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Somatic symptom disorder (SSD)


Somatic symptom disorder (SSD) occurs when a person feels extreme anxiety about physical symptoms such as pain or fatigue. The person has intense thoughts, feelings, and behaviors related to the symptoms that interfere with daily life.

A person with SSD is not faking his or her symptoms. The pain and other problems are real. They may be caused by a medical problem. Often, no physical cause can be found. But it’s the extreme reaction and behaviors about the symptoms that are the main problem.

The somatoform disorders are a group of psychological disorders in which a patient experiences physical symptoms that are inconsistent with or cannot be fully explained by any underlying general medical or neurologic condition. Medically unexplained physical symptoms account for as many as 50% of new medical outpatient visits. [1] Physical symptoms or painful complaints of unknown etiology are fairly common in pediatric populations. [2] Many healthy young children express emotional distress in terms of physical pain, such as stomachaches or headaches, but these complaints are usually transient and do not effect the child’s overall functioning. The somatoform disorders represent the severe end of a continuum of somatic symptoms.

Somatization in children consists of the persistent experience and complaints of somatic distress that cannot be fully explained by a medical diagnosis. They can be represented by a wide spectrum of severity, ranging from mild self-limited symptoms, such as stomachache and headache, to chronic disabling symptoms, such as seizures and paralysis

Up to 50 percent of primary care patients present with physical symptoms that cannot be explained by a general medical condition. Some of these patients meet criteria for somatoform disorders.2,3 Although most do not meet the strict psychiatric diagnostic criteria for one of the somatoform disorders, they can be referred to as having “somatic preoccupation,”4 a subthreshold presentation of somatoform disorders that can also cause patients distress and require intervention.

The unexplained symptoms of somatoform disorders often lead to general health anxiety; frequent or recurrent and excessive preoccupation with unexplained physical symptoms; inaccurate or exaggerated beliefs about somatic symptoms; difficult encounters with the health care system; disproportionate disability; displays of strong, often negative emotions toward the physician or office staff; unrealistic expectations; and, occasionally, resistance to or noncompliance with diagnostic or treatment efforts. These behaviors may result in more frequent office visits, unnecessary laboratory or imaging tests, or costly and potentially dangerous invasive procedures.5–7

Little is known about the causes of the somatoform disorders. Limited epidemiologic data suggest familial aggregation for some of the disorders.1 These data also indicate comorbidities with other mental health disorders, such as mood disorders, anxiety disorders, personality disorders, eating disorders, and psychotic disorders.

The challenge in working with somatoform disorders in the primary care setting is to simultaneously exclude medical causes for physical symptoms while considering a mental health diagnosis. The diagnosis of a somatoform disorder should be considered early in the process of evaluating a patient with unexplained physical symptoms. Appropriate nonpsychiatric medical conditions should be considered, but over-evaluation and unnecessary testing should be avoided. There are no specific physical examination findings or laboratory data that are helpful in confirming these disorders; it often is the lack of any physical or laboratory findings to explain the patient’s excessive preoccupation with somatic symptoms that initially prompts the physician to consider the diagnosis.

Two related disorders, factitious disorder and malingering, must be excluded before diagnosing a somatoform disorder. In factitious disorder, patients adopt physical symptoms for unconscious internal gain (i.e., the patient desires to take on the role of being sick), whereas malingering involves the purposeful feigning of physical symptoms for external gain (e.g., financial or legal benefit, avoidance of undesirable situations). In somatoform disorders, there are no obvious gains or incentives for the patient, and the physical symptoms are not willfully adopted or feigned; rather, anxiety and fear facilitate the initiation, exacerbation, and maintenance of these disorders.

Clinical diagnostic tools have been used to assist in the diagnosis of somatoform disorders.8 One screening tool for psychiatric disorders that is used in primary care settings is the Patient Health Questionnaire

The symptoms can involve one or more different organs and body systems, such as:

Neurologic problems
Gastrointestinal complaints
Sexual symptoms
Many people who have SSD will also have an anxiety disorder.

People with SSD are not faking their symptoms. The distress they experience from pain and other problems they experience are real, regardless of whether or not a physical explanation can be found. And the distress from symptoms significantly affects daily functioning.

Physical symptoms that can occur with SSD may include:

Fatigue or weakness
Shortness of breath
Symptoms may be mild to severe. There may be one or more symptoms. They may come and go or change. Symptoms may be due to a medical condition. They also may have no clear cause.

How people feel and behave in response to these physical sensations are the main symptoms of SSD. These reactions must persist for 6 months or more. People with SSD may:

Feel extreme anxiety about symptoms
Feel concern that mild symptoms are a sign of serious disease
Go to the doctor for multiple tests and procedures, but not believe the results
Feel that the doctor does not take their symptoms seriously enough or has not done a good job treating the problem
Spend a lot of time and energy dealing with health concerns
Have trouble functioning because of thoughts, feelings, and behaviors about symptoms

The exact cause of somatic symptom disorder isn’t clear, but any of these factors may play a role:

Genetic and biological factors, such as an increased sensitivity to pain
Family influence, which may be genetic or environmental, or both
Personality trait of negativity, which can impact how you identify and perceive illness and bodily symptoms
Decreased awareness of or problems processing emotions, causing physical symptoms to become the focus rather than the emotional issues
Learned behavior — for example, the attention or other benefits gained from having an illness; or “pain behaviors” in response to symptoms, such as excessive avoidance of activity, which can increase your level of disability

The goal of treatment is to control your symptoms and help you function in life.

Having a supportive relationship with your health care provider is vital for your treatment.

You should have only one primary care provider. This will help you avoid having unneeded tests and procedures.
You should see your provider regularly to review your symptoms and how you are coping.
You may also see a mental health provider (therapist). It’s important to see a therapist who has experience treating SSD. Cognitive behavioral therapy is a type of talk therapy that can help treat SSD. Working with a therapist can help relieve your pain and other symptoms. During therapy, you will learn to:

Look at your feelings and beliefs about health and your symptoms
Find ways to reduce stress and anxiety about symptoms
Stop focusing as much on your physical symptoms
Recognize what seems to make the pain or other symptoms worse
Learn how to cope with the pain or other symptoms
Stay active and social, even if you still have pain or other symptoms
Function better in your daily life
Your therapist will also treat depression or other mental health illnesses you may have. You may take antidepressants to help relieve anxiety and depression.

You should not be told that your symptoms are imaginary or all in your head. Your provider should work with you to manage both physical and emotional symptoms.

Possible Complications
If not treated, you may have:

Trouble functioning in life
Problems with family, friends, and work
Poor health
An increased risk for depression and suicide
Money problems due to the cost of excess office visits and tests
SSD is a long-term (chronic) condition. Working with your providers and following your treatment plan is important for managing with this disorder.

Little is known about how to prevent somatic symptom disorder. However, these recommendations may help.

If you have problems with anxiety or depression, seek professional help as soon as possible.
Learn to recognize when you’re stressed and how this affects your body — and regularly practice stress management and relaxation techniques.
If you think you have somatic symptom disorder, get treatment early to help stop symptoms from getting worse and impairing your quality of life.
Stick with your treatment plan to help prevent relapses or worsening of symptoms.

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