The Diagnostic Statistical Manual characterises Somatic Symptoms and Related Disorders emerging out of medically unexplained symptoms and causing extreme distress and impairment in functioning. It is a group of disorders marked by extreme sensitivity to bodily symptoms and preoccupation with physical pain and abnormality. There are various subtypes based on the symptoms expressed by the patients.
A person suffering from a somatic symptom disorder is going to exhibit severe impairment in functioning due to relentless pain in a certain part(s) of the body. They tend to exhaust medical diagnostic procedures and may have difficulty believing that there is no diagnosable medical condition underlying their pain. Some patients may present medical conditions but with exaggerated pain symptoms.
They often exhibit high levels of anxiety over their disorder and are highly preoccupied in pain relieving procedures. This adversely affects their functioning and quality of life. They tend to equate their identity with their disorder, meaning, they often talk about it like a person would talk about their day, job and regular life circumstances.
Women show high rates of susceptibility to this disorder. Childhood trauma, prenatal neglect, poor emotional awareness, excessive anxiety are the known possible psychological causes of this disorder.
Recent literature in clinical neuroscience links somatization of symptoms with increased brain activity in the medial dorsal thalamic nuclei and anterior cingulate cortex which are related to sensory pain and affective motivation channels that help in primitive survival actions.
Common Signs and Symptoms
This disorder requires a professional medical diagnosis from a licensed clinical psychologist.
Common Signs and Symptoms include:
- Complaints of pain. Pain areas include chest, abdomen, legs, arms, joints and back.
- Neurological complaints such as headaches, weakness in muscles, loss of movement, dizziness and fainting are also common.
- Some patients may also complain of diarrhoea, sensitivity to certain types of food, bloating, cramping, constipation.
- Sexual incontinence, painful menstruation and pelvic pain are also common complaints.
- Patients are extremely anxious and avoid behaviours that will cause physical exertion.
- They spend a lot of time and energy in activities that alleviate their pain.
Patients generally report more than one symptom. 30 to 60% of the patients may also have a clinical diagnosis of anxiety and/or depression.
Number of studies have demonstrated the prevalence of somatic symptom disorders among women, unmarried, coming from lower socioeconomic groups. Psychological distress in terms of anxiety, depression and other mood disorders is also associated with increase in exhibition of somatic symptoms.
Risk factors may include a history of substance abuse, alcoholism, physical and sexual abuse, emotional neglect, childhood illness, physical trauma, co morbidity for hereditary illness, high risk for certain physical illness, etc.
Certain cultural influences are also reported in certain studies. For instance, dhat, a disorder common among Indian men, which is marked by weakness, dizziness and fatigue. These anxiety and depression related symptoms linked to a single physical attribute, semen loss.
A primary health care provider often carries out medical laboratory tests to rule out medical conditions associated with the pain. They usually refer the patient to a mental health provider or a pain clinic.
A licensed clinical psychologist carries out the diagnostic procedure based on the criteria suggested by either the Diagnostic Statistical Manual or the International Classification of Diseases.
According to Diagnostic Statistical Manual-5, a patient with somatic symptoms should exhibit at least one of the following behaviours for at least six months:
- Excessive thoughts, feelings, and behaviours related to somatic symptoms.
- Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
- High level of health-related anxiety.
- Excessive time and energy devoted to these symptoms or health concerns causing debilitating effects on daily functioning.
Presence of one symptom is categorised as mild, two or more symptoms are moderate and more than two symptoms, severe.
Currently, the onus of a diagnosis has shifted from “medically undiagnosable” symptoms to psycho-behaviours associated with the symptoms. Hence, the exhibition of worry, preoccupation over symptoms and the impairment are the marked measures for the diagnosis of Somatic Symptom Disorder.
Treatment options include a mix of psychotherapy, pain relief medication and physiotherapy(if needed). Treatment principles should be directed towards validation of pain, exploration of psycho-behavioural factors, treatment for anxiety and depression, providing symptomatic measures such as pain relief or digestives for gastrointestinal symptoms, etc. Support groups are also helpful in treatment of somatic symptom disorder.
Psychotherapy, also known as talk therapy, helps in combating intrusive thoughts, reduces stress related to the symptoms, ensures learning of effective management of symptoms, reduces preoccupation with symptoms, addresses depression and other related disorders, improves daily life functioning and communication with loved ones. Cognitive Behaviour Therapy and Mindfulness based therapy are known to be effective in treatment of the disorder.
Medication associated with Somatic Symptom Disorder often includes Antidepressants for patients displaying symptoms of depression and anxiety. Symptomatic pain relief medication and digestives may be prescribed to the patients by their primary health care providers. Scheduling regular appointments, addressing queries related to pain is known to help in the treatment of Somatic Symptom Disorder.
Other medical conditions: The symptoms of many individuals with disorders like irritable bowel syndrome or fibromyalgia would not satisfy the criterion necessary to diagnose somatic symptom 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 are commonly accompanied by somatic symptoms. However, depressive disorders are differentiated from somatic symptom disorder by the core depressive symptoms of low mood and anhedonia.
Illness anxiety disorder:
If the individual has extensive worries about health but no or minimal somatic symptoms, it may be more appropriate to consider illness anxiety disorder.
In conversion disorder, the presenting symptom is loss of function, whereas in somatic symptom disorder, the focus is on the distress that particular symptoms cause.
In somatic symptom disorder, the individual’s beliefs that somatic symptoms might reflect serious underlying physical illness are not held with delusional intensity.
Body dysmorphic disorder:
In body dysmorphic disorder, the individual is excessively concerned about, and preoccupied by, a perceived defect in his or her physical features. In contrast, in somatic symptom disorder, the concern about somatic symptoms reflects fear of underlying illness, not of a defect in appearance.
In somatic symptom disorder, the recurrent ideas about somatic symptoms or illness are less intrusive, and individuals with this disorder do not exhibit the associated repetitive behaviors aimed at reducing anxiety that occur in obsessive- compulsive disorder.
Somatic symptom disorder is comorbid with medical disorders as well as anxiety and depressive disorders.
A primary healthcare provider, psychiatrist and clinical psychologist working in conjecture with pain management specialists is often the recommended standard of care. Primary care providers can schedule short, regular visits, limit diagnostic procedures, and build an alliance with the patient in helping them understand their symptoms.
A psychotherapist is often referred to diagnose the condition, help reduce stress, learn coping behaviours and address emotional issues. A psychiatrist may be referred to for medication related to anxiety and depression. A physiotherapist or an occupational therapist are also referred to if required.