Somatic symptom disorder

Definition

Somatic symptom disorder is defined by two things together. First, one or more distressing physical symptoms that interfere with daily life. Second, excessive thoughts, feelings, or behaviors related to those symptoms, such as persistent worry about their seriousness, high anxiety about health, or a great deal of time and energy spent on the symptoms. The pattern lasts at least 6 months, though any single symptom may come and go.

Here's the key point DSM-5-TR made clear. The physical symptoms can be fully explained by a medical condition, partly explained, or not medically explained at all. None of that decides the diagnosis. What matters is the disproportionate distress and preoccupation. This was a deliberate change. DSM-5-TR reorganized the older "somatoform disorders," and somatic symptom disorder, together with illness anxiety disorder, replaced the diagnosis once called hypochondriasis.

Symptoms and key features

Somatic symptom disorder usually involves:

• one or more genuinely distressing physical symptoms, such as pain, fatigue, or gastrointestinal trouble
• persistent, disproportionate thoughts about how serious the symptoms are
• a high and lasting level of anxiety about health or about the symptoms
• a large amount of time and energy devoted to the symptoms or to health concerns
• frequent medical visits, tests, or checking, often without lasting reassurance
• symptoms that interfere with work, relationships, and daily functioning

What it looks like

• Ongoing pain takes up much of your attention, and the worry about what it means rarely lets up.
• You've had many tests and appointments, but reassurance never seems to settle the fear for long.
• A normal body sensation sets off a chain of anxious thoughts about something serious being wrong.
• The symptoms, and the worry around them, shrink your world: less work, less socializing, less ease.

What people often confuse this with

Illness anxiety disorder. Illness anxiety disorder centers on the fear of having or developing a serious illness, with few or no actual physical symptoms. Somatic symptom disorder centers on actual distressing symptoms and an excessive response to them.

A purely medical problem. A person can have a clear medical illness and also have somatic symptom disorder, because the diagnosis is about the disproportionate distress and preoccupation, not about the absence of disease. The two aren't mutually exclusive.

"Faking" or making it up. Somatic symptom disorder isn't malingering and not factitious disorder. The symptoms and the distress are real and not under the person's voluntary control. This is one of the more harmful confusions, and it gets in the way of care.

What research says

Somatic symptom disorder is studied, though the diagnosis is relatively new and research is still maturing.

• The DSM-5 change was deliberate. Moving away from "medically unexplained symptoms" was intended to reduce the implication that symptoms are imaginary and to focus on the distress and preoccupation that actually cause impairment.
• CBT has evidence. Cognitive behavioral therapy, including approaches that address health-related thoughts, attention, and behaviors, can reduce symptom-related distress and improve functioning.
• The therapeutic relationship matters. Care is generally most effective when a person has a trusting relationship with one consistent clinician who can coordinate care and limit unnecessary testing.
• Co-occurring conditions are common. Anxiety and depression often occur alongside somatic symptom disorder, and treating them is part of effective care.