Somatic Symptom Disorder

Somatic Symptom Disorder (SSD), also known as somatoform disorder or somatisation disorder, is a psychiatric condition characterised by chronic physical symptoms accompanied by maladaptive thoughts, feelings, and behaviours.

These symptoms are not intentionally produced or feigned and may or may not coexist with a known medical condition. SSD often leads to reduced functioning, interpersonal difficulties, and excessive healthcare visits.

Signs and Symptoms

Somatic Symptom Disorder is marked by an ambiguous and inconsistent history of symptoms that are rarely alleviated by medical treatments. Individuals with SSD may interpret normal bodily sensations as signs of severe illness, avoid physical activity, be overly sensitive to medication side effects, and seek care from multiple physicians. The disorder manifests in a variety of symptoms, from specific regional pain to general malaise and fatigue.

Those affected often experience severe anxiety about potential ailments, believe their symptoms are serious despite medical evidence to the contrary, and spend disproportionate amounts of time thinking about their symptoms.

Comorbidities

SSD frequently coexists with other psychiatric conditions, notably major depressive disorder, generalised anxiety disorder, and phobias. It is also often associated with functional pain syndromes like fibromyalgia and irritable bowel syndrome (IBS). Studies have shown that SSD can occur alongside conditions such as asthma, heart conditions, and various forms of arthritis, leading to significant impairment beyond what is expected from these physical ailments alone.

Causes

The exact cause of SSD is unknown. However, it is believed to result from a heightened awareness of physical sensations and a tendency to misinterpret these sensations as medical conditions. Risk factors include childhood neglect and abuse, a chaotic lifestyle, history of substance and alcohol abuse, and psychosocial stressors. Genetic factors also play a role, with studies indicating that genetics contribute 7% to 21% of somatic symptoms.

Diagnosis

Diagnosis of SSD involves psychiatric assessment and is often complicated by the disorder's non-specific symptoms, which can mimic other medical conditions. Minimal laboratory testing is encouraged to avoid false-positive results and unnecessary interventions. The Somatic Symptom Scale – 8 (SSS-8) is a self-report questionnaire used to evaluate the severity of common somatic symptoms.

The DSM-5 criteria for SSD include one or more distressing somatic symptoms and excessive thoughts, feelings, or behaviours related to these symptoms lasting more than six months.

Differential Diagnosis

SSD must be differentiated from other conditions like adjustment disorder, body dysmorphic disorder, obsessive-compulsive disorder, conversion disorder, and illness anxiety disorder. Unlike these conditions, SSD is characterised by a significant focus on the distress and impairment caused by somatic symptoms rather than the symptoms themselves.

Treatment

The primary treatment goal for SSD is to help patients cope with their symptoms rather than attempting to eliminate them. Cognitive-behavioural therapy (CBT) has been shown to significantly improve patient-reported function and reduce somatic symptoms. Psychiatric medications, including selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs), can also be effective, particularly in reducing pain perception.

Brief psychodynamic interpersonal therapy (PIT) has been proven to improve the quality of life for patients with medically unexplained symptoms.

Outlook

SSD is typically chronic, with symptoms that wax and wane over time. Many individuals experience persistent limitations in general function and quality of life, although some may recover. A positive relationship between the physician and patient, characterised by frequent supportive visits, is very important for managing SSD effectively.

Epidemiology

SSD affects 5% to 7% of the general population, with a higher prevalence among females. It can arise in childhood, adolescence, or adulthood, with symptoms often beginning in childhood. SSD is more common among those with functional illnesses like fibromyalgia and IBS. There are cultural differences in the prevalence of SSD, with higher rates observed in Puerto Rico and among African Americans, individuals with lower socioeconomic status, and those with less education.

Self-assessment MCQs (single best answer)

Which of the following best describes Somatic Symptom Disorder (SSD)?

Intentional production of physical symptoms

Chronic physical symptoms with maladaptive thoughts, feelings, and behaviours

Symptoms alleviated by medical treatments

Lack of physical symptoms but severe psychological distress

Exclusively caused by known medical conditions

What is a common characteristic of individuals with SSD?

They intentionally feign their symptoms

They often experience relief from symptoms with standard medical treatment

They interpret normal bodily sensations as signs of severe illness

They rarely seek medical care

They have no anxiety about their symptoms

Which psychiatric conditions are frequently comorbid with SSD?

Schizophrenia and bipolar disorder

Major depressive disorder and generalised anxiety disorder

Antisocial personality disorder and OCD

PTSD and dissociative identity disorder

ADHD and autism spectrum disorder

What percentage do genetic factors contribute to somatic symptoms according to studies?

2% to 5%

7% to 21%

25% to 35%

40% to 50%

60% to 70%

What diagnostic tool is used to evaluate the severity of common somatic symptoms in SSD?

Beck Depression Inventory

General Anxiety Disorder-7

Somatic Symptom Scale – 8 (SSS-8)

PTSD Checklist for DSM-5 (PCL-5)

Mini-Mental State Examination (MMSE)

Which treatment has been shown to significantly improve function and reduce somatic symptoms in SSD patients?

Electroconvulsive therapy (ECT)

Hypnosis

Cognitive-behavioural therapy (CBT)

Acupuncture

Homoeopathy

What is the primary treatment goal for Somatic Symptom Disorder?

Elimination of all physical symptoms

Identifying the underlying medical condition

Helping patients cope with their symptoms

Avoiding psychiatric treatment

Reducing the frequency of healthcare visits

Which of the following is not a differential diagnosis of SSD?

Adjustment disorder

Body dysmorphic disorder

Obsessive-compulsive disorder

Illness anxiety disorder

Schizophrenia

What is the prevalence of SSD in the general population?

1% to 2%

3% to 4%

5% to 7%

8% to 10%

11% to 12%

Which group has a higher prevalence of SSD?

Males

Individuals with high socioeconomic status

Those with less education

People with no functional illnesses

Children under the age of 5

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