Which of the following is a diagnostic criterion for Somatic Symptom Disorder?

Conversion disorder and somatic symptom disorder are both categorized as somatic symptom and related disorders (previously termed somatoform disorders).

Somatic symptom and related disorders are psychiatric conditions where patients experience distressing physical symptoms associated with abnormal thoughts, feelings, and behaviors in response to these symptoms. They may result from psychological stress that is unconsciously (without awareness) expressed somatically, though the underlying cause is not fully understood.

Risk factors include being female, having a history of abuse or adverse childhood events, and having personality traits of alexithymia (difficulty expressing emotions) or neuroticism. Symptoms that persist with an external focus of control, and without awareness of the psychological and stress-related interplay, can lead to considerable functional impairment and distress.

Diagnosis is made by clinical interview, behavioral observation, physical exam suggestive of pseudoneurologic causes, and tests to rule out medical or neurologic causes. The diagnosis should not be made solely on the basis of medically unexplained symptoms; rather, it should be based on evidence from the clinical exam and the patient’s abnormal thoughts, feelings, and behaviors in response to the medically unexplained symptoms.

Good doctor-patient relationships and validation of the patient's suffering are essential for effective management. Treatment includes cognitive behavioral therapy, physical therapy, and avoiding unnecessary medicines, tests, and procedures. Diagnosis and treatment of associated comorbid psychiatric conditions benefit overall functioning and recovery.

Long-term management involves interrupting perpetuating factors, maintaining the same doctor, and providing strategies for self-efficacy, distress tolerance, coping, and modulating the interaction of anxiety, stress, and physical symptoms.

Conversion disorder and somatic symptom disorder are psychiatric conditions that fall under the somatic symptom and related disorders category of the DSM-5-TR (previously termed somatoform disorders). Somatic symptom and related disorders are those with prominent physical symptoms associated with significant distress and impairment of function.

Conversion disorder is characterized by voluntary motor or sensory function deficits that suggest neurologic or medical conditions but are rather associated with clinical findings that are not compatible with such conditions. Somatic symptom disorder is characterized by one or more somatic symptoms that are distressing or result in significant disruption of daily life. To meet DSM-5-TR criteria, these patients must have excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s symptoms; persistently high levels of anxiety about health or symptoms; excessive time or energy devoted to these symptoms or health concerns. Importantly, even if any one somatic symptom is not continuously present, the state of being symptomatic is persistent (typically more than 6 months).

Somatization is said to be present when psychological or emotional distress is manifested in the form of physical symptoms that are otherwise medically unexplained.1 Patients with multiple persistent physical symptoms that seem to have no apparent biologic basis are common in patients presenting to primary care.2

In the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5), the nomenclature for the diagnostic category previously known as somatoform disorders was changed to somatic symptom and related disorders.3 The purpose of this change was to better define these disorders to make them more relevant to the primary care setting.

Somatic symptom disorder may be no less debilitating than physical disorders.4 Patients experiencing somatization whose physicians incorrectly think they may have a biologic disorder can experience harm from unnecessary testing and treatment.5 Some physicians find patients with somatic symptom disorder frustrating, and may describe them in derogatory terms. They may consider physical disorders genuine, while essentially accusing somaticizing patients of manufacturing their symptoms.6 This article provides practical suggestions for improving the care of these patients.

Epidemiology

The prevalence of somatic symptom disorder in the general population is an estimated 5% to 7%,3 making this one of the most common categories of patient concerns in the primary care setting.7 An estimated 20% to 25% of patients who present with acute somatic symptoms go on to develop a chronic somatic illness.8 These disorders can begin in childhood, adolescence, or adulthood.4,9 Females tend to present with somatic symptom disorder more often than males, with an estimated female-to-male ratio of 10:1.9

Etiology

Somatic symptoms may result from a heightened awareness of certain bodily sensations, combined with a tendency to interpret these sensations as indicative of a medical illness.9 The etiology of somatic symptom disorder is unclear. However, studies have determined that risk factors for chronic and severe somatic symptoms include childhood neglect, sexual abuse, chaotic lifestyle, and a history of alcohol and substance abuse. In addition, somatic symptom disorder has been associated with personality disorders.8

Psychosocial stressors and culture affect how patients present to the physician. For example, studies in primary care settings found significantly higher rates of unemployment and impaired occupational functioning in somaticizing patients compared with nonsomaticizing patients (29% vs. 15%, and 55% vs. 14%, respectively).4 Patients may also present with physical symptoms when psychiatric symptoms are stigmatized, as in some cultures.10

Diagnosis

Somatic symptom disorder presents a problem for both the physician and patient because it puts patients at risk of unnecessary testing and treatment.8,9,11 The main feature of these disorders is a concern with physical symptoms that are attributed to a nonpsychiatric disease.12 This concern can manifest as one or more somatic symptoms that result in excessive thoughts, feelings, or behaviors related to those symptoms and that are distressing or result in significant disruption of daily life. One of the following criteria must also be present: significant thoughts about the seriousness of the symptoms; a high level of anxiety about the symptoms; or excessive energy spent with regard to symptomatic concern. Although somatic symptoms need not be continuously present, they must be persistent (present for more than six months). Two specifiers of this condition in the DSM-5 are “with predominant pain” and “persistent.” These disorders can be mild, moderate, or severe (Table 1).3 Characteristics of the subclasses of somatic symptom disorder are described in Table 2.3

Differential Diagnosis

The following diagnoses should be considered in patients with suspected somatic symptom disorder because the symptoms may be indicative of other mental health disorders: depression, panic disorder, generalized anxiety disorder, substance use disorder, syndromes of unclear etiology (e.g., nonmalignant pain syndrome, chronic fatigue syndrome), and nonpsychiatric medical conditions.12

Screening

Although the Patient Health Questionnaire-15 (eTable A) is perhaps the most commonly used screening instrument to detect somatization symptoms in the general population,13 the more recently developed Somatic Symptom Scale-8 (Table 314) shows promise in measuring somatic symptom burden. A study to determine the reliability and validity of this newer tool concluded that it is a reliable and valid self-report measure of somatic symptom burden, and that cutoff scores identify persons with low, medium, high, and very high somatic symptom burden.15 This instrument was validated on a representative random sample, including 2,510 persons 14 years and older, with overall good reliability. Because of overlap with symptoms of depression and anxiety, it is recommended that clinicians assess for these comorbidities as well.14 It should be emphasized, however, that although screening instruments are useful as a first step in the diagnostic process, the DSM-5 criteria still must be met to diagnose somatic symptom disorders.

Management

The management of somatic symptom disorders requires a multifaceted approach tailored to the individual patient. To choose the correct treatment plan, primary care clinicians should keep in mind psychological, social, and cultural factors that influence somatic symptoms.

General treatment tenets for the primary care clinician include scheduling regular, short-interval visits to avoid the need for symptoms to get an appointment; establishing a collaborative, therapeutic alliance with the patient; acknowledging and legitimizing symptoms once the patient has been evaluated for other medical and psychiatric diseases; limiting diagnostic testing; reassuring the patient that serious medical diseases have been ruled out; educating patients about coping with physical symptoms; setting a treatment goal of functional improvement rather than cure; and appropriately referring patients to subspecialists and mental health professionals.16 The CARE MD (consultation/cognitive behavior therapy, assessment, regular visits, empathy, medical/psychiatric interface, do no harm) treatment approach was developed to help primary care clinicians work more effectively with patients who have somatic symptom disorder (Table 4).17 Proven therapies provided by mental health care professionals include cognitive behavior therapy and mindfulness-based therapy (Table 5).18–27

PHARMACOTHERAPY

Medications used to treat somatic symptom disorder include antidepressants, antiepileptics, antipsychotics, and natural products. The effectiveness of many of these treatments has limited support.

Systematic reviews of controlled trials support the use of antidepressants for the treatment of somatic symptom disorder. In a meta-analysis of 94 trials, antidepressants provided substantial benefit, with a number needed to treat of three.25 Tricyclic antidepressants had notable success and were associated with a greater likelihood of effectiveness than selective serotonin reuptake inhibitors. Amitriptyline was the most studied tricyclic, and provided benefits for at least one of the following outcomes: pain, morning stiffness, global improvement, sleep, fatigue, tender point score (based on the number and severity of tender points), and functional symptoms. Of the selective serotonin reuptake inhibitors studied, fluoxetine (Prozac) demonstrated benefit for pain, functional status, global well-being, sleep, morning stiffness, and tender points.26

There is little support for the use of mono-amine oxidase inhibitors, bupropion (Wellbutrin), antiepileptics, or antipsychotics in the treatment of somatic symptom disorder. These medications have significant adverse effects and are best avoided for this use.25

Two randomized, double-blind, placebo-controlled trials reviewed the effectiveness and safety of St. John's wort for the treatment of somatic symptom disorder.26,27 Both of these studies showed that St. John's wort was superior to placebo, and that it is well-tolerated and safe.

Prognosis

Somatic symptom disorders are generally chronic, with waxing and waning symptoms. However, some studies have shown that patients can recover; the natural history of the disorders suggests that approximately 50% to 75% of patients with medically unexplained symptoms show improvement, whereas 10% to 30% deteriorate.28 Better prognostic indicators include having fewer physical symptoms and better functioning at baseline.28,29 A strong, positive relationship between the physician and the patient is essential and should be coupled with frequent, supportive visits, while avoiding the temptation to medicate or test when these interventions are not clearly indicated.

Data Sources: Medline searches via Ovid and PubMed were completed using the key terms somatoform disorder, somatization, somatic, medically unexplained symptoms, and treatment. The search included reviews, meta-analyses and randomized controlled trials. Also searched were the Cochrane Database of Systematic Reviews, Essential Evidence Plus, UpToDate, and evidence-based guidelines from the National Guideline Clearinghouse. Search dates: August 2014 through November 2014.

Which of the following is characteristic of somatic symptom disorder?

What are the 5 somatic disorders?

What is the diagnostic criteria for somatic symptom disorder?