# 02 - 13.2 Somatic Symptom Disorder

# 13.2 Somatic Symptom Disorder

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 13.2 Somatic Symptom Disorder
Somatic symptom disorder, also known as hypochondriasis, is characterized by 6 or
more months of a general and nondelusional preoccupation with fears of having, or the
idea that one has, a serious disease based on the person’s misinterpretation of bodily
symptoms. This preoccupation causes significant distress and impairment in one’s life; it
is not accounted for by another psychiatric or medical disorder; and a subset of
individuals with somatic symptom disorder has poor insight about the presence of this
disorder.
EPIDEMIOLOGY
In general medical clinic populations, the reported 6-month prevalence of this disorder
is 4 to 6 percent, but it may be as high as 15 percent. Men and women are equally
affected by this disorder. Although the onset of symptoms can occur at any age, the
disorder most commonly appears in persons 20 to 30 years of age. Some evidence
indicates that this diagnosis is more common among blacks than among whites, but
social position, education level, gender, and marital status do not appear to affect the
diagnosis. This disorder’s complaints reportedly occur in about 3 percent of medical
students, usually in the first 2 years, but they are generally transient.
ETIOLOGY
Persons with this disorder augment and amplify their somatic sensations; they have low
thresholds for, and low tolerance of, physical discomfort. For example, what persons
normally perceive as abdominal pressure, persons with somatic symptom disorder
experience as abdominal pain. They may focus on bodily sensations, misinterpret them,
and become alarmed by them because of a faulty cognitive scheme.
Somatic symptom disorder can also be understood in terms of a social learning model.
The symptoms of this disorder are viewed as a request for admission to the sick role

made by a person facing seemingly insurmountable and insolvable problems. The sick
role offers an escape that allows a patient to avoid noxious obligations, to postpone
unwelcome challenges, and to be excused from usual duties and obligations.
Somatic symptom disorder is sometimes a variant form of other mental disorders,
among which depressive disorders and anxiety disorders are most frequently included.
An estimated 80 percent of patients with this disorder may have coexisting depressive or
anxiety disorders. Patients who meet the diagnostic criteria for somatic symptom
disorder may be somatizing subtypes of these other disorders.
The psychodynamic school of thought holds that aggressive and hostile wishes toward
others are transferred (through repression and displacement) into physical complaints.
The anger of patients with this disorder originates in past disappointments, rejections,
and losses, but the patients express their anger in the present by soliciting the help and
concern of other persons and then rejecting them as ineffective.
This disorder is also viewed as a defense against guilt, a sense of innate badness, an
expression of low self-esteem, and a sign of excessive self-concern. Pain and somatic
suffering thus become means of atonement and expiation (undoing) and can be
experienced as deserved punishment for past wrongdoing (either real or imaginary) and
for a person’s sense of wickedness and sinfulness.
DIAGNOSIS
According to the fifth edition of Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), the diagnostic criteria for somatic symptom disorder require that patients be
preoccupied with the false belief that they have a serious disease, based on their
misinterpretation of physical signs or sensations (Table 13.2-1). The belief must last at
least 6 months, despite the absence of pathological findings on medical and neurological
examinations. The diagnostic criteria also require that the belief cannot have the
intensity of a delusion (more appropriately diagnosed as delusional disorder) and
cannot be restricted to distress about appearance (more appropriately diagnosed as
body dysmorphic disorder). The symptoms of somatic symptom disorder must be
sufficiently intense to cause emotional distress or impair the patient’s ability to function
in important areas of life. Clinicians may specify the presence of poor insight; patients
do not consistently recognize that their concerns about disease are excessive.
Table 13.2-1
DSM-5 Diagnostic Criteria for Somatic Symptom Disorder

CLINICAL FEATURES
Patients with somatic symptom disorder believe that they have a serious disease that has
not yet been detected and they cannot be persuaded to the contrary. They may maintain
a belief that they have a particular disease or, as time progresses, they may transfer
their belief to another disease. Their convictions persist despite negative laboratory
results, the benign course of the alleged disease over time, and appropriate reassurances
from physicians. Yet, their beliefs are not sufficiently fixed to be delusions. Somatic
symptom disorder is often accompanied by symptoms of depression and anxiety and
commonly coexists with a depressive or anxiety disorder.
A severe case of somatic symptom disorder that highlights diagnostic, prognostic, and
management issues is described in the case study.
Mr. K, a white man in his mid-30s, consulted a general medicine clinic complaining
of gastrointestinal problems. Major presenting symptoms were a long list of physical
symptoms and concerns mostly related to the gastrointestinal system. These included

abdominal pain, left lower quadrant cramps, bloating, persistent sense of fullness in
stomach hours after eating, intolerance to foods, constipation, decrease in physical
stamina, heart palpitations, and feelings that “skin is getting yellow” and “not getting
enough oxygen.” A review of systems disclosed disturbances from virtually every
organ system, including tired eyes with blurred vision, sore throat and “lump” in
throat, heart palpitations, irregular heartbeat, dizziness, trouble breathing, and
general weakness.
The patient reported that symptoms started prior to the age of 30 years. For more
than a decade, he had been seen by psychiatrists, general practitioners, and all kinds
of medical specialists, including surgeons. He used the Internet constantly and
traveled extensively in search of expert evaluations, seeking new procedures and
diagnostic assessments. He had undergone repeated colonoscopies, sigmoidoscopies,
and computed tomographic (CT) scans, magnetic resonance imaging (MRI) studies,
and ultrasound examinations of the abdomen that had failed to disclose any
pathology. He was on disability and had been unable to work for more than 2 years
due to his condition.
About 3 years before his visit to the medicine clinic, his abdominal complaints and
his fixed belief that he had an intestinal obstruction led to an exploratory surgical
intervention for the first time, apparently with negative findings. However, according
to the patient, the surgery “got things even worse,” and since then he had been
operated on at least five other occasions. During these surgeries he has undergone
subtotal colectomies and ileostomies due to possible “adhesions” to rule out
“mechanical” obstruction. However, available records from some of the surgeries do
not disclose any specific pathology other than “intractable constipation.” Pathological
specimens were also inconclusive.
The physical examination showed a well-developed, well-nourished male, who was
afebrile. A complete physical and neurological examination was normal except for
examination of the abdomen, which revealed multiple abdominal scars. Right
ileostomy was present, with soft stool in the bag and active bowel sounds. There was
no point tenderness and no abdominal distension. During the examination, the
patient kept pointing to an area of “hardness” in the left lower quadrant that he
thought was a “tight muscle strangling his bowels.” However, the examination did not
disclose any palpable mass. Skin and extremities were all within normal limits, and
all joints had full range of motion and no swelling. Musculature was well developed.
Neurological examination was within normal limits. The patient was scheduled for
brief monthly visits by the primary care physician, during which the doctor performed
brief physicals, reassured the patient, and allowed the patient to talk about
“stressors.” The physician avoided invasive tests or diagnostic procedures, did not
prescribe any medications, and avoided telling the patient that the symptoms were
mental or “all in his head.” The primary care physician then referred the patient back
to psychiatry.
The psychiatrist confirmed a long list of physical symptoms that started before the
age of 30 years, most of which remained medically unexplained. The psychiatric

examination revealed some anxiety symptoms, including apprehension, tension,
uneasiness, and somatic components such as blushing and palpitations that seemed
particularly prominent in front of social situations. Possible symptoms of depression
included mild dysphoria, low energy, and sleep disturbance, all of which the patient
blamed on his “medical” problems. The mental status examination showed that Mr.
K’s mood was rather somber and pessimistic, although he denied feeling sad or
depressed. Affect was irritable. He was somatically focused and had little if any
psychological insight. The examination revealed the presence of a few life stressors
(unemployment, financial problems, and family issues) that the patient quickly
discounted as unimportant. Although the patient continued to deny having any
psychiatric problems or any need for psychiatric intervention or treatment, he agreed
to a few regular visits to continue to assess his situation. He refused to engage anyone
from his family in this process. Efforts to engage the patient with formal therapy such
as cognitive-behavioral therapy (CBT) or a medication trial were all futile, so he was
seen only for “supportive psychotherapy,” with the hope of developing rapport and
preventing additional iatrogenic complications.
During the follow-up period, the patient was operated on at least one more time
and continued to complain of abdominal bloating and constipation and to rely on
laxatives. The belief that there was a mechanical obstruction of the intestines
continued to be firmly held by the patient and bordered on the delusional. However,
he continued to refuse pharmacological treatment. The only medication he accepted
was a low-dose benzodiazepine for anxiety. He continued to monitor his intestinal
function 24 hours per day and to seek evaluation by prominent specialists, traveling
to high-profile specialty centers far from home in search of solutions. (Courtesy of J. I.
Escobar, M.D.)
Although DSM-5 specifies that the symptoms must be present for at least 6 months,
transient manifestations can occur after major stresses, most commonly the death or
serious illness of someone important to the patient or a serious (perhaps lifethreatening) illness that has been resolved but that leaves the patient temporarily
affected in its wake. Such states that last fewer than 6 months are diagnosed as “Other
Specified Somatic Symptom and Related Disorders” in DSM-5. Transient somatic
symptom disorder responses to external stress generally remit when the stress is
resolved, but they can become chronic if reinforced by persons in the patient’s social
system or by health professionals.
DIFFERENTIAL DIAGNOSIS
Somatic symptom disorder must be differentiated from nonpsychiatric medical
conditions, especially disorders that show symptoms that are not necessarily easily
diagnosed. Such diseases include acquired immunodeficiency syndrome (AIDS),
endocrinopathies, myasthenia gravis, multiple sclerosis, degenerative diseases of the
nervous system, systemic lupus erythematosus, and occult neoplastic disorders.

Somatic symptom disorder is differentiated from illness anxiety disorder (a new
diagnosis in DSM-5 discussed in Section 13.3) by the emphasis in illness anxiety disorder
on fear of having a disease rather than a concern about many symptoms. Patients with
illness anxiety disorder usually complain about fewer symptoms than patients with
somatic symptom disorder; they are primarily concerned about being sick.
Conversion disorder is acute and generally transient and usually involves a symptom
rather than a particular disease. The presence or absence of la belle indifférence is an
unreliable feature with which to differentiate the two conditions. Patients with body
dysmorphic disorder wish to appear normal, but believe that others notice that they are
not, whereas those with somatic symptom disorder seek out attention for their presumed
diseases.
Somatic symptom disorder can also occur in patients with depressive disorders and
anxiety disorders. Patients with panic disorder may initially complain that they are
affected by a disease (e.g., heart trouble), but careful questioning during the medical
history usually uncovers the classic symptoms of a panic attack. Delusional disorder
beliefs occur in schizophrenia and other psychotic disorders, but can be differentiated
from somatic symptom disorder by their delusional intensity and by the presence of
other psychotic symptoms. In addition, schizophrenic patients’ somatic delusions tend to
be bizarre, idiosyncratic, and out of keeping with their cultural milieus, as illustrated in
the case below.
A 52-year-old man complained “my guts are rotting away.” Even after an extensive
medical workup, he could not be reassured that he was not ill.
Somatic symptom disorder is distinguished from factitious disorder with physical
symptoms and from malingering in that patients with somatic symptom disorder
actually experience and do not simulate the symptoms they report.
COURSE AND PROGNOSIS
The course of the disorder is usually episodic; the episodes last from months to years and
are separated by equally long quiescent periods. There may be an obvious association
between exacerbations of somatic symptoms and psychosocial stressors. Although no
well-conducted large outcome studies have been reported, an estimated one third to one
half of all patients with somatic symptom disorder eventually improve significantly. A
good prognosis is associated with high socioeconomic status, treatment-responsive
anxiety or depression, sudden onset of symptoms, the absence of a personality disorder,
and the absence of a related nonpsychiatric medical condition. Most children with the
disorder recover by late adolescence or early adulthood.
TREATMENT
Patients with somatic symptom disorder usually resist psychiatric treatment, although

some accept this treatment if it takes place in a medical setting and focuses on stress
reduction and education in coping with chronic illness. Group psychotherapy often
benefits such patients, in part because it provides the social support and social
interaction that seem to reduce their anxiety. Other forms of psychotherapy, such as
individual insight-oriented psychotherapy, behavior therapy, cognitive therapy, and
hypnosis, may be useful.
Frequent, regularly scheduled physical examinations help to reassure patients that
their physicians are not abandoning them and that their complaints are being taken
seriously. Invasive diagnostic and therapeutic procedures should only be undertaken,
however, when objective evidence calls for them. When possible, the clinician should
refrain from treating equivocal or incidental physical examination findings.
Pharmacotherapy alleviates somatic symptom disorder only when a patient has an
underlying drug-responsive condition, such as an anxiety disorder or depressive
disorder. When somatic symptom disorder is secondary to another primary mental
disorder, that disorder must be treated in its own right. When the disorder is a transient
situational reaction, clinicians must help patients cope with the stress without
reinforcing their illness behavior and their use of the sick role as a solution to their
problems.
OTHER SPECIFIED OR UNSPECIFIED SOMATIC SYMPTOM DISORDER
This DSM-5 category is used to describe conditions characterized by one or more
unexplained physical symptoms of at least 6 months’ duration, which are below the
threshold for a diagnosis of somatic symptom disorder. The symptoms are not caused, or
fully explained, by another medical, psychiatric, or substance abuse disorder, and they
cause clinical significant distress or impairment.
Two types of symptom patterns may be seen in patients with other specified or
unspecified somatic symptom disorder: those involving the autonomic nervous system
and those involving sensations of fatigue or weakness. In what is sometimes referred to
as autonomic arousal disorder, some patients are affected with symptoms that are limited
to bodily functions innervated by the autonomic nervous system. Such patients have
complaints involving the cardiovascular, respiratory, gastrointestinal, urogenital, and
dermatological systems. Other patients complain of mental and physical fatigue,
physical weakness and exhaustion, and inability to perform many everyday activities
because of their symptoms. Some clinicians believe this syndrome is neurasthenia, a
diagnosis used primarily in Europe and Asia. The syndrome may overlap with chronic
fatigue syndrome, which various research reports have hypothesized to involved
psychiatric, virological, and immunological factors. (See Chapter 14, which discusses
chronic fatigue syndrome in depth.) Other conditions included in this unspecified
category of somatic symptom disorder are pseudocyesis (discussed in Chapter 27) and
conditions that may not have met the 6-month criterion of the other somatic symptom
disorders.