    1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms
    2. Persistently high level of anxiety about health or symptoms
    3. Excessive time and energy devoted to these symptoms or health concerns.
  3. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months)

Further, the DSM states that you should specify if the diagnosis is:1

  1. With Predominant Pain (previously pain disorder): The specifier is for individuals whose somatic symptoms predominantly involve pain.
  2. Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).

And the DSM asks that you specify the current severity:1

  1. Mild: Only one of the symptoms specified in Criterion B is fulfilled.
  2. Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
  3. 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).

Etiology

No published research accounts for the etiology of SSD.

Epidemiology including risk factors and primary prevention

Likewise, due to the nascent nature of the diagnosis, no epidemiological research has been published on SSD. Extrapolating data from the prior diagnoses that contribute to SSD would be theoretical at best as not all patients with the former diagnoses will qualify for the SSD diagnoses under the DSM 5, particularly in those with unexplained symptoms.2 likely due to the newly established B and C criteria. Also, there are additional patients with explained medical conditions that can now be diagnosed with SSD if they suffer from the B and C criteria of SSD. There is some concern that these patients with known medical diseases will start to be labeled as mentally ill if they also now qualify for the SSD diagnosis.3,4  Despite all of this, some have still hypothesized in the published literature that the prevalence of SSD will be greater than the <1% of the general population that comprised the old somatization disorder and may be 5-7% of the general population based on old data, but as discussed, this is theoretical at best.1,5
Risk factors/primary prevention:

  1. There is no published research as yet regarding risk factors or primary prevention of SSD. However, there has been research published regarding correlations involving SSD. One study shows that for patients suffering from psychogenic non-epileptic seizures, the patients that also qualify for an SSD diagnosis are more likely to report polyallergy.6 Another study stated that for patients being worked up for multiple sclerosis, if they brought a list of symptoms, there was a high incidence of SSD.7

Patho-anatomy/physiology

There is not a known anatomical or physiological explanation for SSD.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

There is limited data published on the course of SSD, but one study suggests that in elderly individuals with SSD rated as severe, they display lower cognition as measured by the Mini Mental-State Examination.8 Another publication states that old data referring to somatoform disorders in general is applicable to SSD in regards to the idea of patients who self-report bodily weakness, it can be used as a predictor for symptom severity.9

Specific secondary or associated conditions and complications

Associated conditions include:

  1. Dyaesthetic Penoscrotodynia (burning pain in the genital skin) has been found in a retrospective study to be a type of SSD.10
  2. One case report found that that for middle-aged and elderly patients with SSD, having rapid eye movement sleep without atonia can help diagnose a comorbid Lewy body disease such as Parkinson’s or Lewy Body Dementia even before the patient’s match criteria for these diseases.11
  3. The DSM-V says that SSD is associated with high rates of comorbid depression and anxiety but does not cite any published research to back this claim.

No complications have been clearly established for SSD. However, one paper that focused on the somatic symptom burden reports that patients with a high somatic symptom burden were more likely to score high on self-reported measures of health care utilization as well as have high scores on measures of psychological distress as measured by the Kessler-6 questionnaire.12 However, they note that their criteria for somatic symptom burden differs from the DSM V criteria for SSD, and that while the connection to SSD is noteworthy, it’s premature to draw definitive conclusions about SSD utilizing their data.

2. ESSENTIALS OF ASSESSMENT

History

History and interview are essential to diagnose SSD, and patients should fulfill all three criteria. Recognition of polyallergy and the list-sign (of symptoms) which were mentioned as being correlated to SSD above can help clue in to the diagnosis, but is not a part of the diagnostic criteria. The DSM-V suggests SSD patients likely have a high level of medical care utilization and are more likely to avoid physical activity.1,13

It is important to differentiate SSD from Illness anxiety disorder which is also a new diagnosis under the DSM-V where a patient has no or only very mild symptoms, but has great anxiety and preoccupation that they have a serious disease. Another disorder that it is important to distinguish from SSD is generalized anxiety disorder which could be confused with the B criteria, but it is not due solely to somatic symptoms, it is anxiety due to multiple events, situations, or activities.1

Physical examination

There is no physical examination component in the assessment of SSD. Especially because under the new DSM V criteria, there is no need to rule out medical causes of the symptoms, they may be medically explained, or unexplained. It should also be noted that as new symptoms develop, they cannot be merely lumped into a prior SSD diagnosis, but need to be worked up as any other new symptom, including a physical exam.

Functional assessment

As stated above, there may be a tendency amongst SSD patients to avoid physical activity. There is one study that states that patients with high somatic symptom burden have increased functional impairment as measured by the Sheehan Disability Scale, although they note that their study doesn’t match directly with DSM V criteria of SSD, but is somewhat similar.12

Laboratory studies

There is no role for laboratory studies in the assessment of SSD, as once again there is no need to rule out medical causes. SSD can be due to medically explained or unexplained symptoms.

Imaging

There are no imaging studies used to confirm the diagnosis of somatic symptom disorder. There is, however, research stating that there are brain regions associated with a greater vulnerability to pain and catastrophization of symptoms including the dorsolateral prefrontal, insular, rostral anterior cingulate, and premotor and parietal cortices.14 But imaging to assess for irregularities of these areas is neither inclusive nor exclusive of the diagnosis, and no research has shown any correlation with SSD in particular.

Supplemental assessment tools

Several questionnaires have been developed and can be helpful in the assessment of SSD.

  1. Somatic Symptom Disorder-B Criteria Scale (SSD-12) is a self-report questionnaire that has been shown to have enough reliability and validity to warrant further testing in both research and clinical situations.15
  2. A modified shortened version of the Health Attitude Survey (HAS), which is a multidimensional self-report questionnaire, has been shown to be a reliable and valid instrument for assessing the B criteria of SSD.16
  3. The Health Preoccupation Diagnostic Interview (HPDI) has been shown to reliably diagnose SSD compared to independent evaluations by a clinician.17

Early predictions of outcomes

As the diagnosis of SSD was established in 2013, there are no published early predictions of outcomes.

Environmental

It is unclear if environmental influences impact the development, progression, or treatment of SSD. However, the DSM-V reapplies research pre-dating the DSM-V, and believes that SSD is more frequent in patients with low socioeconomic status, few years of education, and those who have recently experience stressful life events.1

Social role and social support system

There is no published data regarding the assessment of SSD specifically in regards to social role or support system.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

There are no guidelines regarding the treatment of SSD. However, if the symptoms are due to an explained medical diagnosis, treating the ailment may resolve SSD at least temporarily. It is also recognized that SSRIs, TCAs, and SNRIs are used to treat this diagnosis, as they were for some of the former DSM IV diagnoses, but there is a lack of research to guide it.18,19 There is one review article that states there are proven forms of treatment for SSD such as pharmacotherapy, cognitive behavior therapy, and mindfulness-based therapy, but it cites evidence that pre-dates the existence of the SSD diagnosis or applies evidence for other related disorders to SSD. 20 This is perhaps due to the fact that these forms of treatment have been used to treat the B criteria directly and therefore should also apply to SSD. There is however some limited research published specifically on treatment of SSD.

  1. One two-patient case study found that Blonanserin, an atypical antipsychotic that is not FDA approved, was useful in treating SSD when given with SSRIs.21
  2. A single-patient case study showed that gabapentin and venlafaxine reduced pain in a patient with somatic symptom disorder.22
  3. Another single-patient case study identified idiopathic burning mouth syndrome as an SSD that responded well to electroconvulsive therapy.23 Although the ECT may have simply been treating the idiopathic burning mouth syndrome following which the SSD resolved.

Rehabilitation guidelines

There are no treatment guidelines when it comes to the physical rehabilitation of patients with SSD. However, developing a close collaboration between the patient and the mental health practitioner would likely be useful in coping with the B criteria. And it is important to note as stated earlier that SSD patients tend to engage in less physical activity and score higher on disability rating systems.

Coordination of care

Early recognition of SSD and involving psychology/psychiatry to help manage is important. It may also be important to educate ancillary staff such as nursing and physical, occupational, and speech therapists regarding SSD.

Patient & family education

Key patient educational issues include:
Physician acknowledgement of the patient’s symptoms and the impact they have on quality of life.

Family education should include:
Education regarding what somatic symptom disorder is, and explaining that it is a medically recognized diagnosis that significantly impacts the patient’s quality of life and can be associated with increased disability.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Early suspicion and involvement of psychology/psychiatry for evaluation and treatment, and realizing that with the propensity to engage in less physical activity and to have more disability, the SSD patient may require more rehabilitation time than a similar patient without SSD.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

The entire diagnosis is still considered cutting edge as patients transition from previous DSM IV diagnoses to DSM V diagnoses such as SSD. Research is still waiting to really take off, particularly in the realm of treatment. Perhaps the most cutting-edge concept would be the previously mentioned blonanserin, an atypical antipsychotic, which is not FDA approved but has been shown to be effective.

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Due to the newness of the diagnosis, there is a large gap of evidence-based knowledge. As mentioned above. A gaps exist for evidence regarding etiology, epidemiology, pathophysiology, assessment, pharmacological and other forms of treatment18, and impact on physical rehabilitation. There is also a need for research regarding specific populations like adolescents and how SSD affects them functionally.24 As of the time of the preparation of this review, there were only 65 articles listed on PubMed that even mentioned “Somatic symptom disorder”, and of those, more than 40% were editorials, commentaries, and reviews.

REFERENCES

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing, 2013.
  2. Claassen-val Dessel N, Van Der Wouden JC, Dekker J, Van De Horst, HE. Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS) Journal of Psychosomatic Research 2016;82:4-10.
  3. Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people asmentally ill. BMJ. 2013;346:f1580.
  4. Hauser W. The somatic symptom disorder in DSM 5 risks mislabeling people with major medical diseases as mentally ill.J Psychosom Res. 2013;75:586-587.
  5. Rosic T, Kalra S, Samaan Z. Somatic symptom disorder, a new DSM-5 diagnosis of an old clinical challenge. BMJ. 2016. doi:10.1136/bcr-2015-212553
  6. Robbins NM, Larimer P, Bourgeois JA, Lowenstein DH. Number of patient-reported allergies helps distinguish epilepsy from psychogenic nonepileptic seizures. Epilepsy & Behavior. 2016;55:174-177.
  7. Anbarasan D, Campion G, Campion P, Howard J. Clinical utility of the list sign as a predictor of non-demyelinating disorders in a multiple sclerosis (MS) practice. CNS Spectr. 2016;3:1-6.
  8. Inamura K, Shinagawa S, Nagata T, Tagai K, Nukariya K, Nakatama K. Cognitive dysfunction in patients with late-life somatic symptom disorder: a comparison according to disease severity. Psychosomatics. 2015;56:486-494.
  9. Voigt K, Wollburg E, Weinmann N, Herzog A, Meyer B, Langs G, Lowe B. Predictive validity and clinical utility of DSM-5 somatic symptom disorder: Prospective 1-year follow-up study.Journal of Psychosomatic Research. 2013;75:358-361.
  10. Anyasodor MC, Taylor RE, Bewley A, Goulding JMR. Dyaesthetic penoscrotodynia may be a somatoform disorder: results from a two-centre retrospective case series. Clin Exp Dermatol. 2016 Mar 1. doi: 10.1111/ced.12824
  11. Munechika T, Fujishiro H, Okuda M, Iwamoto K, Toril Y, Iritani S, Ozaki N. Rapid eye movement sleep without atonia may help diagnose Lewy body disease in middle-aged and older patients with somatic symptom disorder. Psychogeriatrics.2016; doi:10.1111/psyg.12181
  12. Lee S, Creed FH, Ma Y-L, Leung CMC. Somatic symptom burden and health anxiety in the population and their correlates. Journal of Psychosomatic Research. 2015;78:71-76.
  13. Voigt K, Nagel A, Meyer B, et al. Towards positive diagnostic criteria: a systematic review of somatoform disorder diagnoses and suggestions for future classification. J Psychosom Res.2010;68(5):403–414.
  14. Garcia CJ, Payed N, Serrano-Blanco A, Roca M. Brain dysfunction behind functional symptoms: neuroimaging and somatoform, conversive, and dissociative disorders. Curr Opin Psychiatry. 2009;22:224-231.
  15. Toussaint A, Murray AM, Voigt K, Herzog A, Gierk B, Kroenke K, Rief W, Hennigsen P, Lowe B. Development and Validation of the Somatic Symptom Disorder-B Criteria Scale (SSD-12).Psychosomatic Meidicine. 2016;78:5-12.
  16. Schmid G, Dinkel A, Henningsen P, Dieterich M, Hopfner A, Pich C, Lahmann C. Assessment of psychological aspects of somatoform disorders: A study on the German version of the Health Attitude Survery (HAS).Comprehensive Psychiatry.2014;55:155-164.
  17. Axelsson E, Andersson E, Ljotsson B, Wallhed FD, Hedman E. The health preoccupation diagnostic interview: inter-rater reliability of a structured interview for diagnostic assessment of DSM-5 somatic symptom disorder and illness anxiety disorder.Cogn Behav Ther. 2016;20:1-11.
  18. Somashekar B, Jainer A, Wuntakal B. Psychopharmacotherapy of somatic symptoms disorders. Int Rev Psychiatry. 2013;25(1):107-115.
  19. Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barksy A, Lee S, Irwin MR, Levenson J. Somatic symptom disorder: an important change in DSM. Journal of Psychsomatic Research. 2013;75:223-228.
  20. Kurlansik S, Maffei MS. Somatic Symptom Disorder. Am Fam Physician. 2016;93(1):49-54.
  21. Nagoshi Y, Tominaga T, Fukui K. Blonanserin augmentation for treatment-resistant somatic symptom disorder: a case series.Clinical Neuropharmacology. 2016;39:2,112-114
  22. Shebak SS. Gabapentin and venlafaxine reduce pain in a patient with somatic symptom disorder. The Primary Care Companion for CNS Disorders. 2014;16(4):10.4088/PCC.14l01632. doi:10.4088/PCC.14l01632.
  23. McGirr A, Davis L, Vila-Rodriguez F. Idiopathic burning mouth syndrome: a common treatment-refractory somatoform condition responsive to ECT. Psychiatry Research.2014;216:158-159.
  24. Van Geelen SM, Rydelius P-A, Hagquist C. Somatic symptoms and psychological concerns in a general adolescent populations: Exploring the relevance of DSM-5 somatic symptom disorder. Journal of Psychosomatic Research.2015;79:251-258.

Author Disclosure

Jason Hunt, MD
Nothing to Disclose

Ankit Patel, MD
Nothing to Disclose

 

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