Somatic symptom disorder

A somatic symptom disorder, formerly known as a somatoform disorder,^[1][2][3] is a category of mental disorder included in a number of diagnostic schemes of mental illness, including the Diagnostic and Statistical Manual of Mental Disorders, (latest version DSM-5) used by most mental health professionals in the United States. (Before DSM-5 this disorder was split into somatization disorder (Briquet's syndrome) and undifferentiated somatoform disorder.) The diagnosis requires physical symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder (e.g., panic disorder).^[4]

In people who have been diagnosed with a somatic symptom disorder, medical test results are either normal or do not explain the person's symptoms, and history and physical examination do not indicate the presence of a known medical condition that could cause them, though it is important to note that the DSM-5 cautions that this alone is not sufficient for diagnosis.^[1] The patient must also be excessively worried about their symptoms, and this worry must be judged to be out of proportion to the severity of the physical complaints themselves.^[5] A diagnosis of somatic symptom disorder requires that the subject have recurring somatic complaints for at least six months.^[6]

Symptoms are sometimes similar to those of other illnesses and may last for years. Usually, the symptoms begin appearing during adolescence, and patients are diagnosed before the age of 30 years.^[7] Symptoms may occur across cultures and gender.^[6] Other common symptoms include anxiety and depression.^[6] However, since anxiety and depression are also very common in persons with confirmed medical illnesses,^[8] it remains possible that such symptoms are a consequence of the physical impairment, rather than a cause. Somatic symptom disorders are not the result of conscious malingering (fabricating or exaggerating symptoms for secondary motives) or factitious disorders (deliberately producing, feigning, or exaggerating symptoms).^[9] Somatic symptom disorder is difficult to diagnose and treat. Some advocates of the diagnosis believe this is because proper diagnosis and treatment requires psychiatrists to work with neurologists on patients with this disorder.^[6]

Types

Somatic symptom disorders are a group of disorders, all of which fit the definition of physical symptoms similar to those observed in physical disease or injury for which there is no identifiable physical cause. As such, they are a diagnosis of exclusion. They used to be recognized as Somatoform disorders in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. The following^[10] were conditions under the term Somatoform Disorders:

• Conversion disorder: A somatic symptom disorder involving the actual loss of bodily function such as blindness, paralysis, and numbness due to excessive anxiety
• Somatization disorder
• Hypochondriasis
• Body dysmorphic disorder: wherein the afflicted individual is concerned with body image, and is manifested as excessive concern about and preoccupation with a perceived defect of their physical appearance.
• Pain disorder
• Undifferentiated somatic symptom disorder – only one unexplained symptom is required for at least 6 months.

In the newest version of DSM-5 (2013) somatic symptom disorders are recognized under the term Somatic Symptom and Related Disorders:

• Somatic Symptom Disorder: Will take over many of what was formally known as Somatization Disorders, and Hypochondriasis
• Factitious disorder: Can be either imposed on ones self, or to someone else (Formally known as Factitious Disorder by proxy).
• Conversion disorder

• Illness anxiety disorder: A somatic symptom disorder involving persistent and excessive worry about developing a serious illness. This disorder has recently gone under review and has been altered into three different classifications.
• Somatoform disorder Not Otherwise Specified (NOS)^[11]

Included among these disorders are false pregnancy, psychogenic urinary retention, and mass psychogenic illness (so-called mass hysteria).

The ICD-10 classifies conversion disorder as a dissociative disorder.

Somatization disorder as a mental disorder was recognized in the DSM-IV-TR classification system, but in the latest version DSM-5, it was combined with undifferentiated somatoform disorder to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.^[12] Still, ICD-10, the latest version of the International Statistical Classification of Diseases and Related Health Problems, still includes somatization syndrome.^[13]

Proposed disorders

Additional proposed somatic symptom disorders are:

• Abridged somatization disorder^[14] – at least 4 unexplained somatic complaints in men and 6 in women
• Multisomatoform disorder^[6] – at least 3 unexplained somatic complaints from the PRIME-MD scale for at least 2 years of active symptoms

These disorders have been proposed because the recognized somatic symptom disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:^[15]

• Somatization disorder – 1%
• Abridged somatization disorder – 6%
• Multisomatoform disorder – 24%
• Undifferentiated somatoform disorder – 69%

Diagnosis

Each of the specific somatic symptom disorders has its own diagnostic criteria.

Controversy

Somatic symptom disorder has been a controversial diagnosis, since it was historically based primarily on negative criteria - that is, the absence of a medical explanation for the presenting physical complaints. Consequently, any person suffering from a poorly understood illness can potentially fulfill the criteria for this psychiatric diagnosis, even if they exhibit no psychiatric symptoms in the conventional sense.^[16][17] In 2013-4, there were several widely publicized cases of individuals being involuntarily admitted to psychiatric wards on the basis of this diagnosis alone.^[18][19] This has raised concerns about the consequences of potential misuse of this diagnostic category.

Misdiagnosis

In the opinion of Allen Frances, chair of the DSM-IV task force, the DSM-5's somatic symptom disorder brings with it a risk of mislabeling a sizable proportion of the population as mentally ill. “Millions of people could be mislabeled, with the burden falling disproportionately on women, because they are more likely to be casually dismissed as ‘catastrophizers’ when presenting with physical symptoms.”^[17]

Treatment

Psychotherapy, more specifically, cognitive behavioral therapy (CBT), is the most widely used form of treatment for Somatic symptom disorder. In 2016, a randomized 12-week study suggested steady and significant improvement in health anxiety measures with cognitive behavioral therapy compared to the control group.^[20]

Cognitive behavioral therapy can help in some of the following ways:^[21]

• Learn to reduce stress
• Learn to cope with physical symptoms
• Learn to deal with depression and other psychological issues
• Improve quality of life
• Reduce preoccupation with symptom

Antidepressant medication has also been used to treat some of the symptoms of depression and anxiety that are common among people who have somatic symptom disorder.^[21] Medications will not cure somatic symptom disorder, but can help the treatment process when combined with cognitive behavioral therapy.

See also

• Medically unexplained physical symptoms
• Munchausen syndrome by proxy
• Hysteria
• Nocebo

References

External links

• What it is and how to cope at familydoctor.org