Somatic Symptom Disorder DSM-5 300.82 (F45.1)

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 DSM-5 Category: Somatic Symptom and Related Disorders

Introduction

Somatic symptom disorder (SSD) is characterized as recurring and multiple physical complaints that begin before the age of 30. These symptoms are difficult to link to an identifiable medical condition, although under DSM-5 they no longer need to be medically unexplained and may be the consequence of a medical condition. Types of complaints described may include headaches, dizziness, chest pain, abdominal pain and limb pain.

DSM-5 by replacing ‘somatoform’ with ‘somatic symptom disorders’ recognizes that somatic symptoms are prevalent across a number of disorders (Dimsdale, 2013). The somatic symptom related disorders include somatic symptom disorder, as well as factitious disorder, illness anxiety disorder, conversion disorder, and psychological factors affecting other medical conditions. In addition, DSM-5 has added new severity ratings for somatic symptoms.

Somatic Symptom Disorder Symptoms

Somatic symptoms can be difficult to differentiate from those of related disorders in which it is difficult to trace the symptoms to medical disorders, such as mandering and factitious disorder. In the latter two disorders, the symptoms are intentionally produced whereas in SSD the symptoms are unconsciously produced.

Under DSM-IV criteria, somatic symptoms had to be medically unexplained for a diagnosis of somatic symptom disorder. If the symptom could be explained by a medical disorder then a diagnosis of SSD could not be made. This requirement, or mind-body dualism, is removed under DSM-5. Somatic symptom disorder can coexist with a medical disorder.

Under DSM-5, a diagnosis is based on the degree to which a person’s thoughts, feelings and behavior about their somatic symptoms are disproportionate or excessive. Specifically, one must experience six months of one distressing or disrupting somatic symptom that causes disproportionate and persistent thoughts, feelings and behavior or that takes up extra time and energy (APA, 2013).

  • The symptoms must be clinically significant, meaning that they require medical intervention and impair areas of functioning
  • The somatic symptoms cannot be intentionally produced or feigned
  • If the somatic symptoms are medically unexplained, all other criteria for somatic symptom disorder must be met.

 

Somatic Symptom Disorder in Daily Life

Somatic symptoms and one’s abnormal thoughts and feelings about them can have a significant impact on daily functioning. Coping mechanisms can play a role in the onset and severity of somatic symptom disorder. Creating physical complaints may be a way of avoiding certain situations and withdrawing. An association has been made between somatic symptoms and the level of social support. Alternatively, it may be a way of getting attention.

The DSM-5 identifies risk factors for somatic syndrome disorder as family history and genetics, early traumatic experiences, learning that illness attracts attention and cultural and social norms. The child may have learned to complain of symptoms for attention or personal gain. One has a higher risk of acquiring the disorder if a family member has it, or if a child observes family members with illness. Stressful life events and childhood physical illness may also be factors. Those with somatic syndrome disorder report more stressful and traumatic life events, including family conflict and breakup, and physical and sexual abuse.

A common feature of individuals with SSD is a negative perception of their body and health. They feel very threatened by and over-exaggerate negative symptoms. They were excessively over fears of acquiring an illness. In some cases, they are manifesting distress in other areas of their lives. An abused child, for example, may over-exaggerate abdominal pain to gain the attention of medical professionals. A person with low job performance due to dyslexia may develop a somatic disorder to avoid work and a situation in which he feels he cannot cope.

Somatic Symptom Disorder Therapy

While psychological disorders often underlie somatic disorders, those with SSD first seek medical assistance from a family physician in the belief they have a physical ailment. These individuals may spend a lot of time in the mainstream medical system before receiving the psychiatric treatment they require. The new Somatic Symptom and Related Disorders category under DSM-5 endeavors to help primary care providers improve the diagnosis of somatic disorders.

Multicomponent therapy can best treat SSD given the diverse factors that may contribute to its development. A treatment course may include education on somatisation, behavioral therapy to focus on behavior change and reinforcement, psychotherapy to deal with related family and social issues, and hypnosis for the development of coping skills (Shaw, Bernard, DeMaso, 2011).

Treatment of mild-to-severe somatic complaints with cognitive behavioral therapy (CBT) has reduced their severity and long-term maintenance of the improvements have been achieved. CBT helps to change the thought and behavior patterns that have unconsciously triggered the physical complaints. The somatic complaints may be a result of learned behavior, which can be unlearned through CBT. Through behavior modification therapies such as CBT, healthy behavior can be reinforced and negative reinforcement provided for unhealthy behavior (Shaw et al., 2011).

When SSD appears alongside an existing medical condition, identification and treatment can be complicated foremost by the need to differentiate the symptoms. Somatisation symptoms in cancer patients has been shown to have a negative effect on coping and quality of life. Thus, identification and treatment are important. An Italian study found that CBT, relaxation training and psychoeducation could reduce anxiety and tension in cancer patients (Graasi, Caruso, & Nanni, 2013).

Family therapy can address the diverse possible causes of somatic symptom disorder. Parents with mood disorders and somatic symptoms also more frequently consult medical professionals on behalf of their children. Their children may take more time off of school for unexplained illnesses. The stress of the parents can easily be seen manifesting itself in children through, for example, the association of parental anxiety and depression with recurrent abdominal pain in children (Weisblatt, Hindley, & Rask, 2011). The fact that learned behavior and beliefs are passed down from parent to child makes a good case for behavioral therapy such as CBT that can tackle changing thought and behavioral partners across the family.

Two forms of pharmacotherapy are pursued in the treatment of SSD – somatic medication targeting the symptoms and the use of psychotropics to target SSD, often used when somatic medication is not successful (Mundt, 2013).

Those with SSD in childhood often continue to develop similar somatic symptoms in adulthood.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bøen, H., Dalgard, O. S., & Bjertness, E. (2012). The importance of social support in the associations between psychological distress and somatic health problems and socio-economic factors among older adults living at home: a cross sectional study. BMC geriatrics, 12(1), 27.

Dimsdale, J. E. (2013). Somatic Symptom Disorders: a new approach in DSM-5. Die Psychiatrie, 10, 30-32.

Grassi, L., Caruso, R., & Nanni, M. G. (2013). Somatization and somatic symptom presentation in cancer: A neglected area. International Review of Psychiatry, 25(1), 41-51.

Mundt, A. P. (2013). Multiple Medication Use in Somatic Symptom Disorders: From Augmentation to Diminution Strategies. In Polypharmacy in Psychiatry Practice, Volume I (pp. 243-254). Springer Netherlands.

Shaw, Richard J., Rebecca S. Bernard, and David R. DeMaso. "Somatoform disorders." Handbook of Developmental Psychiatry (2011): 397.

Weisblatt, E., Hindley, P., & Rask, C. U. (2011). Medically unexplained symptoms in children and adolescents. Medically Unexplained Symptoms, Somatisation and Bodily Distress: Developing Better Clinical Services, 158.


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