Somatic Symptom Disorder

Somatic * symptom disorder (SSD) is a diagnostic category in DSM-5 that replaces the older category of somatoform disorder. SSD is diagnosed when a person focuses on physical symptoms of some kind (pain, difficulty sleeping, excessive tiredness, headaches, nausea, or others) to the point that he or she has a high level of emotional distress related to the symptoms, and has difficulty functioning in everyday life. The person with SSD may or may not have a known medical condition associated with the symptoms.

Tanya's Story

Rather than feeling reassured by the doctors at her college, Tanya has become even more worried, to the point that she cannot pay attention in class, has difficulty studying, has trouble sleeping, and has started to feel sick in her stomach after meals. Last week, one of her professors told her that she had failed an exam that she should have easily passed. She decides to go home for the weekend and talk to the doctor who took care of her in high school. After listening to Tanya's complaints that the doctors at her college don't take her headaches seriously, her childhood doctor talks with Tanya about her symptoms and compares them with her medical records from high school.

When the doctor hears that Tanya has been having trouble in her schoolwork for the last six months, she suggests to Tanya that she has a disorder called somatic symptom disorder (SSD), a mental disorder characterized by excessive worry about physical symptoms—in Tanyás case, her headaches—out of proportion to the seriousness of the headaches themselves. The doctor is careful to explain to Tanya that a diagnosis of SSD does not mean that the headaches are not real or that Tanya is only pretending to be sick, but that she needs to be treated for a mental condition as well as the physical headaches.

What Is Somatic Symptom Disorder?

Somatic symptom disorder (SSD) is a new diagnostic category introduced in the fifth (2013) edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5. DSM-5 is the basic handbook that psychiatrists and other medical professionals use to classify and diagnose mental disorders, and to guide treatment planning. Previous editions of the DSM included a group of disorders called somatoform disorders, which were defined as disorders in which a patient has physical complaints that cannot be explained by an underlying medical or neurologic * condition. What is different about the new definition of SSD is that the patient's symptoms do not have to be medically unexplained; a person diagnosed with SSD may (or may not) have a coexisting physical disorder.

SSD was defined, as of 2016, as a mental disorder in which the affected person has numerous and recurrent physical complaints associated with excessive and counterproductive feelings and behaviors that interfere with the person's normal life. A person with SSD is not producing the symptoms intentionally (such as forcing him- or herself to vomit) and is not faking the symptoms in order to avoid work or other responsibilities.

A DIAGNOSTIC DISPUTE: THE CASE OF JUSTINA PELLETIER

Justina Pelletier, a Massachusetts teenager, became the central figure in a dispute between her parents, two Massachusetts hospitals, and the Massachusetts Department of Children and Families (DCF). Justina had first been diagnosed at Tufts University School of Medicine with mitochondrial disease * . Mitochondrial disease affects different patients’ bodies in different ways; in Justina's case, she developed symptoms after a case of the flu in early 2013 that included inability to eat and barely able to walk. She was admitted to Tufts Medical Center on February 10, 2013. Three days later, however, doctors at Boston Children's Hospital decided that Justina fit the diagnostic criteria for somatic symptom disorder and needed psychiatric treatment rather than medical tests. They filed a complaint with the Massachusetts DCF on the grounds that Justina's parents were guilty of child abuse for denying her mental health treatment.

When Justina's parents refused to sign a treatment plan and tried to take her back to Tufts for medical treatment, they were told that Massachusetts DCF had taken custody of Justina. For the next 11 months, Justina was kept in the psychiatric ward of Boston Children's Hospital. In January 2014, Justina was transferred to a residential treatment center, where lack of medical treatment for her mitochondrial disease caused her physical condition to worsen. Her hair had fallen out, she had no body strength, and was confined to a wheelchair. In June 2014, a Massachusetts judge ordered Justina to be returned to her family. In December 2014, Justina was treated by specialists at Yale-New Haven Children's Hospital in Connecticut and at Children's Hospital of Philadelphia for her recurrent problems with eating and digestion.

Justina's medical treatment was ongoing as of 2016, but her case contributes to the long-term debate among doctors about somatic disorders: how to diagnose them correctly; how to evaluate and treat the physical symptoms associated with them; and how to remain mindful that each patient is a full human being who is so much more than a collection of symptoms.

How Common Is Somatic Symptom Disorder?

Doctors were not certain as of 2016 how common SSD is in the general population. One reason for this uncertainty is that the category has been used to diagnose people only since 2013, and it is difficult to compile useful data in just a few years. On the basis of statistics recorded for the older category of somatoform disorders, however, doctors estimate that anywhere from less than 1 percent of American adults to 2 percent of women to as high as 11 percent among patients in general hospital clinics meet the criteria for SSD. Most doctors believe that SSD is significantly more common among women than among men, with a sex ratio of 2:1; some doctors think that the ratio may be as high as 5:1.

In terms of age, SSD is most common among adolescents and younger adults. It is thought that the symptoms of the disorder usually begin in childhood, adolescence, or the early adult years, almost always before age 30. SSD is rare in older adults; in fact, doctors usually evaluate older adults for either depression or an undiagnosed medical illness when they have an onset of new somatic symptoms.

What Are the Signs and Symptoms of Somatic Symptom Disorder?

The signs and symptoms of somatic symptom disorder include the following:

How Do Doctors Diagnose and Treat Somatic Symptom Disorder?

Diagnosis

According to DSM-5, the doctor can then diagnose a patient with somatic symptom disorder when he or she meets the following criteria:

Treatment

The treatment that was most often recommended for SSD, as of 2016, was cognitive behavioral therapy * (CBT), a type of psychotherapy in which the person explores the feelings underlying their symptoms; learns how to function more effectively in spite of the symptoms; practices techniques for reducing their worrying about the symptoms; and tries out various ways to lower other forms of stress in their life. In some cases, a psychiatrist * may prescribe an antidepressant medication if the patient's SSD has caused them to become depressed as well as worried about their body.

Treatment for SSD is most effective when the patient has a good relationship with their primary care doctor, who can coordinate all their medical care, see them regularly, and support them in their work with a psychiatrist or cognitive behavioral therapist. SSD generally has a good prognosis * when the affected person is treated early. People who are not treated for SSD and have a severe form of the disorder are at risk of lifelong educational and social impairment.

Can Somatic Symptom Disorder Be Prevented?

Because somatic symptom disorder is still a new diagnostic category, little is known about its causes, whether genetic or environmental. Some doctors think, however, that children whose parents worry a lot about illness or are preoccupied with physical ailments are at increased risk of developing SSD. It is likely that parents who take physical illness in their stride and do not use their symptoms to seek attention from others or avoid responsibilities will teach their children by example to cope well with whatever illnesses may come their way in adult life.

See also Anxiety and Anxiety Disorders: Overview • Conversion Disorder • Depressive Disorders: Overview • Hypochondria • Pain

Resources

Books and Articles

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). Arlington, VA: American Psychiatric Association Publishing, 2013.

Rosic, Tea, Sameer Kalra, and Ζainab Samaan. “Somatic Symptom Disorder, a New DSM-5 Diagnosis of an Old Clinical Challenge.” BMJ Case Reports, January 12, 2016.

Websites

American Psychiatric Association. “Somatic Symptom Disorder.” http://www.dsm5.org/Documents/Somatic%20Symptom%20Disorder%20Fact%20Sheet.pdf (accessed July 18, 2016).

Mayo Clinic staff. “Somatic Symptom Disorder.” http://www.mayoclinic.org/diseases-conditions/somatic-symptom-disorder/basics/definition/con-20124065 (accessed July 18, 2016).

PsychCentral. “Somatic Symptom Disorder.” http://psychcentral.com/disorders/somatic-symptom-disorder/ (accessed July 18, 2016).

Yates, William R. “Somatic Symptom Disorders.” Medscape Reference. http://emedicine.medscape.com/article/294908-overview (accessed July 17, 2016).

Organizations

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., NW, Washington, DC 20016. Telephone: 202-966-7300. Website: http://www.aacap.org (accessed July 18, 2016).

American Psychiatric Association. 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209. Telephone: 703-907-7300. Website: http://www.psychiatry.org (accessed July 18, 2016).

* somatic (soh-MAT-ik) pertaining to or characteristic of the body

* neurologic (new-ro-LOJ-ik) pertaining to the nervous system.

* mitochondrial disease (mi-toe-KON-dree-al) is a rare genetic disorder that is caused by abnormalities in the mitochondria, the tiny organelles inside body cells that provide energy for the cells.

* cognitive behavioral therapy (CBT) a form of talk therapy that focuses on solving current problems and changing unhelpful patterns in one's emotions, thoughts, and behaviors.

* psychiatrist (sigh-KY-ah-trist) is a physician who specializes in diagnosing and treating mental disorders.

* prognosis (prog-NOE-sis) a forecast of the probable outcome of an illness, usually including the patient's chances of recovery.

  This information is not a tool for self-diagnosis or a substitute for professional care.